COMMUNITY-ACQUIRED PNEUMONIA: Infection of the Lower Respiratory Tract CAUSES Strep. Pneumonia Gram (+) H. influenzae/M. catarrhalis lancet-shaped diplococcus in chains Gram (-) coccobacillus, encapsulated Mycoplasma pneumonia / Legionella pneumophilia Chlamydophila pneumonia Gram (-) bacilli Atypical’ bacteria with no cell wall SYMPTOMS Abrupt onset common in smokers, in young adults with prodrome of -Fever with chills COPD, alcoholics fever, chills, headache, sore -Chest pain throat, malaise, dry cough -Productive “rust(mucoid) colored" cough -Transmitted by aerosolization, -Malaise incubation period of 2-4 weeks -Sre throat -Rhinorrhea -Shortness of breath GOAL OF THERAPY RISK FACTORS Assess severity of pneumonia to determine General appropriate initial treatment setting -Altered levels of consciousness (sleep, intoxication Relieve symptoms such as cough, pleuritic chest pain, sputum production and/or dyspnea (alcohol or other CNS depressants), neurological diseases (stroke or seizure, dementia) Prevent morbidity cough/gag reflexes, endotracheal intubation, chest tubes Prevent mortality in nonpalliative patients -Impaired cellular or humoral immunity malnourished Prevent transmission Prevent recurrence elderly, patients on chronic corticosteroids or other immunosuppressed, HIV/AIDS, cancer -Impaired mechanical defenses smoking, impaired -Chronic debilitating diseases asthma, CHF, COPD, cerebrovascular disease, chronic kidney disease, liver disease DIAGNOSTIC TEST CURB 65: C – Confusion (1pt) U—(BUN) >7mmol/L (1pt) R—RR > or = 30/min (1pt) ICU B—BP, <90/ ≤60 (1pt) Age ≥ 65 yrs (1pt) PSI: LAB RESULTS CURB Scores: - 0-1: outpatient - 2: inpatient - 3: inpatient – Chest X-Ray Right lobe unilateral or bilateral infiltrates or Interstitial pattern with Atypical’ bacteria - 4 and 5: ICU Gram stain/Cultures Adequate specimen: >25 Neutrophils Slow onset, then high fever, CNS effects like H/A, obtundation, seizures, malaise, non-productive cough, hyponatremia -recent travel, age, chronic illness Risk Factors for PRSP (penicillin resistant strep pneumonia) -Age >65 years -Beta-lactam therapy within the past 3 months -Alcoholism - Immune-suppressive illness or medications -Multiple medical comorbid conditions -Exposure to a child in a day care center -Score of 90 or less = outpatient -Score of >91+ = admit to hospital Inpatient Treatment: Non-ICU Give B-lactam + Macro/Doxy or Respiratory FQ x 510days -FQ: Levofloxacin 750mg po daily or Moxifloxacin 400mg po daily -B-lactam (oral): Azithromycin 500mg x 1 day, then 250mg po daily -B-lactam (IV): Cefuroxime 750-1500mg IV q8h Ceftriaxone 1-2g IV daily Cefotaxime 1-2g IV q6h Ampicillin 1-2g IV q6h Ertapenem 1g IV q24h Outpatient No Risk Factors/Co-morbidities Empiric Therapy: -Macrolides or Doxycycline: -Azithromycin 500mg x 1, then 250mg daily -Clarithromycin 500mg po bid or clarithromycin ER 100mg po daily -Doxycycline 200mg po once, then 100mg po bid or 1000mg po bid -Duration of therapy: 5-7 days MONITORING Effectiveness -Decrease fever to 37.7 (give acetaminophen) -Decrease Sx (cough, fatigue chills etc...) -CURB score to <1 -HR ≤100BPM -RR ≤24 BPM -Systolic BP ≥ 90mmHG -Arterial O2 sat ≥90% -Normal LOC <10 Epithelial cells per LPF TREATMENT OPTIONS Inpatient Treatment: ICU Give B-lactam IV + Macro or Respiratory FQ x5-14 days -B-lactam (IV): Cefuroxime 750-1500mg IV q8h Ceftriaxone 1-2g IV daily Cefotaxime 1-2g IV q6h Ampicillin 1-2g IV q6h Ertapenem 1g IV q24h -Macrolides: azithromycin 500mg x1 day then 250mg po daily, or clarithromycin 500mg po bid, clarithro-ER 1000mg po daily -FQ: Levofloxacin 750mg po daily or Moxifloxacin 400mg po daily Outpatient with Risk Factors/ Co-morbidities Empiric therapy: B-lactam + macrolide (or doxy as alternative) OR Resp FQ -Levofloxacin 750mg po daily -Moxifloxacin 400mg po daily -B-lactam PO: Amoxicillin 1g po BID-TID, or Amox/clav 875/125mg po BID -B-lactam IV: Cefuroxime 750-1500mg IV q8h, or Ceftriaxone 1-2g IV daily -Macrolide: Azithromycin 500mg PO/IV daily -Duration of therapy: 5-7 days If MRSA -> Add Vancomycin or Linezolids to current therapy -Vancomycin 25-30mg/kg IV once then 15mg/kg IV q8-12h -Linezolid 600mg PO/IV BID for at least 14 days If Pseudomonas: Pip/Tazo, meropenem, or cefepime NON-PHARM -Rest -Smoking cessation -Avoid second-hand smoke -Fluids to stay hydrated -Cold compress if they have fever Safety *side effects of all recommended Rx- name them- presence – time frame (anytime) *allergic reactions to recommend Rx (hives, rash, anaphylaxis – time frame (anytime) URINARY TRACT INFECTION: infection of the upper or lower urinary tract CAUSES mostly E.Coli Others: staphylococcus, klebsiella pneumoniae SYMPTOMS GOALS OF THERAPY DIAGNOSTIC TEST Cystitis: Lower UTI Asymptomatic Polynephritis: Upper UTI -Relieve symptoms in acute • Urinalysis -do not treat infection (Bladder) (Kidney) • Urine culture Voided urine with ≥10^8 cfu/L of -All lower UTI symptoms -Frequency of urination • Sensitivity -Prevent complications of same -Urgency of urination -CVA tenderness untreated acute infection organism +/- pyuria and no S/S (costovertebral angle -Dysuria (pain upon -Prevent recurrent infection -No Treatment in Elderly tenderness) urination) -Prevent pyelonephritis in -Flank pain -Nocturia (peeing at night) pregnancy -Rigors -Fever (rare) -Fever, chills RISK FACTORS LAB RESULTS 1.Obstruction 5.Men Macroscopic urinalysis Tumors, strictures, stones, etc This prevents Anal intercourse, benign prostatic hyperplasia – Appearance Cloudy, turbid, smelly flushing of urine (BPH), congenital disorders – Specific gravity May be a bit dilute BPH causes increased prostate gland – pH > 4.5 to 8.5 2.Post-void Residual Congenital is a structural abnormality – Protein Common finding Neurological diseases, drugs, etc Unable to – Glucose Should be (-) empty bladder 6.Other – Nitrite (+) if gram (-) bacteria -Pregnancy, immunosuppression – Leukocyte (+) if pyuria is present 3.Vesico-Ureteral Reflux -Diabetes Sugar spills into urine, providing Congenital malformation and pregnancies nutrients to bacteria Microscopic urinalysis Reflux causes urine from bladder to go back to -Menopause – WBC > 5/hpf (or >10/mm3) ureter and kidney Estrogen protects women against UTIs; – Casts (+) if pyelonephritis therefore, lose estrogen = risk increases – RBC trauma, catheter 4.Women Decrease in lactobacilli results in a less acidic Rectum is close to vagina Introduces organisms vagina – Epithelial cells <25 cells/hpf into vagina and bladder – Bacteria (+) Treatment Cystitis Uncomplicated Mild to Moderate Complicated UTI Mild to Moderate Pyelonephritis -1st Line: SMX/TMP po x 3 days, or TMP po x 3 -1st Line: Nitrofurantoin PO x 7-10 days, or -1st Line: Ciprofloxacin or levofloxacin PO x 7-14 days, or nitrofurantoin po x 3 days, or fosfomycin SMX/TMP x 7-10 days, or TMP x 7-10 days, or days tromethamine po x 1 dose ciprofloxacin or levofloxacin x 7-10 days -2nd Line: Amoxicillin/Clavulanate PO x 10-14 days, nd -2 Line: Ciprofloxacin, norfloxacin, or -2nd Line: Amox/Clav PO x 7-10 days, or cephalexin or SMX/TMP PO x 10-14 days, or Trimethoprim x levofloxacin po x 3 days, or cephalexin po x 7 days PO x 7-10 days, or cefexime PO x 7-10 days 10-14 days Recurrent Infection NON-PHARM - Increase water intake - avoid spermicidals -avoid scented products -Keep area clean and dry -Avoid wearing thigh pants -wear cotton based underwear MONITORING Effectiveness -Reduce/Eliminate Sx (pain, frequent urination, dysuria, nocturia) -Cure Infection -Reduce/eliminate fever if present -Adherence to med- not skipping dose, finishing course- presence – (timeframe within a few days) Safety *side effects of all recommended Rxname them- presence – time frame (anytime) *allergic reactions to recommend Rx (hives, rash, anaphylaxis – time frame (anytime) C. DIFFICILE (DIARRHEA) CAUSES -Diarrhea associated with C. difficile (CDI) Gram (+), anaerobic, spore forming bacilli - Antibiotics associated diarrhea (ADD) GOAL OF THERAPY SYMPTOMS ADD -Prevent mortality Severe CDI -Diarrhea: mild, 3-4 -Cure infection Pseudomembranous Colitis (PMC) stools/day -Alleviate symptoms -Red, inflamed mucosa and areas -Afebrile, -Prevent complications with white exudate (pseudo -No abdominal pain -Minimize risk of recurrence membranes) on large intestine -WBC is not elevated -Prevent transmission of CDI -Underneath pseudo membranes = -Minimize unnecessary use of Necrosis of mucosal surface antimicrobials -Patient education Toxic Megacolon Minimize adverse drug reactions Dilation of colon; bowels expands and perforates CDI -Presence of diarrhea (3 liquid or loose stools/day) -Fever, rigors, chills, malaise -Increased HR and RR, Decreased BP -Watery diarrhea (mild to profuse, distinct smell) -Blood may present -Loss of appetite, nausea, abdominal pain, tenderness, cramping -Severe infection? Pseudomembranous colitis, colonic ileus, toxic megacolon -Increased SCr (this can be used as a marker) Lab Values -Increased WBC count o Severe: > than 15e109 L o Fulminant: > than 50e109 L -Increased neutrophils, band neutrophils (immature neutrophils), lactate, leukocytes, -Decreased albumin RISK FACTORS - Advanced age - Prolonged hospital stays - GI surgery and inflammatory bowel diseases Immunosuppression, organ transplant, hemotherapy, CKD, exposure to infant carrier or infected adult Gastric acid suppression -Clavulanate: stimulates bowel motility -Erythromycin: stimulates bowels -Broad-spectrum antibiotics: alters intestinal flora (Clindamycin, Cephalosporins, Fluoroquinolones) CLASSIFICATION OF CDI Non-severe -WBC = or < 15 SCr < 133 umol/L Severe -WBC > 15 -SCr > or = 133 umol/L -Pseudomembranous colitis Fulminant Hypotension, shock, ileus, or megacolon present -Acute= <14 days in duration -Chronic= >28 days in duration -Recurrence of CDI symptoms between 2 and 8 weeks Treatment Non-Severe Disease: -Vancomycin 125 mg QID PO × 10 days or -Fidaxomicin 200 mg BID PO × 10 days or (if vancomycin or fidaxomicin unavailable) -Metronidazole 500 mg TID PO × 10 days Severe Disease: -Vancomycin 125 mg QID PO × 10 days or -Fidaxomicin 200 mg BID PO × 10 days Fulminant Disease: -Vancomycin 500 mg QID PO + Metronidazole 500 mg Q8H IV + (if ileus present) Vancomycin 500 mg in 100 mL saline Q6H PR as retention enema DIAGNOSTIC TEST Bristol Stool chart (type 6/7) unless ileus is suspected *Important to test only if clinical presentation is consistent with CDI to avoid detecting colonization Nucleic acid amplication test (NAAT) aka PCR -Looks for c.diff toxin gene -Limitation: cannot detect between active infection vs. Asymptomatic carrier -Should not be used alone for diagnosis Toxin A + B enzyme immunoassay (EIA): can be used as standalone test for dx Glutamate dehydrogenase (GDH) screening -Detects for GDH (enzyme produced by c.diff) -Does not detect toxins, do not use alone Treatment for Recurrence 1st Recurrence: -If metronidazole used for initial episode: Use Vancomycin 125 mg QID PO × 10 days -If vancomycin used for initial episode: Use Fidaxomicin 200 mg BID PO × 10 days -If vancomycin standard regimen used for initial episode: Use Vancomycin tapered and pulsed regimen: -Vancomycin 125 mg QID PO × 10–14 days -Vancomycin 125 mg BID PO × 7 days -Vancomycin 125 mg once daily PO × 7 days -Vancomycin 125 mg Q2–3 days PO × 2–8 wk 2nd Recurrence: -Vancomycin tapered and pulsed regimen -Vancomycin 125 mg QID PO × 10 days; followed by rifaximin 400 mg TID PO × 20 days or -Fidaxomicin 200 mg BID PO × 10 days 3rd Recurrence: As per second recurrence or Fecal microbiota transplantation NON-PHARM MONITORING Effectiveness *(reduction of symptoms -name them) Decrease and time frame *Adherence to med- not skipping dose, finishing course- presence – (timeframe within a few days) -Antimicrobial stewardship -Contact precautions (use gloves and gowns) -Hand hygiene: must be with soap and water; hand sanitizer is not effective against C. difficile spores -drink lots of fluids (electrolytes) Safety *side effects of all recommended Rx- name them- presence – time frame (anytime) *allergic reactions to recommend Rx (hives, rash, anaphylaxis – time frame (anytime) *Specific CDI monitoring points • GI: abdominal exam (daily) – bowel sounds, pain, distension – Bristol Stool Chart: stool frequency/volume/consistency – Diarrhea should be resolving within 4-6 days • Hydration status (daily) • Labs (daily) – CBC with differential, electrolytes (Na, K, Cl), SCr • Imaging: AXR or CT (if concern of ileus, megacolon, perforation) VULVOVAGINITIS: Goals of therapy Vulvovaginal candidiasis (VVC; yeast infection) -Candida albicans (80-90%) -C. glabrata (5-10%) -C. tropicalus (5%) -C. krusei (1%) Sx -itchy, Curd like, clumpy, white colour, erythema, swelling, minimal or no odour, dysuria, dyspareunia excoriation, fissures pH: <4.5 MD referral: 1st time; other CAUSES Bacterial vaginosis (BV) Trichomoniasis Gardnerella vaginalis or anaerobes (mycoplasmas) SYMPTOMS Sx-thin, copious amounts, grey or milky color, fishy smell -pH:5-6 MD referral Partner: no treatment necessary Trichomonas vaginalis Sx -itchy, strong fishy smell, Frothy Yellow green or off-white colour -pH: ≥6 MD referral -Partner: treat, even without screening or asymptomatic (avoid intercourse during treatment) complications Partner: treat only if symptomatic CLASSIFICATION RISK FACTORS NON-PHARM Often absent •More common if sexually active •Current or recent antibiotic use •Hormonal (pregnancy, oral contraceptives, hormone replacement) •Poorly controlled diabetes •Immuno-compromised (corticosteroids, chemotherapy, HIV) -Good genital hygiene -Avoid warm, moist environments -Avoid mechanical and chemical trauma -Apply cold compress to area MONITORING Effectiveness *(reduction of symptoms -name them) Decrease and time frame *Adherence to med- not skipping dose, finishing course- presence – (timeframe within a few days) Safety *side effects of all recommended Rx- name thempresence – time frame (anytime) *allergic reactions to recommend Rx (hives, rash, anaphylaxis – time frame (anytime) SPORT INJURIES Goals of therapy CAUSES -Trauma -Overuse of specific body parts (e.g., muscles or joints) -Environmental (e.g., heat stroke) SYMPTOMS Pain Swelling RISK FACTORS Improper technique Lack of poorly fitting protective equipment Training errors Acute injuries: ligament sprains and muscle strains -Sudden trauma -More likely to occur in contact sports Chronic injuries: Achilles tendonitis, bursitis, plantar fasciitis, shin splints, tennis elbow, stress fractures Repetitive movements “Terrible toos”--too fast, too frequent, too far NON-PHARM - Movement (if safe and possible) - Compression - Elevation ESA E: indicated for condition, most effective/drug choice, optimal dose, freq, duration, route, interaction affecting effectiveness MONITORING Effectiveness *(reduction of symptoms -name them) Decrease and time frame S: no contraindications, adverse drug reactions, DTP, interaction affecting safety, *Adherence to med- not skipping dose, finishing coursepresence – (timeframe within a few days) A: complexity of regimen, product availability, pt preferences (cost, regimen, dosage form, lifestyle, challenges) Safety *side effects of all recommended Rx- name them- presence – time frame (anytime) *allergic reactions to recommend Rx (hives, rash, anaphylaxis – time frame (anytime) LOW BACK PAIN and NECK PAIN CAUSES Back Pain: -mechanical -sprain/strain of muscles -deconditioning of musculature (exacerbated by age and use related deterioration of structures) -poor posture -inciting events (physical labour accidental injury such as workplace, motor vehicle) Goals of therapy Neck Pain: Motor vehicle collisions Assess RED Flags: (Low Back Pain): -Cauda equina syndrome (LBP): (Neck Pain): SYMPTOMS Low Back Pain: -Pain often present in back, buttock and legs - Radiating pain down legs may be present -Can be intermittent or constant but constant is quite rare -Often relieved by flexion or extension -Back (worst pain in back/buttock) or leg dominant (worst pain in legs -thigh, calf, ankle, foot) -Symptoms may be absent or lessened in first 24 hours Assess YELLOW Flags: (Neck Pain) -Duration of work absence Neck pain -Pain and stiffness sometimes extends to head, chest, shoulders, and arms. -Decreased range of motion -Headache, dizziness -Self-reported unexplained high-intensity pain and disability -Cancer -Spinal fracture or compression fracture -Autoimmune cause -Infectious cause -Neurological -Infection -Fracture -Tumor -inflammation -Prior history of absenteeism -High levels of self-reported functional disability -Self-report of extreme pain and constant pain in multiple body areas -History of prolonged sick listing after previous injuries RISK FACTORS Neck pain - Female -Younger age -Prior history of neck pain -Rear collision -Stationary vehicle -Severity of collision -Not being at fault -Monotonous work -Litigation (Australia legislation change reduced LBP Pregnancy: -Overweight -Previous history of back pain -Hormonal changes -Weight gain -Catastrophizing or a belief that pain and activity may potentially be disabling -Depression, anxiety or signs of post-traumatic stress (consider the Patient Health Questionnaire for Depression and Anxiety -Passive coping strategies, possibly manifesting as expectation of passive treatment rather than a belief that active participation will help (consider using the Pain SelfEfficacy Questionnaire -Avoidance of movement -History of previous musculoskeletal pain CLASSIFICATION OF PAIN Neck pain Low Back Pain: •Acute: (within hours) 1-4 weeks • Acute: < 4 weeks • Subacute: 4-12 weeks • Subacute: 4-12 weeks • Chronic: 6 months or more • Chronic: >12 weeks incidence compared to historical numbers) CORE tool (history) - Clinically organized relevant exam - Tool to help with Assessment and management of patients with back pain/ neck pain and triage patients to appropriate specialist intervention when needed NON-PHARM - Encourage patient to continue or resume activity and work as soon as tolerated Avoid unnecessary bedrest Encourage Exercise daily (E.g., walks, stretching) as tolerated Can use heating pad or cooling pad to help with pain relief DIAGNOSTIC TEST Physical Exam (back pain): Physical Exam (neck pain): - Observation of gait - Document range of motion -Standing and associate pain in the -Lying neck as baseline -Sitting -Observe gait -Sensation -Standing -Sitting -Radicular testing -Upper motor neuron screen Diagnostic Imaging: -Use only when red flags are present * -MRI or CT scan for low back pain -Plain radiographs for neck pain lasting for more than a few weeks ESA E: indicated for condition, most effective/drug choice, optimal dose, freq, duration, route, interaction affecting effectiveness MONITORING Effectiveness *(reduction of symptoms -name them) Decrease and time frame S: no contraindications, adverse drug reactions, DTP, interaction affecting safety, *Adherence to med- not skipping dose, finishing course- presence – (timeframe within a few days) - Can massage the area Can try yoga Relaxation therapy Cognitive behavioral therapy Mindfulness-based stress reduction Maintain healthy body weight (low back pain) A: complexity of regimen, product availability, pt preferences (cost, regimen, dosage form, lifestyle, challenges) Safety *side effects of all recommended Rx- name thempresence – time frame (anytime) *allergic reactions to recommend Rx (hives, rash, anaphylaxis – time frame (anytime) Pregnancy: - Water based exercises (LBP) GOUT and HYPERURICEMIA Goals of therapy -Terminate the acute attack of arthritis -Prevent recurrence -Prevent or reverse complications -Treat associated disorders CAUSES -MSU crystal deposits (needle shaped crystals) in joints, soft tissues (cartilage, tendon, bursa) Hyperuricemia (urate levels >360umol/L in females and >420umol/L in males) SYMPTOMS -Abrupt onset -Extreme pain -Inflammation of joint during the night or early morning -Tenderness, warmth, swelling, and redness -Max severity within 12-24hrs -Usually asymmetrical -Commonly affects lower limb; higher frequency in upper limb involvement in women Chronic Gout Tophi in polyarticular joint RISK FACTORS -Asymptomatic hyperuricemia (urate levels >360umol/L in females and >420umol/L in males) -Male and post-menopausal women -Alcohol (excessive consumption) -Obesity -Men at higher risk vs. women -High purine diet and drugs ->65 years old -Genetics LAB RESULTS Urate lowering therapy target: Drugs: -Cyclosporine -Cytotoxic chemotherapy -Diuretics (Thiazide and loop) -Ethambutol -Interferon + ribavirin -Levodopa -Niacin (nicotinic acid) -Pyrazinamide -Salicylates, low-dose -Tacrolimus -teriparatids Comorbidities: -Atherosclerosis -Diabetes (T2DM) -Hyperlipidemia -HTN -Urolithiasis history -Chronic kidney disease DIAGNOSTIC TEST Gout diagnosis calculator: https://www.mdcalc.com/acute-gout-diagnosis-rule - <360umol/L for most patients - <300umol/L if presence of tophi or chronic arthropathy (once resolved, target <360umol/L) Indications for chronic urate lowering therapy (hyperuricemia tx): Diagnosis of gout + one of the following below: - Tophi - Frequent gout flares (2 or more per year) - CKD ≥ Stage 2 (GFR 60-89mL/min) - Past urolithiasis (kidney stones) - Early age of onset (< 40 y.o) + very high serum urate (475umol/L) Treatment Acute Gout -1st Line: NSAIDs, Colchicine, or oral corticosteroid -Colchicine: 1.2 mg PO at first sign of flare, then 0.6 mg 1 h later; start prophylactic therapy 12 h later -Prednisone: 0.5 mg/kg daily × 5 days PO; Effective dose range: 20–50 mg/day -Naproxen: 750 mg STAT, then 500 mg BID × 4–5 days PO Definitive diagnosis (Gold standard): Identification of intracellular monosodium urate crystals in synovial fluid aspirate ACR/EULAR classification criteria: -Score of 8 or more is considered diagnostic for gout -3-part criteria: Clinical presentation (sx, timing, presence of tophi) Labs (crystal in joint aspiration, urate >360umol/L) Imaging (Xray/CT findings) Ultrasonography -Can detect MSU crystals -First choice during acute attack Hyperuricemia (Urate lowering tx) -1st Line: Allopurinol: Starting dose: 100 mg daily PO Usual: 300 mg daily PO titrated to urate levels; maximum: 800 mg daily PO; To improve tolerability, divide doses >300 mg to 2–3 times/day -Alternative: Febuxostat: Starting dose: 40 mg daily PO; may increase to 80 mg daily after 2 wk if serum uric acid levels remain above 360 µmol/L Prophylaxis START after Initiating Urate-Lowering Therapy -Initiation of uric acid lowering therapy can precipitate attacks due to mobilization of tophi Anti-inflammatory medications -1st Line: Colchicine: 0.6 mg once to twice daily PO x 3 – 6 months Alternatives: -Prednisone: < or = 10mg/d x 3 - 6 months -Indomethacin: 25 mg po BID x 3 - 6 months -Naproxen: 250mg po BID x 3 - 6 months Goals of Therapy -Decrease recurrence of gout attacks -Prevent the formulation of tophi -Prevention of progressive joint damage -Improve/maintain quality of life NON-PHARM -Topical ice application - Weight loss (maintain healthy BMI) -Exercise regularly -Quit smoking -Stay hydrated, drink lots of fluids -Avoid organ meats high in protein such as liver, and kidneys -avoid foods and beverages high in fructose and corn syrup -encourage low fat or non-fat dairy products and vegetables -Use assisted devices (eg: cane) ESA E: indicated for condition, most effective/drug choice, optimal dose, freq, duration, route, interaction affecting effectiveness MONITORING Effectiveness *(reduction of symptoms -name them) Decrease and time frame S: no contraindications, adverse drug reactions, DTP, interaction affecting safety, *Adherence to med- not skipping dose, finishing course- presence – (timeframe within a few days) A: complexity of regimen, product availability, pt preferences (cost, regimen, dosage form, lifestyle, challenges) Safety *side effects of all recommended Rx- name thempresence – time frame (anytime) OSTEOARTHRITIS CAUSES SYMPTOMS RISK FACTORS Wearing out of hyaline articular cartilage Joint pain Stiffness (<30 minutes, does not feel as bad in morning) Decreased range of motion Increasing age Increased BMI Genetics Poor diet Injury, malalignment, abnormal loading of joints *allergic reactions to recommend Rx (hives, rash, anaphylaxis – time frame (anytime) DIAGNOSTIC TEST X-Ray findings: White -> bone (due to calcium) Grey/black -> cartilage (due to no calcium) In OA: Clusters of white -> indicates cartilage destroyed and bone is touching and grinding against another bone Result: progressive fibrillation occurs due to loss of cartilage (cannot grow cartilage back) LAB RESULTS THOUGH PROCESS -Look at symptoms -Identify cause of disease -Identify risk factors -BMI, past injury? -Check vital signs -Check lab value -Write down goals of therapy CTC -Underline desired outcome -Find DTP based on NESA -Check if any contraindications -Check for drug interactions -Check patient allergies -Check patient preferences and concerns -Check social history -Make recommendation write full regimen (rationale for recommendation based on ESA) -Find alternative (pros and cons) write full regimen -MOA of prescribed Rx (generic, class) and recommended drugs -Write Non-pharm -Write Monitoring NON-PHARM Education Exercise (land-based aerobic, land-based resistance, aquatic) Weight management Physiotherapy RHEUMATOID ARTHRITIS CAUSES Autoimmune disorder ESA E: indicated for condition, most effective/drug choice, optimal dose, freq, duration, route, interaction affecting effectiveness MONITORING Effectiveness *(reduction of symptoms name them) Decrease and time frame S: no contraindications, adverse drug reactions, DTP, interaction affecting safety, *Adherence to med- not skipping dose, finishing course- presence – (timeframe within a few days) A: complexity of regimen, product availability, pt preferences (cost, regimen, dosage form, lifestyle, challenges) Safety *side effects of all recommended Rx- name them- presence – time frame (anytime) *allergic reactions to recommend Rx (hives, rash, anaphylaxis – time frame (anytime) SYMPTOMS Joint pain during activity/rest Morning stiffness (>30-60min) Pain (worst in morning) Inflammation, swelling, warmth Systemic symptoms are common RISK FACTORS Female Smoking Alcohol, coffee, oral contraceptives use Genetics Low socioeconomic status VITAL SIGNS DIAGNOSTIC TEST Diagnostic Criteria for RA Suspect RA If 6 points or more Points Joint involvement 0 1 medium/large joint 1 2-10 medium joints 2 1-3 small joints 3 4-10 small joints Serology Negative RF and ANA Acute-phase reactant Normal ESR and CRP Elevated ESR and CRP Duration <6 weeks >6 weeks Low positive RF and ANA High positive RF and ANA 5 >10 joints (at least 1 small joint) THOUGH PROCESS NON-PHARM -Look at symptoms -application of cold -Identify cause of disease compress -Identify risk factors -educate patient about -Check vital signs disease -Check table 3 CTC, for poor -emotional and prognostics? (for combo therapy) psychological support -Check lab value, CrCl? -physical rehabilitation -Active TB? Need for Vaccine? -encourage physical activity -Write down goals of therapy CTC (cardiorespiratory fitness, -Underline desired outcome flexibility, muscle strength, -Find DTP based on NESA ESA E: indicated for condition, most effective/drug choice, optimal dose, freq, duration, route, interaction affecting effectiveness S: no contraindications, adverse drug reactions, DTP, interaction affecting safety, MONITORING Effectiveness *(reduction of symptoms name them) Decrease and time frame *Adherence to med- not skipping dose, finishing course- presence – (timeframe within a few days) Safety -Check if any contraindications -Check for drug interactions -Check patient allergies -Check patient preferences and concerns -Check social history -Make recommendation write full regimen (rationale for recommendation based on ESA) -Find alternative (pros and cons) write full regimen -Does patient need folic acid or adjunct therapy? -MOA of prescribed Rx (generic, class) and recommended drugs -Write Non-pharm -Write Monitoring and neuromotor performance) A: complexity of regimen, product availability, pt preferences (cost, regimen, dosage form, lifestyle, challenges) *side effects of all recommended Rx- name them- presence – time frame (anytime) *allergic reactions to recommend Rx (hives, rash, anaphylaxis – time frame (anytime) ACNE CAUSES SYMPTOMS RISK FACTORS Multifactorial inflammatory disease centered on the pilosebaceous gland of the skin Follicular hyperkeratinization, microbial colonization with Cutibacterium acnes (aka propionibacterium acnes), sebum production, inflammatory mechanism involving both innate and acquire immunity Impaired skin barrier Genetic Diet Hormones Comedonal Acne Mild: Moderate: Severe: Only presence of Open or closed Several Inflammatory Multiple nodules, open of closed comedones present lesions (papules and cysts, and scarring comedones pustules) Few papules and Numerous papules pustules May contain a few and pustules nodules Conglobate acne Stress Pre-menstrual flares Use of oil products Local friction Improper cleansing of hair and skin Drug induced: oral contraceptives (especially with androgenic progestins e.g., levonorgestrel), androgens, barbiturates, corticosteroids, haloperidol, lithium, phenytoin, bromides, iodides Diet (controversial): high glycemic load diets may exacerbate acne; dairy ingestion is weakly associated with acne THOUGH PROCESS NON-PHARM ESA MONITORING -Look at symptoms E: indicated for condition, Effectiveness -Identify cause of disease -avoid picking, squeezing or most effective/drug choice, *(reduction of symptoms -Identify risk factors scratching inflammatory optimal dose, freq, duration, name them) Decrease and -Check vital signs lesions as it delays healing route, interaction affecting time frame -Check lab value and promotes scarring effectiveness -Write down goals of therapy CTC -use fragrance-free *Adherence to med- not -Underline desired outcome moisturizers S: no contraindications, skipping dose, finishing -Find DTP based on NESA -reduce psychological adverse drug reactions, DTP, course- presence – (timeframe -Check if any contraindications stress (e.g., meditation) interaction affecting safety, within a few days) -Check contraceptive ingredient -find ways to help boost on CPS if contains self-esteem A: complexity of regimen, Safety -Check for drug interactions -wear sunscreen or hat product availability, pt *side effects of all -Check patient allergies when under sunlight for a preferences (cost, regimen, recommended Rx- name -Check patient preferences and long period of time dosage form, lifestyle, them- presence – time frame concerns -patients should wash no challenges) (anytime) -Check social history more than twice daily with -Make recommendation mild soap or soapless *allergic reactions to write full regimen (rationale for cleanser recommend Rx (hives, rash, recommendation based on ESA) anaphylaxis – time frame -Find alternative (pros and cons) (anytime) write full regimen -MOA of prescribed Rx (generic, class) and recommended drugs -Write Non-pharm -Write Monitoring ROSACEA CAUSES Immune dysfunction Ultraviolet radiation and temperature extremes Vascular hyperreactivity/neurovascular degeneration --> flushing Microorganism Genetics TRPs (transient receptor potential channels) are activated and release substance P & CGRP --> pain/edema, vasodilation SYMPTOMS Flushing Persistent erythema (Centrofacial—forhead, nose, chin, cheeks) Telangiectasia Papules/pustules Phymatous changes Ocular manifestations RISK FACTORS Epidemiology: Women Ages between 30-50yo SUBTYPES OF ROSACEA Triggers Fair skinned northern European descent Affect people who blush/flush easily People with sensitive skin 1. Erythematotelangiectactic 2. Papulopustular rosacea (Vascular phase) rosacea (inflammatory phase) Persistent central Small papules and erythema; prolonged pustules, no flushing comedones Telangiectasia Burning, stinging, Roughness (scaling) flushing Burning and stinging Episodes of facial edema may be present 3. Phymatous rosacea Marked skin thickening and irregular nodularities of nose, chin, ears, forehead, or eyelids Rhinophyma – sebaceous gland hyperplasia & fibrous connective tissue 4. Ocular rosacea Water, blood-shot eyes Dry eyes, Irritation, Foreign body sensation Photophobia Blepharitis Conjunctivitis Scleritis Keratitis Eyelid irregularities inflammation Sunlight Heat Hot beverages Spicy foods, vinegar Alcohol Emotional stress Use of astringents (alcohol or acetone-based products) Drugs: CCBs, niacin, nicotinic acid, nitrates, topical corticosteroids, sildenafil, opioid analgesics, amiodarone, topical steroids, nasal steroids, high doses of VitB6 and VitB12 THOUGH PROCESS NON-PHARM ESA MONITORING -Look at symptoms E: indicated for condition, Effectiveness -Identify cause of disease -avoid triggers most effective/drug choice, *(reduction of symptoms -Identify risk factors -wear sunscreen (SPF 30 and optimal dose, freq, duration, name them) Decrease and -Check vital signs above) route, interaction affecting time frame -Check lab value -general skin care for effectiveness -Write down goals of therapy CTC sensitive skin (Fragrance*Adherence to med- not -Underline desired outcome free moisturizers, non-soap S: no contraindications, skipping dose, finishing -Find DTP based on NESA cleansers, avoid astringents) adverse drug reactions, DTP, course- presence – -Check if any contraindications -use of camouflage makeup interaction affecting safety, (timeframe within a few -Check for drug interactions -wear hat when exposed to days) -Check patient allergies sunlight for a long period of A: complexity of regimen, -Check patient preferences and time product availability, pt Safety concerns -stress reduction preferences (cost, regimen, -Check social history -Make recommendation write full regimen (rationale for recommendation based on ESA) -Find alternative (pros and cons) write full regimen -MOA of prescribed Rx (generic, class) and recommended drugs -Write Non-pharm -Write Monitoring dosage form, lifestyle, challenges) *side effects of all recommended Rx- name them- presence – time frame (anytime) *allergic reactions to recommend Rx (hives, rash, anaphylaxis – time frame (anytime) PSORIASIS CAUSES T cells migrate to the epidermal and dermal areas of skin and cause excess production of cytokines and proinflammatory factors SYMPTOMS RISK FACTORS Grey scaly plaques on skin Exogenous triggers Climate (cold, dry, sunny) Stress, infections, trauma, smoking, obesity, alcohol Drugs DIAGNOSTIC Body Surface Area (BSA): Mild= <5% BSA TEST Moderate= 5-10% BSA Severe= >10% BSA THOUGH PROCESS NON-PHARM -Look at symptoms Phototherapy with a 308 nm -Identify cause of disease excimer laser (if available) may -Identify risk factors be considered in scalp -Check vital signs, BMI? psoriasis that is resistant to -Check lab value topical therapies -Write down goals of therapy -smoking cessation CTC -encourage to maintain a -Underline desired outcome healthy BMI/ diet -Find DTP based on NESA -limit alcohol consumption -Check if any -reduce stress (e.g., try contraindications meditation) -Check for drug interactions -use an emollient** -Check patient allergies -Check patient preferences and concerns -Check social history -Make recommendation write full regimen (rationale for recommendation based on ESA) Lithium Beta blockers Anti-malarials NSAIDs ACE-inhibitors Abrupt withdrawal of corticosteroids Benzodiazepines, tetracycline, interferon-alpha Comorbid conditions Depression CV disease Hypertension Obesity Psoriatic arthritis Inflammatory bowel disease Multiple sclerosis Psoriasis Area Severity Index (PASI)50/70/100 ESA E: indicated for condition, most effective/drug choice, optimal dose, freq, duration, route, interaction affecting effectiveness MONITORING Effectiveness *(reduction of symptoms name them) Decrease and time frame S: no contraindications, adverse drug reactions, DTP, interaction affecting safety, *Adherence to med- not skipping dose, finishing course- presence – (timeframe within a few days) A: complexity of regimen, product availability, pt preferences (cost, regimen, dosage form, lifestyle, challenges) Safety *side effects of all recommended Rx- name them- presence – time frame (anytime) *allergic reactions to recommend Rx (hives, rash, anaphylaxis – time frame (anytime) -Find alternative (pros and cons) write full regimen -MOA of prescribed Rx (generic, class) and recommended drugs -Write Non-pharm -Write Monitoring ATOPIC DERMATITIS Abnormality of epidermal structure and function impairs skin barrier function, causing deficiency in SYMPTOMS ceramides (lipids) and filaggrin (proteins) Inflammatory skin condition characterized by pruritus, erythema and scale IgE associated but NOT defined as type 1 IgE-mediated reaction RISK FACTORS CAUSES TYPES OF ATOPIC DERMATITIS Age <5 years old Family history of atopic dermatitis Other atopic conditions Environmental factors (high sugar diet, small family size, high household education level, living in an urban setting) Mild Moderate Severe Localized patches of dry skin Localized patches of dry skin >30% of BSA Erythema Infrequent itching Pruritus THOUGH PROCESS -Look at symptoms - is quality of life affected? -Identify cause of disease -Identify risk factors -Check vital signs -Check lab value -Write down goals of therapy CTC -Underline desired outcome -Find DTP based on NESA -Check if any contraindications -Check for drug interactions -Check patient allergies -Check patient preferences and concerns -Check social history -Make recommendation write full regimen (rationale for recommendation based on ESA) -Find alternative (pros and cons) write full regimen -MOA of prescribed Rx (generic, class) and recommended drugs -Write Non-pharm -Write Monitoring Some impact on sleep, daily activities NON-PHARM Keep fingernails short Bathe once a day to remove crusts, irritants, and allergens; immediately following with moisturizers Use warm water, not cold or hot Wet-wraps can be used in significant flare-ups Persistent pruritus, extensive lichenification, crackling, oozing, and altered pigmentation Major impact on sleep and daily activities ESA E: indicated for condition, most effective/drug choice, optimal dose, freq, duration, route, interaction affecting effectiveness MONITORING Effectiveness *(reduction of symptoms name them) Decrease and time frame S: no contraindications, adverse drug reactions, DTP, interaction affecting safety, *Adherence to med- not skipping dose, finishing course- presence – (timeframe within a few days) A: complexity of regimen, product availability, pt preferences (cost, regimen, dosage form, lifestyle, challenges) Safety *side effects of all recommended Rx- name them- presence – time frame (anytime) *allergic reactions to recommend Rx (hives, rash, anaphylaxis – time frame (anytime) SCABIES AND LICE CAUSES Scabies and Lice exposure SYMPTOMS Head Lice: May be asymptomatic Wheals develop within 24hrs Lesions on scalp Pruritis Excoriations may be as visible as red papules around the ears, face, and neck Itching may be delayed until sensitization occurs after 4-6wks for patients without prior infestation Generalized rash, conjunctivitis, cervical lymphadenopathy Body Lice: Lesions on flanks, waist, neck, and axillae (trunk) Pruritis and skin reactions (parallel linear excoriations, red marks) Scabies: May take 4-6wks for symptoms to develop Erythematous papular rash, burrows Lesions are white-silvery linear or S-shaped burrows Inflammation, papules, vesicles, scales Intense itching 3-10wks later; particularly at night; itching can persist for wks Pubic Lice: Pruritis in pubic area Rust-colored specks on pubic hair Excoriations Bluish macules in the pubic area May also affect the eyelashes, eyebrows, beard, or axillae RISK FACTORS Head Lice (prevalence): Children 3-12 yo Females > males More cases in August to November Affects all SES levels No causal relationship between hygiene and nutritional status Body Lice: Poor hygiene Pubic Lice: Most common in 15-40 yo May be associated with coexisting STIs Head Lice: Scabies: Direct head-to-head/ hair-to-hair contact Pets are not vectors for human head lice Lice present on host’s scalp Body lice: TRANSMISSION Highly contagious Direct skin-to-skin contact Can be present in web spaces of fingers, front of wrists, sides of hands & feet, back of elbow, skin folds, underarms, breasts, groin, abdomen, back (Rarely above neck) Direct physical contact Contact with infested clothing, bedding, etc Lice present in the seams of clothing Pubic Lice: DIAGNOSTIC TEST THOUGH PROCESS Physical contact, sexual exposure to an infected person Visual detection of lice, and nits Scabies diagnosis should be made/confirmed by physician (dermatologist) NON-PHARM ESA MONITORING -Look at symptoms -Identify cause of disease -Identify risk factors -Check vital signs -Check lab value -Write down goals of therapy CTC -Underline desired outcome -Find DTP based on NESA -Check if any contraindications -Check for drug interactions -Check patient allergies -Check patient preferences and concerns -Check social history -Make recommendation write full regimen (rationale for recommendation based on ESA) -Find alternative (pros and cons) write full regimen -MOA of prescribed Rx (generic, class) and recommended drugs -Write Non-pharm -Write Monitoring -identify and examine potential human contacts -soak combs and brushes in disinfectant solution (e.g., Lysol 2% for 1hr or rubbing alcohol for 10-20mins) or in hot water (at least 50C for 510 mins) -use hot water cycle to wash all clothing items, bedsheets, pillowcases, towels, etc. of infected person -seal items in plastic bag for 2wks -(Body lice) improve hygiene -(pubic lice) if in eyelashes, use white petrolatum (vaseline) can be applied to lashes 2-4 times daily for 10 days, remove lice and nits with forceps or tweezers -(pubic lice) refer to physician for concurrent STIs -(scabies) use cold compress x20mins for severely itchy areas -(scabies) avoid body contact with others until full treatment cycle is completed OTITIS MEDIA CAUSES SYMPTOMS AOM: Streptococcus pneumoniae (most common) Viruses H. influenzae Moraxella catarhalis Group A streptococci Staph aureus OME: E: indicated for condition, most effective/drug choice, optimal dose, freq, duration, route, interaction affecting effectiveness Effectiveness *(reduction of symptoms -name them) Decrease and time frame S: no contraindications, adverse drug reactions, DTP, interaction affecting safety, Safety *side effects of all recommended Rx- name thempresence – time frame (anytime) A: complexity of regimen, product availability, pt preferences (cost, regimen, dosage form, lifestyle, challenges) *Adherence to med- not skipping dose, finishing course- presence – (timeframe within a few days) *allergic reactions to recommend Rx (hives, rash, anaphylaxis – time frame (anytime) Rapid onset Otalgia (Ear tugging) Otorrhea Headache Fever RISK FACTORS -Young age -Allergies - Daycare -Second-hand smoke - Immunodeficiency -Pacifier use Strategy for: WATCHFUL WAITING Hearing loss Tinnitus Vertigo Otalgia Irritability, difficulty sleeping Loss of appetite Vomiting, diarrhea -Upper respiratory tract infections - Family history of recurrent OM - Craniofacial abnormalities - Trisomy 21 (down syndrome) - Short duration of breast feeding -GERD Close monitoring and follow-up: Children >6mos, with unilateral AOM, mild If symptoms worsen or fail to improve after 48-72hrs, symptoms (otalgia <48hrs, with temp (po) <39C) follow up with MD visit, or start antibiotic Rx Children >24mos, with mild symptoms and unilateral or bilateral AOM DIAGNOSTIC Requires otoscopy TEST Redness, inflammation, bulging tympanic membrane Opaque yellow tympanic membrane Impaired mobility of tympanic membrane THOUGH PROCESS NON-PHARM ESA MONITORING -Look at symptoms -don’t share pillowcases, E: indicated for condition, Effectiveness -Identify cause of disease and clean and wash most effective/drug choice, *(reduction of symptoms -Identify risk factors infected person’s pillow optimal dose, freq, duration, name them) Decrease and -Check vital signs cases route, interaction affecting time frame -Check lab value -avoid loud noises; it can effectiveness -Write down goals of therapy CTC irritate ears *Adherence to med- not -Underline desired outcome -Fever: cold compress, S: no contraindications, skipping dose, finishing -Find DTP based on NESA cooling fan, tepid bath adverse drug reactions, DTP, course- presence – -Check if any contraindications -get lots of rest interaction affecting safety, (timeframe within a few -Check for drug interactions -stay hydrated, drink lots of days) -Check patient allergies fluids A: complexity of regimen, -Check patient preferences and -warm facial product availability, pt Safety concerns packs/compresses preferences (cost, regimen, *side effects of all -Check social history -sleeping with the head of dosage form, lifestyle, recommended Rx- name -Make recommendation the bed elevated challenges) them- presence – time frame (anytime) write full regimen (rationale for recommendation based on ESA) -Find alternative (pros and cons) write full regimen -MOA of prescribed Rx (generic, class) and recommended drugs -Write Non-pharm -Write Monitoring *allergic reactions to recommend Rx (hives, rash, anaphylaxis – time frame (anytime) SINUSITIS (Acute RHINOSINUSITIS in CTC) CAUSES SYMPTOMS RISK FACTORS Acute: Classification Viruses (most common) Strept pneumoniae H. influenzae Moraxella catarhalis Staph aureus Anaerobes (more likely in chronic infection) Facial pain, pressure or fullness Referred pain to ears, teeth Headache Purulent nasal discharge Fever Altered smell, taste Halitosis Cough Cough and rhinorrhea are most common symptoms in children Recent upper viral respiratory tract infection Asthma Allergic rhinitis, rhinitis medicamentosa Smoking or second-hand smoke Anatomy (e.g., deviated septum, turbinate deformity) Viral: <4wks Chronic: Symptomatic > or = 12 wks Recurrent: 4 or more episodes per year Symptoms rapidly peak, and start to decline by the 3rd day, ends in 1 wk Will overall be improving even if symptoms last over a week Bacterial: 10 days or longer with no improvement Severe symptoms and high fever (>39C) with purulent discharge or facial pain 3-4 consecutive days at start of illness with complete resolution between episodes DIAGNOSTIC TEST NON-PHARM -nasal saline irrigation or steam inhalation may be helpful -avoid exacerbating factors such as allergen exposure, environmental toxins, tobacco smoke -rest -stay hydrated, drink lots of fluids -hand washing is the best way to reduce the spread of viral infections PHARYNGITIS Symptoms start to improve, but get worse by 10 days (“double sickening”) Differentiate between viral and bacterial based on symptom timeline THOUGH PROCESS -Look at symptoms, how long? -Bacterial or viral ? -give signs of referral? -Identify cause of disease -Identify risk factors -Check vital signs -Check lab value -Write down goals of therapy CTC -Underline desired outcome -Find DTP based on NESA -Check if any contraindications -Check for drug interactions -Check patient allergies -Check patient preferences and concerns -Check social history -Make recommendation write full regimen (rationale for recommendation based on ESA) -Find alternative (pros and cons) write full regimen -MOA of prescribed Rx (generic, class) and recommended drugs -Write Non-pharm -Write Monitoring CAUSES Viruses (most common) Streptococcus Pyogenes (Group A strep)* Group C, G streptococci ESA E: indicated for condition, most effective/drug choice, optimal dose, freq, duration, route, interaction affecting effectiveness S: no contraindications, adverse drug reactions, DTP, interaction affecting safety, A: complexity of regimen, product availability, pt preferences (cost, regimen, dosage form, lifestyle, challenges) MONITORING Effectiveness *(reduction of symptoms -name them) Decrease and time frame *Adherence to med- not skipping dose, finishing course- presence – (timeframe within a few days) Safety *side effects of all recommended Rx- name them- presence – time frame (anytime) *allergic reactions to recommend Rx (hives, rash, anaphylaxis – time frame (anytime) SYMPTOMS RISK FACTORS Complications DIAGNOSTIC TEST Arcanobacterium hemolyticum N. Gonorrheae Corynebacterium diptheriae Fusobacterium necrophorum (Lemierre’s disease) Acute primary HIV infection General: Bacterial: Absence of cough, odynophagia, Abrupt onset pharyngeal/tonsilar erythema (+/ Sore throat, exudate exudate), fever, palatal petechiae, Odynophagia tender cervical adenopathy, scarlet Tonsillar swelling fever, winter/spring presentation Palatal petechiae Viral: Odynophagia, cough, rhinorrhea, conjunctivitis, hoarseness; diarrhea, rash Fever, chills Tender cervical adenopathy Malaise Headache Smoking, secondhand smoke Allergic rhinitis Seasonality (November to May) Behavioral risk factors (e.g., N. gonorrhea) Exposure to infected person within last two weeks (transmitted via airborne droplets) Epidemiology: Kids 5-10 yo in winter/spring Uncommon if <3 yo Infectious complications: Postinfectious complications: Peritonsillar or retropharyngeal abscess Cervical lymphadenitis Sinusitis Otitis media Mastoiditis Acute rheumatic fever (autoimmune inflammatory disorder) glomerulonephritis Throat culture Rapid antigen detection test (RADT) Testing not routinely recommended for children <3 yo Modified Centor Score: 0-1 criteria: low risk (<3%), no testing 4 or more points (50%), test CTC: If cumulative score is 3, 4 and more points, it increases likelihood that the patient has GAS pharyngitis THOUGH PROCESS -Look at symptoms -Modified centor test -RADT (rapid antigen test) sensitive -culture (specific) -Identify cause of disease -Identify risk factors -Check vital signs -Check lab value -Write goals of therapy CTC -Underline desired outcome -Find DTP based on NESA -Check if any contraindications -Check for drug interactions -Check patient allergies -Check patient preferences and concerns -Check social history -Make recommendation write full regimen (rationale for based on ESA) -Find alternative (pros and cons) write full regimen -MOA of prescribed Rx (generic, class) and recommended drugs -Write Non-pharm NON-PHARM -rest -soft food diet -stay hydrated, drink lots of fluids -handwashing is the best way to reduce the spread of viral infections -fever: cooling fan, tepid bath, cold compress on forehead ESA E: indicated for condition, most effective/drug choice, optimal dose, freq, duration, route, interaction affecting effectiveness MONITORING Effectiveness *(reduction of symptoms name them) Decrease and time frame S: no contraindications, adverse drug reactions, DTP, interaction affecting safety, *Adherence to med- not skipping dose, finishing course- presence – (timeframe within a few days) A: complexity of regimen, product availability, pt preferences (cost, regimen, dosage form, lifestyle, challenges) Safety *side effects of all recommended Rx- name them- presence – time frame (anytime) *allergic reactions to recommend Rx (hives, rash, anaphylaxis – time frame (anytime) -Write Monitoring CONJUNCTIVITIS CAUSES SYMPTOMS RISK FACTORS Conjunctivitis Airborne allergens contacting eye CLINICAL FINDINGS itching redness discharge Bacterial Viral Staph aureus (common) Adenovirus (most common) Strep pneumoniae H. influenzae Moraxaella catarrhalis VIRAL BACTERIAL ALLERGIC minimal minimal severe generalized generalized generalized Profuse, serous Moderate, mucopurulent Moderate, serous, mucoid or purulent Bacterial Exposure to virulent/unique bacterial strains Immunocompromised Diabetes Regular contact lens wearers Recent ocular surgery VITAL SIGNS DIAGNOSTIC TEST THOUGH PROCESS -Look at symptoms -Identify cause of disease -Identify risk factors -Check vital signs -Check lab value -Write down goals of therapy CTC -Underline desired outcome -Find DTP based on NESA -Check if any contraindications NON-PHARM Avoid contact lenses until resolves Avoid makeup, smoke, wind, and other irritants Apply cold compresses for allergic and viral conjunctivitis; ESA E: indicated for condition, most effective/drug choice, optimal dose, freq, duration, route, interaction affecting effectiveness S: no contraindications, adverse drug reactions, DTP, interaction affecting safety, MONITORING Effectiveness *(reduction of symptoms name them) Decrease and time frame *Adherence to med- not skipping dose, finishing course- presence – (timeframe within a few days) -Check for drug interactions -Check patient allergies -Check patient preferences and concerns -Check social history -Make recommendation write full regimen (rationale for recommendation based on ESA) -Find alternative (pros and cons) write full regimen -MOA of prescribed Rx (generic, class) and recommended drugs -Write Non-pharm -Write Monitoring warm compresses for bacterial conjunctivitis Practice lid hygiene for blepharitis (inflammation of eyelids): Warm water compresses to closed eyelid for 5- 10 mins, followed by gentle scrubbing of lid margins with warm water. Repeat daily at bedtime Hand hygiene Consider all shared objects that may contact infected eye(s) (towel) A: complexity of regimen, product availability, pt preferences (cost, regimen, dosage form, lifestyle, challenges) Safety *side effects of all recommended Rx- name them- presence – time frame (anytime) *allergic reactions to recommend Rx (hives, rash, anaphylaxis – time frame (anytime) ALLERGIC RHINITIS CAUSES SYMPTOMS RISK FACTORS Atopy: abnormal tendency to develop IgE response to innocuous and ubiquitous environmental allergens Often genetic Local immune response to allergen Visible signs: Nasal congestion Persistent mouth breathing Nasal itch Rubbing at the nose or obvious transverse Rhinorrhea nasal crease Sneezing Frequent sniffling or throat clearing Allergic conjunctivitis Allergic shiners (dark circles under the eyes that are due to nasal congestion) Concomitant asthma Family history of atopy (asthma, allergic rhinitis, atopic dermatitis) Ethnic origin other than white European Heavy maternal smoking in first year of life Early introduction of food or formula No older siblings Allergen exposure (aeroallergens, food allergens, occupational allergens) Pollutants Higher SES Heavy alcohol consumption Medical complications: Complications DIAGNOSTIC TEST Headaches Cough Ocular symptoms (itchy watery, red, swollen eyes) Otitis media with effusion Nasal polyps Recurrent URTI AR is an independent risk factor for developing asthma Skin Testing: Preferred over serum IgE testing, unless conditions exist that make it unsatisfactory (e.g., widespread skin disease or inability to stop antihistamine therapy) Primary method, more sensitive See procedure in lecture notes* THOUGH PROCESS NON-PHARM ESA MONITORING -Look at symptoms E: indicated for condition, Effectiveness -Identify cause of disease -allergen avoidance most effective/drug choice, *(reduction of symptoms -Identify risk factors (pollen, animal dander, optimal dose, freq, duration, name them) Decrease and -Check vital signs dust mites, mould) route, interaction affecting time frame -Check lab value -saline irrigation effectiveness -Write down goals of therapy CTC -cold or warm compress to *Adherence to med- not -Underline desired outcome help reduce conjunctivitis S: no contraindications, skipping dose, finishing -Find DTP based on NESA symptoms adverse drug reactions, DTP, course- presence – (timeframe -Check if any contraindications interaction affecting safety, within a few days) -Check for drug interactions -Check patient allergies A: complexity of regimen, Safety -Check patient preferences and product availability, pt *side effects of all concerns preferences (cost, regimen, recommended Rx- name -Check social history dosage form, lifestyle, them- presence – time frame -Make recommendation challenges) (anytime) write full regimen (rationale for recommendation based on ESA) -Find alternative (pros and cons) write full regimen -MOA of prescribed Rx (generic, class) and recommended drugs -Write Non-pharm -Write Monitoring *allergic reactions to recommend Rx (hives, rash, anaphylaxis – time frame (anytime) OTITIS EXTERNA CAUSES Impacted Cerumen – Acute (< 3 weeks) – Chronic (>= 3 mo) – Malignant otitis externa SYMPTOMS – Fullness, hearing loss, tinnitus, itchiness – Pain should not be present RISK FACTORS – Anatomic variations in ear canal (excess narrowing, degree of curvature, ear hair) – Overproduction of cerumen – Migration failure (Aging changes cerumen production and skin changes in the ear) – Foreign objects placed in the ear (Q-tips) including hearing aids – History of prior impaction – Older age 2 most common organisms: Pseudomonas Aeruginosa (20-60%) Staph Aureus (10-70%) Rare: Fungal infection: Otomycosis, Aspergillus, Candida Albicans Otitis Externa Pain (otalgia) ranges from mild to severe— exacerbated by the movement of lobe, acute onset within 48hrs, unilateral in 90% cases Itching/pruritis Ear fullness Headache Discharge (otorrhea) Swollen ear canal Loss of hearing Too little cerumen—cerumen provides antibacterial action by physically protecting the canal and maintaining a low pH Too much cerumen can lead to maceration and occlusion Moisture (swimming, bathing, water sports, increased humidity) macerates underlying skin and raises pH Trauma to the external auditory canal (fingernails, cotton-swabs, foreign objects) Use of objects occluding the auditory canal Chronic derm conditions Hearing aids Narrow, hairy ear canal Age: high incidence in children 7-12 yo; rates decline after 50 – Rash in ear or ear infection suspected – History of ear surgery or tubes in ear – Foreign object in ear – Suspected burst ear drum: REFERRAL • Bleeding/discharge from ear • Dizziness • Pain • Ringing sound • Hearing loss DIAGNOSTIC Based on clinical findings, history, and duration TEST Otoscopy to distinguish between OM vs. OE Rule out malignant OE, AOM, derm conditions affecting the ear (eczema, seborrhea), sensitization from otic medications THOUGH PROCESS NON-PHARM ESA MONITORING -Look at symptoms E: indicated for condition, Effectiveness -Identify cause of disease -avoid trauma (cotton most effective/drug choice, *(reduction of symptoms -Identify risk factors swabs, hair pins) in ear optimal dose, freq, duration, name them) Decrease and -Check vital signs canal route, interaction affecting time frame -Check lab value -avoid getting water into effectiveness -Write down goals of therapy CTC the ear canal *Adherence to med- not -Underline desired outcome -use acidifying drops S: no contraindications, skipping dose, finishing -Find DTP based on NESA before or after swimming adverse drug reactions, DTP, course- presence – (timeframe -Check if any contraindications -examine hearing aids for interaction affecting safety, within a few days) -Check for drug interactions proper fit -check if any ototoxicity drugs? A: complexity of regimen, Safety -Check patient allergies product availability, pt *side effects of all -Check patient preferences and preferences (cost, regimen, recommended Rx- name concerns dosage form, lifestyle, them- presence – time frame -Check social history challenges) (anytime) -Make recommendation write full regimen (rationale for *allergic reactions to recommendation based on ESA) recommend Rx (hives, rash, -Find alternative (pros and cons) anaphylaxis – time frame write full regimen (anytime) -MOA of prescribed Rx (generic, class) and recommended drugs -Write Non-pharm -Write Monitoring DRY EYE DISEASE CAUSES SYMPTOMS RISK FACTORS Hyperosmolarity of tear film damages ocular surface by causing inflammation Instability and dysfunction of tear film Dry, scratchy, sandy feeling Foreign body sensation Pain and soreness Increased blinking Eye fatigue Redness Photosensitivity Older age Female Postmenopausal estrogen therapy Asian VITAL SIGNS DIAGNOSTIC TEST Aqueous Tear Flow (Schirmer Test) o Normal: >15mm in 5 minutes Tear Breakup Time (TBUT) o Normal: >10 seconds for 1st dry spot to appear after blinking THOUGH PROCESS -Look at symptoms -Identify cause of disease -Identify risk factors -Check vital signs -Check lab value -Write down goals of therapy CTC -Underline desired outcome -Find DTP based on NESA -Check if any contraindications -Check for drug interactions -Check patient allergies -Check patient preferences and concerns -Check social history -Make recommendation NON-PHARM ESA Environmental E: indicated for condition, Avoid smoking or staying in most effective/drug choice, smoky rooms optimal dose, freq, duration, Avoid air drafts (e.g., route, interaction affecting ceiling fans) effectiveness Wear sunglasses when outdoors Use humidifiers Use moisture chamber glasses Wear ski or swim goggles (± moistened gauze) Use cool, moist compresses for temporary relief Lifestyle MONITORING Effectiveness *(reduction of symptoms name them) Decrease and time frame S: no contraindications, adverse drug reactions, DTP, interaction affecting safety, *Adherence to med- not skipping dose, finishing course- presence – (timeframe within a few days) A: complexity of regimen, product availability, pt preferences (cost, regimen, dosage form, lifestyle, challenges) Safety *side effects of all recommended Rx- name them- presence – time frame (anytime) write full regimen (rationale for recommendation based on ESA) -Find alternative (pros and cons) write full regimen -MOA of prescribed Rx (generic, class) and recommended drugs -Write Non-pharm -Write Monitoring Screen time: decrease screen time; take regular breaks; lower computer screen to below eye level; make a conscious effort to blink more often Increase fluid intake Increase sleep *allergic reactions to recommend Rx (hives, rash, anaphylaxis – time frame (anytime) Punctal occlusion Punctal plugs Temporary—usually collagen-based; absorb in 1–16 weeks Permanent—usually silicone-based Heat or electrocautery (permanent) GLAUCOMA CAUSES CLASSIFICATION DIAGNOSTIC TEST Group of ocular diseases associated with: • elevated intraocular pressure (IOP) • thinning of retinal nerve fibre and macular ganglion layer • optic disk cupping & peripheral vision loss Open-angle glaucoma Angle-closure Glaucoma Optic neuropathy characterized • Closure of the angle between the by progressive visual iris and cornea, field loss, usually associated with obstructing the outflow of aqueous elevated intraocular humor pressure (IOP) • About 1/3 of all glaucoma cases • About 2/3 of all glaucoma cases • Primarily through •Comprehensive eye examination comprehensive eye urgently (Refer) secondary/acquired glaucoma examinations and IOP measurements - Chronic, often asymptomatic SYMPTOMS RISK FACTORS -Progressive visual loss -Elevated IOP • Demographics: – Older age – Female – African ancestry • Family history • Medical history: – Diabetes, high blood pressure, taking corticosteroids • Prior eye injury or surgery (e.g. cataract surgery) • Increased IOP – Not always the case, some with normal IOP will have glaucoma and some with high IOP never develop glaucoma -Usually asymptomatic in early disease -Can lead to permanent blindness within 24 hours pain, blurry vision, halos around lights, headache, N/V • Demographics: – Older age – Female – East Asian ancestry • Family history • Other ocular factors Prognosis includes: – Some may have residual OAG – Reoccurring angle-closure glaucoma – Progressive vision loss – Resolution of acute attack and successful long term management • Congenital defects • Trauma, surgery, insult/infection • Corticosteroid use VITAL SIGNS THOUGH PROCESS -Look at symptoms -Identify cause of disease -Identify risk factors -Check vital signs -Check lab value -Write down goals of therapy CTC -Underline desired outcome -Find DTP based on NESA -Check if any medical contraindications -Check for drug interactions -Check patient allergies -Check patient preferences and concerns -Check social history -Make recommendation write full regimen (rationale for recommendation based on ESA) -Find alternative (pros and cons) NON-PHARM – Aerobic exercise can lower IOP modestly in some patients with glaucoma -Patient Education ESA E: indicated for condition, most effective/drug choice, optimal dose, freq, duration, route, interaction affecting effectiveness MONITORING Effectiveness *(reduction of symptoms -name them) Decrease and time frame S: no contraindications, adverse drug reactions, DTP, interaction affecting safety, *Adherence to mednot skipping dose, finishing coursepresence – (timeframe within a few days) A: complexity of regimen, product availability, pt preferences (cost, regimen, dosage form, lifestyle, challenges) Safety *side effects of all recommended Rxname them- write full regimen -MOA of prescribed Rx (generic, class) and recommended drugs -Write Non-pharm -Write Monitoring VTE PADUA score https://www.mdcalc.com/padua-prediction-score-risk-vte#next-steps presence – time frame (anytime) *allergic reactions to recommend Rx (hives, rash, anaphylaxis – time frame (anytime) (Medical patient only, not for surgery) SYMPTOMS Deep Vein Thrombosis: - pain and/or tenderness - swelling - warm to touch - change in color Pulmonary Embolism: - SOB - Increased RR - Chest pain - Cough Increased HR Abnormalities of surfaces in contact with blood - Vascular injury/trauma - Major surgery (orthopedic) - Valvular heart disease - Heart valve replacement - Atherosclerosis - Central venous catheters - Previous DVT/PE RISK FACTORS Abnormalities of Blood Flow - Immobility (bed rest, paralysis, travel) - Left ventricular dysfunction (i.e., heart failure) - Atrial fibrillation - Venous obstruction (tumor, obesity, pregnancy) Abnormalities of Clotting components - Protein S or C deficiency - ATIII deficiency - Factor V Leiden mutation - Antiphospholipid antibody syndrome - Homocystenemia - Malignancy - Increased estrogen - Pregnancy DIAGNOSTIC TEST POSSIBLE THERAPIES Start ONE of - IV UFH---(use if renal impairment present, Heparin Induced Thrombocytopenia) - SC LMWH—renally cleared, don’t use in low CrCL, less AEs, more cost effective - SC fondaparinux - SC UFH (weight-based) Start Warfarin on the same day Continue UFH/LMWH/FONDA x 5 days (min) and until INR > 2 x 48 hrs. Usual dose: 0.5–6 mg daily PO Adjust dose to maintain INR 2–3; higher doses may be necessary in some patients. ***CHECK FOR INTERACTIONS*** Duration of Therapy: Provoked aka “idiopathic with known cause” (reversible cause) x 3 months Irreversible provoked cause—treat as unprovoked Unprovoked: NON-PHARM ESA E: indicated for condition, most effective/drug choice, optimal dose, freq, duration, route, interaction affecting effectiveness S: no contraindications, adverse drug reactions, DTP, interaction affecting safety, A: complexity of regimen, product availability, pt preferences (cost, regimen, dosage form, lifestyle, challenges) MONITORING Effectiveness *(reduction of symptoms name them) Decrease and time frame Monitor: - Baseline INR daily until stabilized INR 2-3 and Baseline CBC while on UFH/LMWH/FONDA *Adherence to med- not skipping dose, finishing course- presence – (timeframe within a few days) Safety *side effects of all recommended Rx- name them- presence – time frame (anytime) *allergic reactions to recommend Rx (hives, rash, anaphylaxis – time frame (anytime) Proximal DVT/PE (first or recurrence) --> extended duration Isolated distal DVT (first episode) x 3 months Isolated distal DVT (recurrence) --> extended duration VTE prophylaxis PADUA score https://www.mdcalc.com/padua-prediction-score-risk-vte#next-steps (Medical patient only, not for surgery) Caprini score https://www.mdcalc.com/caprini-score-venous-thromboembolism-2005 (surgery pt only) don’t use for orthopedic surgery considered high risk surgery RISK FACTORS
