User:Keptium
USEFUL WEBSITES/ TABLES
[edit]CARDIOVASCULAR
[edit]ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery
[edit]- Algorithm for surgical clearance.
http://www.acc.org/qualityandscience/clinical/guidelines/perio/update/fig1.htm
10-year risk based on the Framingham risk score
[edit]- To use when deciding whether or not to treat hyperlipidemia.
http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof
Reynolds Risk Score
[edit]- If you are healthy and without diabetes, the Reynolds Risk Score is designed to predict your risk of having a future heart attack, stroke, or other major heart disease in the next 10 years.
http://www.reynoldsriskscore.org/
PHARMACY/ MEDICATIONS
[edit]Opioid Conversion Calculator
[edit]http://www.medcalc.com/narcotics.html
- Table and opioids may be too dangerous, considering removing before final product
| Opioid | PO | IV/SC/IM |
| Codeine | 130mg | 75mg |
| Fentanyl | NA | 0.1mg |
| Hydrocodone | 20mg | NA |
| Hydromorphone | 7.5mg | 1.5mg |
| Methadone | 5-15mg | 2.5-10mg |
| Morphine | 30mg | 10mg |
| Oxycodone | 20mg | NA |
| Oxymorphone | 10mg | 1mg |
Statin Dose Equivalency Chart
[edit]| % LDL Reduction | Atorvastatin (Lipitor) | Lovastatin (Mevacor) | Simvastatin (Zocor) | Pravastatin (Pravachol) | Rosuvastatin (Crestor) | Fluvastatin (Lescol) | Simvastatin/ Ezetimibe (Vytorin) |
| 20-30% | na | 20mg | 10mg | 20mg | na | 20-40mg | na |
| 30-40% | 10mg | 40mg | 20mg | 40-80mg | na | 20-40mg | na |
| 40-45% | 20mg | 80mg | 40mg | na | 5mg | 80mg | 10/10mg |
| 46-50% | 40mg | na | 80mg | na | 10mg | na | 10/20mg |
| 50-55% | 80mg | na | na | na | 20mg | na | 10/40mg |
| 56-60% | na | na | na | na | 40mg | na | 10/80mg |
Potency of Topical Steroids
[edit]| Potency | Generic | Brand | Administration Vehicle | Available Quantities |
| Ultra High (I) | Clobetasol Propionate 0.05% | Temovate g | C, O, G | 15, 30, 45g for C,O. 15, 30, 60g for G. |
| Halobetasol Propionate 0.05% | Ultravate g | C, O | 15, 50g | |
| High (II) | Flucinonide 0.05% | Lidex g | O | 15, 30, 60g |
| Desoximetasone | Topicort 0.25% g | C, O | 15, 60g | |
| Medium to High (III) | Triamcinolone Acetonide 0.5% | g | O | 15g |
| Medium (IV and V) | Desoximetasone 0.05% | Topicort LP g | C | 15, 60g |
| Hydrocortisone Butyrate 0.1% | Locoid g | O | 5, 10, 15, 30, 45g | |
| Hydrocortisone Probutate 0.1% | Pandel | C | 15, 45, 80g | |
| Hydrocortisone Valerate 0.2% | Westcort g | C, O | 14, 45, 60g. (120g C only) | |
| Mometasone Furoate 0.1% | Elocon g | C, L, O | 15, 45g for C, O and 30, 60 ml for L | |
| Triamcinolone acetonide 0.025% | Kenalog g | C, L, O | 15, 80, 454g for C, O and 60mL for L | |
| Triamcinolone acetonide 0.1% | Triderm g | C | 15, 80, 454g | |
| Low (VI) | Desonide 0.05% | Desowen g | C, O | 15, 60g |
| Hydrocortisone Butyrate 0.1% | Locoid g | C | 5, 10, 15, 30, 45g | |
| Least Potent | Hydrocortisone 1%, 2.5% | g | C, L, O | 20, 30, 120g for C, O and 60, 120mL for L |
C = Cream, O = Ointment, L = Liquid.
g- Available as Generic
PULMONARY
[edit]Peak Flow Normals
[edit]- Pediatrics (less then 20 years old)- http://www-users.med.cornell.edu/~spon/picu/calc/peakflow.htm
ENDOCRINOLOGY
[edit]Hemoglobin A1c to Average Blood Glucose Calculator
[edit]- Use the Mean Whole Blood Glucose to determine the average blood glucose
http://www.pace-med-apps.com/a1ccalc.htm
FRAX Calculator
[edit]The Frax calculator has been developed by the WHO to evaluate the fracture risk of patients. The link takes you to the calculator for caucasians living in the United States. To choose a different ethnicity simply click on the calculation tool drop down menu. http://www.shef.ac.uk/FRAX/tool.jsp?locationValue=9
OPHTHALMOLOGY
[edit]A useful website through the university of michigan to help identify and treat various conditions associated with ophthalmology-http://www.kellogg.umich.edu/theeyeshaveit/red-eye/index.html
FORMULARIES, PRESCRIPTION PLANS
[edit]WHP Formulary Information and Materials http://www.ewashtenaw.org/government/departments/public_health/whp/Formulary_Materials]]
Kroger $4/ $10 Medication List [[ http://www.kroger.com/generic/Pages/alpha_listing.aspx]]
Meijer Free Antibiotic List and Free PreNatal Vitamins [[ http://www.meijer.com/content/content_leftnav_manual.jsp?pageName=free_antibiotics]]
Target $4 Medication List [[ http://www.rxassist.org/providers/documents/TargetGenericsProgramDrugList.pdf]]
Walmart/ Sam's Club $4/ $10 Medication List [[ http://i.walmartimages.com/i/if/hmp/fusion/customer_list.pdf]]
SUBSTANCE ABUSE
[edit]MAPS (Michigan Automated Prescription System) Home Page [[ https://sso.state.mi.us/]]
Smoking Cessation Resources
State of Michigan Resources [[ http://www.michigan.gov/mdcs/0,1607,7-147-22854_24290_25460-141127--,00.html]]
University of Michigan Tobacco Consultation Services [[ http://www.med.umich.edu/mfit/tobacco/]]
Quit the Nic Program for Blue Cross and Blue Shield [[ http://www.bcbsm.com/pdf/quit_the_nic.pdf]]
UM Clinical Care Guidelines and Patient Information [[ http://www.med.umich.edu/1info/fhp/practiceguides/smoking.html]]
MUSCULOSKELETAL
[edit]University of Michigan Sports Medicine Handouts -Information for patients on various musculoskeletal injuries. See Educational Resources.
Sports Medicine Orthopedics Rotation -Learning objectives with links to instructional videos and information. [[ https://um.medhub.com/files/curriculum/curriculum_fmed_smo1_2009.doc]]
Ottawa Ankle Injury Guidelines -Used to decide whether or not imaging is necessary. [[ http://www.mdcalc.com/ottawa-ankle-rules]]
Wheeless' Textbook of Orthopaedics -Online reference for orthopedic injuries/ diseases. [[ http://www.wheelessonline.com/]]
TRAVEL MEDICINE
[edit]CDC Website [[ http://wwwn.cdc.gov/travel/default.aspx]]
HEALTH MAINTENANCE EXAM
[edit]- USPSTF Reccomendations- Search and Browse U.S. Preventive Services Task Force recommendations.
http://epss.ahrq.gov/ePSS/search.jsp
| Service | Targeted Population |
| Blood Pressure | All pt's q year if borderline or q 2 years if BP < 120/80 |
| Abdominal Aortic Aneurysm Screening | Men 65 to 75 yo who are current or former smokers. 1-time screening for AAA has been recommended by some for men 65 to 75 yo who have never smoked but have a 1st-degree relative who required repair of or died from an AAA |
| Breast Cancer Screening | Women 40 - 50 yearly. Screen until life expectancy is < 10 years. |
| Clinical Breast Examination | Yearly for women (age???) |
| Cervical Cancer Screening (Pap smear) | Sexually active women with an intact cervix, starting at 21. Women older than 65 who have repeated negative Pap smears, and are not at increased risk (more than one sexual partner in past five years or immunosuppression) do not need to be screened. Women w/o a cervix who have not had prior gynecological cancer, CIN 3, or history of DES exposure should not be screened. |
| Chl and GC Screening | Chl- women ages 15 to 25 years, and older who have behavioral risk factors. GC- sexually active women 15 to 29 who live in areas of high prevalence or at risk. |
| Colorectal Cancer Screening | Patients age 50 to 75 years. Rules change if there is a FH of Colon CA. |
| Prostate Cancer Screening | Discuss with men 50-74, Screen until comorbidities or age (75 years) limit life expectancy to less than 10 years. Benefits of screening (reducing prostate ca mortality) are limited. Benefits may be outweighed by the harms (need for biopsy, and impotence or incontinence occurring in at least 50% of men who undergo treatment for a dz that may be indolent) |
| Diabetes Screening | Pt's w/ BP ≥135/80, the ADA recommends screening pt's age 45 and older w/o risk factors and in adults who are overweight or obese (BMI ≥25 kg/m2) and have one or more additional risk factors for diabetes. |
| Bone Mineral Density Screening | Women > 65 years (or women 60-64 who are at high risk) |
| Vision and Hearing Screening | Pt's over 65. (Snellen chart, hearing questionarie or "whisper voice test") |
HYPERTENSION
[edit]Definition:
BP > 140/90 at least 3 different weeks, 3 different situations. However, JNC 7 report recommends blood pressure cutoff if using ambulatory monitoring should be 135/85 while awake and 120/75 while asleep.
Diagnostic workup recommended by JNC 7
1. Electrocardiogram (ECG) 2. Urinalysis 3. Fasting blood glucose 4. Serum potassium, creatinine, and calcium 5. Hematocrit 6. Lipid profile - HDL cholesterol, LDL cholesterol, triglycerides
Optional - urinary albumin/creatinine ratio or urinary albumin excretion
Assess for other major cardiovascular disease risk factors
obesity (BMI > 30), cigarette smoking, physical inactivity, age (men > 55 years, women > 65 years), family history of premature cardiovascular disease (men < 55 years, women < 65 years)
Assess for identifiable causes White Coat HTN, Sleep apnea, Drugs (including steroids), Chronic kidney disease, Primary aldosteronism, Renovascular disease, Cushing's syndrome, Pheochromocytoma, Coarctation of aorta, Thyroid disease, Parathyroid disease
Treatment/ Prevention
1. Moderate physical activity (decrease SBP by 4 mm HG)
2. Maintain normal body weight
3. Limit alcohol use
4. Reduce sodium intake (decrease SBP by 3 mm HG)
5. Maintain adequate potassium intake
6. Diet rich in fruits, vegetables and low-fat dairy products and reduced in saturated and total fat (decrease SBP by 5 mm HG)
Medical Management
1. Low-dose thiazide/thiazide-type diuretics are most cost-effective first-line therapy for hypertension. Uncommon risk of cross-sensitivity in patients with sulfa allergy. Checking potassium/ sodium level within 2-8 weeks after initiation of diuretics should detect most cases of hypokalemia/ hyponatremia.
2. ACEi/ARB Check potassium/ creatanine in 2 weeks.
3. Additional medications- Beta Blocker, CCBs, diuretics (Spironolactone, Triamterene), alpha-2 agonists (eg Clonidine, Methyldopa)), vasodilators (Hydralazine, Minoxidil)
UM Clinical Care Guidelines and Patient Information
http://www.med.umich.edu/1info/fhp/practiceguides/newhtn.html
HYPERLIPIDEMIA
[edit]-USPSTF and AAFP recommends routine screening for men 35 years and older and women 45 years and older. USPSTF also recommends screening younger adults (over the age of 20) if they have other risk factors for CHD (Coronary Heart Disease). Screening intervals are not clear. Probably atleast every 5 years in healthy patients and more frequently in patients with borderline numbers (such as yearly). An age to stop screening has not been established, but repeated screening after age 65 is less important because lipid values tend to level off.
-Consider screening for secondary causes of dyslipidemia with TSH, fasting glucose and creatinine.
When to treat-
Hyperlipidemia Treatment
| Risk Category | LDL-C Goal | Initiate Therapeutic Lifestyle Changes | Consider Drug Therapy |
| High Risk: CHD or Risk Equivalents (10 yr risk > 20%) | <100mg/dL (optional goal <70mg/dL) | All (per UM guidelines) | All (per UM guidelines) |
| Mod High Risk: 2+ risk factors (10 yr risk 10% - 20%) | <130mg/dL | ≥130mg/dL | ≥130mg/dL (optional > 100mg/dL) |
| Mod Risk: 2+ risk factors (10 yr risk < 10%) | <130mg/dL | ≥130mg/dL | ≥160mg/dL |
| Lower Risk: 0-1 risk factors | <160mg/dL | ≥160mg/dL | ≥190mg/dL (optional 160-189mg/dL) |
CHD equivalents
Symptomatic carotid artery disease, peripheral artery disease, abdominal aortic aneurysm, diabetes mellitus, +/- chronic renal insfficiency
Risk Factors
Cigarette smoking, Hypertension, HDL < 40, Family history of premature CHD (CHD in 1st degree relative male < 55 or female < 65), Age (Men 45 tears, women 55 years), HDL greater then 60 mg/dL is a negative risk factor (remove one risk factor)
10-year risk based on the Framingham risk score
[[
http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof]]
Treatment
Start with a statin. Check baseline ALT. Would need to stop statin if ALT > 3 x normal. Maximum effect in 4-6 weeks of therapy.
UM Clinical Care Guidelines and Patient Information
http://www.med.umich.edu/1info/fhp/practiceguides/lipids.html
HEADACHE/ CEPHALGIA
[edit]Evaluation
-Good Hx to determine characteristics (location, triggers, duration, frequency, etc), Associated sxs (photophobia, N/V, fever, stiff neck, tearing, nasal congestion, focal neurologic changes), Meds (BP meds, OCPs, etc can cause HAs, rebound HAs from frequent use of pain meds, caffeine), PMHx (CVA, cancer, trauma, HTN, etc), Fam Hx (migraines can be hereditary)
-Physical Exam including HEENT (TMJ pain, temporal artery pain), Neck (supple, trapezius spasms), Neuro exam
Differential Diagnosis
-Primary HAs- Migraine (Classic vs common), Tension, Cluster, Mixed (usually migraine/ tension), Rebound, Neuralgias. -Secondary HAs- Mass lesion, CVA/TIA, Infection (meningitis, sinusitis), Trauma (Subdural, Epidural hematoma), SAH, Temporal arteritis, Pseudotumor cerebri, Sleep apnea (HA in the morning), Glaucoma, HTN induced, CO poisoning
Diagnostic Testing
Often no testing needed, but based on sxs- Imaging if concern for mass or bleed (HAs due to masses are almost always present, the mass doesn't come and go, so the HA shouldn't come and go), LP/CBC if concern for infection, ESR (If concern for Temporal arteritis)
Treatment
1) Depends on etiology. Migraine: Abortive- Triptans, Acetaminophen, NSAIDs, Midrin. Prophy- Inderal, Verapamil. Tension- Abortive- Acetaminophen, NSAIDs, Excedrin, Relaxation techniques, muscle relaxors, cautious with narcotics. Other causes of HAs need varying degrees of treatment and further evaluation
URINARY TRACT INFECTIONS
[edit]Classification
-Uncomplicated: Cystitis in nonpregnant women w/o underlying structural or neurological disease
-Complicated: Upper tract infection in women or any UTI in men, pregnant women, immunosuppressed or underlying structural dz and possibly the elderly.
Differential Diagnosis
Prostatitis, STI, Urethral diverticula, Pyelo, Renal Abscess (sxs like pyelo only fever will persist despite appropriate abx treatment)
Diagnostic Evaluation
-UA +/- culture depending on the presentation
-Check for Chl and Gonorrhea in sexually active pts with sterile pyuria
-If pt has a catheter consider yeast as a pathogen
-Uro work-up if recurrent UTI in men or pediatrics (Renal U/S, VCUG, CT scan)
Treatment
-Cipro or Bactrim x 3 days if uncomplicated vs 10-14 days for complicated
-Be careful with Bactrim in elderly
-If pregnant chose a safe antibiotic (Amox, Keflex, etc)
UM Clinical Care Guideline and Patient Information
http://www.med.umich.edu/1info/fhp/practiceguides/uti.html
CELLULITIS
[edit]Definition
An acute spreading bacterial infection below the surface of the skin
Diagnosis
Largely clinical, Look for rubor (redness), tumor (swelling), calor (warmth), dolor (pain). Blood cx helpful if +, but rarely obtained as outpatient due to low yield.
Treatment
-1st generation cephalosporin (Keflex)
-If MRSA suspected then add or use Bactrim or Clinda
-If abscess present then need to I + D and consider antibiotics
-If not improving may require hospitalization for IV antibiotics
-Immunocompromised (DM, transplant, etc) may need broader antibiotic coverage
ACUTE LOW BACK PAIN
[edit]Definition/ General Info
Pain that occurs posteriorly in the region between the lower rib margin and the proximal thighs and that is of less than six weeks' duration.
-Sciatica is pain that radiates down the posterior or lateral leg beyond the knee.
-Most back pain is nonspecific lumbar strain or idiopathic back pain. The natural history of back pain is favorable overall; studies show that 30 to 60 percent of patients recover in one week, 60 to 90 percent recover in six weeks, and 95 percent recover in 12 weeks. However, relapses and recurrences are common, occurring in about 40 percent of patients within six months.
Differential Diagnosis
-Mechanical low back pain: Lumbar strain or sprain (≥ 70%), Degenerative disk or facet process (10%), Herniated disk (4%), Osteoporotic compression fracture (4%), Spinal stenosis (3%), Spondylolisthesis (2%)
-Nonmechanical spinal conditions: Neoplasia (0.7%), Inflammatory arthritis (0.3%), Infection (0.01%)
-Nonspinal/visceral disease: Pelvic organs-prostatitis, pelvic inflammatory disease, endometriosis. Renal organs-nephrolithiasis, pyelonephritis. Aortic aneurysm. Gastrointestinal system-pancreatitis, cholecystitis, peptic ulcer. Shingles.
Evaluation
-Red Flag Findings:
1) Caudia Equina Syndrome- Progressive motor or sensory deficit, Saddle anesthesia, bilateral sciatica or leg weakness, difficulty urinating, fecal incontinence. Order MRI and urgent neurosurg referral.
2) Fracture- Age > 50 years, Significant trauma, History of osteoporosis, Chronic oral steroid use. Order films (consider A/P, lateral, oblique) and then MRI if needed.
3) Cancer- Age > 50 years, Unrelenting night pain or pain at rest, Progressive motor or sensory deficit, Unexplained weight loss, History of cancer or strong suspicion for current cancer, Failure to improve after six weeks of conservative therapy. Order CBC, Sed Rate, CRP and films then MRI if needed.
4) Infection- Fevers, chills, recent urinary tract or skin infection, penetrating wound near spine, unrelenting night pain or pain at rest, immunosuppression, chronic oral steroid use, intravenous drug use, substance abuse, failure to improve after six weeks of conservative therapy.
-If Red Flag findings then consider: CBC, Sed Rate, CRP and films vs MRI if needed.
-Screening tests to detect a herniated disk include asking about the presence of sciatica, the straight leg raise, the crossed straight leg raise (i.e., raising the contralateral, unaffected leg), and testing strength and reflexes in the lower extremities. Herniated disks are unlikely in patients with no history of sciatica (i.e., with pain that does not radiate beyond the knee). Four percent of patients with acute low back pain have a herniated disk, but 95 percent of patients with herniation have sciatica; therefore, the likelihood of a symptomatic herniated disk in a patient with acute back pain but no symptoms of sciatica is approximately one in 500.
Treatment
-In the absence of red flag findings, four to six weeks of conservative care is safe and appropriate, and imaging is not indicated.
-Start with NSAIDS, muscle relaxors- cyclobenzaprine (Flexeril) 5mg TID is as effective as 10mg TID with less side effects. Use 10mg at night to increase sedation and allow for sleep. Heat can also help and have the pt continue activity as tolerated.
UM Clinical Care Guidelines and Patient Information
http://www.med.umich.edu/1info/fhp/practiceguides/back.html
ACUTE BRONCHITIS
[edit]Definition/ General Info
-Respiratory tract infection of the trachea-bronchial tree -90-95% of cases are viral (Influenza, Parainfluenza, Adenovirus, Rhinovirus). Bacterial cases include- Mycoplasma pneumonia, M. catarrhalis, H. influenzae
Differential Diagnosis
-PNA, Asthma, COPD, GERD, URI, CHF, Foreign Body, Toxic Exposure, Lung CA
Evaluation
-Diagnosis based on history and exam. If concern for other pathology (PNA, Lung CA, etc) may need further work-up
Treatment
-Generally Supportive. Can use OTC meds such as Decongestants, Expectorants, Mucolytics (but likely do not shorten duration).
-Can also consider Albuterol Inhaler, Cough Suppresants
-Let patients know the cough can last 1 - 3 weeks, and 25% have a cough > 1 month
-If you suspect a bacterial pathogen then antibiotics would be appropriate
ACUTE SINUSITIS/ RHINOSINUSITIS
[edit]Definition/ General Info
-Inflammation of the paranasal sinuses and nasal cavity lasting no longer then 4 weeks (most commonly the maxillary sinuses)
-Most common pathogens are viral, commmon bacterial causes are S. pneumoniae, H. influenzae, M. catarrhalis
Differential Diagnosis
-Allergic Rhinitis, Atypical facial pain, Headache, migraine or tension, nasal drying, GERD, atrophic rhinitis, TMJ or dental pain
Evaluation
Best Predictors of Acute Bacterial Rhinosinusitis per UM Guidelines
- Maxillary toothache
- Purulent secretion by examination
- Poor response to decongestants
- Abnormal transillumination
- History of colored nasal discharge
| Predictors | Probability |
| 0 | 9% |
| 1 | 21% |
| 2 | 40% |
| 3 | 63% |
| 4 | 81% |
| 5 | 92% |
Treatment
-70% of pts improve w/n 2 wks without antibiotics, 85% improve w/n 2 wks with antibiotics and 15% of pts take longer then 2 weeks even with antibiotics
-1st line treatment for bacterial sinusitis. Amoxicillin 875mg q 12 hours for 10-14 days or Bactrim-DS 160/800mg q 12 hrs for 10-14 days.
-If you suspect viral you can treat with OTC meds, nasal irrigation, Afrin nasal spray (short course to prevent dependence)
-Recurrent or chronic sinusitis needs further treatment and evaluation
UM Clinical Care Guidelines and Patient Information
http://www.med.umich.edu/1info/fhp/practiceguides/Rhino.html
CARDIOVASCULAR
[edit]Pediatric Blood Pressure Charts
[edit]- How to use these tables-
To use the tables in a clinical setting, the height percentile is determined from the standard growth charts. The child's measured systolic and diastolic BP is compared with the numbers provided in the table (boys or girls) for age and height percentile. The child is normotensive if BP is below the 90th percentile. If the child's BP (systolic or diastolic) is at or above the 95th percentile, the child may be hypertensive and repeated measurements are indicated. BP measurements between the 90th and 95th percentiles are prehypertensive and warrant further observation and consideration of other risk factors.
Boys 1-17 years old. http://www.cc.nih.gov/ccc/pedweb/pedsstaff/bptable1.PDF
Girls 1-17 years old. http://www.cc.nih.gov/ccc/pedweb/pedsstaff/bptable2.PDF
Normal Pediatric Vital Signs
[edit]- Quick table to be used for a GENERAL guideline
| Age | Pulse | Respiration | Blood Pressure |
| NB | 120-160 | 30-60 | Systolic = 60-70 |
| <1yr | 90-170 (135) | 30-50 | |
| 1-2yrs | 100-140 (120) | 30-40 | systolic = 70 + (2 x age) |
| 3-5yrs | 100-120 | 20-30 | diastolic = 2/3 systolic |
| 6-12yrs | 80-110 | 16-20 | |
| 12-adult | 60-100 | 12-20 |
WELL CHILD INFORMATION
[edit]Immunizations
[edit]- Child with minor illness (URI) but afebrile (<101F) may still recieve scheduled immunizations
- Children with chronic disease who are susceptible to pneumococcus (sickle cell, asplenia, renal disease, HIV, and other immunodeficiency states) should recieve PNEUMOVAX (given once) after 2 years
- Children susceptible to influenza (severe asthma, CF, bronchopulmonary dysplasia, cardiac disease, HIV, and other immunodeficiency states) should receive influenza vaccine yearly after age 6 months. Will need 2 doses, 4 weeks apart for first 2 doses.
Fluoride Recommendations
[edit]- Monitor fluoride in children younger than 6 yrs becasue over use can result in enamel flurosis. Use pea-size amonth of fluoride toothpaste in <6 yrs
Lead Screening Recommendations
[edit]- Primary prevention - Anticipatory guidance for parents regarding exposure to lead-based paint chips, dust, soil. Discuss dietary iron to prevent absorption of environmental lead.
- Secondary Prevention - Once at 9-12 months, Again at 2 yrs. Use risk assessment questionnaires.
- Does your child live in or regularly visit a house or child care facility built before 1950?
- Does your child live in or visit a house or child care facility built before 1978 that is being or has been recently renovated?
- Does your child have a sibling or playmate who has or did have lead poisoning?
- Special populations - Immigrants from countries with high level of lead poisoning, iron-deficiency anemia, developmental delay +/- pica, abuse or neglect vitcims, parental exposure to lead at work, low-income families receiving government assistance]
- Elevated Blood Lead Levels: Always confirm!
- Lead Level 10/14mcg/dL: Education on reducing environmental exposure, Repeat test in 3 months
- Lead level 15-19 mcg/dL: Careful environmental history, Optimize nutrition with iron and calcium supplements, Frequent small meals to decrease absorption of lead, Repeat test in 2 months
- Lead Level >20mcg/dL: Obtain confirmatory test w/in 1 wk, referall to local health department, referall to specialist in lead toxicity therapy
- Lead Level >70mcg/dL: Hospitalize patient
Formula and Breast Feeding Issues
[edit]Yeast infection
[edit]- Infant may develop thrush and pass infection to mother
- Thrush Nipples" are red, swolen, cracked, and painful. Both parties need to be treated
- Infant - Nystantin Oral suspension (100,000u/mL) 1mL PO QID x 2wks after nursing
- Mother - Antifungal ointment after nursing
Mastitis
[edit]- Mother may have flu-like symptoms and one breast may become red, tender, and swollen in one area
- Management - Most common cause staph or strept.
- Frequent breast feeding, rest, fluids, Tylenol, and warm compresses
- Antibiotics Keflex 250-500mg QID x10-14days or Erythromycin/Clindamycin for PCN allergic
- Bilaterally Mastitis - concern for GBS infection. This is serious and would require treatmetn of both parties.
Supplementations
[edit]Vitamin D Supplementation
[edit]- All infants and children need 400IU per day
- Breast fed or partially breast fed infants - 400IU supplements in the first few days unless infant is taking in >1qt/day of VitD fortified formula
- Common Brands - Most MVI liquid preparations have 400IU in a dose, Poly-Vi-Sol, Bio-D-Mulsion, Baby Drops, Just D Infant drops
Iron Supplementation
[edit]- No clear consensus
- A term newborn has 4 months worth of iron stores
- Preterm infant needs supplementation starting at birth
Fluoride Supplementation
[edit]- Not needed if child received "city" or "commerical" water or if the well water has >0.6ppm F.
- Not recommended if child is breast feeding
- If Supplementation is indicated
- <0.3ppm in water: 0.25mgF/day for 6mnths-3yrs, 0.5mg F/day for 3-6yrs, 1.0mg F/day for 6-16yrs
- 0.3-0.6ppm in water: NONE for 6mnths-3yrs, 0.25mg F/day for 3-6yrs, 0.5mg F/day for 6-16yrs
NEONATAL JAUNDICE/BILIRUBIN
[edit]A fantastic website that will calculate light treatment level without having to look at graphs.
RESPIRATORY
[edit]Asthma
[edit]Clinical classification of asthma severity
[edit]| Severity | Symptom frequency | Nighttime symptoms | Peak expiratory flow rate or FEV1 of predicted | Variability of peak expiratory flow rate or FEV1 |
|---|---|---|---|---|
| Intermittent | < once a week | ≤ twice per month | ≥ 80% predicted | < 20% |
| Mild persistent | > once per week but < once per day | > twice per month | ≥ 80% predicted | 20–30% |
| Moderate persistent | Daily | > once per week | 60–80% predicted | > 30% |
| Severe persistent | Daily | Frequent | < 60% predicted | > 30% |
Treatment is a step wise approach
[edit]- Intermittent asthma = Step 1
- Persistent asthma = Step 2 - 6
- Step 1- Short Acting Beta Agonist (SABA), i/e. Albuterol Inh w/ spacer vs Nebs
- Step 2- Add Low-dose Inhaled Corticosteroid (ICS)
- Step 3- Increase to Medium-dose ICS
- Step 4- Medium-dose ICS + either Long Acting Beta Agonist (LABA) or Montelukast (Singulair)
- Step 5- High-dose ICS + either LABA or Montelukast (Singulair)
- Step 6- High-dose ICS + either LABA or Montelukast (Singulair) and consider systemic corticosteroids
Estimated Comparative Daily Dosages for Inhaled Corticosteroids
[edit]- Child <11yrs
| Drug | Low Daily Dose Child | Medium Daily Dose Child | High Daily Dose Child |
| Beclomethasone HFA
40 or 80mcg/puff |
80-160mcg | 160-320mcg | >320mcg |
| Budesonide DPI
90, 180, or 200mcg/INH |
180-400mcg | >400-800mcg | >800mcg |
| Budesonide INH
for Nebulization |
0.25-0.5mg | >0.5-1.0mg | >1.0-2.0mg |
| Flunisolide
250mcg/puff |
500-750mcg | 1000-1250mcg | >1250mcg |
| Flunisolide HFA
80mcg/puff |
160mcg | 320mcg | >640mcg |
| Fluticasone HFA/MDI
44,110,or 220mcg/puff |
88-176mcg | 176-352mcg | >352mcg |
| Triamcinolone acetonide
75mcg/puff |
300-600mcg | >600-900mcg | >900mcg |
- Clinical Care Guidelines-
http://www.med.umich.edu/1info/fhp/practiceguides/asthma.html
- Peak Flow Tables-
http://www.med.umich.edu/1info/FHP/practiceguides/asthma/pefrates.pdf
Croup
[edit]- Typically a viral infection of the larynx associated with mild upper respiratory symptoms (rhinorrhea, cough, inspiratory stridor, fever). The key symptom is a harsh "barking" cough. It's usually not serious, and kids recover within a few days, but a small percentage of patients will develop breathing difficulties and may need medical attention.
- Usually in kids 3 months - 3 years and frequently in the Fall season. Also usually preceeded by a viral prodrome or URI symptoms.
Classification
[edit]One tool for measuring the severity of croup is the Westley croup score.
| Feature | Severity | |||
|---|---|---|---|---|
| Chest wall retraction | None = 0 | Mild = 1 | Moderate = 2 | Severe = 3 |
| Stridor | None = 0 | With agitation = 1 | At rest = 2 | |
| Cyanosis | None = 0 | With agitation = 4 | At rest = 5 | |
| Level of consciousness | Normal = 0 (including sleep) |
Disoriented = 5 | ||
| Air entry | Normal = 0 | Decreased = 1 | Markedly decreased = 2 | |
- A Westley score of ≤ 2 designates mild croup. The characteristic barking cough and hoarseness may be present but without resting stridor.
- A score of 3 to 7 is classed as moderate croup, and typically there will be signs of increased respiratory effort, including muscles of respiration|accessory muscle recruitment and sternal recession.
- A score of ≥ 8 indicates severe croup, and these children are at the greatest risk of respiratory failure. There is marked in drawing of the sternum, and the child may become fatigued and distressed.
- An alarming feature is a decrease of stridor in a child previously demonstrating severe obstructive signs. With worsening airway obstruction, air movement is so limited that the characteristic sound is lost.
- Diff Dx
- Epiglottitis, Foreign Body, Bacterial Tracheitis, Subglottic stenosis
- Evaluation
- Usually just a clinical diagnosis. More severe cases may require further evaluation. (Pulse ox, PA and lateral neck films- "steeple sign" with Croup vs the "thumb sign" with Epiglottitis)
- Treatment
- Dexamethasone 0.6mg/kg IM or PO as a 1 time dose.
- Mod - Severe cases: racemic epinephrine 0.05-0.1 ml/kg/dose mixed w/ normal saline. There may be rebound so pt need to be monitored for 2-4 hours. Hospitalize if more then 1 treatment is needed.
- Inhalation of humidified air is frequently reccomended, but it's not clear this offers a real benefit.
- Indications for Hospitalization: Stridor at rest, low O2 sat, tachypnea/retractions, ill appearance, decreased consciousness
Bronchiolitis
[edit]- Inflammation of the bronchioles, usually caused by viruses.
- Often presents in Winter and Spring.
- Clinical Diagnosis Includes:
- 1st episode of acute wheezing, age < 24 months, PNA ruled out, NO Family Hx of asthma, Sxs associated w/ viral infection
- Symptoms
- Expiratory wheezing and inspiratory rales
- Temp typically < 101
- Intercostal retracions, grunting, dyspnea, tachypnea, prolonged expiratory phase
- ST, cough, coryza
- Diff Dx
- Asthma, Allergies, PNA, Foreign body, Cystic Fibrosis, GERD, CHF
- Evaluation
- CXR
- If sxs sever can consider ABG, pulse ox, viral nasal swab (RSV)
- Treatment
- 1 in 50 kids will require hospitalization
- Most pt's can be treated at home with symptomatic relief
- Tylenol, Ibuprofen for fevers
- Dextromethorphan for coughs if older > 2.
- Bronchodilator therapy
- Maintain hydration
- Parents need to seek medical care if the condition worsens. Steroids not helpful.
- Inpatient criteria- tachypnea, retractions, resp distress, cyanosis, hypoxemia, dehydration, immunocompromised pt's, pt's w/ cardiopulmonary dz
OTITIS MEDIA
[edit]Must have ALL of the following: 1) fever or ear pain, 2) middle ear fluid, and 3) red or opaque TM
General Treatment
[edit]- Re-evaluate in 2weeks to see if treatment worked and if there is an effusion, if present consider
- Re-evaluate in 6wks
- Re-reat with different antibiotic
- Analgesics PO
- Tylenol - 10/15mg/kg q4-6hrs
- Drops 0.8mL=80mg, Suspension 160mg/5cc
- Ibuprofen - 5-10mg/kg q8hrs
- Drops 1.25mL=50mg, Suspension 100mg/5cc
- Tylenol - 10/15mg/kg q4-6hrs
- Analgesics Topicall
- Auralgan otic suspension 2-4gtt in ear QID (not to be used if perforated)
Antibiotic Doses and Availability
[edit]| Drug | Dose | Availability |
| Amoxicillin | 80-90mg/kg/day (high dose)
in 2-3 divided doses |
Suspension: 125, 200, 250, 400mg/5cc
Chewable 125, 200, 250, 400mg Tabs/Cap: 250, 500, 875mg |
| Bactrim
(children >2mnts) |
SMG 40mg/kg/day
TMP 8mg/kg/day in 2 divided doses |
Suspension: SMX 200mg/5mL TMP 40mg/5mL
Tabs: SS: SMX 400mg and TMP 80mg DS: SMX 800mg and TMP 160mg |
| Augmentin | 40-45mg/kg/day
in 2-3 divided doses In treatment failure 90mg/kg/day of Augmentin ES-600 |
Suspension 125, 200, 250, 400mg/5mL
Chewable: 125, 200, 250, 400mg Tabs: 250, 500, 875mg ES-600: 600mg/5mL, less clavulanic acid |
| Cefixime (Suprax)
children>6mnths |
8mg/kg/day in 1 dose | Suspension 100mg/5mL |
| Cefdinir
(Omnicef) |
7mg/kg/q12hr
14mg/kg/q24hr |
Suspension:125mg/5mL
Capsule:300mg |
| Azithromycin | Day 1: 10mg/kg x1
Day 2-5 5mg/kg |
Suspension: 100, 200mg/5mL
Caps: 250mg |
| Clindamycin | 30-40mg/kg/day
in 3 divided doses |
Suspension 75mg/5mL
Caps: 75, 150, 300mg |
- Clinical Care Guidelines-
http://www.med.umich.edu/1info/fhp/practiceguides/om.html
Persistent Effusion
[edit]- May persist for 2-3months after treatment, does not require treatment
- Check hearing at 3months if patients with cognitive or developmental delay
Recurrent Otitis
[edit]- 3 episodes in 6mnth or 4 in 12mnths
- Consider other diagnosis: Sinsusitis, allergies, C3/C5 deficiency, submucous cleft palate, tumor
- Prevention
- Eliminate the use of pacifiers
- Avoid smoke exposure
- Encourage breast-feeding
- Decrease day-care exposure
- Administer Xylitol syrup or gum
- Tympanostomy/Myringotomy
Ruptured TM
[edit]- Treat with Cortisporin Otic: 2gtt QID x3-5days in addition to PO antibiotics
- Fluoroquinolone otic (Ofloxacin Otic): Recently approved for children
- Consider referall if persistent otorrhea >2wks despite antibiotics
- Chronic otorrhea >6wks is commonly caused by immunodeficiency, cancern, foreign body, cholesteatoma.
Serous Otitis
[edit]- Persistent effusion without infection
- Check hearing at 3months, if persistent, refer to ENT
- No need for PO steroids or decongestants.
PHARYNGITIS
[edit]- Inflammatory response involving the mucus membranes of the oropharynx.
- Kids can return to school after 24 hours of abx.
- In patients where Group A strep pharyngitis is suspected and a rapid strep screen is performed (specificity of >95% and a sensitivity ranging from
67% to 84%), confirm all negative results with culture in patients <16 years old.
- Viral agents cause most cases of pharyngitis: around 90% in adults and 70% in children
- Clinical Suspicion based on Centor Criteria
- 1. History of fever
- 2. Tonsillar exudates
- 3. Tender anterior cervical adenopathy
- 4. Absence of cough
- The presence of all 4 variables indicates a 40 - 60% positive predictive value. The absence of all 4 indicates a negative predictive value of > 80%. Thus, it's more felpful for ruling out strep.
- Treatment
- PCN is drug of choice. Pen VK 250 mg bid-tid (for < 60 lbs or 27 kg) and 500 mg bid-tid (for heavier kids & adolescents) for 10 days
- Amoxicillin 40 mg/kg/24 hr bid-tid or 750 mg (250 mg 3 tabs) as a single daily dose for 10 days is adequate if compliance is a concern
- If suspension must be prescribed, Amox is better tolerated due to the extremely bitter taste of PCN. Erythromycin is preferred for patients allergic to PCN. For pts expected to be intolerant or non-compliant with an erythromycin product (e.g., younger patients), consider azithro or a narrow spectrum oral cephalosporin like cephalexin. Abx's must be started w/n 9 days of the acute illness and continued for 10 days (5 days for azithromycin) to eradicate GABHS and prevent acute rheumatic fever.
DIARRHEA
[edit]- Increase in number, volume or fluidity of BMs compared to baseline. Acute if < 2 weeks.
- 60% due to viruses, 20% due to bacteria, 10% due to parenteral illness, 5% due to parasites, 5% due to unknown etiology.
- Causes of Diarrhea
- Acute- Gastroenteritis (viral), systemic infxn, ATB use, disaccharidase deficiency, Hirschsprung, food poisoning, toxic ingestion, hyperthyroid
- Chronic- postinfectious 2/2 to lactase deficiency, cow's milk intolerance, celiac dissease, soy milk intolerance, cystic fibrosis, secretory tumors, familial villous atrophy, primary immune defects, IBD, IBS, lactose intolerance, factitious diarrhea, anxiety/stress
- History
- Well Water?
- New foods or exposures?
- Travel?
- Developmental Status?
- Hydration Status (urine output)?
- Blood in stool?
- Exam
- Hydration Status (vitals, MMM, tears, cap refill, fontanelles)
- General well being??
- Abdomen, Derm, GU exam
- Assessment of Dehydration (Mild 3-5%, Mod 6-9%, Severe >10%)
- Evaluation
- Not usually needed in mild, short term diarrhea.
- If pt is ill can obtain Stool leukocytes, occult blood, stool culture, O+P, C Diff, Salmonella, Shigella, Campylobacter, Yersinia
- Basic, CBC
- Treatment
- Rehydration with oral fluids (pedialyte, Gatorade) in mild cases, if severe then will require IV fluids.
- Can give smaller volume more frequent feeds.
NEWBORN
[edit]- NICU Cheatsheet http://www.med.umich.edu/i/h3/Articles/ArtNICUcheat.pdf
- Bili calculator http://www.bilitool.org
CONTRACEPTIONS
[edit]Oral Contraceptive Side Effects Adjustment
[edit]| Symptom | Probable Etiology | Change Required |
| Break through bleeding
first 10 days |
Estrogen deficiency | Increase Estrogen |
| Break through bleeding
second 10 days |
Estrogen +/- Progestin
deficiency |
Increase estrogen or progestin |
| Prolonged or heavy menses | Progestin deficiency | Increase progestin |
| Delayed onset of menses | Progestin deficiency | Increase progestin |
| Shortened menses | Progestin excess | Decrease progestin |
| No menses | Progestin excess or
estrogen deficiency |
Continue one cycle then
increase estrogen |
| Weight gain | Progestin excess | Decrease progestin |
| Hirsutism, acne, hair loss | Progestin excess | Decrease progestin or
change to progestin with low androgenicity |
| Cervicitis, yeast vaginitis | Progestin excess | Decrease progestin |
| Depression, decreased libido
fatigue |
Progestin excess | Decrease progestin |
| Nausea, vomiting | Extrogen excess | Decrease estrogen |
| Skin discoloration | Extrogen excess | Decrease estrogen |
| Uterine cramps | Extrogen excess | Decrease estrogen |
| Migraine, blurred vision | Estrogen excess | Needs further evaluation
Consider stopping medication |
| Edema, breast tenderness, headache | On pills - Estrogen excess
On Placebo week - Progestin excess |
Decreased offending medication, diuretic |
| Androgenic symptoms | Progestin excess | Change to 3rd generation progestin
(desogestrel) |
| Dyslipidemia | Progestin excess | Change to 3rd generation progestin
(desogestrel) |
Common Composition of Combination OCPs
[edit]LOW Androgenic Activity of Progestin Component
[edit]| Type | Name | Estrogen ug | Progestin | mg |
| Monophasic | Necon0.5/35 | 35 | Norethindrone | 0.5mg |
| Ovcon 35 | 35 | Norethindrone | 0.4 | |
| Ortho-Cyclen, Mononessa, Sprintec | 35 | Norgestimate | 0.25 | |
| Desogen, Apri, Orho-Cept | 30 | Desogestrel | 0.15 | |
| Yasmin | 30 | Drospirenone
antiandrogenic activity |
3 | |
| Yas 24/4 | 20 | Drospirenone
antiandrogenic activity |
3 | |
| Loestrin Fe 24 | 20 | Norethindrone | 1 | |
| Biphasic
Ultra-low dose |
Mircette, Kariva | 20/10 | Desogestrel | 0.15 |
| Triphasic | Ortho tri-cyclen trinessa, Tri-sprintec | 35 | Norgestimate | 0.18/0.215/0.25 |
| Triphasic
Ultra low dose |
Ortho-tri Cyuclen Lo | 25/25/25 | Norgestimate | 0.18/0.215/0.25 |
MEDIUM Androgenic Activity of Progestin Component
[edit]| Type | Name | Estrogen amnt ug | Progestin | mg |
| Monophasic | Ovcon 50 | 50 | Norethindrone | 1.0 |
| Ortho-Novum 1/50 | 50
(mestranol) |
Norethindrone | 1.0 | |
| Ortho-Novum 1/35, Necon 1/35,
Norcept-E 1/35 |
35 | Norethindrone | 1.0 | |
| Loestrin 21 1/20, Loestrin Fe 1/20
Loestrin 24 FE |
20 | Norethindrone acetate | 1.0 | |
| Alesse, Lessina | 20 | Levonorgestrel | 0.1 | |
| Biphasic | Ortho-Novum 10/11, Necon 10/11,
NEE 10/11 |
35/35 | Norethindrone | 0.5/1.0 |
| Triphasic | Ortho-Novum 7/7/7, Necon 7/7/7 | 35/35/35 | Norethindrone | 0.5/0.75/1.0 |
| Triphasil | 30/40/30 | Levonorgstrel | 0.05/0.075/0.125 |
HIGH Androgenic Activity of Progestin Component
[edit]| Type | Name | Estrogen amnt ug | Progestin | mg |
| Monophasic | Ovral, Ogestrel | 50 | Norgestrel | 0.5mg |
| Loestrin Fe 1.5/30, Loestrin 21 1.5/30
Microgestrin Fe 1.5/30 |
30 | Norethindrone | 1.5 | |
| Lo-Ovral, Lo-Ovral 21 | 30 | Norgestrel | 0.3 | |
| Nordette, Levora | 30 | Levonorgestrel | 0.15 | |
| Extended cycle | Seasonale 91day,
Seasonique 91day |
30 | Levonorgestrel | 0.15 |
Progestin Only Pills
[edit]- Commonly used for post-partum OCPs as effect on lactation is minimal
| Type | Name | Estrogen amnt ug | Progestin | mg |
| Monophasic | Micronor, Nor-QD, Errin | none | Norethindrone | 0.35 |
| Ovrette | none | Norgestrelone | 0.075 |
Emergency Contraception
[edit]- Copper IUD
- Place within 120hours of unprotected sex
- Reduces risk of pregnancy up to 99%
- Plan B (Levonorgestrel)
- 0.75mg tab within 72hours ang again in 12hours
- May take 1.5mg in one dose
- Consider repeating dose if emesis occurs within 1 hour of administration
- Available OVER THE COUNTER for >18yrs and by prescription for any age
- Reduces pregnancy risk up to 85%
- Yuzpe Regimen
- Ethinyl Estradiol(100mcg) and Levonorgestrel (0.5mg)x2 q12hours
- For example - Ovral: 2 white pills q12hrs x 2
- Reduces pregnancy risk to 75-80%
- Major side effect of nausea/emesis, consider meclizine prior to first dose
- Ethinyl Estradiol(100mcg) and Levonorgestrel (0.5mg)x2 q12hours
- Miferpristone (RU-486)
- Indicated for termination of pregnancy. NOT to be used as emergency contraception
- Only supplied to physicians who sign and return a prescriber's agreement
- FDA with strict guidelines regarding the use of this drug
Informational Handouts
[edit]IUD Patient education materials
- Mirena IUD Website http://www.mirena-us.com/
- Paraguard IUD Website http://www.paragard.com/
- UM IUD information http://health.med.umich.edu/healthcontent.cfm?xyzpdqabc=0&id=6&action=detail&AEProductID=HW_Knowledgebase&AEArticleID=tw9516
Tubal Ligation education materials
- UM Information http://health.med.umich.edu/healthcontent.cfm?xyzpdqabc=0&id=6&action=detail&AEProductID=hw_knowledgebase&AEArticleID=hw7305
INFECTIONS
[edit]CDC's Treatment Guideline for STDs
[edit]http://www.cdc.gov/STD/treatment/2006/toc.htm
- Contains information on diagnosis and treatment of a wide variety of sexually transmitted disease. Also includes information on clinical prevention guidelines, special populations (pregnancy, adolescents, children, MSM, and WSW), Hepatitis A,B, and C, scabies, body lice, STDs in the setting of a sexual assault
- Uncomplicated Chlamydia infection http://www.cdc.gov/STD/treatment/2006/urethritis-and-cervicitis.htm#uc4
- Uncomplicated Gonorrhea infection http://www.cdc.gov/STD/treatment/2006/urethritis-and-cervicitis.htm#uc6
- Bacterial Vaginosis http://www.cdc.gov/STD/treatment/2006/vaginal-discharge.htm#vagdis2
- Cervicitis http://www.cdc.gov/STD/treatment/2006/urethritis-and-cervicitis.htm#uc3
- Nongonococcal Urethritis http://www.cdc.gov/STD/treatment/2006/urethritis-and-cervicitis.htm#uc2
- Male Patients Who Have Urethritis http://www.cdc.gov/STD/treatment/2006/urethritis-and-cervicitis.htm#uc1
- Trichomoniasis http://www.cdc.gov/STD/treatment/2006/vaginal-discharge.htm#vagdis3
- Vulvovaginal Candidiasis http://www.cdc.gov/STD/treatment/2006/vaginal-discharge.htm#vagdis4
- PID treatment http://www.cdc.gov/STD/treatment/2006/pid.htm#pid2
- Genital HSV http://www.cdc.gov/STD/treatment/2006/genital-ulcers.htm#genulc3
- Genital Warts http://www.cdc.gov/STD/treatment/2006/genital-warts.htm#warts1
- Syphillis http://www.cdc.gov/STD/treatment/2006/genital-ulcers.htm#genulc6
- Scabies http://www.cdc.gov/STD/treatment/2006/ectoparasitic.htm#ecto2