Generated by All in One SEO v4.9.6.2, this is an llms.txt file, used by LLMs to index the site. # Time of Care Online Medicine Notebook ## Sitemaps - [XML Sitemap](https://www.timeofcare.com/sitemap.xml): Contains all public & indexable URLs for this website. ## Posts - [Blog](https://www.timeofcare.com/blog/) - [Topical antihistamines with mast cell stabilizing activity (dual-activity agents)](https://www.timeofcare.com/topical-antihistamines-with-mast-cell-stabilizing-activity-dual-activity-agents/) - Topical antihistamines with mast cell stabilizing activity (dual-activity agents) for the treatment of allergic conjunctivitis. Alcaftadine 0.25% (Lastacaft), Solution: 1 drop once daily Azelastine 0.05%, Solution: 1 drop twice daily. Bepostatine 1.5% (Bepreve) , Solution: 1 drop twice daily. Epinastine 0.05%, Solution: 1 drop twice daily. Ketotifen 0.025% (Zaditor), Solution: 1 drop twice daily. Olopatadine - [Allergic Conjunctivitis](https://www.timeofcare.com/conjunctivitis-allergic/) - Diagnosis -H&P: Pt endorses itching, tearing, swollen eyelids, redness. Bilaterally. Often associated with allergic rhinitis. -Avoid allergens/precipitants when possible. -Don't wear contact lenses while symptomatic. -Artificial tears PRN. -Topical antihistamines and mast cell stabilizers, alone or in combination are effective. Will Rx Ketotifen ophthalmic (Zatidor) 1 gtt BID until symptoms resolve. Ketotifen is both an - [Musculoskeletal](https://www.timeofcare.com/musculoskeletal/) - Musculoskeletal Pearls Intra-articular fractures with 25% or greater involvement of the joint surface should be referred to orthopedics for surgical treatment. Musculoskeletal Red Flags. Features SCFE (Slipped Capital Femoral Epiphysis) Excellent SCFE video -Occurs more commonly during the adolescent growth spurt (11-13 years of age for girls, 13-15 years for boys) when the femoral head - [Obesity](https://www.timeofcare.com/obesity/) - -BMI reviewed. -Comprehensive high-intensity (12 to 26 sessions/year) lifestyle interventions, including a combination of diet (food choices & reduced caloric intake), exercise, and behavioral modification discussed with the patient. -Nutritionist/dietician referral for help with food choice, meal planning, etc. -Behavioral counseling/motivational interviewing. -SMART weight loss goal: 1lb per week. -Exercise Counseling. -Indications for pharmacologic therapy - [Diagnostic Criteria for Parkinson Disease](https://www.timeofcare.com/diagnostic-criteria-for-parkinson-disease/) - MDS Clinical Diagnostic Criteria for PD—Executive Summary/Completion Form The first essential criterion is parkinsonism, which is defined as bradykinesia, in combination with at least 1 of rest tremor or rigidity. Examination of all cardinal manifestations should be carried out as described in the MDS–Unified Parkinson Disease Rating Scale. Once parkinsonism has been diagnosed: Diagnosis of - [Hypercalcemia](https://www.timeofcare.com/hypercalcemia/) - Diagnosis Hypercalcemia algorithm reviewed (AAFP). H&P Causes of hypercalcemia. Common presentation. Diagnostic studies *An isolated elevated calcium level should be repeated before further workup is indicated. Order CMP with ionized calcium. Treatment 1st-line -Hydration with Normal Saline IV is the initial treatment of choice. This helps to correct the volume depletion that is invariably present - [Hemorrhoids](https://www.timeofcare.com/hemorrhoids/) - -Definition: Hemorrhoids are engorged fibrovascular cushions lining the anal canal. -DDx: Anal canal cancer; Colorectal Cancer; Anal fissure; IBD; Condyloma; Perianal Abscess; Rectal polyp; Cirrhosis/portal hypertension -Predisposing factors: "Older age, constipation, straining (including exercise), gravity, lack of dietary fiber, increased intra-abdominal pressure (due to pregnancy, obesity, or ascites), multiple vaginal deliveries, irregular bowel habits (constipation/diarrhea), - [PCI Versus Medical Therapy](https://www.timeofcare.com/pci-versus-medical-therapy/) - “No study to date has demonstrated that PCI in patients with SIHD improves survival rates… Evaluation of 61 trials of PCI conducted over several decades shows that despite improvements in PCI technology and pharmacotherapy, PCI has not been demonstrated to reduce the risk of death or MI in patients without recent ACS” Circulation 2012. SIDH - [Urinary Casts and Crystals](https://www.timeofcare.com/urinary-casts-and-crystals/) - Urinalysis with microscopy -Hyaline and fine granular casts often seen in pre-renal failure -Tubular epithelial cells or casts: ATN, ( AIN) -WBC CASTS, Urine eosinophils: AIN (Hansel’s stain) -RBC, RBC CASTS: suggests Glomerulonephritis + blood on Dipstick but no RBCs on microscopic: consider Rhabdomyolysis, check serum CK level Urinary Casts and Associated Pathologic Conditions, Table - [Interpreting a Urinalysis](https://www.timeofcare.com/interpreting-a-urinalysis/) - This page discusses how to interprete a urinalysis. - [Contrast-induced nephropathy (CIN)](https://www.timeofcare.com/contrast-induced-nephropathy-cin/) - "Contrast-induced nephropathy (CIN) is associated with a rapid and often irreversible decline in kidney function following the administration of iodinated contrast agents. CIN is the third leading cause of acute kidney injury (acute renal failure) in hospitalized patients, and substantially increases mortality, morbidity, and length of hospitalization. It follows a predictable time of onset and - [Hypercoagulable States Workup](https://www.timeofcare.com/hypercoagulable-states-workup/) - ***Proteins C, S and ATIII levels are affected by acute thrombosis and anticoagulation. Therefore, it's best to check levels at least two weeks after completing the anticoagulation course. Hereditary Factors Hypercoagulable State Initial Workup Test Confirmation / Comments Factor V Leiden Activated Protein C Resistance Assay Factor V Leiden SNP analysis (also called Factor 5 - [Amenorrhea, Primary](https://www.timeofcare.com/amenorrhea-primary/) - Diagnosis Definition of primary amenorrhea. Diagnosis is clinical when the patient meets the definition of primary amenorrhea. -H&P. -Common presentation: -Ddx and Causes: -Algorithm for secondary amenorrhea reviewed (from the AAFP) Diagnostic tests -Pregnancy test (Beta-hCG in urine or serum). Serum LH, FSH, TSH, Prolactin, and Estradiol. -CBC, CMP, and urinalysis to help r/o systemic - [Amenorrhea, Secondary](https://www.timeofcare.com/amenorrhea-secondary/) - Assessment and Plan for Secondary Amenorrhea -Algorithm for secondary amenorrhea reviewed (from AAFP). -History & Physical performed. -Reviewed all medications, including contraceptives and illicit drugs. -Definition: The cessation of previously regular menses for 3 months or the cessation of previously irregular menses for six months. -Pregnancy test (Beta-hCG in urine or serum). Serum LH, FSH, - [Indications Implantable Cardiac Defibrillator (ICD)](https://www.timeofcare.com/indications-implantable-cardiac-defibrillator-icd/) - See this ACC link: http://circ.ahajournals.org/content/117/21/2820 "Class I ICD therapy is indicated in patients who are survivors of cardiac arrest due to ventricular fibrillation or hemodynamically unstable sustained VT after evaluation to define the cause of the event and to exclude any completely reversible causes. (Level of Evidence: A) ICD therapy is indicated in patients with structural heart - [Risk Factors For Cervical Cancer](https://www.timeofcare.com/cervical-cancer/) - Risk Factors For Cervical Cancer Smoking Cigarettes Early onset of sexual activity Having multiple sexual partners HPV infection HIV infection "Cervical cancer screening strategies differ based on risk. Cigarette smoking independently increases the risk of cervical cancer 2–4 times (SOR B). It is the only nonsexual behavior associated with cervical dysplasia and cancer. There is - [Spontaneous Bacterial Peritonitis (SBP)](https://www.timeofcare.com/spontaneous-bacterial-peritonitis-sbp/) - SBP = an ascitic fluid infection without an evident intra-abdominal surgically treatable source. SBP usually occurs in patients with cirrhosis and ascites Dx is made with a positive ascitic fluid bacterial culture and an ascitic fluid absolute polymorphonuclear leukocyte count ≥250 cells/mm3. -Perform abd paracentesis and obtain ascitic fluid (AF) -Order AF cell count and - [Vitamin D Supplementation for Infants](https://www.timeofcare.com/vitamin-d-supplementation-for-infants/) - PDF version of Vitamin D Supplementation in Infants The American Academy of Pediatrics (AAP) recommends that all babies, whether breastfed or bottle-fed, should be supplemented with Vitamin D. Vitamin D is important for forming strong bones and for preventing rickets. The current recommendation is to give your baby 400 IU of Vitamin D per day. Research - [Vitamin D Deficiency / Disorder](https://www.timeofcare.com/vitamin-d/) - Background Pathogenesis: The function of the Parathyroid Hormone. 2) Vitamin D Action. -What is Vitamin D? -How is vitamin D made? -Undiagnosed vitamin D deficiency is common. -Test: 25-hydroxyvitamin D is the barometer for vitamin D status. Most experts define vitamin D deficiency as a 25-hydroxyvitamin D level - [STOP-Bang questionnaire for Obstructive Sleep Apnea](https://www.timeofcare.com/stop-bang-questionnaire-for-obstructive-sleep-apnea/) - STOP-Bang Questionnaire for Obstructive Sleep Apnea. Please answer the following questions by circling "yes" or "no" for each one. Snoring (Do you snore loudly (Loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night?) Yes No Tiredness (Do you often feel tired, fatigued, or sleepy during the daytime - [Hyperlipidemia (HLD) or Dyslipidemia: Screening, Treatment, and Prevention](https://www.timeofcare.com/hyperlipidemia/) - H&P + Dx Exercise? Diet? FHx of premature CAD? Risk factors for ASCVD? Known ASCVD in pt? BMI? xanthoma? xanthelasma? Carotid bruits? Screening recs. Labs: Lipid panel (non-fasting). Baseline LFTs (CMP) and CK. Repeat the lipid panel to confirm HLD. TSH, A1C, CMP, U/A to r/o secondary causes of hyperlipidemia, as needed. Consider labs to - [Vitamin E](https://www.timeofcare.com/vitamin-e/) - Vitamin E has been shown to be good for Alzheimer disease. However, the following study showed that it increased all-cause mortality. "A meta-analysis has found an increase in all-cause mortality associated with the use of vitamin E at a dosage of >400 mg/day. In addition, β-Carotene has been found in clinical trials with smokers to - [Shingles Vaccine](https://www.timeofcare.com/shingles-vaccine/) - Shingrix "Routine Vaccination of People 50 Years Old and Older CDC recommends Shingrix (recombinant zoster vaccine, or RZV) for the prevention of herpes zoster (shingles) and related complications. CDC recommends two doses of Shingrix separated by 2 to 6 months for immunocompetent adults aged 50 years and older: Whether or not they report a prior - [Contraception, Birth Control, Family Planning](https://www.timeofcare.com/contraception-birth-control/) - -See HPI. -LMP: ___ -Cycle day#:____ of a 28-day cycle. -Pregnancy test today: Negative. -Different methods of contraception discussed with her including benefits, risks, and side effects. -Counseling: No contraceptive method is perfect. Patient understands that the right method of contraception is the one that meets her unique needs and which she can consistently. and - [Physician Orders - Medications](https://www.timeofcare.com/physician-orders-medications/) - Med - Route - Dose - Time - Site - initials Aspirin 325mg PO Benadryl (Diphenhydramine) 12.5mg or 25mg or 50mg IM / IV Bicillin LA 6 million / 1ml. Give: 3million units (i.e. 1/2ml) or 6million units (i.e. 1ml) or 9million units (1.5ml) IM Bicillin LA 1.2 million units / 2ml. Give: 600,000 units - [Hypothyroidism](https://www.timeofcare.com/hypothyroidism/) - Diagnosis and treatment of Hypothyroidism - [Benign paroxysmal positional vertigo( BPPV)](https://www.timeofcare.com/benign-paroxysmal-positional-vertigo-bppv/) - Am Fam Physician. 2017;95(3):154-162. https://www.aafp.org/pubs/afp/issues/2017/0201/p154.html Diagnosis with Dix-Hallpike Maneuver Treatment with Epley Maneuver - [Smoking Cessation: Pharmacotherapy](https://www.timeofcare.com/smoking-cessation-pharmacotherapy/) - First line agents Nicotine replacement therapy (NRT): Nicotine gum, transdermal patch, lozenges, nasal spray, inhaler. Varenicline (Chantix) Bupropion Second line agents For people who can't use a first-line agent or need an adjunct with it. Nortriptyline Cytisine (not available in the U.S.) - is a partial agonist at the alpha-4 beta-2 nicotinic acetylcholine receptor (like varenicline) - [Active Cardiac Conditions that are a contraindication to Elective Surgery](https://www.timeofcare.com/active-cardiac-conditions-that-are-a-contraindication-to-elective-surgery/) - Patients with any of the following are at very high risk for perioperative MACE (MI, heart failure, ventricular fibrillation or primary cardiac arrest, complete heart block, and cardiac death.) MI within the last 60 days Unstable angina or ACS Decompensated heart failure, NYHA class IV CHF, worsening or new-onset CHF. Significant Arrhythmias e.g. Mobitz II, high-grade - [Pre-Operative Risk Assessment / Pre-Surgery Evaluation/ Preoperative Evaluation](https://www.timeofcare.com/preoperative-evaluation/) - The preoperative history and physical exam have been performed (above) and the risk of major adverse cardiac events (MACE) is estimated below. That risk depends on 1) the risk of the proposed surgery and 2) the patient's risk and functional capacity. Risk Assessment: 1) Patient doesn't have contraindications to elective surgery (that makes them a very high - [Drug Eluting Stents and Bare Metal Stents](https://www.timeofcare.com/drug-eluting-stents-and-bare-metal-stents/) - Why do patients with Drug-Eluting Stents (DES) have to continue dual antiplatelet therapy for longer than those with Bare Metal Stents (BMS)? The simple answer is that even though DES do a better job at preventing restenosis, it increased the risk of thrombosis (especially after the DAPT was stopped). As such, when patients are on - [Revised Cardiac Risk Index (RCRI)](https://www.timeofcare.com/revised-cardiac-risk-index-rcri/) - Revised Cardiac Risk Index (RCRI) The RCRI covers the Brain, Heart, Kidneys, DM on insulin, and the type of surgery can be calculated using the table below. RISK FACTOR POINTS History of cerebrovascular disease (Prior TIA or stroke) 1 History of ischemic heart disease History of MI; a history of positive exercise test; current chest pain - [Cardiac Risk by Type of Surgery](https://www.timeofcare.com/cardiac-risk-by-type-of-surgery/) - AKA: Surgery-specific cardiac Risk, Risk of Cardiac Death and Nonfatal MI for Noncardiac Surgical Procedures Cardiac Risk by Type of Surgery (% cardiac Death / nonfatal MI) "The degree of surgical risk contributes to a patient's risk for cardiac complications. In general, procedures that are longer and have greater potential for blood loss, hemodynamic instability, - [Labs, Imaging, and Studies During Preoperative Risk Assessment](https://www.timeofcare.com/labs-imaging-and-studies-during-preoperative-risk-assessment/) - Get a pregnancy test for every woman who can be pregnant. Use the estimated risk of a major adverse cardiac event (from RCRI, ACS-SRC, or another calculator) to categorize patients into low-risk or higher-risk. Further work-up is determined by the patient's risk (which is calculated based on information from the patient's history and physical exam). - [Determine Patient-Specific Risk](https://www.timeofcare.com/determine-patient-specific-risk/) - Determine the patient-specific cardiac risk using either the Revised Cardiac Risk Index (RCRI) or the American College of Surgeons Surgical Risk Calculator (ACS-SRC). Revised Cardiac Risk Index (RCRI) on this site. Revised Cardiac Risk Index (RCRI) on QXMD.com The American College of Surgeons Surgical Risk Calculator (ACS-SRC). ACS-SRC direct link. *Pre-existing medical problems confer risk - [Preoperative Physical Exam](https://www.timeofcare.com/preoperative-physical-exam/) - -Vital signs: No HTN. Normal pulse. -HEENT: Normal. Mallampati score: ___. No retrognathia. -Neck: Normal ROM. -CV: Normal CV exam: No murmurs, no carotid bruits, JVP, pedal edema. -Heart: RRR, no m/r/g. -Lungs: Normal exam. CTAB. No wheezes. -Abdomen: Normal. No surgical scars, no palpable masses, no bruits. //End// **The focus of the physical exam - [Preoperative Evaluation: History](https://www.timeofcare.com/preoperative-evaluation-history/) - --- year-old --- with a PMH of --- comes in for preoperative risk assessment. Surgery type: Date: Social support they will need to recover:___ Negative history of diseases of the heart, lungs, kidneys, or any bleeding diathesis. Specifically, -No angina (chest pain), dyspnea, palpitations, syncope, presyncope, or claudication. -No hx of heart disease--no prior MI, - [Functional Capacity](https://www.timeofcare.com/functional-capacity/) - The patient's functional capacity has been shown to correlate well with maximal oxygen uptake on treadmill testing. Functional status or capacity is important to know because exercise capacity is a reliable predictor of future cardiac events. Functional capacity is usually expressed in metabolic equivalents (METs). Greater than 7 METs of activity tolerance is considered excellent, - [Obstructive Sleep Apnea (OSA), Adults](https://www.timeofcare.com/obstructive-sleep-apnea/) - H&P + Diagnosis Pt assessed for risk factors and associated conditions. BMI = __; Neck circumference = ____; Posterior chin position (retrognathia) is ______ present/absent. Morning headaches __ present/absent. STOP-Bang questionnaire score: Mallampati score: Epworth Sleepiness scale: Labs: Treatment Polysomnography: Will refer to sleep medicine for a nocturnal PSG in a sleep lab. Home OSA tests - [Mallampati Score](https://www.timeofcare.com/mallampati-score/) - Image Source: https://www.clinicaladvisor.com/home/the-waiting-room/understanding-the-mallampati-score/ - [Metabolic Equivalent Task (MET)](https://www.timeofcare.com/metabolic-equivalent-task-met/) - Measuring Physical Activity Using METs Physical activity is measured in metabolic equivalents task units (METs). One MET is defined as the energy it takes a 70 kg man to sit quietly. In other words, one MET is defined as the oxygen consumption of a 70-kg man at rest. Another rendition of this definition is, "A MET - [CHRIST: Mnemonic for Generalized Anxiety Disorder](https://www.timeofcare.com/christ-mnemonic-for-generalized-anxiety-disorder/) - If you are a Christian or know something about Christian theology, you'll like this mnemonic (CHRIST). In GAD, the anxiety and worry cause significant distress or impairment and is associated with three or more of the following six symptoms: Concentration problems Headaches and muscle tension Restlessness or being on the edge Irritability Sleep disturbances - [Sleep Hygiene and Stimulus Control Counseling](https://www.timeofcare.com/sleep-hygiene-and-stimulus-control-counseling/) - Sleep hygiene and stimulus control counseling are a vital part of the treatment of insomnia. Sleep Hygiene Counseling Sleep hygiene refers to actions you can take that will tend to improve and maintain good sleep. Keep a regular sleep schedule. A time for bed and a time to wake up. A regular wake-up time in - [Hypertension in a Cocaine Intoxicated Patient](https://www.timeofcare.com/hypertension-in-a-cocaine-intoxicated-patient/) - "In patients with cocaine-induced chest pain and hypertension, initial management with an intravenous benzodiazepine can relieve chest pain and produce beneficial cardiac hemodynamic effects. In addition, by reducing the central stimulatory effects of cocaine, benzodiazepines also reduce anxiety, which often leads to resolution of the hypertension and tachycardia. Administration of sublingual or intravenous nitroglycerin and - [Severe Symptomatic Hypertension (Hypertensive Crisis)](https://www.timeofcare.com/severe-symptomatic-hypertension-hypertensive-crisis/) - Severe Symptomatic Hypertension (Hypertensive Crisis) IV Drugs Oral Medications Clonidine 0.1-0.2 mg Labetalol 200-400mg BID. Start: 100mg po BID, may increase by 200 mg / dayq2-3 days. Max 2400 mg/day. May divide dose TID. Taper dose over 1-2 wks to D/C. Hydralazine 10-50 mg PO qid. Start: 10 mg po qid x 2-4 days, then - [Rebound hypertension](https://www.timeofcare.com/rebound-hypertension/) - Rebound hypertension occurs when blood pressure rises after you stop taking or lower the dose of a drug (typically a medicine to lower high blood pressure). This is common for medicines that block the sympathetic nervous system like beta-blockers and clonidine. https://medlineplus.gov/ency/article/000155.htm - [Hypertension Medications in Gout](https://www.timeofcare.com/hypertension-medications-in-gout/) - "Compatible with their urate lowering properties, calcium channel blockers and losartan are associated with a lower risk of incident gout among people with hypertension. By contrast, diuretics, β blockers, angiotensin converting enzyme inhibitors, and non-losartan angiotensin II receptor blockers are associated with an increased risk of gout." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3257215/ - [Hypertension](https://www.timeofcare.com/hypertension/) - Essential Hypertension (New Diagnosis). Secondary Hypertension. Resistant Hypertension. Severe Asymptomatic Hypertension (Hypertensive Urgency). Severe Symptomatic Hypertension (Hypertensive Crisis) Hypertension in elderly patients. Gestational Hypertension. Hypertension in dialysis patients. Important Links Definition of Hypertension in Adults. Evaluation of a patient newly diagnosed with Hypertension. The New ACC/AHA High Blood Pressure Guidelines (2017). JNC 8 Hypertension - [The American Diabetes Association (ADA) Blood Pressure Recommendations](https://www.timeofcare.com/the-american-diabetes-association-ada-blood-pressure-recommendations/) - "The American Diabetes Association (ADA) defines hypertension as SBP ≥140 mmHg and DBP ≥90 mmHg that is confirmed during separate clinic visits (7). Current ADA guidelines recommend a treatment goal of SBP - [ACE inhibitors](https://www.timeofcare.com/ace-inhibitors/) - Increase in creatinine upon initiating ACE inhibitors You start a lisinopril in a patient and it worked well for the patient and brings her BP to your goal. However, her creatinine rises from 1.25 to 1.5. What should you do? Continue the current medication. "ACE inhibitors such as lisinopril do not need to be discontinued unless - [Acne Vulgaris](https://www.timeofcare.com/acne-vulgaris/) - Diagnosis H&P consistent with acne vulgaris. Acne severity: ______ DDx of Acne:_____ Inflammatory lesions vs. noninflammatory lesions. Treatment -Treatment per acne severity based on acne algorithm from the Global Alliance to Improve Acne. -Pharmacologic and nonpharmacologic treatment modalities discussed. -Will start patient on:_________________ -Patient education provided as well as alternative treatment options, risks, and benefits. - [Acne Management - One Dermatologist's approach](https://www.timeofcare.com/acne-management-one-dermatologists-approach/) - Wash face with mild soap or salicylic acid cleanser OTC morning and night with their hands. Use a towel separate from the one used on the rest of the body for patting the face dry. Clindamycin topical lotion, solution or gel twice daily after washing morning and night. 5% hydrocortisone lotion after clindamycin in the - [Penile Adhesions](https://www.timeofcare.com/penile-adhesions/) - N47.5 Adhesions of prepuce and glans penis Treatment: Betamethasone dipropionate 0.05% external cream. - [M-CHAT Scoring Template](https://www.timeofcare.com/m-chat-scoring-template/) - Items 2, 5, and 12 are NO. All other items are YES. If a response agrees with the above, assign a score of 0. If response does not agree with the above, assign a score of 1. Score is 0-2: LOW RISK: No further action; re-screen if < 24 month old Score is 3-7: MEDIUM - [Vitamin D Supplementation in Infants, Children, and Adolescents](https://www.timeofcare.com/vitamin-d-supplementation-in-infants-children-and-adolescents/) - 400 IU vitamin D supplementation for ALL infants (both breast and formula fed) and children beginning in the first few days of life. Note that 400 IU of Vitamin = 10 mcg of Vitamin D Supplementation can be stopped if: -taking >1000ML formula daily ->1 year and taking Vit-D fortified milk at >32 oz/day Vitamin - [Converting Vitamin D doses from mcg to IU and vice versa](https://www.timeofcare.com/converting-vitamin-d-doses-from-mcg-to-iu-and-vice-versa/) - To convert Vitamin D: From IU to mcg: IU/40 = mcg For example: 400 IU/40 = 10 mcg From mcg to IU: mcg * 40 =IU i.e. 400 IU of Vitamin = 10 mcg of Vitamin D Source: https://dietarysupplementdatabase.usda.nih.gov/ingredient_calculator/help.php - [Seeing Friends and Family](https://www.timeofcare.com/seeing-friends-and-family/) - Seeing Friends and Family as a physician. Fam Pract Manag. 2017 Jul-Aug;24(4):44. https://www.aafp.org/fpm/2017/0700/p44.html https://www.aafp.org/journals/fpm/blogs/inpractice/entry/friends_and_family.html - [Oral Contraceptives - COPs & POP](https://www.timeofcare.com/oral-contraceptives/) - CHC=combined hormonal contraception (pill, patch, and, ring); COC=combined oral contraceptive; POP=progestin-only pill; EE=Ethinyl Estradiol Monophasic COCs 21/7 Regimen (21 days of combined progestin and estrogen + 7 days of placebo) -Microgestin 1/20 (ie. Norethindrone /EE) -Junel 1/20 is another brand name for the same med as Migrogestin. -MonoNessa 0.25mg / 35mcg (i.e. Norgestimate / EE) - [Ingrown Toenail Removal Equipment](https://www.timeofcare.com/ingrown-toenail-removal-equipment/) - Non-sterile Tray for the Procedure Nail Splitter (Nail Nipper) Two straight hemostats (straight forceps) Nail elevator (toenail spatula) -Probe with Eye Iris scissors Alcohol Swabs. Syringe: A 5-10-mL syringe filled with 1% lidocaine without epinephrine and a 27 or 30-gauge needle Povidone-iodine sticks or 4 × 4-inch gauzes soaked with a povidone-iodine solution Nonsterile gloves 4 - [Writing prescription for Insulin, needles, lancets, monitors(Glucometer), etc.](https://www.timeofcare.com/writing-prescription-for-insulin-needles-lancets-monitors-etc/) - Insulin Concentration and Vial Size Insulin Concentration: Long-acting, regular, and rapid insulin comes in a concentration of 100 units/ml. Some may come in 200 units/ml or 500 units/ml which would be reserved for people taking HUGE amounts of insulin per day. Vial Size: A good average vial size is 10 ml. That means if the - [Immunizations](https://www.timeofcare.com/immunizations/) - Influenza Vaccine The live attenuated intranasal influenza vaccine is more effective in children age 2-6 years than the inactivated vaccine. The live attenuated intranasal influenza vaccine is recommended for healthy non-pregnant persons 2-9 years of age. It is more effective than the inactivated vaccine in children 2-6 years; for patients who are 6-49 years of age, - [Office Management](https://www.timeofcare.com/office-management/) - 1) Agenda Setting Form. Have patients fill out an Agenda form. 2) Have an MA announce next appointment I recently worked with a physician who was my preceptor and his office is set up in a way that a medical assistant knocks and announces that the next patient is ready or it's time for his - [Evidence-Based Medicine (EBM)](https://www.timeofcare.com/evidence-based-medicine/) - "Positive predictive value refers to the percentage of patients with a positive test for a disease who actually have the disease. The negative predictive value of a test is the proportion of patients with negative test results who do not have the disorder. The percentage of patients with a disorder who have a positive test - [Well Adult Exam](https://www.timeofcare.com/well-adult-exam/) - Screening Recommendations. Labs and Vendors. Quality Metrics for Primary Care. Preventive Health Template. Physical Exam Template. Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2018 Medicare Annual Wellness Visit. Pneumococcal Vaccine Timing for Adults. - [Quality Metrics in Primary Care](https://www.timeofcare.com/quality-metrics-in-primary-care/) - Quality Metrics are currently being tracked nationally for all providers and it follows the provider for the rest of their lives. Tenet gets Quality Metrics from a company called Tableau for their providers. Link to quality measures on cms.gov (the centers for Medicare and Medicaid Services): https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Core-Measures.html Scroll to the bottom to see the primary - [Pre Operative Patient Education Video - Spanish](https://www.timeofcare.com/pre-operative-patient-education-video-spanish/) - [Opioid Addiction: Perinatal Patient Education](https://www.timeofcare.com/opioid-addiction-perinatal-patient-education/) - [Medication Refills / Recargas de Medicamentos](https://www.timeofcare.com/medication-refills-recargas-de-medicamentos/) - The most popular way to say medication refill that I've found used is to use the word recargar and noun recarga. An alternative way uses rellenar and rellenos (n) . Con el portal de pacientes de MyHealth usted puede: “Solicitar recargas de recetas” -- Borrego health flyer. “Surta su receta y haga su recarga a - [Fruits and Vegetables in Spanish](https://www.timeofcare.com/vegetables-in-spanish/) - Las mejores verduras bajas en carbohidratos la espinaca (spinach) la lechuga (lettuce) el / la coliflor, (cauliflower) la col (f) / el repollo (m) = cabbage el aguacate (avocado) las aceitunas (olives) / la aceituna (olive) el espárrago (asparagus) el pepino (cucumber) el tomate (tomato) el calabacín (zucchini) la berenjena (eggplant) el brócoli = broccoli - [Los Recursos (FDA, Medlineplus, etc)](https://www.timeofcare.com/los-recursos/) - FDA in Spanish: MedlinePlus in Spanish. Pruebas de laboratorio. (https://medlineplus.gov/spanish/pruebas-de-laboratorio/) FDA en Español. Mayo Clinic in Spanish. Low carb high fat. Alimentos bajos en carbohidratos: Qué comer.(https://www.dietdoctor.com/es/low-carb/alimentos-bajos-en-carbohidratos) Grasas y salsas bajas en carbos: las mejores y las peores. (https://www.dietdoctor.com/es/keto/grasas-y-salsas) - [Well Child Check](https://www.timeofcare.com/well-child-check/) - Group 1 Well Child Checks: What MA's Should Do at each visit. M-CHAT Scoring Template. AAP Periodicity Schedule (Prevention Schedule). Link to AAP site | On TimeofCare.com. Childhood Immunization Schedule. Well Child Check Notes. Teen Defies Mother's Anti-Vaccination Ideas. Group 2 NUTRITION AND GROWTH (My Handout for new Mothers). Vaccine Trade Names in my clinic. - [Teen Defies Mother's Anti-Vaccination Ideas](https://www.timeofcare.com/teen-defies-mothers-anti-vaccination-ideas/) - [Well Child Checks - What MAs should do](https://www.timeofcare.com/well-child-checks-what-mas-should-do/) - VITALS: All ages: Height, weight, Temp, Resp, Pulse, Head circumference ( < 2- 3 years) 3 years and up: Blood pressure. 12 years and up: Depression screening (Every 3 months) 13 years and up: Teen PMH (once a year) Asthma visit: Peak flow (per provider preference) {Print PMF and any record pertaining to visit} Well - [Los antónimos / Los Opuestos en Español](https://www.timeofcare.com/los-antonimos-los-opuestos-en-espanol/) - see more lists of antonymns here. detrás, atrás, tras - delante, enfrente abrir – cerrar to open – to close aburrido – divertido boring – fun aceptar – rechazar /rehusar to accept – to reject acertado – equivocado accurate – wrong acertar – fallar to get right – to fail activo – - [Developmental Questions](https://www.timeofcare.com/developmental-questions/) - Medical Spanish: motor, language, social development; developmental questions 1. ¿Sonríe mucho al interactuar con Usted? (Does he/she smile a lot interacting with you?) 2. ¿El bebé puede darse la vuelta? (Can the baby roll over?) 3. ¿Le parece que el bebé puede ver y oír bien? (Does it seems to you that the baby can - [Review of Systems](https://www.timeofcare.com/review-of-systems/) - 1. ¿Ha tenido problemas con la vista? (Have you had vision problems?) Note: Keep in mind that the translation, "you," can be replaced here with "he" or "she." This also holds for the rest of the following review of systems questions below, unless it is gender-specific content. 2. ¿Se ha sentido mareado? (Have you felt - [Labs and Lab Vendors](https://www.timeofcare.com/labs-and-lab-vendors/) - Lab Corp Quest IEHP EMPG (Empire Physicians) UNITED HEALTH CARE LaSalle Health Net Mercy Insurance LEGION Desert Oasis Design Benefits Administration Administrative Concepts Inc Vantage Tricare West Alpha Care Humana SFS (Sliding Fee Scale) CARE 1st CIGNA BLUE CROSS / BLUE SHIELD MISP MEDICAL FAM PACT NORIDIAN (MEDI CARE PART B) MEDITAIN HEALTH (Employee) AETNA - [Preventative Health Template](https://www.timeofcare.com/preventative-health/) - Significant Past Medical History: Screening Dates Last Physical: Women's health -Pap Smear (≥ 21 yrs): -Mammogram (≥ 40 yrs): -DEXA Scan (≥ 65 yrs): Men's Health -Abdominal U/S (AAA Screen - 65-75 yr who have ever smoked): -PSA: Colon cancer screening -Colonoscopy (≥ 50 yrs): -Stool Guaiac (≥ 50 ): Diabetes patients -Ophthalmology Evaluation: -Monofilament: - [Patient Information](https://www.timeofcare.com/patient-information/) - Name and Address ¿Cuál es su _____? What is your _____? el nombre first name el apellido last name el nombre de soltera maiden name el nombre completo complete name el número de teléfono telephone number el número de teléfono celular cell phone number el número de seguro social social security number la dirección address - [Specialists / especialistas](https://www.timeofcare.com/specialists-especialistas/) - el especialista (m), la especialista (f) el alergista, la alergista (alt. el alergólogo, la alergóloga) = allergist el anestesista, la anestesista = anesthetist el bacteriólogo, la bacterióloga = bacteriologist el cardiólogo, la cardióloga = cardiologist el quiropráctico, la quiropráctica chiropractor el dentista, la dentista = dentist el dermatólogo, la dermatóloga = dermatolotist el dietista, la dietista = - [Los antónimos #2](https://www.timeofcare.com/los-antonimos/) - Antonyms in Spanish Antonyms in English abajo arriba below above abrir cerrar open close abstracto concreto abstract specific aburrido emociante boring exciting acortar prolongar cut short prolong alegria tristeza pleasure grief allí aquí there here altruista egoista altruistic selfish amanecer anochecer get light get dark amargo dulce bitter sweet angel diablo angel devil antiguo moderno - [The Perfect Tense (in English and Spanish)](https://www.timeofcare.com/the-perfect-tense/) - The Perfect Tenses in English "The three perfect tenses in English are the three verb tenses which show action already completed. (The word perfect literally means "made complete" or "completely done.") They are formed by the appropriate tense of the verb to have plus the past participle of the verb. Present Perfect: I have seen it. (Present tense of to have plus participle. Action is - [Screening Recommendations (18 years and older)](https://www.timeofcare.com/screening-recommendations/) - ≥ 40 Year Old Cervical cancer: women 21 to 64 years. Pap smear Q3yr for 21-29. After that q3rs or q5 w/ HPV co-testing Breast cancer: women ≥ 40 years. Mammogram q1yr to 2yr. Osteoporosis: All women ≥ 65 years or postmenopausal women < 65 years who are at increased risk of osteoporosis. DEXA scan. - [What Medical Assistants Do](https://www.timeofcare.com/what-medical-assistants-do/) - Ask preventive medical history questions and put them in the EHR e.g. an MA in my clinic (A-Rod) does for his provider (Dr. R) for preventive/establish care visits. Enter meds into the EHR. When patient is getting checked in, ask what meds they are taking and add them into the chart. Discontinue meds that the - [Sexually Transmitted Infections (STIs, STDs)](https://www.timeofcare.com/sexually-transmitted-infections-stis-stds/) - Diagnosis STI Screening Recommendations. Treatment Screening and treating STIs or STDs. Important Links Reporting Infectious Diseases to state agencies. - [Reporting Infectious Diseases (STI, STDs, etc)](https://www.timeofcare.com/reporting-infectious-diseases/) - Most states require reporting certain infectious diseases. For the county of Riverside in CA, the following forms and links are helpful. https://www.rivcoph.org/ContactUs.aspx (this site gives you the number of the Riverside Public Health Department. Call them if you have questions. PDF form to fill and submit to Riverside county Infection Control Department PDF Form for - [Las Partes Del Cuerpo](https://www.timeofcare.com/las-partes-del-cuerpo/) - Head & Neck la cabeza (f) -- head la frente -- forehead el cabello / el pelo (m) --hair el ojo / los ojos -- eye/eyes la oreja / las orejas -- the ear/ears (la oreja es la parte externa) el oído / los oidos ---the ear/ears (el oído es la parte interna) la boca - [Global Health Resources](https://www.timeofcare.com/global-health-resources/) - Global Health Data Sources: Global Health Observatory of WHO (https://www.who.int/gho/en/) The World Bank (data.worldbank.org) UNICEF Childmortality.org Global Burden of Disease at the Institute of Health Metrics and Evaluation at the University of Washington, USA Gapminder.org Gapminder.org/world https://www.gapminder.org/answers/ National and Sub-national Data Sources: Bangladesh Bureau of Statistics Health and Household Surveys: Multiple Indicator Cluster Survey (MICS) USAID - [The Reversible Causes of Cardiac Arrest (The H and Ts)](https://www.timeofcare.com/the-reversible-causes-of-cardiac-arrest-the-h-and-ts/) - The 5 H's and 5 T's that may cause cardiac arrest 5 H's 5 T's Hypovolemia Tension Pneumothorax Hypoxia Tamponade (Cardiac) Hydrogen ion (acidosis) Toxins Hypothermia Thrombosis, pulmonary (PE) Hypo- / Hyperkalemia Thrombosis, coronary (MI) Also, treat: Hypoglycemia Anemia - [The AV blocks Clearly Explained](https://www.timeofcare.com/the-av-blocks/) - AV blocks are also called junctional blocks, nodal blocks, or heart blocks. AV blocks happen when the electrical current that is being transmitted from the atrium to the ventricles is held in the AV node for a little too long or so long that it's not even allowed to leave at all (i.e. it's completely blocked). - [The 8 D’s of Stroke Care](https://www.timeofcare.com/the-8-ds-of-stroke-care/) - Detection Detection of symptoms of a stroke and call 911. Dispatch Rapid EMS dispatch. Delivery Rapid EMS delivery of the patient by rapid EMS transport. Door The "door" stands for the effective triage of the patient including assigning a room. Data Collection of data. History and focused H&P. Decision Decision regarding treatment. Use the fibrinolytic - [Low Income](https://www.timeofcare.com/low-income/) - Child Health and Disability Prevention (CHDP) Program. WIC (Women, Infants, and Children): https://m.wic.ca.gov; https://www.cdph.ca.gov/Programs/CFH/DWICSN/Pages/Program-Landing1.aspx - [Chest Pain: Differential Diagnosis](https://www.timeofcare.com/chest-pain-differential-diagnosis/) - Differential Diagnosis of Chest Pain - [Vasospastic angina (previously called Prinzmetal angina)](https://www.timeofcare.com/vasospastic-angina-previously-called-prinzmetal-angina/) - Vasospastic angina (previously called Prinzmetal/variant angina) are episodes of rest angina associated w/ ST elevations that promptly respond to sublingual nitrates. Cause = coronary artery vasospasm. - [Chest Pain: Chronic Stable Angina / Stable Ischemic Heart Disease](https://www.timeofcare.com/chronic-stable-angina/) - Diagnosis Hx is consistent with chronic stable angina, not ACS. OPQRST-A. Angina type (Typical, Atypical, Nonspecific)?: CVD risk factors in this pt are:_____________ Pretest Probability of CAD: High / Intermediate / Low / Very low HEART score: (The HEART score outperforms the TIMI score). Differential diagnosis. Pleuritic chest pain? recent URI? hemoptysis? recent surgery - [Coronary Artery Disease(CAD) vs. Coronary Heart Disease(CHD)](https://www.timeofcare.com/coronary-artery-diseasecad-vs-coronary-heart-diseasechd/) - Is there a difference between Coronary Artery Disease(CAD) and Coronary Heart Disease(CHD)? Yes. However, some health professionals use the terms interchangeably. CAD generally refers to the disease process affecting the coronary arteries (mostly due to atherosclerosis). Some people use it interchangeably/synonymously with CHD. CHD covers diagnoses such as angina pectoris, acute coronary syndrome, silent myocardial - [Unexplained Infertility](https://www.timeofcare.com/unexplained-infertility/) - -Avoid smoking, alcohol use, drug use. -Will confirm ovulation with a serum progesterone level on day 21 of a 28-day cycle or one week before presumed onset of menses. -Hysterosalpingography will be offered to screen for uterine and tubal abnormalities in this woman with infertility who has no history of pelvic infections, endometriosis, or ectopic - [Patients with a history of seizures taking seizure medications](https://www.timeofcare.com/patients-with-a-history-of-seizures-taking-seizure-medications/) - If a patient has seizures that are well controlled on carbamazepine (Tegretol). No other issues. Doesn't want to get pregnant for the next several years. What is the best option for her? Answer: Mirena IUD. An effective option for women taking antiepileptic medications would be an intrauterine device. The levonorgestrel (progestin only) IUD and copper - [Contraception options for smokers ≥35 years of age](https://www.timeofcare.com/contraception-options-for-smokers-≥35-years-of-age/) - “Cigarette smoking, increasing age, and exogenous estrogen, particularly at the supraphysiologic doses used in contraceptives, all increase risk for vascular events such as venous thromboembolism and stroke. The use of estrogen-containing contraception in smokers ≥35 years is contraindicated because of this risk.”ABFM Critique Progestin-only contraceptives are good options for this patient. These include: Etonogestrel implant - [Polycystic Ovarian Syndrome (PCOS)](https://www.timeofcare.com/pcos-polycystic-ovarian-syndrome/) - H&P + Diagnosis PCOS is a clinical syndrome, not a single d/o. It is defined by hyperandrogenism, ovulatory dysfunction, & polycystic ovaries. Dx is made w/ the Rotterdam criteria. The patient needs 2 of 3 criteria + exclude phenotypically similar androgen excess disorders. Menstrual hx: amenorrhea/oligomenorrhea? Onset & freq. of menses? S/sx of hyperandrogenism (acne, hirsutism, - [Polycystic Ovarian Syndrome (PCOS) - Differential Diagnosis](https://www.timeofcare.com/polycystic-ovarian-syndrome-pcos-differential-diagnosis/) - Hyperandrogenism is a necessary aspect of PCOS. The differential diagnosis of PCOS is the differential diagnosis of hyperandrogenism as well as ddx of other features of PCOS such as ovulatory dysfunction. The differential diagnosis of PCOS includes both endocrine and malignant causes. All conditions that mimic PCOS must be ruled out before a diagnosis of - [Clinical features associated with hyperandrogenism](https://www.timeofcare.com/clinical-features-associated-with-hyperandrogenism/) -  Acne, especially over the face, neck, back and chest.  Degree, pattern and severity of hirsutism.  Acanthosis nigricans (velvety skin hyperpigmentation), associated with insulin resistance.  Deepened voice.  Male pattern balding.  Breast atrophy.  Clitoromegaly.  Loss of normal feminine body shape.  Height, weight, and body mass index.  Distribution - [COPD](https://www.timeofcare.com/copd/) - COPD (Chronic Obstructive Pulmonary Disease) – Stable. COPD Exacerbation (Inpatient). COPD Exacerbation (Outpatient). - [COPD (Chronic Obstructive Pulmonary Disease) - Stable](https://www.timeofcare.com/chronic-obstructive-pulmonary-disease-copd-stable/) - Emphysema + chronic bronchitis Etiology: tobacco smoke, alpha-1 antitrypsin deficiency, talcosis (from IV drug use). H&P + Diagnosis Symptoms: SOB, cough, sputum production? Risk Factors: Smoking hx, occupational dust, biomass fuel exposure, asthma, childhood infections, prematurity, FHx of chronic lung disease? Comorbidities: Heart disease, Metabolic syndrome, Osteoporosis, OSA, Depression, Lung cancer, skin wrinkling? Differential diagnosis. - [Distinguishing Asthma from COPD](https://www.timeofcare.com/distinguishing-asthma-from-copd/) - The common features of asthma and COPD can be used in distinguishing asthma from COPD. "A careful history that considers age; symptoms (in particular, onset and progression, variability, seasonality or periodicity, and persistence); history; social and occupational risk factors (including smoking history, previous diagnoses, and treatment); and response to treatment." Feature Asthma COPD Age Onset - [Differential Diagnosis of COPD](https://www.timeofcare.com/differential-diagnosis-of-copd/) - COPD Asthma (chronic obstructive asthma) Bronchiectasis Cystic fibrosis Chronic bronchitis with normal spirometry Bronchiolitis Intrathoracic airway obstruction (e.g. from bronchogenic or metastatic cancer, lymphadenopathy, or scarring from an endotracheal tube) Heart failure Tuberculosis Recurrent pulmonary emboli Obliterative bronchiolitis Diffuse panbronchiolitis - [Syncope and Presyncope: Differential Diagnosis](https://www.timeofcare.com/syncope-and-presyncope-differential-diagnosis/) - A) THE 3 CLASSES OF SYNCOPE Syncope can be divided into two main categories: 1) Cardiac syncope and 2) Non-cardiac syncope. Non-cardiac syncope is sub-divided into neurally mediated (reflex) and orthostatic hypotension syncope. This makes a total of 3 main classes of syncope. 1. NEURALLY MEDIATED (REFLEX) SYNCOPE This includes the following 3 types of - [Atrial Fibrillation](https://www.timeofcare.com/atrial-fibrillation/) - This article shows you a brief and concise assessment and plan of treatment for atrial fibrillation at the time of care. - [Palpitations](https://www.timeofcare.com/palpitations/) - Palpitations are an unpleasant sensation that one's heart is beating abnormally. Pertinent H&P findings are ____ DDx of palpitations in this pt is ___ Risk Factors in this patient are___ Distinguish cardiac vs. non-cardiac cause. Rule out an ischemic cause. Diagnostic testing Labs1: CBC, CMP, TSH, Mg. Consider serum/urine catecholamines/metanephrines ECG in everybody. TTE if - [Palpitations: Causes and Differential Diagnosis of Palpitations](https://www.timeofcare.com/palpitations-differential-diagnosis/) - Causes of palpitations can be divided into four main categories: 1) Psychiatric, 2) cardiac, 3) Medication, and 4) Systemic medical causes. Psychiatric/Psychosomatic causes Anxiety disorder; Stress Panic attacks/Panic disorder Depression Somatization disorder Cardiac Causes Arrhythmias Premature atrial contractions (PACs) / Premature supraventricular contractions. Premature ventricular contractions (PVCs) Atrial fibrillation Atrial flutter Sinus tachycardia or arrhythmia - [Types of Ischemic Heart Disease](https://www.timeofcare.com/types-of-ischemic-heart-disease/) - "There are three main types of ischemic heart disease: obstructive coronary artery disease; nonobstructive coronary artery disease; and coronary microvascular disease. Coronary artery disease affects the large arteries on the surface of the heart and many people have both obstructive and nonobstructive forms of this disease. Coronary microvascular disease affects the tiny arteries in the - [Cholesterol Algorithm - Primary Prevention](https://www.timeofcare.com/cholesterol-algorithm-primary-prevention/) - Source: https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000625 - [Cholesterol Algorithm for Patients with Clinical ASCVD](https://www.timeofcare.com/cholesterol-algorithm-for-patients-with-clinical-ascvd/) - [ASCVD and Very High Risk of Future ASCVD Events](https://www.timeofcare.com/ascvd/) - Past ASCVD events are risk factors for future events. The existence of high-risk conditions as well. From the AHA/ACC 2018 cholesterol guidelines. Clinical ASCVD Clinical ASCVD consists of the following conditions of atherosclerotic origin. ACS, history of MI, stable or unstable angina or coronary other arterial revascularization, stroke, transient ischemic attack (TIA), or peripheral artery - [Lipid Screening / Cholesterol Screening](https://www.timeofcare.com/lipid-screening-cholesterol-screening/) - USPSTF recommends universal lipid screening in adults aged 40 to 75 and tx of HLD if certain criteria are met. "The USPSTF recommends that adults without a history of cardiovascular disease (CVD) (ie, symptomatic coronary artery disease or ischemic stroke) use a low- to moderate-dose statin for the prevention of CVD events and mortality when - [Cholesterol Classification](https://www.timeofcare.com/cholesterol-classification/) - Source: https://www.nhlbi.nih.gov/files/docs/guidelines/atglance.pdf Last Accessed June 2019 http://applications.emro.who.int/dsaf/dsa699.pdf Last Accessed June 2019 - [Diabetes Mellitus Type 2, Subsequent Visits](https://www.timeofcare.com/diabetes-chronic/) - History and Physical. A1C goal for this patient:______ Last HbA1c (needed q3-6mo) was_____ Will screen for Vitamin B12 deficiency annually in patients on Metformin. Last annual dilated retinal exam was____ Last annual diabetic foot exam was____ Last annual microalbuminuria screening with spot urine albumin/creatinine ratio was_____ Last annual eGFR, BUN / Cr was____ The patient has had diabetes since - [Atherosclerotic Cardiovascular Disease (ASCVD) Risk Factors](https://www.timeofcare.com/cardiovascular-disease-risk-factors/) - Nearly all cases of coronary heart disease are caused by atherosclerosis. People with 2 of the risk factors are at high risk of developing CAD. The commonly recognized risk factors for CAD are shown below. Age Gender/sex Race/ethnicity (e.g., South Asian ancestry, is high-risk) Family history of CAD (< 55 y in a male or - [Moderate and High Intensity Statin Therapy](https://www.timeofcare.com/moderate-and-high-intensity-statin-therapy/) - Statin High Moderate Low Lipid-lowering¢ ≥50% 30%–49% <30% Rosuvastatin 20–40 mg 5–10 mg Atorvastatin 40–80 mg 10–20 mg Simvastatin 40 mg 10 mg Lovastatin 40 mg 20 mg Pravastatin 40 mg 10–20 mg Fluvastatin 40 mg twice daily 20–40 mg Pitavastatin 2–4 mg 1 mg ¢ "LDL-C lowering that should occur with the dosage listed - [Statins: Benefits and Functions](https://www.timeofcare.com/statins-benefits-and-functions/) - Statins do the following: Lowering cholesterol, Reduce vascular inflammation, Improve endothelial function, and Stabilize atherosclerotic plaques. Statins are recommended for the following uses Vascular or coronary surgery. Reduces cardiovascular risk when given perioperatively. For the most protection, statins should be started 4 weeks prior to the procedure and continued after surgery. Stroke patients Elevated ASCVD - [Hyperlipidemia / Dyslipidemia, Causes](https://www.timeofcare.com/causes-of-hyperlipidemia/) - Idiopathic Diabetes mellitus Alcohol Abuse. Hypothyroidism Nephrotic syndrome Chronic kidney disease Obstructive (cholestatic) liver disease Anorexia nervosa Cushing’s syndrome Familial, eg, familial hypercholesterolemia Obesity Smoking - smoking decreases HDL and causes insulin resistance. Medications: thiazides (short-term effect), beta-blockers (short-term effect), oral contraceptives, corticosteroids, cyclosporine - [Coding Guide for Evaluation and Management (E&M) Services](https://www.timeofcare.com/evaluation-and-management-coding-guide/) - Medical Decision Making (MDM) Section (shows the 3 parts of MDM coding and how to use it). Coding for procedures and skin surgery. Modifier 25 (Billing for both Preventive and other Diagnosis and other Services during the same visit). Prescription Drug Management – Meaning. MDM Documentation Tips (What to include in your note). Coding Benchmarks, 2017. - [Using Exams and Medical Decision Making Documented by Medical Students](https://www.timeofcare.com/using-exams-and-medical-decision-making-documented-by-medical-students/) - The AAFP answers this question in 2019: "Q: Under Medicare's rules for medical review of student documentation, what must a teaching physician document when he or she agrees with the exam findings, assessment, and plan noted by the student? A: According to Medicare, after personally re-performing the exam and medical decision making, the teaching physician - [Medical Decision Making (MDM) Section](https://www.timeofcare.com/medical-decision-making/) - For MDM, you need 2 of 3 sections. Throw out the lowest score. The new visit codes 99202-99205 MEDICAL DECISION MAKING 2 out of 3 need to be met Straightforward (99212/99202) Low Complexity (99213/99203) Moderate Complexity (99214/99204) High Complexity (99215/99205) A. # of DX Minimal (0-1) Low (2) Moderate (3) High (4+) B. Data Reviewed - [New vs. Established Problem in Medical Decision Making](https://www.timeofcare.com/new-vs-established-problem/) - What does a new vs. established problem mean in medical decision making (MDM)? A former billing auditor told me that in MDM, “new problem” means new to the provider and "established problem" means established to the provider. This means if you see a patient with a history of DM on Metformin who changed doctors and - [New Vs. Established Patient in the Outpatient Setting](https://www.timeofcare.com/new-vs-established-patient-in-the-outpatient-setting/) - The CMS website says: "For purposes of billing for E/M services, patients are identified as either new or established, depending on previous encounters with the provider. New Patient: An individual who did not receive any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group - [MDM Documentation Tips (What to include in your note)](https://www.timeofcare.com/mdm-documentation/) - Number of Diagnoses and/or Management Options "Here are some important points to keep in mind when documenting the number of diagnoses or management options. You should document: 1) An assessment, clinical impression, or diagnosis for each encounter, which may be explicitly stated or implied in documented decisions for management plans and/or further evaluation: A) For - [Coding for Procedures and Skin Surgery](https://www.timeofcare.com/coding-for-procedures-and-skin-surgery/) - Neoplasm of uncertain behavior of skin, ICD code D48.5 The AAFP 2019 had the following pertinent Q&A "CODING FOR REMOVAL OF SKIN LESIONS: BIOPSY OR NO? Q: My patient had a lesion that was irritated by her waistband. I used a shave technique to remove the lesion and sent it to pathology for examination. Should - [MDM Table of Risk](https://www.timeofcare.com/mdm-table-of-risk/) - See a PDF version of the Table of Risk from the CMS. The MDM table of risk takes into account the risk of complications, morbidity, and mortality based on the patient's condition. Use the highest level of risk based on ONE element from ANY of the categories below. The highest level determines the overall risk. - [Prescription Drug Management - Meaning](https://www.timeofcare.com/prescription-drug-management-meaning/) - In the level of risk for MDM, level 4 includes "Prescription drug management". But what qualifies as prescription drug management? A new Rx, Rx refill, increasing or decreasing Rx dose, discontinuing Rx, and continuing Rx all qualify as prescription drug management. Any management of prescription medication qualifies as moderate risk. The Fam Pract Manag. 2019 - [LDL Cholesterol Calculation and High Triglycerides](https://www.timeofcare.com/ldl-cholesterol-calculation-and-high-triglycerides/) - As you may already know, the LDL cholesterol that is usually reported when a lipid panel is ordered is not measured but calculated. When the triglycerides are high, LDL cannot be accurately calculated because triglycerides are part of the equation. How is LDL-C Calculated? LDL-C is most often calculated using a formula based on other - [Statin Doses: Real Americans Still Love Playing Football (Equivalent Doses for Statins)](https://www.timeofcare.com/statin-doses-real-americans-still-love-playing-football-equivalent-doses-for-statins/) - Real Americans Still Love Playing Football (Equivalent Doses for Statins) Gives you six Statin drugs with equivalent doses doubling from 10, 20, 40, 80 and stay at 80, 80. Rosuvastatin, Atorvastatin, Simvastatin, Lovastatin, Pravastatin, Fluvastatin Rosuvastatin(10)= Atorvastatin (20) = Simvastatin (40) = Lovastatin (80) = Pravastatin (80) = Fluvastatin (80) - [Tumor Markers / Cancer Antigens](https://www.timeofcare.com/tumor-markers-cancer-antigens/) - CA-19-9 (Cancer Antigen 19-9) is the most common serum tumor marker used for pancreatic ductal adenocarcinoma, which is expressed in pancreatic and hepatobiliary disease. In symptomatic patients, it can help confirm the diagnosis and aid in assessing the prognosis and predicting the likelihood of recurrence after resection. CA-125 (Cancer antigen 125) is a tumor marker for - [Rhinosinusitis(RS), Acute](https://www.timeofcare.com/acute-rhinosinusitis/) - Most cases of RS are caused by viral URIs. Cannot distinguish b/n viral and bacterial causes based on s/sx alone. Diagnosis -H&P consistent with acute RS. -OPQRST-A -Duration of URI s/sx? =______ -Double sickening present? -Purulent nasal secretion? -Is purulent rhinorrhea predominantly unilateral? Labs: ESR Treatment -Watchful waiting with symptomatic tx for the first 7 to - [Hyperhidrosis (Excessive Sweating) / Night Sweats : Differential Diagnosis](https://www.timeofcare.com/hyperhidrosis-excessive-sweating-night-sweats-differential-diagnosis/) - Innervation of sweat glands. Primary Focal Hyperhidrosis vs. Generalized hyperhidrosis. The differential diagnosis for generalized hyperhidrosis is similar to the differential diagnosis of night sweats Here are some health conditions that may cause excessive sweating. Environmental exposure to heat. (the most common cause of generalized sweating) Idiopathic hyperhidrosis Primary focal hyperhidrosis Generalized hyperhidrosis. Anxiety / - [Asthma Triggers / Precipitants](https://www.timeofcare.com/asthma-triggers/) - The following things can trigger asthma attacks. Identify your triggers and avoid them to prevent attacks. Tobacco Smoke - both smoking and "secondhand smoke" Dust Mites Outdoor Air Pollution Cockroach Allergen. Pets e.g. cats, and other furry pets. Mold Smoke From Burning Wood or Grass Seasonal pollens, allergies bad weather, such as thunderstorms or high - [Asthma](https://www.timeofcare.com/asthma/) - Asthma Exacerbation, 12 years and older (Urgent care, ED, and Inpatient Treatment). Asthma Exacerbation, peds. Asthma in Patients 0 to 4 years old and 5 to 11 years old. Asthma in Patients 12 years and older (includes Adults). Cough Variant Asthma. Exercised-induced Asthma. Immunizations: Influenza and PSV23 recommended. Common Asthma Triggers/Precipitants. New diagnosis (never treated) - [Asthma Exacerbation, 12 years and older (Urgent care, ED, and Inpatient Treatment)](https://www.timeofcare.com/asthma-exacerbation/) - Acute Respiratory distress 2/2 to Asthma Exacerbation H&P performed. Differential diagnosis. Causes of asthma exacerbation. Peak expiratory flow (PEF): ___ Oxygen saturation: ___ Asthma Severity Classification. Consider CXR, ABG, and CBC and CMP as indicated. These are not necessary for most patients. Treatment -Oxygen to keep SpO2 > 92% (or 95% if pregnant). -Inhaled SABA - [Asthma, Differential Diagnosis](https://www.timeofcare.com/asthma-differential-diagnosis/) - COPD CHF Pulmonary Embolism (PE) GERD (Aspiration in GERD) Tumor (mechanical airway obstruction) ACEI induced cough. Cystic fibrosis Bronchiectasis Bronchiolitis obliterans Hypersensitivity pneumonitis Allergic bronchopulmonary aspergillosis (ABPA) Vocal cord dysfunction / paralysis Central airway obstruction Extrathoracic obstruction Eosinophilic pneumonia Foreign-body aspiration Laryngotracheal mass Tracheal stenosis Tracheomalacia Angioedema Airway edema from inhalation injury Churg-Strauss syndrome Factitious - [Asthma Exacerbation, peds](https://www.timeofcare.com/asthma-exacerbation-peds/) - Treatment Beta-agonists: Short-course oral steroids Albuterol 4 Puffs q4hr and reduce to 2 puffs q4hr. Can D/C patient if they are tolerating q4h albuterol. Provide albuterol for home and school. Write an order on a script for the school nurse to keep albuterol at school. **Ipratropium is only used in the ED. There is no - [Asthma Action Plan](https://www.timeofcare.com/asthma-action-plan/) - Asthma Action Plan (from nhlbi.nih.gov: https://www.nhlbi.nih.gov/files/docs/public/lung/asthma_actplan.pdf ) Example Asthma Action Plan Completed. http://www.cdc.gov/asthma/tools_for_control.htm (Other Asthma Action plans can be found on this CDC link). https://www.nhlbi.nih.gov/files/docs/public/lung/asthma_actplan.pdf - [Asthma in Patients 0 to 4 years old and 5 to 11 years old](https://www.timeofcare.com/asthma-in-patients-0-to-4-years-old-and-5-to-11-years-old/) - Age 0-4 years of age Classifying Asthma severity and initiating treatment in children 0 to 4 years of age. Stepwise Rx treatment of Asthma in Children 0-4 years of Age. Classification of Asthma Control in Children 0-4 years of Age. Age 5 to 11 years of age Classifying Asthma Severity and Initiating Treatment in children - [Stepwise Treatment of Asthma in Children 5–11 Years of Age](https://www.timeofcare.com/stepwise-treatment-of-asthma-in-children-5-11-years-of-age/) - Leukotriene receptor antagonists (LTRA) e.g. Montelukast and Zafirlukast. LTRAs have both bronchodilator and anti-inflammatory effects. Note: IgE-dependent allergic asthma that may respond to omalizumab. Omalizumab is indicated for patients who have allergies. - [Classifying Asthma Severity and Initiating Treatment in children 5 to 11 years of age](https://www.timeofcare.com/asthma-severity-and-initiating-treatment-for-ages-5-to-11-years/) - Assessing severity and initiating therapy in children who are not currently taking long-term control medication. Level of severity is determined by both impairment and risk. Components of severity Classification of asthma severity (5 to 11 years of age) Intermittent Persistent Mild Moderate Severe Impairment Symptoms ≤2 days/week >2 days/week but not daily Daily Throughout the - [Classifying Asthma severity and initiating treatment in children 0 to 4 years of age](https://www.timeofcare.com/asthma-severity-and-initiating-treatment-for-ages-0-to-4-years/) - Assessing severity and initiating therapy in children who are not currently taking long-term control medication. The level of severity is determined by both impairment and risk. NB: Kids 0-4 years old can't do spirometry, so it's not included. Components of severity Classification of asthma severity (0 to 4 years of age) Intermittent Persistent Mild Moderate - [Stepwise Management of Asthma in Children 0-4 years of Age](https://www.timeofcare.com/stepwise-management-of-asthma-in-children-0-4-years-of-age/) - Stepwise Approach for Managing Asthma in Children 0-4 years of Age - [Classification of Asthma Control in Children 0-4 years of Age](https://www.timeofcare.com/classification-of-asthma-control-in-children-0-4-years-of-age/) - Source: http://www.nhlbi.nih.gov/files/docs/guidelines/08_sec4_lt_0-11.pdf Full Report: http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-report - [Erectile Dysfunction (ED)](https://www.timeofcare.com/erectile-dysfunction-ed/) - Diagnosis and Treatment of Erectile Dysfunction (ED) - [Premature ejaculation (PE)](https://www.timeofcare.com/premature-ejaculation-pe/) - "Premature ejaculation (PE) is also referred to as rapid or early ejaculation and is defined according to three essential criteria: (1) brief ejaculatory latency; (2) loss of control; and (3) psychological distress in the patient and/or partner." UTD. You need all 3 aspects to qualify for the diagnosis. Treatment options 1st-line Rx: SSRIs.Doses e.g. Paroxetine - [How a Penile Prosthesis (Implants) for Erectile Dysfunction Work](https://www.timeofcare.com/how-a-penile-prosthesis-implants-for-erectile-dysfunction-work/) - [Causes of Erectile Dysfunction (ED)](https://www.timeofcare.com/causes-of-erectile-dysfunction/) - Causes of Erectile Dysfunction - [Rheumatoid arthritis (RA)](https://www.timeofcare.com/rheumatoid-arthritis/) - Diagnosis and treatment of Rheumatoid arthritis - [Risk Factors for Rheumatoid arthritis](https://www.timeofcare.com/risk-factors-for-rheumatoid-arthritis/) - Risk Factors for Rheumatoid arthritis - [Headaches](https://www.timeofcare.com/headaches/) - Migraine Headaches. Chronic Migraine Headaches. Migraine medications in the clinic, ER, or urgent care. Tension Headaches. Cluster Headaches. Unspecified Headache Type. http://www.uptodate.com/contents/evaluation-of-headache-in-adults A young adult woman with a history of a continuous right-sided headache for several months. Associated symptoms: Tearing + nasal congestion only on the right. She has not responded to - [Otitis Media (OM) Treatment](https://www.timeofcare.com/otitis-media-om-treatment/) - The most common pathogens: Streptococcus pneumoniae, nontypeable Haemophilus influenzae, Moraxella catarrhalis. Also S. pyogenes, S. aureus, respiratory viruses. No antibiotic use in the last one month. -Amoxicillin 80-90 mg/kg/day PO divided twice daily for 7-10 days. This works for kids 2 months and older. For kids < 2 mo, it's 30 mg/kg/day divided twice daily x 10d. - [Otitis Media (OM)](https://www.timeofcare.com/otitis-media/) - Definition: Otitis media includes acute otitis media and otitis media with effusion. Different types of OM. Causative agents and treatment options. Treatment Causative agents and treatment options. Acetaminophen, NSAIDs, and topic anesthetic ear drops, prn analgesia. Immediate antibiotic use seems most beneficial in children younger than two years with bilateral AOM and in children who - [#Unilateral Swelling of Cheek, Differential Diagnosis](https://www.timeofcare.com/unilateral-swelling-of-cheek-differential-diagnosis/) - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5773992/ Agrawal A, Singh V, Kumar P, Bhagol A, Narwal A, Singh I. Unilateral swelling of cheek. Natl J Maxillofac Surg. 2017;8(2):157–161. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5773992/ - [Functional dyspepsia (FD)](https://www.timeofcare.com/functional-dyspepsia/) - Diagnosis Definition: There are two subtypes of functional dyspepsia: postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS) H&P Consistent with FD Rome III diagnostic criteria for functional dyspepsia. DDx of Dyspepsia. R/o alarm symptoms. R/o organic or structural causes of dyspepsia. Labs: CBC, CMP (LFTs), serum lipase and amylase, H. Pylori testing. EGD if - [GERD and Dyspepsia: Red Flags / Alarm Symptoms](https://www.timeofcare.com/gerd-red-flags-alarm-symptoms/) - Dysphagia Odynophagia GI Bleeding Anemia (Unexplained iron deficiency anemia) Unintentional weight loss Recurrent or persistent vomiting Palpable mass or lymphadenopathy Family history of upper gastrointestinal cancer - [Dyspepsia (Indigestion)](https://www.timeofcare.com/dyspepsia/) - Occurs in > 20 % of population. Functional Dyspepsia. Up to 75% have a functional (idiopathic or nonulcer) dyspepsia with no underlying cause on diagnostic evaluation. "Functional (idiopathic or nonulcer) dyspepsia requires exclusion of other organic causes of dyspepsia". Dyspepsia secondary to organic (structural or biochemical) disease. 25 % of patients with dyspepsia have an - [Strep Pharyngitis / Acute Pharyngitis / Strep throat](https://www.timeofcare.com/strep-pharyngitis-acute-pharyngitis-strep-throat/) - History & Physical. Differential diagnosis. Red flags: -s/sx of epiglottitis: Acute onset of dysphagia, odynophagia, drooling, high fever, anxiety, and muffled voice; -s/sx of peritonsillar abscess: fever, sore throat, dysphagia, trismus, a muffled voice (“hot potato” voice), malaise, Odynophagia / severe unilateral pain, Otalgia (ipsilateral), severe sore throat, worse on one side, drooling, cervical lymphadenitis, - [Congestive Heart Failure (CHF)](https://www.timeofcare.com/congestive-heart-failure-chf/) - "CAD is the underlying cause in more than two-thirds of chronic HF patients." Heart Failure with Reduced Ejection Fraction (HFrEF). Heart Failure with Preserved Ejection Fraction (HFpEF). Heart Failure, Acute Decompensated HFrEF (CHF Exacerbation). Reference https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.109.917922 - [Hypothyroidism as a risk factor for heart disease](https://www.timeofcare.com/hypothyroidism-as-a-risk-factor-for-heart-disease/) - "Low thyroid hormone levels should be interpreted as a cardiovascular risk factor" (von Hafe M, 2019). "Thyroid hormones modulate every component of the cardiovascular system necessary for normal cardiovascular development and function. When cardiovascular disease is present, thyroid function tests are characteristically indicated to determine if overt thyroid disorders or even subclinical dysfunction exists" (Grais, - [Chest pain: ACS in the clinic](https://www.timeofcare.com/chest-pain-acs-in-the-clinic/) - Definition of ACS (acute coronary syndrome). Diagnosis See workup for chronic stable angina in the clinic setting. Treatment -Send the patient to the ED immediately. Some of the following will be done in the ED, do what you can with clinic resources. -Morphine prn pain. -Oxygen only if need to keep SaO2 > 91%. -NTG - [Pre-test Probability of Coronary Artery Disease (CAD)](https://www.timeofcare.com/pretest-probability-of-coronary-artery-disease-cad/) - The optimal diagnostic imaging strategy depends on the pre-test probability. "For example, patients with a very high probability of CAD may be started on medical therapy, whereas in patients with an intermediate probability additional diagnostic imaging should be performed. In patients with a (very) low probability of CAD, one may consider forgoing additional testing." CAD - [OPQRST-A : The Key Features of Every Symptom](https://www.timeofcare.com/the-key-features-of-every-symptom/) - For all symptoms, it is important to fully understand the essential characteristics. Always pursue the following features for every symptom. The Bates textbook calls them the features of every symptom. **When describing the symptoms in a problem presentation, use semantic qualifiers whenever possible. OPQRST-A Onset - Onset means the beginning of something. Describe the onset in detail with - [Typical Chest Pain vs. Atypical Chest Pain](https://www.timeofcare.com/typical-vs-atypical-chest-pain/) - Typical (classic) angina chest pain consists of (1) Substernal chest pain or discomfort that is (2) Provoked by exertion or emotional stress and (3) relieved by rest or nitroglycerine (or both). Atypical (probable) angina chest pain applies when 2 out of 3 criteria of classic angina are present. Non-specific chest pain: If ≤ 1 of - [Chest Pain, History](https://www.timeofcare.com/chest-pain-history/) - OPQRST-A Chest pain type (Typical, Atypical, Nonspecific): Cardiac Risk Factor Evaluation Cardiac risk factors. BMI: PE risk factor eval: Patient denies immobility, long plan/car rides, malignancy, or history of clotting d/o. Patient denies cocaine use or other illicit drug use, pleuritic chest pain, recent URI, hemoptysis, or recent surgery or procedures. - [Sore Throat (Pharyngitis)](https://www.timeofcare.com/sore-throat-pharyngitis/) - *Infections are the cause of an acute sore throat in the overwhelming majority of cases. Red flag / life-threatening ddx. -s/sx of epiglottitis: Acute onset of dysphagia, odynophagia, drooling, high fever, anxiety, and muffled voice; -s/sx of peritonsillar abscess: fever, sore throat, dysphagia, trismus, a muffled voice (“hot potato” voice), malaise, Odynophagia / severe unilateral - [CENTOR criteria](https://www.timeofcare.com/centor-criteria/) - The Centor criteria are a widely used and accepted clinical decision tool for identifying patients with GAS. Cough is absent. Exudates are present on the tonsils. Nodes are tender in the anterior cervical region. Temperature of 100.4 F by history (i.e. fever by history). oldness - age is included in the Modified Centor criteria, which - [Allergic Rhinitis](https://www.timeofcare.com/allergic-rhinitis/) - Allergic Rhinitis, Severe Persistent Symptoms. Allergic Rhinitis, Moderate symptoms. - [Allergic Reaction (Anaphylaxis) in the outpatient setting](https://www.timeofcare.com/allergic-reaction-anaphylaxis-in-the-outpatient-setting/) - This article discusses Allergic Reaction (Anaphylaxis) in the outpatient setting - [Back Pain](https://www.timeofcare.com/back-pain/) - Acute low back pain without radiculopathy. Acute low back pain with radiculopathy. Chronic Low Back Pain. Back pain in children and adolescents. Back pain associated with acute or chronic vertebral compression. - [Back pain associated with acute or chronic vertebral compression](https://www.timeofcare.com/back-pain-associated-with-acute-or-chronic-vertebral-compression/) - Pain associated with acute and chronic vertebral compression fractures can be treated with calcitonin-salmon. "Calcitonin-salmon is useful in the management of pain associated with acute or chronic vertebral fractures. Calcitonin is an antiresorptive agent that has been shown to decrease the risk of vertebral fractures, but it is not considered a first-line treatment for osteoporosis - [Back Pain, Acute Low back pain without radiculopathy](https://www.timeofcare.com/back-pain-acute/) - Diagnosis H & P consistent with low back pain. -No red flags. Treatment NSAIDs and acetaminophen, separate or combined. Muscle relaxants (e.g. cyclobenzaprine, baclofen). Diclofenac (Voltaren) gel if oral NSAIDs contraindicated. Apply ice or heat. Physical therapy. Early ambulation. Discourage bed rest. Patient education. ---//--- "Nonbenzodiazepine muscle relaxants such as cyclobenzaprine are beneficial for the - [Onychomycosis (Tinea Unguium) - Nail Fungus, adults](https://www.timeofcare.com/onychomycosis/) - Treatment: Oral terbinafine(Lamisil) daily for 12 weeks Oral terbinafine is quite safe and rarely causes side effects. Confirm diagnosis (with fungal culture or KOH observation under a microscope) before starting treatment. Get a clipper in the clinic, cut small pieces of the nails, include scrapings of the whitish debris, put it in a small enclosed - [ADHD (Attention-Deficit Hyperactivity Disorder) in Children & Adults](https://www.timeofcare.com/adhd/) - Diagnosis in Children -Vanderbilt ADHD Assessment Forms (Both teacher and parent forms). -Coexisting or mimicking conditions, considered. -Labs: CBC, CMP, TSH, 25 hydroxy Vit D level. Treatment -Preschool age ( < 6 years old, i.e 5 years and younger) - Behavioral therapy (BT) alone. -School Age (≥ 6 years of age) - Start with medication. Add - [Fatigue, Malaise](https://www.timeofcare.com/fatigue/) - Patient w/ fatigue. Differential diagnosis. Labs CBC, CMP, TSH, 25-OH Vit D. Creatine Kinase (if muscle pain or weakness Treatment Counseling provided. Sleep hygiene. Hydration. Exercise. Healthy Diet. Will treat cause when identified. Will do an empiric trial of antidepressants if depressive symptoms present even if criteria for MDD not met. If no improvement will - [Diabetes](https://www.timeofcare.com/diabetes/) - This page covers diabetes in detail - [Diabetes Mellitus Type 2, initial visit](https://www.timeofcare.com/diabetes-mellitus-type-2-initial-visit/) - Diagnosis -History and physical. -Screening recommendations reviewed. -ADA's diagnostic criteria reviewed. -Confirm the diagnosis of pre-DM or DM type 2 by repeating the same test on a different day (per USPSTF). Repeat in 1-2 weeks. -Before starting Metformin, I will obtain the patient’s eGFR (per FDA). -Will check eGFR at least annually in all patients - [Prediabetes (Impaired Glucose Tolerance / Impaired Fasting Glucose)](https://www.timeofcare.com/prediabetes/) - Pre-DM is a risk factor for DM, and not a disease itself. Diagnosis -A1C 5.7 to 6.4 % / FBS 100-125 / impaired glucose tolerance. -Confirm the dx of pre-DM or DM type 2 by repeating the same test on a different day. -The patient is at risk of progression from pre-DM to DM. Treatment - [Secondary Hypertension](https://www.timeofcare.com/secondary-hypertension/) - -This patient likely has secondary hypertension. -History and physical exam -The Causes of Secondary Hypertension, reviewed. -BPs have been repeated for accuracy. -Diet and drug-related causes reviewed. -2017 AAFP Algorithm reviewed. Diagnostic studies: -TSH, ECG, UA and Urine Creatine, CBC (Hct), CMP (Cr, eGFR, gluc.), Fasting lipid panel. -Renin and aldosterone levels to calculate the - [Secondary Hypertension, Differential diagnosis](https://www.timeofcare.com/causes-of-secondary-hypertension/) - Causes of Secondary Hypertension: ABCDEF Apnea (OSA), Adrenals (aldosteronism), Accuracy of diagnosis. Bruit and Bad kidneys. Bruits come from blood vessel narrowing (RAS). Bad kidneys (glomerular disease & renal parenchymal disease). Catecholamines, Cushing's sydrome, and coarctation of the aorta. Drugs (Medications and illicit drugs) Endocrine disorders or Erythropoietin Food or diet. See this AFP article - [Evaluation of a patient newly diagnosed with Hypertension](https://www.timeofcare.com/hypertension-evaluation-of-a-patient-newly-diagnosed-with-htn/) - The following are generally agreed-upon initial workup of the hypertensive patient. Uptodate has a great article for consultation. The following tests should be performed in all patients with newly diagnosed hypertension : History & Physical CMP (Electrolytes, BUN/creatinine, eGFR) Fasting glucose CBC Urinalysis Lipid profile (total and HDL-cholesterol, triglycerides) Electrocardiogram (ECG) Other tests to consider Moderately - [Resistant Hypertension](https://www.timeofcare.com/resistant-hypertension/) - Definition of Resistant Hypertension. The most common cause of resistant HTN non-adherence. Diagnosis H&P: -Identify and reversible risk factors such as obesity/overweight, lack of exercise, high salt diet, increased alcohol intake. -Screen for OSA and treat if present. -Check for meds that may be contributing to HTN and d/c if possible. -Workup for secondary HTN. - [Essential Hypertension (New Diagnosis)](https://www.timeofcare.com/hypertension-new-diagnosis/) - Definition of Hypertension. Diagnosis Hypertension guidelines (JNC8, etc) reviewed. Will confirm dx by obtaining measurements outside of the clinical setting before starting treatment (per USPSTF 2015). Given BP card and instructed on how to take home BPs. Will initiate acquisition of home BP machine. Self-Measured Blood Pressure Monitoring lowers blood pressure compared to usual care - [Billing for both Preventive and other Diagnosis and other Services during the same visit](https://www.timeofcare.com/billing-for-both-preventive-and-other-diagnosis-and-other-services-during-the-same-visit/) - Using Modifier 25 A preventive visit is as the name says, for prevention, not for treatment or acute or chronic conditions. When you treat an acute or chronic condition you may need to bill a CPT code 99212-99215 in addition to the preventive medicine service CPT code 99381-99397 or a Medicare wellness visit code (HCPCS - [Coding Benchmarks](https://www.timeofcare.com/coding-benchmarks/) - Coding Benchmarks from CMS 2017 data. The source of the data is shown below. The following table is a summary of info I got from an AFP Excel Spreadsheet. CPT Code % 99201 OV, New, Straightforward 0.57% 99202 OV, New, Expanded 12.01% 99203 OV, New, Low 50.17% 99204 OV, New, Moderate 33.00% 99205 OV, New, - [Assessing Risk in Clinic Patients - High Risk](https://www.timeofcare.com/assessing-risk-in-clinic-patients/) - High Risk From AAFP 2014 "High risk is associated with high complexity medical decision-making. High risk could be associated with visits involving patients who have severe exacerbations of their problems or acute injuries that pose a threat to bodily functions. Diagnostic procedures or management options associated with highly complex care include cardiac electrophysiology studies, diagnostic - [Rosacea](https://www.timeofcare.com/rosacea/) - Diagnosis History and Physical Differential diagnosis. Treatment Treatment goals: 1) Decrease exposure to triggers, 2) Reduce bacterial burden, 3) Reduce inflammation. Nonpharmacologic treatment -Sunscreen with both UVA/ UVB protection via physical barriers (titanium dioxide or zinc oxide), -Moisturizers. -Avoid harsh cleansers with acetone & vasodilating drugs (e.g., CCBs or nicotinic acid). -Avoid triggers! Pharmacologic therapy: - [Rash on face / Red Facial Rash, Differential diagnosis](https://www.timeofcare.com/rash-on-face-red-facial-rash-differential-diagnosis/) - Seborrheic dermatitis / Seborrhea Atopic dermatitis (Eczema) Acne Vulgaris Rosacea (Acne Rosacea) Lupus: Acute cutaneous lupus erythematosus; lupus tumidus erythematosus Erysipelas Cellulitis Impetigo Contact dermatitis (Allergic, Irritant) Shingles (Herpes zoster) Tinea (Tinea faciei) Psoriasis Perioral dermatitis (the skin immediately adjacent to the vermillion border of the lip is classically spared). Angioedema Necrotizing fasciitis Erysipeloid Dermatomyositis (purplish/violaceous rash - [Medicare Annual Wellness Visit (AWV)](https://www.timeofcare.com/medicare-annual-wellness-visit/) - The following 11 points are elements of Medicare annual wellness visit per CMS.gov from August 2018: Perform a Health Risk Assessment (HRA). This is a form that the patient completes before the provider sees the patient. See the Medicare link below for what should be on the form. Medical assistants can help ensure this is - [Tobacco Abuse / Smoking Cessation](https://www.timeofcare.com/tobacco-abuse-smoking-cessation/) - -The number of pack per day: -The number of pack years: -Patient denies psychiatric illness, CVD, seizure disorder, and pregnancy. -Committed to smoking cessation. -Motivational interviewing & counseling for smoking cessation performed. -A combination of behavioral support and pharmacologic therapy discussed (as these are superior to either alone). -Discussed tobacco cessation resources like 1-800-QUIT-NOW, 1-800 NO BUTTS, - [Vaping and E-Cigarettes](https://www.timeofcare.com/vaping-and-e-cigarettes/) - An excellent TED talk on Vaping and E-Cigarettes. - [CASE DIAGNOSED! A Great New Mnemonic for Coming Up with a Differential Diagnosis](https://www.timeofcare.com/a-mnemonic-for-coming-up-with-a-differential-diagnosis/) - “I once sat through an hour lecture on why children fail to thrive, and every possible differential diagnosis was discussed except the possibility that maybe they didn’t have enough food.”1 Sandra Hoyt Stenmark, MD, Pediatrician. I think that social determinants of health belong on our differential diagnosis. As we know, they contribute more to premature death - [Eczema vs. Dermatitis vs. Atopic Dermatitis - Meaning and Types of Eczema](https://www.timeofcare.com/eczema-vs-dermatitis-vs-atopic-dermatitis-meaning-and-types-of-eczema/) - According to Habif's clinical dermatology, 5th edition, "Eczema (Eczematous inflammation) is the most common inflammatory skin disease. Although the term dermatitis is often used to refer to an eczematous eruption, the word means inflammation of the skin and is not synonymous with eczematous processes. Recognizing a rash as eczematous rather than psoriasiform or lichenoid, for - [Atopic Dermatitis (Eczema): Differential Diagnosis](https://www.timeofcare.com/atopic-dermatitis-eczema-differential-diagnosis/) - Atopic dermatitis Seborrheic dermatitis Irritant contact dermatitis Irritant hand eczema / Irritant hand dermatitis (housewives' eczema or detergent hands) - from repeated exposure to various chemicals and hand washing. Allergic contact dermatitis e.g. poison ivy. Impetigo Psoriasis Neurodermatitis / Lichen simplex chronicus Scabies Systemic diseases Dermatitis herpetiformis Dermatophyte infection Candidiasis Tinea HIV Hypersensitivity drug reaction. - [Dermatitis, Differential Diagnosis](https://www.timeofcare.com/dermatitis-differential-diagnosis/) - See the differential diagnosis of atopic dermatitis. - [Atopic Dermatitis (Eczema)](https://www.timeofcare.com/atopic-dermatitis-eczema/) - Atopic Dermatitis (Eczema) - [Breastfeeding: How long should each breastfeeding be?](https://www.timeofcare.com/breastfeeding-how-long-should-each-breastfeeding-be/) - Week 1: Offer both breasts at each feeding. This will help bring in your milk supply. Do 10 minutes on the first breast, then switch to the second breast if your baby is still hungry. Alternate the breast you start on. You may need to stimulate your baby to suck on the second breast. That - [NUTRITION AND GROWTH IN INFANTS](https://www.timeofcare.com/nutritionandgrowth/) - Infancy is divided into three main stages, each of which is unique in terms of growth, developmental achievements, nutrition needs, and feeding patterns. -Early infancy (birth to 6 months of age): The most rapid changes occur in early infancy. -Middle infancy (from ages 6 to 9 months): Growth slows but still remains rapid. -Late infancy - [When Should Breastfed Babies Be Supplemented with Iron?](https://www.timeofcare.com/iron-supplementation/) - Infants who are born at term usually have sufficient iron stores for 4 to 6 months. However, since breast milk contains very little iron, breastfed infants are at risk of iron deficiency by age 6 months and should receive an iron supplement beginning at age 4 months. The ABFM puts it this way, "Healthy full-term - [When Should I Introduce Water?](https://www.timeofcare.com/introducing-water/) - The WHO recommends that babies should be exclusively breastfed for the first six months. That means that the baby only gets breastmilk and nothing else, not even water, and not even when it is hot. Breastmilk is 80% water. As such, every time the baby breastfeeds, the baby is getting water. At six months old - [When Should I Introduce Solid Foods?](https://www.timeofcare.com/introducing-solid-foods/) - May start solid foods after 4-6 months. However, the best time to start solid foods depends not only on your child's age, but also on your child's ability to sit up, support his or her head, and meet other developmental milestones. 4-6 months old: Start with iron-fortified cereals (four tablespoons/serving, one serving per day. 6-9 - [When Should I Introduce Cow's Milk?](https://www.timeofcare.com/introducing-milk/) - Whole cow's milk - Start at 1 year (12 months) of age. Don't give it before because of risks of iron deficiency and allergies. Cow's milk doesn't contain adequate iron. Skim milk or 2% milk - Start at 2 years of age. Don't use skim milk before 2 years. Babies need the fat from whole - [Formula-Feeding: How long should each feeding last?](https://www.timeofcare.com/formula-feeding-how-long-should-each-feeding-last/) - -A feeding shouldn't last more than 20 minutes. If it does, the baby is either overfeeding or the nipple is clogged. Try changing nipples. A nipple that is working well should drip about 1 drop per second when the bottle of formula is inverted. - [Formula Feeding: How often should I feed my baby?](https://www.timeofcare.com/formula-feeding-how-often-should-i-feed-my-baby/) - Basic information -Most formulas come from cow's milk. A few come from soybeans and are for babies who may be allergic to the type of proteins in cow's milk. -Use an iron-fortified formula to prevent anemia. -Most formulas come as either: 1) Powder, 2) Concentrated liquid, and 3) Ready-to-serve liquid. Powder and concentrated liquid formulas - [Formula Feeding: How Much Formula Should my Baby be Eating?](https://www.timeofcare.com/formula-feeding-how-much-formula-should-my-baby-be-eating/) - -Most newborns start with 1 ounce per feeding and by 7 days of life, they can take 3 ounces. -You can calculate how much formula your child should be eating by using their weight in kilograms, their estimated daily energy requirements for his age, gender, and exercise/activity level, and the conversion rate that 1Oz of - [Estimating Energy Needs in Infants, Children, and Adolescents](https://www.timeofcare.com/estimating-energy-needs-in-children-and-adolescents/) - Estimated Energy Requirements from Harriet Lane. Energy Requirements of children and Adolescents, by the Food and Agriculture Organization of the U.N. Interactive DRI (Dietary Reference Intake) for HealthCare Professionals, from the USDA.gov Children's Energy Needs Calculator by Baylor College of Medicine, Houston. Calories Needed Each Day, from NIH.gov. Original link available here: https://www.nhlbi.nih.gov/health/educational/wecan/downloads/calreqtips.pdf, last accessed - [How do you know if the baby is getting enough breast milk or formula?](https://www.timeofcare.com/how-do-you-know-if-the-baby-is-getting-enough-breast-milk-or-formula/) - Whether formula or breastfeeding, you know by counting the number of wet diapers and bowel movements. -Baby's urine output: day 1 = 1 wet diaper; day 2 = 2 wet diapers; day 3 = 3 wet diapers; greater than 6 days old = 6-8 diapers in a 24-hour period. -Baby's stool should change from meconium - [Breastfeeding: How often should you breastfeed?](https://www.timeofcare.com/how-often-should-you-breastfeed/) - -The first 2 weeks to 1 month: Until your milk supply is well established and the baby is gaining weight--usually 2 weeks--feed the baby whenever he cries or seems hungry. This is called demand feeding. This would usually be about every 1.5hrs to 2hrs. -When your baby is 1-month-old and your milk supply is in, - [Weight Changes at Different Ages](https://www.timeofcare.com/weight-changes-at-different-ages/) - Weight loss and weight gain from birth to 2 years of life. Infants: -Lose 5 to 10% of their body weight in the first few days of life. This is because of fluid loss and some breakdown of tissue. This weight loss should not lose more than 10% of birth weight. -Regain birth weight by 10 - [Calculating How Much Formula or Breastmilk a Child Should Be Eating](https://www.timeofcare.com/calculating-how-much-formula-or-breastmilk-a-child-should-be-eating/) - Energy Requirements or Calorie Intake for Infants, Children, and Adolescents -Formula and Breastmilk each has 20 kcal/oz. That is, 1 Oz of formula or breastmilk has 20 kcal of energy. -30 ml = 1oz. -Look at an energy requirement's chart to get the energy requirement in Kcal/Kg/day for each child's age, gender, and exercise/activity level. - [Anti-itch (Antipruritic) medications, Topical and Systemic](https://www.timeofcare.com/anti-itch-medications-topical-and-systemic/) - Nonpharmacologic Treatment of Pruritus. Topical anti-itch medications (Antipruritic Creams and Lotions) Topical Menthol Eucerin calming itch relief lotion. Contains Menthol 0.15% Topical Antihistamines (Weak evidence of efficacy) -Benadryl itch stopping cream (Diphenhydramine / Zinc acetate) -Doxepin 5% cream (Zonalon). Drowsiness and sedation are common. Avoid in children. Topical Anesthetics Pramoxine 1% topical e.g. Caladryl cream. - [The Circulatory System (Cardiovascular System)](https://www.timeofcare.com/the-circulatory-system/) - The circulatory system = The cardiovascular system = The vascular system. The circulatory system is an organ system that circulates blood and nutrients (e.g. amino acids, sugars, electrolytes, etc), O2, CO2 hormones, and blood cells to and from the cells in the body to provide nourishment and help in fighting diseases, stabilize temperature and pH, - [Differential Diagnosis: VINDICATED MEN](https://www.timeofcare.com/differential-diagnosis-mmemonic-vindicate/) - Mechanisms of Disease To come up with a differential diagnosis, a preferred framework to use is: 1) an Anatomic framework, or 2) a Physiologic framework. However, I have found that applying a mechanisms-of-disease based approach within the context of an anatomic framework works very well. An example of mechanisms based approach is the mnemonic VINDICATED MEN that gives - [Dermatology](https://www.timeofcare.com/dermatology/) - Articles from dermatologist Dr. Donald Scott Aldara-cream-imiquimod-application Aldara-pictures-basal-cell Derm-dilemma-role-of-immune-response-modifiers Imiquimod-to-treat-different-cancers-of-the-epidermis Imiquimod-tx-for-melanoma-in-situ-lentigo-maligna Treatment-of-nodular-basal-cell-w-cryo Tx-of-lentigo-maligna (melanoma-in-site)-with-imiquimod Dr-sunshine Salt-water-pools-HOA A good way to view skin cancer is as Melanoma Skin Cancer vs. NonMelanoma Skin Cancer. The nonmelanoma skin cancer is treated in a similar way. It includes: BCC, SCC, MCC; precursors to SCC include AKs and SCC in - [Skin Biopsy Indications](https://www.timeofcare.com/skin-biopsy-indications/) - "A skin biopsy is used to diagnose or rule out skin conditions and diseases. It may also be used to remove skin lesions. A skin biopsy may be necessary to diagnose or to help treat skin conditions and diseases, including: Actinic keratosis Bullous pemphigoid and other blistering skin disorders Dermatitis, psoriasis and other inflammatory skin - [Autoimmune Diseases](https://www.timeofcare.com/autoimmune-diseases/) - American Autoimmune Related Diseases Association lists over 150 autoimmune diseases and includes some very common diseases. Rheumatologists treat musculoskeletal and autoimmune diseases. Rheumatoid arthritis Lupus (SLE, and the other types) Systemic lupus erythematosus (SLE) Drug-induced lupus, Discoid lupus Neonatal Lupus Multiple sclerosis Sarcoidosis Myasthenia gravis Dermatitis herpetiformis Dermatomyositis Myositis Psoriasis Psoriatic arthritis Narcolepsy Achalasia Addison’s - [Describing Skin Lesions](https://www.timeofcare.com/describing-skin-lesions/) - https://www.merckmanuals.com/professional/dermatologic-disorders/approach-to-the-dermatologic-patient/description-of-skin-lesions - [Atopic Dermatitis (Eczema): Presentation by Age](https://www.timeofcare.com/atopic-dermatitis-eczema-presentation-by-age/) - The clinical presentation of atopic dermatitis varies with age. There are 3 phases of eczema present that differently. Infantile stage (0-2 years of age) - Occurs on the face, scalp, extensor surfaces of limbs, and on the trunk. Infants may have generalized body eczema. Lesions are pruritic, red, weeping or scaly, and crusted lesions. Childhood - [Jaundice (Hyperbilirubinemia) in Neonates](https://www.timeofcare.com/jaundice/) - -Phototherapy Chart. -Differential diagnosis. Red Flags Findings of Jaundice The following findings are of particular concern: Jaundice in the first day of life TSB > 18 mg/dL Rate of rise of TSB > 0.2 mg/dL/h or > 5 mg/dL/day Conjugated bilirubin concentration > 1 mg/dL if TSB is < 5 mg/dL or > 20% of - [Neonatal Jaundice or Hyperbilirubinemia: Differential Diagnosis](https://www.timeofcare.com/neonatal-jaundice-or-hyperbilirubinemia-differential-diagnosis/) - Unconjugated No Hemolysis Physiologic jaundice Breast milk jaundice Infant of mother with diabetes Internal hemorrhage Polycythemia Hypothyroidism Immune thrombocytopenia Gilbert syndrome, Crigler-Najjar syndrome, Pyloric stenosis Hemolysis present Blood group incompatibility: ABO, Rh factor, minor antigens Infection Thalassemia(Hemoglobinopathies) G6PD, Pyruvate kinase Spherocytosis Ovalocytosis Conjugated Cytomegalovirus infection, Hyperalimentation cholestasis, Neonatal hepatitis, Sepsis, TORCH infection, Urinary tract infection - [HIV / AIDS](https://www.timeofcare.com/hiv-aids/) - Initial diagnosis -Screening test: -Confirmation test: See HIV testing here. HIV RNA or p24 if an acute infection is suspected. Management Screen for STIs. @ follow up CD4 count. Consider CD8. Viral load. Key Points Preexposure Prophylaxis (PrEP) for the Prevention of HIV. Opportunistic infections in HIV, Prophylaxis. Syphilis in patients with HIV. - [Screening for STIs (Sexually Transmitted Infections) and Treating STIs](https://www.timeofcare.com/screening-for-stis-sexually-transmitted-infections/) - Screening and Treating STIs Ordering STD or STI tests Chlamydia DNA probe Gonorrhea DNA probe HIV Test Syphilis (RPR or VRDL) Hepatitis B Testing (if not immunized) Trichomonas RNA PCR (NAAT) is new CDC recommendation. Vaginal Wet prep is okay but misses many true cases of trich. Consider Urinalysis Testing for STIs generally involves a - [HIV Screening and Confirmation Tests](https://www.timeofcare.com/hiv-screening-and-confirmation-tests/) - CDC guide on testing for HIV. Check this! Helpful. "Screening Tests. The conventional serum test for diagnosing HIV infection is the repeatedly reactive immunoassay followed by confirmatory Western blot or immunofluorescent assay. The test is highly accurate (sensitivity and specificity greater than 99.5%), and results are available within one to two days from most commercial - [Epididymitis](https://www.timeofcare.com/epididymitis/) - Definition: Inflammation of the epididymis. -Differential Diagnosis. -Etiology and treatment are based on patient age and the likely causative organisms. -Most Common Cause: --Children younger than 14 years: Reflux of urine into the ejaculatory ducts. --Sexually active men age 14 to 35 years: GC / CT are the most common pathogens. Tx: Ceftriaxone 250mg IM x - [Opportunistic infections in HIV, Prophylaxis](https://www.timeofcare.com/opportunistic-infections-in-hiv-prophylaxis/) - Patients with HIV / AIDS and other severe immunodeficiency diseases are at risk for certain opportunistic infections. Susceptibility to opportunistic infections can be measured by CD4+ T lymphocyte counts. Pneumocystis pneumonia: Patients with a CD4+ count - [Venous Thromboembolism (VTE): DVT and PE](https://www.timeofcare.com/venous-thromboembolism-vte-dvt-and-pe/) - Diagnosis H&P Risk factors? Provoked vs. Unprovoked PE? - Massive vs. Sub-massive? Wells criteria. Wells Criteria doesn't work well inpatient. Complications? - Differential diagnosis & Etiology. Diagnostic studies: Treatment Outpatient tx vs. Inpatient tx? -"Most patients with DVT or low-risk PE can be treated in the outpatient setting with LMWH and a vitamin K antagonist - [Syncope and Presyncope](https://www.timeofcare.com/syncope/) - Definition and classification of syNCOpe and presyncope. -Neurally mediated syncope vs. cardiac syncope vs. orthostatic hypotension syncope. -Patients with presyncope have similar prognoses to those with syncope and should undergo a similar evaluation" (AFP 2017) H&P performed. Differential Diagnosis reviewed. Risk stratification: San Francisco Syncope Rule. Management: -Orthostatic vitals in all patients. -12-lead ECG in - [Definition and classification of syncope and presyncope](https://www.timeofcare.com/syncope-mnemonic-for-the-classification-of-syncope/) - Definition of Syncope and Presyncope Syncope is a sudden, brief, complete loss of consciousness (LOC) and postural tone caused by global cerebral hypoperfusion. It is followed by spontaneous recovery. The decreased perfusion to the cerebral cortex or reticular activating system (RAS) leads to the LOC. Presyncope is a state of lightheadedness, muscular weakness, blurred vision, - [What is the difference between calories and kilocalories?](https://www.timeofcare.com/what-is-the-difference-between-calories-and-kilocalories/) - The U.D. Department of Agriculture says: "The "calorie" we refer to in food is actually kilocalorie. One (1) kilocalorie is the same as one (1) Calorie (uppercase C). A kilocalorie is the amount of heat required to raise the temperature of one kilogram of water one degree Celsius." The philips.com site says: "Scientifically, 1 kilocalorie (1000 calories or 1 - [Neck Pain, Differential Diagnosis](https://www.timeofcare.com/neck-pain-differential-diagnosis/) - Neck strain, eg, poor sleeping posture, whiplash injury Herniated disk (discogenic neck pain) Axial neck pain Whiplash associated disorder (WAD) Radiculopathy Cervical myelopathy Shoulder disorder Compression fracture Osteoarthritis, eg, cervical spondylosis seen on x-ray Osteomyelitis Deep neck infection, eg, Ludwig’s angina Subarachnoid hemorrhage Meningitis Migraine Neoplasm e.g. spinal cord tumor Metastatic cancer Rheumatoid arthritis Ankylosing - [Low Back Pain, Differential Diagnosis](https://www.timeofcare.com/low-back-pain-differential-diagnosis/) - Muscular strain Osteoarthritis - Hip osteoarthritis Herniated disk Spinal stenosis Cauda equina tumor Sciatica Sacroiliitis, eg, ankylosing spondylitis Idiopathic (sprain, strain) Spondylosis (disk, annulus, facet) Compression fracture - e.g. caused by osteoporosis, multiple myeloma Traumatic fracture Spondylolisthesis Kyphosis, Scoliosis, Malignancy - Primary or Metastatic cancer Infection - Osteomyelitis or epidural abscess Ankylosing spondylitis, psoriatic spondylitis, Reiter’s - [Hypokalemia](https://www.timeofcare.com/hypokalemia/) - -Rule of thumb in patients with normal renal function: every 10 mEq KCL given will raise the serum potassium level by 0.1 mmol/dL. -PO is the best way to replace potassium if the patient can take PO. -10mEq/hr is the recommended rate for giving KCL peripherally. -If you want to give it faster than 10mEq/hr, - [Magnesium Deficiency Aggravates Hypokalemia](https://www.timeofcare.com/magnesium-deficiency-aggravates-hypokalemia/) - "Magnesium deficiency is frequently associated with hypokalemia. Concomitant magnesium deficiency aggravates hypokalemia and renders it refractory to treatment by potassium. Herein is reviewed literature suggesting that magnesium deficiency exacerbates potassium wasting by increasing distal potassium secretion. A decrease in intracellular magnesium, caused by magnesium deficiency, releases the magnesium-mediated inhibition of ROMK channels and increases potassium - [Anion-Gap Metabolic Acidosis, Causes and Differential Diagnosis (MUD PILES / GOLD MARK)](https://www.timeofcare.com/causes-of-anion-gap-metabolic-acidosis/) - A) Causes of Increased Anion Gap Metabolic Acidosis MUD PILERS Methanol (antifreeze, windshield fluid, fuel, solvents), Ethanol, etc. Methanol is metabolized to formic acid. And formic acid gives off the H+ that is picked up by bicarb, leaving its conjugate base to raise the AG. Uremia (renal failure) DKA, alcoholic ketoacidosis Paraldehyde - Iron, Isoniazid - [Salicylate toxicity leads to metabolic acidosis and respiratory alkalosis](https://www.timeofcare.com/salicylate-toxicity/) - Salicylates are a group of chemicals derived from salicylic acid. E.g. aspirin (acetylsalicylic acid), salicylic acid, bismuth subsalicylate (Pepto-Bismol), Mesalamine (5-aminosalicylic acid), etc. Salicylate overdose causes a high anion gap metabolic acidosis in both children and adults and respiratory alkalosis 2/2 to hyperventilation in adults. Direct stimulation of the respiratory center in the brain causes - [ENT Medications (Decongestants, Antihistamines, Antitussives, Expectorants)](https://www.timeofcare.com/ent-medications/) - Everything you need to know about ENT Medications Recently, I reviewed a pharmacopeia that listed over forty common brand names for ENT medications. They all had the following classes of medications occurring in different combinations and sold under different brand names. Because of this, many cold and cough medicines contain the same active ingredients. Take - [Lactic Acidosis - Types, Causes, and Differential Diagnosis](https://www.timeofcare.com/causes-and-types-of-lactic-acidosis/) - Definition: Lactic acidosis is defined as a plasma lactate concentration of 4 mmol/L or higher. Lactate levels > 2 mmol/L defines hyperlactatemia Cause: Impaired tissue oxygenation → increased anaerobic metabolism → lactate. Lactic acid levels rise b/c of either increased production or decreased use or both. This happens by 3 mechanisms. 1) Increased pyruvate production. 2) Reduced entry - [Anaerobic Respiration to Make Lactic Acid](https://www.timeofcare.com/anaerobic-respiration-to-make-lactic-acid/) - The following image from KhanAcademy.com shows the process of anaerobic respiration to make lactic acid in the muscles. When a person is exercising hard, the muscles do not have enough oxygen to continue the aerobic respiration pathway. This low oxygen causes the muscles to shift to an alternative pathway, anaerobic respiration that doesn't require oxygen - [Alcohol Withdrawal Treatment in the Hospital](https://www.timeofcare.com/alcohol-withdrawal-treatment-in-the-hospital/) - -Rule out other possible dx: CNS infection, CNS bleed, metabolic d/o, drug overdose, liver failure, and GI bleed that can mimic or coexist with alcohol withdrawal. Consider CT head and lumbar puncture. -Evaluate patient for complications of alcohol abuse and alcohol withdrawal. -CIWA-Ar Protocol. -CBC, CMP, Urine Drug Screen, Urinalysis. -Supportive care: IV Fluids, nutritional supplementation, - [Treatment vs Prophylaxis of alcohol withdrawal](https://www.timeofcare.com/treatment-vs-prophylaxis-of-alcohol-withdrawal/) - This article discusses the difference between treatment vs Prophylaxis of alcohol withdrawal - [Clinical Institute Withdrawal Assessment (CIWA-Ar) for Alcohol Withdrawal](https://www.timeofcare.com/clinical-institute-withdrawal-assessment-ciwa-ar-for-alcohol-withdrawal/) - This page discusses the Clinical Institute Withdrawal Assessment (CIWA-Ar) for Alcohol Withdrawal. - [Treating Alcohol Withdrawal Syndrome with Benzodiazepines](https://www.timeofcare.com/treating-alcohol-withdrawal-syndrome-with-benzodiazepines/) - Information on Treating Alcohol Withdrawal Syndrome with Benzodiazepines. - [The Delta Ratio (delta delta): The delta anion gap / delta Bicarb Ratio](https://www.timeofcare.com/the-delta-anion-gap-delta-bicarb-ratio/) - The delta anion gap/delta HCO3- Ratio in patients with a high anion gap metabolic acidosis The delta AG/delta HCO3 ratio is the ratio of the increase in AG above baseline to the decrease in HCO3 below the baseline. The delta-delta helps us determine if there are additional metabolic acid-based disorders present. The delta-delta is also called - [Compensation for Acid-Base Disorders (Equations, etc)](https://www.timeofcare.com/compensation-for-acid-base-disorders/) - If the compensation is less or greater than expected (or predicted by the equation), a second acid-base disorder will be present in addition to the primary disorder. Such a situation is called a mixed disorder. For example: -If PaCO2 is too low, there is an additional respiratory alkalosis; If PaCO2 is too high, there is - [Non-Anion Gap Metabolic Acidosis, Causes and Differential Diagnosis (USED CARP and HARD UP)](https://www.timeofcare.com/differential-diagnosis-or-causes-of-non-anion-gap-metabolic-acidosis/) - Causes of Normal Anion Gap (Hyperchloremic) Metabolic Acidosis Non-anion gap metabolic acidosis is by definition hyperchloremic. Bicarb is lost from the system directly without taking up the hydrogen from a conjugate acid and leaving behind a conjugate base to increase the AG. Causes of normal anion gap metabolic acidosis can be broken into two: 1) - [Acid-Base Disturbances](https://www.timeofcare.com/acid-base-disturbances/) - How Acid-Base Balance is Maintained Our bodies are huge and complex chemical factories with many reactions going on within our cells. Every day, our metabolism produces huge amounts of acids that our bodies must manage to avoid deadly acidemia. These acids are expired/exhaled (by the lungs), excreted (by the kidneys), metabolized to non-charged neutral molecules, - [Primary Acid-Base Disorders](https://www.timeofcare.com/primary-acid-base-disorders/) - There are four primary disorders; if you count the acute and chronic phases of the respiratory disorders. Metabolic acidosis Metabolic alkalosis Respiratory Acidosis (Acute and Chronic) Respiratory Alkalosis (Acute and Chronic) From the Henderson Hasselbach equation, we can see the following compensations. Determine the primary disorder/process by looking at the pH and the PCO2 Primary - [My Approach to Diagnosing Acid Base Disturbances](https://www.timeofcare.com/approach-to-diagnosing-acid-base-disturbances/) - 7 Steps to diagnosing acid-base disturbances Is this acidemia or alkalemia? - Look at the pH. Is the primary disorder metabolic or respiratory? Is the degree of compensation appropriate? "A substantially reduced or excessive level of compensation is indicative of a mixed acid-base disorder". Is the anion gap(AG) elevated or not? The Anion Gap is only - [The Delta Gap (is different from delta-delta or delta ratio)](https://www.timeofcare.com/the-delta-gap/) - The delta gap is different from the delta ratio (delta-delta) but is used for similar purposes. The advantage of using the Delta Gap over the Delta Ratio is that the delta gap equation can be simplified to be used with limited data and without a bicarbonate level.B Delta Ratio (delta-delta)=ΔAG/ΔHCO3- Delta Gap=ΔAG-ΔHCO3- Delta Gap=ΔAG-ΔHCO3-=Na+-(Cl++HCO3-)-12-(24-HCO3-)=Na+-Cl--36 Delta - [The Anion Gap(AG) and AG corrected for Albumin](https://www.timeofcare.com/anion-gap/) - Anion Gap Formula Measured cations + unmeasured cations = Measured anions + unmeasured anions. Na+ + unmeasured cations = (Cl- + HCO3-) + unmeasured anions. Anion gap (AG) = Na+ - (Cl- + HCO3-) = unmeasured anions - unmeasured cations. The AG measures anions that are not normally included in routine electrolyte studies such as - [My Discharge Summary](https://www.timeofcare.com/my-discharge-summary/) - Admissions Date: Discharge Date: Service: __________ ; Attending Physician: Dr. ________; Resident: Dr. _______ PCP / Referring Physician: Discharge Diagnosis: (Copy and paste problem list from last Progress Note) Consultants: Name, MD/DO, Date Name, MD/DO, Date List all of them. Procedures Performed: Name of the procedure, Date Name of the procedure, Date List all of - [Acid-Base Examples](https://www.timeofcare.com/acid-base-examples/) - The following video goes over several examples of acid-base disorders. More Questions - [Acid-Base Nomogram](https://www.timeofcare.com/acid-base-nomogram/) - Notice that on the x-axis (pH), 7.4, normal pH is in the middle. Notice that it crosses the y-axis (bicarb), at 24. That location with coordinates of 7.4 on the x-axis and 24 on the y-axis is called normal. Notice that the graph is like three intersecting curves drawn with a paintbrush with broad - [Interpreting an Arterial Blood Gas (ABG)](https://www.timeofcare.com/interpreting-an-arterial-blood-gas-abg/) - Normal ABG Values Normal ABG Values. The physiologic approach to interpreting Acid-Base Disturbances The physiologic approach to interpreting Acid-Base Disturbances. Base Excess (BE) in an ABG Base Excess (BE) in an ABG. Good resources 1) https://geekymedics.com/abg-interpretation/ 2) https://fpnotebook.com/renal/Lab/AbgIntrprtn.htm - [Base Excess (BE) in an ABG](https://www.timeofcare.com/base-excess-be-in-an-abg/) - "The base excess is another surrogate marker of metabolic acidosis or alkalosis. A high base excess (> +2mmol/L) indicates that there is a higher than normal amount of HCO3- in the blood, which may be due to a primary metabolic alkalosis or a compensated respiratory acidosis. A low base excess (< -2mmol/L) indicates that there is a lower than normal amount of HCO3- in the blood, suggesting either a - [Normal ABG Values](https://www.timeofcare.com/normal-abg-values/) - ABG: pH / PaCO2 / PaO2 / HCO3- / Oxygen Sat / Base Excess Normal ABG values pH: 7.35-7.45 PaCO2: 35-45 mm Hg (Partial pressure of carbon dioxide in arterial blood) PaO2: 80-100 mm Hg (Partial pressure of oxygen in arterial blood) HCO3: 21-27 mEq/L (Bicarbonate) Oxygen saturation: 95%-98% Base excess: -2mEq/L to 2mEq/L (.ie. from - [Oxygen Delivery Methods](https://www.timeofcare.com/oxygen-delivery-methods/) - Note: With oxygen delivery methods, it's really about how much FIO2 can be delivered, not really the flow rate in liters. Related article: Fraction of Inspired Oxygen (FiO2). Method FIO2 and Flow Rates Indications Comments First-Line Options Standard nasal cannula The NC can deliver an inspiratory oxygen fraction (FIO2) of 24-40% at supply flows ranging - [Fraction of Inspired Oxygen (FiO2)](https://www.timeofcare.com/fraction-of-inspired-oxygen-fio2/) - Related article: Oxygen Delivery Methods I just spoke with a respiratory therapist who taught me the following rules for estimating FiO2. I verified and the information is true. For a patient on NC, to determine the FiO2, you multiply the number of liters by 4% and then add to 20% (which is an estimate of - [Dyspnea (Shortness of Breath) Differential Diagnosis](https://www.timeofcare.com/dyspnea-differential-diagnosis/) - Fever Deconditioning, Pulmonary Asthma Chronic obstructive pulmonary disease Infection: Pneumonia, Bronchitis, TB, Fungal infection. Aspiration Pulmonary embolus Pneumothorax Pulmonary hypertension Pleural effusion Interstitial fibrosis Upper airway obstruction: epiglottitis, croup, Epstein-Barr virus Foreign body aspiration Granulomatosis with polyangiitis, (formerly called Wegener's granulomatosis) Acute respiratory distress syndrome (ARDS); Pulmonary edema. Tumor; metastatic disease hypercapnia, Heart and CV Heart - [Metabolic Acidosis](https://www.timeofcare.com/metabolic-acidosis/) - Definition and Pathogenesis of Metabolic Acidosis Definition — Metabolic acidosis is defined as an increase in the concentration of hydrogen ions in the body and reduction the HCO3 concentration. Look at the simplified pH equation above. The pH represents the concentration of hydrogen ions. If bicarb increases, pH increases. If bicarb reduces, pH reduces. If paCO2 increases, - [GOLDMARK vs. MUDPILES Mnemonics For Anion Gap Metabolic Acidosis](https://www.timeofcare.com/goldmark-vs-mudpiles-mnemonics-for-anion-gap-metabolic-acidosis/) - GOLD MARK is a new mnemonic recommended to replace MUDPILES for causes of anion-gap metabolic acidosis GOLD MARK Glycols (propylene glycol and ethylene glycol) Oxoproline - 5-oxoproline (or pyroglutamic acid) is associated with chronic acetaminophen use, often by malnourished women. L-lactate, D-lactate - D-lactic acid can occur in some patients with short bowel syndromes Methanol, - [The Differences between a Holter Monitor, Event Monitor, and an Implantable Loop Recorder](https://www.timeofcare.com/the-differences-between-a-holter-monitor-event-monitor-and-loop-recorder/) - Continuous (Holter) Monitor - Worn for 24-48 hours. Best for patients with frequent symptoms or symptoms that are associated with activity. Event monitor: Can do intermittent or continuous recording. The patient can activate it when he feels symptoms. Best for people with infrequent episodes. "There are two types of event recorders: a loop memory monitor - [What are Palpitations?](https://www.timeofcare.com/what-are-palpitations/) - Palpitations are an unpleasant abnormal sensation that one's heart is beating abnormally. The heartbeat is sensed to be unusually rapid, strong, or irregular and described by patients as pounding or racing. HR usually over 120 bpm. They are most often caused by anxiety/panic attacks as well as by cardiac arrhythmias. A palpitation is perceptible to - [Acute Kidney Injury (AKI)](https://www.timeofcare.com/acute-kidney-injury-aki/) - -H&P: Review history for any recent procedures, IV contrast, nephrotoxic meds; thirst; volume status; vital signs; orthostatic vitals; s/s of obstruction, vascular or systemic dis. -AKI stage:____ -DDx: Prerenal vs Intrinsic vs Postrenal causes. -Eval for complications of AKI. Diagnostic testing -CMP (serum electrolytes, creatinine, etc.), -Urinalysis (to look for cells, casts, protein) and urine - [Causes of AKI and diagnostic tests](https://www.timeofcare.com/causes-of-aki-and-diagnostic-tests/) - Selected causes of AKI requiring immediate diagnosis and specific therapies Recommended diagnostic tests Decreased kidney perfusion Volume status and urinary diagnostic indices Acute glomerulonephritis, vasculitis, interstitial nephritis, thrombotic microangiopathy Urine sediment examination, serologic testing and hematologic testing Urinary tract obstruction Kidney ultrasound Source: Table 5 from KDIGO https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2012-AKI-Guideline-English.pdf - [Definition and Staging of Acute Kidney Injury (AKI)](https://www.timeofcare.com/definition-and-staging-of-acute-kidney-injury-aki/) - Acute Kidney Injury (AKI) According to KDIGO, AKI is defined as an: 1) Increase in serum creatinine by ≥0.3 mg/dL within 48 hrs; OR, 2) Increase in serum creatinine to ≥1.5 times baseline (i.e. 50% above baseline), which is known or presumed to have occurred within the prior 7 days; OR, 3) Urine volume - [Fractional Excretion of Sodium (FENa)](https://www.timeofcare.com/fractional-excretion-of-sodium-fena/) - Determines if renal failure is due to pre-renal, post-renal, or intrinsic renal pathology. FENA is only useful in AKI, not CKD. FENa cannot be used in patients on diuretics. Use FEUrea instead. Consider obstructive uropathy as a differential for AKI, no matter what the FENa score, as it is easy to correct. You can do - [BUN / Creatinine Ratio](https://www.timeofcare.com/bun-creatinine-ratio/) - We may look at the BUN / Creatinine ratio to help determine the cause of renal failure. The ratio of BUN to creatinine is usually between 10:1 and 20:1. An increased ratio may be due to a condition that causes a decrease in the flow of blood to the kidneys, such as CHF or dehydration. - [Indications for (Endoscopy) EGD in GERD patients](https://www.timeofcare.com/indications-for-egd-in-gerd-patients/) - The ACP indications for EGD in patients with GERD. EGD is indicated in:1)Alarm symptoms: Men and women with heartburn and alarm symptoms (dysphagia, bleeding, anemia, weight loss, and recurrent vomiting).2)Failed PPI therapy: Men and women with typical GERD symptoms that persist despite a therapeutic trial of 4 to 8 weeks of twice-daily proton-pump inhibitor therapy.3)Severe - [Constipation Medications (Laxatives)](https://www.timeofcare.com/medications-for-treatment-of-constipation/) - First Line Drugs: 1) Bulk-forming agents, 2) Tension reduces (stool softeners), 3) Osmotic laxatives. Route: Oral Second Line Drugs: 1) Stimulants, 2) Suppositories / Enemas. Route: Oral or Rectal Other Drugs: Lubiprostone, Linaclotide, Methylnaltrexone, Naloxegol Treatment Algorithm for constipation from the AAFP, 2015 The following table of treatment options can be seen presented with pictures in my powerpoint on treating - [Hyponatremia](https://www.timeofcare.com/hyponatremia/) - Proximate cause: Excess of water in relation to sodium. It can be induced by 1) taking in too much water (e.g. primary polydipsia) and/or by 2) impaired water excretion (e.g. due, to advanced renal failure) or by 3) persistent release ADH. "Hyponatremia is almost always due to increased ADH". H&P Performed. Eval for volume status - [Short- and Long-Term Risk Factors for Syncope](https://www.timeofcare.com/short-and-long-term-risk-factors-for-syncope/) - Short-term risk (associated with outcomes in the ED and up to 30 days after syncope) and long-term risk (up to 12 months of follow-up). Table 5. Short- and Long-Term Risk Factors* Short-Term Risk Factors (≤30 d) Long-Term Risk Factors (>30 d) History: Outpatient Clinic or ED Evaluation Male sex74,85,101,102 Male sex68,90 Older age (>60 y)88 Older - [Causes of SIADH (Syndrome of Inappropriate Antidiuretic Hormone)](https://www.timeofcare.com/causes-of-siadh-syndrome-of-inappropriate-antidiuretic-hormone/) - Malignancy: lung, brain, GI, GU, lymphoma, leukemia, thymoma, mesothelioma Pulmonary conditions: Pneumonia, asthma, COPD, Pneumothorax, positive pressure ventilation, TB, aspergillosis. Intracranial causes: Trauma, stroke, hemorrhage, infection, hydrocephalus, Guillain-Barre syndrome. Drugs: Antipsychotics, antidepressants (esp. SSRIs), chemotherapy, AVP, MDMA Other causes: Pain, nausea, postoperative state. Source of above list: Pocket Medicine "The root cause is the pathologic - [Composition of commonly used intravenous fluids](https://www.timeofcare.com/composition-of-commonly-used-intravenous-fluids/) - Osmolality Tonicity Na+ Cl− K+ Mg2+ Ca2+ Buffera Plasma 288 Reference 140 103 4.5 1.25 2.5 24 0.9% NaCl 308 Isotonic 154 154 0 0 0 0 Lactated Ringer’s 279 Hypotonic 130 111 4.0 0 2.7 29 PlasmaLyte N/A Isotonic 140 98 5.0 1.5 0 50 Sterofundin 309 Isotonic 140 127 4.0 1.0 2.5 29 - [Atrial Fibrillation with RVR](https://www.timeofcare.com/atrial-fibrillation-with-rvr/) - Atrial fibrillation with RVR, new onset, likely 2/2 to __________ (or unknown etiology) Differential diagnosis of A-fib reviewed. Causes of a-fib reviewed. ECG reviewed. Will admit the pt to telemetry bed. Cardiac monitor. CHA2DS2-VASc score = ____ HAS-BLED score = ___ Rate control: Will acutely rate control with________. Goal rate will be < 85 bpm - [Anticoagulant/Antithrombotic Therapies for Patients with Atrial Fibrillation](https://www.timeofcare.com/anticoagulantantithrombotic-therapies-for-patients-with-atrial-fibrillation/) - Note - for valvular a-fib, you have to use warfarin. For non-valvular a-fib, you can use DOACs, the Heparins, and Warfarin. Aspirin may be used for patients with low CHA2DS2-VASc scores. For pts w/ A-fib w/ RVR (admitted), in anticipation of any procedures that may be done, start patient on Heparin(UFH) continuous infusion. When you - [Diverticulitis of the large intestine](https://www.timeofcare.com/diverticulitis-of-the-large-intestine/) - #Diverticulitis of the large intestine without perforation or abscess and without bleeding H&P. LLQ pain... Risk factors: DDx / Etiology Labs/Imaging: CT abd, BCx, CBC, CMP, Lipase Treatment Inpatient tx Admit pt to Med-Surg floor. IVFs, NPO, NGT if needed. Zosyn (to cover anaerobes + GNR) Zofran and Phenergan for N/V Morphine / Dilaudid for pain - [CHA2DS2-VASc Score](https://www.timeofcare.com/cha2ds2-vasc-score/) - The CHA2DS2-VASc score calculates the stroke risk for patients with atrial fibrillation, possibly better than the CHADS2 score. Click here to use it on MDCalc.com. It's basically CHADS-VAS with the two subscripts put on the two letters in the first part that repeat in the second part. A and S are the only two repeating numbers - [Preoperative Evaluation before Dental Procedure](https://www.timeofcare.com/preoperative-evaluation-before-dental-procedure/) - Dental Preoperative Risk Assessment; Preoperative Evaluation. -H&P performed. -Antibiotic Prophylaxis before the dental procedure is Not indicated in this patient. -The incidence of perioperative cardiovascular events varies according to the patient risk profile, patient's functional capacity, and risk of the proposed surgery. 1) Active Cardiac Conditions that are Contraindications to Elective Surgery: None present. 2) Surgery-Specific Cardiac - [Treatment of Severe Symptomatic Hyponatremia](https://www.timeofcare.com/treatment-of-severe-symptomatic-hyponatremia/) - If sodium is < 125 mEq per L and the patient has severe symptoms (e.g. AMS, seizures, etc), then you should treat with 3 % saline. AAFP Algorithm for treating Severe Hyponatremia. Reference article: https://www.aafp.org/afp/2015/0301/p299.html - [Empiric Antibiotic Therapy Guidelines](https://www.timeofcare.com/empiric-antibiotic-therapy-guidelines/) - Empiric Antibiotic Therapy Guidelines and Antibiogram for DRMC (2018). Empiric Antibiotic Therapy Guidelines for DRMC (older). - [Workup of Hyponatremia](https://www.timeofcare.com/workup-of-hyponatremia/) - In a few simple steps, this article shows you how to work up a patient with hyponatremia. - [Hypertension Medications for Urgent Care and Inpatient Settings](https://www.timeofcare.com/hypertension-medications-for-urgent-care-and-inpatient-settings/) - Oral Medication to bring BP down quickly I use often use: Clonidine 0.2 mg PO x 1 Another option is: Captopril 6.25 mg or 12.5 mg PO x 1 (if the patient is not volume overloaded) IV Blood Pressure Medications to bring BP down quickly Hydralazine 10-20 mg IV Push, Q4hr Labetalol 20 mg IV Push, Q15 - [Comfort or PRN Medications (Inpatient and Outpatient)](https://www.timeofcare.com/comfort-or-prn-medications/) - Note, many EHRs allow you to simply type "PRN Medications" to bring up power sets that allow you to choose prn meds. Check yours. It could make your job easier. Common Comfort or PRN Meds for Inpatient and Outpatient use. Pain control Pain management - PRN Medications. Antipyretics Acetaminophen(Tylenol) 650mg PO q6h PRN pain, fever - [Benzonatate (Tessalon Perles)](https://www.timeofcare.com/benzonatate-tessalon-perles/) - Benzonatate (Tessalon Perles) comes as 100 mg capsules. Cough Benzonatate (Tessalon Perles) 100-200 mg PO tid prn. Max: 600 mg/day. Don't open or dissolve the capsule. Mechanism of action It "anesthetizes respiratory passage, lung, and pleural stretch receptors, reducing the cough reflex. It is an ester local anesthetic. - [Antidiarrheal Meds (Diarrhea Medications)](https://www.timeofcare.com/antidiarrheal-medications/) - Loperamide (Imodium) 2mg PO after each loose stool. Max: 16 mg/day. Diphenoxylate/Atropine (Lomotil) 2.5mg / 0.025 mg, take 1-2 tabs po bid-qid prn for diarrhea. *Also comes as a suspension. Bismuth Subsalicylate (Pepto-Bismol, Kaopectate) 265 mg, take 2 tabs po q1h prn for diarrhea. Max: 4200 mg/24h. *Also comes as a suspension. Fiber supplements Opiates - [Pain Management](https://www.timeofcare.com/pain-management/) - Pain Management - PRN Medications. Oral Opioid Medications. How to Write Patient Controlled Analgesia (PCA) Orders. Opioid Conversions. Opioid allergies and cross-reactivity. Opioid selection, principles. Pain Management for patients with Allergic Reaction to Morphine. Pain Management Compounded Treatments. Pain mgt in patients with CKD (Renal Insufficiency or ESRD on Dialysis). Pain management in patients with - [Pain Management - PRN Medications](https://www.timeofcare.com/pain-management-prn-medications/) - Mild Pain Acetaminophen(Tylenol) 650mg PO q6h PRN pain, fever Acetaminophen (Tylenol) 650 mg Rectal suppository, Q4hr PRN pain, fever Motrin (Ibuprofen) 600mg PO q8h PRN mild pain Moderate Pain -Naproxen 500mg PO then 250mg q8h (max 1250mg/ day) PRN -Ketorolac (Toradol) 15-30mg IV/ IM or 10mg PO q6h PRN mod pain (max dose 40mg/ day - [Osteomyelitis: Cellulitis r/o Osteomyelitis](https://www.timeofcare.com/osteomyelitis-cellulitis-ro-osteomyelitis/) - #Cellulitis r/o Osteomyelitis, condition, stable. The most common cause is strep or staph. H&P performed. Probed to bone? At ___cm? Labs: Imaging: CXR shows _____; MRI ____ Admit to Med/Surg Treatment Vancomycin + Zosyn. Elevate extremity. F/u BCx. Consult Podiatry/Wound Care for debridement, biopsy for cultures. Consider consulting vascular surgery. If diagnosis confirmed, will need 4-6 - [Antibiotic Coverage](https://www.timeofcare.com/antibiotic-coverage/) - When doing empiric abx coverage, you want to think of covering the following as needed. MRSA (see risk factors for MRSA) Pseudomonas (see risk factors for Pseudomonas) GNR (Gram-negative rods) Gram positives (Cocci & Rods) Anaerobes Also, see risk factors for Multi-drug Resistant Pathogens. Antibiotics that Cover Pseudomonas Aeruginosa Zosyn (piperacillin & tazobactam); Piperacillin; Timentin (Ticarcillin & - [Acute Pericarditis](https://www.timeofcare.com/acute-pericarditis/) - Diagnosis: -H&P -Echo, CXR, EKG (Diffuse ST elevations, PR depressions) -CBC, CMP, -Troponins, CRP, ESR. -Consider ordering antiviral/antibacterial/anti-fungal labs to find the cause. -Check flu, HIV. TB if risk factors. -DDx and Etiologies. Treatment: -Consult cardiology -Colchicine 0.6 mg daily -Ibuprofen 600 mg q8h -Pantoprazole 40 mg daily (prevention of GI toxicity from NSAIDs) -Recheck - [Acute Abdominal Pain](https://www.timeofcare.com/acute-abdominal-pain/) - Diagnostic Imaging: CT of the abdomen and pelvis, preferably with contrast. - [Acute Abdominal Pain - Imaging of Choice](https://www.timeofcare.com/acute-abdominal-pain-imaging-of-choice/) - Diagnostic imaging of acute abdominal pain in adults: CT of the abdomen and pelvis, preferably with contrast, is the imaging modality of choice if there is significant concern about serious pathology or if the diagnosis is unclear from the H&P and lab tests. Cartwright SL, Knudson MP: Diagnostic imaging of acute abdominal pain in adults. Am - [CT - Contrast or No Contrast ?](https://www.timeofcare.com/ct-contrast-or-no-contrast/) - This article talks about indications for contrast CT and indications for non-contrast CT - [Immune reconstitution inflammatory syndrome (IRIS) in HIV Patients](https://www.timeofcare.com/immune-reconstitution-inflammatory-syndrome-iris-in-hiv-patients/) - "Antiretroviral therapy (ART) initiation in HIV-infected patients leads to recovery of CD4+T cell numbers and restoration of protective immune responses against a wide variety of pathogens, resulting in reduction in the frequency of opportunistic infections and prolonged survival. However, in a subset of patients, dysregulated immune response after initiation of ART leads to the phenomenon - [Heparin Induced Thrombocytopenia (HIT)](https://www.timeofcare.com/heparin-induced-thrombocytopenia/) - HIT occurs in 5 % of patients exposed, regardless of the dose, schedule, or route of administration. HIT is caused by an autoantibody directed against platelet factor 4 (PF4) in complex with heparin. HIT antibodies activate platelets and can cause catastrophic arterial and venous thrombosis. HIT can cause arterial thrombosis which leads to vital organs - [Hepatic Encephalopathy, Acute](https://www.timeofcare.com/hepatic-encephalopathy-acute/) - Acute Hepatic Encephalopathy 2/2 to ________ Symptoms caused by a failure of liver to detoxify NH3 and other substances that cause cerebral edema and/or act as false neurotransmitters (GABA-like) Precipitating causes evaluated. PE: Asterixis present? Pt has hepatic encephalopathy stage____ Labs: Ammonia level, CMP (look for electrolyte abnormalities), CBC (look for signs of infection) Studies: Consider - [Alcoholic Hepatitis](https://www.timeofcare.com/alcoholic-hepatitis/) - Treatment -Prevent and treat alcohol withdrawal. -Alcohol abstinence -Supportive Care: --Fluid management and Nutritional support --Monitor for infection --Prophylaxis against gastric mucosal bleeding --D/c nonselective beta-blockers in patients with severe alcoholic hepatitis. If beta-blockers are indicated, don't start them until the patient has recovered. -The severity of alcoholic hepatitis determined by using the Maddrey's Discriminant - [Tumor Lysis Syndrome (TLS)](https://www.timeofcare.com/tumor-lysis-syndrome-tls/) - This page discusses how to prevent and treat tumor lysis syndrome. - [Precipitating causes of Hepatic Encephalopathy](https://www.timeofcare.com/precipitating-causes-of-hepatic-encephalopathy/) - increased dietary protein, constipation, GIB, med noncompliance, infection (including SBP and UTI), azotemia/renal failure, hypoxia, hypokalemia, metabolic alkalosis, hypovolemia, HCC, portosystemic shunt, meds, hepatic or portal vein thrombosis, sedative or tranquilizer use, hypoglycemia. - [Transfusions](https://www.timeofcare.com/transfusions/) - The Difference between a Type and Screen and a Crossmatch. Go and sign the consent form with the patient. Here is a sample consent form, the hospital has specific forms to order. Don't give two units when one unit will do. Each unit of packed red blood cells (PRBCs) is expected to raise circulating hemoglobin - [Anemia](https://www.timeofcare.com/anemia/) - Definition: Hgb - [Adrenal insufficiency & Adrenal Crisis](https://www.timeofcare.com/adrenal-insufficiency/) - H&P performed. Definition: Adrenal crisis = acute adrenal insufficiency. It is a life-threatening emergency that requires immediate treatment. Pt in adrenal crisis, not just adrenal insufficiency. S/Sx of adrenal crisis reviewed. DDx of adrenal crisis. Pathophysiology reviewed. Will distinguish primary, secondary, and tertiary causes. Labs: Imaging: BMP usually shows a slightly low sodium level and - [Understanding Adrenal Insufficiency and Adrenal Crisis](https://www.timeofcare.com/understanding-adrenal-insufficiency-and-adrenal-crisis/) - What is adrenal insufficiency? Adrenal insufficiency means the adrenal glands are not producing enough of some or all of its hormones. Its production is insufficient. Adrenal insufficiency can be primary or secondary. "Addison’s disease, the common term for primary adrenal insufficiency, occurs when the adrenal glands are damaged and cannot produce enough of the adrenal - [The Difference Between Adrenal Insufficiency and Adrenal Crisis](https://www.timeofcare.com/the-difference-between-adrenal-insufficiency-and-adrenal-crisis/) - "Adrenal crisis is an acute life-threatening condition precipitated by an internal or external process in the setting of known or unknown adrenal insufficiency and corticosteroid deficiency. It is important to note that there is a difference between adrenal insufficiency and adrenal crisis. Addison's disease, among other causes, is characterized by long-term adrenal insufficiency, whereas adrenal - [Clostridium Difficile (C. Diff)](https://www.timeofcare.com/clostridium-difficile/) - H&P performed. Risk Factors: Typical Presentation: Classifying C. diff Severity and Treatment. DDx reviewed. Diagnostic Tests: Treatment -Contact precautions: Put the patient in contact isolation with enteric precautions. Healthcare team to wash hands before and after patient contact. Hand hygiene with soap and water likely more effective than alcohol-based hand sanitizers in removing C. difficile spores - [Choosing Antibiotic Coverage](https://www.timeofcare.com/choosing-antibiotic-coverage/) - Antibiotic Coverage Principles. Antibiotic Classes and Mechanisms of Action. Penicillin Family Antibiotics. Anti-Ribosomal Antibiotics. Antibiotic Treatment Duration By Disease State and Location. Risk Factors For Pseudomonas Infection. Risk Factors for Multidrug-Resistant Organisms. Risk Factors for MRSA. MRSA in adults: Treatment of skin and soft tissue infections. Cephalosporins. First Generation Cephalosporins. Intravenous to Oral Antibiotic - [Antibiotic Classes and Mechanisms of Action](https://www.timeofcare.com/antibiotic-classes-and-mechanisms-of-action/) - Sulfonamides Source: http://www.orthobullets.com/basic-science/9059/antibiotic-classification-and-mechanism - [Acute Pancreatitis, Assessment & Plan](https://www.timeofcare.com/acute-pancreatitis-assessment-plan/) - See Acute Pancreatitis. - [Risk Factors for Multidrug-Resistant Pathogens](https://www.timeofcare.com/risk-factors-for-multidrug-resistant-pathogens/) - Risk factors for MDR VAP Prior intravenous antibiotic use within 90 d Septic shock at time of VAP ARDS preceding VAP Five or more days of hospitalization prior to the occurrence of VAP Acute renal replacement therapy prior to VAP onset Risk factors for MDR HAP Prior intravenous antibiotic use within 90 d Risk factors - [Risk Factors for MRSA](https://www.timeofcare.com/risk-factors-for-mrsa/) - History of colonization or infection with MRSA Recent (within 3 months) hospitalization or concurrent prolonged hospitalization > 2 weeks Prolonged hospital stay Residence in a long-term care facility (e.g. transfer from a nursing home or subacute facility) Recent antibiotic therapy HIV infection Men who have sex with men Injection drug use Hemodialysis Incarceration Military service - [Risk Factors For Pseudomonas Infection](https://www.timeofcare.com/risk-factors-for-pseudomonas-infection/) - A compromised immune system (eg, HIV-infected patients, solid organ or hematopoietic cell transplant recipients, neutropenic hosts, and those on immunosuppressive or immunomodulatory agents such as TNF-alfa inhibitors) Recent antibiotic use in the last 3 months. Recent hospitalization, Recent Intubation, / Mechanical ventilation Recent enteral tube feeding Cirrhosis of the liver Structural lung abnormalities such as - [Mechanisms causing the anemia](https://www.timeofcare.com/mechanisms-causing-the-anemia/) - Is there evidence for decreased RBC production? Is there evidence for increased red cell destruction (hemolysis)? Is there a history of bleeding? - [Anemia Workup / Diagnostic Tests for Anemia](https://www.timeofcare.com/anemia-workup/) - Initial labs for all pts should be a CBC w/ diff, reticulocyte count, and peripheral blood smear. These 3 tests will help classify the anemia in microcytic, normocytic, and macrocytic anemia, evaluate bone marrow response, and evaluate RBC morphology. After you have interpreted the first three tests, order additional tests from the list below to - [Anemia in adults - Causes & Differential diagnosis](https://www.timeofcare.com/anemia-in-adults-causes-differential-diagnosis/) - Microcytic anemia: MCV - [Hemolytic Anemia - Differential Diagnosis](https://www.timeofcare.com/hemolytic-anemia-differential-diagnosis/) - Alloimmune: Transfusion reactions, hemolytic disease of the fetus and newborn. Neonatal DAT is positive. Autoimmune hemolytic anemia: Warm or cold autoimmune hemolytic anemia. DAT positive. Drug-induced: Drug-induced thrombotic microangiopathy, drug-induced immune hemolytic anemia, oxidative hemolysis. Envenomation: Insects, cobra, brown recluse spider Enzymopathy: G6PD or pyruvate kinase deficiencies. Lab test = Enzyme activity measurement Hemoglobinopathy: Sickle - [Anemia Workup Algorithm](https://www.timeofcare.com/anemia-workup-algorithm/) - Anemia Workup Algorithm. Initial steps in evaluating anemia Hemoglobin - That's how we diagnose anemia and determine severity. From CBC. MCV - This helps classify it down into Microcytic, Normocytic, and Macrocytic Anemias. From CBC. Reticulocyte count - This gives information about the bone marrow response and so whether the anemia is originating from failure - [What is in a Complete Blood Count (CBC)](https://www.timeofcare.com/what-is-in-a-complete-blood-count-cbc/) - Sample Complete Blood Count (CBC) Report. - [Hemolytic Anemia Labs Explained Clearly](https://www.timeofcare.com/hemolytic-anemia-labs-explained-clearly/) - Elevated Lactate dehydrogenase (LDH) Elevated indirect Bili Reduced haptoglobin Why increased LDH? Lactate dehydrogenase (LDH or LD) is an enzyme found in nearly all living cells (animals, plants, and prokaryotes). LDH catalyzes the conversion of lactate to pyruvic acid and back, as it converts NAD+ to NADH and back. A dehydrogenase is an enzyme that - [How to Use a Peak Flow Meter](https://www.timeofcare.com/how-to-use-a-peak-flow-meter/) - [Urinary Tract Infection (UTI) - Urethritis, Cystitis, Pyelonephritis](https://www.timeofcare.com/urinary-tract-infection-uti/) - Pyelonephritis Treatment (Inpatient and Outpatient). Pyelonephritis (Outpatient Management). Uncomplicated Cystitis. Urethritis. - [Urethritis](https://www.timeofcare.com/urethritis/) - Urethritis. Read: https://www.uptodate.com/contents/urethritis-in-adult-men - [Uncomplicated Cystitis](https://www.timeofcare.com/uncomplicated-cystitis/) - -H&P performed. -Risk factors for uncomplicated UTI reviewed. Treatment -Antibiotic choices for uncomplicated cystitis. References Am Fam Physician. 2011 Oct 1;84(7):771-776. http://www.aafp.org/afp/2011/1001/p771.html - [Pyelonephritis (Outpatient Management)](https://www.timeofcare.com/pyelonephritis-outpatient/) - -Most common cause: E. Coli -Mild to moderate pyelonephritis can be safely treated outpatient. -Antibiotic treatment pyelonephritis outpatient reviewed with the patient. References Am Fam Physician. 2011 Sep 1;84(5):519-526. http://www.aafp.org/afp/2011/0901/p519.html IDSA Guidelines 2011 https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540458/all/Pyelonephritis__Acute__Uncomplicated - [Pyelonephritis in adults](https://www.timeofcare.com/urinary-tract-infection-uti-pyelonephritis/) - Treatment Use local sensitivities to guide your selection of empiric antibiotic regimen. Outpatient Treatment -Ciprofloxacin 500 mg PO twice daily for 7 days -Levofloxacin 750 mg PO once daily for 5 days. -Bactrim DS 1 tab PO twice daily for 14 days. -Cephalexin 500 mg PO four times daily for 10-14 days. Related article: Pyelonephritis - [Opioid Selection](https://www.timeofcare.com/opioid-selection/) - "Morphine is the best first choice for chronic potent opioid therapy (SOR B). It is reliable and inexpensive, and equivalent doses can be easily calculated if the patient must later be switched to another medication. Transdermal fentanyl and hydromorphone are reasonable second-line choices; however, they are not recommended as first-line therapy because they are expensive - [Physician Orders - Immunizations](https://www.timeofcare.com/physician-orders-immunizations/) - See Immunization charts on the CDC website. When you order or record them in your note, include the Dose#. Adult Td IM Tdap IM Dose#_____ DTaP IM Dose #____ Gardasil (HPV) IM Dose#_____ Hepatitis A IM Pediatric Dose / Adult Dose #___ Hepatitis B IM Pediatric Dose / Adult Dose#___ Haemophilus influenza B (HiB) IM - [Pain management in patients with both chronic liver and kidney disease](https://www.timeofcare.com/pain-management-in-patients-with-both-chronic-liver-and-kidney-disease/) - "In patients with significant renal or hepatic dysfunction, fentanyl (given IV) is the opioid of choice." Pain mgt in patients with CKD (Renal Insufficiency or ESRD on Dialysis). Pain management in patients with advanced chronic liver disease or cirrhosis. - [Pain Management in Patients with Advanced Chronic Liver Disease or Cirrhosis](https://www.timeofcare.com/pain-management-in-patients-with-advanced-chronic-liver-disease-or-cirrhosis/) - Nociceptive pain. -Acetaminophen "is an effective and safe analgesic for most patients with chronic liver disease." Limit to 2g per day. Avoid it in patients with severe alcoholic hepatitis or acute liver injury. -Opioids. Use "cautiously in patients with advanced chronic liver disease or cirrhosis". "Fentanyl appears to be safe in patients with modest hepatic dysfunction". - [Pain Management in Patients with Chronic Kidney Disease (Renal Insufficiency or ESRD on Dialysis)](https://www.timeofcare.com/pain-management-in-patients-with-chronic-kidney-disease-renal-insufficiency-or-esrd-on-dialysis/) - Management of chronic pain in chronic kidney disease Safe options for pain management in renally impaired and dialysis patients include: Acetaminophen ... Tramadol in lower doses may also be safely used in renally impaired and dialysis patients. Fentanyl, hydrocodone, and hydromorphone are the safest opioids to use in renally-impaired and dialysis patients. Low-dose gabapentin and - [Migraine or Headache Cocktail](https://www.timeofcare.com/migraine-or-headache-cocktail/) - AKA: Migraine Cocktail; Headache Cocktail NSAID - Ketorolac (Toradol) 30mg IV, Dopamine Antagonist - Metoclopramide or Prochlorperazine. E.g. Metoclopramide 10mg IV/IM, Antihistamine - Diphenhydramine (Benadryl) 25mg IV **The diphenhydramine (or benztropine) helps avoid akathisia, in addition to helping with the pain. Dopamine antagonist options include prochlorperazine 10 mg, metoclopramide 10 mg IV/IM, Chlorpromazine 0.1 - [Pain Medications/Therapeutic Agents by Class](https://www.timeofcare.com/pain-medications-therapeutic-agents-by-class/) - Neuropathic pain: Amitriptyline / Gabapentin / pregabalin; also SNRIs e.g. duloxetine. -Restless leg syndrome: Requip/ Ropinirole -Duloxetine is used by Dr. Toby for a patient who doesn't do well with Gabapentin. Can use both. Anti-inflammatory: Mobic (systemic) and Voltaren Gel(topical). Ketorolac = Toradol; Meloxicam=Mobic Muscle relaxer: Baclofen, Flexeril (Cyclobenzaprine) Lidocaine patch Opioids (cause itchiness from histamine - [Chronic Pain](https://www.timeofcare.com/chronic-pain/) - Diagnosis Distinguish between Neuropathic pain and Nociceptive pain. "Treatment options for chronic pain generally fall into six major categories: pharmacologic, physical medicine, behavioral medicine, neuromodulation, interventional, and surgical approaches." "Currently available treatment modalities on average result in only about a 30 percent decrease in pain. But even a partial response of 30 percent can be - [Pain Management for patients with Allergic Reaction to Morphine](https://www.timeofcare.com/pain-management-for-patients-with-allergic-reaction-to-morphine/) - Patients with allergies to morphine can use synthetic opioids(group 3). Synthetic opioids - Tramadol, Fentanyl, propoxyphene, methadone, and meperidine. Non-opioid pain medications. - [Opioid Allergies and Cross-reactivity](https://www.timeofcare.com/opioid-allergies-and-cross-reactivity/) - A patient has a history of anaphylaxis to morphine, almost died from it. Are there some opioids you can give to them? Yes. You simply need to choose one that is structurally different. Opioids are classified into three groups: Group 1 - The Natural occurring agents derived from the opium plant. These are the opiates. Morphine, - [Common Pain Management Proceudres](https://www.timeofcare.com/common-pain-management-proceudres/) - Procedures I saw at the pain management clinic. ESI=Epidural Steroid Injection Cervical ESI Lumbar ESI L3-L4 Transforaminal ESI Removal of spinal stimulator probes/electrodes Medial nerve block (medial nerve branch block) Caudal injection - when the patient has back surgery the epidural space is compromised and so they do a caudal approach. Facet joint injection Medial - [Definition of Chronic Constipation](https://www.timeofcare.com/definition-of-chronic-constipation/) - Rome III Criteria for Chronic Constipation A patient has chronic constipation if the patient has: Symptom onset more than 6 months prior to the diagnosis, with the following criteria fulfilled for the past 3 months: -Doesn't meet the criteria for a diagnosis of irritable bowel syndrome, -Rarely has loose stools without the use of laxatives, - [ How to Write Patient Controlled Analgesia (PCA) Orders](https://www.timeofcare.com/how-to-write-patient-controlled-analgesia-pca-orders/) - How to Write a PCA Order with morphine, hydromorphone (Dilaudid), or fentanyl. - [Pneumonia (CAP, HAP, and VAP)](https://www.timeofcare.com/pneumonia/) - Classification of pneumonia. -Community-Acquired Pneumonia (CAP) inpatient treatment. -Hospital-acquired Pneumonia (HAP). -Ventilator-Associated Pneumonia (VAP). -Healthcare-Associated Pneumonia (HCAP). - no longer recognized as an entity. - [Cellulitis](https://www.timeofcare.com/cellulitis/) - Cellulitis is divided into two categories with different treatment. Suppurative (Purulent) Cellulitis. Non-suppurative (Nonpurulent) Cellulitis. References http://www.hopkinsmedicine.org/amp/guidelines/Antibiotic_guidelines.pdf http://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540106/all/Cellulitis - [Suppurative (Purulent) Cellulitis](https://www.timeofcare.com/suppurative-purulent-cellulitis/) - Definition: Cellulitis with purulent drainage or exudates but without a drainable abscess. Usually caused by S. aureus (MSSA and MRSA). Severity: *Mild / Moderate to Severe H&P performed. Labs: Imaging/Studies: Treatment: -Parenteral (Moderate to Severe): Vancomycin -Duration: 5-7 days -"Always elevate affected extremity. Treatment failure is more commonly due to failure to elevate than a - [Non-suppurative (Nonpurulent) Cellulitis](https://www.timeofcare.com/non-suppurative-nonpurulent-cellulitis/) - -Definition: Cellulitis with intact skin and no evidence of purulent drainage. -The most common cause is strep or staph. Usually caused by beta-hemolytic streptococci (e.g. group A, B, C, G streptococci) and MSSA. Tx: Parenteral (Mod to Severe): --Cefazolin 1g IV q8h or --Ampicillin/Sulbactam 3g IV q6h. --PCN allergy: Clindamycin 600mg IV Q8H [At DRMC - [Hyperkalemia](https://www.timeofcare.com/hyperkalemia/) - Acute Hyperkalemia. Chronic Hyperkalemia (usually outpatient). - [Chronic Hyperkalemia (Usually Outpatient)](https://www.timeofcare.com/chronic-hyperkalemia/) - Treatment - Low potassium diet - Polystyrene sulfonate (Kayexalate) 15g PO qd-qid in the short term. Alternately you can do 30-50g PR q6h. - Lasix 10mg (low dose) short-term - Patiromer (Veltassa) in the long run. Requires application and receiving med from the company, Relypsa. Not yet available in drug stores as of 3/2017. For - [Acute Hyperkalemia](https://www.timeofcare.com/acute-hyperkalemia/) - Workup -Repeat CMP/BMP as needed. -Get EKG, always. Treatment -Hyperkalemia Treatment. Pearls "Because hyperkalemia can have deleterious effects on the myocardium, an EKG is the first diagnostic test in the workup of a patient with hyperkalemia. Although not all patients with hyperkalemia will have an abnormal EKG, those who do need to be given - [Hyperkalemia Treatment](https://www.timeofcare.com/hyperkalemia-treatment/) - For mild elevation (5 to 6 mEq/L), remove potassium from the body with Furosemide and Kayexalate. For moderate elevation (6 to 7 mEq/L), shift potassium intracellularly with Glucose plus insulin, Sodium bicarbonate, and Nebulized albuterol For severe elevation (>7 mEq/L with toxic ECG changes), you need to shift potassium into the cells and eliminate potassium from the body. Therapies that shift potassium will - [Stroke (CVA) or TIA](https://www.timeofcare.com/stroke-or-tia/) - Strokes are either ischemic or hemorrhagic. Acute Ischemic Stroke (87 % of us U.S strokes). Hemorrhagic Stroke (13 % hemorrhagic stroke). - [Ischemic stroke or TIA](https://www.timeofcare.com/ischemic-stroke-or-tia/) - L. sided weakness and numbness. R/o acute ischemic Stroke -H&P performed. -Ddx of stroke, reviewed. -Likely ischemic stroke (which is 87 % of us U.S strokes vs. 13 % hemorrhagic stroke). -admit to telemetry. Cardiac monitor for arrhythmias. -No dextrose in IVFs for stroke pts. b/c it worsens outcomes. -f/u transthoracic echo (TTE) to assess for - [Constipation in adults, Chronic](https://www.timeofcare.com/constipation-adults/) - Chronic Constipation in Adults: Assessment and Plan History, above. -Established diagnosis with Rome III criteria & reviewed main symptoms. --Bristol stool type:____ -R/o alarm features. -Medication review: No Drugs that cause constipation. -DDx reviewed to identify and treat reversible causes. PE: Abd. exam and rectal exam (visualization & digital rectal exam) done. Anoscopy routinely in elderly patients. Labs/Imaging: - [Hypernatremia](https://www.timeofcare.com/hypernatremia/) - Two types: Acute Hypernatremia. Chronic Hypernatremia (Almost all patients with hypernatremia have chronic hypernatremia). - [GI Bleeding: Acute lower gastrointestinal bleeding in adults](https://www.timeofcare.com/acute-lower-gastrointestinal-bleeding-in-adults/) - #Acute Lower GI bleed, active, likely 2/2 to __________ Definition: Acute lower GI bleeding refers to acute blood loss originating the colon. -DDx: LGI - Diverticulosis, angiodysplasia, AVM, neoplasm, IBD, infectious colitis, anorectal disease (hemorrhoids, fissures). -A rectal exam performed. Guaiac stool. -Admit to telemetry -D/C and avoid all meds that can cause or worsen - [GI Bleed: Upper GI Bleed (Active Bleeding)](https://www.timeofcare.com/ugi-bleed-active-bleeding/) - #Upper GI bleed, active, likely 2/2 to __________ -Admit to telemetry -DDx: UGI - Esophageal varices, Mallory-Weiss tear, Dieulafoy's lesion, PUD, esophagitis, neoplasm, aortoenteric fistula (if hx of AAA repair). -A rectal exam performed. Guaiac stool. -D/C and avoid all meds that can cause or worsen GI bleed (Anticoagulants, antiplatelets, NSAIDs) -Reviewed initial CBC, CMP, - [Delirium (Confusional States / Altered Mental Status)](https://www.timeofcare.com/delirium/) - Diagnosis Definition: Delirium vs. dementia. Diagnosis is made clinically using the Confusion Assessment Method (CAM). The first step in the diagnosis delirium is to r/o underlying medical causes. H&P performed. Meds reviewed. No focal or lateralized neurologic findings. Common presentation: Risk Factors: Red flags: Questions for diagnosing Delirium. Ddx and causes. Dx studies: -CMP (electrolytes, creatinine, - [COPD Exacerbation (Inpatient)](https://www.timeofcare.com/copd-exacerbation/) - Dx: Acute respiratory distress 2/2 COPD exacerbation -Likely 2/2 to ______________________ - admit to telemetry -Bronchodilators (SAA + SABA): Ipratropium + albuterol nebs or MDI -Systemic steroids (PO or IV) -Antibiotics: Will start abx if infection suspected. -Oxygen: cont O2 supplement & continuous pulse ox. -NIV as needed. -Flu / Pneumonia shots. -f/u CBC & CMP - [Acute COPD Exacerbation Treatment](https://www.timeofcare.com/copd-exacerbation-treatment/) - This article discusses COPD Exacerbation Treatment - [COPD Medications](https://www.timeofcare.com/copd-medications/) - Related Article: COPD Exacerbation Treatment. COPD Medications available in the United States Anticholinergics Short-acting anticholinergics Ipratropium (Atrovent).Two sprays four times per day (MDI). Long-acting anticholinergics Tiotropium (Spiriva). One puff per day (DPI). Aclidinium bromide (Tudorza Pressair). One puff two times per day (DPI) Side effects for all anticholinergics are the same: "Anaphylaxis, angle-closure glaucoma, hypersensitivity reaction, paradoxical bronchospasm" - [Stroke, Hemorrhagic](https://www.timeofcare.com/stroke-hemorrhagic/) - -Initial CT shows hemorrhage. -Will repeat CT (at least once) to ensure that the bleed is not increasing. -Neurological surgery consulted. -Will keep SBP between 110-140 -Swallow eval by Speech therapy -PT / OT as needed -Frequent neuro checks ** See Ischemic stroke approach for imaging etc. - [The New ACC/AHA High Blood Pressure Guidelines (2017)](https://www.timeofcare.com/the-new-acc-aha-high-blood-pressure-guidelines-2017/) - See link on ACC website. "Blood pressure categories in the new guideline are: Normal: Less than 120/80 mm Hg; Elevated: Systolic between 120-129 and diastolic less than 80; Stage 1: Systolic between 130-139 or diastolic between 80-89; Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg; Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients - [Diabetic Ketoacidosis (DKA)](https://www.timeofcare.com/dka-diabetic-ketoacidosis/) - -H&P, performed. -Patient meets diagnostic criteria for DKA. -DKA Protocol. *DKA 2/2 1) Noncompliance w insulin/diet, 2) Infection, 3) MI (Get EKG) *BUN/Cr elevation due to dehydration *WBC due to DKA, dehydration, r/o infection *Abd. pain due to DKA vs Gastroenteritis or Gastritis or PUD or Pancreatitis or Cholecystitis or Diverticulitis or UTI Initial workup - [Principles and Pathophysiology of Sodium and Water Homeostasis](https://www.timeofcare.com/principles-and-pathophysiology-of-sodium-and-water-homeostasis/) - This article discusses the three fundamental principles of sodium and water homeostasis and the pathophysiology of common disorders of sodium. - [Pancreatitis, Acute](https://www.timeofcare.com/pancreatitis/) - Diagnosis H&P: Risk Factors: DDx and common causes, reviewed. Studies: Lipase (which is more specific than amylase). Imaging: CT abd. w/ contrast or U/S of abd; KUB/CXR Category: Interstitial edematous vs. necrotizing acute pancreatitis (which type is it?) Severity: Mild, moderate, and severe acute pancreatitis (what is the severity?). Diagnostic criteria, classification, and severity reviewed. - [Assessing Severity in Acute Pancreatitis](https://www.timeofcare.com/assessing-severity-in-acute-pancreatitis/) - There are several methods for assessing severity in acute pancreatitis. Two common and easy to use methods are: 1. The SIRS score The presence of SIRS in patients w/ pancreatitis is associated with increased mortality. The higher the number of features of SIRS that are present, the more severe the acute pancreatitis is. Features of - [Preload and Afterload](https://www.timeofcare.com/preload-and-afterload/) - "The pre- and after- in preload and afterload refer to before and after(really during) the contraction of the heart muscle." KTA Preload "Preload is the degree of myocardial distension prior to shortening (i.e. shortening during contraction). As initially demonstrated by Otto Frank and Ernest Starling, an intrinsic property of myocardial cells is that the force - [Heart Failure, Acute Decompensated HFrEF (CHF Exacerbation)](https://www.timeofcare.com/acute-decompensated-heart-failure-chf-exacerbation/) - Acute respiratory distress 2/2 acute decompensated systolic LV heart failure - (HFrEF) Cause of CHF exacerbation:____ Baseline function is:---------------; the Last echo was------------- H&P performed, see above. -CXR, ECG, Echo (if none recently), CBC w/ diff, CMP, Mg/Phos, BNP, cardiac enzymes. If concerned for PE will get CTA w/ contrast. In the ED pt received: - [How to Assess Degree of Congestion and Adequacy of Perfusion in Heart Failure Patients](https://www.timeofcare.com/how-to-assess-degree-of-congestion-and-adequacy-of-perfusion-in-heart-failure-patients/) - No Congestion (Dry) Congestion present (Wet) Adequate perfusion (Warm) Warm & Dry Outpatient Rx Warm & Wet Diuresis Low perfusion (Cold) Cold & Dry Inotropes (CCU) Cold & Wet Diuresis, inotropes, and/or vasodilator (CCU) "Patients are described as either ‘wet’ or ‘dry’ depending on their fluid status and either ‘cold’ or ‘warm’ depending on - [Sepsis and Septic Shock](https://www.timeofcare.com/sepsis-and-septic-shock/) - Definition: Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Diagnosis H&P consistent with sepsis. Labs: -CBC w/ diff, CMP, Coags (PT/INR), D-dimer -Serum lactate -ABG (as needed to eval for acidosis, hypoxemia, or hypercapnia). -Cultures (see below). -UA, Procalcitonin. -Imaging targeted at suspected site of infection (e.g. CXR, CT chest/and or abd). Diagnostic - [Sepsis Bundles from the Surviving Sepsis Campaign](https://www.timeofcare.com/sepsis-bundles-from-the-surviving-sepsis-campaign/) - To be measured within 3 hours 1. Draw Lactate: Measure lactate level 2. Draw Blood Cx: Obtain blood cultures prior to administration of antibiotics 3. Antibiotics: Administer broad-spectrum antibiotics 4. Fluids: Administer 30ml/Kg crystalloid for hypotension or lactate ≥ 4 mmol/L 5. Source control. Surgical source control when appropriate (e.g. appendicitis, abscess, etc). To be completed - [Chest pain, r/o Acute Coronary Syndrome (ACS)](https://www.timeofcare.com/chest-pain-ro-acs/) - This article shows you how to approach acute coronary syndrome. Diagnosis: Chest pain rule out acute coronary syndrome. - [Indications for Early Invasive Strategy](https://www.timeofcare.com/indications-for-early-invasive-strategy/) - Send NSTE-ACS patients with either a high-risk feature or a moderate to high TIMI score to early invasive strategy (with angiography and intent for revascularization with PCI or CABG surgery as defined by the anatomy) vs. a conservative strategy with medical therapy. 1. High-risk features that are indications for early invasive strategy Non-ST elevation ACS - [AMERICA - TIMI Score Mnemonic](https://www.timeofcare.com/america-timi-score-mnemonic/) - TIMI score = Thrombolysis in Myocardial Infarction score. It is a validated risk score. The TIMI score was initially validated as a prognostic tool for patients admitted for ACS but has been studied for use in the diagnosis of MI. TIMI Risk Score for UA/NSTEMI Estimates risk at 14 days of all-cause mortality, new or - [Acute Coronary Syndrome (ACS)](https://www.timeofcare.com/acute-coronary-syndrome-acs/) - Acute Coronary Syndrome (ACS) vs. Chronic Coronary Syndrome (CCS) Note: Stable Angina is NOT part of ACS. Stable angina is chest pain on exertion that is relieved by rest and or nitroglycerin. Stable angina is part of chronic coronary syndrome (CCS). CCS is also called chronic angina syndrome. Acute Coronary Syndrome (ACS) The three types/presentations - [Pain Control in Acute Pancreatitis](https://www.timeofcare.com/pain-control-in-acute-pancreatitis/) - First, give adequate fluid resuscitation b/c hypovolemia from vascular leak and hemoconcentration can cause ischemic pain and resultant lactic acidosis. Fluid replacement is the first step to treating pain in these patients. IV opioids, usually PCA pump. Hydromorphone or fentanyl (intravenous), Morphine is fine. Even though morphine can cause an increase in sphincter of Oddi pressure, it's - [qSOFA (Quick SOFA) Criteria](https://www.timeofcare.com/qsofa-quick-sofa-criteria/) - Systolic blood pressure ≤100 mm Hg Respiratory rate ≥22/min Altered mentation - [Chronic Rate Control Therapy for Atrial Fibrillation](https://www.timeofcare.com/chronic-rate-control-therapy-for-atrial-fibrillation/) - Oral beta-blockers are preferred in pts w/ with CAD, HF due to systolic dysfunction, and in pts in whom the ventricular rate increases inappropriately during exercise. BBs increase survival in CAD and HF 2/2 systolic dysfunction. An Oral non-dihydropyridine CCB is preferred in pts with chronic lung disease and in pts who do not tolerate - [Atrial Fibrillation: Rate Control Medications](https://www.timeofcare.com/atrial-fibrillation-rate-control-medications/) - MOA: CCB (Diltiazem and Verapamil), BB (Metoprolol, etc), and Digoxin work in AF by blocking the AV node. They block AV nodal conduction. They are AV-nodal blocking agents. **Nodal blocking agents must be avoided in WPW. If there is no significant heart failure or hypotension, use IV beta blockers or non-dihydropyridine calcium channel blockers. Prefer - [Diabetes Medications and their Classes](https://www.timeofcare.com/diabetes-drugs-and-their-classes/) - Diabetic Medications, Dosages, and Routes (non-insulin). Five Mechanisms used to lower blood sugars. Insulin types, onset, and duration of action. Injectable Diabetes Medications. Diabetes Medications that promote Weight Loss. Diabetes Medications that promote weight gain. There are 10 classes of common diabetes medications to know. Only 3 of them are injectables. The other 7 are - [Incretin-Based Medications for Type 2 Diabetes](https://www.timeofcare.com/incretin-based-medications-for-type-2-diabetes/) - Incretin-Based Medications for Type 2 Diabetes - [Midfoot (Lisfranc) Injury / Tarsometatarsal Joint Complex Injuries](https://www.timeofcare.com/midfoot-lisfranc-injury-tarsometatarsal-joint-complex-injuries/) - If there is a dislocation or bony injury, surgery is needed. If there are no fractures or dislocations in the joint and the ligaments are not completely torn, wear a non-weight-bearing cast or boot for 6 weeks. A) PRICE-M (Acute treatment) "Following diagnosis, the acute management of a tarsometatarsal (TMT) joint complex follows the standard - [Infectious Mononucleosis (IM)](https://www.timeofcare.com/infectious-mononucleosis/) - ** Cause: Epstein Bar Virus (EBV). IM is a syndrome caused by EBV. Most EBV inf Test: Heterophile "infectious mononucleosis (IM). The syndrome most commonly occurs between 15 and 24 years of age. It should be suspected in patients presenting with sore throat, fever, tonsillar enlargement, fatigue, lymphadenopathy, pharyngeal inflammation, and palatal petechiae." AAP Treatment: - [Streptococcal Pharyngitis: Differential Diagnosis](https://www.timeofcare.com/streptococcal-pharyngitis-sore-throat-differential-diagnosis/) - See Differential Diagnosis of Sore Throat (Pharyngitis). - [Neutropenic Fever](https://www.timeofcare.com/neutropenic-fever/) - #Neutropenia and Fever -Definition: Temperature > 38.3°C (101°F) + ANC < 500. [NB: Fever in a neutropenic patient is defined as a single temperature >38.3°C (101°F) or a sustained temperature >38.0°C (100.4°F) for >1 hour.] -Admit to Med-Surg -CBC, Manual diff, Blood cultures, CMP, Lactate, Procalcitonin, UA, UCx, Sputum Cx, CXR, -1 Liter bolus -Cefepime - [Neutropenia (Low Neutrophils)](https://www.timeofcare.com/neutropenia-low-neutrophils/) - Neutropenia in adults is usually due to either decreased granulocyte production (in the bone marrow) or increased destruction (in the periphery). Decreased Granulocyte production caused by bone marrow disorders Drug-induced neutropenia. Common culprits are antithyroid drugs (e.g. Methimazole), sulfasalazine, Bactrim (trimethoprim-sulfamethoxazole), dipyrone combined with analgesics, clomipramine, and carbimazole. Chemotherapy Aplastic anemia Cyclic neutropenia Pure white - [How to Calculate the Absolute Neutrophil Count (ANC)](https://www.timeofcare.com/how-to-calculate-the-absolute-neutrophil-count-anc/) - See this page from Washington University to see sample values. They also show a method to calculate it which is accurate but I find is not intuitive. See page here: HowtoCalculateANC The following intuitive formula gives an easy way to calculate the ANC. To find out your ANC, multiply the percentage of neutrophils by the - [Diabetes foot exams](https://www.timeofcare.com/diabetes-foot-exams/) - Last foot exam was: Consent was obtained and the procedure explained. Adequate exposure of entire legs was done. Visual inspection: Gen inspection reveals no missing limb, toes. Normal limb color (no erythema or pallor). On close examination, no hair loss (e.g. from PVD) or skin changes. No dryness/erythema. No venous or arterial ulcers. No joint - [TYPES OF STUDIES IN EPIDEMIOLOGY](https://www.timeofcare.com/types-of-studies-in-epidemiology/) - Case-Control Study "A case-control study is designed to help determine if an exposure is associated with an outcome (i.e., disease or condition of interest). In theory, the case-control study can be described simply. First, identify the cases (a group known to have the outcome) and the controls (a group known to be free of the - [Cervical Cancer Screening / Pap Smear](https://www.timeofcare.com/cervical-cancer-screening/) - Pap Smear Results: ASCCP Management Guidelines. Screening Recommendations How to Classify Pap smear Results and Cervical Biopsy Results. Risk Factors for Cervical Cancer. - [How to Classify Pap Smears & Cervical Biopsy Results](https://www.timeofcare.com/classification-of-pap-smears-cervical-biopsy-results/) - 1. Pap Smear (Cytology) Results Classification Normal Atypical squamous cells of undetermined significance (ASC-US). ASC-US is the most common abnormal Pap test result. Low-grade squamous intraepithelial lesion (LSIL) High-grade squamous intraepithelial lesion (HSIL) Atypical squamous cells, cannot exclude HSIL (ASC-H) Atypical glandular cells (AGC). What is the difference between SIL and CIN? ASCUS - 1) - [Strep Pharyngitis Antibiotics](https://www.timeofcare.com/strep-pharyngitis-antibiotics/) - From AAFP: https://www.aafp.org/afp/2016/0701/p24.html Recommended Antibiotics for Treatment of GABHS Pharyngitis DRUG DOSAGE DURATION COST* First-line treatments Amoxicillin Children: 50 mg per kg per day orally (maximum: 1,000 mg per day) 10 days $4 Adults with mild to moderate GABHS pharyngitis: 500 mg orally two times per day Adults with severe GABHS pharyngitis: 875 mg orally - [Nexplanon Insertion Procedure Note](https://www.timeofcare.com/nexplanon-insertion-procedure-note/) - PRE-OP DIAGNOSIS: Patient desires long-term, reversible contraception. POST-OP DIAGNOSIS: Same PROCEDURE: Nexplanon placement Performing Physician: Supervising Physician: PROCEDURE: -Written and verbal informed consent obtained, risks discussed included: bleeding, irregular menses, infection, pain/discomfort, cost for removal. -The appropriate timeout was taken and the patient's non-dominant hand was identified. -Patient was instructed to lie supine on the - [Nexplanon Insertion Equipment](https://www.timeofcare.com/nexplanon-insertion-equipment/) - Upon patient arrival. UCG test Implant insertion and consent form Complete Patient Implant Insertion Checklist In procedure room. Povidone iodine or Chlorhexidine in cup with swabs 2 cc 1% Lidocaine with 25 gauge x 1.5” needle and syringe OR Spray-on anesthesia Nexplanon package Marker Gauze 4” x 4” (sterile) Bandage Adhesive and pressure dressing (e.g. CobanTM) - [Physical Exam Template - Adult (12 years and Older)](https://www.timeofcare.com/physical-exam-template-adult-12-years-and-older/) - Detailed Version VITALS: Reviewed. WEIGHT/BMI reviewed. GEN: Healthy appearing, well-developed, NAD. PSYCH: Good Judgment. AOx3. Normal memory, mood, and affect. HEENT -Head: NC/AT; -Eyes: PERRL, EOMI. No discharge or redness; -Ears: External ears are normal. Normal TMs. -Nose: Normal nares. -Mouth and throat: MMM. Normal gums, mucosa, palate,. Good dentition. NECK: Supple, with no masses. - [Physical Exam Template 2, 4, 6, 9 Months](https://www.timeofcare.com/16697-2/) - – VITALS: Reviewed. – GROWTH CHART: Following growth curve well in all parameters. – GEN: Normal general appearance. NAD. – HEAD: NCAT. AFOSF. – EYES: Red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus. – ENMT: TMs, nares, and OP normal. MMM. No abnormal oral lesions. – NECK: Supple, with no masses. – - [Physical Exam Template - 1yr, 15 months and 18 months](https://www.timeofcare.com/physical-exam-template-1yr-15-months-and-18-months/) - – VITALS: Reviewed – GROWTH CHART: Following growth curve well in all parameters. – GEN: Normal general appearance. NAD. – HEAD: NCAT. – EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus. – ENMT: TMs, nares, and OP normal. MMM. Normal gums, mucosa, palate. Good dentition. – NECK: Supple, with no - [Physical Exam Template - Children 2 to 11 years](https://www.timeofcare.com/physical-exam-template-children-2-to-11-years/) - Detailed Version VITALS & BMI: Reviewed. GEN: Normal general appearance. NAD. HEENT -Head: NC/AT. -Eyes: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus. -Ears: Normal external ears, normal TMs. -Nose: Normal nares -Mouth and Throat: MMM. Normal gums, mucosa, palate. Good dentition. NECK: Supple, with no masses. CV: RRR, no m/r/g. - [ECG Leads placement and their deflection on paper](https://www.timeofcare.com/ecg-leads-placement-and-their-deflection-on-paper/) - ECG Lead placement. The diagram below shows a heart and the direction of the resultant electrical vector. Below it, the 12 leads are shown as typically appear on an ECG tracing. The three limp leads, the three augmented limp leads, and the six precordial chest leads. The plus or negative sign with a circle around - [Procedure Reference](https://www.timeofcare.com/procedures/) - Procedure Reference - [Pediculosis (Head Lice)](https://www.timeofcare.com/pediculosis-head-lice/) - Diagnosis H&P: Risk factors: Common presentation:- Pruritus is the most common presenting symptom in pediculosis. How a diagnosis is made: Head and pubic lice infestations diagnosed by visualization of live lice. Ddx and cause: Treatment -Permethrin 1% lotion or shampoo (1st-line treatment). -Follow permethrin 1% treatment with nit removal and wet combing. The treatment should - [Gilbert’s syndrome](https://www.timeofcare.com/gilberts-syndrome/) - Also called constitutional hepatic dysfunction and familial nonhemolytic jaundice Hereditary asymptomatic unconjugated hyperbilirubinemia "Gilbert syndrome is a hereditary condition characterized by a 70% reduction in the ability to conjugate bilirubin, resulting in asymptomatic intermittent unconjugated hyperbilirubinemia. Gilbert syndrome is present in 5% to 10% of Western European populations." unconjugated hyperbilirubinemia is usually with a bilirubin level - [Proton pump inhibitors (PPIs)](https://www.timeofcare.com/proton-pump-inhibitors/) - Long-term PPI use increases the risk of: Clostridium difficile-associated diarrhea. Other enteric infections Osteoporosis and Osteoporosis fractures. Fractures (of the Hip, wrist, and spine) Community-acquired pneumonia Hypomagnesemia Cardiac events when coadministered with clopidogrel. Vitamin B12 Deficiency. Affect absorption of other vitamins and minerals including iron and folate. Reference Am Fam Physician 2012;86(1):66-70 Ann Fam Med - [Headaches, Migraine (Chronic)](https://www.timeofcare.com/headaches-chronic-migraines/) - Chronic Migraine Headaches (CM HA) Diagnosis -Meets definition of chronic migraines. -Risk factors reviewed. -No HA red flags present. -Differential diagnosis reviewed. -Workup to get or review: CBC, CMP, TSH. Consider Polysomnography. -Considered chronic migraine vs medication overuse HA (MOH) Treatment -Headache diary: To identify freq, triggers, pattern, associated sx, and response to tx. -Avoid triggers when possible. - [Headaches: Abortive Medications for Migraines](https://www.timeofcare.com/headaches-abortive-medications-for-migraines/) - Acute or Abortive Medications for Migraines Take ASAP for max efficacy. Avoid using > 2 x / wk as can lead to overuse HA. Will develop “toolbox” of different medications for different presentations (mild/early vs. severe vs. refractory) with patient. Over the counter NSAIDS: 1st line for mild to moderate headache. OTC medications: Ibuprofen (Motrin), - [Headache: Preventive Migraine Medications](https://www.timeofcare.com/headache-preventive-migraine-medications/) - Preventive Medications for Migraines Consider in pts with > 1-2 episodes or 3 days of sx / month. OCPs: Consider continuous monophasic low-dose OCPs in pts with a menstrual trigger; however, contraindicated in pts with aura & can worsen sx or cause pt to develop aura. If that happens, d/c Rx. Herbal / Alternative therapies: Petasites - [Acupuncture for Migraine Treatment](https://www.timeofcare.com/acupuncture-for-migraine-treatment/) - "Acupuncture reduces the frequency of migraine headaches when used as an adjunct to, or in place of, medical management. (Strength of Recommendation: A, based on meta-analyses)." Am Fam Physician. 2017 Jul 1;96(1):23-24. https://www.aafp.org/afp/2017/0701/p23.html Am Fam Physician. 2010 Apr 15;81(8):1036-1037. https://www.aafp.org/afp/2010/0415/p1036.html - [Headache, differential diagnosis](https://www.timeofcare.com/headache-differential-diagnosis/) - Classification of Headaches Headache red flags. The International Classification of Headache Disorders 3rd edition classifies headaches into primary and secondary headaches. I. Primary Headaches (e.g., tension, migraine, cluster) Primary headaches are headache syndromes not due to another cause. Primary headaches are often chronic and the diagnosis is established early in adulthood. Migraine Tension-type headache Cluster - [Headaches, Migraine](https://www.timeofcare.com/migraine-headaches/) - Diagnosis Diagnostic criteria reviewed. No red flags. Frequency is less than for chronic migraines. Differential diagnosis reviewed. Labs to order or review: CBC, CMP, TSH, etc. Cause is likely multi-factorial. Treatment -Stay Hydrated: Drink 2-3 liters of water per day (about eight 8 oz glasses of water). -I advise quiet, dark room when episodes occur, avoid - [Headache Diary](https://www.timeofcare.com/headache-diary/) - Headache diary from the Headache Foundation. Keeping a headache diary helps with determining headache triggers & response to treatment. Print Headache diary. - [SNOOP: Red Flags for Headache](https://www.timeofcare.com/snoop-red-flags-for-headache/) - Get MRI with contrast if you need to get imaging for HA. "Red flag signs and symptoms include focal neurologic signs, papilledema, neck stiffness, an immunocompromised state, sudden onset of the worst headache in the patient's life, personality changes, headache after trauma, and headache that is worse with exercise." SNOOP: Red Flags for Headache Stands - [Definition of Chronic Migraines](https://www.timeofcare.com/definition-of-chronic-migraines/) - A patient is said to have chronic migraines if she/he has headaches on more than 15 days per month with migraine features on at least 8 days. That is, headaches on more than half the days of the month with migraine symptoms on more than half of those days. - [Imaging Patients with Headache](https://www.timeofcare.com/imaging-patients-with-headache/) - Imaging is usually not indicated in a headache patient except a patient has red flag symptoms. MRI with contrast "If a scan is ordered to evaluate a headache disorder, MRI with contrast is preferred as it is a more sensitive test than CT and does not involve any radiation. However, as it is so sensitive, - [Migraine Risk Factors](https://www.timeofcare.com/migraine-risk-factors/) - Article discusses the risk factors for migraines and migraine severity. - [Colonoscopy, Screening](https://www.timeofcare.com/colonoscopy-screening/) - Risk Factors for Colorectal Cancer: Family history of colorectal cancer, Age, IBD, and history of abdominal irradiation. Important Colonoscopy Links Colorectal Cancer Screening Tests and Intervals. Preparing for a colonoscopy. When to Repeat a Colonoscopy. Cologuard Common types of GI polyps Hyperplastic polyps Inflammatory polyps Hamartomatous polyps Tubular adenomas Villous adenomas Which histologic type of colonic - [Cologuard](https://www.timeofcare.com/cologuard/) - Colonoscopy is generally considered the criterion standard for test characteristic studies, although it does miss some cases of colorectal cancer. "In the largest study assessing the test characteristics of the only FIT-DNA test available in the United States (Cologuard; Exact Sciences), its sensitivity and specificity to detect colorectal cancer was 92% (95% CI, 84% to - [Newborn PE Template](https://www.timeofcare.com/newborn-pe-template/) - OBJECTIVE:- VITALS: _- WEIGHTS: BW _. Today's weight _.- GEN: Normal general appearance. NAD.- HEAD: NCAT. No cephalohematoma. AFOSF.- EENT: Red reflex present bilaterally. Normal ext ears, nose, lips.- MOUTH: MMM. Normal gums, mucosa, palate, OP.- NECK: Supple.- CV: RRR, no m/r/g. Normal femoral pulses.- LUNGS: CTAB, no w/r/c.- ABD: Soft, NT/ND, NBS, no masses - [Abdominal Aortic Aneurysms (AAA)](https://www.timeofcare.com/abdominal-aortic-aneurysms/) - Definition: An AAA is defined as abdominal aorta with a maximal diameter >3.0 cm. A small AAA has a diameter - [Agenda Setting Form](https://www.timeofcare.com/agenda-setting-form/) - Hello, I'm Dr. Acha. I'm excited to serve you today! Taking care of my patients is my joy, passion, and calling. My dream is to spend unlimited time with my patients. Unfortunately, government and insurance policies have created a system that limits most office visits to 15 minutes. With such little time, we are usually only able - [Fontanelles Closure Times in children](https://www.timeofcare.com/fontanelles-closure-times-in-children/) - The posterior fontanelles close first (usually closes by 1 - 2 months of age). The anterior fontanelle closes last (usually closes between 7 - 19 months). - [Well Child Check Visit Notes](https://www.timeofcare.com/well-child-check-visit-notes/) - From Ventura Family Medicine Residency. NEWBORN WT/COLOR CHECK SUBJECTIVE: _-day old infant born to a _ year old G_ at _ weeks by _. No pregnancy or delivery problems. Mother was blood type _, HBsAg neg, rubella immune, GBS _, other labs also unremarkable. In the hospital, the patient received the initial HBV vaccine, passed - [Coding Guide](https://www.timeofcare.com/coding-guide/) - Evaluation and Management Coding Guide -- (use this) HPI Table Table of Risk from the CMS Audit Sheet used by medical billing cms.gov: SELECTING THE CODE THAT BEST REPRESENTS THE SERVICE FURNISHED (scroll down to find this section) Doc on Patient Evaluation and Management Coding CMS.gov page on Evaluation and Management Services PFSH = Past medical - [Agenda Setting Form Resources](https://www.timeofcare.com/agenda-setting-form-resources/) - Agenda Setting Form. Ask the patient to complete the form ideally in advance of a visit, but if that is not possible, then in the waiting room prior to seeing the provider. Sample Agenda Setting Form Patient Name: __________________________________ Hello. I'm excited to get to serve you today. Taking care of my patients is my - [Causes of Inaccurate Blood Pressure Measurements](https://www.timeofcare.com/causes-of-inaccurate-blood-pressure-measurements/) - Common causes of inaccurate BP Measurements When the patient has... BP can appear higher by... A full bladder 10-15 mmHg An unsupported back 5-10 mmHg Unsupported feet 5-10 mmHg Crossed legs 2-8 mmHg Cuff over clothing 10-40 mmHg Unsupported arm 10 mmHg A conversation or is talking 10-15 mmHg The table comes from the AMA website. - [Potential sources of inaccuracy when measuring Blood Pressure](https://www.timeofcare.com/potential-sources-of-inaccuracy-when-measuring-blood-pressure/) - The following tables come from the source referenced below. Empirically-evaluated potential sources of inaccuracy in the measurement of adults’ resting blood pressure Range of reported significant mean effects (in mmHg) unless specified Potential source of inaccuracy SBP DBP Patient-related 1. Acute meal ingestion −6a −5 to −1.9 2. Acute alcohol use −23.6 to +24 −14 - [Syphilis](https://www.timeofcare.com/syphilis/) - Diagnosis A presumptive diagnosis of syphilis requires use of two tests: a nontreponemal test (i.e. VDRL] or RPR]) and a treponemal test (i.e., FTA-ABS tests, TP-PA assay, EIAs, chemiluminescence immunoassays, immunoblots, or rapid treponemal assays). The nontreponemal tests (RPR or VDRL) are only screening tests which can have false positives. The confirmation is with the - [Neurosyphilis Workup](https://www.timeofcare.com/neurosyphilis-workup/) - "Further testing is warranted for persons with clinical signs of neurosyphilis (e.g., cranial nerve dysfunction, auditory or ophthalmic abnormalities, meningitis, stroke, acute or chronic altered mental status, and loss of vibration sense). Laboratory testing is helpful in supporting the diagnosis of neurosyphilis; however, no single test can be used to diagnose neurosyphilis in all instances. - [Syphilis in patients with HIV](https://www.timeofcare.com/syphilis-in-patients-with-hiv/) - "For most persons with HIV infection, serologic tests are accurate and reliable for diagnosing syphilis and following a patient’s response to treatment. However, atypical nontreponemal serologic test results (i.e., unusually high, unusually low, or fluctuating titers) might occur regardless of HIV-infection status. When serologic tests do not correspond with clinical findings suggestive of early syphilis, - [Screening for syphilis with a treponemal test](https://www.timeofcare.com/screening-for-syphilis-with-a-treponemal-test/) - Some labs are screening for syphilis using treponemal tests, (usually EIA or chemiluminescence immunoassays) instead of RPR and VRDL. "Most patients who have reactive treponemal tests will have reactive tests for the remainder of their lives, regardless of treatment or disease activity. That means that this reverse screening algorithm for syphilis testing (with treponemal tests - [Following Nontreponemal test (RPR or VDRL) titers](https://www.timeofcare.com/following-nontreponemal-test-rpr-or-vdrl-titers/) - "Nontreponemal test antibody titers might correlate with disease activity and are used to follow treatment response. Results should be reported quantitatively. A fourfold change in titer, equivalent to a change of two dilutions (e.g., from 1:16 to 1:4 or from 1:8 to 1:32), is considered necessary to demonstrate a clinically significant difference between two nontreponemal - [Causes of False-Positive Nontreponemal (RPR or VRDL) tests](https://www.timeofcare.com/causes-of-false-positive-nontreponemal-rpr-or-vrdl-tests/) - False-positive nontreponemal test results can be associated with various medical conditions and factors unrelated to syphilis, including: Other infections (e.g., HIV), Autoimmune conditions, Immunizations, Pregnancy, injection-drug use, Older age. Therefore, persons with a reactive nontreponemal test should always receive a treponemal test to confirm the diagnosis of syphilis. Reference https://www.cdc.gov/std/tg2015/syphilis.htm - [How White Blood Cells Work](https://www.timeofcare.com/how-white-blood-cells-work/) - How do white blood cells work to protect us? White blood cells (leukocytes) protect the body against both infectious disease and foreign invaders. Broadly, WBCS are categorized by structure (granulocytes or agranulocytes) or by cell lineage (myeloid cells or lymphoid cells). These broadest categories can be further divided into the five main types: neutrophils, eosinophils (acidophiles), basophils, monocytes, and lymphocytes. Bands are immature neutrophils. These - [Diaper Rash](https://www.timeofcare.com/diaper-rash/) - Diagnosis DDx & Etiology. Risk Factors: -Age 8-10 months old; -Poor hygiene (leaving stool/urine diapers on too long); -Diarrhea (e.g. from infection or when teething); -Introducing new solid foods into diet; -Taking antibiotics (encourages growth of yeast) Complications: Superinfection. Treatment Treatment per etiology. Contact irritant dermatitis -Frequent diaper checks (q2-3h intervals) to minimize exposure to - [Diaper Rash (Diaper Dermatitis) differential diagnosis](https://www.timeofcare.com/diaper-rash-differential-diagnosis/) - Irritant Contact Dermatitis. Allergic Contact Dermatitis Diaper Candidiasis Impetigo; Streptococcal infection. Cellulitis Seborrheic Dermatitis and Psoriasis Infected Contact Dermatitis (contact dermatitis with superinfection / suprainfection) e.g. Staphylococcal pustulosis. Diaper candidiasis is often a superinfection. Herpes simplex virus (HSV) infection Molluscum Warts Scapies Selected Differential Diagnosis Comparison for Diaper Rash Am Fam Physician. 2014 Jun 15;89(12):973-974. CONDITION SKIN SYMPTOMS COLOR ULCERATION/EROSION - [Diagnoses to help you order labs for patients](https://www.timeofcare.com/diagnoses-to-help-you-order-labs-for-patients/) - To order lab-work for a patient, insurance companies want to see an active diagnosis to justify the labs that they will pay for. You can't just order labs for screening or with annual exam. Here are some diagnosis to look for in your patient that will allow you to order labs and have them paid. - [Hyperhidrosis (excessive sweating)](https://www.timeofcare.com/hyperhidrosis-excessive-sweating/) - -Differential diagnosis of hyperhidrosis. Primary focal hyperhidrosis, Treatment 1st line = Antiperspirants -Mild hyperhidrosis: Treat with nonprescription antiperspirants -If nonprescription antiperspirants fail, use prescription strength antiperspirants such as 20% aluminum chloride hexahydrate or 6.25% aluminum chloride hexahydrate. Other options: Tap water iontophoresis 2nd-line = Botox Intradermal botulinum toxin injection helps alleviate hyperhidrosis. Generalized hyperhidrosis Start Oxybutinin at 2.5 - [Sustainable Development Goals](https://www.timeofcare.com/sustainable-development-goals/) - The U.N. Sustainable Development Goals World bank link. - [Should you give Oxygen to patients with Chest Pain or MI?](https://www.timeofcare.com/should-you-give-oxygen-to-patients-with-chest-pain-or-mi/) - This article assesses the need for oxygen in patients with chest pain or myocardial infarction. Is it necessary or helpful to give them oxygen? - [Medication Doses and Needle Choices for Intra-articular or Soft-Tissue Joint Injections](https://www.timeofcare.com/medication-doses-and-needle-choices-for-intra-articular-or-soft-tissue-joint-injections/) - Larger Joints (Shoulder or Knee) Inject 5 ml lidocaine (Xylocaine) + 1 ml of triamcinolone acetonide 40mg/ml (Kenalog) using a 1.5-inch, 21 gauge needle. Note: For the knee, you may go up to 2ml or 80 mg Kenalog. Ankle joint Inject 3 to 5 ml lidocaine (Xylocaine) + 0.5 ml to 1 ml of triamcinolone - [Shoulder Joint Injection Pre-procedure Checklist](https://www.timeofcare.com/shoulder-joint-injection-pre-procedure-checklist/) - Betadine/Povidone Iodine (1 bottle or 3 swab-sticks) Alcohol prep pads Lidocaine 1% without epinephrine Triamcinolone Acetonide 40mg/mL (Kenalog) Syringe, 5cc Needle, 18-gauge, 1-0.5 inch length --to draw meds. Needle, 21 to 23-gauge, >1.25-inch length (I prefer 1.5 inch) --to inject. Injection: 5 ml of Lidocaine 1% without epinephrine and 1ml of Kenalog 40 mg/1mL for a - [Shoulder Injection Procedure Note](https://www.timeofcare.com/shoulder-injection/) - Procedure Name: Shoulder Joint Injection Indication: Pain Location: ******* Pre-Procedure Diagnosis: **** Post-Procedure Diagnosis: Same Informed Consent and Counseling: The procedure, alternative treatment options, risks, and benefits were thoroughly explained to the patient and informed consent was obtained. Appropriate equipment and medications were set up. PROCEDURE: The appropriate timeout was taken. We identified and marked - [Needle Sizes for Intraarticular Steroid Injections](https://www.timeofcare.com/needle-sizes-for-intraarticular-steroid-injections/) - Larger Joints (e.g. knee or shoulder) A 1.5 inch, 21-gauge needle is usually used. Smaller Joints A 0.5 inch, 23- or 25-gauge needle can be used. Note that viscous steroid preparations can't be injected through small-bore needles. You have to use a larger one. Hip Joint Spinal Needle. A 20–22 gauge 3.5-inch standard cutting spinal needle. - [Contraindications to Intraarticular or Soft Tissue Glucocorticoid Injections](https://www.timeofcare.com/contraindications-to-intraarticular-or-soft-tissue-glucocorticoid-injections/) - Contraindications include: Periarticular infection/skin infection overlying injection site Broken skin at the injection site, Septic arthritis, Periarticular or intra-articular fracture, Joint instability, Juxta-articular osteoporosis Severe joint destruction Known hypersensitivity to the agent to be injected. Prosthetic joint (a relative contraindication) Unstable coagulopathy Before total joint replacements. Don't do steroid injections in patients waiting for a total - [Complications of Intra-articular or Soft Tissue Glucocorticoid Injections](https://www.timeofcare.com/complications-of-intraarticular-or-soft-tissue-glucocorticoid-injections/) - The following is a list of potential complications of intra-articular or soft tissue steroid injections Cushing's syndrome -- if administered more than once per month. Steroid arthropathy. Charcot-like arthropathy Tendon rupture (due to atrophy) Fat necrosis or calcification Osteonecrosis (incidence is low) Joint infection (Iatrogenic) – very low incidence Pericapsular calcification Median nerve atrophy (due - [The Difference Between Risk Factors and Determinants of Health](https://www.timeofcare.com/the-difference-between-risk-factors-and-determinants-of-health/) - Say a patient came to the E.R with chest pain. You will first address his Chest pain and potential MI. Then you will assess for risk factors like smoking, diabetes, HTN, lack of exercise, etc. Finally, you will look at underlying determinants of health such as poverty, culture, environment, etc. Risk Factors A risk factor is - [Alkaline Phosphatase (ALP) Elevated, Causes](https://www.timeofcare.com/alkaline-phosphatase-alp-elevated-causes/) - Non-hepatic cause of elevated alkaline phosphatase GGT is normal in non-hepatic causes. Physiological Pregnancy Adolescence Following a fatty meal in subjects with blood group O or B Bone disease Healing Fracture Paget’s Disease Osteomalacia Vitamin D insufficiency Rickets Malignancy: osteogenic sarcoma, bone metastases Renal Renal Failure Heart Heart Failure Endocrine Hyperthyroidism Hyperparathyroidism Malignancy Lymphoma Leukemia - [Elevated Alkaline Phosphatase (ALP) in an asymptomatic patient](https://www.timeofcare.com/elevated-alkaline-phosphatase-alp-in-an-asymptomatic-patient/) - -Step 1: Repeat CMP while fasting to confirm that the ALP is truly elevated. Also, check to make sure that it's not from something physiologic such as pregnancy or a post-prandial increase. If the repeat ALP is within normal limits, continue to monitor the patient and repeat CMP in 6-12 months. If it's still elevated, go - [Alkaline Phosphatase (ALP) that is low, causes](https://www.timeofcare.com/alkaline-phosphatase-alp-that-is-low-causes/) - Malnutrition Hypothyroidism Zinc deficiency Vitamin C deficiency Low phosphorus level Pernicious anemia Wilsons Disease - [Treating Acne with Diet](https://www.timeofcare.com/treating-acne-with-diet/) - Significance of diet in treated and untreated acne vulgaris. Advances in Dermatology and Allergology/Postȩpy Dermatologii i Alergologii. 2016;33(2):81-86. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4884775/ - [Integrative Medicine Labs](https://www.timeofcare.com/integrative-medicine-labs/) - Labs cardiothoracic specialist, Dr. Gundry, orders on most patients. Requisition Form. Supplements. A) Corus - CAD from Cardiodx.com. It gives you a score that gives you a probability that the patient has obstructive coronary artery disease. Sample Chorus CAD test result. B) Tests from Veridia diagnostics. Cardiac function -SMC Cardiac Troponin -I -NT-ProBNP Inflammation SMC Interleukin-6 - [Supplements for Integrative Medicine](https://www.timeofcare.com/supplements-for-integrative-medicine/) - [Requisition Forms](https://www.timeofcare.com/requisition-forms/) - [Integrative Medicine Labwork](https://www.timeofcare.com/integrative-medicine-labwork/) - [Anti-Inflammatory Diet](https://www.timeofcare.com/anti-inflammatory-diet/) - [Vitamin B12 (Cobalamin) deficiency](https://www.timeofcare.com/vitamin-b12-deficiency/) - Oral dissolvable B12 (No need for shots) Kirkland Signature Sublingual B-12 5000 mcg Quick Dissolve B‑12 5000 mcg. Highly bioavailable methylcobalamin. Get it from Costco or on Amazon. Put under the tongue, don't swallow, don't suck, don't dissolve in a drink. Bypasses the stomach so you don't have to worry about pernicious anemia or lack - [Hot Flashes (Vasomotor Symptoms) in menopausal or perimenopausal women](https://www.timeofcare.com/hot-flashes-in-menopausal-or-perimenopausal-women/) - -History and Physical done, as above. -Counseling: "Although estrogen is the most effective treatment for hot flashes, nonhormonal alternatives such as low-dose paroxetine, venlafaxine, and gabapentin are effective alternatives." -Will start low dose paroxetine (i.e. Paroxetine 7.5mg QD, trade name, Brisdelle), which the only nonhormonal medication approved by the FDA to treat hot flashes. Will consider - [Circumcision, visit for procedure](https://www.timeofcare.com/circumcision-visit-for-procedure/) - Order for procedure verified. History and Physical performed. Baby is doing well. Feeding, voiding, stool well. No fever or illness. Informed Consent obtained. Time of the last feeding:____ Upon arrival in the procedure room, the patient's band was checked and verified the order in the chart with another nurse. Time-out: Time-out was taken to verify - [How to Properly Measure the Blood Pressure](https://www.timeofcare.com/how-to-properly-measure-the-blood-pressure/) - Causes of Inaccurate Blood Pressure Measurements How to properly take the blood pressure See the following links. https://jamanetwork.com/journals/jama/fullarticle/2643764 https://wire.ama-assn.org/delivering-care/one-graphic-you-need-accurate-blood-pressure-reading https://wire.ama-assn.org/delivering-care/how-get-most-accurate-blood-pressure-measurement http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/KnowYourNumbers/Monitoring-Your-Blood-Pressure-at-Home_UCM_301874_Article.jsp#.WuHhFlMvyi4 - [Hypertension in Children and Adolescents, Definition of](https://www.timeofcare.com/hypertension-in-children-and-adolescents-definition-of/) - Normal blood pressure values for children and adolescents are based on sex, age, and height, and are available in standardized tables. Prehypertension is defined as a blood pressure in at least the 90th percentile, but less than the 95th percentile, for age, sex, and height, or a measurement of 120/80 mm Hg or greater. Hypertension - [Recommended Dimensions for BP Cuff Bladders for all age groups.](https://www.timeofcare.com/recommended-dimensions-for-bp-cuff-bladders-for-all-age-groups/) - Age Range Width, cm Length, cm Maximum Arm Circumference, cm* Newborn 4 8 10 Infant 6 12 15 Child 9 18 22 Small adult 10 24 26 Adult 13 30 34 Large adult 16 38 44 Thigh 20 42 52 * Calculated so that the largest arm would still allow the bladder to encircle arm by - [Cognitive Behavioral Therapy (CBT)](https://www.timeofcare.com/cognitive-behavioral-therapy/) - Diseases that CBT treats. Somatic Symptom Disorder. Anxiety (GAD), Panic disorder Depression (MDD & Dysthymia) Posttraumatic stress disorder, Attention-deficit/hyperactivity disorder, Autism, Obsessive-compulsive disorders, Tic disorders, Personality disorders, Eating disorders (Anorexia, Bulimia), Insomnia / Sleeping problems. Obesity. Motivational Interviewing (MI) helps with Weight loss. Tobacco Abuse. MI. helps with quitting smoking. Addiction and Substance Use Disorder. - [Iron Deficiency without Anemia](https://www.timeofcare.com/iron-deficiency-without-anemia/) - A lot of patients may have symptoms of iron deficiency like fatigue even before they develop anemia and microcytosis. I didn’t know this until I worked with a naturopathic doctor, Scott Buesing, and he brought that up. I asked heme-onc, Dr. Bucher and she said she had several patients she is treating for iron deficiency - [Carpal Tunnel Syndrome](https://www.timeofcare.com/carpal-tunnel-syndrome/) - Diagnosis Provocative tests. Treatment Activity modification. If possible, avoid activities that provoke symptom. Splinting at night (Nocturnal wrist splinting). A brace that holds the wrist in the neutral position is the recommended initial therapy. This prevents waking up with numbness. Splinting for 8 weeks (e.g. a Cock-up wrist splint to wear when symptomatic). Steroid injection. Inject methylprednisolone (40 mg) Oral - [Vaginitis](https://www.timeofcare.com/vaginitis/) - Background Definition: Vaginitis is the general term for disorders of the vagina caused by infection, inflammation, or changes in the normal vaginal flora or epidermis. Main types: 1) Infectious vaginitis (caused by Trichomonas, BV, and Candida), and 2) Atrophic Vaginitis (caused by estrogen deficiency), and 3) Allergic or irritant contact forms of vaginitis. Diagnosis Presentation: Signs and - [Vaginitis Plus (VG+), NuSwab®](https://www.timeofcare.com/vaginitis-plus-vg-nuswab/) - TEST: 180021 CPT: 87481(x2); 87491; 87591; 87661; 87798(x3) Indications Bacterial vaginosis (BV): As an aid to the diagnosis of bacterial vaginosis (BV) in women with a clinical presentation consistent with this disorder. The BV test utilizes semiquantitative PCR analysis of the three most predictive marker organisms (Atopobium vaginae, BVAB-2, and Megasphaera-1) to generate a total score that - [H. Pylori Disease](https://www.timeofcare.com/h-pylori-disease/) - Treatment -Triple Rx: [PPI (standard dose BID) + Amoxicillin 1g BID + Clarithromycin 500mg BID] all three for 7-14 days. Will do a 10-day course. Will beware of increased clarithromycin resistance. Will consider alternate regiments. -Confirming eradication: Will confirm eradication by repeating stool Ag test or Urea breath test after 6-8 weeks. Pt should preferably - [H. Pylori Treatment Failure](https://www.timeofcare.com/h-pylori-treatment-failure/) - You have treated a patient with triple therapy and confirmation of cure with stool antigen or breath test comes back showing that the patient is still positive. What do you do? About 20% of H. pylori treatment fails after initial treatment. Make sure that the patient is compliant with medications. Since the patient has failed - [Dermatomes](https://www.timeofcare.com/dermatomes/) - An anatomical way to look at dermatomes is with the patient bent over on all fours and head facing forward. Resources: http://emedicine.medscape.com/article/1878388-overview - [Constipation, Opiate Induced](https://www.timeofcare.com/opiate-induced-constipation/) - Lubiprostone is an effective medication approved for the treatment of opiate induced constipation. Opiates bind delta, kappa and mu receptors. Although all three receptors are related to pain mitigation, these are all also linked to decreased gastrointestinal motility. Lubiprostone works independently of these receptors by binding chloride channels in the intestine which leads to increased - [Opioid Antagonists](https://www.timeofcare.com/opioid-antagonists/) - Naloxone, Naltrexone, and MethylNaltrexone Naltrexone is a longer acting agent than naloxone and is used more for long-term needs. Naloxone, on the other hand, acts fast and is used to reverse opioid effects quickly, as in opioid overdose. Agent Mechanism of Action* Use Common Adult Doses Comments Naloxone (Narcan) Antagonizes various opioid receptors (Opioid antagonist) - [Pain Management Alternatives](https://www.timeofcare.com/pain-management-alternatives/) - Compound Prescription Order Meloxicam 0.18% / Topiramate 2.5% / Lidocaine 2.5% / Prilocaine 2.5% Cream Apply 1-2 pumps (1-2gm) 4 times daily, Rub in for 2 minutes. Dispense 60 gm OR 120 gm. ___ Refills Ketoprofen Cream 10% or 20% Apply 2 to 3 times daily, rub in for 2 mins. Dispense 60 gm OR 120 - [Prostatitis (Acute Bacterial)](https://www.timeofcare.com/prostatitis/) - Diagnosis Definition: How is the diagnosis made?* H&P (Pertinent H&P findings including med review & key vital signs) -Common presentation: -Clinical Manifestations: -Associated Conditions: -Risk factors: -Red flags: -Complications: Prostatic abscesses, Chronic Prostatitis. Ddx & Etiology: Diagnostic studies: Assess severity/acuity: In sexually active males < 35 years of age AND in men > 35 years - [Insect, Spider, Mite, and Tick Bites](https://www.timeofcare.com/insect-spider-mite-and-tick-bites/) - Distinguishing between bites Bedbugs: A rash with multiple exposures on skin that is often not covered by clothing is typical of fleas or bedbugs in a house. Other members of the family may not have it. Bedbugs tend to bite on the upper body and neck. Flea bites are usually at ankle height because fleas jump. Flees - [B-type natriuretic peptide (BNP) & NT-proBNP](https://www.timeofcare.com/b-type-natriuretic-peptide-bnp/) - B-type natriuretic peptide (BNP) and N-terminal pro b-type natriuretic peptide (NT-proBNP) Is a polypeptide secreted from heat ventricles in response to ventricular volume expansion and pressure overload. The major source of BNP is the cardiac ventricles. Only a minimal amount of BNP is found storage granules. As such, its release is directly proportional to ventricular dysfunction. A BNP reliably predicts the presence - [Hypertension in children and adolescents](https://www.timeofcare.com/hypertension-in-children-and-adolescents/) - Diagnosis Definition of HTN in children and adolescents reviewed with the patient. The goal of initial diagnostic evaluation will be to 1) Identify children with curable HTN who may have a curable disease, 2) Identify other comorbid risk factors (eg, obesity and dyslipidemia) for CVD) or diseases associated with an increased risk for CVD (eg, diabetes - [Risk Factors for hypertension in children and adolescents](https://www.timeofcare.com/risk-factors-for-hypertension-in-children-and-adolescents/) - Risk Factors for primary hypertension in children and adolescents BMI is the strongest risk factor for HTN in children and adolescents. The prevalence of HTN in obese children is 11%, which is more than double that of the general pediatric population (reported at 1%–5%). Family history of hypertension, Low birth weight, Male sex Certain ethnic backgrounds. - [Age-Related Physiological Changes](https://www.timeofcare.com/age-related-physiological-changes/) - Maximal heart rate with exercise decreases with age. "A frequently used formula for predicting maximal heart rate is 220 minus age, with a correction factor of 0.85 often applied for females, who have a lower peak heart rate and a more gradual decline." Myocardial collagen increases with age. Myocardial mass increases with age. Ventricular compliance decreases - [Aortic Stenosis](https://www.timeofcare.com/aortic-stenosis/) - Diagnosis Symptomatic vs. Asymptomatic patients. H&P Presentation of symptomatic patients: mild shortness of breath, lightheadedness with exertion... Treatment -Treatment for symptomatic aortic stenosis is prompt aortic valve replacement. -Treatment for asymptomatic patients with mild aortic stenosis is to repeat echocardiography every 3–5 years. "Symptomatic patients with severe aortic stenosis have 2-year mortality rates of more than - [Urticaria (Hives)](https://www.timeofcare.com/urticaria/) - Treatment of Acute Urticaria (Hives) -R/o anaphylaxis. Epinephrine IM is urgently indicated for laryngeal swelling and respiratory symptoms. This should be done first, before anything else. -H1-antihistamines (1st-line tx). 2nd Generation H1 antihistamines are preferred to 1st generation (Diphenhydramine and Hydroxyzine) b/c they last longer and have less s/e like drowsiness. -H2 + H1 blockers. H2-blockers are - [Ankle Brachial Index](https://www.timeofcare.com/ankle-brachial-index/) - What is an ankle-brachial index?: "The Ankle Brachial Index (ABI) is the systolic pressure at the ankle, divided by the systolic pressure at the arm. It has been shown to be a specific and sensitive metric for the diagnosis of Peripheral Arterial Disease (PAD). Additionally, the ABI has been shown to predict mortality and adverse - [Heart Failure with Reduced Ejection Fraction (HFrEF)](https://www.timeofcare.com/heart-failure-with-reduced-ejection-fraction-hfref/) - Systolic Heart Failure -Definition / Diagnostic criteria reviewed. -Classification reviewed: -Nonpharmacologic & pharmacologic treatments reviewed. Important Links ProBNP is low in Obese Patients. BNP and NT-pro BNP. Chronic Heart Failure Classification and Treatment. - [Pressure Ulcers / Wound Care](https://www.timeofcare.com/pressure-ulcers/) - -Clean with either saline or tap water and cover with hydrocolloid foam or another non-adherent dressing that promotes a moist environment. -Don't clean with povidone/iodine, Dakin’s solution, hydrogen peroxide, wet-to-dry dressings, or any solutions that may impede granulation tissue formation -Protein supplements help with wound healing. Protein supplementation improves wound healing and also appears to help - [Autosomal dominant polycystic kidney disease (ADPCKD)](https://www.timeofcare.com/autosomal-dominant-polycystic-kidney-disease-adpckd/) - -ADPCKD is the most common genetic kidney disease and accounts for 4.7% of ESRD cases in the U.S. -Many patients with ADPCKD are asymptomatic, but early symptoms may include flank pain, gross hematuria, or recurrent UTIs. -Hypertension is the most common extrarenal manifestation of ADPCKD. Treatment -An ACE-I/ARB are recommended first-line treatment for HTN in these - [Gestational Hypertension](https://www.timeofcare.com/gestational-hypertension/) - -Induce labor at 37 weeks and deliver. -If there is ever **Note according to the ACOG 2013 Guidelines, Gestational HTN and Preeclampsia without severe features are both managed and delivered at 37 weeks. It's preeclampsia with severe features that require immediate delivery. That means if you have someone at 39 weeks who develops HTN but - [JNC 8 Hypertension Guidelines](https://www.timeofcare.com/jnc-8-hypertension-guidelines/) - JNC8 Hypertension Guidelines Booklet (pdf version of the laminated card) JNC 8 Guidelines for the Management of Hypertension in Adults, reviewed on AAFP - [Hypertension Guidelines](https://www.timeofcare.com/hypertension-guidelines/) - 1. JNC8 Hypertension Guidelines, from 2014 2. ACP and AAFP Guideline for Treatment of Hypertension in Adults 60 Years Old and Older (Jan 2017) Modification to the treatment cutoff of 150/90 for adults 60 or older to use the normal cutoff of 140/90 if the patient, 1) Has a history of stroke or TIA, or - [Puncture Wounds](https://www.timeofcare.com/puncture-wounds/) - Through the rubber sole of a shoe - Cover Pseudomonas Most puncture wound infections are caused by gram-positive organisms like Staphylococcus aureus (the most common) and other staphylococcal and streptococcal species. However, when the puncture wound is through the rubber sole of an athletic shoe, Pseudomonas becomes the most frequent organism. Treatment: Ciprofloxacin 750 mg twice - [Preeclampsia](https://www.timeofcare.com/preeclampsia/) - Definition: New onset of hypertension and proteinuria, [or new onset of hypertension and significant end-organ dysfunction with or without proteinuria] after 20 weeks of gestation. HTN in preeclampsia is defined as SBP ≥140 mmHg or DBP ≥90 mmHg on two occasions at least 4 hours apart. Proteinuria in preeclampsia is defined as: ≥0.3 g protein in - [Treatment of Chronic Heart Failure Failure](https://www.timeofcare.com/treatment-of-chronic-heart-failure/) - Treatment of Chronic Heart Failure with reduced ejection fraction (HFrEF). In addition to diet and exercise, LMNOP ( for acute decompensated HF), the following mnemonic gives you treatment for chronic CHF. ABCDEFGH of chronic HFrEF A-ACE / ARB,* Aldosterone antagonist (spironolactone for moderate to severe congestive heart failure)* B- Beta blockers* C-Cardiac Rehab; Cigarette cessation†; - [Atherosclerotic Cardiovascular Disease (ASCVD)](https://www.timeofcare.com/atherosclerotic-cardiovascular-disease-ascvd/) - Statin Use for Primary Prevention of ASCVD, USPSTF Recommendations. The 2013 ACC/AHA cholesterol guidelines According to the ACC/AHA, there are 4 major groups are in whom statin therapy is indicated: (1) individuals with clinical atherosclerotic cardiovascular disease (ASCVD), (2) those with primary elevations of LDL-C >190 mg/dL, (3) patients age 40–75 with diabetes mellitus, an - [Statin Use for Primary Prevention of ASCVD](https://www.timeofcare.com/statin-use-for-primary-prevention-of-ascvd/) - USPSTF and ACC/AHA recommendations for Statin Use for Primary Prevention of ASCVD - [Porphyria cutanea tarda (PCT)](https://www.timeofcare.com/porphyria-cutanea-tarda-pct/) - -Suspect PCT in patients who present with blistering lesions on sun-exposed skin. -Risk Factors: Things that cause liver damage (e.g. as alcohol use and hepatitis C); also smoking, estrogen use, HIV infection, and HFE mutations. Initial diagnostic test: total serum, plasma, or spot urine porphyrins. - [Lactose Intolerance](https://www.timeofcare.com/lactose-intolerance/) - Diagnosis Common symptoms: Bloating, flatulence, and abd. pain. Children may have diarrhea as well and adolescents may have nausea/vomiting. Cause: Caused by lactose malabsorption. Patients have low levels of lactase in the duodenum and so cannot digest the lactose-containing foods. A presumptive diagnosis can be made from a history of symptoms with consumption of lactose foods - [Common Causes of Lactose Malabsorption](https://www.timeofcare.com/common-causes-of-lactose-malabsorption/) - A list of the common Causes of Lactose Malabsorption - [Acromegaly](https://www.timeofcare.com/acromegaly/) - -Acromegaly = the body producing too much growth hormone (GH) after puberty (or closure of growth plates. -Gigantism occurs if the excessive GH production occurs before closure of growth plate). -Most common cause of acromegaly is pituitary adenoma that produces GH. "Symptoms: Increase in hand and foot size, change in facial features (large mandible), carpal - [Diabetes Screening Recommendations](https://www.timeofcare.com/diabetes-screening-recommendations/) - Diabetes Screening Recommendations from USPSTF and ADA - [Glucose 6-Phosphate Dehydrogenase Deficiency (G6PD)](https://www.timeofcare.com/glucose-6-phosphate-dehydrogenase-deficiency-g6pd/) - -Presence of Heinz bodies (which denatured globin chains inside of a red cell membrane) -Is an X-linked disorder that involves enzymes inside RBCs → Hemolysis of RBCs caused by infections, meds, foods, etc. Hemolysis → anemia, jaundice, pallor, dark urine and Heinz bodies, red cell fragments, or bite cells on a peripheral blood smear. - [Nephroblastoma (Wilms tumor)](https://www.timeofcare.com/nephroblastoma-wilms-tumor/) - Is the most common abdominal cancer in children. Clinical Presentation: "The most common manifestation of Wilms tumor is an asymptomatic abdominal mass; an abdominal mass occurs in 80% of children at presentation. Abdominal pain or hematuria occurs in 25%. Urinary tract infection and varicocele are less common findings than these. Hypertension, gross hematuria, and fever - [Fibroadenoma vs. Fibrocystic changes](https://www.timeofcare.com/fibroadenoma-vs-fibrocystic-changes/) - Fibroadenoma=the most common breast mass in adolescents and young adult women. Fibroadenomas are painless, firm, mobile, slow-growing, solitary breast mass. It stays there over several menstrual cycles and may grow slowly. Fibrocystic changes, on the other hand, varies in size during the course of a menstrual cycle. They can be painful and are usually bilateral. Ultrasound is the - [Congenital Hypothyroidism](https://www.timeofcare.com/congenital-hypothyroidism/) - -On newborn screen. -Refer to a pediatric endocrinologist. -The patient will be treated with levothyroxine for life. Titration with goal TSH WNL. "All infants with a low T4 concentration and a TSH concentration greater than 40 mU per L are considered to have congenital hypothyroidism and should have immediate confirmatory serum testing. Replacement levothyroxine (LT4) treatment - [Urinary Incontinence](https://www.timeofcare.com/urinary-incontinence/) - -History & Physical, see above. -Different causes of urinary incontinence reviewed w/ patient. -Treatable causes of urinary incontinence discussed. -UA, UCx, CBC, CMP. Consider A1C and B12. -Will Consider U/S to r/o a bladder pathology (diverticulum, mass, etc) -Will Consider measuring the post-void residual. -Cough stress-test. A positive cough stress test result is the most reliable - [Bladder Stress Test](https://www.timeofcare.com/bladder-stress-test/) - Indication: To make a diagnosis of stress incontinence when it is suspected. Method: Have the patient stand upright with a full bladder. The clinician visualizes the urethra as the patient performs a Valsalva maneuver or coughs. The goal is to determine whether or not there is leakage of urine from the urethra. This test is also called - [Suicide Risk Factors (SAD PERSONS)](https://www.timeofcare.com/suicide-risk-factors/) - Mnemonic: SAD PERSONS Sex Age Depression Previous attempt Ethanol and Substance Use. Rational thought loss Sickness Organized plan No spouse Social support lacking - [Diphtheria](https://www.timeofcare.com/diphtheria/) - Diphtheria - [Pterygium (Surfer's Eye or Eye Web)](https://www.timeofcare.com/pterygium-surfers-eye-or-eye-web/) - https://www.aao.org/eye-health/diseases/pinguecula-pterygium https://www.aao.org/eyenet/article/management-of-pterygium-2 - [Essential Tremor](https://www.timeofcare.com/essential-tremor/) - Treatment -Beta-blockers -Anti-convulsants https://www.aafp.org/afp/2018/0201/p180.html - [Alcohol Amnestic Disorder (Korsakoff syndrome)](https://www.timeofcare.com/alcohol-amnestic-disorder-korsakoff-syndrome/) - Korsakoff syndrome is also called alcohol-induced persisting amnestic disorder. Korsakoff is a chronic memory disorder caused by severe deficiency of thiamine (vitamin B-1). Korsakoff syndrome is most commonly caused by alcohol misuse, but certain other conditions also can cause the syndrome. - [Colorectal Cancer Screening Tests and Intervals](https://www.timeofcare.com/colorectal-cancer-screening-tests-and-intervals/) - Characteristics of Colorectal Cancer Screening Strategiesa (From the USPSTF 2017) Note: gFOBT need 3 stool specimens/samples collected in a row. Screening Method Frequencyb Evidence of Efficacy Other Considerations Stool-Based Tests gFOBT Every year RCTs with mortality endpoints: High-sensitivity versions (eg, Hemoccult SENSA) have superior test performance characteristics than older tests (eg, Hemoccult II) Does not - [Apophysitis of the Tibial Tuberosity (Osgood-Schlatter Disease)](https://www.timeofcare.com/apophysitis-of-the-tibial-tuberosity/) - Apophysitis of the Tibial Tuberosity (Osgood-Schlatter Disease) Further Reading Apophysitis of the Tibial Tuberosity (Osgood-Schlatter Disease): A Review. Muacevic A, Adler JR, eds. Cureus. 2016;8(9):e780. - [Lung Cancer](https://www.timeofcare.com/lung-cancer/) - -Risk factors: Secondhand smoke/passive smoke, a family history of lung cancer, COPD, radon exposure, asbestosis, and idiopathic pulmonary fibrosis. -Screening per USPSTF Most common form = Adenocarcinoma "The European Prospective Investigation into Cancer and Nutrition (EPIC) trial found an inverse relationship between lung cancer risk and vitamin B6 levels, as well as serum methionine levels." - [The Difference Between Primary, Secondary, and Tertiary Prevention](https://www.timeofcare.com/the-difference-between-primary-secondary-and-tertiary-prevention/) - This page discusses the difference between Primary, Secondary, and Tertiary Prevention - [Anthrax](https://www.timeofcare.com/anthrax/) - Requires 60 days of continuous antibiotic treatment. - [Travelers' Diarrhea](https://www.timeofcare.com/travelers-diarrhea/) - Azithromycin: Use it for traveler's diarrhea in South and Southeast Asia where Campylobacter is highly resistant to quinolones. Ciprofloxacin: It is recommended for travel to South and Central America and to Africa. Loperamide: May be used to as sole therapy for mild diarrhea or as adjunctive therapy for moderate or severe diarrhea. Travelers’ diarrhea definitions (CDC) - [Travelers' Diarrhea and Fluoroquinolone Resistance in South and Southeast Asia](https://www.timeofcare.com/travelers-diarrhea-and-fluoroquinolone-resistance-in-south-and-southeast-asia/) - "The effectiveness of a particular antimicrobial drug depends on the etiologic agent and its antibiotic sensitivity. As empiric therapy or to treat a specific bacterial pathogen, first-line antibiotics have traditionally been the fluoroquinolones, such as ciprofloxacin or levofloxacin. Increasing microbial resistance to the fluoroquinolones, especially among Campylobacter isolates, may limit their usefulness in many destinations, particularly South - [How to Remember USPSTF Grades](https://www.timeofcare.com/how-to-remember-uspstf-grades/) - An easy way to remember USPSTF Grades - [Invasive Meningococcal Disease](https://www.timeofcare.com/invasive-meningococcal-disease/) - Definition: Diagnosis Treatment Postexposure prophylaxis -Indicated for any close contact regardless of immunization status. "Close contacts include those exposed in households, dormitories, or child care centers, or those who have direct contact with the source patient's oral secretions. Travelers who are seated next to a confirmed case on a prolonged flight (> eight hours) or - [Palliative Chemotherapy](https://www.timeofcare.com/palliative-chemotherapy/) - Palliative chemotherapy provides no survival benefit. However, patients who receive palliative chemotherapy for end-stage cancers are: less likely to die at home (where many would like to die), more likely to undergo CPR, and more likely to undergo mechanical ventilation. are referred to hospice later. Reference / Further Reading BMJ 2014;348: g1219. Associations between palliative chemotherapy - [Emergency Contraception](https://www.timeofcare.com/emergency-contraception/) - This article discusses emergency contraception. - [Neuropathic vs. Nociceptive Pain](https://www.timeofcare.com/neuropathic-vs-nociceptive-pain/) - The difference between Neuropathic vs. Nociceptive Pain - [Delirium Meds - Drugs to treat delirium](https://www.timeofcare.com/delirium-meds-drugs-to-treat-delirium/) - Basically using the newer antipsychotics. Olanzapine (Zyprexa) Comes as: PO tablets, Rapid disintegrating tablets, IM Starting: 2.5 mg PO QD Daily: 5-10 mg/day Risperidone (Risperdal) PO tabs and syrup, Rapidly disintegrating tablet (for those who can ’t swallow) Starting: 0.25 mg PO BID Daily: 0.25-1.5 mg/day Quetiapine (Seroquel) PO tabs, Extended-release tabs (50 mg +) - [Coin Rubbing](https://www.timeofcare.com/coin-rubbing/) - Is practiced in SouthEast Asian countries like Cambodia, Korea, China, and Vietnam. They believe that one's illness should be drawn out of the body and try to do so with the coin, producing red marks that to them are a sign of the release but to a stranger could be perceived as a sign of - [Opioid-Induced Hyperalgesia (OIH)](https://www.timeofcare.com/opioid-induced-hyperalgesia/) - Definition: "Opioid-induced hyperalgesia (OIH) is defined as a state of nociceptive sensitization caused by exposure to opioids. The condition is characterized by a paradoxical response whereby a patient receiving opioids for the treatment of pain could actually become more sensitive to certain painful stimuli." PP 2011 OIH occurs in patients receiving high doses of parenteral - [Dyspnea in Terminally Ill or Dying Patients](https://www.timeofcare.com/dyspnea-in-terminally-ill-or-dying-patients/) - Common presentation: Hospice patient develops SOB. Oxygen Sats 91%. Lungs: CTAB except for mildly diminished breath sounds. Treatment: Morphine sulfate sublingually, Intravenously or orally. Emerg Med Pract. 2013 May;15(5):1-19. Emergency management of dyspnea in dying patients. - [Hypodermoclysis](https://www.timeofcare.com/hypodermoclysis/) - https://www.aafp.org/afp/2001/1101/p1575.html - [Fecal Impaction](https://www.timeofcare.com/fecal-impaction/) - Can occur in children all the way to elderly. In fact, it's common in children and elderly patients. - [Non–Medically Indicated (Elective) Inductions of Labor or C-Sections](https://www.timeofcare.com/16141-2/) - AAFP and ACOG recommend that non–medically indicated (elective) inductions of labor or C-sections should be scheduled after what 39 weeks, 0 days gestational age. Delivery prior to 39 weeks, 0 days is associated with an increased risk of learning disabilities and may increase morbidity and mortality. Further Reading / Reference Elimination of non-medically indicated (elective) - [Child Abuse](https://www.timeofcare.com/child-abuse/) - Child Abuse Pearls Posterior or posteromedial rib fractures in a child should be assumed as child abuse until proven otherwise. Notify CPS or send to the ER for appropriate workup. Neglect is the most common form of child abuse in the U.S. Neglect > Physical abuse > sexual abuse in prevalence. Neglect is also the - [Biphasic Anaphylactic Reactions](https://www.timeofcare.com/biphasic-anaphylactic-reactions/) - Exposure to allergen → Anaphylaxis (phase 1) → Patient self-administers Epinephrine autoinjector → Symptoms resolve → in about 2 hrs to 3 days → another anaphylactic reaction (phase 2) without a second exposure to the allergen. That is a biphasic anaphylactic reaction. A biphasic reaction is a two-phase anaphylactic reaction. "This means that after anaphylaxis is treated and the symptoms go - [Basketball](https://www.timeofcare.com/basketball/) - [Female Athlete Triad](https://www.timeofcare.com/female-athlete-triad/) - Definition (ACOG 2017): "The female athlete triad is a medical condition observed in physically active females involving three components: 1) Low energy availability with or without disordered eating, 2) Menstrual dysfunction, and 3) Low bone density." Diagnosis Assess all active females for the components of the triad. If one or more of the components are found, - [Fever in infants (neonates and older)](https://www.timeofcare.com/fever-in-infants/) - Approach to Fever in a neonate or infant - [Motion Sickness Treatment](https://www.timeofcare.com/motion-sickness-treatment/) - Scopolamine patch is the most effective medication for motion sickness. The patch is more effective than the oral scopolamine. Scopolamine 1.5 mg transdermal patch; apply 1 patch to mastoid at least 4 hours before travel, then every 3 days(72 hours) as need. Promethazine 25 mg for adults or 12.5 to 25 mg for children, taken - [Bee, Wasp, and other Hymenoptera Stings](https://www.timeofcare.com/bee-wasp-and-other-hymenoptera-stings/) - Systemic allergic reaction (Anaphylaxis). IM Epinephrine is the first treatment to give. Local Reaction Cold compresses. Elevate extremity if the sting is on a limb. Oral prednisone 40 to 60 mg x1 dose or tapered over 2-5 days for significant swelling. Pain: NSAIDs. Pruritis: Oral antihistamines or topical high potency steroids applied q4h until itching - [Get Up and Go Test (The Timed Up and Go Test)](https://www.timeofcare.com/get-up-and-go-test/) - Explanation of the Get Up and Go Test - [Low-dose Aspirin for the Prevention of Preeclampsia](https://www.timeofcare.com/low-dose-aspirin-for-the-prevention-of-preeclampsia/) - Low-dose aspirin (81 mg/day), initiated at 12 weeks (or between 12 and 28 weeks). Both ACOG and the USPSTF recommend this in high-risk women. In 2013, ACOG defined high-risk women as women with a history of early-onset preeclampsia and preterm delivery at less than 34 0/7 weeks of gestation, OR women with more than one - [Hypertension in Pregnancy](https://www.timeofcare.com/hypertension-in-pregnancy/) - Drugs for treating Hypertension in Pregnancy. - [Lyme Disease](https://www.timeofcare.com/lyme-disease/) - Background Is the most common vector-borne infection in the United States and Europe. NE USA Campers/hikers Ixodes tick harbors Borrelia burgdorferi Stages: Stage I: erythema migrans (pathognomonic), viral-like syndrome Stage II: arthritis, myocarditis, bilateral Bell’s palsy Stage III: chronic arthritis, chronic encephalopathy Treatment -Prophylaxis in asymptomatic patients after a known tick bite. Only recommended for tick attachment longer than 36 hours, - [Vitamin Supplementation](https://www.timeofcare.com/vitamin-supplementation/) - Trials have shown an increase in all-cause mortality associated with supplementation with vitamin A, vitamin E, and β-carotene. No benefits or reductions in all-cause mortality were shown for vitamin C or selenium. Further Reading / References Antioxidant supplements to prevent mortality. JAMA 2013;310(11):1178-1179. Ann Intern Med. 2005;142:37–46. Meta-Analysis: High-Dosage Vitamin E Supplementation May Increase All-Cause - [Carbon monoxide (CO) exposure](https://www.timeofcare.com/carbon-monoxide-co-exposure/) - Diagnosis Common presentation: During the winter/cold months, a patient comes in with an acute SOB, tachypnea, tachycardia, nausea, and a headache. The patient looks very ill. Pulse oximetry shows an oxygen saturation of 100% on room air. ABG shows a PaO2 of 96 mm Hg. Common manifestations: Symptoms include a headache, nausea, vomiting, and weakness, a flushed skin complexion. Symptoms commonly attributed - [Pathophysiology of Carbon Monoxide Poisoning](https://www.timeofcare.com/pathophysiology-of-carbon-monoxide-poisoning/) - Carbon Monoxide Displaces Oxygen from Hemoglobin to form Carboxyhemoglobin. CO has a higher affinity for hemoglobin than oxygen does. As such, CO displaces oxygen from hemoglobin resulting in the formation of a complex called carboxyhemoglobin, which doesn't carry oxygen. CO is very effective and occupies all oxygen carrying sites. Oxygen cannot displace CO. What that - [Acute Mountain Sickness (AMS)](https://www.timeofcare.com/acute-mountain-sickness/) - See Acute High Altitude Sickness. Diagnosis Definition: How is the diagnosis made?* H&P (Pertinent H&P findings including med review & key vital signs) -Common presentation: -Clinical Manifestations: -Associated Conditions: -Risk factors. -Red flags: -Complications: Ddx & Etiology: Diagnostic studies: Assess severity/acuity: Treatment Treatment options, med s/e, and complications. -Non-pharmacological. -Pharmacological therapies. -Prevention. -Indications for a referral. - [Risk factors for Acute Mountain Sickness](https://www.timeofcare.com/risk-factors-for-acute-mountain-sickness/) - The following are risk factors for AMS: a history of previous acute mountain sickness, fast ascent (≥625 m per day above 2000 m) lack of previous acclimatization. living at low altitudes ( - [Acute High Altitude Sickness](https://www.timeofcare.com/acute-high-altitude-sickness/) - Acute high altitude Sickness (High Altitude Sickness) is the umbrella term for 3 different conditions that can happen when a person ascents to altitudes ≥2500 m. Acute Mountain Sickness (AMS) High-Altitude Pulmonary Edema (HAPE) High-Altitude Cerebral Edema (HACE) "At any point 1–5 days following ascent to altitudes ≥2500 m, individuals are at risk of developing - [Medications for the prevention and treatment of acute altitude illness](https://www.timeofcare.com/medications-for-the-prevention-and-treatment-of-acute-altitude-illness/) - Dosage for prevention Dosage for treatment AMS Acetazolamide 125 or 250 mg every 12 h 250 mg every 12 h Dexamethasone 2 mg every 6 h OR 4 mg every 12 h 4 mg every 6 h HACE Dexamethasone 8 mg once then 4 mg every 6 h HAPE Nifedipine 30 mg sustained - [Hyperkalemia with ECG changes](https://www.timeofcare.com/hyperkalemia-with-ecg-changes/) - Pt with diastolic heart failure and CKD stage 3 and CHF. Potassium 7. What is the best initial management to reduce his potassium level? Answer: Intravenous insulin and glucose. Potassium of 7 is severe hyperkalemia. You want to urgently bring down the potassium. IV insulin followed by glucose will shift potassium intracellularly and is an - [Severe Features of Preeclampsia](https://www.timeofcare.com/severe-features-of-preeclampsia/) - In a woman with preeclampsia, the presence of one or more of the following features indicates a diagnosis of "preeclampsia with severe features" Organ systems affected are: CNS; Lungs, Liver; Kidney, Lungs, as well as Cardiovascular system (low platelets, and elevated pressures) SBP of ≥ 160 mm Hg, or DBP of ≥ 110 mm Hg - [Eclampsia](https://www.timeofcare.com/eclampsia/) - Eclampsia = New-onset coma or convulsions in a woman with preeclampsia. Eclampsia is the development of new-onset seizures or coma in a woman with preeclampsia. These generalized, tonic-clonic seizures are one of the severe features of preeclampsia. - [Peanut Allergy: Introducing Peanuts to Children's diet](https://www.timeofcare.com/introducing-peanuts-to-childrens-diet/) - Evidence now shows that early introduction of peanut-containing products for most children reduces the incidence of peanut allergy. As a result, The AAP now recommends early introduction. Begin introducing these foods before 12 months of age Consider first doing allergy testing in children at high risk for an allergic reaction (e.g., kids with severe eczema or a - [STI Screening Recommendations](https://www.timeofcare.com/sti-screening-recommendations/) - From CDC.gov "All adults and adolescents from ages 13 to 64 should be tested at least once for HIV. Annual chlamydia screening of all sexually active women younger than 25 years, as well as older women with risk factors such as new or multiple sex partners, or a sex partner who has a sexually transmitted infection Annual gonorrhea - [IgA Vasculitis (Formerly Henoch-Schönlein purpura)](https://www.timeofcare.com/iga-vasculitis/) - Background Immunoglobulin A vasculitis (IgA vasculitis, IgAV) was formerly called Henoch-Schönlein purpura (HSP). Pathophysiology: In IgA vasculitis, IgA immune complexes are deposited in small vessels. When that happens in the skin, we see petechiae and palpable purpura. When immune complexes occur in small vessels of the intestinal wall, we see GI complications (including GI hemorrhage). If the immune - [Rochester Criteria for Febrile Infants](https://www.timeofcare.com/rochester-criteria-for-febrile-infants/) - Rochester Criteria for Febrile Infants - [The Step-by-Step approach to Fever in Infants](https://www.timeofcare.com/the-step-by-step-approach-to-fever-in-infants/) - Using the the Step-by-Step approach to Fever in Infants - [Borderline Personality disorder](https://www.timeofcare.com/borderline-personality-disorder/) - Mnemonics for Borderline Personality disorder. Treatment: Psychotherapy Reference Treating patients with borderline personality disorder in the medical office. Am Fam Physician 2013;88(2):140-141. - [Hoarding Disorder (HD)](https://www.timeofcare.com/hoarding-disorder/) - -See DSM-5 definition of hoarding disorder. -Disposing of the items causes extreme anxiety and emotional distress. Background Affects 2% and 6% of adults.w The key distinguishing feature of hoarding disorder is that with hoarders, disposing of the items causes extreme anxiety and emotional distress. Further Reading / Reference N Engl J Med 2014;370(21):2023-2030. http://www.nejm.org/doi/full/10.1056/NEJMcp1313051 - [Narcolepsy](https://www.timeofcare.com/narcolepsy/) - -Sleepiness, Cataplexy. -Some patients may also have vivid hallucinations when falling asleep or waking up. Treatment -Improve nighttime sleep (both quality & quantity). Sleep hygiene + Sodium oxybate. These improve daytime alertness and cataplexy. -Scheduled daytime naps. -Pharmacotherapy: Stimulants e.g. methylphenidate - improves daytime function. Cataplexy = An episode of sudden loss of muscle tone and strength, usually associated with an emotional stimulus, like laughing. Cataplexy - [Antipsychotics: Side Effects](https://www.timeofcare.com/antipsychotics-side-effects/) - Atypical antipsychotics -Pine and -done groups. -Pine group. Clozapine Olanzapine Quetiapine -Done and -azole group. Risperidone (Risperdal) Ziprazidone (Geodon) Lurasidone (Latuda) Aripiprazole The difference between dystonia, dyskinesia, akinesia, bradykinesia, Akathisia. The motor side effects of antipsychotics can be divided into 5 categories. Dystonias Parkinsonism Akathisia Withdrawal dyskinesias Tardive dyskinesias MOA Clozapine Antagonizes -dopamine - [Dementia](https://www.timeofcare.com/dementia/) - Diagnosis Definition: H&P Risk Factors Different types Common presentation DDx and causes. Diagnostic tests -Mini-Cog score:_______ -Montreal Cognitive Assessment (MOCA) Treatment Watch out for aspiration pneumonia in advanced dementia (2/2 to swallowing problems). Hospice or palliative care should be offered to patients w/ advanced dementia. Background Dementia pearls and Links Tests for Acute vs. - [Dementia / Memory Loss, Differential Diagnosis](https://www.timeofcare.com/dementia-memory-loss-differential-diagnosis/) - Irreversible causes Alzheimer's Disease Mild Cognitive Impairment (MCI) Vascular (multi-infarct) dementia Mixed Dementia Dementia with Lewy Bodies (Lewy body dementia) Parkinson's Disease Frontotemporal Dementia Creutzfeldt-Jakob Disease (Prion disease) Progressive supranuclear palsy Huntington's Disease Wernicke-Korsakoff Syndrome, Alcohol Progressive multifocal leukoencephalopathy Reversible causes Pseudodementia (depression) Medications (e.g antihistamines, anticholinergics, sedatives, antipsychotics, opioids) Vitamin B12 deficiency Thiamine deficiency - [Tests for Acute vs. Chronic Cognitive Changes](https://www.timeofcare.com/tests-for-acute-vs-chronic-cognitive-changes/) - Tests for Acute Changes in Cognition The Confusion Assessment Method (CAM) is designed for diagnosing delirium which is an acute change in cognition. Tests for Chronic Cognitive Changes The following tests are designed to chronic baseline cognitive function and are ineffective for evaluating acute cognitive changes. The Mini-Mental State Examination (MMSE), Mini-Cog, Montreal Cognitive Assessment - [Psychogenic nonepileptic seizures (PNES) - Pseudoseizures](https://www.timeofcare.com/psychogenic-nonepileptic-seizures-pnes-pseudoseizures/) - The gold standard for diagnosis of PNES is Inpatient video-electroencephalography (vEEG) monitoring. Things that have been used but are unreliable: presence or absence of self-injury and incontinence, the ability to induce seizures by suggestion, psychologic tests, and ambulatory EEG. These are insufficient for diagnosing PNES. Further Reading / References Psychogenic nonepileptic seizures. Am Fam - [Video-EEG monitoring](https://www.timeofcare.com/video-eeg-monitoring/) - Video-EEG monitoring combines extended EEG monitoring + time-locked video. This allows for analysis of clinical and electrographic features during a captured event. - [Alcohol Use Disorder](https://www.timeofcare.com/alcohol-use-disorder/) - -Single-question screening three-question AUDIT-C screening used. -Patient meets DSM-V criteria for the diagnosis of alcohol use disorder. Patient indeed has a problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least 2 of the 11 criteria occurring within a 12-month period. Treatment -Brief behavioral counseling (Motivational Interviewing) to - [ABUSERS: Substance Abuse](https://www.timeofcare.com/abusers-substance-abuse/) - ABUSERS Affecting his life negatively, yet he continues to do it. Appointments/Assignments/work/job are affected negatively by the substance use. (1) Stopping or reducing important social, occupational, or recreational activities due to opioid use. (2) Repeatedly unable to carry out major obligations at work, school, or home due to opioid use. (3) Recurrent use of the - [Alcohol Withdrawal Treatment](https://www.timeofcare.com/alcohol-withdrawal-treatment/) - Important Links Treatment vs. Prophylaxis of Alcohol Withdrawal. Alcohol Withdrawal Prophylaxis. Alcohol Withdrawal Treatment in the Hospital. Alcohol Withdrawal Treatment in the Outpatient. Complications of Alcohol Abuse and Alcohol Withdrawal. Fixed schedule vs. Symptom-triggered therapy of Alcohol Withdrawal Symptoms. CIWA-Ar. Alcoholic Hepatitis. - [Alcohol Withdrawal Syndrome - Outpatient Management](https://www.timeofcare.com/alcohol-withdrawal-syndrome-outpatient/) - Related article: Alcohol Withdrawal Treatment. Diagnosis Definition: Diagnosis is clinical based on hx of heavy alcohol use, abstinence, and now having signs and symptoms consistent with alcohol withdrawal. H&P (Pertinent H&P findings including med review & key vital signs) -Common presentation: -Clinical Manifestations -Associated Conditions. -Risk factors: Alcohol Dependence. -Red flags. -Complications. Ddx & Etiology - [Depression in adolescents](https://www.timeofcare.com/depression-in-adolescents/) - Treatment Nonpharmacologic: First do a trial of psychotherapy (CBT). Pharmacologic: Fluoxetine is 1st-line. Monitor the patient weekly for side effects for a month after starting fluoxetine. Counsel about FDA's black box warning and other side effects. 2nd-line: If fluoxetine doesn't work, try sertraline or citalopram. Don't use Venlafaxine. It is associated with a greater - [Black Box Warning For SSRIs](https://www.timeofcare.com/black-box-warning-for-ssris/) - "In the FDA review, no completed suicides occurred among nearly 2,200 children treated with SSRI medications. However, about 4 percent of those taking SSRI medications experienced suicidal thinking or behavior, including actual suicide attempts—twice the rate of those taking placebo, or sugar pills. In response, the FDA adopted a "black box" label warning indicating that antidepressants may - [Depression (MDD) with Atypical Features](https://www.timeofcare.com/atypical-depression/) - Major depressive disorder with atypical features is a subtype of major depression. Diagnostic criteria for atypical depression "To be diagnosed with atypical depression, you must meet the symptom criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association. For a diagnosis of atypical depression, you must - [Psychosis](https://www.timeofcare.com/psychosis/) - Get Urine Drug Screen. Illicit drug use is the most common medical cause of acute psychosis. Further Reading. Am Fam Physician. 2015 Jun 15;91(12):856-863. Recognition and Differential Diagnosis of Psychosis in Primary Care. - [Autism Spectrum Disorder (ASD)](https://www.timeofcare.com/autism-spectrum-disorder/) - Diagnosis Key diagnostic features of ASD include: -Deficits in social communication and interaction across multiple contexts and restricted, -Repetitive patterns of behavior, interests, or activities. AAP recommends screening with MCHAT at 18 to 24 months of age. Kids with autism often have an abnormal sensitivity to sound - become upset by normal noises. Background The - [Behavioral disorders in dementia](https://www.timeofcare.com/behavioral-disorders-in-dementia/) - Refractory aggressive behavioral and psychological symptoms of dementia Typical presentation: A nursing home patient with dementia has acute onset of serious aggressive behaviors. She is physically aggressive toward caregivers and has tried to punch them several times. She is at risk of harm to herself and to others. Nonpharmacologic interventions haven't been effective. Treatment First, rule out - [Bipolar I Disorder](https://www.timeofcare.com/bipolar-i-disorder/) - Background: Diagnosis H&P Bipolar and related disorders. Treatment Mood stabilizers for maintenance therapy: lithium, valproate, lamotrigine, some atypical antipsychotics such as olanzapine, quetiapine, and risperidone. Keep patients on maintenance mood stabilizers because the rate of recurrence of mania is high when they get off them. Atypical antipsychotics cause weight gain and adverse metabolic abnormalities. Test for DM2 - [Nightmares Associated with PTSD](https://www.timeofcare.com/nightmares/) - Diagnosis PTSD associated nightmares H&P: Typical presentation: Patient with PTSD appropriately treated with SSRI + CBT with some improvement but still having nightmares and sleep disturbances. DDx Treatment -Prazosin 1-6mg. Start with 1mg and increase as needed to treat nightmares. -F/u in 4 weeks. -PHQ-9: -GAD-7: ---//--- Prazosin is an alpha-adrenergic receptor antagonist. Clonidine - [Somatic Symptom Disorder (Somatization disorder)](https://www.timeofcare.com/somatic-symptom-disorder/) - Treatment Schedule regular visits at short intervals to establish a collaborative relationship with the patient. Limit diagnostic testing and reassure the patient that serious diseases have already been ruled out. Screen for other mental illnesses. CBT and mindfulness-based therapies are effective. Pharmacotherapy: SSRIs or TCAs. -Amitriptyline has a greater likelihood of success compared to SSRIs to - [Depression: Major Depressive Disorder (MDD)](https://www.timeofcare.com/depression-major-depressive-disorder/) - Diagnosis Diagnosis is made clinically with help of validated tools like the PHQ-9 H&P: -Common presentation: -Clinical Manifestations -Associated Conditions: -Risk factors: Recent MI, significant, Medical Morbidities, Fam Hx, etc. -Red flags. -Complications: Ddx & Etiology Diagnostic studies: CBC, CMP, TSH, 25-Hydroxy Vit D. Assess severity/acuity. No SI/HI PHQ-9 score: GAD-7 Score: Treatment Refer to psychotherapy - [Schizophrenia](https://www.timeofcare.com/schizophrenia/) - DSM-V Diagnostic Criteria for Schizophrenia Combining antipsychotic medication + Psychosocial treatment is more effective. Psychosocial tx includes CBT, family therapy, social skills training, etc. Further Reading Am Fam Physician. 2014 Dec 1;90(11):775-782. - [Anorexia Nervosa](https://www.timeofcare.com/anorexia-nervosa/) - Background Both Anorexia nervosa and bulimia nervosa are more common adolescent females. Diagnosis Definition Diagnosis is made clinically using DSM-V criteria. H&P (Pertinent H&P findings including med review & key vital signs) -Common presentation: -Clinical Manifestations: -Associated Conditions: MDD, other psychiatric disorders. -Risk factors. -Red flags. -Complications: Ddx & Etiology Diagnostic studies (labs/imaging/etc) Assess severity/acuity: Severity - [Acute stress disorder (ASD)](https://www.timeofcare.com/acute-stress-disorder-asd/) - -The main difference between ASD and PTSD is time. -To diagnose PTSD the symptoms have to be present for at least 1 month. -There is a spectrum of trauma-related disorders from adjustment disorder(AD) to PTSD. ASD is in the middle of AD and PTSD. Symptoms include intrusion, negative mood, dissociation, avoidance, and arousal Adjustment disorder is less - [Obesity in pediatric patients](https://www.timeofcare.com/obesity-pediatric-population/) - Definition of Obesity in individuals 0-18 years of age. Ages 0–2 years: Obesity is defined based on the weight-for-length ratio Ages 2–18 years: Obesity is defined based on age and either BMI < 2 years of age -Overweight = weight-for-length ratio > 95th percentile for their sex. -The term obese is not used for children - [Down Syndrome (DS)](https://www.timeofcare.com/down-syndrome/) - -Get a checklist for all screening for Down Syndrome kids with age. All infants with Down syndrome need to be screened for heart, feeding, vision, hearing, thyroid, and hematologic abnormalities. All newborn Down Syndrome babies need an echocardiogram and a cardiology consult. Up to 50% of them have congenital cardiac defects! Hypotonia may cause feeding difficulties. Assess - [Postpartum Depression (PPD)](https://www.timeofcare.com/postpartum-depression/) - Diagnosis -H&P -No SI/HI -Edinburgh Postnatal Depression Scale score is: -DDx and Etiology. *Evaluate and treat mothers at her baby's well child check. Don't tell them to come days later. Treatment -CBT -SSRIs. -F/u in 6 weeks. ---END--- How do you differentiate between PPD and the blues? -The Edinburgh Postnatal Depression Scale has been shown - [Sudden infant death syndrome (SIDS)](https://www.timeofcare.com/sudden-infant-death-syndrome-sids/) - "Back to sleep" campaign from the AAP helped reduce SIDS by about 50%. Proper sleep position is crucial to reducing SIDs. Risk Factors for SIDS / Things that increase the risk of SIDS. -Side sleeping -Prone sleeping -Bed sharing -Male sex, -Native American ethnicity, -birth weight - [Sepsis Definition and Diagnostic Criteria](https://www.timeofcare.com/sepsis-definition-and-diagnostic-criteria/) - -Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. -Suspected infection and 2 or more qSOFA variables. -A positive qSOFA score should prompt further evaluation for infection and organ dysfunction. For that, you calculate a SOFA score. -A SOFA score of ≥ 2 with suspected infection indicates sepsis. -A - [Chronic Fatigue Syndrome (Myalgic Encephalomyelitis)](https://www.timeofcare.com/chronic-fatigue-syndrome-myalgic-encephalomyelitis/) - myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) Diagnosis CFS mnemonic. Diagnosis is made clinically when patient symptoms match definition and other systemic causes of symptoms are ruled out. Symptoms must last at least 6 months and include: Pathologic fatigue, along with a combination of other symptoms including post-exertional fatigue, impaired focus/concentration, orthostatic intolerance, and unrefreshing sleep. - [Nonpharmacologic Treatment and Prevention of Delirium](https://www.timeofcare.com/delirium-prevention/) - Assess bowel and bladder Early mobilization + frequent mobilization Continuous observation - Sitter. Strictly limit the use of restraints. Nutrition/hydration (feeding assistance) Pain management - Be vigilant for and treat pain Sleep enhancement - Promote normal sleep-wake cycle Correct sensory deficits - Hearing and vision adaptations Environmental modification: Frequent orientation, familiar objects, family and caregiver - [Differential Diagnosis of Delirium - DELIRIUMS mnemonic ](https://www.timeofcare.com/deliriums-mnemonic/) - The differential diagnosis of Delirium using the DELIRIUMS mnemonic Common etiologies of delirium: Remember: delirium usually has more than one cause D Drug effect or withdrawal: benzos, narcotics, EtOH, SSRI, anticholinergics, Digoxin, antihistamines, muscle/bladder relaxants; especially in the elderly, even in low doses. Drugs also cover toxins and heavy metals. E Environmental factors (malfunction or lack - [Delirium, Differential diagnosis](https://www.timeofcare.com/delirium-differential-diagnosis/) - I. Using the VINDICATED MEN mnemonic Vessels (flow): In the head and brain: TIA, Stroke/intracranial hemorrhage; Brain stem stroke Heart failure (poor perfusion) Liver failure (encephalopathy). (lack of flow) Renal failure (uremic encephalopathy), (lack of flow) Fecal impaction, urinary retention (lack of flow). Hypertensive encephalopathy Rest of the body: MI, PE, anemia, porphyria, etc. Infection + - [CONSCIOUS: Questions for diagnosing delirium](https://www.timeofcare.com/delirium-questions-for-diagnosing-delirium/) - Mnemonic: CONSCIOUS. You can use the 9 features that distinguish delirium from dementia and other similar conditions to help you diagnose delirium. This is a rough version of the validated short CAM that follows the mnemonic, confusion. Feature of Delirium Evaluating Question Points Consciousness Is there a change or altered level of consciousness (ALOC) from the patient's baseline?. Either - [Frailty / Age-Related Physical Debility](https://www.timeofcare.com/frailty-age-related-physical-debility/) - Gait speed test The gait speed test is a great test to assess for frailty as a component of the preoperative assessment. "Frailty is an age-related, multidimensional state of decreased physiologic reserves. Frail patients are at increased risk of decline as a result of illness or stressors such as surgery. The definition and assessment of frailty - [Feeding Problems / Difficulties in infants and toddlers](https://www.timeofcare.com/feeding-problems-difficulties-in-infants-and-toddlers/) - Diagnosis Common presentation: Frustrated mother brings her infant or toddler to PCP complaining about his eating habits. Mother says when she puts the patient on her high chair to eat, she throws tantrums + pushes the food to the floor and won't eat. Mother has been giving her cookies, crackers, and juice, which she says are - [Conduct disorder](https://www.timeofcare.com/conduct-disorder/) - Behavioral problems associated with conduct disorder are more severe than those of oppositional defiant disorder. They involve "a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least 3 of the following 15 criteria in - [Oppositional defiant disorder (ODD)](https://www.timeofcare.com/oppositional-defiant-disorder-odd/) - To meet the DSM-5 criteria for ODD, the symptoms must be ongoing for at least 6 months and include at least 4 out of 8 symptoms from any of the following 3 categories: Angry/irritable mood 1. Often loses temper, 2. Is often touchy or easily annoyed, 3. Is often angry and resentful), Argumentative/defiant behavior 4. - [Bilateral Pedal Edema](https://www.timeofcare.com/bilateral-pedal-edema/) - Diagnosis. H&P Risk Factors: DDx and Causes. Look for systemic causes like liver, heart, and kidney failure. Diagnostic studies: -Echocardiography - to r/o HF and evaluate for pulmonary hypertension. -Polysomnography if OSA is suspected. -Duplex U/S if skin changes such as hemosiderin deposits or venous ulcerations are present; Evaluate for Chronic venous insufficiency. Other tests to - [Turner Syndrome (45, X Syndrome)](https://www.timeofcare.com/turner-syndrome-45-x-syndrome/) - Diagnosis Definition: H&P: Common presentation: 13 yo Female with primary amenorrhea. PE shows short stature, low hairline, webbed neck, and no pubertal development. "Turner syndrome is a chromosomal disorder that affects development in females. It results when a female's cells have one normal X chromosome and the other X chromosome is either missing or structurally - [Definition of Primary Amenorrhea](https://www.timeofcare.com/definition-of-primary-amenorrhea/) - Primary amenorrhea is defined as having: No Menses, PLUS Being 13 years or older with no pubertal development (breast development, etc), OR Being 5 years after initial breast development, OR Being 15 years old with pubertal development (secondary sexual characteristics). Primary amenorrhea is usually caused by chromosomal problems that lead to primary ovarian insufficiency or anatomic - [Generalized Anxiety Disorder (GAD)](https://www.timeofcare.com/treating-anxiety/) - Diagnosis Diagnosis is clinical. Use a brief validated screening tools like the GAD-7 scale to assess the severity of symptoms and response to treatment. H&P: Risk Factors: Common presentation: Associated conditions: Diagnostic studies: DDx & Causes: Assessment. GAD-7 score: Treatment -1st line therapy: CBT, pharmacotherapy (with SSRI/SNRI), or combination of CBT + SSRI/SNRI. -To avoid relapse, - [Medications for Anxiety (GAD) and Panic Attacks](https://www.timeofcare.com/medications-for-anxiety-gad-and-panic-attacks/) - -1st line treatment (SSRIs, SNRIs, and Azapirones [like Buspirone]). -2nd-line agents: Hydroxyzine, TCAs (Amitriptyline, Nortryptyline, Imipramine), antiepileptics (like Pregabalin), and antipsychotics (Quetiapine). -3rd-line agents: MAO inhibitors (like Isocarboxazid, Phenelzine, and Tranylcypromine) Benzodiazepines: May be used for augmentation in the short-term. "When used in combination with antidepressants, benzodiazepines may speed recovery from anxiety-related symptoms but do not - [Obsessive-Compulsive Disorder (OCD)](https://www.timeofcare.com/obsessive-compulsive-disorder-ocd/) - Background OCD is characterized by "intrusive and unwanted thoughts, images, or urges that cause distress or anxiety and repetitive thoughts or actions that the person feels driven to perform." Obsessions (repetitive/persistent, intrusive, unwanted thoughts/images/urges that cause distress/anxiety) → Compulsions (recurring thoughts/actions/rituals done to suppress the obsession). Treatment Psychotherapy. CBT: Exposure and response prevention (ERP) is - [Pituitary adenomas](https://www.timeofcare.com/pituitary-adenomas/) - Common presentation: a premenopausal woman with amenorrhea, headache, and vision changes (bitemporal hemianopsia). Diagnostic testing -MRI of the brain. Background "Pituitary adenomas are the most common disorder of the pituitary gland and are responsible for 10%–15% of all intracranial masses. They present with symptoms of hormone secretion or a neurologic mass effect, or as an incidental - [Subacute Thyroiditis](https://www.timeofcare.com/subacute-thyroiditis/) - Background Subacute thyroiditis = deQuervain thyroiditis=a common, transient condition that usually presents after a recent viral illness such as an upper respiratory infection. Typically affects young and middle-aged women. Symptoms include an acute, very painful enlargement of the thyroid gland with dysphagia, fever, and fatigue. The pain often radiates to the jaw or ears. About - [Hyperparathyroidism (Primary and Secondary)](https://www.timeofcare.com/hyperparathyroidism/) - Background Primary vs. secondary vs. tertiary Hyperparathyroidism. Primary hyperparathyroidism is the most common cause of hypercalcemia in the outpatient setting. Pathogenesis: 1) The function of the Parathyroid Hormone. 2) Vitamin D Action. Causes of secondary hyperparathyroidism. Diagnosis A high or unexpectedly “normal” PTH level in the presence of a high corrected calcium generally is diagnostic - [Parathyroid Hormone Action](https://www.timeofcare.com/parathyroid-hormone-action/) - PTH has one and only one job: That is to control the serum calcium level and keep it within the right range. If serum calcium is low, the parathyroid glands (four of them) secrete PTH. These glands make and store PTH to release it when needed. When released, PTH works with and through vitamin D - [Thyroid Diseases](https://www.timeofcare.com/thyroid-diseases/) - Mechanisms or pathogenesis or causes of thyroid disease Thyroiditis Acute thyroiditis | Subacute thyroiditis | Chronic thyroiditis (Hashimoto's) Silent thyroiditis (painless thyroiditis) Postpartum thyroiditis (probably a variant of silent thyroiditis) NB: Both silent and postpartum thyroiditis are subacute in length (i.e. most patients recover from it) but are not painful like subacute thyroiditis. Hyperstimulation (of - [Central hypothyroidism](https://www.timeofcare.com/central-hypothyroidism/) - Definition: "Central hypothyroidism is defined as hypothyroidism due to insufficient stimulation by thyroid stimulating hormone (TSH) of an otherwise normal thyroid gland. It can be secondary hypothyroidism (pituitary) or tertiary hypothyroidism (hypothalamus) in origin." In centrally mediated hypothyroidism, such as hypothyroidism due to pituitary disease, TSH levels alone are unreliable for assessing the response to treatment - [Hypoglycemia in Diabetic Patients](https://www.timeofcare.com/hypoglycemia-in-diabetic-patients/) - Diabetic kidney disease is the most common cause of hypoglycemia in a previously stable, well-controlled diabetic patient who has not changed their diet or insulin dosage. Common presentation: A diabetic patient whose been taking insulin for several years to decades starts having episodes of hypoglycemia. His blood sugars have been well controlled for a long time - [Bariatric Surgery](https://www.timeofcare.com/bariatric-surgery/) - Treatment of Obesity with Bariatric Surgery - [Euthyroid sick syndrome](https://www.timeofcare.com/euthyroid-sick-syndrome/) - "The euthyroid sick syndrome refers to alterations in thyroid function tests seen frequently in hospitalized patients, and abnormal thyroid function tests may be seen early in sepsis. These changes are statistically much more likely to be secondary to the euthyroid sick syndrome than to unrecognized pituitary or hypothalamic disease" ABFM critique. Further Reading / - [Pelvic Inflammatory Disease (PID)](https://www.timeofcare.com/pelvic-inflammatory-disease-pid/) - Background PID is a polymicrobial infection of the upper genital tract. It primarily affects young, sexually active women. Chlamydia trachomatis and Neisseria gonorrhoeae are the most common organisms involved; however, other microorganisms especially anaerobes are often involved. Diagnosis The diagnosis of PID is based primarily on clinical evaluation. Significant consequences occur if treatment is delayed. Don't wait - [Things that Impair Levothyroxine Absorption](https://www.timeofcare.com/things-that-impair-levothyroxine-absorption/) - Levothyroxine absorption is impaired by many GI conditions, including: Atrophic gastritis, Chronic proton pump inhibitor use, Helicobacter pylori infection. Celiac disease IBD etc.) When H. Pylori is the cause of poor absorption, treatment of H. pylori infection reverses this effect. After eradication of H. Pylori, a reduction of the levothyroxine dose by 30% or more will - [Hypoparathyroidism](https://www.timeofcare.com/hypoparathyroidism/) - Background The normal action of parathyroid hormone (PTH) is to increase serum calcium levels and decrease serum phosphate levels. PTH affects the kidneys by increasing calcium reabsorption, decreasing renal phosphate reabsorption, and increasing active vitamin D formation, and affects the bones by increasing osteoclast activity. -Parathyroid Hormone Action. -Vitamin D Mechanism of Action. Laboratory testing - [Hyperthyroidism](https://www.timeofcare.com/hyperthyroidism/) - Definition: Diagnosis History and physical. Labs/studies ordered/reviewed: -TSH first. If low, then free T4 and T3. CBC, CMP (review calcium level). R/o elevated alkaline phosphatase or hypercalciuria. -RAIU scan. -Thyroglobulin if concern for exogenous T4 overdose (it will be low). -U/S if nodule noted on exam. Treatment Beta-blockers to control the adrenergic symptoms. Indicated for - [Radioactive Iodine Uptake (RAIU) Thyroid Scan](https://www.timeofcare.com/radioactive-iodine-uptake-and-thyroid-scan/) - RAIU is used to differentiate causes of hyperthyroidism. You cannot do a RAIU thyroid scan if the patient recently got IV contrast or an amiodarone load because iodine blocks uptake of radioactive iodine (RAI). In that case, you will check autoantibodies instead. On a personal note, we admitted a patient with thyrotoxic periodic paralysis who - [Chronic Kidney Disease (CKD)](https://www.timeofcare.com/chronic-kidney-disease-ckd/) - Background DM is the #1 cause of CKD in the U.S. HTN is #2. GFR decreases with age. On average, GFR decreases by 10 per decade starting from age 20. Definition of CKD. Staging of CKD. Diagnosis H&P: Screen all patients with Risk Factors for CKD. DDx and Etiology: Screening studies for CKD -eGFR (estimated from - [When to refer CKD patients to a nephrologist](https://www.timeofcare.com/when-to-refer-ckd-patients-to-a-nephrologist/) - Consider referring to a nephrologist when: The underlying cause unclear after your basic work-up Management of the underlying cause is beyond your scope of practice. A biopsy is needed. There is a rapid progression of the CKD AKI superimposed on CKD. Stage 3a CKD and up - co-manage with nephrology. - [Chronic kidney disease mineral and bone disorder (CKD-MBD)](https://www.timeofcare.com/chronic-kidney-disease-mineral-and-bone-disorder-ckd-mbd/) - xxx - [Causes of Secondary Hyperparathyroidism](https://www.timeofcare.com/causes-of-secondary-hyperparathyroidism/) - The site, parathyroid.com has an excellent explanation of secondary hyperparathyroidism. Chronic Kidney Disease that produces 1) Decreased levels of 1,25-dihydroxyvitamin D, 2) Hyperphosphatemia, 3) Hypocalcemia. Vitamin D deficiency (due to low dietary intake/lack of sun exposure, malabsorption, liver disease, and other chronic illness) Related Article: Tertiary Hyperparathyroidism. Note: To understand how CKD causes decreased levels of 1,25-dihydroxyvitamin - [Tertiary hyperparathyroidism](https://www.timeofcare.com/tertiary-hyperparathyroidism/) - From secondary to tertiary hyperparathyroidism This text in quotation is from the following citation. "Patients with severe chronic kidney disease and secondary hyperparathyroidism usually have low or normal serum calcium concentrations but, with prolonged disease, may develop hypercalcemia. The rise in plasma calcium most often occurs in patients with adynamic bone disease and markedly reduced - [Hypoglycemia in adult patients with no Diabetes](https://www.timeofcare.com/hypoglycemia-in-patients-with-no-diabetes/) - *Admit pts with ingestion of a long-acting hypoglycemic agent, recurrent hypoglycemia during observation, and those unable to eat. Admit to intermediate care. Blood glucose Insulin, Proinsulin, C-peptide, Beta-hydroxybutyrate (BHOB), Screen for oral hypoglycemic agents TSH Cortisol level *Lactate and procalcitonin, if pt is sick *If pt doesn't have AMS and can drink and swallow safely - [Hyperparathyroidism or Hypercalcemia: "Stones, Bones, abdominal Groans, thrones and psychiatric overtones"](https://www.timeofcare.com/hyperparathyroidism-or-hypercalcemia-stones-bones-abdominal-groans-thrones-and-psychiatric-overtones/) - "Stones, Bones, Groans, moans, thrones and psychiatric overtones" The six key organ systems affected by hypercalcemia: “Stones, Bones, Groans (abd. groans), Moans, Thrones, and Psychiatric Overtones!” Signs and symptoms of primary hyperparathyroidism or hypercalcemia. They are summarized by "stones, bones, abdominal groans, thrones and psychiatric overtones". "Stones" refers to kidney stones and the renal system. - [Corrected Calcium (Calcium Correction for Hypoaluminemia)](https://www.timeofcare.com/corrected-calcium/) - Corrected serum calicum = measured serum calcium +[ 0.8(4.0 – measured serum albumin)] Calcium conc. measured in mg/ dL, albumin in g/dL Obviously, serum calcium and serum albumin are all concentrations, not total body masses. Online calculator, MDCalc.com - [Hypogonadism (Low Testosterone) in Males](https://www.timeofcare.com/hypogonadism-low-testosterone-male/) - -Hematocrit should be monitored during testosterone replacement. - Case by Dr. T Pt with testosterone of 6.8. Hx of fatigue, stress, ED/decreased libido, male pattern baldness. *Starting patient on testosterone replacement is like putting a patient on thyroid replacement. It requires frequent f/u, at 2-3 mo, then 6mo, then yearly to f/u. It also requires - [Gestational Diabetes](https://www.timeofcare.com/gestational-diabetes/) - TX: Diet and exercise. Insulin Oral medications lack long-term safety data. But many people use it. Treating GDM improves outcomes for both the mother and infant. These include: -a decreased risk for operative delivery, -large-for-gestational-age infants, -shoulder dystocia, and -maternal preeclampsia. Tx doesn’t reduce risk of developing DM2. “Clinicians who care for pregnant women need - [Falsely Lowered A1C and Falsely Elevated A1C](https://www.timeofcare.com/falsely-lowered-a1c-and-falsely-elevated-a1c/) - Falsely Elevated A1C "Any condition that prolongs the life of the erythrocyte or is associated with decreased red cell turnover exposes the cell to glucose for a longer period of time, resulting in higher A1c levels. Iron deficiency anemia is a commonly reported condition associated with falsely elevated A1c. Studies in patients with and without - [Amsel Criteria: Diagnostic Criteria for Bacterial Vaginosis](https://www.timeofcare.com/amsel-criteria-diagnostic-criteria-for-bacterial-vaginosis/) - Amsel Criteria: Diagnostic Criteria for Bacterial Vaginosis - [Graves Disease](https://www.timeofcare.com/graves-disease/) - -Graves disease = the most common cause of hyperthyroidism in the United States. -Graves’ disease (thyrotoxicosis) is an autoimmune disorder in which a unique antibody called thyroid-stimulating antibody (also called TSH Receptor Antibodies) stimulates the TSH receptors causing thyroid cells to grow larger and to produce excessive amounts of thyroid hormones (T4 & T3). In - [Methimazole](https://www.timeofcare.com/methimazole/) - Methimazole adverse reactions Agranulocytosis. Before starting treatment, advise the patient to be alert for a fever and severe sore throat. Hepatotoxicity is another adverse effect to watch out for. - [Subclinical Hypothyroidism](https://www.timeofcare.com/subclinical-hypothyroidism/) - Diagnosis -Repeat TSH level 1–3 months as TSH may fluctuate in patients without thyroid disease and return to normal on subsequent testing. -"In a patient with a normal free T4, the TSH level must be greater than 10 µU/mL for a diagnosis of hypothyroidism. -Mild TSH elevations may be a normal manifestation of aging." ABFM - [Diabetic Nephropathy (Diabetic Kidney Disease)](https://www.timeofcare.com/diabetic-nephropathy/) - - Will get a spot urine albumin/creatinine ratio annually. Screening for microalbuminuria with a spot urine albumin/creatinine ratio identifies the early stages of nephropathy. - Will also evaluate GFR and Creatinine annually (because diabetic neuropathy may also manifest as increased creatinine or decreased GFR). "Screening for microalbuminuria with a spot urine albumin/creatinine ratio identifies the early - [Diabetes Treatment Algorithm](https://www.timeofcare.com/diabetes-treatment-algorithm/) - In 2016, the ADA published an excellent algorithm that I use for treating my diabetes patients. Source: Diabetes Care 2016 Jan; 39(Supplement 1): S52-S59 Larger image. Reference Diabetes Care 2016 Jan; 39(Supplement 1): S52-S59. http://care.diabetesjournals.org/content/39/Supplement_1/S52 - [Constipation in kids 1 year and older](https://www.timeofcare.com/constipation-in-kids-1-year-and-older/) - Is it mild or severe constipation? For mild, start with educating the patient. Use methylcellulose and psyllium, increased water intake, dietary changes, exercise, etc. Let patients know that increasing fiber intake may cause bloating and flatulence. Patient to increase dietary fiber slowly and drink lots of water to reduce bloating and flatulence. If the conservative - [Keloid](https://www.timeofcare.com/keloid/) - Treatment -Intralesional corticosteroid injections (1st-line) -"Silicone gel sheeting, topical imiquimod, and intralesional fluorouracil and Bleomycin injections can be used when first-line therapy fails, but these methods are more often associated with recurrence. Laser therapy and surgical excision are associated with a high rate of recurrence when used as monotherapy." "A keloid is a benign overgrowth - [Abscess](https://www.timeofcare.com/abscess/) - A simple abscess with no overlying cellulitis should be treated with incision and drainage alone. It doesn't require antibiotics. If there is surrounding erythema / overlying cellulitis, treat with antibiotics. When treating cellulitis, remember purulent vs. nonpurulent categorization. - [Serotonin Syndrome (Serotonin Toxicity)](https://www.timeofcare.com/serotonin-syndrome/) - Diagnosis The diagnosis is based on a history of taking a serotonergic agent PLUS specific clinical findings. See the Hunter Serotonin Toxicity Criteria. H&P: Risk factors: Typical presentation: DDx: NMS, Malignant hyperthermia, Anticholinergic syndrome, others. Cause: Excessive serotonergic activity in the CNS and PNS. Complications: Diagnostic testing: Consider a CBC, CMP (Electrolytes, BUN, Cr, liver enzymes), - [Diagnostic Criteria for Serotonin Syndrome](https://www.timeofcare.com/diagnostic-criteria-for-serotonin-syndrome/) - Several diagnostic criteria for serotonin syndrome have been proposed. The Hunter Serotonin Toxicity Criteria are the most accurate (sensitivity of 84%, specificity of 97%) The diagnosis of serotonin syndrome is based on a history of taking a serotonergic agent and clinical findings. No labs are needed. To fulfill the Hunter Criteria, a patient must have - [Serotonin Syndrome, Differential diagnosis](https://www.timeofcare.com/serotonin-syndrome-differential-diagnosis/) - Neuroleptic malignant syndrome (NMS), Malignant hyperthermia, Anticholinergic syndrome (anticholinergic toxicity) Intoxication from sympathomimetic agents, Sedative-hypnotic withdrawal, Meningitis /encephalitis. - [Benign Prostatic Hyperplasia (BPH)](https://www.timeofcare.com/benign-prostatic-hyperplasia-bph/) - This article discusses how to treat Benign Prostatic Hyperplasia (BPH) - [Endometriosis](https://www.timeofcare.com/endometriosis/) - Patient with dysmenorrhea, pelvic pain, and dyspareunia. Endometriosis is caused by menstrual tissue in the pelvic peritoneal cavity. Infertility, dysmenorrhea, and dyspareunia with postcoital bleeding are common. Get Transvaginal Ultrasonography. Laparoscopy (with histology) is the gold standard for diagnosis. However, transvaginal U/S is the noninvasive test of choice. CA-125 will often be elevated but is - [Abnormal Uterine Bleeding in Non-Pregnant Women of Reproductive Age](https://www.timeofcare.com/abnormal-uterine-bleeding-in-non-pregnant-women-of-reproductive-age/) - Diagnosis Definition: Abnormal uterine bleeding (AUB) refers to menstrual bleeding of abnormal quantity, duration, or schedule (i.e. it's irregular, lasts too long, or too heavy) H&P Distinguish b/n uterine vs. non-uterine bleeding with the H&P. Ovulatory (regular menses) vs. anovulatory (irregular menses) AUB Ddx(PALM-COEIN). Diagnostic studies -R/o pregnancy. Treatment -Based on type - Ovulatory vs. non-ovulatory. - [Primary Dysmenorrhea (Painful menstruation)](https://www.timeofcare.com/primary-dysmenorrhea/) - Treatment -NSAIDs are 1st-line. Start NSAID at the onset of menstruation and continue for the first 2-3 days of the menstrual cycle. Alternatively, start 1-2 days before the expected onset of menstrual period and continue on a fixed schedule for 2-3 days. Eg. Naproxen 375mg or 500mg po BID; Ibuprofen 400mg po q6-8h. All NSAIDs - [Pelvic pain (Acute): Differential diagnosis](https://www.timeofcare.com/pelvic-pain-acute-differential-diagnosis/) - Gastrointestinal Appendicitis Bowel obstruction Constipation Diverticulitis Fecal impaction Gastroenteritis Hirschsprung disease Incarcerated hernia Intussusception Irritable bowel syndrome Meckel's diverticulitis Neoplasm Perforated viscous Regional ileitis (Crohn disease) Ulcerative colitis Volvulus Urologic Cystitis Neoplasm Urethritis Pyelonephritis Calculi Musculoskeletal Abdominal wall hematoma or infection Trauma Herniated disc Arthritis Strain or sprain Hernia Neoplasm Gynecological Pregnancy complications Abortion Dysmenorrhea - [Testicular Torsion](https://www.timeofcare.com/testicular-torsion/) - Diagnosis Treatment Immediate urologic consultation for surgical exploration. "Surgical exploration is the immediate priority, with ischemic damage starting between 4 and 8 hours after onset. Attempts at manual detorsion should not delay surgical exploration and often require analgesia or sedation. If surgery is not an immediate option, manual detorsion is performed by rotating the - [Testicular Cancer](https://www.timeofcare.com/testicular-cancer/) - Diagnosis -H&P -Risk factors: Cryptorchidism especially if orchiopexy is done after puberty. -DDx and etiology. Imaging: U/S Biopsy: contraindicated if U/S suggestive of testicular cancer since it may contaminate the scrotum or alter the lymphatic drainage. CT (chest, abdomen, and pelvis) + measurement of the tumor markers for staging and as an indication of tumor burden. Treatment - [Undescended Testicle (Cryptorchidism)](https://www.timeofcare.com/undescended-testicle-cryptorchidism/) - Background Undescended Testes (UDT) is the most common genital disorder identified at birth. Diagnosis Palpate testes for quality and position at every well-child visit. Cryptorchidism (detected at birth) vs. newly diagnosed (acquired) cryptorchidism after 6 months (corrected for GA) Don't do U/S or any other imaging before referring (Per AUA). It rarely helps in decision - [PostPartum Hemorrhage in patient with decreased Uterine Tone](https://www.timeofcare.com/postpartum-hemorrhage-in-patient-with-decreased-uterine-tone/) - Uterotonic agents for treating PPH 2/2 to uterine atony Oxytocin (Pitocin) -- 1st line agent. Misoprostol (Cytotec) Methylergonovine - CONTRAINDICATED in patients with any degree of HTN or history of HTN Carboprost (Hemabate) - CONTRAINDICATED in patients with asthma. Also, should be avoided in patients with hepatic, renal, or cardiac disease. Oxytocin and Misoprostol - [Mimicking Pregnancy: The Way Hormonal Contraceptives Work](https://www.timeofcare.com/mimicking-pregnancy-the-way-hormonal-contraceptives-work/) - "The birth control pill functions primarily by preventing ovulation. The pill elevates the body’s levels of progesterone, which mimics pregnancy. The body behaves as though it is pregnant, disrupting the normal menstrual cycle and the release of additional hormones that cause a woman to ovulate. Progestin also thickens cervical mucus, which helps prevent sperm from - [Ovarian Cysts](https://www.timeofcare.com/ovarian-cysts/) - Diagnosis H&P Functional ovarian cysts. DDx of ovarian cyst / Etiologies DDx of adnexal mass. Diagnostic tests -Pregnancy test (for all peri- and premenopausal women); Serial quantitative β-hCG if an ectopic pregnancy is suspected. -CBC with diff to r/o infection. -U/S Treatment Algorithm. Sample case: You perform a PE on a 42-year-old female and notice a fullness in - [Hearing Loss in Newborns](https://www.timeofcare.com/hearing-loss-in-newborns/) - The most common cause of hearing loss in newborns is genetic inheritance. - [Amyotrophic lateral sclerosis (ALS)](https://www.timeofcare.com/amyotrophic-lateral-sclerosis-als/) - ALS is a pure motor disorder involving anterior horn cells in the spinal cord and their brainstem homologs. ALS may begin as lower motor or bulbar palsy, and the median survival is 3–5 years. - [Corneal abrasion](https://www.timeofcare.com/corneal-abrasion/) - Corneal abrasion - [Age-Related Macular Degeneration](https://www.timeofcare.com/age-related-macular-degeneration/) - An elderly male with a gradual loss of his vision over the past 12 months. RF: He has smoked 1 pack of cigarettes per day for the past 60 years. No other sig. PMH. On Amsler grid testing he notes distorted grid lines. Diagnosis Risk factors: Smoking, Age, ... Treatment Counsel to stop smoking to prevent - [Concussion](https://www.timeofcare.com/concussion/) - -Patient meets criteria for a concussion. -History & Physical, above. -Post Concussion Symptom Scale completed. -No red flags (no focal neurologic deficits, no anticoagulation use or coagulopathy, no evidence of basilar skull fracture (hemotympanum, raccoon eyes, Battle sign) which would demand an immediate referral to the ED. -Indications for neuroimaging reviewed. Not indicated at this time. - [Herpes Zoster (Shingles) and Postherpetic Neuralgia](https://www.timeofcare.com/herpes-zoster-shingles-and-postherpetic-neuralgia/) - Acute Herpes Zoster Infection Etiology: "Shingles is caused by the varicella-zoster virus (VZV), the same virus that causes chickenpox. After a person recovers from chickenpox, the virus stays dormant (inactive) in the body. For reasons that are not fully known, the virus can reactivate years later, causing shingles." CDC Diagnosis Diagnosis is clinical by seeing the - [Diabetic Neuropathy (Distal Symmetric Polyneuropathy)](https://www.timeofcare.com/diabetic-neuropathy/) - Background Present in up to 10%–15% of DM patients at the time of diagnosis. It's present in up to 50% of patients within 10 years of diagnosis. AKA: Diabetic Peripheral Neuropathy Diagnosis How is the diagnosis made? Treatment 1st-line treatments -Pregabalin (FDA approved) -Duloxetine (FDA approved) Other Medications that work. Tricyclic antidepressants - Significant side effects. Avoid in - [Subarachnoid Hemorrhage (Nontraumatic)](https://www.timeofcare.com/subarachnoid-hemorrhage-nontraumatic/) - Diagnosis How is the diagnosis made? Clinical + CT head. If normal CT, do LP to look for Xanthochromia. The absence of Xanthochromia r/o subarachnoid hemorrhage. -Headache Red Flags. "Early diagnosis of a nontraumatic subarachnoid hemorrhage is paramount for achieving a good outcome when a patient presents with a headache that is unusually severe and - [Cubital tunnel syndrome](https://www.timeofcare.com/cubital-tunnel-syndrome/) - Is the second most common peripheral neuropathy. Ulnar nerve compression in the upper extremity, leading to sensory paresthesias in the ulnar digits and intrinsic muscular weakness. Diagnosis Provocative testing: -Tinel’s sign over the cubital tunnel, -The elbow flexion test with paresthesias elicited over the ulnar nerve. "Carpal tunnel syndrome causes paresthesias in the distal median - [Herpes Zoster Oticus (Ramsay Hunt syndrome)](https://www.timeofcare.com/herpes-zoster-oticus-ramsay-hunt-syndrome/) - CC: Painful sores in the mouth. HPI: Painful sores in the mouth that appeared a few days ago. Pain with eating but patient is able to swallow without difficulty. Now having some pain around his right ear today. No difficulty hearing. Denies URI symptoms. No significant PMH. Meds = SSRI. PE: You see vesicles on the - [Conjunctivitis, Bacterial](https://www.timeofcare.com/conjunctivitis-bacterial/) - Bacterial Conjunctivitis -History of eye morning matting present. -No red flags such photophobia (elicited via pupillary constriction) and anisocoria (greater than 1mm). -No vision loss (indication for prompt referral to ophthalmology). -Don't wear contact lenses while symptomatic. -Good hand hygiene to decrease transmission. -Consider cool compresses and artificial tears prn. -Rx: Moxifloxacin ophthalmic 0.5% (Vigamox) - [Conjunctivitis, Neonatal](https://www.timeofcare.com/neonatal-conjunctivitis/) - Neonatal Conjunctivitis (Ophthalmia neonatorum) Prophylaxis xxx Treatment A) Neonatal Conjunctivitis 2/2 to gonorrhea "Infantile gonococcal infection is usually the result of exposure to infected cervical exudate during delivery and manifests 2–5 days after birth. Ophthalmia neonatorum and sepsis are the most severe gonococcal infections in newborns and immediate treatment is warranted based on the presumptive diagnosis. - [Multiple Sclerosis (MS)](https://www.timeofcare.com/multiple-sclerosis-ms/) - - IV or PO steroids are the first-line treatment for acute exacerbations of MS. --Methylprednisolone (Medrol) IV "Corticosteroids, either orally or parenterally, are the first-line treatment for acute exacerbations of multiple sclerosis (MS) (SOR A). A Cochrane review found no significant differences in outcomes based on the route of administration. Disease-modifying agents such as interferon - [Pruritus (Itching)](https://www.timeofcare.com/pruritus/) - Diagnosis H&P DDx and Etiology. Diagnostic studies -CBC, CMP (fasting glucose, Alk phos, BUN, Creatinine), TSH -Consider skin biopsy. -Consider scraping (KOH, mineral oil) -Consider culture (fungal, viral, bacterial) -Consider HIV test and CXR if a systemic condition is suspected (generalized pruritus, pruritus > 3 weeks, H&P) Algorithm from the AAFP. Treatment Treat based on - [Soaks / Bath Additives for Children with Eczema](https://www.timeofcare.com/soaks-bath-additives-for-children-with-eczema/) - Dilute Bleach Baths. Making a bleach bath is so easy. It’s just a matter of putting a little bit of bleach into the bath water. The bleach kills bacteria like Staph aureus that grow on the skin. Studies have shown that bleach baths help children with Eczema. -Add a 1/2 of a cup of 6% - [Nonpharmacologic Treatment of Pruritus and Dry Skin](https://www.timeofcare.com/nonpharmacologic-treatment-of-pruritus-and-dry-skin/) - Prevent itching and xerosis (dry skin) Take steps to reduce dry skin, which worsens itching. -Avoid skin irritants (e.g. wool, fiberglass, and detergents) which irritate the skin and increase pruritus. -Cool environment (lower temperature); -Reduce stress; -Avoid scratching (perpetual itch-scratch cycle); -Use of a humidifier to increase the relative humidity of indoor air during the dry, cold - [Brachioradial Pruritus](https://www.timeofcare.com/brachioradial-pruritus/) - http://www.aocd.org/page/BrachioradialPruritu - [Tinnitus](https://www.timeofcare.com/tinnitus/) - Diagnosis H&P: Tinnitus classification. Evaluate for treatable causes of tinnitus. Risk Factors: Common Presentations: Tinnitus red flag symptoms. DDx of tinnitus. Diagnostic tests -Audiometry (audiogram) with tympanometry to determine the presence and degree of hearing loss. -Electronystagmography to assess vestibular function -Neuroimaging is indicated only if the "tinnitus is localized to one ear, is pulsatile, or - [Classification of Tinnitus](https://www.timeofcare.com/classification-of-tinnitus/) - The etiology of tinnitus can be divided into tinnitus originating from within the auditory system (also called subjective tinnitus) and tinnitus originating from outside the auditory system (objective tinnitus). Some authors divide it into two kinds as follows: A) Tinnitus originating from within the auditory system Subjective tinnitus is tinnitus only the patient can hear. This is - [Assessment and Plan of Tinnitus](https://www.timeofcare.com/assessment-and-plan-of-tinnitus/) - -DDx of tinnitus reviewed. -No tinnitus red flag symptoms. -Cognitive behavioral therapy (CBT), sound therapy, and hearing aid trial encouraged. -Audiometry with tympanometry ordered. -Electronystagmography to assess vestibular function -Vestibular Therapy -Will consider neuroimaging as needed. - [Bronchiolitis](https://www.timeofcare.com/bronchiolitis/) - Background Bronchiolitis is a viral infection. Respiratory syncytial virus (RSV) is the most common cause of bronchiolitis. In North America, RSV season is November to April. Most cases occur from December to March. RSV is rarely associated with a bacterial superimposition. Diagnosis H&P: Assess hydration status (UOP, oral secretions, cap refill, etc). Risk factors: DDx: - [Thalassemia](https://www.timeofcare.com/thalassemia/) - “This presentation is consistent with β-thalassemia minor trait in a generally asymptomatic patient. Hemoglobin electrophoresis will be abnormal, with HbA2 increased and HbA decreased. The free T4 level is likely to be normal in a patient with a normal TSH level. A ferritin level is also likely to be normal given the normal levels of - [Chronic Lymphocytic Leukemia (CLL)](https://www.timeofcare.com/chronic-lymphocytic-leukemia/) - Flow cytometry and immunophenotyping of peripheral blood is routinely required to establish a diagnosis of chronic lymphocytic leukemia. “Flow cytometry and immunophenotyping of peripheral blood demonstrate clonality of the circulating lymphocytes in chronic lymphocytic leukemia (CLL). Absolute lymphocytosis is defined as >5000 cells/mm3. Ninety percent of CLL patients are asymptomatic at the time of diagnosis. Imaging procedures - [Monoclonal gammopathy of undetermined significance (MGUS)](https://www.timeofcare.com/monoclonal-gammopathy-of-undetermined-significance-mgus/) - Patients with MGUS will require regular follow-up visits because of the risk this condition will progress to multiple myeloma "Monoclonal gammopathy of undetermined significance (MGUS) is present in approximately 2%–3% of the white population older than 50. It is associated with a risk of progression to multiple myeloma at a rate of 1% per year. Most - [Preexposure Prophylaxis (PrEP) for the Prevention of HIV](https://www.timeofcare.com/preexposure-prophylaxis-prep-for-the-prevention-of-hiv/) - -History & Physical exam done above. -Current CDC PrEP Guidelines reviewed with the patient. -HIV test: Will document negative HIV test result before prescribing PrEP -Symptom assessment: Patient has no signs/symptoms of acute HIV infection. -Renal function: CMP to document normal renal function before starting prep. -Med-Review: Medication review doesn't show any contraindicated medications. -Hep - [Iron supplementation in infants](https://www.timeofcare.com/iron-supplementation-in-infants/) - “Healthy full-term infants receive 60%–80% of their iron stores from their mothers during the third trimester of pregnancy. Thus, even an exclusively breastfed infant will not typically be at risk of developing iron deficiency anemia until the age of 4 months. Iron supplementation should then be started and continued until the child is eating foods - [Unintentional Injuries in Children](https://www.timeofcare.com/unintentional-injuries-in-children/) - The most common cause of unintentional deaths in children is Motor vehicle accidents "Unintentional injuries account for 40% of childhood deaths. Motor vehicle accidents are the most frequent cause of these deaths (58.2% of unintentional deaths). The proper use of child restraints is the most effective way to prevent injury or death, and the American - [Psoriasis](https://www.timeofcare.com/psoriasis/) - Diagnosis H&P Diagnosis is clinical. Risk Factors: Common presentation: DDx Treatment Mild to moderate disease: Topical treatments - corticosteroids, vitamin D analogs (calcipotriene and calcitriol), tazarotene, calcineurin inhibitors Severe psoriasis: Phototherapy, systemic medications; Biologics (including TNF inhibitors) --Systemic drugs: Acitretin (Soriatane), Adalimumab (Humira), Cyclosporine (Sandimmune), Etanercept (Enbrel), Infliximab (Remicade), Methotrexate, Ustekinumab (Stelara) Background Reference http://www.aafp.org/afp/2013/0501/p626.html - [The ABCDEFs of Secondary Hypertension](https://www.timeofcare.com/the-abcdes-of-secondary-hypertension/) - The ABCDEFs of Secondary Hypertension Apnea (OSA) Blood pressure measuring technique. Circulatory system problems: coarctation of the aorta, renal artery stenosis, and renal disease (glomerular disease & renal parenchymal disease). Drugs (medications and illicit drugs) Endocrine disorders Food or diet. OSA=Obstructive sleep apnea; RAS=Renal Artery Stenosis (Renovascular disease); COA=Coarctation of the aorta. Primary aldosteronism = Conn's syndrome Alternative - [Anemia, Iron Deficiency](https://www.timeofcare.com/anemia-iron-deficiency/) - Diagnosis H&P: Risk Factors: Common Presentation: DDx Treatment Ferrous Sulfate 325 mg PO three times daily if enteral therapy is possible (and the patient can absorb iron). IV iron - Iron sucrose (Venofer) if oral iron is inadequate. Take oral iron with Vitamin C or a meal rich in meat protein to increase iron absorption. - [Inflammatory lesions vs. noninflammatory lesions in Acne Vulgaris](https://www.timeofcare.com/inflammatory-lesions-vs-noninflammatory-lesions-in-acne-vulgaris/) - Noninflammatory acne lesions are comedones. Inflammatory lesions include papules, pustules, and nodules. "Grading acne based on the type of lesion and severity helps guide therapy. Topical retinoids prevent the formation of comedones and reduce their number, and are indicated as monotherapy for noninflammatory acne. Topical antibiotics are used primarily for the treatment of mild to - [Neuropathy (peripheral), Paresthesias / Numbness / Tingling: Ddx](https://www.timeofcare.com/neuropathy-peripheral-paresthesias-numbness-ddx/) - Diabetes mellitus Idiopathic peripheral polyneuropathy Compression of the spinal cord or peripheral nerves. Disk disease Carpal tunnel syndrome Meralgia paresthetica Herpes Zoster Alcoholism Stroke Guillain-Barré syndrome Hypothyroidism; Hyperthyroidism Deficiencies of: Vitamin B12, folate, B6 deficiency; Thiamine (B1). Also, Vitamin B6 excess. Multiple sclerosis Multiple myelomas Monoclonal gammopathy of undetermined significance (MGUS) Psychiatric; hyperventilation syndrome Drugs: - [Positive Predictive Value (PPV)](https://www.timeofcare.com/positive-predictive-value/) - An easy way to understand PPV is to dissect the name. In Positive Predictive Value, we are looking at how good a positive test is at predicting that a person actually has a disease. Positive predictive value refers to the percentage of patients with a positive test for a disease who actually have the disease. For - [Intimate Partner Violence and Domestic Abuse](https://www.timeofcare.com/intimate-partner-violence-and-domestic-abuse/) - Being female (female gender) is the only consistent risk factor for being a victim of domestic violence. Further Reading https://www.cdc.gov/violenceprevention/intimatepartnerviolence/index.html Am Fam Physician. 2016 Oct 15;94(8):646-651. Intimate Partner Violence. - [ERYTHEMA INFECTIOSUM (FIFTH DISEASE)](https://www.timeofcare.com/erythema-infectiosum-fifth-disease/) - Background Also called fifth disease. Diagnosis H&P: Ddx Cause: Parvovirus B19, an erythrovirus. Typical presentation: A prodrome of low-grade fever sore throat, nausea, headache, malaise, followed a few days later by a characteristic erythematous facial rash on the cheeks that is classically described as a slapped-cheek appearance and lacy exanthem. The rash only lasts a few days - [Bites from Dogs and Cats](https://www.timeofcare.com/dog-and-cat-bites/) - Treat high-risk wounds with antibiotics. High-Risk Wounds "Factors associated with a high risk include: a bite on an extremity with underlying venous and/or lymphatic compromise, a bite involving the hand, a bite near or in a prosthetic joint, cat bites, crush injuries, delayed presentation, puncture wounds, underlying diabetes mellitus, immunosuppression. A Cochrane review of nine trials - [Risk Factors for Abdominal Aortic Aneurysms](https://www.timeofcare.com/risk-factors-for-abdominal-aortic-aneurysms/) - The classic risk factors for atherosclerosis are also risk factors for AAA. Tobacco smoking, Male sex, Age, low HDL cholesterol, HIgh total cholesterol / Use of statins Hypertension, - [Kawasaki Disease (Typical and Atypical)](https://www.timeofcare.com/kawasaki-disease-typical-and-atypical/) - Background Kawasaki disease (KD), also called Mucocutaneous Lymph Node Syndrome, is an acute, systemic vasculitis of small and medium-sized arteries. "KD is characterized by systemic inflammation in all the medium-sized arteries and in multiple organs and tissues during the acute febrile phase, leading to associated clinical findings." AHA 2017 Mainly affects patients 5 months to - [The diagnostic criteria for classic Kawasaki disease](https://www.timeofcare.com/kawasaki-disease/) - CRASH & Burn the heart Imagine a 5 month to 5-year-old child riding a Kawasaki motorcycle. He is using his hands and feet to do it. He has been riding and burning for 5 days and is going to CRASH and burn his heart. Typical (Complete) Kawasaki The diagnostic criteria for typical (complete) Kawasaki disease is a - [Algorithm for Evaluating Suspected Incomplete Kawasaki](https://www.timeofcare.com/algorithm-for-evaluating-suspected-incomplete-kawasaki/) - From the AHA - [Clinical Findings Associated with Kawasaki Disease](https://www.timeofcare.com/clinical-findings-associated-with-kawasaki-disease/) - "Kawasaki is characterized by systemic inflammation in all the medium-sized arteries and in multiple organs and tissues during the acute febrile phase, leading to associated clinical findings". In addition to the classic clinical features used to diagnose Kawasaki disease (KD), the following findings are also associated with KD: Liver (hepatitis), Lung (interstitial pneumonitis), Gastrointestinal tract - [Supplemental labs for Kawasaki](https://www.timeofcare.com/supplemental-labs-for-kawasaki/) - You don't need any lab work to diagnose typical Kawasaki disease (KD). It's all a clinical diagnosis. However, in ambiguous cases, certain lab findings characteristic of KD may support the diagnosis. Supplemental laboratory testing can help in the diagnosis of these atypical Kawasaki cases. The AHA/AAP recommended the following labs to evaluate atypical Kawasaki disease. CRP or ESR - [Impetigo](https://www.timeofcare.com/impetigo/) - Diagnosis H&P: Causative agents: Streptococcus pyogenes and MSSA Common distribution/presentation: Poststreptococcal glomerulonephritis. Possible complications (rare): Ddx Diagnostic criteria Treatment Based on extent. -Localized disease; one or a few lesions - Mupirocin 2% ointment/cream; OR Fusidic acid 2% ointment; OR Retapamulin 1% ointment (Altabax) -Extensive disease; multiple lesions - Systemic antibiotic: Cephalexin (Keflex) PO. -If you suspect MRSA, use - [Adenomyosis](https://www.timeofcare.com/adenomyosis/) - Adenomyosis presents with painful periods painful intercourse chronic pelvic pain heavy menstrual bleeding - [What is the difference between Adenomyosis and Endometriosis](https://www.timeofcare.com/what-is-the-difference-between-adenomyosis-and-endometriosis/) - Although they can occur together, endometriosis and adenomyosis are two different things. Endometriosis is when endometrial cells (the lining of the uterus) are in a location outside of the uterus. Adenomyosis is when endometrial cells exist or grow into the uterine wall. Although both can cause pain, endometriosis does not always cause heavy bleeding. Reference https://innovativegyn.com/learn-the-difference-between-adenomyosis-and-endometriosis/ - [Preparing for a Colonoscopy](https://www.timeofcare.com/preparing-for-a-colonoscopy/) - [Colonoscopy, When to Repeat](https://www.timeofcare.com/colonoscopy-when-to-repeat/) - 2012 Recommendations for Surveillance and Screening Intervals in Individuals With Baseline Average Risk Baseline colonoscopy: most advanced finding(s) Recommended surveillance interval (y) No polyps 10 Small ( - [Gastroesophageal Reflux Disease (GERD) in infants and children](https://www.timeofcare.com/gastroesophageal-reflux-disease-gerd-in-infants-and-children/) - Diagnosis H&P Reflux vs. Reflux Disease (GER vs. GERD) Risk factors: Common presentation: Complications: DDx and Etiology. Treatment of Reflux in infants Nonpharmacologic tx (lifestyle & dietary changes) -Position changes while awake, -Reduce feeding volume and increase feeding frequency, -Thicken the formula - Add 1 tbsp rice cereal per oz of formula -Formula fed-infants: Anti-regurgitant - [The Difference Between Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD)](https://www.timeofcare.com/the-difference-between-gastroesophageal-reflux-ger-and-gastroesophageal-reflux-disease-gerd/) - "Gastroesophageal reflux (GER) happens when stomach contents come back up into the esophagus causing heartburn. Gastroesophageal reflux disease (GERD) is a more serious and long-lasting form of GER and may prevent an infant from feeding." nih.gov "GER is a normal physiologic process that occurs throughout the day in infants and less often in children and - [Diagnostic Criteria for Acute Pancreatitis](https://www.timeofcare.com/diagnostic-criteria-for-acute-pancreatitis/) - The diagnosis of acute pancreatitis requires that 2 out of 3 of the following criteria must be met: Abdominal pain in the upper quadrant[Clinical] Lipase or amylase >3x the upper limit of normal. [Laboratory] Imaging (CT, MR, ultrasound) findings consistent with the diagnosis of acute pancreatitis. [Imaging] - [Gallstones (Cholelithiasis)](https://www.timeofcare.com/gallstones-cholelithiasis/) - -Asymptomatic gallstones found incidentally on imaging should be managed expectantly unless the patient develops symptoms of biliary colic. Surgical and nonsurgical management of gallstones. Am Fam Physician 2014;89(10):795-802. - [Gastroesophageal Reflux Disease (GERD)](https://www.timeofcare.com/gastroesophageal-reflux-disease-gerd/) - Diagnosis H&P: -GerdQ Questionnaire: Total score = ___ points = ___ percent likelihood of GERD. -Assess for red flags or alarming symptoms. -Assess for indications for EGD. -H. Pylori testing is not routinely recommended in patients with GERD. -DDx / Etiology: Treatment -Lifestyle modifications. -Pharmacotherapy options reviewed. Step-up and step-down tx approaches discussed. -Discussed compliance and when to - [Esophageal cancer](https://www.timeofcare.com/esophageal-cancer/) - Diagnosis H&P: Risk factors. Common Presentation: Patient with risk factors presents with dysphagia with or without unintentional weight loss. Dysphagia starts with solids first, then advances to liquids as the disease progresses. Diagnostic studies -Upper endoscopy with biopsy of suspicious lesions is the diagnostic study of choice. -If cancer is confirmed, CT and PET scanning - [Adenocarcinoma of the Esophagus](https://www.timeofcare.com/adenocarcinoma-of-the-esophagus/) - See Esophageal Cancer. http://www.cancer.net/cancer-types/esophageal-cancer/risk-factors - [Risk Factors for Esophageal Cancer](https://www.timeofcare.com/risk-factors-for-esophageal-cancer/) - Risk factors for squamous carcinoma Smoking / Tobacco use Alcohol Smoking Achalasia Black race Diet high in starch and low in fruits and vegetables. Age 60-70 years. Risk factors for esophageal adenocarcinoma Chronic GERD (Gastroesophageal reflux Disease) Barret's Esophagus Tobacco use Obesity Gender Race Age 50 to 60 years Further Reading / Reference Esophageal - [Abnormal Uterine Bleeding in non-pregnant premenopausal Women: Differential diagnoses](https://www.timeofcare.com/abnormal-uterine-bleeding-in-non-pregnant-premenopausal-women-differential-diagnoses/) - PALM - COEIN "There are 9 main categories, which are arranged according to the acronym PALM-COEIN. In general, the components of the PALM group are discrete (structural) entities that can be measured visually with imaging techniques and/or histopathology, whereas the COEIN group is related to entities that are not defined by imaging or histopathology (non-structural)." - [Atopic Dermatitis (Eczema), Assessment & Plan](https://www.timeofcare.com/atopic-dermatitis-eczema-assessment-plan/) - Patient w/ rash consistent with atopic dermatitis. Moisturizers -Cerave baby moisturizing 1% lotion. Or any other moisturizers with a high oil content and low water content. E.g. Creams (Cetaphil, Eucerin) and petrolatum-based ointments (hydrolatum/petroleum jelly, Aquaphor). -Moisturize every part of the body liberally, even parts that are asymptomatic. -Moisturize at least two times per day - [Diagnostic Criteria for Atopic Dermatitis (Eczema)](https://www.timeofcare.com/diagnostic-criteria-for-atopic-dermatitis-eczema/) - Pruritus (itchy skin) and xerosis (dry skin) are key symptoms of atopic dermatitis. If a patient doesn't have them, the diagnosis of eczema should be questioned. Below, we I share two criteria commonly used. The U.K. Working party is highly validated and has high sensitivity and specificity as shown below. 1. The U.K. Working Party's Diagnostic - [Indications for Referring Patients with Atopic Dermatitis (Eczema)](https://www.timeofcare.com/indications-for-referring-patients-with-atopic-dermatitis-eczema/) - Refer to a dermatologist when: The diagnosis is unclear to you. There is severe or refractory disease; your attempts at management haven't controlled the symptoms. The eczema is causing a lot of psychosocial stress such as with work/school attendance. There is eczema on the face that hasn't responded to treatment. The patient has frequent flare-ups. Oral - [Topical Steroids for Eczema: Effective Use and Side Effects](https://www.timeofcare.com/topical-steroids-for-eczema-effective-use-and-side-effects/) - Use the lowest potency for the shortest amount of time and at the lowest frequency. Steroids have significant side effects. To reduce these side effects, use the lowest effective potency (strength), for the shortest amount of time at lowest frequency possible. Ointments are preferred because they are most hydrating. Intermittent use (twice weekly) can decrease the potential for - [Soak and Seal Treatment for Eczema or Dry Skin](https://www.timeofcare.com/soak-and-seal-treatment-for-eczema-or-dry-skin/) - How to apply the Soak and Seal Treatment for Eczema or Dry Skin - [Things that Trigger or Exacerbate Atopic Dermatitis (Eczema)](https://www.timeofcare.com/things-that-trigger-or-exacerbate-atopic-dermatitis-eczema/) - Factors that Exacerbate Atopic Dermatitis (Eczema) - [Probiotics](https://www.timeofcare.com/probiotics/) - -Probiotic foods such as yogurt are as effective as probiotic supplements. Some commonly available probiotics include: VSL#3 (Bifidobacterium breve, B. longum, B. infantis, Lactobacillus acidophilus, L. plantarum, L. paracasei, L. bulgaricus, Streptococcus thermophilus) Align (B. infantis) Culturelle (L. rhamnosus GG) DanActive (L. casei) Mutaflor (E. coli Nissle 1917) Florastor (Saccharomyces boulardii) In our hospital, we - [Treating Atopic Dermatitis (Eczema)](https://www.timeofcare.com/treating-atopic-dermatitis-eczema/) - 1. Emollients (Moisturizers): Goal is to restore barrier function; “Soak & seal” use of emollients leads to a decrease in skin dryness, decrease in itching, protects the skin from irritants, improves appearance; daily lukewarm (not hot) bath 15– 20 mins, soap only where/ when necessary, pat (not rub) to dry skin, followed by application of - [Eczema in infants: A case close to home](https://www.timeofcare.com/eczema-in-infants-a-case-close-to-home/) - My second child had eczema as an infant and we saw a dermatologist and he was treated with desonide 0.05% cream for ears, face, and genitals, and triamcinolone 0.1% for other areas. We also used Aquaphor lotion. We put lotion when his skin was still wet, without wiping it too much, to lock the moisture within. - [Vaginitis: Bacterial Vaginosis (BV)](https://www.timeofcare.com/bacterial-vaginosis/) - Vaginitis: Bacterial Vaginosis - [Sample Bronchiolitis Patient](https://www.timeofcare.com/sample-bronchiolitis-patient/) - 5-week old male, ex 37-week male, with a cough and congestion for 3 days PTA. The patient developed decreased PO and difficulty breathing so was brought to our ED. In the hospital, the patient developed respiratory distress, bronchiolitis, pneumonia, hypoxia. He had retractions (subcostal and suprasternal), head bobbing, nasal flaring. The patient had this course: - [Classifying and Treating an initial Clostridium difficile Infection](https://www.timeofcare.com/classifying-and-treating-an-initial-clostridium-difficile-infection/) - There are no accepted guidelines for defining the severity of C. diff. Below I share a few found in the literature. The following table is from: https://gi.org/guideline/diagnosis-and-management-of-c-difficile-associated-diarrhea-and-colitis/ C. Diff. Infection severity scoring system and summary of recommended treatments Severity Criteria Treatment Comment Mild-to-moderate disease Diarrhea plus any additional signs or symptoms not meeting severe or complicated criteria - [Injectable Diabetes Medications](https://www.timeofcare.com/injectable-diabetes-medications/) - Injectable Diabetes Medications - [Gout](https://www.timeofcare.com/gout/) - Definition: Results from precipitation of monosodium urate crystals in a joint space. Diagnosis -H&P. -Definitive diagnosis: Joint aspiration of synovial fluid, examination under polarized light microscopy to identify negatively birefringent uric acid crystals. -Arthrocentesis strongly recommended when possible. -Validated diagnostic rule for gout (when arthrocentesis not feasible). -DDx: -R/o Septic arthritis. Treatment -Acute and Chronic Gout - [Diuretic-Induced Hyperuricemia and Gout](https://www.timeofcare.com/diuretic-induced-hyperuricemia-and-gout/) - "Hyperuricemia is a relatively common finding in patients treated with a loop or thiazide diuretic and may, over a period of time, contribute to new-onset gouty arthritis or, more promptly, recurrence of established gout. Diuretics reduce urate excretion by both directly and indirectly increasing urate reabsorption and decreasing urate secretion; the effect is dose dependent. - [Constipation in older adults](https://www.timeofcare.com/constipation-in-older-adults/) - See Chronic Constipation in Adults. “For functional constipation in older adults, behavioral changes should be first-line management. These include scheduled toileting with proper positioning, increased intake of fiber and fluids, and avoiding bedpan use. If there is not an adequate response to behavioral interventions, osmotic laxatives should be initiated. Polyethylene glycol is more effective and - [Cirrhosis with Ascites](https://www.timeofcare.com/cirrhosis/) - -Abdominal paracentesis Treatment -D/c alcohol and consider Baclofen treatment to increase abstinence. -D/c all medications that can decrease renal perfusion (NSAIDs, Beta-blockers, ACE-I, ARBS) -Treat any underlying liver disease when possible. -Sodium-restricted diet (2g per day) -Diuretics: Spironolactone 100 mg per day plus Furosemide 40 mg PO qAM. May titrate the doses to a maximum - [Salmonella](https://www.timeofcare.com/salmonella/) - Only treat severe cases “Salmonella is a common cause of gastroenteritis. Transmission is most often associated with eggs, poultry, undercooked ground meat, and dairy products from contaminated animals, or produce contaminated by their waste. Salmonella infection is usually associated with nausea, vomiting, diarrhea, and fever starting 6–48 hours after ingestion of contaminated water or - [Bicuspid aortic valve](https://www.timeofcare.com/bicuspid-aortic-valve/) - Diagnosis Common Presentation: Incidental finding of a harsh systolic murmur in a young adult whose parent had a “heart valve replacement” at a relatively young age. “Bicuspid aortic valve is the most likely cause of heart valve disease in this family. It is the most common congenital heart defect in the United States, with a prevalence - [Transjugular Intrahepatic PortoSystemic Shunt (TIPS)](https://www.timeofcare.com/transjugular-intrahepatic-portosystemic-shunt-tips/) - see Medscape article "Indications Accepted indications for TIPS include the following: Uncontrolled variceal hemorrhage from esophageal, gastric, and intestinal varices that do not respond to endoscopic and medical management [4] Refractory ascites Hepatic pleural effusion (hydrothorax) Controversial indications for TIPS include the following: Bridge to transplantation and retransplantation Budd-Chiari syndrome Hepatorenal syndrome (HRS) Veno-occlusive disease - [Parenteral Nutrition](https://www.timeofcare.com/parenteral-nutrition/) - During parenteral nutrition, blood count, urea electrolytes, glucose, magnesium, phosphate, liver function, calcium, and albumin should be checked daily, then weekly when the patient is stable. - [Obstructive and Restrictive Lung Diseases](https://www.timeofcare.com/obstructive-and-restrictive-lung-diseases/) - PFT Findings in Obstructive and Restrictive Lung Diseases Obstructive Lung Disease Restrictive Lung Disease FEV1 - [Peritonsillar abscess](https://www.timeofcare.com/peritonsillar-abscess/) - Diagnosis H&P: Diagnosis of peritonsillar abscess is on the clinical presentation and PE. Common presentation: Risk Factors: Complications: DDx and Etiology: Diagnostic testing: -CT / MRI if Treatment -Drain the abscess: The key to treating a peritonsillar abscess is drainage of the abscess either by needle drainage or by incision and drainage. Immediate tonsillectomy is less favored - [Postmenopausal Uterine Bleeding](https://www.timeofcare.com/postmenopausal-uterine-bleeding/) - Postmenopausal women shouldn't be bleeding. Every bleeding in them is abnormal and needs to be worked up. Postmenopausal Bleeding Definition: Postmenopausal bleeding is any bleeding that occurs >1 year after the last menstrual period. Cancer must always be ruled out. -Transvaginal U/S is the preferred initial test for painless postmenopausal bleeding. Endometrial biopsy is another option - [Honey For Cough](https://www.timeofcare.com/honey-for-cough/) - Honey decreases both the frequency and severity of cough in children. Honey is safe for children ≥ 1 years of age. Avoid it in younger children because of the risk of botulism. Honey is the only treatment for cough with good data to support it. Avoid Codeine in young children. Reference / Further Reading - [Indications for Bronchoprovocation](https://www.timeofcare.com/indications-for-bronchoprovocation/) - When should you do bronchoprovocation? Bronchoprovocation (e.g., methacholine challenge, mannitol inhalation challenge, exercise testing) should be done if the pulmonary function test results are normal, but the provider still suspects exercise- or allergen-induced asthma. Am Fam Physician. 2014 Mar 1;89(5):359-366. - [Side Effects of Sympathomimetic Decongestants (Phenylephrine, Pseudoephedrine)](https://www.timeofcare.com/side-effects-of-sympathomimetic-decongestants-phenylephrine-pseudoephedrine/) - Sympathomimetic decongestants like Phenylephrine and Pseudoephedrine can: Elevate blood pressure Elevate intraocular pressure, Worsen existing urinary obstruction (in elderly patients), and Adversely interact with β-blockers, methyldopa, tricyclic antidepressants, oral hypoglycemic agents, and MAOIs. Speed up the heart rate - [Indications for Palivizumab use for RSV Prophylaxis](https://www.timeofcare.com/indications-for-palivizumab-use-for-rsv-prophylaxis/) - Recommended Palivizumab in the first year of life for: 1) Infants born before 29 weeks, 0 days' gestation, 2) Preterm infants with chronic lung disease (CLD) of prematurity, defined as birth at <32 weeks, 0 days’ gestation and a requirement for >21% oxygen for at least 28 days after birth. 3) Infants with hemodynamically significant heart - [Asthma in Patients 12 years and older (includes Adults)](https://www.timeofcare.com/asthma-in-patients-12-years-and-older-includes-adults/) - Diagnosis and Treatment of Asthma in Youths ≥12 Years of Age and Adults - [Inhaled Corticosteroids / Inhaled Steroids](https://www.timeofcare.com/inhaled-corticosteroids/) - Related Article: Side effects of Inhaled Corticosteroids. Inhaled Steroids Types and Doses Per age. Fluticasone propionate DPI (Flovent Diskus). Age 4 to 11 years: 100 to 200 mcg per day; Age > 11 years: 100 to 1,000 mcg per day Fluticasone propionate HFA (Flovent HFA). Age 4 to 11 years: 88 to 176 mcg per day; Age - [Side Effects of corticosteroids (Oral, Inhaled, and Topical)](https://www.timeofcare.com/side-effects-of-corticosteroids/) - Side Effects of Oral corticosteroids Side effects of Short-term Steroid Use. Elevated blood sugars an increase in appetite, weight gain, fluid retention, and Neuropsychiatric effects -Insomnia, -Mood changes (feel irritable, or anxious). Side effects of long-term steroid use (≥ 3 months). Diabetes Cataracts and glaucoma Hypertension Osteoporosis / Osteopenia Thromboembolic complications Weight gain, Fluid retention Suppressed - [Bronchitis, Acute](https://www.timeofcare.com/acute-bronchitis/) - Diagnosis -H&P. -Dx usually made clinically. No CXR needed. Indications for Chest X-Ray. DDx and Etiology: Indications for CXR in patients with symptoms of Acute Bronchitis Treatment Background Cough is the #1 chief complain in the ambulatory setting in the U.S. Cough lasts an average of 18 days in bronchitis. Further Reading Kinkade - [Indications for a Chest X-Ray in Adults with symptoms of Acute Bronchitis](https://www.timeofcare.com/indications-for-a-chest-x-ray-in-adults-with-symptoms-of-acute-bronchitis/) - "In patients with acute cough and sputum production suggestive of acute bronchitis, the absence of the following findings reduces the likelihood of pneumonia sufficiently to eliminate the need for a chest radiograph: (1) heart rate > 100 beats/min; (2) Respiratory rate > 24 breaths/min; (3) Oral body temperature of > 38°C; and (4)Chest examination findings of - [Drugs that cause lung disease](https://www.timeofcare.com/drugs-that-cause-lung-disease/) - "Many drugs can cause lung disease. Amiodarone has been known to cause both bronchiolitis obliterans organizing pneumonia (BOOP) and interstitial pneumonitis. BOOP, also known as cryptogenic organizing pneumonia, is characterized by interstitial inflammation superimposed on the dominant background of alveolar and ductal fibrosis. This is a very distinctive pattern of lung response to exposure to - [Bronchiolitis Obliterans with Organizing Pneumonia (BOOP)](https://www.timeofcare.com/bronchiolitis-obliterans-with-organizing-pneumonia-boop/) - Background BOOP is also known as cryptogenic organizing pneumonia (COP). BOOP is characterized by interstitial inflammation superimposed on the dominant background of alveolar and ductal fibrosis. This is a very distinctive pattern of lung response to exposure to several drugs. Diagnosis H&P Risk factors DDx Causes Common presentation: Treatment Stop the offending drug, if caused - [Causes of Bronchiolitis Obliterans with Organizing Pneumonia (BOOP)](https://www.timeofcare.com/causes-of-bronchiolitis-obliterans-with-organizing-pneumonia-boop/) - Drugs Infections: Viral infections, HIV Connective tissue disorders, Radiation therapy, Inhalation of toxic gases Inflammatory bowel disease, Cause unknown. In many cases, the underlying cause of BOOP is unknown. These are termed Idiopathic BOOP or cryptogenic organizing pneumonia (COP) - [Drugs that Cause Bronchiolitis Obliterans with Organizing Pneumonia (BOOP)](https://www.timeofcare.com/drugs-that-cause-bronchiolitis-obliterans-with-organizing-pneumonia-boop/) - Amiodarone, Bleomycin, Gold, Penicillamine, Sulfasalazine, Radiation, Interferons, Methotrexate, Mitomycin C, Cyclophosphamide, Cocaine - [Chronic Asthma](https://www.timeofcare.com/chronic-asthma/) - Important links Classifying asthma severity and initiating treatment in children 5 to 11 years of age. Further Reading International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. Eur Respir J 2014;43(2):343-373. Medications for chronic asthma. Am Fam Physician 2016;94(6):454-462. - [Croup (laryngotracheobronchitis)](https://www.timeofcare.com/croup-laryngotracheobronchitis/) - Background -Viral URI. Parainfluenza is the most common cause -Croup is common amongst children ages 6 to 36 months although it can present between 6 months and 12 years. Diagnosis H&P: -Triad of hoarse voice, barking cough, and inspiratory stridor. -Westley Croup Score to quantify croup severity. -X-ray shows the classic “Steeple sign”. However, x-rays are - [Solitary Pulmonary Nodule](https://www.timeofcare.com/solitary-pulmonary-nodule/) - -"Management is based on the size of the nodule and the probability of malignancy." -Risk factors for lung cancer. "Radiologic features indicative of malignancy include a nodule diameter >10 mm, an upper lung location, irregular or spiculated borders, no calcifications, a ground-glass appearance, and increasing size over time. Radiologic characteristics suggesting benign disease include a - [Risk Factors For Lung Cancer](https://www.timeofcare.com/risk-factors-for-lung-cancer/) - Risk Factors for Lung Cancer Hx of smoking Second-hand smoke Personal or family history of lung cancer. Age ≥ 65 Radiation to the chest Radon, Asbestos exposure Environmental exposure, industrial chemicals (arsenic, beryllium, air pollution from vehicle and diesel exhausts and industrial and residential emissions, etc. ) https://www.cdc.gov/cancer/lung/basic_info/risk_factors.htm - [Kidney Stones (Nephrolithiasis / Urolithiasis)](https://www.timeofcare.com/kidney-stone-nephrolithiasis/) - Workup of nephrolithiasis (kidney stones) CT without contrast. Get a non-contrast helical CT - ureteral dilation without stone suggests recent passage. A non-contrast CT is 97% sensitive and 95% specific for the diagnosis of urolithiasis. U/A & UCx CMP (electrolytes, BUN/Cr, Ca), phosphate (PO4), PTH Strain urine for stones to analyze. 24-hour urine x2 (>6wk - [Pertussis (Whooping Cough)](https://www.timeofcare.com/pertussis-whooping-cough/) - Background Pertussis has three stages: Catarrhal stage > Paroxysmal stage > Convalescent stage (2-3 weeks). Causative agent: Bordetella pertussis Diagnosis H&P Risk factors: Common presentation: DDx Diagnostic studies: The CDC recommends both a nasopharyngeal culture and polymerase chain reaction (PCR) testing to confirm the diagnosis. Serologic testing is useful only in research settings. Treatment Azithromycin or - [How to Order Inhaled Albuterol and a Nebulizer Machine](https://www.timeofcare.com/how-to-order-inhaled-albuterol-and-a-nebulizer-machine/) - Detailed explanation on how to write orders for inhaled albuterol and a nebulizer machine for both children and adults. - [Insulin Syringe Sizes: How to choose the right size for your situation](https://www.timeofcare.com/insulin-syringe-sizes-how-to-choose-the-right-size-for-your-situation/) - Insulin syringes come in three common sizes: 3/10ml syringe, also called a 0.3ml syringe 1/2ml syringe, also called a 0.5ml syringe 1.0ml syringe How many units can each size draw? 3/10ml syringe draws up to 30 units. 1/2 ml syringe draws up to 50 units. 1.0ml syringe draws up to 100 units. What size syringe - [Reactive Airway Disease](https://www.timeofcare.com/reactive-airway-disease/) - Reactive Airway Disease - [Pneumonia in adults, Community Acquired, (Inpatient)](https://www.timeofcare.com/community-acquired-pneumonia-cap/) - Inpatient Management of Community-Acquired Pneumonia (CAP) in adults Diagnosis H&P: Dx: Hypoxemic Respiratory distress likely 2/2 CAP in the context of possible COPD CURB-65 score and Pneumonia Severity Index (PSI) score: -Admit to telemetry -Reviewed respiratory hx -Reviewed CXR, VS -Reviewed CBC, CMP -CBC and BMP in the AM -f/u on sputum culture, sputum gram stain, and - [CURB-65 Score for Pneumonia Severity](https://www.timeofcare.com/curb-65-score-for-pneumonia-severity/) - The CURB-65 score estimates mortality of community-acquired pneumonia to help us determine whether inpatient vs. outpatient management is best for the patient. Each of the 5 parameters in CURB-65 is awarded 1 point for a maximum of 5 total points. CURB-65 Confusion Uremia: BUN > 19 mg/dL (> 7 mmol/L) Respiratory Rate ≥ 30 BP: Systolic - [Procalcitonin Use](https://www.timeofcare.com/procalcitonin/) - AAFP: "A procalcitonin-guided antibiotic therapy algorithm should be used to decrease antibiotic use in adults with acute respiratory infections. (Strength of Recommendation [SOR]: A, based on a meta-analysis of multiple randomized controlled trials [RCTs].)" Read the article here. "Procalcitonin is a biomarker that is elevated with bacterial infections but not with viral infections. The laboratory - [Angioedema due to an ACE inhibitor](https://www.timeofcare.com/angioedema-due-to-an-ace-inhibitor/) - Diagnosis H&P: Typical presentation: Patient was started on Lisinopril. A few hours after taking the first dose, he shows up to the ER with facial, lip, tongue edema, tightness in his throat that has been gradually progressing over the last few hours. He has some mild stridor but no rash and no pruritus. DDx Treatment Icatibant (a - [Hemoptysis](https://www.timeofcare.com/hemoptysis/) - "The first step in the evaluation of nonmassive hemoptysis is to obtain a chest radiograph. If this is normal and there is a high risk of malignancy (patient age 40 years or older with at least a 30-pack-year smoking history), chest CT should be ordered. Bronchoscopy should also be considered in the workup of high-risk - [Allergic Rhinitis, Severe Persistent Symptoms](https://www.timeofcare.com/allergic-rhinitis-severe-persistent-symptoms/) - Diagnosis H&P Treatment Algorithm for treating allergic rhinitis from AAFP. -Allergen avoidance and patient education. Pharmacotherapy -Intranasal Steroids (1st-line tx): Fluticasone Nasal Spray - 2 sprays/nostril QD or 1 spray/nostril BID OR combination tx with Azelastine/fluticasone (Dymista) -Antihistamine: Oral antihistamine (Loratidine, desloratadine, fexofenadine etc.) or a nasal antihistamine (Azelastine). -Nasal irrigation with Neti pot (using - [Colchicine](https://www.timeofcare.com/colchicine/) - Colchicine mechanism of action. - [Exercise-Induced Bronchoconstriction (Asthma)](https://www.timeofcare.com/exercise-induced-bronchoconstriction-asthma/) - Treatment -Albuterol inhaler 10-15 minutes before exercise. Reference / Further Reading https://www.aafp.org/afp/2011/0815/p427.html - [Asthma severity and initiating treatment for ages 12 years and older](https://www.timeofcare.com/asthma-severity-and-initiating-treatment-for-ages-12-years-and-older/) - CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN YOUTHS ≥ 12 YEARS OF AGE AND ADULTS Assessing severity for patients who are not currently taking long-term control medications. Components of severity Classification of asthma severity (≥12 years of age) Intermittent Persistent Mild Moderate Severe Impairment Normal FEV1/FVC: 8 to 19 years 85 percent 20 to 39 - [Chronic Kidney Disease (CKD) Stages](https://www.timeofcare.com/chronic-kidney-disease-ckd-stages/) - An explanation of Chronic Kidney Disease (CKD) Stages - [CKD Clinical Action Plan](https://www.timeofcare.com/ckd-clinical-action-plan/) - CKD Clinical Action Plan from the National Kidney Foundation (KDOQI Guidelines) - [Bacterial Meningitis](https://www.timeofcare.com/bacterial-meningitis/) - -Vanc + Ceftriaxone + Ampicillin (> 50 years) Ceftriaxone covers N. meningitidis Ampicillin covers Listeria. Why Vancomycin for Meningitis? "With the worldwide increase in the prevalence of penicillin-resistant pneumococci (.i.e. penicillin-resistant Streptococcus pneumoniae), vancomycin should be added to cefotaxime or ceftriaxone as empiric treatment until culture and susceptibility results are available." - [Asymptomatic Bacteriuria](https://www.timeofcare.com/asymptomatic-bacteriuria/) - Diagnosis and treatment of asymptomatic Bacteriuria - [Panic Disorder](https://www.timeofcare.com/panic-disorder/) - Panic disorder is intense fear with multiple somatic symptoms (palpitations, etc). "Panic disorder typically presents in late adolescence or early adulthood with unpredictable episodes of palpitations, sweating, gastrointestinal distress, dizziness, and paresthesias. The attacks are sporadic and last 10–60 minutes. Generalized anxiety disorder is more common, and common symptoms include restlessness, fatigue, muscle tension, irritability, - [HSV infections of CNS](https://www.timeofcare.com/hsv-infections-of-cns/) - Aseptic meningitis (HSV-2) -Benign course -Treatment of unclear benefit, IV->PO acyclovir -May recur (Mollaret'ssyndrome) Encephalitis (HSV-1) -Severe neurologic impairment -Classical MRI changes (temporal lobes) -Start treatment when you suspect the diagnosis -Dx: PCR -Treatment -IV acyclovir (10 mg/kg IV q8) - [Necrotizing Fasciitis](https://www.timeofcare.com/necrotizing-fasciitis/) - -Is a surgical emergency. Call surgery ASAP. -Broad antimicrobial therapy: Pip/Tazo (gram negatives/anaerobes) + Vancomycin (MRSA) + Clindamycin (group A strep) Clinda reduces toxin production by Group A Strep. Important links Clindamycin for necrotizing fasciitis. Reference https://www.cdc.gov/features/necrotizingfasciitis/index.html - [Complications of Chronic Kidney Disease](https://www.timeofcare.com/complications-of-chronic-kidney-disease/) - Patients with a GFR below 60 mL (i.e. meet the definition of CKD) should be monitored for these complications of CKD: Hyperkalemia Hyperphosphatemia, Hypocalcemia (secondary hyperparathyroidism) Hyponatremia, Acidosis Hypoalbuminemia Decreased immunoglobulins Dyslipidemia, CAD HTN Anemia Renal Osteodystrophy(due to high PTH) Uremia (needing dialysis or transplant) - [Definition of Chronic Kidney Disease (CKD)](https://www.timeofcare.com/definition-of-chronic-kidney-disease-ckd/) - The National Kidney Foundation and the KDIGO CKD guidelines define CKD as: -GFR - [Nephrotic Syndrome](https://www.timeofcare.com/nephrotic-syndrome/) - Diagnosis and treatment of Nephrotic Syndrome - [Causes of Nephrotic syndrome](https://www.timeofcare.com/causes-of-nephrotic-syndrome/) - A list of the causes of nephrotic syndrome - [Complications of Nephrotic Syndrome](https://www.timeofcare.com/complications-of-nephrotic-syndrome/) - Hyperlipidemia, Lipiduria, Thromboembolism / thrombotic disease (increased risk of both venous and arterial thrombosis), Protein malnutrition, hypovolemia, acute kidney injury, Urinary loss of hormones, Potential for accelerated atherosclerosis, increased susceptibility to infection - [Systemic Lupus Erythematosus (SLE)](https://www.timeofcare.com/systemic-lupus-erythematosus-sle/) - Diagnosis -H&P. Med review for meds known to cause drug-induced lupus. -Need ≥4 of 11 ACR criteria to diagnose SLE. Having ≥4 criteria diagnoses SLE with 95% specificity and 85% sensitivity (AFP). -Algorithm for the diagnosis of SLE from the AAFP -H&P (esp. skin, joints, liver/spleen, and CV to look for a pericardial rub or murmurs). -Labs: - [Average GFR by Age](https://www.timeofcare.com/average-gfr-by-age/) - On average, GFR decreases by 10 per decade starting from age 20. According to National Kidney Foundation (NKF), the average estimated GFRs for different ages are shown below. Note that these are just averages and there is a lot of individual and racial variabilities. Age 20-30: 116 mL/min/1.73m2 Age 30-40: 107 mL/min/1.73m2 Age 40-50: 99 - [Risk Factors for Chronic kidney disease](https://www.timeofcare.com/risk-factors-for-chronic-kidney-disease/) - Diabetes. (#1 cause of CKD in the U.S) High blood pressure. (#2 cause of CKD in the U.S) Family history of kidney disease. Cardiovascular disease. Age over 60 years old History of recurrent UTI History of urinary obstruction Smoking. Obesity. Race (Being African-American, Native American or Asian-American). Abnormal kidney structure. A systemic illness that affects - [Labs for Ruling out Glomerulonephritis or Vasculitis as causes of CKD](https://www.timeofcare.com/labs-for-ruling-out-glomerulonephritis-or-vasculitis-as-causes-of-ckd/) - Commonly ordered labs to rule out glomerulonephritis or vasculitis: Glomerulonephritis: C3, C4, anti-ASO, ASK, HIV, HBsAg, HCV, RPR, blood cultures; if there is rash or arthritis: ANA, ANCA, cryoglobulin, SPEP, UPEP Vasculitis: C3, C4, ANA, ANCA; HBsAg, HCV, cryoglobulins, ESR, RF, SS-A, SS-B, HIV (SS-A = anti-Ro antibody; SS-B = anti-La antibody) - [Complications of Kidney Disease (AKI and CKD)](https://www.timeofcare.com/complications-of-kidney-disease/) - Encephalopathy? (confusion/somnolence) Chest pain?(pericarditis) CHF / Fluid overload symptoms? Pulmonary or Peripheral Edema? Significant Hypertension? Bleeding? (platelet dysfunction) - [PIRATES Mnemonic for causes of new onset atrial fibrillation](https://www.timeofcare.com/pirates-mnemonic-for-causes-of-new-onset-atrial-fibrillation/) - P.I.R.A.T.E.S Mnemonic for new-onset atrial fibrillation Pulmonary causes (OSA, PE, COPD, pneumonia) Ischemia/Infarction/CAD Rheumatic heart disease and Mitral Regurgitation (abnormal heart valve) Alcohol / Anemia (high output failure) Thyrotoxicosis / Toxins, especially stimulant medications, caffeine, tobacco or alcohol Electrolytes/Endocarditis Sepsis (infection) / Sick sinus syndrome. OSA = Obstructive sleep apnea Other causes: High blood pressure Congenital - [DEATH: Life-Threatening Causes of Chest Pain](https://www.timeofcare.com/death-life-threatening-causes-of-chest-pain/) - Dissection (aneurysm) Embolism (pulmonary) Acute coronary syndrome Tension PTX Hole in GI tract (Esophageal rupture, Perforated ulcer) Mnemonic created by Dr. David M. Schneider - [Urinary Retention](https://www.timeofcare.com/urinary-retention/) - Common Causes -Obstructive causes e.g. BPH -Medications e.g. Pain medications -Spinal pathology Treatment options Acute urinary retention: -Indwelling bladder catheter (Foley), -Intermittent catheterization if the patient can do it. -Catheter removal and trial of spontaneous voiding should be attempted every 48-72 hours. Catheter-associated UTI risk is about 5% per day. -Start tamsulosin (alpha-blocker) will increase - [Postvoid Residual (PVR)](https://www.timeofcare.com/postvoid-residual-pvr/) - Postvoid Residual (PVR): Urine that remains in the bladder, measured by a catheter or U/S, after the patient attempts to urinate. A PVR >200 ml suggests bladder obstruction or weakness. Normal functional bladder capacity in adults ranges from approximately 300 to 400 ml. (IJCP 2011). Normal bladder size: 300-400cc At 120-130 cc, you start getting - [Little League shoulder (proximal humeral epiphysitis)](https://www.timeofcare.com/little-league-shoulder-proximal-humeral-epiphysitis/) - Background Little League shoulder is proximal humeral epiphysitis. It is a stress fracture of the growth plate of the humerus. It most often develops as an overuse injury in baseball pitchers age 11–16. Mechanism of injury: Overuse injury that results from a throwing motion. It's a fracture of the physeal plate (Salter-Harris type I). Diagnosis H&P: - [Patellofemoral Syndrome](https://www.timeofcare.com/patellofemoral-syndrome/) - Definition: Anterior knee pain that is worse with running downhill or going downstairs. Diagnosis H&P: Risk factors: DDx & Etiology: Diagnostic studies: Common presentation: The most common symptom is pain beneath the patella. Treatment -Modify running program, -Start an exercise program to strengthen the quadriceps and hips, -Use a knee sleeve with a doughnut-type cushion that the - [Dietary Changes to Prevent Gout](https://www.timeofcare.com/dietary-changes-to-prevent-gout/) - Lose weight. Weight gain is a risk factor for gout in men.Weight loss reduces the risk. Reduce high-fructose corn syrup intake. It increases uric acid production. Limit intake of purine-rich animal proteins (e.g., organ meats, beef, lamb, pork, shellfish) Avoid alcohol (especially beer). Drink adequates amounts of water. Further Reading mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/gout-diet/art-20048524 - [Fetal Alcohol Syndrome](https://www.timeofcare.com/fetal-alcohol-syndrome/) - "thin upper lip, a smooth philtrum, a flat nasal bridge, small palpebral fissures, "railroad track" ears, a curved fifth finger (clinodactyly), and a widened upper palmar crease that ends between the second and third fingers." - [Immune Thrombocytopenic Purpura](https://www.timeofcare.com/immune-thrombocytopenic-purpura/) - Patients are usually not sick, usually normal. Compared with HSP where children are usually sick. Also called idiopathic thrombocytopenic purpura. "idiopathic thrombocytopenic purpura (ITP) is an acquired autoimmune disorder that results in platelet destruction. It often follows a viral illness and is more common in children than adults. It is characterized by thrombocytopenia in the absence of - [Intussusception](https://www.timeofcare.com/intussusception/) - "Invagination/telescoping of the proximal intestine into the adjacent bowel -Often a “lead point” in the Peyer’s Patch -Most common cause of intestinal obstruction between 3 months and 6 years of age Etiology unknown in 95%" - [Enuresis (Bed-Wetting)](https://www.timeofcare.com/enuresis/) - Background -Enuresis=intermittent urinary incontinence during sleep in a child who is at least 5 years of age (i.e. 5 years or older). -Approximately 5% to 10% of all seven-year-olds have enuresis, and an estimated 5 to 7 million children in the United States have enuresis. Diagnosis -H&P and urinalysis will be done as the initial - [Infantile Colic](https://www.timeofcare.com/infantile-colic/) - Background Infantile colic (IC) is benign and a very common (affects 10% to 40% of infants worldwide). Definition: Diagnosis is made when the infant has paroxysms of inconsolable crying for more than 3 hours per day, more than 3 days per week, for more than 3 weeks. -IC peaks at about 6 weeks of age - [Delayed Meconium Passage](https://www.timeofcare.com/delayed-meconium-passage/) - Passing meconium at birth doesn't count. They need to pass stool again before they are discharged. - [Acute Inflammatory Demyelinating Polyradiculoneuropathy (AIDP) - Guillain-Barré syndrome](https://www.timeofcare.com/acute-inflammatory-demyelinating-polyradiculoneuropathy-aidp-guillain-barre-syndrome/) - "During the acute phase of GBS, characteristic findings on CSF analysis include albuminocytologic dissociation, which is an elevation in CSF protein (>0.55 g/L) without an elevation in white blood cells. The increase in CSF protein is thought to reflect the widespread inflammation of the nerve roots" https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Guillain-Barr%C3%A9-Syndrome-Fact-Sheet - [Mycoplasma hominis and Ureaplasma urealyticum infections](https://www.timeofcare.com/mycoplasma-hominis-and-ureaplasma-urealyticum-infections/) - Mycoplasma hominis infections: Drug of choice is a tetracycline (eg, doxycycline). Alternatives are clindamycin or a fluoroquinolone (e.g. moxifloxacin). Avoid macrolides, M. hominis is not susceptible to macrolides. Ureaplasma spp. infections: Doxycycline in adults. Alternatives: Macrolides (eg, azithromycin) and fluoroquinolones (eg, moxifloxacin). Don't use clindamycin because is not active against ureaplasmas. When to treat: Treat disease, not colonization. "Patients - [Spontaneous Abortion](https://www.timeofcare.com/abortion/) - Threatened Abortion. Threatened abortion is characterized by bleeding, a closed cervical os, and no passage of POCs. It is managed expectantly until the patient's symptoms resolve or there is a progression to an inevitable, incomplete, or complete abortion Inevitable abortion: The patient has vaginal bleeding, usually with crampy pelvic pain, and the cervix is dilated (i.e - [Ectopic Pregnancy](https://www.timeofcare.com/ectopic-pregnancy/) - "Early diagnosis of ectopic pregnancy requires a high index of suspicion. Risk factors include previous ectopic pregnancy, tubal sterilization, pelvic inflammatory disease, IUD use, and in utero exposure to diethylstilbestrol. The classic triad of missed menses, pain, and bleeding may not always be present. In early pregnancies of less than 5 weeks gestation, serial hCG levels - [Hypertension in pregnancy (Drug Choices)](https://www.timeofcare.com/hypertension-in-pregnancy-drug-choices/) - Hypertension in pregnancy (Drug Choices) - [Obstetric Perineal Laceration Repair Equipment](https://www.timeofcare.com/obstetric-perineal-laceration-repair-equipment/) - Sterile drapes and gloves Irrigation solution Needle holder Metzenbaum scissors Suture scissors Forceps with teeth Allis clamps Gelpi or Deaver retractor (for use in visualizing third- or fourth-degree perineal lacerations, or deep vaginal lacerations) 10-mL syringe with a 22-gauge needle 1% lidocaine (Xylocaine) 3-0 polyglactin 910 (Vicryl) suture on CT-1 needle (for vaginal mucosa sutures) - [Contraceptive Options for obese women](https://www.timeofcare.com/contraceptive-options-for-obese-women/) - Most effective reversible contraceptive options for obese women Intrauterine Device (IUD) is the best contraceptive choice for obese women. Both copper IUD and the levonorgestrel-releasing IUD are great options for obese women. Failure rates for IUDs are the same for normal, overweight, and obese women. Contraceptive implant. The etonogestrel (Nexplanon) and levonorgestrel (Norplant) work well - [Premenstrual dysphoric Syndrome (PMS)](https://www.timeofcare.com/premenstrual-dysphoric-syndrome-pms/) - Pyridoxine (vitamin B6) 100 mg taken daily helps with PMS - [Pyelonephritis in Pregnancy](https://www.timeofcare.com/pyelonephritis-in-pregnancy/) - Pyelonephritis in Pregnancy - [Death Certificate Completion](https://www.timeofcare.com/death-certificate-completion/) - Important Links Death Pronouncement: Declaring Someone as Dead. References / Further Reading Brooks EG, Reed KD. Principles and Pitfalls: a Guide to Death Certification. Clinical Medicine & Research. 2015;13(2):74-82. https://www.aafp.org/afp/2005/0215/p652.html - [Bleeding Vaginally While on Contraception](https://www.timeofcare.com/bleeding-vaginally-while-on-contraception/) - Nexplanon Within the First 3 months, spotting or breakthrough bleeding is common. Treatment usually is done for bleeding beyond 3 months that bothers the patient. Treatment Try NSAIDs: Ibuprofen 400 to 800 mg three times a day for 5 to 10 days. Exogenous Estrogen to stabilize the endometrial lining. -Combined OCP or as mono-therapy can - [Osteoporosis](https://www.timeofcare.com/osteoporosis/) - Diagnosis -H&P. -Screening guidelines. -Risk Factors for Osteoporosis and Related Fractures, reviewed and patient counseled. -The ten-year fracture risk determined using the FRAX tool from the WHO are: --The 10-year probability of a hip fracture is: ___ % --The 10-year probability of a major osteoporosis-related fracture is: ___% –BMD assessment with DXA scan shows: -Nonpharmacologic Therapy - [Excisional Biopsy of Melanoma](https://www.timeofcare.com/excisional-biopsy-of-melanoma/) - An excisional biopsy with a 1- to 3-mm border around the lesion "The AAD recommends doing an excision with narrow margins (1–3 mm) that includes the entire gross lesion with clinically negative margins to a depth that ensures the lesion is not transected. For smaller lesions punch excision with sutures or shave removal to an adequate - [Falls in Geriatric Patients](https://www.timeofcare.com/falls-geriatrics/) - Diagnosis -H&P: -Risk Factors: -Patients with a history of recent falls are at highest risk for recurrent falls. -Med Review for culprit meds. Decrease or D/C psychoactive medications to prevent falls. -Will evaluate for postural hypotension (orthostatic hypotension), as this can be a contributor to falls, especially after prolonged bed rest. -Evaluate for dementia -Basic labs: CBC, - [Overflow Incontinence](https://www.timeofcare.com/overflow-incontinence/) - -Check Postvoid residual. > 200-250 - [Toe Fractures](https://www.timeofcare.com/toe-fractures/) - Diagnosis and treatment of Toe Fractures - [Musculoskeletal Red flags](https://www.timeofcare.com/musculoskeletal-red-flags/) - Red flags in musculoskeletal disorders - [Ottawa Ankle Rules](https://www.timeofcare.com/ottawa-ankle-rules/) - ** These rules guide you to determine whether you should get an ankle XR alone, a foot XR alone, ankle and foot XR or no XR at all. MDCalc.com link. - If a patient cannot walk 4 steps by themselves at the scene and with the provider (ER, clinic, etc), they buy themselves XR - - [Validated Scoring System for Gout](https://www.timeofcare.com/validated-scoring-system-for-gout/) - Validated Diagnostic Rule to Help with Clinical Diagnosis of Gout without Joint Aspiration. NB: Always consider other causes in the Ddx of a patient suspected of having gout e.g. Septic arthritis, pseudogout, etc. If you suspect gout, you may use the following validated scoring system. You may add up the points yourself or use a - [Calcaneal Apophysitis (Sever disease)](https://www.timeofcare.com/calcaneal-apophysitis-sever-disease/) - Background The heel apophysis usually closes by the age of 15. Diagnosis H&P: DDx and Etiology: Risk Factors: Common Presentation: Diagnostic studies: X-Ray is usually normal and so doesn't help in diagnosis. However, when done may show fragmented or sclerotic calcaneal apophysis. Treatment -Activity modification (decrease pain-inducing activities), -Ice packs and/or moist heat, -Stretching and strengthening of - [Developmental dysplasia of the hip (DDH) / Congenital Hip Dislocation](https://www.timeofcare.com/developmental-dysplasia-of-the-hip/) - Definition: Developmental dysplasia of the hip encompasses both subluxation and dislocation of the newborn hip, as well as anatomic abnormalities. DDH results from an abnormality of the acetabulum or femoral head that presents in infancy. Diagnosis H&P Screening: The AAP and the pediatric orthopedic society recommend doing DDH on all babies. The USPSTF gives an "I" - [Paget’s disease of bone](https://www.timeofcare.com/pagets-disease-of-bone/) - -Bone pain is continuous. Unlike the pain of OA, the bone pain of Paget’s disease usually increases with rest, when the limbs are warmed, and at night. Bowing may occur in Tibia. Alkaline Phosphatase is elevated but GGT is normal. -Most common neurologic complication = Hearing loss from cochlear damage. "CONCLUSIONS: We recommend that plain - [Scaphoid Fracture](https://www.timeofcare.com/scaphoid-fracture/) - Diagnosis and treatment of a Scaphoid Fracture - [Stress Fractures](https://www.timeofcare.com/stress-fracture/) - Diagnosis and Treatment of Stress Fractures - [De Quervain Tenosynovitis](https://www.timeofcare.com/de-quervain-tenosynovitis/) - Treatment -Rest and thumb spica splint. - [Gout: Acute Treatment and Chronic Prevention](https://www.timeofcare.com/medications-for-acute-gout-treatment-and-medications-for-chronic-gout-prevention/) - Acute Treatment: NSAIDs are 1st-line (Indomethacin, Naproxen, and Ibuprofen all may be used to tx acute gout). Also and Colchicine. Corticosteroids are used when NSAIDs and Colchicine cant be used. Colchicine inhibits microtubule formation reducing the inflammatory response to uric acid crystals. Almost universal S/E of colchicine include N/V/D. Chronic Treatment: Allopurinol, Probenecid, Pegloticase, Febuxostat, and Colchicine. Allopurinol - [Indications for Pharmacologic Treatment of Osteoporosis and Osteopenia](https://www.timeofcare.com/indications-for-pharmacologic-treatment-of-osteoporosis-and-osteopenia/) - Consider FDA-approved medical therapies in postmenopausal women and men aged 50 years and older, based on the following: A hip or vertebral (clinical or morphometric) fracture Osteoporosis: T-score ≤ -2.5 at the femoral neck or spine after appropriate evaluation to exclude secondary causes. Osteopenia or Low bone mass (T-score between -1.0 and -2.5 at the - [Hip Labral Tear](https://www.timeofcare.com/hip-labral-tear/) - -Do the FADIR and FABER tests which are effective for detecting intra-articular pathology. Both have high sensitivity but low specificity. -MR arthrography of the hip with intraarticular gadolinium administration is the diagnostic test of choice for labral tears. It delineates the anatomy of the joint, including the acetabular labrum, articular cartilage, and ligamentum teres, and - [I PASS: Mnemonic for Musculoskeletal Exam of Shoulder, Knee, etc](https://www.timeofcare.com/i-pass-mnemonic-for-musculoskeletal-exam-of-shoulder-knee-etc/) - I PASS I PASS stands for Inspection, Palpation, Active ROM (& Passive ROM), Strength, Special Tests. This is a good mnemonic for doing Musculoskeletal exams e.g. shoulder, knee, etc. Inspection Palpation Active ROM Strength Special tests Inspection - key things to look for. Surface anatomy Alignment. Evaluate the overall alignment of the limb or spine before - [A Mnemonic for Medical History (MISS FAMILY)](https://www.timeofcare.com/a-mnemonic-for-medical-history-miss-fima/) - After the chief complaint and history of present illness, I've created the following easy mnemonic to help people to remember the pertinent portions of the medical history. MISS FAMILY -Med history: -Interventions and Procedures: -Social & sexual history: -Surgical history: -Family history: No significant family history. -Allergies: NKDA -Medications: See Medication list in EHR. -Immunizations - [Ingrown Toenail Removal Procedure Note](https://www.timeofcare.com/ingrown-toenail-removal-procedure-note/) - Procedure Name: Ingrown Toenail Removal Indication: Pain, infection Location: ________ Pre-Procedure Diagnosis: Ingrown Toenail Post-Procedure Diagnosis: Same, removed Informed consent: Procedure, alternate treatment options, risks, and benefits were thoroughly explained to the patient and informed consent was obtained before the procedure started. Equipment for the procedure was set up. PROCEDURE An appropriate timeout was taken. The - [Ingrown Toenail](https://www.timeofcare.com/ingrown-toenail/) - Diagnosis H&P Diagnosis is clinical. Treatment Antibiotics if infected. May need to treat the infection before doing an ingrowing toenail removal. Ingrown Toenail Removal. Important Ingrown toenail links Ingrown toenail removal equipment. Ingrown toenail removal procedure note. - [Osteoarthritis of the Knee](https://www.timeofcare.com/osteoarthritis/) - Diagnosis H&P Risk factors: genetics, female sex, past trauma, advancing age, and obesity. X-ray (look for the radiographic signs of OA.) DDx & Causes: Treatment The mainstay of treatment of OA of the knee is active rehabilitation and exercise. -Exercise-based physical therapy. Start with regular home stretching and strengthening exercises for muscle strength. -Refer to PT if home exercise - [Osteopenia](https://www.timeofcare.com/osteopenia/) - Definition of osteopenia. Diagnosis -H&P –Screening guidelines. –Risk Factors for Osteoporosis and Related Fractures. -The ten-year fracture risk determined using the FRAX tool from the WHO are: --The 10-year probability of a hip fracture is: ___ % --The 10-year probability of a major osteoporosis-related fracture is: ___% -Diagnostic studies: --BMD assessment with DXA scan shows: --Labs: Serum - [Osteoporosis Screening](https://www.timeofcare.com/osteoporosis-screening/) - USPSTF Screening Guidelines The USPSTF recommends screening for osteoporosis in women aged 65 years and older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. The USPSTF concludes that the current evidence is insufficient to assess the balance of - [Osteopenia, Severe, initiating Bisphosphonate Treatment](https://www.timeofcare.com/osteopenia-severe-initiating-bisphosphonate-treatment/) - Pt with significantly worsening in T-score from previous DEXA scan. Now -2.3 from -1.5. Nonpharmacologic therapy to reduce fractures reviewed and encouraged. Denies any issues with her jaw - no jaw pain. She also denies any history of gastritis or esophagitis. Choosing to pursue bisphosphonate therapy. Will check 25-Hydroxyvitamin D, calcium levels, and renal function - [Back pain, Acute lumbar pain with radiculopathy](https://www.timeofcare.com/back-pain-acute-lumbar-pain-with-radiculopathy/) - "Patient w/ severe back and left leg pain that started yesterday afternoon. Pt was moving couch when he heard a pop in his left lumbar region. Over the subsequent few hours he developed gradually increasing pain in his low back that radiates down the posterolateral side of his left leg and onto the top of his left foot. - [Anemia in Infants and Children](https://www.timeofcare.com/anemia-in-infants-and-children/) - Diagnosis and treatment of Anemia in Infants and Children - [Tennis elbow, (Lateral Epicondylitis)](https://www.timeofcare.com/tennis-elbow-lateral-epicondylitis/) - Tennis elbow / Lateral Epicondylitis / Lateral Epicondylalgia Definition: It's an overuse tendinopathy of the common extensor tendon origin in the lateral elbow. It's not an inflammatory condition. Conservative treatment. -Rest: Modify her work routines to offload the involved tendons. This would improve the patient's long-term outcome. -NSAIDs: Ibuprofen 800 mg TID. Voltaren gel (Diclofenac - [Plantar Fasciitis](https://www.timeofcare.com/plantar-fasciitis/) - Diagnosis H&P -Hx: Heel pain that is worse with the first steps in the morning or after prolonged rest. -PE: Heel tenderness present. Palpation of the medial plantar calcaneal region elicits a sharp pain. Discomfort in the proximal plantar fascia elicited by passive ankle/first toe dorsiflexion. DDx and etiology: Risk Factors: Treatment Conservative treatment -Rest, activity - [Meniscal Tears / Meniscus Tear](https://www.timeofcare.com/meniscal-tears/) - Diagnosis H&P Positive McMurray test. Positive Thesally test. MRI was done. Shows a meniscal tear. Treatment Physical Therapy and Exercise regimen. Counseling: Studies have shown that meniscectomy for a tear of the meniscus is no more beneficial than conservative therapy in terms of functional status at six months. As such, we will continue for PT and - [Slipped Capital Femoral Epiphysis (SCFE)](https://www.timeofcare.com/slipped-capital-femoral-epiphysis-scfe/) - Background SCFE happens most commonly during the adolescent growth spurt (11-13 years of age for girls, and 13-15 years of age for boys). Diagnosis H&P -DDx of hip pain/limping. -Risk factors. -Limited internal rotation of the flexed hip on physical exam is pathognomonic for SCFE. -XR -Consider Including CBC, CRP, ESR, CMP to r/o infection and - [Risk Factors for Slipped Capital Femoral Epiphysis (SCFE)](https://www.timeofcare.com/risk-factors-for-slipped-capital-femoral-epiphysis-scfe/) - Males > Females African-Americans and Pacific Islanders Overweight or Obesity Physical activity - [Muscle Strength Grading](https://www.timeofcare.com/muscle-strength-grading/) - Muscle strength is scored on a scale of 0 to 5. 0 – No contraction; the patient is unable to even contract the muscle. This is scored as a zero. 1 – No movement but slight visible/palpable muscle contraction is present; contraction without movement is scored as grade 1 strength. 2 – Movement without gravity-- i.e. - [Achilles Tendinopathy](https://www.timeofcare.com/chronic-midsubstance-achilles-tendinopathy/) - Chronic mid-substance Achilles tendinopathy -Definition: midsubstance Achilles tendinopathy with symptoms lasting longer than 6 weeks. Treatment -The preferred first-line treatment is an intense eccentric strengthening program of the gastrocnemius/soleus complex. "In randomized, controlled trials, eccentric strengthening programs have provided 60%–90% improvement in pain and function. To perform eccentric strengthening for Achilles tendinopathy the patient should stand - [Hidradenitis Suppurativa (HS)](https://www.timeofcare.com/hidradenitis-suppurativa/) - Background HS is a chronic, recurrent, inflammatory skin disease that affects the hair follicles of apocrine sweat glands. Common sites are the axillae and the inguinal and anogenital regions. HS can be a disabling disorder that relentlessly progresses, frequently causing keloids, contractures, and immobility. Diagnosis H&P Diagnosis is clinical. -Use the Hurley classification or staging to stage it. - [Antibiotics with anti-inflammatory properties](https://www.timeofcare.com/antibiotics-with-anti-inflammatory-properties/) - Macrolides Reference/Further reading Buret AG. Immuno-modulation and anti-inflammatory benefits of antibiotics: The example of tilmicosin. Canadian Journal of Veterinary Research. 2010;74(1):1-10. - [Positional Skull Deformities in infants](https://www.timeofcare.com/positional-skull-deformities-in-infants/) - Background -PSD may be present at birth or may develop during the first few months of life. -Incidence increased since the AAP's "back to sleep" recommendations to reduce SIDs started. SIDs incidence has decreased but PSDs have increased. -"Are generally benign, reversible head-shape anomalies that do not require surgical intervention, as opposed to craniosynostosis, which - [Insomnia](https://www.timeofcare.com/insomnia/) - Diagnosis H&P DDx & Etiologies: Evaluate for diseases that cause insomnia. 2-week sleep log/diary. Diagnostic tests: Treatment -Sleep hygiene and stimulus control counseling, provided. -CBT, 1st-line treatment. Referral entered. -AAFP 2017 Algorithm for Treatment of Insomnia reviewed with the patient. -Insomnia medications: Will start short-term pharmacotherapy if insomnia doesn't improve with sleep hygiene, stimulus counseling, and - [Insomnia Medications](https://www.timeofcare.com/insomnia-medications/) - This page discusses common medications for treating insomnia based on the most current available evidence that we have. - [Acne Vulgaris Medications](https://www.timeofcare.com/acne-vulgaris-medications/) - The following categories medications are used to treat acne. Topical retinoids Topical non-antibiotic therapy Topical antibiotics Oral antibiotics OCPs Spironolactone Oral retinoids (isotretinoin) Topical Retinoids for the Treatment of Acne Vulgaris Adapalene topical - comes as a cream 0.1%; Gel (0.1% 0.3%) ---[Pregancy category C] . Differin gel OTC is Adapalene topical 0.1%. Tretinoin topical - [Circumcision, Bleeding after](https://www.timeofcare.com/bleeding-after-circumcision/) - -Apply pressure -Chemical cautery with silver nitrate. -Order PT/PTT and CBC (for platelet count). There was an infant who was circumcised in PCP's clinic. 24 hours later, the child returned with bleeding into the diaper. There had been no bleeding at the time of circumcision. But now patient was bleeding. PT/PTT and Platelet count were - [Drug Screen, False Positive](https://www.timeofcare.com/drug-screen-false-positive/) - Things that can cause a false-positive test for opioids on a urine drug screen Dextromethorphan, diphenhydramine, ibuprofen, and even fluoroquinolones are among the many agents that can cause a false-positive urine drug screen for opioids. Pseudoephedrine can cause a false-positive test for amphetamines Further Reading / References Pitfalls & pearls for 8 common lab tests. - [Constipation in Children and Adolescents](https://www.timeofcare.com/constipation-in-children-and-adolescents/) - -History and physical exam, above. -No red flags. -Non-pharmacological and pharmacological therapies discussed. "Oral osmotics such as polyethylene glycol–based solutions are recommended as an appropriate initial approach to constipation in children because they are effective, easy to administer, noninvasive, and well tolerated (SOR C). Rectal therapies are similar in terms of effectiveness but are more invasive - [Microscopic colitis](https://www.timeofcare.com/microscopic-colitis/) - -"Characterized by intermittent secretory diarrhea in older patients, although all ages can be affected." -The cause is unknown Diagnosis H&P Risk factors: More than 6 months of NSAID use, ... DDx and Etiology. Biopsy of the transverse colon. "Only a biopsy from the transverse colon can confirm the diagnosis. Two histologic patterns are found: lymphocytic - [Boxer's Fracture](https://www.timeofcare.com/boxers-fracture/) - "The radiograph shows a fracture of the fifth metacarpal head, commonly known as a boxer’s fracture. There is only slight volar angulation and no displacement. The proper treatment for this fracture is an ulnar gutter splint, which immobilizes the wrist, hand, and fourth and fifth digits. The wrist should be positioned in slight extension with - [Physical Activity Recommendations](https://www.timeofcare.com/physical-activity-recommendations/) - -"Guidelines recommend at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity and at least two days of muscle-strengthening activities per week." AAFP 2017 Further Reading Am Fam Physician. 2017 Apr 1;95(7):425-432. Exercise Prescriptions in Older Adults. https://www.aafp.org/afp/2017/0401/p425.html Meriwether RA, Lee JA, Lafleur AS, et al: Physical activity counseling. Am - [Lymphadenitis](https://www.timeofcare.com/lymphadenitis/) - [Lymphadenopathy (Enlarged Lymph Nodes) - Peds & Adults](https://www.timeofcare.com/lymphadenopathy/) - Diagnosis -H&P: Review meds for culprits. -Risk factors for cancer: -R/o palpable popliteal, iliac, and supraclavicular nodes which are always abnormal. Evaluate for palpable epitrochlear nodes greater than 5 mm which would be abnormal as well. DDx & Causes. -Ultrasonography: Initial imaging modality for children up to 14 years per ACR -CT: The initial imaging modality for - [Anchoring bias](https://www.timeofcare.com/anchoring-bias/) - "Diagnostic error is important because it is very common. Anchoring bias, also known as premature closure, is defined by the Agency for Healthcare Research and Quality as relying on an initial diagnostic impression despite subsequent information to the contrary. This is the most frequent single cause of diagnostic error. In this case, once the diagnosis - [Subclinical Hyperthyroidism](https://www.timeofcare.com/subclinical-hyperthyroidism/) - Vignette: You have a patient with a TSH of 0.27 and normal T3 and T4 levels. How would you handle this patient? -Dx: likely 2/2 central hypothyroidism, nonthyroidal illness, hyperthyroidism recovery, excessive ingestion biotin, etc -Pt is asx at this point. -Will f/u closely because about 15% pts progress to overt hyperthyroidism in 2yrs. Also, - [Diarrhea in Adults (Acute)](https://www.timeofcare.com/acute-diarrhea-in-adults/) - http://www.aafp.org/afp/2014/0201/p180.html Healthy Patient with a non-severe salmonella infection. "A 52-year-old healthy male presents with a 2½-week history of diarrhea, consisting of 4–6 watery stools daily. He is afebrile and his examination is normal. You recommend symptomatic care. Two days later the laboratory notifies you that Salmonella is growing in his stool culture. You call the - [Back pain in children and adolescents](https://www.timeofcare.com/back-pain-in-children-and-adolescents/) - "Back pain that regularly occurs at night and awakens a child is usually associated with tumors or infections, such as osteomyelitis, diskitis, osteoid osteoma, osteoblastoma, and spinal cord tumors. Other possible symptoms associated with nighttime back pain include fever, malaise, and weight loss. Back pain that occurs at night is an indication for immediate medical - [Wells Criteria and Modified Wells Criteria: Assessment for Pulmonary Embolism](https://www.timeofcare.com/wells-criteria-and-modified-wells-criteria-assessment-for-pulmonary-embolism/) - When to use: "The Wells’ Criteria risk stratifies patients for pulmonary embolism (PE) and provides an estimated pre-test probability. The physician can then chose what further testing is required for diagnosing pulmonary embolism (I.E. d-dimer or CT angiogram)." MdCalc.com Clinical symptoms of DVT (leg swelling, pain with palpation) 3.0 Other diagnoses less likely than pulmonary - [Facial Pain, differential diagnosis](https://www.timeofcare.com/facial-pain-differential-diagnosis/) - Sinusitis Temporomandibular joint (TMJ) syndrome Dental carries/abscess Bruxism (teeth grinding) Dental misalignment Temporal arteritis Trigeminal neuralgia Herpes zoster; Postherpetic neuralgia Trauma to the face. Salivary gland disorders: Sialadenitis (eg, parotitis); Sialolithiasis (salivary gland stone) Glaucoma Recurrent painful ophthalmoplegic neuropathy Numb chin syndrome (mental neuropathy) due to malignancy in the mandible Idiopathic facial pain; Atypical facial pain Migraine Dacryocystitis - [Lumbar Spinal Stenosis](https://www.timeofcare.com/lumbar-spinal-stenosis/) - -Increased pain with lumbar spine extension is consistent with lumbar spinal stenosis. -Pain gets worse with spine extension. Spinal flexion reduces the pain. Why? "Spinal extension that increases lumbar lordosis decreases the cross-sectional area of the spinal canal, thereby compressing the spinal cord further. Walking downhill can cause this. Spinal flexion that decreases lordosis has - [Intestinal Ischemia (Acute Mesenteric Ischemia)](https://www.timeofcare.com/intestinal-ischemia-acute-mesenteric-ischemia/) - Diagnosis -History and Physical. -Risk Factors: -DDx and Etiology: -A very high index of suspicion is needed for timely diagnosis. Time is bowel. Timely dx is key to avoiding bowel infarction which can occur within hours. -Labs: Often normal or nonspecific early on. Later often shows leukocytosis, acidosis, elevated HCT (from hemoconcentration). Order: CBC, CMP, LDH, - [Intestinal Ischemia (Colon Ischemia) - Ischemic Colitis](https://www.timeofcare.com/intestinal-ischemia-colon-ischemia-ischemic-colitis/) - https://www.aafp.org/afp/2006/1101/p1537.html - [Mesenteric Ischemia, H&P](https://www.timeofcare.com/mesenteric-ischemia-hp/) - History: -Hematochezia due to mucosal sloughing (right colon supplied by SMA) -"“Intestinal angina”: postprandial abd pain, early satiety, & decreased wt from gastric vascular “steal”; may occur wks to mos before the onset of acute pain in pts w/ chronic mesenteric ischemia" Pocket Medicine Physical Exam: -PE may be normal, or may only show - [Chronic Mesenteric Ischemia](https://www.timeofcare.com/chronic-mesenteric-ischemia/) - Hohenwalter EJ. Chronic Mesenteric Ischemia: Diagnosis and Treatment. Seminars in Interventional Radiology. 2009;26(4):345-351. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3036470/ - [Well-Woman Visits (Premenopausal): Health Maintenance](https://www.timeofcare.com/well-woman-visits-premenopausal-health-maintenance/) - Adolescents A/P Template Cervical cancer screening should begin at age 21 Adolescents should be screened for obesity and provided appropriate behavioral counseling. Sex education programs have been associated with a reduction in the rates of sexually transmitted infections in adolescents. Clinicians should meet with adolescents privately to provide confidentiality. " ABFM critique. Folic acid 0.4–0.8 - [Well Man Visit (Adult)](https://www.timeofcare.com/well-man-visit-adult/) - "Sex education programs have been associated with a reduction in the rates of sexually transmitted infections in adolescents. Clinicians should meet with adolescents privately to provide confidentiality. " ABFM critique. Adolescents should be screened for obesity and provided appropriate behavioral counseling. Further Reading / References Am Fam Physician. 2012 May 15;85(10):964-971. The Adult Well - [Well Woman Visit (Postmenopausal Women) - Health Maintenance](https://www.timeofcare.com/well-woman-visit-postmenopausal-women-health-maintenance/) - http://www.aafp.org/afp/2017/0501/p561.html http://www.aafp.org/fpm/2014/0700/oa1.html - [Amyloidosis](https://www.timeofcare.com/amyloidosis/) - "An 82-year-old white male consults you following several syncopal episodes that are clearly orthostatic in nature. During the course of your evaluation, you find that he has a large tongue, mild cardiomegaly, and findings that suggest bilateral carpal tunnel syndrome. The most likely diagnosis at this time is Amyloidosis." "Amyloidosis is defined as the extracellular - [Pernicious Anemia (anemia due to lack of intrinsic factor)](https://www.timeofcare.com/pernicious-anemia/) - Background Definition: Pernicious anemia is caused by a lack of intrinsic factor (IF) which leads to vitamin B12 deficiency resulting in megaloblastic anemia. -The name pernicious anemia dates from the era when treatment had not yet been discovered and the disease was fatal. -Anything that reduces production of intrinsic factor (IF) by the parietal cells can - [Thrombocytopenia (low platelets), Causes](https://www.timeofcare.com/causes-of-thrombocytopenia/) - Decreased platelet production (problem with production in the bone marrow) MOA: Hypocellular bone marrow vs. Hypercellular bone marrow vs. Marrow replacement vs. Bone marrow suppression Bone marrow failure (e.g., aplastic anemia, paroxysmal nocturnal hemoglobinuria, Shwachman-Diamond syndrome) Bone marrow suppression (e.g. drugs (Linezolid, Daptomycin), chemotherapy, or irradiation) Chronic alcohol abuse Infections (cause bone marrow suppression): Viral infections (CMV, - [Thrombocytopenia (Low Platelets)](https://www.timeofcare.com/thrombocytopenia-low-platelets/) - Definition: Diagnosis H&P Labs: DDx and causes. Treatment -Treatment is based on the underlying disease. - [Asplenia / Fever in a Splenectomy Patient](https://www.timeofcare.com/asplenia/) - Asplenic patients should get antibiotics for any episode of fever Asplenic patients who develop a fever should be given parenteral antibiotics immediately. Due to the increased risk of pneumococcal sepsis in asplenic patients, vaccinations against these particular bacteria are specifically recommended. Since pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23) can interact with each - [Pain at the End of Life](https://www.timeofcare.com/pain-at-the-end-of-life/) - Am Fam Physician 2014;90(1):26-32. Pharmacologic management of pain at the end of life. - [Light's Criteria for Exudative Effusions](https://www.timeofcare.com/lights-criteria-for-exudative-effusions/) - Light’s criteria (= Exudate Criteria) are 99.5% sensitive for diagnosing exudative effusions and differentiate exudate from transudative effusions in 93-96% of cases. Light’s criteria for fluid being exudate are: Pleural fluid protein to serum protein ratio > 0.5, Pleural fluid LDH to serum LDH ratio > 0.6, and/or pleural LDH > 2/3rds (i.e. 0.67 times) the upper - [Hip impingement (Femoroacetabular Impingement)](https://www.timeofcare.com/hip-impingement-femoroacetabular-impingement/) - Further Reading Am Fam Physician 2009;80(12):1429-1434. Hip impingement: Identifying and treating a common cause of hip pain. - [Severe Asymptomatic Hypertension (Hypertensive Urgencies)](https://www.timeofcare.com/severe-asymptomatic-hypertension-hypertensive-urgencies/) - Diagnosis Treatment Further Reading / References Am Fam Physician. 2017 Apr 15;95(8):492-500. Severe Asymptomatic Hypertension: Evaluation and Treatment. https://www.aafp.org/afp/2017/0415/p492.html - [Otitis Externa](https://www.timeofcare.com/otitis-externa/) - Treatment Ciprofloxacin 0.3%/dexamethasone 0.1% (Ciprodex) topically When to consider oral antibiotics If the infection has spread beyond the ear canal, If the patient has diabetes mellitus or If the patient is immunocompromised. Ear discharge in children with ventilation tubes in place A Cochrane review showed that "Antibiotic eardrops with or without corticosteroid were more effective - [Adnexal mass: Differential diagnosis](https://www.timeofcare.com/differential-diagnosis-of-an-adnexal-mass/) - Article covers the Differential diagnosis of an Adnexal mass - [Functional Ovarian cysts](https://www.timeofcare.com/functional-ovarian-cysts/) - Each month, ovaries normally grow cyst-like structures called follicles. Follicles produce the hormones estrogen and progesterone and release an egg when ovulation occurs. "If a normal monthly follicle keeps growing, it's known as a functional cyst. There are two types of functional cysts: Follicular cyst. Around the midpoint of your menstrual cycle, an egg bursts out of - [Celiac Disease](https://www.timeofcare.com/celiac-disease/) - Diagnosis Anti-TTG IgA (i.e. Anti-Tissue Transglutaminase IgA) is the first test you do. It is 1st-line. It has a sensitivity of 95% and specificity of 95%. You may add a total IgA because patients with IgA deficiency are at risk of a false negative. In IgA deficient patients, do an IgG-based DGP (anti-deamidated gliadin peptide - [Abdominal Wall Pain](https://www.timeofcare.com/abdominal-wall-pain/) - Diagnosis -H&P -Typical presentation: Patient comes in with lower abd./pelvic pain. During PE, with the patient in supine, you palpate the tender area of her lower abd. When you have her raise both legs off the table while you palpate the abdomen, her pain intensifies. -Positive Carnet Sign. -DDx & Etiology: A hematoma within the abdominal - [Venous insufficiency (Varicose Veins, Thrombophlebitis)](https://www.timeofcare.com/venous-insufficiency-varicose-veins-thrombophlebitis/) - Diagnosis H&P Treatment -Leg elevation, -Compression stockings. Will try 20-30 mmHg which works for most patients. -Aspirin or NSAIDs and topical anti-inflammatory gels. -Will try treatment for 6 months, if no significant improvement, will refer to vascular surgery for ablation or laser treatment. ----///--- **Many insurance companies require documentation of compression of 30 mmHg - [Edema of leg (Pedal Edema), Differential Diagnosis](https://www.timeofcare.com/edema-of-leg-differential-diagnosis/) - This page shows you a differential diagnosis of leg edema or pedal edema - [Endometrial Cancer](https://www.timeofcare.com/endometrial-cancer/) - Risk factors for developing endometrial cancer Early menarche, nulliparity, late menopause, obesity and family history of endometrial cancer. KTA: Notice that these RFs have to do with an extended exposure of the uterus to estrogen and female hormonal changes that happen throughout the menstrual cycle. Early menarche and late menopause mean that you have more - [Pityriasis rosea](https://www.timeofcare.com/pityriasis-rosea/) - Diagnosis "Typically presents with a single herald patch that is oval-shaped and scaly with central clearing, followed by a symmetric rash on the trunk in a typical distribution along the Langer lines." Chrismas tree pattern because of the rash distribution along Langer lines. Treatment The rash may last up to 12 weeks and no treatment - [Roseola infantum](https://www.timeofcare.com/roseola-infantum/) - Background Caused by human herpesvirus 6 Diagnosis Typical presentation: "High fever in a child with either mild upper respiratory symptoms or no other symptoms. After the fever subsides, a rash will appear." ABFM critique. Treatment The rash is self-limited and no treatment is required. - [Hematuria](https://www.timeofcare.com/hematuria/) - Diagnosis Get a good history: Has this happened in the past? OPQRST-A questions. PMH /PSH, FHx of GU cancer, Soc Hx (SAD), sexual history, Medications (any renotoxic meds?), allergies. Microscopic hematuria vs. gross hematuria. PE: Examine genital area and general PE. DDx and Etiology. CBC, CMP, PT, INR to evaluate for blood loss anemia and - [Hematuria, Differential Diagnosis](https://www.timeofcare.com/hematuria-differential-diagnosis/) - Distinguish between Microscopic hematuria vs. Gross Hematuria. Transient unexplained hematuria Urinary tract infection Urethritis Benign prostatic hyperplasia Stones / Urinary calculi Menstruation (contaminated urine) Exercise Trauma Atrophic vaginitis Bladder cancer Kidney cancer Prostate cancer Prostatitis Radiation cystitis Renal infarction; Renal vein thrombosis Factitious (finger stick) Glomerular disease (IgA nephropathy, hereditary nephritis, postinfectious glomerulonephritis) Hypercalciuria Polycystic - [Dermatomyositis](https://www.timeofcare.com/dermatomyositis/) - Dermatomyositis is "distinguished from autoimmune myopathies and polymyositis by distinct dermatologic findings, including Gottron’s sign (nonpalpable macules over the extensor surface of joints). Patients may also have dilated nail-fold capillaries and ragged, thickened cuticles. " ABFM critique Further Reading Eye of the beholder. N Engl J Med 2016;374(18):1774-1779. - [Lichen Planus (LP)](https://www.timeofcare.com/lichen-planus/) - Definition: "Lichen planus is a chronic, inflammatory, autoimmune disease that affects the skin, oral mucosa, genital mucosa, scalp, and nails. " AFP Diagnosis H&P -Lichen planus is associated with Hepatitis C. So check CMP for mildly elevated transaminases. -6Ps. Lichen planus lesions are described as planar (flat-topped), purple, polygonal, pruritic, papules, plaques. -Lesions can be found on - [Postexposure Prophylaxis for Common Infectious Diseases](https://www.timeofcare.com/postexposure-prophylaxis-for-common-infectious-diseases/) - Needle-stick - Housekeeper picks trash that has an improperly disposed insulin needle and her thumb is pierced. She comes to the ED. Postexposure Prophylaxis after exposure to bloodborne pathogens -Will obtain baseline testing for HIV, hepatitis B virus, and hepatitis C virus antibodies, and repeat testing in six weeks, three months, and six months. -CMP, - [Polymyalgia rheumatica (PMR)](https://www.timeofcare.com/polymyalgia-rheumatica/) - Diagnosis -H&P -ESR, CRP -Prednisone 15mg po daily (max 20-30 mg/day) with a slow taper over 1-2 years. -A response to treatment with prednisone would help to confirm the diagnosis of PMR. "The hallmark of this condition is the rapid and often dramatic response, typically within a few days, to low-dose corticosteroids. In fact, the lack - [Upper airway cough syndrome (Postnasal drip)](https://www.timeofcare.com/upper-airway-cough-syndrome-postnasal-drip/) - Diagnosis and Treatment of Upper airway cough syndrome - [Gout and MTP Joint Arthrocentesis](https://www.timeofcare.com/gout-and-mtp-joint-arthrocentesis/) - Send joint fluid for fluid analysis, including: Cell count and differential, Gram stain, Culture and sensitivity, and Microscopic analysis for crystals. If crystals are found, their shape and appearance under polarized light are diagnostic. In gout, crystals of monosodium urate (MSU) appear as needle-shaped intracellular and extracellular crystals. Negatively birefringent urate crystals are seen under a - [Septic arthritis](https://www.timeofcare.com/septic-arthritis/) - "Septic arthritis must be diagnosed and treated promptly, because irreversible damage can occur within 4-6 hours and the joint can be completely destroyed within 24-48 hours." - [Criteria for diagnosing Gout](https://www.timeofcare.com/criteria-for-diagnosing-gout/) - Validated Scoring System for Gout. Acute Gout Diagnosis Rule on MDCalc. Alternative criteria 2015 ACR and European Gout Classification criteria. Online Calculator for 2015 ACR and European Gout Criteria. http://goutclassificationcalculator.auckland.ac.nz/ --- ---///--- EULAR = European League Against Rheumatism References - [Patient with Adrenal Crisis](https://www.timeofcare.com/patient-with-adrenal-crisis/) - I had a patient with known Addison's who had been on steroids for almost 40 years since his Addison's disease was diagnosed. He came in with pyelonephritis and the admitting physician didn't start the stress dose steroids. When we saw the patient the next day and the patient was lethargic and couldn't keep his eyes - [Criteria for Diagnosing Diabetes](https://www.timeofcare.com/criteria-for-diagnosing-diabetes/) - According to the current criteria of the ADA, the diagnosis of diabetes mellitus should be made if any one of the following criteria is met: Hemoglobin A1c ≥6.5% Fasting plasma glucose ≥126 mg/dL 2-hour post-load plasma glucose ≥200 mg/dL on oral glucose tolerance testing A random plasma glucose ≥200 mg/dL in a patient with symptoms of diabetes. - [Hemoglobin A1C Goals](https://www.timeofcare.com/hemoglobin-a1c-goals/) - Goal - [Systemic Sclerosis](https://www.timeofcare.com/systemic-sclerosis/) - Systemic sclerosis (SS) in its final stages often produces a restrictive lung disease similar to idiopathic pulmonary fibrosis. Further Reading Systemic sclerosis/scleroderma: A treatable multisystem disease. Am Fam Physician 2008;78(8):961-968. Interstitial lung disease associated with systemic sclerosis and idiopathic pulmonary fibrosis: How similar and distinct? Arthritis Rheumatol 2014;66(8):1967-1978. - [Marijuana use can cause arrhythmias](https://www.timeofcare.com/marijuana-use-can-cause-arrhythmias/) - In addition to stimulant drugs like cocaine, Methamphetamines, NMDA etc, "marijuana use can cause arrhythmias and should be assessed in patients presenting with palpitations." Source: Am Fam Physician. 2017 Dec 15;96(12):784-789. Palpitations: Evaluation in the Primary Care Setting. - [Steroids Beneficial As Adjunctive Treatment for Community-Acquired Pneumonia](https://www.timeofcare.com/steroids-beneficial-as-adjunctive-treatment-for-community-acquired-pneumonia/) - Steroids Beneficial As Adjunctive Treatment for Community-Acquired Pneumonia - [Antibiotic-associated diarrhea (AAD)](https://www.timeofcare.com/antibiotic-associated-diarrhea-aad/) - Diagnosis and Treatment of antibiotic-associated diarrhea (AAD) - [Spiritual Assessment](https://www.timeofcare.com/spiritual-assessment/) - -ICD -10 Code: Z71.81 Spiritual or Religious Counseling -Use a trusted tool like the FICA Spiritual History Tool or HOPE Questions for Spiritual Assessment. -"A recent review of more than 1,200 studies of religion and health reported that at least two-thirds of the studies evaluated had shown significant associations between religious activity and better mental health, better - [Bullying](https://www.timeofcare.com/bullying/) - If you discover a patient is being bullied at school, advise the parents to discuss the situation with school personnel. Further Reading Pediatrics 2013;132(4):720-729. Bullied children and psychosomatic problems: A meta-analysis. J Fam Pract 2017;66(2):82-89. What family physicians can do to combat bullying. - [GOLD combined COPD assessment](https://www.timeofcare.com/gold-combined-copd-assessment/) - GOLD combined COPD assessment diagrams - [How Hair Grows](https://www.timeofcare.com/how-hair-grows/) - "Hair cycle implies sequential phases of growth and rest that each follicle goes through which includes anagen (active hair growth), catagen (involution) and telogen phase (resting). The anagen phase may last for about 2 to 8 years, the catagen phase lasts for 4 to 6 weeks and the telogen phase lasts for 2 to 3 - [Hair Loss, Differential Diagnosis](https://www.timeofcare.com/hair-loss-differential-diagnosis/) - Male pattern baldness (Androgenetic Alopecia) Female pattern hair loss (Androgenetic Alopecia) Alopecia areata (spot baldness); Alopecia totalis or universalis Traction alopecia Trichotillomania Trichorrhexis nodosa Tinea capitis Telogen effluvium (illness, pregnancy, weight loss) Anagen effluvium (chemotherapy, radiation) Medications (anticoagulants, anticonvulsants, hormones, anti-lipid agents, antihypertensives) Iron deficiency anemia Thyroid dysfunction Malnutrition Discoid lupus Loose anagen syndrome Primary cicatricial - [Androgenetic alopecia](https://www.timeofcare.com/androgenetic-alopecia/) - Definition: Androgenetic alopecia is the most common form of hair loss in both men and women. It is a normal physiologic variant. In men, this condition is also known as male-pattern baldness. In women, this form of hair loss is associated with an increased risk of polycystic ovary syndrome (PCOS). Diagnosis H&P Hair loss occurs in a - [Ibuprofen Dosing Charts for Children & Infants](https://www.timeofcare.com/ibuprofen-dosing-charts-for-children-infants/) - https://www.motrin.com/children-infants/dosing-charts - [Acetaminophen (Tylenol) Dosing Chart by Weight](https://www.timeofcare.com/acetaminophen-tylenol-dosing-chart-by-weight/) - Acetaminophen (Tylenol) Dosing Chart by Weight for infants and children Child's weight (pounds) 6-11 12-17 18-23 24-35 36-47 48-59 60-71 72-95 96+ lbs Liquid 160 mg/ 5 milliliters (mL) 1.25 2.5 3.75 5 7.5 10 12.5 15 20 mL Liquid 160 mg/ 1 teaspoon (tsp) -- ½ ¾ 1 1½ 2 2½ 3 4 tsp - [Skilled Nursing Facility (SNF) Coverage Criteria](https://www.timeofcare.com/skilled-nursing-facility-snf-coverage-criteria/) - The following information comes from page 17 of the following Medicare booklet. https://www.medicare.gov/Pubs/pdf/10153.pdf When will Medicare cover skilled nursing facility (SNF) care? "Medicare will cover SNF care only if all of these are true: 1. You have Medicare Part A* (Hospital Insurance) and have days left in your benefit period (see next page) available to - [Disability Evaluations](https://www.timeofcare.com/disability-evaluations/) - Completing Disability Forms Understanding the patient's job requirements and limitations is the foundation. PT and OT are helpful for accurately documenting range of motion and functional limitations. Occupational Therapy referral to help out with filling certain forms. The Disability Evaluation The disability evaluation includes: -Targeted H&P examination -Diagnostic tests as appropriate -Referrals as appropriate Examples - [TRAP: The Signs of Parkinson's Disease](https://www.timeofcare.com/trap-the-signs-of-parkinsons-disease/) - The TRAP of Parkinson's Disease (PD) The PD TRAP The cardinal signs of Parkinson's Disease are: Tremor The tremor in PD is a rest tremor which means that it is most visible when the shaking body part (e.g. a hand) is at rest supported by gravity and not engaged in any purposeful activity. This tremor - [Mnemonic for Pediatric Immunizations](https://www.timeofcare.com/mnemonic-for-pediatric-immunizations/) - Watch this youtube video. Hep B is 0, 1 to 2, 6 months. 2 months is DR. HIP for DTaP, Rotavirus, Hib, IPV, PCV13 4 months also DR. HIP. 6 months is DR. HIP plus influenza starts at 6 months and the last dose of Hep B is at six months. 12-15 months is MAD - [Histoplasmosis](https://www.timeofcare.com/histoplasmosis/) - I actually saw a patient who worked on the farms in the region around the Mississippi river who had Histoplasmosis in the past. Exposure to bird or bat droppings is a risk factor for Histoplasma capsulatum infection. Found in spelunkers, caves, bats, and bird droppings. "Histoplasma capsulatum is the fungus that causes histoplasmosis. Commonly found - [Legionella Pneumophila](https://www.timeofcare.com/legionella-pneumophila/) - The following is a sample question and explanation from the ABFM that explains the presentation of Legionella Pneumophilla "Legionella should be considered as a pathogen for community-acquired pneumonia when the patient has a history of a hotel stay or cruise ship travel within the past couple of weeks. " "A previously healthy 74-year-old male presents - [Pneumonia in adults, Community Acquired (Outpatient)](https://www.timeofcare.com/community-acquired-pneumonia-in-adults/) - -Fever/chills, cough, tachypnea. -CURB-65 / PSI to determine site/setting of treatment discussed. -Antibiotic choices discussed. ---///--- Tools for evaluation of pneumonia severity include: SMART-COP - Predicts the likelihood of the need for invasive ventilation or vasopressor support, SMART-COP - Predicts the risk of 30-day mortality and the need for admission to the intensive-care unit, and CURB-65 - [Chronic Heart Failure Classification and Treatment](https://www.timeofcare.com/heart-failure-chronic/) - See: http://www.aafp.org/afp/2014/0801/p186.html Chronic Therapy by Heart Failure Stage AHA/ACC Stage (not NYHA class) Pt characteristics Treatment A High risk for HF. No structural heart disease. Asymptomatic. HTN, DM, CAD, cardiotoxin exposure. FHx of CMP Tx focuses on reducing modifiable risk factors, including mgt of HTN, HLD, DM, SVT, Stop smoking, decr. alcohol; incr. exercise. B - [Joint Pain (Arthralgias), Polyarticular/Polyarthritis: Differential Diagnosis](https://www.timeofcare.com/joint-pain-arthralgias/) - Most common: Viral arthritis, Osteoarthritis Osteoarthritis Viral arthritis (see common types of viruses) Rheumatoid arthritis Inflammatory osteoarthritis Psoriatic arthritis Inflammatory bowel disease Polyarticular gout Pseudogout Bacterial endocarditis Lyme disease Disseminated gonococcal infection Septic joint Other infections Reactive arthritis Rheumatic fever Enteric infection e.g. Whipple's disease Ankylosing spondylitis Systemic lupus erythematosus Systemic vasculitis Systemic sclerosis Polymyositis/dermatomyositis Polymyalgia - [Hypertensive Urgency](https://www.timeofcare.com/hypertensive-urgency/) - Hypertensive urgency is now called severe asymptomatic hypertension. - [Severe Asymptomatic Hypertension (Hypertensive Urgency)](https://www.timeofcare.com/severe-asymptomatic-hypertension-hypertensive-urgency/) - Content coming soon. Sample Case treated *Likely from pain caused by his brain lesion, Methamphetamine abuse, and noncompliance to BP meds *Upon admission was 238/187, by the time hospitalist examined pt it was 160/94 -Pt evaluated for end-organ damage. None is present. In the ED, BP was reduced with multiple doses of Enalapril (Vasotec) IV, Hydralazine - [Definition of Hypertension in Adults](https://www.timeofcare.com/definition-of-hypertension/) - Normal: BP - [Hypertension in dialysis Patients](https://www.timeofcare.com/hypertension-in-dialysis-patients/) - Hypertension Medications in ESRD. - [Hypertension in elderly patients](https://www.timeofcare.com/hypertension-elderly/) - Age-related physiologic differences such as wider pulse pressure should be a consideration when treating hypertension in the elderly. Compared to younger patients, elderly patients have: Lower cardiac output, higher peripheral resistance, lower intravascular volume, and lower renal blood flow. Wider pulse pressure "Pulse pressure (the difference between systolic blood pressure and diastolic blood pressure) is - [Bacteremia](https://www.timeofcare.com/bacteremia/) - MRSA bacteremia Diagnosis BCx Echocardiogram to r/o endocarditis. Assess for indwelling devices such as prosthetic heart valves or vascular grafts. Treatment Antibiotics If patient responses to antibiotic treatment, repeat blood cultures 2–4 days after the initial cultures and as needed thereafter to document clearance of bacteremia. After that, I get daily BCx until I get - [Infantile hemangiomas](https://www.timeofcare.com/infantile-hemangiomas/) - -Usually appear by 4 weeks of age and stop growing by 5 months of age. -"As many as 70% leave residual skin changes, including telangiectasia, fibrofatty tissue, redundant skin, atrophy, dyspigmentation, and scarring." Treatment Oral propranolol Oral corticosteroids Intralesional corticosteroids injections (for small, bulky, well-localized lesions in infants). Laser therapy can treat early lesions or - [Breast Mass in Prepubertal Children, DDx](https://www.timeofcare.com/breast-mass-in-prepubertal-children-ddx/) - Neonatal disorders -Influx of maternal hormones through the placenta -Mastitis neonatorum (infection) Breast abscesses. Benign premature thelarche (isolated breast development in females aged 6 months to 9 years) Precocious puberty Intraductal papillomas, Phyllodes tumors, Primary breast cancer (rare) Metastatic lesions (rare) Further Reading Semin Plast Surg. 2013 Feb; 27(1): 19–22. Management of Pediatric and Adolescent - [Insulin Types, Onset, and Duration of Action](https://www.timeofcare.com/insulin-types-onset-and-duration-of-action/) - Insulin type Onset of action Peak Duration of action Comments Lispro, aspart, glulisine 5 to 15 mins 45 to 75 mins 2-4 h Give immediately before meal Regular about 30 mins 2-4 h 5-8 h Give ~ 30 min before meal NPH about 2 h 4 to 12 h 18 to 28 h Can cause - [Diabetes Mellitus Type I, Chronic](https://www.timeofcare.com/diabetes-mellitus-type-i-chronic/) - -Consider Continuous glucose monitoring ---//--- A patient with type 1 diabetes mellitus for 15 years begins having episodes of hypoglycemia. His glucose levels were previously stable and well controlled. There has been no recent change in his diet or insulin regimen. What's the most likely cause of the hypoglycemia? Answer: Renal disease "The most common - [Metabolic Syndrome](https://www.timeofcare.com/metabolic-syndrome/) - Definition of Metabolic Syndrome as well as how to treat it. - [Motivational Interviewing](https://www.timeofcare.com/motivational-interviewing/) - Motivational interviewing resources Fam Pract Manag. 2016 Sep-Oct;23(5):32-38. Using Motivational Interviewing to Promote Healthy Weight. https://www.aafp.org/fpm/2016/0900/p32.html http://www.motivationalinterviewing.org/ Four core skills you need to master to do motivational interviewing well. Mnemonic: OARS Open questions Affirmations Reflections Summaries - [PHATS - Metabolic Syndrome](https://www.timeofcare.com/phats-metabolic-syndrome/) - Mnemonic PHATS Current ATP III criteria define the metabolic syndrome as the presence of any 3 of the following 5 traits: Pressure: Blood pressure ≥130/85 mmHg or drug treatment for elevated blood pressure. ** BP in the top half of prehypertension. HDL is low: Serum high-density lipoprotein (HDL) cholesterol - [Bipolar and related disorders](https://www.timeofcare.com/bipolar-and-related-disorders/) - Bipolar I disorder Bipolar II disorder Cyclothymic disorder Substance/Medication-induced Bipolar and related disorder Bipolar and related disorder due to another medical condition Other specified bipolar and related disorder -Short-duration hypomanic episodes (2-3 days) and major depressive episodes. -Hypomanic episodes with insufficient symptoms and major depressive episodes -Hypomanic episode without prior depressive episode -Short-duration cyclothymia (less - [Olecranon Bursitis (Septic vs. Aseptic)](https://www.timeofcare.com/olecranon-bursitis/) - See for help: http://orthoinfo.aaos.org/topic.cfm?topic=a00028 I saw one in the ED and aspirated 18ml from it. Treat conservatively first, if no improvement, aspirate Aspirating the olecranon bursa Get the following equipment. -Lidocaine with Epinephrine -30 ml Syringe -Sterile container to take fluid to the lab ASAP. It needs to be walked over to the lab. -Iodine - [Hyperaldosteronism](https://www.timeofcare.com/hyperaldosteronism/) - "Up to 28% of patients may be defined as having resistant hypertension (not controlled on three drugs or controlled on four or more drugs). Primary aldosteronism is present in up to 5%–10% of all hypertensive patients and 7%–20% of those with resistant hypertension. This may be due to bilateral adrenal hyperplasia or a unilateral - [Pneumonia in Children, Community Acquired, (Outpatient)](https://www.timeofcare.com/pneumonia-community-acquired-pediatrics/) - The most likely etiologic agents and treatment of CAP in children are based on age. Diagnosis -History and physical consistent with CAP. -Diagnosis based mainly on H&P. -Fever + respiratory signs and symptoms (cough, tachypnea). -Vital signs: RR, Oxygen sats, and HR, Temp, BP. -Pneumonia severity assessed. -CXR and Labs as needed. -Viral testing as needed. Treatment - [Community Acquired Pneumonia in Children: OutpatientTreatment](https://www.timeofcare.com/community-acquired-pneumonia-in-children-treatment/) - CAP in children is treated based on age. The most likely etiologic agents in a school-age child are Mycoplasma pneumoniae, Chlamydia pneumoniae, and Streptococcus pneumoniae. Age Antibiotic Most common Causative Agent *2 months to 5 years High-dose oral amoxicillin Streptococcus pneumoniae 5-16 years Macrolide antibiotic e.g. Azithromycin Mycoplasma pneumoniae and Chlamydia pneumoniae *2 months = 60 - [Diagnostic Criteria for Functional Dyspepsia](https://www.timeofcare.com/diagnostic-criteria-for-functional-dyspepsia/) - Rome III diagnostic criteria for functional dyspepsia. According to the 2006 Rome III criteria, functional dyspepsia is divided into two subgroups: postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS). At least 3 months, with onset at least 6 months previously, of one or more of the following: • bothersome postprandial fullness • early satiation • - [Intermittent explosive disorder](https://www.timeofcare.com/intermittent-explosive-disorder/) - "Intermittent explosive disorder involves repeated sudden episodes of impulsive, aggressive, violent behavior or angry verbal outbursts in which the person reacts grossly out of proportion to the situation. Road rage, domestic abuse, throwing or breaking objects, or other temper tantrums may be signs of intermittent explosive disorder." ABFM critique - [Glenohumeral (Shoulder) Dislocation](https://www.timeofcare.com/glenohumeral-dislocation/) - -The most common joint to be dislocated, -Over 90% dislocating anteriorly. -MOA of anterior dislocation: The injury typically occurs as a result of forced external rotation when the arm is abducted. Presentation of anterior dislocation: "On presentation, there is a loss of normal contour of the shoulder and the arm is typically held in an abducted - [Frozen Shoulder, Adhesive Capsulitis](https://www.timeofcare.com/frozen-shoulder-adhesive-capsulitis/) - Definition : "Frozen shoulder is an inflammatory contracture of the shoulder capsule and mostly affects the anterosuperior and anteroinferior capsular ligaments, limiting glenohumeral movement. -Diabetic patients have a 10%–20% lifetime risk of frozen shoulder. -Only two other common conditions selectively limit passive external rotation: locked posterior dislocation and osteoarthritis. Plain films of the shoulder should - [When a breach of confidentiality is justified](https://www.timeofcare.com/when-a-breach-of-confidentiality-is-justified/) - There are three situations when a breach of confidentiality is justified: Abuse of a vulnerable person (child or elderly), a public health risk (communicable disease), or a substantial danger to the patient or others. For example, chlamydia is a communicable disease. "Contacting sexual partners to notify and treat them to stem the spread of disease - [Actinic Keratoses (AK)](https://www.timeofcare.com/actinic-keratoses/) - Definition Skin-colored, pink, or erythematous macule with gritty scale (no papule). -Easier to feel than to see; -AK is a premalignant lesion with the potential to progress to SCC. -Cutaneous horns (15% with SCC at the base) -Common on the head, neck, forearms -Prevalence of AK in US 16–25% and incidence increases with age. -In patients with - [Clavicular fractures (Clavicle Fractures)](https://www.timeofcare.com/clavicular-fractures/) - Management of Clavicular fractures (Clavicle Fractures) - [Factors that increase the Risk of Relapse of Atrial Fibrillation after Cardioversion](https://www.timeofcare.com/factors-that-increase-the-risk-of-relapse-of-atrial-fibrillation-after-cardioversion/) - Factors that increase the Risk of Relapse of Atrial Fibrillation after Cardioversion - [Anticoagulation Risk-Benefit Analysis in Patients with Atrial Fibrillation.](https://www.timeofcare.com/anticoagulation-risk-benefit-analysis-in-patients-with-atrial-fibrillation/) - To weigh the risks and benefits of anticoagulation in patients with atrial fibrillation, use two validated tools, the CHA2DS2-VASc score, and the HAS-BLED score. A CHAD2DS2-VASc of ≥ 2 argues for anticoagulation and a HAS-BLED score of ≥ 3 argues against anticoagulation. "The European Society of Cardiology 2016 Guidelines for Atrial Fibrillation state that the benefits of - [Paroxysmal Atrial Fibrillation](https://www.timeofcare.com/paroxysmal-atrial-fibrillation/) - Paroxysmal Atrial Fibrillation "Paroxysmal atrial fibrillation is treated like persistent atrial fibrillation. The risk of stroke is the same." Dr. Bernstein, Cardiologist. - [Tuberculosis, Latent TB Infection](https://www.timeofcare.com/tuberculosis-latent-tb-infection/) - Diagnosis -H&P that is consistent with latent TB. -Prior BCG Vaccination: No -Patient screened positive. -Test interpretation explained to the patient. -Risk factors for acquiring TB reviewed w/ patient. -Risk factors for developing TB also reviewed / patient. -Pathogenesis and Epidemiology of TB reviewed. -Will exclude active TB by getting a CXR (in addition to - [Acne Algorithm from the Global Alliance algorithm to improve outcomes in acne](https://www.timeofcare.com/acne-algorithm-from-the-global-alliance-algorithm-to-improve-outcomes-in-acne/) - Global Alliance algorithm to improve outcomes in acne. (http://www.download.thelancet.com/cms/attachment/2048237148/2058285104/gr5.jpg) Global Alliance algorithm to improve outcomes in acne. (From Medscape) †With small nodules (>0.5–1 cm). ‡Consider physical removal of comedones. §Second course in case of relapse. ¶There was not consensus on this alternative recommendation; however, in some countries, azelaic acid prescribing is appropriate practice. #For pregnancy, - [Definition of Short and Tall Stature in Children](https://www.timeofcare.com/definition-of-short-and-tall-stature-in-children/) - "Short stature is defined as a height more than two standard deviations below the mean for age (less than the 3rd percentile). Tall stature is defined as a height more than two standard deviations above the mean for age (greater than the 97th percentile)." Reference Am Fam Physician. 2015 Jul 1;92(1):43-50. Evaluation of Short - [Acute Uncomplicated Pyelonephritis: Empiric Outpatient Treatment](https://www.timeofcare.com/acute-uncomplicated-pyelonephritis-empiric-outpatient-treatment/) - Related article: FDA Warnings for Fluoroquinolones. A) Fluoroquinolone is the first-line treatment for mild and moderate pyelonephritis [If local rates of E. coli fluoroquinolone resistance are low (< 10%)]: Ciprofloxacin 500 mg PO twice daily x 7 d Ciprofloxacin extended-release 1000 mg PO x 7 d Levofloxacin 750 mg orally x 5-7 d B) If fluoroquinolone resistance is >10%, start with an - [FDA warnings for fluoroquinolone antibiotics](https://www.timeofcare.com/fda-warnings-for-fluoroquinolone-antibiotics/) - The FDA says quinolones are associated with disabling and potentially permanent side effects and recommends that providers limit their use in patients with less serious bacterial infections. Limit their use for acute bacterial sinusitis, acute bacterial exacerbation of chronic bronchitis and uncomplicated urinary tract infections In 2016, the FDA released a warning regarding the serious - [Antibiotics for Acute Uncomplicated Cystitis](https://www.timeofcare.com/antibiotics-for-acute-uncomplicated-cystitis/) - First Option Nitrofurantoin (Macrobid) 100 mg po BID x 5 days. -- (Avoid if early pyelonephritis suspected.) Trimethoprim/sulfamethoxazole (Bactrim) 160/800 mg BID x 3 days.---(avoid if resistance prevalence is known to exceed 20 or if used for UTI in previous 3 months) Fosfomycin 3-g single dose. ---(lower efficacy than some other recommended agents; avoid if early - [Medroxyprogesterone Acetate (Depo-Provera)](https://www.timeofcare.com/medroxyprogesterone-acetate/) - Don't use it for more than 2 years total. FDA warning indicated that a woman should use Depo-Provera for more than two years only if other contraceptive methods are inadequate for her. This warning also applies to new lower-dose formulations of DMPA. Black Box Warnings In the Epocrates app, the Black Box warning reads as follows. - [Major symptoms and signs of hypothyroidism](https://www.timeofcare.com/major-symptoms-and-signs-of-hypothyroidism/) - Mechanism Symptoms Signs Slowing of metabolic processes Fatigue and weakness Cold intolerance Dyspnea on exertion Weight gain Cognitive dysfunction Mental retardation (infantile onset) Constipation Growth failure Slow movement and slow speech Delayed relaxation of tendon reflexes Bradycardia Carotenemia Accumulation of matrix substances Dry skin Hoarseness Edema Coarse skin Puffy facies and loss of eyebrows Periorbital - [Conditions that Require Higher Doses of Thyroid Medication (Levothyroxine)](https://www.timeofcare.com/conditions-that-require-higher-doses-of-thyroid-medication-levothyroxine/) - This article discusses conditions in patients with hypothyroidism that cause them to require higher doses of thyroid medication (Levothyroxine) - [Diabetes insipidus (DI)](https://www.timeofcare.com/diabetes-insipidus/) - This page covers Diabetes insipidus - [The Meaning of Insipidus and Mellitus as used with Diabetes](https://www.timeofcare.com/the-meaning-of-insipidus-and-mellitus-as-used-with-diabetes/) - Explanation of the Meaning of Insipidus and Mellitus as used with Diabetes. - [Sickle Cell Crisis](https://www.timeofcare.com/sickle-cell-crisis/) - #Sickle Cell Crisis Pert +/- Hx: Endorses/Denies: Vaso-occlusion and infarction symptoms: painful crises, acute chest syndrome, hand-foot syndrome, priapism. Denies/endorses: S/sx of infection (meningitis, bacteremia, Pneumonia) s/sx of cardiac disease (cardiomyopathy, heart failure, MI, dysrhythmia, sudden death), neurologic s/sx (TIA, stroke or CVA, seizures,PRES--posterior reversible encephalopathy syndrome), pulmonary s/sx (asthma, pneumonia, acute chest syndrome, sleep disordered breathing), skeletal - [Failure to thrive (Weight Faltering)](https://www.timeofcare.com/failure-to-thrive-weight-faltering/) - Definition -Definition of FTT: Weight below the 5th percentile for sex and corrected age/weight for length below the 5th percentile/ BMI for age below the 5th percentile OR a fall in weight by two major percentiles on a growth curve (AAFP 2016). Other authorities go with 2 percentile as cut off. Diagnosis -Will search for - [Widened, Regular, monomorphic QRS](https://www.timeofcare.com/widened-regular-monomorphic-qrs/) - A 60-year-old male in the hospital. He can talk coherently and is complaining a sudden onset of lightheadedness. He is AOx3 and coherent. HR = 175 beats/min and his blood pressure is 120/62 mm Hg. Rhythm strip shows a widened, regular, monomorphic QRS. What is the initial treatment? Adenosine. We know adenosine is the right - [Fibromyalgia Medications](https://www.timeofcare.com/fibromyalgia-medications/) - Strong Evidence for Efficacy. Amytriptyline 25-50 mg at bedtime Cyclobenzaprine 10-30 mg at bedtime Pregabalin 300-450 mg / day Gabapentin 1600-2400 mg / day Duloxetine 60-120 mg / day Milnacipran100-200 mg / day. Weak evidence for efficacy. Tramadol 200-300 mg / day SSRIs (fluoxetine, sertraline) SSRIs produce up to a 30% reduction in pain scores - [Prevention](https://www.timeofcare.com/prevention/) - USPSTF A & B Recommendations, by date. AAP Screening Recommendations. Immunization for Adults. Adult Immunization Schedule by Medical and Other Indications. Vaccinations for children. Well child check. Vaccinations: https://medlineplus.gov/ency/article/002024.htm Live Vaccines in the U.S. MMR (Measles, Mumps, Rubella) Varicella Shingles (Varicella Zoster) Rotavirus (oral route) Intranasal influenza Yellow Fever, Oral typhoid, and BCG are also live. BCG - [AAP Screening Recommendations](https://www.timeofcare.com/aap-screening-recommendations/) - Periodicity Schedule from AAP https://www.aap.org/en-us/Documents/periodicity_schedule.pdf https://www.aap.org/en-us/professional-resources/practice-transformation/managing-patients/Pages/Periodicity-Schedule.aspx Am Fam Physician. 2016 Aug 15;94(4):324.AAP Updates Recommendations for Routine Preventive Pediatric Health Care https://www.aafp.org/afp/2016/0815/p324.html - [Corticosteroid Injections](https://www.timeofcare.com/corticosteroid-injections/) - This article reviews the benefits of Corticosteroid Injections - [Direct Observational Therapy (DOT)](https://www.timeofcare.com/direct-observational-therapy-dot/) - Benefits of DOT are that it has been shown to: Decrease both the acquisition and transmission of drug-resistant tuberculosis, and Increase treatment success in HIV-positive patients Further Reading Clin Infect Dis. 2016 Oct 1;63(7):e147-e195. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible - [Rabies](https://www.timeofcare.com/rabies/) - Bat, skunk, raccoon, fox are the four major animal reservoirs of rabies in the U.S. right now. Rabies Postexposure Prophylaxis Rabies immune globulin should be given only to people who have NEVER been vaccinated against rabies previously. "For people who have NEVER been vaccinated against rabies previously, postexposure anti-rabies vaccination should always include administration of both - [Species that Transmit Rabies](https://www.timeofcare.com/species-that-transmit-rabies/) - This article lists the common carriers of rabies in the United States. - [Contraception: Initiating the Pill, Patch, Ring, or Injection](https://www.timeofcare.com/contraception-initiating-the-pill-patch-ring-or-injection/) - Quick Start: Office visit occurring between menses "The “quick start” method allows most women with a negative urine pregnancy test to begin using the birth control pill, patch, or vaginal ring immediately after an office visit, at any point in the menstrual cycle" (AFP 2006) For someone less than 35 and not smoking, "The - [Contraception in Transplant Patients](https://www.timeofcare.com/contraception-in-transplant-patients/) - -IUD is the best option. It is reliable and doesn't interact with many immunosuppressive therapies. Female fertility typically increases post-transplant so patients need contraception. "Pregnancy should be avoided during the 12 months following transplantation because of the increased risk of preterm delivery and graft rejection." Further Reading / Reference US medical eligibility criteria - [Commonly Asked Questions about Contraception](https://www.timeofcare.com/commonly-asked-questions-about-contraception/) - Q: Do I need backup protection? A patient just got a Mirena IUD put in on the last day of her menses which started 5 days ago. A pregnancy test is negative. She asks, do I need a backup plan? The answer is NO. If a pt gets Mirena put in within 7 days of - [Contraception Failure Rates](https://www.timeofcare.com/contraception-failure-rates/) - Article shows Contraception Failure Rates - [Sarcoidosis](https://www.timeofcare.com/sarcoidosis/) - Treatment (if indicated) -1st-line treatment: Corticosteroids. -2nd-line and 3rd-line tx: Methotrexate, azathioprine, leflunomide, and biologic agents. Further Reading / References Am Fam Physician. 2016 May 15;93(10):840-8. Diagnosis and Management of Sarcoidosis. https://www.ncbi.nlm.nih.gov/pubmed/27175719 - [Diuretics and Diuresis](https://www.timeofcare.com/diuretics-and-diuresis/) - Daily weight is the best way to track successful diuresis. Diuretics inhibit sodium reabsorption in specific parts of the nephron, resulting in increased urinary sodium and water excretion. "Loop diuretics are the most potent diuretics." Electrolyte & BP 2015 Diuretics help in the treatment of HTN, renal failure, cirrhosis, etc. Loop Diuretics Types: Furosemide, torsemide, - [Sigmoid Dose-Response Curve in Loop Diuretics](https://www.timeofcare.com/sigmoid-dose-response-curve-in-loop-diuretics/) - This article discusses the Sigmoid Dose-Response Curve in Loop Diuretics - [HAS-BLED score](https://www.timeofcare.com/has-bled-score/) - This article explains the HAS-BLED score. - [Advance Care Planning (Advance Directives)](https://www.timeofcare.com/advance-care-planning-advance-directives/) - Advance Care Planning (ACP) & End-of-Life Planning Two CPT codes are used to report ACP services: 99497 and 99498. Advance directives include the following four elements Durable power of attorney for healthcare. Living will DNR or Do not resuscitate order POLST or Physician Orders for Life-sustaining Treatment Advance directives – spells out what you will want to - [Infectious Endocarditis or Bacterial Endocarditis](https://www.timeofcare.com/infectious-endocarditis-or-bacterial-endocarditis/) - "Over 85% of cases of infectious endocarditis are caused by gram-positive cocci. In patients suspected of having acute infectious endocarditis, empiric antibiotic treatment should be started immediately after obtaining initial blood cultures and should include coverage against gram-positive cocci with vancomycin. For patients with prosthetic heart valves, initial coverage should include vancomycin plus rifampin. Clindamycin, - [Dental Procedures: Antibiotic Prophylaxis](https://www.timeofcare.com/antibiotic-prophylaxis-before-dental-procedures/) - This page discusses antibiotic options for prophylaxis before dental and oral procedures. - [Irritable Bowel Syndrome (IBS)](https://www.timeofcare.com/ibs-irritable-bowel-syndrome-adults/) - -Patient meets the definition of IBS. -H&P performed, see above. -TSH, BMP, CBC, Stool Studies, FOBT. Abdominal imaging if needed. Treatments that work for IBS Nonpharmacologic treatment. -No alarm symptoms. -Patient education and reassurance provided. Exercise and dietary modification -Exercise -Exclude gas-producing foods like beans, onions, celery, carrots, raisins, bananas, apricots, prunes, Brussels sprouts, wheat - [Treatment of symptomatic hemorrhoids in adults](https://www.timeofcare.com/treatment-of-symptomatic-hemorrhoids-in-adults/) - **Use topical steroids only for short-term to avoid thining of skin. No more than 7 days. Lidocaine 5% topical ointment, apply 1-4 times daily as needed Dibucaine 1% topical ointment, apply tid-qid prn. Benzocaine 5 to 20% rectal ointment, apply up to six times daily as needed. Proctofoam HC (Hydrocortisone / Pramoxine topical) Pramoxine 1% - [Troponinemia (Hypertroponinemia): Differential diagnosis of elevated troponins](https://www.timeofcare.com/troponinemia-differential-diagnosis-of-elevated-troponins/) - ACS related Acute MI (STEMI & NSTEMI) Post‐PCI Open heart surgery / Any cardiac surgery Non‐ACS related Tachycardia: SVT, V-Tach, A-Fib with RVR or any tachycardia. Atrial Fibrillation Pericarditis, Myocarditis, Endocarditis Massive or submassive Pulmonary Embolism Sepsis Hypotension Critical illness (Medical ICU patients) Viral illness Hypertension Thrombotic thrombocytopenic purpura CVA (Stroke): Hemorrhagic stroke (Subarachnoid hemorrhage); Ischemic - [Febrile seizures](https://www.timeofcare.com/febrile-seizures/) - Graves RC, Oehler K, Tingle LE: Febrile seizures: Risks, evaluation, and prognosis. Am Fam Physician 2012;85(2):149-153 - [Hirsutism (Excessive Hairiness)](https://www.timeofcare.com/hirsutism-excessive-hairiness/) - -Excessive growth of hair in women. This hair is usually in a male pattern. -Presence of abnormal androgen action → Excessive hairiness. Treatment -Oral contraceptives are the first-line drug for treatment of hirsutism in women not trying to conceive. -Antiandrogens (e.g. spironolactone) are another option for premenopausal women Metformin works only for PCOS. There is no - [DKA and HHS Protocols for Adults](https://www.timeofcare.com/dka-and-hhs-protocols-for-adults/) - Uptodate.com has an easy-to-use version of the above guidelines. For easy to Print Version, Click here to Print. University of Iowa, Family Medicine, DKA Guidelines. You can also find it here. 2009 Updated Guidelines from ADA. This article can also be found here on the ADA website. 2006 Guidelines for Managing DKA. This article can also be - [Bridging Insulin & Feeding the Patient After DKA](https://www.timeofcare.com/bridging-insulin-feeding-the-patient-after-dka/) - When to start SC insulin and bridge with insulin drip -After the DKA has resolved and when the patient is able to eat, start SC basal insulin (like insulin glargine). In addition, order a pre-meal insulin Lispro regimen, AC TID. -Continue IV insulin infusion for 2hrs after starting the SC insulin glargine to create a 2-hour - [Bell's Palsy](https://www.timeofcare.com/bells-palsy/) - Idiopathic Facial Paralysis / Facial nerve palsy / Bell's Palsy -Prednisone 60mg po daily x 7 days. -Valacyclovir 1g po TID x 7 days. -Artificial tears (Liquid or gel formulation) - E.g. Gonak (2.5% Sterile Hypromellose Ophthalmic Demulcent Solution. Apply every hour while the patient is awake. -Artificial tears (ointment formulation) - E.g. Lacri-Lube ophthalmic ointment which - [Disease and Cancer Screening](https://www.timeofcare.com/disease-and-cancer-screening/) - The Society of General Internal Medicine does not recommend cancer screening in adults with a life expectancy of less than 10 years. - [Peripheral Artery Disease (PAD)](https://www.timeofcare.com/peripheral-artery-disease-pad/) - -History and Physical, above. -Patient with symptomatic PAD with intermittent claudication. -ABI measurements show: -Start a daily dose of either aspirin or clopidogrel (to prevent cardiovascular events such as an MI or stroke). -ASCVD score: -Smoking cessation. -Start a walking program. -Will start Cilostazol (a phosphodiesterase inhibitor with both antiplatelet and arterial vasodilatory activity) ---///--- - [Pacemaker Code](https://www.timeofcare.com/pacemaker-code/) - Pacemakers use a 5-letter code. The first 3 letters are the most important 1st Letter: Chamber Paced A= Atrium V= Ventricle D= Dual (A+V) 2nd Letter: Chamber Sensed A= Atrium V= Ventricle D= Dual (A+V) O= None 3rd Letter: Response after Sensing (i.e. Response to sensed beat) I = Pacing Inhibited T= Pacing Triggered D= - [Pulmonary Hypertension](https://www.timeofcare.com/pulmonary-hypertension/) - Definition: Mean pulmonary arterial pressure of 25 mm Hg or greater. Results from different pathophysiologic mechanisms. "Echocardiography is recommended as the initial step in the evaluation of patients with suspected pulmonary hypertension." AAFP 2016 Influenza and pneumonia immunizations Am Fam Physician. 2016 Sep 15;94(6):463-469. Pulmonary Hypertension: Diagnosis and Treatment. https://www.aafp.org/afp/2016/0915/p463.html - [Influenza Vaccine](https://www.timeofcare.com/influenza-vaccine/) - If a patient has had a severe anaphylactic reaction to eggs in the past, he/she can only get the Recombinant trivalent influenza vaccine. The Recombinant influenza vaccine is made without using eggs. The other flu vaccines are all prepared using eggs. Live attenuated trivalent influenza vaccine Inactivated trivalent influenza vaccine Inactivated quadrivalent influenza vaccine Influenza vaccine - [Tinnitus Red Flags](https://www.timeofcare.com/tinnitus-red-flags/) - Tinnitus red flags symptoms include: Unilateral tinnitus Pulsatile tinnitus Tinnitus associated with asymmetric hearing loss Tinnitus associated with significant vertigo Tinnitus causing psychological distress Tinnitus associated with significant neurological symptoms and/or signs Tinnitus that appeared suddenly If red flag symptoms are present, immediately refer the patient to ENT. - [Duration of Dual Antiplatelet Therapy in CAD Patients](https://www.timeofcare.com/duration-of-dual-antiplatelet-therapy-in-cad-patients/) - **Dual antiplatelet therapy is only indicated in ACS patients after a stent has been placed. If a patient has an ACS and a heart catheterization is done but no stent is placed, that patient doesn't require dual antiplatelet therapy (DATP). Patients with ACS but not stent placement only require aspirin therapy. Some ACC/AHA Guideline on Duration - [Tinnitus, Differential Diagnosis](https://www.timeofcare.com/tinnitus-differential-diagnosis/) - This page covers the Differential Diagnosis of Tinnitus - [Aphthous Ulcers (Canker sore)](https://www.timeofcare.com/aphthous-ulcers/) - This page discusses treatment of Aphthous ulcers. - [Complications of Alcohol Abuse and Alcohol Withdrawal](https://www.timeofcare.com/complications-of-alcohol-abuse-and-alcohol-withdrawal/) - When treating a patient with alcohol abuse, it's wise to evaluate and treat the patient for complications of both alcohol abuse and alcohol withdrawal. Complications of Alcohol Withdrawal Minor withdrawal symptoms (6-48 hours after last drink. start about 6 hrs after last drink and resolve within 24 to 48 hours if withdrawal doesn't progress). Due to - [Fixed schedule vs. Symptom-triggered therapy of Alcohol Withdrawal Symptoms](https://www.timeofcare.com/fixed-schedule-vs-symptom-triggered-therapy-of-alcohol-withdrawal-symptoms/) - Symptom-triggered therapy: Benzodiazepines are given only when the patient has symptoms of alcohol withdrawal. No symptoms, no medication. Patients are given the treatment they need, only when they need it. Fixed schedule therapy: Benzodiazepine is given at fixed intervals even if symptoms are absent. There is a lot of evidence against this approach. The symptom-triggered therapy - [Richmond Agitation-Sedation Scale (RASS)](https://www.timeofcare.com/richmond-agitation-sedation-scale-rass/) - The Richmond Agitation-Sedation Scale (RASS) ranks agitation and possibility for sedation. Use the Richmond agitation-sedation scale (RASS) instead of CIWA-Ar in alcohol withdrawal patients who cannot talk, e.g. patients who are intubated in the ICU. Shoot for a score of 0 to -2 when using the RASS to manage alcohol withdrawal patients who cannot talk. - [Banana bag: What's in it?](https://www.timeofcare.com/banana-bag-whats-in-it/) - The banana bag is popular in hospitals and is used in patients with alcohol withdrawal and sometimes for patients with prolonged vomiting. A banana bag contains: Thiamine 100 mg, Folic acid 1mg, Multivitamin, Isotonic saline (Normal Saline 1,000 mL) +/- 5 percent dextrose. +/- Magnesium Sulfate 2g. The banana bag contains a combination of 100 mg - [Alcohol Withdrawal Prophylaxis](https://www.timeofcare.com/alcohol-withdrawal-prophylaxis/) - -Alcohol level on admission _____ -CIWA protocol -Long-acting Benzo, scheduled. Chlordiazepoxide (Librium) 25 to 100 mg q6h for one day, followed by 25 to 50 mg q6h for an additional two days. May use 25mg q12h instead q6h. -Short-acting Benzo, prn: Ativan 0.5-1mg q4h, prn -Banana bag (NS IVF with multivitamin, Thiamine, and Folate added). Multivitamin tablets daily - [The Gamma Gap](https://www.timeofcare.com/the-gamma-gap/) - The Gamma Gap is the difference between total serum protein and albumin. It is frequently used clinical screening measure for both latent infection, malignancy, Multiple Myeloma. "The gamma gap is an independent risk factor for all-cause mortality at values as low as 3.1 g/dl (in contrast to the traditional definition of 4.0 g/dl), and is - [Seizures](https://www.timeofcare.com/seizures/) - Todd's Paralysis Post-Ictal Paralysis / Post-Seizure Paralysis / Post epileptic paralysis https://www.ninds.nih.gov/disorders/all-disorders/todds-paralysis-information-page - [Opioid Conversions](https://www.timeofcare.com/opioid-conversions/) - This Opioid Conversion page helps you to convert between different opioids. It also helps when seeking equivalent dosages. - [Opioid Conversion, Expanded Table](https://www.timeofcare.com/opioid-conversion/) - Medication Route Onset of Action Duration of Action Usual Dosing Interval Equi-Analgesic Dosing Morphine (IR) (MSIR®, Roxanol®, various) PO 30 to 60min 3 to 6hr 3 to 6hr 30mg PO IV 5 to 10min 3 to 6hr 3 to 6hr 10mg IV SC 15 to 30min 3 to 6hr 3 to 6hr 10mg IM/SC - [Procalcitonin can help in Cellulitis](https://www.timeofcare.com/procalcitonin-can-help-in-cellulitis/) - Serum Procalcitonin Level Reflects the Severity of Cellulitis The following study in the Annals of Dermatology in 2016 shows that measuring Procalcitonin levels in patients with cellulitis can be helpful. The study results say, "Procalcitonin, WBC, and CRP showed a positive correlation with body temperature. In addition, procalcitonin, WBC, ESR, and CRP showed a positive ## Pages - [TIME OF CARE Medicine Notebook](https://www.timeofcare.com/) - Time of Care OUTpatient Adults Book. Time of Care OUTpatient Peds Book. Time of Care INpatient Adults Book. Time of Care INpatient Peds Book. Time of Care Differential Diagnosis Book. Time of Care Procedures Checklists. About Time of Care How I started Time of Care I started Time of Care during residency to serve as my - [Resources](https://www.timeofcare.com/resources/) - www.ncbi.nlm.nih.gov Free Clinician Consultation Center from UCSF. STDCCN.org (STD Clinical Consultation Network sponsored by the CDC, provides help to providers). phototherapyguidelines.com. nobaproject.com (Free Psychology resources) Color Atlas of Family Medicine (this is a textbook you can find on Amazon). https://www.drnajeeblectures.com/ Who owns Copyrights Within the UC system? AAFP, Board Preparation: http://www.aafp.org/test/fpcomp/index.html Free Medical Images. Imaging. Reading. - [Forms & Charts](https://www.timeofcare.com/forms/) - Common Forms Diabetes Blood Glucose Monitoring Sheet Hypertension Blood Pressure Monitoring Sheet AHA Blood pressure log Blood Pressure Monitoring Sheet - Spanish Agenda Setting Agenda Setting Form. Headache Headache diary. Depression and Anxiety Forms PHQ-9 Depression Screening GAD-2 & GAD-7 Screening for Anxiety Disorders Edinburgh Postnatal Depression Scale Mental Status / Dementia Forms The Montreal - [Spanish / Español](https://www.timeofcare.com/spanish/) - Want to learn medical Spanish? That's what I'm doing. You may find the following resources helpful. - [ACLS](https://www.timeofcare.com/acls/) - This uptodate.com article has ACLS Algorithms. Contraindications for Nitroglycerin during ACS. Severe bradycardia. Tachycardia. Hypotension Phosphodiesterase inhibitors within the past 24 to 48 hours (often used for erectile dysfunction) Right ventricular infarction - often presents as inferior wall STEMIs. Get right-sided 12-lead ECG. If RV infarction is present, nitrates are contraindicated. If NTG doesn't relieve - [The Most Common Outpatient Conditions](https://www.timeofcare.com/the-most-common-outpatient-conditions/) - Cardiovascular Essential Hypertension. Hyperlipidemia. Chest Pain: Chronic Stable Angina / Stable Ischemic Heart Disease. Chest pain: ACS in the clinic. Congestive Heart Failure. Syncope & Presyncope. Palpitations. Atrial Fibrillation & Atrial Flutter. Coronary Artery Disease. Respiratory System, ENT, & Ophthalmology Asthma. Chronic Sinusitis. Acute Rhinosinusitis. Acute pharyngitis. Allergic rhinitis. Otitis media. COPD. OSA. Chronic Cough. - [Pharmacy and Therapeutics](https://www.timeofcare.com/pharmacy/) - List of Pharmacy and Therapeutics articles. - [Differential Diagnosis](https://www.timeofcare.com/differential-diagnosis/) - Differential Diagnosis of the Top 100 Complaints in Primary Care How to Come Up with a Differential Diagnosis 5 Steps to generating a differential diagnosis. The Differential Diagnosis Grid To come up with a thorough differential diagnosis, use the differential diagnosis grid. Use an anatomic framework plus a Mnemonic like CASE DIAGNOSED! or VINDICATED - [Quick Medical Reference](https://www.timeofcare.com/quick-medical-reference/) - Parameter Normal Range, Formula, etc Normal Urine output (adult): 0.5 ml/kg/hr to 1 ml /kg /hr Normal Urine output (infant): 2ml / kg / hr Ounce, Tablespon, and Teaspon conversions: 1 tsp = 5ml 1 tbsp = 3 tsp = 15 ml 1 oz = 30ml Blood Pressure CO x SVR = BP Cardiac - [The Acid-Base Disturbances Page](https://www.timeofcare.com/the-acid-base-disturbances-page/) - [Book Chapter in Time of Care](https://www.timeofcare.com/bookchapter/) - Time of Care is designed to create content to help providers at the time of care. Each book chapter is made up of three main sections: Diagnosis, Treatment, and Background. The chapters are arranged in a way that most physicians think when a patient is in front of them. This happens to be also how most - [The 25 Most Common Inpatient Conditions](https://www.timeofcare.com/the-most-common-inpatient-conditions/) - According to the 20-80 rule (the Pareto principle), if you master these conditions, you would have mastered about 80% of the conditions you would see in a hospital setting! Cardiovascular 1. Atrial Fibrillation with RVR. 2. Acute Coronary Syndrome. 3. Acute Decompensated HFrEF. 4. Syncope and presyncope. 5. Stroke(CVA) or TIA. 6. Venous Thromboembolism (VTE): - [Hospital Quick Reference](https://www.timeofcare.com/hospital-quick-reference/) - Medications, etc Transfusion. DRMC Empiric Therapy for Hospitalized Patients. Antibiotic Duration by Disease State Antibiotic Coverage Comfort or PRN Medications for adults. Medications for Treatment of Constipation Common Psyche-Neuro Meds in the Hospital Antacids and Anti-gas Meds. Monoarthritis. Evaluation Tools NIH Stroke Scale Schedule, Tips, and Work Sheets Inpatient List, Template (Excel) In-Patient Months: - [Less Common Inpatient Conditions](https://www.timeofcare.com/more-common-inpatient-conditions/) - [INpatient Adults Book](https://www.timeofcare.com/inpatient-adults-book/) - The Most Common Inpatient Conditions. - [Direct Primary Care (DPC) Resources](https://www.timeofcare.com/direct-primary-care-dpc/) - Direct Primary Care dpcboca.com/about/ Resources from the AAFP DPC: An Alternative to Fee-for-Service Direct Primary Care Coalition dpcare.org - [Acute Salpingitis](https://www.timeofcare.com/acute-salpingitis/) - A 20-year-old female comes to the clinic with a 3-day history of progressively worsening abd. pain. LMP was 5 days ago. She endorses nausea and vomiting. PE: T=38.5°C. Lower quadrant abd. pain + mild rebound. Vaginal exam shows a mucopurulent cervical discharge, tenderness with cervical motion, and right adnexal fullness. The uterus is normal in - [Ulnar Neuropathy (Ulnar Nerve Entrapment)](https://www.timeofcare.com/ulnar-neuropathy/) - Background Ulnar nerve entrapment is the 2nd most common neuropathy of the upper extremity. Median nerve entrapment the carpal tunnel is the most common. Diagnosis H&P Risk Factors: Activities that involve repetitive or prolonged wrist extension e.g. cycling, playing catcher in baseball. Common presentation: 35-year-old male with wrist discomfort and sensory changes in the 4th and - [INpatient Peds Book](https://www.timeofcare.com/inpatient-pediatrics-book/) - [OUTpatient Adults Book](https://www.timeofcare.com/outpatient-adults-book/) - [OUTpatient Peds Book](https://www.timeofcare.com/outpatient-pediatrics-book/) - [INpatient Books](https://www.timeofcare.com/inpatient-assessment-and-plans/) - ADULT INpatient Book PEDIATRICS INpatient Book - [OUTpatient Books](https://www.timeofcare.com/outpatient-assessment-and-plans/) - ADULT OUTpatient Book PEDIATRICS OUTpatient Book - [Medical Checklists Save Lives](https://www.timeofcare.com/medical-checklists-save-lives/) - Checklists and quick references can improve diagnosis. http://www.aafp.org/afp/2016/0915/p426.html Atul Gawande advocates surgical checklist and they have been shown to save lives. See this article. http://www.who.int/bulletin/volumes/86/7/08-010708/en/ https://www.hsph.harvard.edu/news/press-releases/south-carolina-post-surgical-deaths-surgical-safety-checklist/ Atul Gawande, The Checklist Manifesto: How to Get Things Right. See the book on Amazon. Why did I miss the diagnosis? Some cognitive explanations and educational implications. https://www.ncbi.nlm.nih.gov/pubmed/10536619 Developing - [Domain Name Change](https://www.timeofcare.com/domain-name-change/) - Duplicate the site using the Wordpress app called Duplicator – WordPress Migration Plugin, By Snap Creek. You can also Duplicate Manually and copy the content into another folder and create a new database and copy the files to it. If you duplicated another way, use the plugin called "Velvet Blues Update URLs" update your URLs on the pages - [About TimeOfCare.com](https://www.timeofcare.com/about/) - Mission: To empower health care providers (physicians, residents, physician assistants, nurse practitioners) to provide fast, efficient, and excellent health care in the outpatient (clinic) and inpatient setting. Vision: We envision a comprehensive resource that is providing evidenced-based assessment and plans for 99% of diagnoses encountered in the outpatient and inpatient setting, in a format that - [Pediatric Emergencies](https://www.timeofcare.com/pediatric-emergencies/) - [Rating Strength of Evidence in Medical Publications](https://www.timeofcare.com/rating-strength-of-evidence-in-medical-publications/) - Assigning Levels of Evidence to references The AAFP createed and uses the SORT taxonomy. SORT stands for Strength of Recommendation Taxonomy Am Fam Physician. 2004 Feb 1;69(3):548-556. http://www.aafp.org/afp/2004/0201/p548.html Several primary care books, like the 5-Minute Consult, use the SORT Taxonomy from the American Academy of Family Physicians (http://www.aafp.org/afp/20040201/548.html) to assign level of evidence to their individual references. Also - [Book Chapter Of Other Books](https://www.timeofcare.com/book-chapter-of-other-books/) - Organizing a book Chapter Definition and Epidemiology Etiology and Pathophysiology Risk Factors Clinical Manifestations/ Presentation and Associated Conditions. Pertinent H&P findings Associated Conditions. Diagnosis and Workup. DDx Diagnostic studies Treatment & Prevention Non-pharmacological Therapies Pharmacological Therapies Referrals Follow up Care & Prognosis References: Am Fam Physician. 2011 Dec 1;84(11):1245-1252. http://www.aafp.org/afp/2011/1201/p1245.html Cecil Essentials of Medicine Pocket Medicine 5 Minute Consult. - [ite](https://www.timeofcare.com/ite/) - 2016IteCritique 2015IteCritique 2014IteAnswers 2013IteAnswers - [DISEASE SPECIFIC HISTORY TEMPLATES](https://www.timeofcare.com/history-templates/) - Templates for Disease Specific HPI and other pertinent histories. History includes both present and past pertinent history. Templates that are coming soon. Preoperative clearance Chest pain SOB Diabetes HTN Top 20 diagnosis in primary care. COMPLETED HPI TEMPLATES - [Obgyn](https://www.timeofcare.com/obgyn/) - Ob-gyn category page Gyne topics with fertility expert Dr. Abdallah. Textbook: Clinical Gynecologic Endocrinology and Infertility, by Marc Fritz, MD and Leon Speroff, MD Publisher: Lippincott Williams & Wilkins; Publication Date: 2011 Work up of Infertility in Males and Females (Aug 11) Endometriosis (Aug 15) Thyroid disease (Hypothyroidism) and intertility (Aug 18) Fibroids / Leiomyomas (Aug - [Notes](https://www.timeofcare.com/notes/) - Welcome to the Notes Page - [Medical Mnemonics](https://www.timeofcare.com/mnemonics-medical/) - MEDICAL MNEMONICS AND MEMORY DEVICES - [Swim](https://www.timeofcare.com/swim/) - Treading Water - [Interests and Elective Options](https://www.timeofcare.com/interests-and-elective-options/) - Counseling: Cognitive Behavioral Therapy (CBT), Motivational Interviewing (MI) Nutrition Counseling Weight loss and maintenance of health. Ultrasonography Dermatology - [Incomplete Assessments and Plans](https://www.timeofcare.com/incomplete-assessments-and-plans/) - Incomplete A&Ps for both clinic and hospital setting - [Inpatient A/P, Adults](https://www.timeofcare.com/inpatient-ap-adults/) - Dr. Wiprud's admit orders: http://www.aafp.org/fpm/2006/0900/fpm20060900p49-rt1.pdf Assessments and plans completed or almost - [Procedure Notes](https://www.timeofcare.com/procedurenotes/) - Insert procedure notes on this page. Coming soon! - [Thyroid Function Tests, Explained Clearly](https://www.timeofcare.com/thyroid-function-tests-explained-clearly/) - This page explains the thyroid function tests clearly. http://www.thyroid.org/thyroid-function-tests/ - [Rare/Interesting Topics](https://www.timeofcare.com/rareinteresting-topics/) - Disease Sample Board Case Thyrotoxic Periodic Paralysis: 31-year-old Hispanic male with a PMH of HTN (on Bystolic) comes in with acute onset paralysis. Potassium 1.6 on admission. Monomorphic V-tach > V-fib in the ED > successfully shocked. Discovered to have thyrotoxicosis. Had received amiodarone, so couldn't do thyroid scan. Saw endocrine and nephrology in ICU. - [Jenkins, Colorectal Surgery](https://www.timeofcare.com/jenkins/) - [Inpatient A/P, Peds](https://www.timeofcare.com/inpatient-ap-peds/) - [Outpatient A/P Peds](https://www.timeofcare.com/outpatient-ap-peds/) - Outpatient A/P, Peds - [Outpatient A/P, Adults](https://www.timeofcare.com/outpatient-ap-adults/) - Commonly encountered outpatient assessments and plans for adult patients. - [Physicians in Media](https://www.timeofcare.com/physicians-in-media/) - andrewlammd.com KevinMD.com - [Psychiatry](https://www.timeofcare.com/psychiatry/) - [Search Results](https://www.timeofcare.com/search_gcse/) - Search Results - [Orders](https://www.timeofcare.com/orders/) - [Geriatrics](https://www.timeofcare.com/geriatrics/) - Geriatrics Page - [Celebrity Diseases](https://www.timeofcare.com/celebrity-diseases/) - Sjogren's - Venus Williams Melanoma - Spread to the liver and brain - President Carter Multiple Sclerosis - Anne Romney Lupus - Selena Gomez; Toni Braxton ADHD - Simone Biles http://www.celebzen.com/9-celebrities-with-autoimmune-diseases/2/ - [Clinic Quick Reference](https://www.timeofcare.com/clinic-quick-reference/) - Agenda Setting Form (Edit as needed. Got this form from Dr. Saguil) - [Archives](https://www.timeofcare.com/archives/) - [Common Medications](https://www.timeofcare.com/common-medications/) - Treatment for Constipation Polyethylene Glycol Miralax - Polyethylene glycol 3350 Golytely Lactulose Magnesium Hydroxide (Milk of Magnesia) Docusate sodium (Colace / Docusoft) Magnesium Citrate Senna with docusate Lubiprostone: Chloride channel activator used to tx IBS-C Linaclotide: cGMP activator used to treat IBS-C - [Tips](https://www.timeofcare.com/tips/) - Don't combine Narcotics and Benzos. Dr. D. Medicare eligibility for home oxygen therapy is based on oxygen saturation. To qualify for continuous long-term oxygen therapy the patient must have a PaO2 less than or equal to 55 mm Hg or an SaO2 less than or equal to 88 mm Hg. SIADH syndrome "The syndrome of - [Clinic Issues](https://www.timeofcare.com/clinic-issues/) - Filling out Forms Some forms that pts bring to be filled out require you to answer questions such as how much they can lift, how much sitting or standing they can do etc. Refer those patients to Occupational Therapy. They will actually do tests to answer those questions accurately. - [The BioPsychoSocioSpiritual Model of Medicine](https://www.timeofcare.com/biopsychosociospiritual-model-of-medicine/) - http://www.ncbi.nlm.nih.gov/pubmed/18441628 AAFP and the Bio-Psychosocial Model The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry The BioSpychoSocioSpiritual Model can be shortened to Bio-PsychoSocial model. In this case, spiritual life is viewed as an aspect of social life. - [Medical Images](https://www.timeofcare.com/medical-images/) - In public Domain ** Images by the U.S government are automatically public domain. Probably those of state governments as well. http://www.cdc.gov/media/subtopic/images.htm http://phil.cdc.gov/phil/home.asp commons.wikimedia.org (simply type and search the disease or condition. E.g. Tinea Corporis) http://www.public-domain-image.com/ - [Intubation Tips](https://www.timeofcare.com/intubation/) - Scissoring the Mouth The index finger (of your right hand) goes first and pulls the upper teeth upwards and the thumb goes second and pushes the bottom teeth down to scissor or pry the mouth open. You open towards the molar section (at the corner) of the mouth--not in the middle--to get the - [Intraining Exam](https://www.timeofcare.com/intraining-exam/) - Here are the questions and answers I want combined into separate PowerPoints. If you choose to do it, combine the first five questions and answers in the 2014 exam and show me the powerpoint for approval before moving forward to do more. Here is a link to view the 2013 Questions and Answers and the - [Procedures](https://www.timeofcare.com/procedures-2/) - UCR Fam Med Required Procedures - [Routine Obstetric Visits](https://www.timeofcare.com/routine-obstetric-visits/) - Routine Obstetric Visits First Obstetric Visit Prenatal Labs Pregnancy Risk Assessment - [Healthy Lifestyle](https://www.timeofcare.com/healthylifestyle/) - The right diagnosis is key. *** The problem people who gain weight have is not food, it's not weight, it's the lifestyle. If you don't diagnose the problem correctly, you will apply the wrong treatment to it. 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