Domino, Frank - The 5-Minute Clinical Consult Standard 2015 (23rd Ed)

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The 5-Minute Clinical Consult Standard

2015 23RD EDITION

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The 5-Minute Clinical Consult Standard Editor-in-Chief

2015 23RD EDITION

Includes 30-Day Free Trial to 5minuteconsult.com

Frank J. Domino, MD Professor Director of Predoctoral Education Department of Family Medicine and Community Health University of Massachusetts Medical School Worcester, Massachusetts

Associate Editors Robert A. Baldor, MD, FAAFP Professor and Vice-Chairman, Educational Affairs Department of Family Medicine and Community Health University of Massachusetts Medical School Worcester, Massachusetts Jeremy Golding, MD, FAAFP Professor of Family Medicine and Obstetrics & Gynecology University of Massachusetts Medical School Quality Officer Department of Family Medicine and Community Health University of Massachusetts Memorial Health Care Hahnemann Family Health Center Worcester, Massachusetts Jill A. Grimes, MD, FAAFP Clinical Instructor Department of Family Medicine University of Massachusetts Medical School Worcester, Massachusetts Attending Physician University of Texas Health Services Austin, Texas

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Acquisitions Editor: Rebecca Gaertner Product Development Editor: Leanne Vandetty Production Project Manager: Priscilla Crater Senior Manufacturing Coordinator: Beth Welsh Strategic Marketing Manager: Stephanie Manzo Design Coordinator: Teresa Mallon Production Service: Aptara, Inc.  C 2014 Wolters Kluwer Health Two Commerce Square 2001 Market Street Philadelphia, PA 19103 USA LWW.com

All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. Printed in China

Library of Congress Cataloging-in-Publication Data ISBN-13: 978-1-4511-9214-8 ISBN-10: 1-4511-9214-2

Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of the information in a particular situation remains the professional responsibility of the practitioner. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in the publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320. International customers should call (301) 223-2300. Visit Lippincott Williams & Wilkins on the Internet: at LWW.com. Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6 pm, EST. 10 9 8 7 6 5 4 3 2 1

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As I sat down to write this, the radio announced the passing of Nelson Mandela. Imagine being imprisoned for your beliefs for 27 years! Nelson Mandela stood quietly and soundly on his beliefs, knowing the world would be a better place for his personal turmoil. History’s high points occur when someone comes forward to take an unpopular stand, believing the world will be a better place for their suffering. Is the world of medicine ready to step up? Choosing Wisely (http://www.choosingwisely.org/). These two words made a huge impact this past year, as most every medical specialty and health care–related group (over 60!) found consensus on what tests and treatments were of use and beneficial to society. . . . and which were wasteful and harmful. Despite each group’s involvement, many called this heresy. It is not. This effort is the beginning of applying evidence-based medicine and a cost effective approach to care of our patients. Like it or not, the Affordable Care Act, complete with flaws and technological blunders, was brought forward in an effort to bring health insurance to 47 million US citizens who were previously uninsured; that is 1 in 6 people. President Obama voluntarily addressed something most Americans believe to be necessary—health insurance coverage for all. The Congressional Budget Office, a nonpartisan group that provides the US Congress with real numbers, continues to report lower than expected costs, with significant patient benefits (https://www.cbo.gov/topics/health-care/affordable-care-act). Other changes are rapidly occurring in health care. In some, solid, evidence-based medical research has yielded results that shake up the status quo, directing us toward changes that will prevent long term morbidity and mortality: —Head trauma from sports-related activities during adolescence and early adulthood causes permanent damage. Concussion prevention is the priority. Will football soon be a sport played only in college and after? —Prescription narcotics had a rough year: First, a call for training in appropriate use of long-term agents for nonmalignant pain and a systematic review of data showing no benefit of opioids for chronic low back pain. Accidental prescription opioid death is the most common cause of death in those under the age of 50 in the US and is our responsibility. Pulling back on prescribing these agents will be a challenge we must accept with the grace and strength of Mandela. —Curing hepatitis C can be at hand, and doing so will move cirrhosis and hepatoma from their leading role as causes of cancer death worldwide. Screen those born between 1945 and 1965 once and all who practice high-risk behaviors (blood transfusion before 1992, long-term hemodialysis, born to an HCV-infected mother, incarceration, intranasal drug use, getting an unregulated tattoo, and other percutaneous exposures). —HIV has become a chronic disease and like hepatitis C should now be part of our universal routine adult health screening; the new guidelines recommend screening all adolescents and adults ages 15 to 65 years, all pregnant women, and those younger adolescents and older adults who are at increased risk. —Bacteria in our gut may play a huge role in our degree of health, influencing illness from viral URIs to coronary artery disease. . . and even maybe obesity! In our efforts to overcome obesity, we will need to advocate a more vegetarian-based diet as an intervention to alter the gut microbiome and prevent illness. —Prevention of cardiovascular morbidity and mortality is clearly benefited by use of statins where cardiovascular risk is high but is not achieved by reaching a simple LDL goal. Again, we will need to prioritize helping patients to stop smoking and to start exercising. The benefit of medications to prevent heart disease hinges on these interventions, not just a pill. Mandela said “resentment is like drinking poison and then hoping it will kill your enemies.’’ Clinicians in all disciplines should remember that our differences in opinion are so much smaller than our common goal of helping others. This year’s 5-Minute Clinical Consult is dedicated to those who have suffered long and risked much to make our patients better. Let’s make certain their efforts were just the beginning of a better future.

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PREFACE

Any man may easily do harm but not every man can do good to another. —PLATO

B

orn in the 3rd century BC, Plato understood the essential role of providing care to those in need. And when you hold this book, you too have enormous potential to serve humanity, one person at a time. Welcome to The 5-Minute Clinical Consult 2015. Our editorial team has collaborated with hundreds of authors so that you may deliver your patients the best care. Each topic provides you with quick answers you can trust, where and when you need them most, either in print or online at www.5minuteconsult.com. This highly organized content provides you with: r Differential diagnosis support from an accessible, targeted search, delivering the answers you need quickly r Current evidence-based designations highlighted in each topic r A revised and updated Health Maintenance section r 880+ commonly encountered diseases and disorders in print, and more than 1,200 additional topics online, including 500 topics from The 5-Minute Pediatric Consult and over 620 topics from The 5-Minute Emergency Medicine Consult r FREE Point of Care CME and CE: 1/2 hour credit for every digital search r 200+ diagnostic and treatment algorithms r Color images and videos for procedures, treatment, and physical therapy R r A to Z Drug Database from Facts & Comparisons r More than 1,250 patient handouts in English and Spanish from the AAFP r ICD-10 Codes and DSM-V criteria; in addition, ICD-9 and SNOMED codes are available online.

5minuteconsult.com delivers quick access to continually updated online content—an ideal resource when you’re treating patients. Integrate 5-Minute content into your workflow, with online access, so you never have to skip a beat. If you purchased the Premium Edition your access includes 1 year FREE; the Standard Edition includes a free 30-day trial! The site promises an easy-to-use interface, allowing smooth maneuverability between topics, algorithms, images, videos, and patient education materials, as well as over 1,200 online-only topics. Evidence-based health care is the integration of the best medical information with the values of the patient and your skill as a clinician. We have updated our EBM content and its visibility, so you can focus on how to best apply it in your practice. The Health Maintenance 1-page summaries have been updated through December 2013 and are based on the US Preventive Services Task Force recommendations. The Algorithm section includes both diagnostic and treatment algorithms. This easy-to-use graphic method helps you evaluate an abnormal finding and prioritize treatment. They are also excellent teaching tools, so share them with the learners in your office. In our role as clinicians, caring for those who are ill or helping to prevent illness, we use tests and prescribe treatments, hoping they improve outcomes. As importantly, our words and actions, even a shared smile, can make a huge difference. We can “do good’’ for our patients, especially when we meet them at their most vulnerable. Thank you for making a difference. The 5-Minute Clinical Consult editorial team values your observations, so please share your thoughts, suggestions, and constructive criticism through our Web site, www.5mintueconsult.com. FRANK J. DOMINO, MD January 1, 2014

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EVIDENCE-BASED MEDICINE WHAT IS EVIDENCE-BASED MEDICINE?

R

emember when we used to treat every otitis media with antibiotics? These recommendations came about because we applied logical reasoning to observational studies. If bacteria cause an acute otitis media, then antibiotics should help it resolve sooner, with less morbidity. Yet, when rigorously studied (via a systematic review), we found little benefit to this intervention. The underlying premise of evidence-based medicine (EBM) is the evaluation of medical interventions, and the literature that supports those interventions, in a systematic fashion. EBM hopes to encourage treatments proven to be effective and safe. And when insufficient data exists, it hopes to inform you on how to safely proceed. EBM uses as endpoints of real patient outcomes; morbidity, mortality and risk. It focuses less on intermediate outcomes (bone density) and more on patient conditions (hip fractures). Implementing EBM requires 3 components: The best medical evidence, the skill and experience of the provider, and the values of the patients. Should this patient be screened for prostate cancer? It depends on what is known about the test, on what you know of its benefits and harms, your ability to communicate that information, and that patient’s informed choice. This book hopes to address the first EBM component, providing you access to the best information in a quick format. While not every test or treatment has this level of detail, many of the included interventions here use systematic review literature support. The language of medical statistics is useful to interpreting the concepts of EBM. Below is a list of these terms, with examples to help take the confusion and mystery out of their use. Prevalence: Proportion of people in a population who have a disease (in the US, 0.3% [3 in 1,000] people over the age 50 have colon cancer). Incidence: How many new cases of a disease occur in a population during an interval of time; for example, “the estimated incidence of colon cancer in the US is 104,000 in 2005.’’ Sensitivity (Sn): Percent of people with disease who test positive; for mammography, the sensitivity is 71–96%. Specificity (Sp): Percent of people without disease who test negative; for mammography, the specificity is 94–97%. Now suppose you saw ML, a 53-year-old woman, for a Health Maintenance visit, ordered a screening mammogram, and the report demonstrates an irregular area of microcalcifications. She is waiting in your office to receive her test results; what can you tell her? Sensitivity and specificity refer to characteristics of people who are known to have disease (sensitivity) or those that are known not to have disease (specificity). But, what you have is an abnormal test result. To better explain this result to ML, you need to know the positive predictive value. Positive predictive value (PPV): Percent of positive test results that are truly positive; the PPV for a woman aged 50–59 is approximately 22%. That is to say that only 22% of abnormal

screening mammograms in this group truly identified cancer. The other 78% are false positives. You can tell ML only 1 out of 5 abnormal mammograms correctly identify cancer; the 4 are false positives, but the only way to know which mammogram is correct is to do further testing. The corollary of the PPV is the Negative predictive value (NPV), which is the percent of negative test results that are truly negative. The PPV and NPV tests are population dependent, while the Sensitivity and Specificity are characteristics of the test, and have little to do with the patient in front of you. So when you receive an abnormal lab result, especially a screening test like mammography, understand their limits based on their PPV and NPV. Treatment Information is a little different. In discerning the statistics of randomized, controlled trials of interventions, first consider an example. The Scandinavian Simvastatin Survival Study (4S) (Lancet. 1994;344[8934]:1383–1389) found using simvastatin in patients at high risk for heart disease for 5 years resulted in deaths in 8% of patients vs. 12% of those on placebo; this results in a relative risk of 0.70, a relative risk reduction (RRR) of 33%, and a number needed to treat of 25. There are two ways of considering the benefits of an intervention with respect to a given outcome. The absolute risk reduction (ARR) is the difference in the percent of people with the condition before and after the intervention. Thus, if the incidence of MI was 12% for the placebo group and 8% for the simvastatin group, the ARR is 4% (12% − 8% = 4%). The RRR reflects the improvement in the outcome as a percentage of the original rate and is commonly used to exaggerate the benefit of an intervention. Thus, if the risk of MI were reduced by simvastatin from 12% to 8%, then the RRR would be 33% (4%/12% = 33%); 33% may appear better than 4%, the 4% that reflects the true outcome. ARR is usually a better measure of clinical significance of an intervention. For instance, in one study, the treatment of mild hypertension was been shown to have a RRR of 40% over 5 years (40% fewer strokes in the treated group). However, the ARR was only 1.3%. Because mild hypertension is not strongly associated with strokes, aggressive treatment of mild hypertension yields only a small clinical benefit. Don’t confuse Relative Risk Reduction with Relative Risk. Absolute (or attributable) risk (AR): The percent of people in the placebo or intervention group who reach an end point; in the simvastatin study, the absolute risk of death was 8%. Relative risk (RR): The risk of disease of those treated or exposed to some intervention (i.e., simvastatin) divided by those in the placebo group or who were untreated. —If RR 1.0, it increases the risk—the greater the number, the greater the risk increase. Relative risk reduction (RRR): The relative decrease in risk of an end point compared to the percent of that end point in the placebo group. If you are still confused, just remember the RRR is an overestimation of the actual effect. Number needed to treat (NNT): This is the number of people who need to be treated by an intervention to prevent one adverse outcome. A “good” NNT can be a large number (>100) if risk of serious outcome is great. If the risk of an outcome is not that dangerous, then lower (3 drinks on any one occasion for women, and >14 drinks per week or >4 drinks on any one occasion for men. OR Screen: “On any occasion during the last 3 months, have had >5 alcohol drinks” or CAGE: Tried to CUT down, been ANGERED by questions about your drinking, felt GUILTY about your drinking, had an EYE OPENER (drink in the morning) Screen all women of childbearing age, and provide intervention or refer those who screen positive “Do you feel safe in your present relationship?” “Have you been hit, kicked, punched, or otherwise hurt in the last year?” Question about drug use and related problems should be considered in all adolescents and adults. Risk factors include history of mood or other mental disorder, substance abuse, and history of “deliberate self-harm.”

Against (D grade) Coronary heart disease via ECG, ETT, etc. Hemochromatosis Scoliosis screening Testicular cancer

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D: Do Not Screen D: Do Not Screen D: Do Not Screen D: Do Not Screen

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HEALTH MAINTENANCE: 25–45 YEARS (www.uspreventiveservicestaskforce.org/uspstopics.htm)

Leading causes of death:

Immunizations (www.cdc.gov/vaccines/schedules/hcp/adult.html or www.immunizationed.org)

r Unintentional injury (especially

Tetanus Influenza

accidental overdose [narcotics]) r Suicide r Cardiovascular disease r Malignant neoplasm

Tdap every 10 years or just at age 50 (if completed primary series) All adults

Disease

Recommended intervention (A or B grade)

General

Height, weight, BMI, BP, injury prevention (seat belts, firearms), low-saturated-fat diet, physical exercise Screen all for alcohol and substance misuse and provide those at risk with brief counseling to reduce misuse (see below for tools) Refer for genetic counseling if: Ashkenazi heritage, or 2 first-degree relatives with breast or ovarian cancer at 135/80 mm Hg Screen all women of childbearing age Intensive behavioral dietary counseling for patients with known risk factors for cardiovascular and diet-related chronic disease All adults who are at increased risk (multiple partners, IV drug use, etc. and all pregnant women) Screen all aged 15–65 years, including all pregnant woman, and those younger and older who are at increased risk All pregnant women and those with multiple sexual partners, IV drug use, etc. Men: 35 and older for lipid disorders Women: 45 and older for lipid disorders If depressed* Ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco If high risk: Travel, immigrant, alcohol abuse, IV drug use

Alcohol and substance abuse Breast and ovarian cancer by genetic testing Breast cancer screening by mammography Cervical cancer screening Coronary heart disease

Depression Diabetes mellitus, type II (if BP >135/80) Domestic/family violence Diet/obesity Chlamydia, gonorrhea, syphilis testing HIV screening Hepatitis B Lipid disorders Suicide screening Tobacco abuse Tuberculosis screening

*Additional screening Alcohol abuse

Domestic violence Substance abuse Suicide

“Risky”/“hazardous” alcohol use: >7 drinks per week or >3 drinks on any one occasion for women, and >14 drinks per week or more than 4 drinks on any one occasion for men. OR Screen: “On any occasion during the last 3 months, have had more than 5 alcohol drinks” or CAGE: Tried to CUT down, been ANGERED by questions about your drinking, felt GUILTY about your drinking, had an EYE OPENER (drink in the morning) Screen all at-risk patients (all women, especially when pregnant) “Do you feel safe in your present relationship?” “Have you been hit, kicked, punched, or otherwise hurt in the last year?” Questioning about drug use and related problems should be considered in all adolescents and adults. Risk factors include history of mood or other mental disorder, substance abuse, and history of “deliberate self-harm.”

Recommends against Aspirin Testicular cancer

The USPSTF recommends against the use of aspirin for stroke prevention in women younger than 55 years and for myocardial infarction prevention in men younger than 45 years. The USPSTF recommends against testicular exam to screen for testicular cancer.

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HEALTH MAINTENANCE

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HEALTH MAINTENANCE: 45–65 YEARS (www.uspreventiveservicestaskforce.org/uspstopics.htm) Leading causes of death:

Immunizations (www.cdc.gov/vaccines/schedules/hcp/adult.html or www.immunizationed.org)

r Cardiovascular disease

Tetanus Influenza

r Malignant neoplasm r Accidents r Cirrhosis

Tdap every 10 years or just at age 50 (if completed primary series) All adults

Disease

Recommended intervention (A or B grade)

General

Height, weight, BMI, BP, injury prevention (seat belts, firearms), low-saturated-fat diet, physical exercise Screen all for alcohol and substance misuse and provide those at risk with brief counseling to reduce misuse (see below for tools) Recommends use of aspirin for men age 45–79 and women age 55–79 years when potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in GI hemorrhage Refer for genetic counseling if: Ashkenazi heritage, or 2 first-degree relatives with breast or ovarian cancer at 135/80 mm Hg Screen all women of childbearing age Intensive behavioral dietary counseling for patients with known risk factors for cardiovascular and diet-related chronic disease Screen all aged 15–65 years, including all pregnant women, and those younger and older who are at increased risk All pregnant women and those with multiple sexual partners, IV drug use, etc. Screen all adults born between 1945 and 1965 once for hepatitis C All adults over 45 should be screened If depressed* Only screen in women younger than 65 years if their fracture risk is equivalent to that of a 65-year-old Ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco If high risk: Travel, immigrant, alcohol abuse, IV drug use

Alcohol and substance abuse Aspirin Breast and ovarian cancer by genetic testing Breast cancer screening by mammography Cervical cancer screening Chlamydia, gonorrhea, syphilis testing Colon cancer Coronary heart disease

Depression Diabetes mellitus, type II if BP >135/80 Domestic/family violence Diet/obesity HIV screening Hepatitis B Hepatitis C Lipid disorders Suicide screening Osteoporosis Tobacco abuse Tuberculosis screening

*Additional screening Alcohol abuse

Domestic violence Substance abuse Suicide

“Risky”/”hazardous” alcohol use: >7 drinks per week or >3 drinks on any one occasion for women, and >14 drinks per week or >4 drinks on any one occasion for men. OR Screen: “On any occasion during the last 3 months, have had more than 5 alcohol drinks” or CAGE: Tried to CUT down, been ANGERED by questions about your drinking, felt GUILTY about your drinking, had an EYE OPENER (drink in the morning) Screen all at-risk patients (all women, especially when pregnant) “Do you feel safe in your present relationship?” “Have you been hit, kicked, punched, or otherwise hurt in the last year?” Questioning about drug use and related problems should be considered in all adolescent and adult. Risk factors include history of mood or other mental disorder, substance abuse, and history of “deliberate self-harm.”

Recommends against Prostate cancer Ovarian cancer

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The USPSTF recommends against PSA-based screening for prostate cancer. The USPSTF recommends against screening for ovarian cancer in women.

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HEALTH MAINTENANCE

HEALTH MAINTENANCE: 65 YEARS AND ABOVE (www.uspreventiveservicestaskforce.org/uspstopics.htm)

Leading causes of death:

Immunizations (www.cdc.gov/vaccines/schedules/hcp/adult.html or www.immunizationed.org)

r Cardiovascular disease

Tetanus Influenza

r Malignant neoplasm

Tdap every 10 years (if completed primary series) All adults

Disease

Recommended Intervention (A or B Grade)

r Stroke

General

r Dementia

Alcohol and substance abuse

Height, weight, BMI, BP, injury prevention (seat belts, firearms), low-saturated-fat diet, physical exercise Screen all for alcohol and substance misuse and provide those at risk with brief counseling to reduce misuse (see below for tools) Recommends use of aspirin for men age 45–79 and women age 55–79 years when potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in GI hemorrhage Refer for genetic counseling if: Ashkenazi heritage, or 2 first-degree relatives with breast or ovarian cancer at 135/80 Domestic/family violence Diet/obesity Fall prevention HIV screening Hepatitis B Hepatitis C Lipid disorders Osteoporosis Suicide screening Tobacco abuse Tuberculosis screening

Start at age 50–75 by fecal occult blood testing, sigmoidoscopy, or colonoscopy Evidence is insufficient to recommend using nontraditional risk factors (high-sensitivity C-reactive protein [hs-CRP], ankle-brachial index [ABI], leukocyte count, fasting blood glucose level, periodontal disease, carotid intima-media thickness [carotid IMT], coronary artery calcification [CAC] score on electron-beam computed tomography [EBCT], homocysteine level, and lipoprotein[a] level) to screen asymptomatic men and women with no history of CHD to prevent CHD events In clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up Random serum glucose if sustained BP (either treated or untreated) >135/80 mm Hg *If sexually active Intensive behavioral dietary counseling for patients with known risk factors for cardiovascular and diet-related chronic disease The USPSTF recommends exercise or physical therapy and vitamin D supplementation (>800 IU/d) Screen all until age 65 years, and those older who are at increased risk All pregnant women and those with multiple sexual partners, IV drug use, etc. Screen all adults born between 1945 and 1965 once for hepatitis C All adults over 45 should be screened All women at 65; insufficient evidence to support screening men If depressed* Ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco If high risk: Travel, immigrant, alcohol abuse, IV drug use

*Additional screening Alcohol abuse

Domestic violence Substance abuse Suicide

“Risky”/”hazardous” alcohol use: >7 drinks per week or >3 drinks on any one occasion for women, and >14 drinks per week or >4 drinks on any one occasion for men. OR Screen: “On any occasion during the last 3 months, have had more than 5 alcohol drinks” or CAGE: Tried to CUT down, been ANGERED by questions about your drinking, felt GUILTY about your drinking, had an EYE OPENER (drink in the morning) Screen all at-risk patients (all women, especially when pregnant) “Do you feel safe in your present relationship?” “Have you been hit, kicked, punched, or otherwise hurt in the last year?” Questioning about drug use and related problems should be considered in all adolescent and adult. Risk factors include history of mood or other mental disorder, substance abuse, and history of “deliberate self-harm.”

Recommends against Prostate cancer Ovarian cancer

The USPSTF recommends against PSA-based screening for prostate cancer. The USPSTF recommends against screening for ovarian cancer in women.

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Diagnosis and Treatment: An Algorithmic Approach This section contains flowcharts (or algorithms) to help the reader in the diagnosis of clinical signs and symptoms, and treatment of a variety of clinical problems. They are organized by the presenting sign, symptom, or diagnosis. These algorithms were designed to be used as a quick reference and adjunct to the reader’s clinical knowledge and impression. They are not an exhaustive review of the management of a problem, nor are they meant to be a complete list of diseases.

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Abdominal Pain, Chronic ABDOMINAL PAIN, CHRONIC Common causes: Irritable bowel syndrome, functional dyspepsia, domestic violence, Hx incest/rape, celiac, PID, endometriosis, anxiety, child abuse/neglect

Yes

Screen for abuse, domestic violence

Red flags: • Weight loss • Age 75 µg/mL (497 µmol/L) at 8 hours OR APAP level >40 µg/mL (265 µmol/L) at 12 hours after ingestion OR lab evidence of hepatotoxicity

No

No

Yes

Repeated supratherapeutic ingestion (RSTI)

APAP >10 μg/ml OR elevated AST or ALT

Yes

Administer NAC (best w/in 8 hours may be effective up to 36 hours after ingestion). Do not delay for charcoal! PO/NG

IV preferred

No 72-hour PO regimen: 140 mg/kg loading dose THEN 70 mg/kg q4h × 17 total doses for 17 total doses

Aggressive patient education

IV regimen: 150 mg/kg in 200 mL D5W over 60 minutes THEN 50 mg/kg in 500 mL D5W over 4 hours THEN 100 mg/kg in 1 L D5W over 16 hours

Check APAP, ALT, AST, PT/INR every 4 hours

Discontinue NAC

Yes

APAP ≤10 μg/ml, ALT/AST have peaked are improving, INR ≤1.3

No

Extended IV regimen: 150 mg/kg in 200 mL D5W over 60 minutes THEN 50 mg/kg in 500 mL D5W over 4 hours THEN 100 mg/kg in 1 L D5W over 16 hours, then 6.25 mg/kg/hr until INR 3.0 OR pH 3.2 and INR >6.5 and encephalopathy

*APAP = Acetaminophen NAC = N-acetylcysteine

Christine Jacobs, MD, FAAFP Hodgman MJ, Garrard AR. A review of acetaminophen poisoning. Crit Care Clin. 2012;28(4):499–516.

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Acid Phosphatase Elevation ACID PHOSPHATASE ELEVATION Acid phosphatase is produced by the prostate, RBCs, seminal fluid, and bony turnover

Common causes: Prostate cancer (most common), neoplasm, multiple myeloma, Paget’s, Gaucher’s, ITP, liver disease, renal failure, hyperparathyroidism, trauma

Rectal exam PSA

Normal rectal exam and PSA

Abnormal rectal exam or PSA

Irregular prostate: Skeletal survey and urology referral

Search for other causes: CBC, electrolytes, alkaline phosphatase, SPEP, UPEP, ESR, LFTs, B12, anti-tTG, TSM

Anemia

Evaluate and treat for hemolytic anemia

No anemia

High ALK

Paget’s, advanced Gaucher’s

Low ALK

Hypothyroidism B12 deficiency Celiac disease Malnutrition

Liver disease, early Gaucher’s, multiple myeloma

Laura Hagopian, MD and Michael Snyder, MD Scarnecchia L, Minisola S, Pacitti MT, et al. Clinical usefulness of serum tartrate-resistant acid phosphatase activity determination to evaluate bone turnover. Scand J Clin Lab Invest. 1991;51(6):517–524.

A-7

DIAGNOSIS AND TREATMENT

P1: OSO/OVY

P1: OSO/OVY

P2: OSO/OVY

LWBK1309-Algo

QC: OSO/OVY

LWBK1211-Domino

T1: OSO

February 7, 2014

23:0

Acidosis ACIDOSIS Suspect with low HCO3 (2.5 U/S with polycystic ovaries, High/high-normal total testosterone

30–50 years old

Varies

Facial flushing, erythema with telangectasias, inflammatory papules and pustules, ocular dryness, nasal sebaceous gland hypertrophy

Cushingoid appearance: Central obesity, moon facies, buffalo hump, proximal weakness, easy bruisability, violaceous striae, impotence

Rosacea

Increased 24-hour cortisol, overnight low-dose dexamethasone suppression test

PCOS Cushing syndrome

Elise Bognanno, MD and Frank J. Domino, MD Titus S, Hodge J. Diagnosis and treatment of acne. Am Fam Physician. 2012;86:734–740.

A-9

DIAGNOSIS AND TREATMENT

P1: OSO/OVY

P1: OSO/OVY

P2: OSO/OVY

LWBK1309-Algo

QC: OSO/OVY

LWBK1211-Domino

T1: OSO

February 7, 2014

23:0

Alcohol Withdrawal, Treatment ALCOHOL WITHDRAWAL, TREATMENT History: Duration and quantity of alcohol intake, time since last drink, previous episodes of alcohol withdrawal, concurrent substance use, preexisting medical and psychiatric conditions, prior detoxification admissions, prior seizure activity, living situation, social supports, stressors, triggers, etc.

Physical: VS (fever, tachycardia, tachypnea, hypertension), CIWA (see below), MSE (arousal, orientation, hallucinations), HEENT (diaphoresis, scleral icterus), CV (arrhythmias, M/R/G), eval s/sx liver failure (ascites, varices, caput medusae, asterixis, palmar erythema), neuro (nystagmus, tremor, seizure activity) Include assessment of conditions likely to complicate, exacerbate or precipitate alcohol withdrawal: Arrhythmias, CHF, CAD, dehydration, GI bleeding, infections, liver disease, pancreatitis, neurologic deficits

Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA) – Nausea and vomiting 0–7; (7-constant nausea, frequent dry heaves/vomiting) – Tremor 0–7; (7-severe, even with arms not extended) – Paroxysmal sweats 0–7; (7-drenching sweats) – Anxiety 0–7; (7-acute panic state) – Agitation 0–7; (7-constantly thrashing about or pacing) – Tactile disturbances 0–7; (4–7 for hallucinations, 1–3 for pruritus or paresthesias) – Auditory disturbances 0–7; (4–7 for hallucinations, 1–3 for increased sensitivity) – Visual disturbances 0–7; (4–7 for hallucinations, 1–3 for increased sensitivity) – Headache, fullness in head 0–7 – Orientation and clouding of sensorium 0–4: Cannot do serial additions or is uncertain about date Disoriented to date but within 2 calendar days Disoriented to date by >2 days Disoriented to place or person

Mild withdrawal; CIWA 0–7 (onset 5–8 hours after cessation or significant decrease in consumption): Anxiety, restlessness, agitation, mild nausea, decreased appetite, sleep disturbance, facial sweating, mild tremulousness, fluctuating tachycardia and hypertension, possible mild cognitive impairment

May be monitored as outpatient, unless pregnant, history of seizures or withdrawal seizures, chronic or acute comorbid illness requiring inpatient observation, lack of ability to follow-up

– Admit to inpatient detox program for monitoring – Vital signs q4h; CIWA q1–3h

Moderate withdrawal; CIWA 8–14 (onset 24–72 hours after cessation): Marked restlessness and agitation, moderate tremulousness with constant eye movement, diaphoresis, nausea, vomiting, anorexia, diarrhea

Severe withdrawal/delirium tremens; CIWA >15 (onset 72–96 hours after alcohol cessation): Marked tremulousness, fever, drenching sweats, severe hypertension and tachycardia, delirium

– Admit to ICU for inpatient detox – VS q30h – CIWA q1h – NPO, IVF – Lateral decubitus position, restrain if necessary – Glucose, Na, K, PO4, Mg replacement as needed

– Admit to inpatient detox program – Private room if possible – Vital signs q4h – CIWA q1–3h – Institute seizure precautions – IVF

Diazepam 20 mg PO q1–2h until CIWA30, Deepening of voice LH/FSH ratio >2

Eating disorders Check labs: DHEA-S, testosterone (increased)

Galactorrhea

FSH LH

Hot flashes Sleep difficulty Decreased libido

Elevated TSH

Increased serum prolactin

Pituitary MRI

Hypothyroidism

Creatinine

Medications: Oral contraceptives Metoclopramide Antipsychotics

PCOS

Menopause

Pituitary adenoma

Renal disease

Normal Labs

GYN exam, Transvaginal US

Obtain: Cortisol, serum Testosterone

Asherman syndrome Cervical stenosis

Cushing disease Androgen tumor

Maria Montanez, MD and Fozia Akhtar Ali, MD Master-Hunter T, Heiman DL. Amenorrhea: Evaluation and treatment. Am Fam Physician. 2006;73:1374–1382.

A-13

DIAGNOSIS AND TREATMENT

P1: OSO/OVY

P1: OSO/OVY

P2: OSO/OVY

LWBK1309-Algo

QC: OSO/OVY

LWBK1211-Domino

T1: OSO

February 7, 2014

23:0

Anemia ANEMIA

Common causes: Iron deficiency, anemia of chronic disease, chronic renal failure, acute blood loss, hemolysis, B12 deficiency, myelodysplasia, chemotherapy

Low MCV

Normal MCV

High MCV

Check labs: Fe, TIBC, ferritin, hemoglobin electrophoresis

Check labs: Fe, TIBC, ferritin, TSH, BUN, creatinine

Check labs: Reticulocyte count

Iron deficiency Thalassemia Hemoglobinopathy Sideroblastic anemia Lead poisoning

Increased reticulocyte count

Anemia of chronic disease Chronic renal failure Hypothyroidism Mixed microcytic/ macrocytic anemia

Normal reticulocyte count

Check labs: Indirect bilirubin

Increased bilirubin

Hemolysis

G6PD deficiency Pyruvate kinase deficiency Hereditary spherocytosis Hereditary elliptocytosis Mechanical heart valve Viral infections SLE

B12 deficiency Folate deficiency Alcohol abuse Liver disease Myelodysplasia No increased bilirubin

Acute blood loss

Medications

Methyldopa Quinidine Penicillin

Trauma Epistaxis Menorrhagia Hematemesis Diverticulosis

Robert A. Baldor, MD and Alan M. Ehrlich, MD Smith DL. Anemia in the elderly. Am Fam Physician. 2000;62:1565–1572.

A-14

Medications

Sulfonamides ZDV (AZT) Chemotherapy Phenytoin

P2: OSO/OVY

LWBK1309-Algo

QC: OSO/OVY

LWBK1211-Domino

T1: OSO

February 7, 2014

23:0

Anxiety ANXIETY

Common causes: Generalized anxiety disorder, phobias, panic disorder, medications

Symptoms suggestive of medical illness or abnormal physical exam Yes

Check: CBC, glucose, electrolytes, calcium, TSH, urine tox screen, ECG

No

Medication or drug effect

Anxiety disorder due to another medical condition Yes

Abnormal labs

Normal labs

Anemia Hyperthyroidism Cushing syndrome Hypoglycemia Hyponatremia Hypocalcemia Cardiac arrhythmia

Anxiety due to another medical condition (asthma, seizures, etc.)

Asthma Postconcussive syndrome Brain tumor Partial complex seizures

No Acute effect of caffeine, bath salts, cocaine, amphetamines, hallucinogens, anticholinergics

Withdrawal from alcohol, narcotics, nicotine, cannabis PCP or benzodiazepines

Dilated pupils=anticholinergic drug effect or bath salts

Constricted pupils=opioid drug effects or pontine hemorrhage

Culture bound anxiety (Ataque de nervios, khyal cap—wind attacks)

Specific phobia, social anxiety disorder (social phobia), separation anxiety, selective mutism

Avoidance of anxiety-producing social setting

Agoraphobia

Fear with somatic symptoms such as chest pain, shortness of breath, palpitations, sweating, tightness in throat, trembling, numbness or tingling, dizziness

Panic disorder

Anxiety and worry occurring most days for >6 months

Generalized anxiety disorder

Bettina Bernstein, DO Kavan MG, Elsasser G, Barone EJ. Generalized anxiety disorder: Practical assessment and management. Am Fam Physician. 2009;79(9):785–791.

A-15

DIAGNOSIS AND TREATMENT

P1: OSO/OVY

P1: OSO/OVY

P2: OSO/OVY

LWBK1309-Algo

QC: OSO/OVY

LWBK1211-Domino

T1: OSO

February 7, 2014

23:0

AST Elevation AST ELEVATION Common causes: Hemolysis, liver disease, myocardial infarction, CHF, acute renal failure, biliary obstruction, pancreatitis, muscle disorders, medications

Check: LFTs, consider CBC, BUN, creatinine, hepatitis serologies, CPK, amylase, CXR, ultrasound/CT of abdomen

Jaundice

Chest pain or dyspnea

Abdominal pain Elevated amylase

Edema

Liver disease Biliary obstruction Hemolysis Viral hepatitis

Myocardial infarction CHF

Pancreatitis

CHF Acute renal failure

Muscle disorder or injury

Liver toxicity

Alcohol Medications

Robert A. Baldor, MD and Alan M. Ehrlich, MD Giboney PT. Mildly elevated liver transaminase levels in the asymptomatic patient. Am Fam Physician. 2005;71:1105–1110.

A-16

P2: OSO/OVY

LWBK1309-Algo

QC: OSO/OVY

LWBK1211-Domino

T1: OSO

February 7, 2014

23:0

Asthma Exacerbation, Pediatric Acute ASTHMA EXACERBATION, PEDIATRIC ACUTE Initial evaluation: Brief history, physical exam History: Emergency department visits, hospital and ICU admissions, repeated courses of oral steroids, history of intubation, rapidly progressive episodes, or food allergy Physical exam: Auscultation, use of accessory muscles, ability to speak, heart rate, respiratory rate

Severity Normal Mild Moderate Severe

Respiratory rate (6 yr) 30 20 31–45 21–35 46–60 36–50 >60 >50

Mild exacerbation: Inhaled β-agonist (nebulized or MDI with spacer) ×1 Consider systemic corticosteroid PO/IM if no immediate response or history of recent course of corticosteroids. Check initial oxygen saturation level; no need for continuous pulse-ox monitoring.

Yes

Wheezing

Inspiratory Accessory expiratory ratio muscle use None 2:1 None End expiration 1:1 + Entire expiration 1:2 ++ Inspiration and expiration 1:3 +++

Moderate exacerbation: Inhaled β-agonist (nebulized or MDI with spacer) q20min, up to 3 doses in 1 hour Inhaled ipratropium ×3 doses Systemic corticosteroids PO/IM Supplemental O2 to achieve SaO2 >90%

Oxygen saturation (room air) 99–100% 96–98% 93–95% 90% Consider IM epinephrine if imminent respiratory failure

Discharge criteria met? In first 2 hours: – Decreased/absent wheezing and retractions; – Sustained SaO2 >90% at least 60 minutes after last albuterol dose

Moderate exacerbation: Inhaled β-agonist q20min Continue treatment 1–3 hours, provided there is improvement. Make admit decision in 2 days/week but not every day

Daily

Throughout the day

Nighttime awakenings

≤2 times/month

3 or 4 times/month

>1 time weekly, but not nightly

Often 7 times weekly

Short-acting ␤2-agonist use for symptom control

≤2 days/week

>2 days/week, but not daily, and not more than 1 time on any day

Daily

Several times daily

Interference with normal activity

None

Minor limitation

Some limitation

Extremely limited

Lung function

Astma exacerbations requiring oral steroids

Recommended step for initiating treatment

• Normal FEV1 between exacerbations • FEV1 >80% predicted • FEV1/FVC normal

• FEV1 >80% predicted • FEV1/FVC normal

• FEV1 >60% but 5%

≥2/year

Step 4 or 5 Step 4

Preferred and alternative pharmacotherapy based on step

Preferred: Short-acting ␤2-agonist as needed

Preferred: Low-dose ICS Alternative: Leukotriene modifier or theophylline

Preferred: Low-dose ICS + LABA or medium-dose ICS Alternative: Low-dose ICS + leukotriene modifier, theophylline or zileuton

Preferred: Medium-dose ICS + LABA Alternative: Medium-dose ICS + leukotriene modifier, theophylline or zileuton Step 5 Preferred: High-dose ICS + LABA and consider omalizumab for patients with allergies Step 6 Preferred: High-dose ICS + LABA + oral corticosteroid and consider omalizumab for patients with allergies

Michael C. Barros, PharmD, BCPS, BCACP, Colleen M. Prinzivalli, PharmD, BCPS, and J. Michael O’Connell, Jr., MD Elward KS, Pollart SM. Medical Therapy for Asthma: Updates from the NAEPP Guidelines. Am Fam Physician. 2010;82:1242–1251.

A-18

LWBK1309-Algo

P2: OSO/OVY

QC: OSO/OVY

LWBK1211-Domino

T1: OSO

February 7, 2014

23:0

Asthma, Maintenance ASTHMA, MAINTENANCE Assessing Control Re-evaluate patient in 2–6 weeks and adjust therapy based on components of control

Well controlled

Not well controlled

Very poorly controlled

Symptoms

≤2 days/week

Symptoms

>2 days/week

Symptoms

Throughout the day

Nighttime awakenings

≤2 times/month

Nighttime awakenings

1–3 times/week

Nighttime awakenings

≥4 times/week

Interference with normal activity

None

Interference with normal activity

Some limitation

Interference with normal activity

Extremely limited

Short-acting β2 agonist use for symptoms control

≤2 days/week

Short-acting β2 agonist use for symptoms control

>2 days/week

Short-acting β2 agonist use for symptoms control

Several times per day

FEV1 or peak flow

>80% predicted/ personal best

FEV1 or peak flow

60–80% predicted/ personal best

FEV1 or peak flow

3 months

Treatment: • Step up 1 step • Re-evaluate in 2–6 weeks

Treatment: • Consider oral corticosteroids • Step up 1–2 steps • Re-evaluate in 2 weeks

FVC = forced vital capacity; FEV1 = forced expiratory volume in 1 second; ICS = inhaled corticosteroid; LABA = long acting

Michael C. Barros, PharmD, BCPS, BCACP, Colleen M. Prinzivalli, PharmD, BCPS, and J. Michael O’Connell, Jr., MD Elward KS, Pollart SM. Medical Therapy for Asthma: Updates from the NAEPP Guidelines. Am Fam Physician. 2010;82:1242–1251.

A-19

DIAGNOSIS AND TREATMENT

P1: OSO/OVY

P1: OSO/OVY

P2: OSO/OVY

LWBK1309-Algo

QC: OSO/OVY

LWBK1211-Domino

T1: OSO

February 7, 2014

23:0

Ataxia ATAXIA Common causes: Labyrinthitis, multiple sclerosis, stroke, BPPV normal pressure hydrocephalus alcoholism, spinal cord disorders, multisensory loss

Acute onset

TIA Stroke Acute alcohol intoxication Encephalitis Head trauma Postviral status HIV infection Any infection or acute metabolic disturbance in the elderly Muscle weakness

Gradual onset

Medications

Tinnitus, vertigo, and/or hearing loss

Toxic exposure

Mercury Lead Thallium Carbon tetrachloride Toluene Labyrinthitis ` ` disease Meniere Acoustic neuroma Phenytoin Carbamazepine Phenobarbital Anticholinergic drugs Aminoglutethimide Aminoglycosides

No toxic exposures

Family history of ataxias

Friedreich ataxia Ataxia telangiectasia

No family history

Sensory loss in extremities

Peripheral neuropathy Syphilis Spinal cord tumor or injury Vitamin B12 deficiency Multiple sclerosis HIV infection Multisensory loss

Robert A. Baldor, MD and Alan M. Ehrlich, MD Pandolfo M. Friedreich ataxia. Arch Neurol. 2008;65(10):1296–1303.

A-20

No sensory loss

Posterior fossa lesions Multiple sclerosis Hypothyroidism Syphilis Normal pressure hydrocephalus

P2: OSO/OVY

LWBK1309-Algo

QC: OSO/OVY

LWBK1211-Domino

T1: OSO

February 7, 2014

23:0

Breast Discharge BREAST DISCHARGE Breast discharge

Nonspontaneous multiduct

Age ≥40

Age 3 feet) and/or Trauma above the clavicles (e.g., frontal head or face) EMS primary survey Airway Breathing Circulation Disability

EMS primary survey

If necessary, intubate using manual in-line intubation before proceeding to secondary survey/immobilization.

On-Scene (EMS)

Restrict activity until follow up without patient physician.

No to all

On-scene/side-line evaluation (EMS): Assessment of mechanism—high risk? Neurologic exam—impaired motor, sensory or reflexes? Nonambulatory? Neck range of motion—impaired?

Yes to any Immobilize C-spine and transport to medical facility.

Hockey/football helmet and pads

No helmet/pads

*Leave helmet/pads in place. Remove facemask.* Rigid collar, spine board Physician primary survey Hemodynamically unstable

ABCDs

IV crystalloid, blood transfusion, pressors search for hemorrhagic source Intubate with MLI if necessary

Hemodynamically stable Yes Physician secondary survey

Imaging for clinically significant spinal injury?

Goal MAP 90 mmHg?

No Neurogenic shock Administer IV steroids Emergent surgical decompression with postop imaging

Meets all 5 criteria

A-24

NEXUS low-risk criteria: No posterior cervical midline tenderness No abnormal level of alertness No evidence of intoxication No painful/distracting injuries No abnormal neurologic symptoms (unconscious, numbness, weakness, paralysis, or neck pain/cervical tenderness)

P2: OSO/OVY

LWBK1309-Algo

QC: OSO/OVY

LWBK1211-Domino

T1: OSO

February 7, 2014

23:0

Cervical Hyperextension Injury OR Fails any 1 of the criteria

Neurologic symptoms indicative of cord compression or central cord syndrome?

Yes to ≥1 No Conservative Management: NSAIDs, analgesics, muscle relaxants Rest with possible soft collar Follow up in 3 weeks.

Yes

No

Canadian cervical spine rules: High Risk?: Dangerous/high-speed mechanism Age: >65 or 99%) – Tubal ligation—can be done laparoscopically or after a C-section – Vasectomy—outpatient procedure

Can she reliably take medication daily? No

Fertility Awareness Methods: – Less effective (76%) – Nonhormonal, nonsurgical, natural methods – Based on avoiding prime ovulation days during cycle – Ovulation – Standard Day – Two Day – Symptothermal

Yes

Breastfeeding 90 kg – Black Box Warning: Increased estrogen-related AE, especially VTE

Intravaginal Method: – Nuva-Ring – Good efficacy (91%) – Lower hormone doses – Simple to use – Once a month dosing – Many nonconctraceptive benefits, ↓ dysmenorrhea, cycle control

Yes Long-Acting Reversible Methods

Injectable Method: Depo-Provera – Good efficacy (94%), good for 3 months – High likelihood of unscheduled bleeding

Implantable Methods: – Implanon, Nexplanon – Sino-Implant – Very effective (>99%), good for 3–5 years – Simple office procedure with no ongoing effort required – High likelihood of unscheduled bleeding and/or prolonged amenorrhea

Intrauterine Methods: – Mirena IUD – Copper T 380A IUD—nonhormonal – Very effective (>99%) good for 5–10 years – Outpatient office procedure with no ongoing effort required – Prompt return to fertility – Good when breastfeeding – May cause irregular bleeding and cramping for first 3–6 months – Option for adolescents and nulliparous women

LWBK1309-Algo

P2: OSO/OVY

QC: OSO/OVY

LWBK1211-Domino

T1: OSO

February 7, 2014

23:0

Contraception

Combined oral contraceptive methods

Acne/Hirsutism/PCOS

Abnormal uterine bleeding

3rd-generation combined oral contraceptive Progestin: Norgestimate • Ortho-tricyclen, • Ortho-cyclen • Srintec • Tri-sprintec • Othens Progestin: Desogestrel • Apri • Desogen • Ortho-cept • Othens (slight ↑ VTE rish)

Bleeding day 5–14

Proliferative (follicular) phase

Use OCP containing >20 mcg estrogen or vaginal ring

Age ≤35 years

Initiation and no special concerns

No

Evaluate for endometrial CA: • TVUS Endometrial biopsy

Combined OCP (use pill with ≤35 mcg EE)

Yes • Take OCP same time each day • Rule out STI • Stop smoking

Midcycle

Ovulation

• Severe dysmenorrhea • Leiomyomata • Adenomyosis • Endometriosis • PMD/PMDD • Menstrual migraine

Bleeding day 14–28

Luteal phase defect (progestin insufficiency)

Offer continuous pill formulations • Seasonale • Seasonique

Use OCP with progestin norgestrel or levonorgestrel

Mary Le, MD and Anne Powell, MD Blenning CE, Paladine H. An approach to the postpartum office visit. Am Fam Physician. 2005;72(12):2491–2496.

A-35

DIAGNOSIS AND TREATMENT

P1: OSO/OVY

P1: OSO/OVY

P2: OSO/OVY

LWBK1309-Algo

QC: OSO/OVY

LWBK1211-Domino

T1: OSO

February 7, 2014

23:0

Cough, Chronic COUGH, CHRONIC Common causes: GERD, medications, postviral status, allergic rhinitis, mediastinal mass, TB, sarcoid, anxiety

ACE inhibitor use No

Yes

Dyspnea at rest No

Yes

Weight loss

Trauma

Yes

Mediastinal mass

No

Tuberculosis

GERD

ACE inhibitor– induced chronic cough

Sarcoid

Postviral status

Postnasal drip: Sinusitis, allergic rhinitis

Yes

No

Pneumothorax

History of cardiac disease Yes

Bronchiectasis

CHF

No

History of tobacco abuse

COPD

Robert A. Baldor, MD and Alan M. Ehrlich, MD Pratter MR. Unexplained (idiopathic) cough: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1 Suppl):220S–221S.

A-36

LWBK1309-Algo

P2: OSO/OVY

QC: OSO/OVY

LWBK1211-Domino

T1: OSO

March 5, 2014

11:19

Deep Venous Thrombosis, Diagnosis and Treatment DEEP VENOUS THROMBOSIS, DIAGNOSIS AND TREATMENT Diagnosis Determine Wells Score • Active cancer • Calf swelling >3 cm • Collateral superficial veins • Pitting edema • Previous DVT • Swelling of entire leg • Pain along venous system • Paralysis or recent immobilization (cast) • Recently bedridden or general anesthesia • Alternate diagnosis

+1 +1 +1 +1 +1 +1 +1 +1 +1 –2

Scoring

0–1 = Low probability

>2: Intermediate probability ≥3: High probability

D-Dimer

Negative

Positive

Perform duplex US with compression

Positive

DVT ruled out

DVT confirmed Negative

Check D-dimer

Negative

Positive

DVT unlikely. Reassess in 24–48 hours.

Clinically

Consider repeat US in 5–7 days

– Any respiratory symptoms – Proximal VTE – Candidate for thrombolysis – Active bleeding – Renal failure – History of H.I.T. – Severe cyanosis and edema No

Yes

Consider outpatient management

Admit

Outpatient management

A-37

DIAGNOSIS AND TREATMENT

P1: OSO/OVY

P1: OSO/OVY

P2: OSO/OVY

LWBK1309-Algo

QC: OSO/OVY

LWBK1211-Domino

T1: OSO

February 7, 2014

23:0

Deep Venous Thrombosis, Diagnosis and Treatment DEEP VENOUS THROMBOSIS, DIAGNOSIS AND TREATMENT Treatment

Outpatient management

Low-molecular-weight heparin (LMWH) • Enoxaparin 1 mg/kg SC BID or • Dalteparin 200 units/kg SC daily for patients with cancer

Maintenance Therapy • Treatment with LMWH, UFH, or fondaparinux is recommended for at least 5 days AND until INR 2 for 2 consecutive days. • Hypercoagulation testing before starting warfarin • Start Warfarin on same day as LMWH, UFH, and fondaparinux. • Goal INR 2–3 • Continue for 3–6 months after 1st DVT • LMWH or heparin SC can be continued for patients with allergy to warfarin • Warfarin is contraindicated in pregnancy – Substitute warfarin with heparin SC 15,000 units b.i.d. with target aPTT 1.5–2 control

Inpatient management indications

• Massive DVT • Symptomatic PE • High-risk bleeding with anticoagulation therapy • Comorbid conditions

• IV unfractionated heparin (UFH): 80 units/kg bolus or 5,000 units continuous infusion with initial dose 18 units/kg/hr Titrate to goal PTT 60–85 sec or • UFH 250 units/kg SC b.i.d. or • Enoxaparin 1.5 mg/kg SC daily or • Fondaparinux 5–10 mg SC daily depending on weight • UFH preferred in patients with renal impairment

Bency K. Louidor-Paulynice, MD and Elizabeth A. Erban, MD Wilbur J, Shian B. Diagnosis of deep venous thrombosis and pulmonary embolism. Am Fam Physician. 2012;86:913–919.

A-38

P2: OSO/OVY

LWBK1309-Algo

QC: OSO/OVY

LWBK1211-Domino

T1: OSO

February 7, 2014

23:0

Dehydration, Pediatric DEHYDRATION, PEDIATRIC Determine severity of dehydration 1. Calculate: % Dehydration = Preillness wt (kg) – illness wt (kg)/preillness wt (kg) × 100 OR 2. Use clinical assessment using below physical findings Physical finding

Mild (3–5%)

Moderate (6–9%)

Severe (10%)

Pulse rate

Full, normal

Rapid

Rapid, weak

Buccal mucosa

Slightly dry

Dry

Parched

Eyes

Normal

Sunken

Markedly sunken

Skin turgor

Normal

Reduced

Tenting

Skin

Normal

Cool

Cool, mottled

Systemic signs

Thirst

Irritable

Lethargic

Capillary refill

>1.5–2 sec

2–3 sec

>3 sec

Tears

Present

Decreased

Absent

No

Pt have ongoing losses, intractable vomiting, acute abdomen, severe gastric distention, or >10 mL/hr stool loss ?

Yes

Oral Replacement Solutions (ORS) Pedialyte, Rehydrlalyte, WHO Solution

Parenteral Rehydration Phase I: Emergency bolus 20 mL/kg isotonic fluid (NS or LR) over 5–10 min Repeat up to 60 mL/kg total

Deficit Replacement Mild: 50 mL/kg ORS over 4 hours; in frequent small amounts Moderate: 100 mL/kg ORS over 4 hours; in frequent small amount

Maintenance ORS by age

Responds to fluid bolus and serum Na = 130–150 mEq/L?

Yes

ORS by wt/hr

Infants: 1oz/hr

20 kg: 60 ml + 1 mL/kg (per kg >20)

No Reassess etiology if no improvement. Treat for hypo-or hypernatremia.

Ongoing losses: For every loose stool, give 10 mL/kg ORS. For every emesis episode, give 2 mL/kg ORS.

Continued excessive stool output, persistent vomiting, and/or inadequate rehydration

Phase II: Maintenance 100 mL/kg for first 10 kg, then 50 mL/kg for next 10 kg, then 25 mL/kg for each kg >20 kg Give first half over 8 hours and second half over next 16 hours.

L. Michelle W. Seawright, DO and Nathaniel Stepp, DO Tschudt M, Arcara K. Harriet Lane Handbook, 19 ed. Philadelphia: Elsevier; 2012:271–291.

A-39

DIAGNOSIS AND TREATMENT

P1: OSO/OVY

P1: OSO/OVY

P2: OSO/OVY

LWBK1309-Algo

QC: OSO/OVY

LWBK1211-Domino

T1: OSO

February 7, 2014

23:0

Delayed Puberty DELAYED PUBERTY History/Physical Exam: Growth pattern (stalled vs. delayed), sexual development, nutrition and exercise habits, family history (height and pubertal history), medication, and medical history

Labs: *Basic CBC, ESR, Creatinine, BUN, Liver function enzymes, TSH/FreeT4 *Hormones: FSH, LH, Prolactin, DHEA, Estrodiol (girls), Total Testosterone (boys)

Images: Bone age of left hand and wrist

Primary hypogonadism: Elevated FSH, LH

Decreased estradiol Primary gonadal Failure:

Secondary hypogonadism: Normal or low FSH, LH

Decreased testosterone Primary gonadal Failure:

Elevated prolactin, neurologic symptoms

Functional hypogonadotropic hypogonadism

Elevated TSH, low free T4

Hypogonadism Imaging: CNS Imaging

Constitutional delay of growth and puberty

Elevated ESR, creatinine, BUN, liver function enzymes, abnormal CBC

Chronic disease

Poor nutrition

Permanent hypogonadotropic hypogonadism

Idiopathic hypogonadotropic hypogonadism

Poor/No ability to smell

Malnutrition, anorexia, bulimia, excessive exercise

Kallmann syndrome

Diabetes mellitus, sickle cell anemia, Crohn disease, chronic renal failure, celiac, other chronic disease

Pituitary adenoma, craniopharyngioma

Primary hypogonadism

Decreased estradiol

Autoimmune destruction: Diabetes mellitus or other autoimmune endocrinopathies

Webbed neck, short stature

Labs: Karyotype

45, X or 45, X/46,XX

Idiopathic gondal failure

History of chemotherapy or radiation

Chemo-induced gondal toxicity

Turner syndrome

Decreased testosterone

Long legs, small testes

Absent or diminishing testicular volume

Labs: Karyotype

Anorchism or vanishing testis syndrome

47, XXY or 46, XY/47XXY

Klinfelter syndrome

History: Chemotherapy or radiation, bilateral cryptochidism, teticular torison, mumps orchitis

Chemo-induced gondal toxicity

Vanessa Hand, MD and Frank J. Domino, MD Master-Hunter T, Heiman DL. Amenorrhea: evaluation and treatment. Am Fam Physician. 2006;73(8):1374–1382.

A-40

LWBK1309-Algo

P2: OSO/OVY

QC: OSO/OVY

LWBK1211-Domino

T1: OSO

February 7, 2014

23:0

Delirium DELIRIUM Common causes: Medications, infection, electrolyte abnormality, toxic ingestion, hypoxia, neurologic disorder, psychiatric illness, hepatic encephalopathy, uremia, sundowning

Check all medications Yes

No

No medication used

Benzodiazepines Anticholinergic drugs Narcotics Digoxin Anticonvulsants Diabetes drugs Cimetidine Numerous others

Check: CBC, electrolytes, renal function, urinalysis, TSH, pulse ox, ABG (arterial blood gas), CXR, LFTs, toxic substance screen

Abnormal

Normal

Infection Thyroid dysfunction Hyponatremia Hypernatremia Hypoglycemia Hepatic encephalopathy Hypoxia Uremia Toxic ingestion

Check brain CT or MRI

Normal (consider LP or EEG)

Abnormal

Psychiatric illness Hypertensive Concussion Alcohol withdrawal Seizure disorder Cerebral infection

Subdural hematoma Brain tumor Stroke

Jaclyn EA Legg, DO and Gautam J. Desai, DO, FACOFP Gleason OC. Delirium. Am Fam Physician. 2003;67:1027–1034.

A-41

DIAGNOSIS AND TREATMENT

P1: OSO/OVY

P1: OSO/OVY

P2: OSO/OVY

LWBK1309-Algo

QC: OSO/OVY

LWBK1211-Domino

T1: OSO

February 7, 2014

23:0

Dementia DEMENTIA Common causes: Alzheimer disease, ischemic vascular dementia, Lewy body dementia, frontotemporal dementia, normal pressure hydrocephalus, HIV disease, depression (pseudodementia), medications

Check labs: TSH, RPR, B12, folate, CBC, metabolic profile VDRL or RPR

Abnormal labs

Normal labs

Thyroid disorder Syphilis B12 deficiency Folate deficiency Electrolyte abnormalities Uremia Infectious causes

Brain CT or MRI

Check medications

Abnormal

Normal

Multi-infarct dementia Normal-pressure hydrocephalus Pick disease and other frontotemporal dementia

Alzheimer disease Parkinson disease Lewy body dementia Chronic alcohol use

Robert A. Baldor, MD and Alan M. Ehrlich, MD Knopman DS, DeKosky ST, Cummings JL, et al. Practice parameter: Diagnosis of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001;56(9):1143–1153.

A-42

LWBK1309-Algo

P2: OSO/OVY

QC: OSO/OVY

LWBK1211-Domino

T1: OSO

February 7, 2014

23:0

Depressive Episode, Major DEPRESSIVE EPISODE, MAJOR

Yes

Imminent serious risk of self-harm

Refer for stabilization, emergency mental health evaluation and treatment.

No

Medications comorbid medical conditions, substance abuse contibute to symptoms

Yes

Provide medical treatment (including substance abuse treatment) and follow-up.

No

Yes

Mania, hypomania, or psychosis

Consider referral to mental health specialty care.

No Obtain history, physical, lab tests: Obtain symptom score using PHQ-9 1. Depressed mood* 2. Loss of interests/pleasure* 3. Change in sleep 4. Change in appetite or weight 5. Change in psychomotor activity 6. Loss of energy 7. Trouble concentrating 8. Thoughts of worthlessness or guilt 9. Thoughts about death or suicide

Determine symptom severity and functional impairment Yes

Severity Mild Moderate Severe

PHQ-9 Score 10–14 15–19 >20

Determine and document DSM-V criteria for MDD: *presence of symptoms 1, 2, or both, plus 5 or more symptoms during the same 2-week period

Follow-up in 2–3 weeks: – If Improved and stable (by PHQ score), then every 2–3 months. – If NOT improved, consider referral to psychiatrist and/or change medication dose.

Intiate treatment strategies for MDD: • Mild: Start with monotherapy of either antidepressant or psychotherapy referral • Moderate: A combination of both antidepressant and psychotherapy • Severe: Emphasize combination of both antidepressant and psychotherapy, may consider multiple drug therapy, somatic interventions, or referral to psychiatrist or inpatient stabilization

Wendy K. Marsh, MD, MSc US Department of Verterans Affairs. VA/DoD Clinical Practice Guideline for Management of Major Depressive Disorder. Washington, DC: Department of Veteran Affairs; 2010.

A-43

DIAGNOSIS AND TREATMENT

P1: OSO/OVY

P1: OSO/OVY

P2: OSO/OVY

LWBK1309-Algo

QC: OSO/OVY

LWBK1211-Domino

T1: OSO

February 7, 2014

23:0

Diabetes Mellitus, Type 2 DIABETES MELLITUS, TYPE 2 Obtain urine microalbumin every 12 months Hgb A1C every 6 months Yearly ophthalmologic evaluation

Lifestyle interventions Comprehensive dietary and exercise program for 3 months

Is Hgb A1C ≤ target* No

Yes

Continued close follow-up

Start metformin and titrate to 850 mg b.i.d. for 3 months with continued lifestyle modifications

Obtain urine micro albumin every 12 months Hgb A1C every 6 months Yearly ophthalmologic evaluation

Is Hgb A1C ≤ target*

Yes

Yes

No Add another oral agent (sulfonylurea, others) for 3 months

No

Is Hgb A1C ≤ target*

Consider adding 3rd class of oral agent

A1C ≤ target*

No BMI >30

Consider starting exenatide (Byetta) 5 mcg SC b.i.d. within 1 hour before meals in morning and evening, based on response, may increase to 10 mcg SC b.i.d. after 1 month

Initiate insulin therapy Start bedtime or morning long-acting insulin (10 units or 0.2 U/kg) for 3 months

Check fingerstick glucose daily and increase dose by 2 units every 3 days until fasting levels are within 70–130 mg/dL

*Target uncertain. Newly diagnosed diabetics without major comorbidities, target likely