1. health and fitness
2. disease

‫اﻟﺪﻟﻴﻞ اﻟﺴﺮﻳﺮي اﻟﻌﻤﻠﻲ ﻟﻸﻃﺒﺎء اﻟﻌﺎﻣﻠﻴﻦ ﻓﻲ ﻣﺮاآﺰ اﻟﺮﻋﺎﻳﺔ اﻟﺼﺤﻴﺔ اﻷوﻟﻴﺔ‬
‫‪Practical Clinical Guide for Lebanese Primary Care Health Center Physicians‬‬
‫‪English Version‬‬
‫‪March 2000‬‬
‫اﻟﺠﻤﻌﻴﺔ اﻟﻌﻠﻤﻴﺔ ﻟﻄﺐ اﻟﻌﺎﺋﻠﺔ‬
‫ﺑﺎﻟﺘﻨﺴﻴﻖ ﻡﻊ‬
‫ادارة اﻟﻤﺮاآﺰ اﻟﺼﺤﻴﺔ ﻓﻲ وزارة اﻟﺼﺤﺔ اﻟﻌﺎﻡﺔ‬
‫و ﻡﺸﺎرآﺔ‬
‫اﻟﺠﻤﻌﻴﺎت اﻟﻌﻠﻤﻴﺔ ﻓﻲ ﻥﻘﺎﺑﺔ اﻻﻃﺒﺎء ﻓﻲ ﺑﻴﺮوت‬
‫‪Lebanese Society of Family Medicine Continuing Education Committee‬‬
‫‪1‬‬
Contributors
Chief editor: Ghassan Hamadeh, MD - Associate Professor of Family Medicine, American University of Beirut.
Contributing authors (by alphabetical order):
Chapters
Academic affiliation
Dr. Camille Aizarani
Dr. Madeleine Akel
Dr. Khalil Ashkar
Dr. Rayana Buhaka
Dr. Nabil Kanaan
Dr. Beatrice Khater
Dr. Malek Makarem
Dr. Umayya Musharrafieh
Dr. Jibrail Razzouk
Hyperlipidemia, vaccination.
Diabetes, obesity.
Breast mass, back pain, depression, thyroid nodule.
Burns, exanthems, diarrhea, fever in children, well child.
Abdominal pain, constipation, otitis, viral URI.
Amenorrhea, dysmenorrhea, red eye.
Congestive heart failure, hypertension, anemia.
Bronchiolitis, croup, tuberculosis.
Bronchitis, pharyngitis, dysuria, hematuria, headache.
Dr. Bassem Saab
Dyspepsia, peptic ulcer disease, sinusitis, adult health
maintenance.
Asthma, panic disorder.
Vaccination, well child, otitis, bronchiolitis, croup.
Family Medicine, USJ
Family Medicine, AUB
Family Medicine, AUB
Pediatrics, MoPH
Family Medicine, AUB
Family Medicine, USJ
Family Medicine, AUB
Family Medicine, AUB
Family Medicine
Private Practice
Family Medicine, AUB
Dr. Josette Sfeir
Dr. Durriya Sinno
Dr. Jinan Usta
Contraception, vaginal discharge, prenatal care, hormone
replacement therapy.
Family Medicine, USJ
Pediatrics,
Private practice
Family Medicine, AUB
Contributing individual reviewers and their specialties (by alphabetical order):
Dr. Hassan Awada
Dr. Sami Azar
Dr. Judy Bahhouth
Dr. Mohammad Bulbul
Dr. Michel Daher
Dr. Hassan El Amin
Dr. Bernard Jirbaka
Dr. Elie Karam
Dr. Abdul-ghani Kibbi
Dr. Salman Mroueh
Dr. Baha Noureddine
Dr. Assad Soueid
Dr. George Zeytoun
Specialty
Academic Affiliation
Rheumatology
Endocrinology
Pulmonology
Urology
General Surgery
Psychiatry
Pediatrics
Psychiatry
Dermatology
Pediatrics
Ophthalmology
Gastroenterology
Otolaryngology
USJ
AUB
LU
AUB
LU
AUB
LU
USJ
AUB
AUB
AUB
AUB
AUB
Contributing Scientific Committees of the Order of Physicians
Lebanese society of
Cardiology
Lebanese society of
Endocrinology
Lebanese society of
Gastroenterology
Lebanese society of
General medicine (co-editors in final review)
Lebanese society of
Nephrology and Hypertension
Lebanese society of
Obstetrics & Gynecology
Lebanese society of
Pediatrics
Lebanese society of
Pulmonology
Lebanese society of
Rheumatology
AUB: American University of Beirut, MoPH: Ministry of Public Health, LU: Lebanese University, USJ: University Saint Joseph
2
Table of contents
Contributors ............................................................................................................................................ 2
‫ ﻡﻘﺪﻡﺔ‬......................................................................................................................................................... 4
Common acute problems ........................................................................................................................ 5
Abdominal pain evaluation ........................................................................................................ 6
Acne ........................................................................................................................................... 9
Low back pain.......................................................................................................................... 13
Acute bronchitis ....................................................................................................................... 19
Burns........................................................................................................................................ 21
Constipation ............................................................................................................................. 25
Dyspepsia................................................................................................................................. 28
Dysuria..................................................................................................................................... 31
Headache.................................................................................................................................. 35
Hematuria................................................................................................................................. 40
Pharyngitis ............................................................................................................................... 43
Community acquired pneumonia ............................................................................................. 46
Peptic Ulcer Disease ................................................................................................................ 50
The red eye............................................................................................................................... 54
Sinusitis.................................................................................................................................... 56
Thyroid Nodule........................................................................................................................ 61
Urinary incontinence in the elderly.......................................................................................... 63
Viral Upper Respiratory Tract Infection (Common Cold)....................................................... 67
Common chronic problems................................................................................................................... 70
Asthma ..................................................................................................................................... 71
Congestive Heart Failure ......................................................................................................... 78
Depression ............................................................................................................................... 86
Diabetes ................................................................................................................................... 94
Hyperlipidemia ...................................................................................................................... 105
Hypertension.......................................................................................................................... 114
Obesity ................................................................................................................................... 118
Panic Disorder........................................................................................................................ 121
Tuberculosis........................................................................................................................... 124
Women’s health .................................................................................................................................. 127
Amenorrhea ........................................................................................................................... 128
Breast nodule ......................................................................................................................... 130
Contraception counseling....................................................................................................... 133
Dysmenorrhea & Premenstrual Syndrome ............................................................................ 137
Menopause, hormone replacement & osteoporosis ............................................................... 139
Prenatal care........................................................................................................................... 143
Approach to a patient with vaginal discharge........................................................................ 147
Children health.................................................................................................................................... 150
Bronchiolitis........................................................................................................................... 151
Croup ..................................................................................................................................... 153
Diarrhea in children ............................................................................................................... 156
Childhood Exanthems............................................................................................................ 160
Fever without a source under 3 years..................................................................................... 163
Acute otitis media .................................................................................................................. 166
Preventive health................................................................................................................................. 171
Well child health supervision................................................................................................. 172
Periodic Health Examination ................................................................................................. 176
Immunizations ....................................................................................................................... 178
3
‫ﻣﻘﺪﻣﺔ‬
‫ﻱﻀﻊ هﺬا اﻟﻜﺘﻴﺐ ﺑﻴﻦ ﻱﺪي اﻟﻄﺒﻴﺐ اﻟﻌﺎم )ﻃﺒﻴﺐ اﻷﻃﻔﺎل‪ ،‬اﻟﻌﺎﺋﻠﺔ‪ ،‬اﻟﻨﺴﺎﺋﻲ اﻟﻌﺎم أو اﻟﺪاﺧﻠﻲ ‪(Generalist-‬‬
‫ﺧﻼﺹﺔ ﻡﺒﺴﻄﺔ ﻋﻠﻰ ﺵﻜﻞ )‪ (Aide-Memoir‬ﻟﻤﻘﺎرﺑﺔ اﻷرﺑﻌﻴﻦ ﺡﺎﻟﺔ اﻷآﺜﺮ ﺵﻴﻮﻋﺎ ﻓﻲ اﻟﺮﻋﺎﻱﺔ اﻟﺼﺤﻴﺔ‬
‫اﻷوﻟﻴﺔ ﻓﻲ ﻟﺒﻨﺎن ‪.‬‬
‫دﻻﺋﻞ اﻟﻌﻤﻞ هﺬﻩ )‪ (Guidelines‬ﻡﺮاﺝﻌﺔ ﺱﺮﻱﻌﺔ ﺕﻌﺘﻤﺪ ﻋﻠﻰ دﻻﺋﻞ ﻋﺎﻟﻤﻴﺔ أو ﻡﺤﻠﻴﺔ ﻡﻮﺝﻬﺔ ﻟﻠﻄﺒﻴﺐ اﻟﻌﺎم‬
‫ﻓﻲ ﻡﺮاآﺰ اﻟﺮﻋﺎﻱﺔ اﻟﺼﺤﻴﺔ اﻷوﻟﻴﺔ و هﻲ ﻡﺘﺤﺮآﺔ ﺱﺘﻌﻤﻞ اﻟﺠﻤﻌﻴﺎت اﻟﻌﻠﻤﻴﺔ ﻓﻲ اﻟﻨﻘﺎﺑﺔ ﻋﻠﻰ ﻡﺘﺎﺑﻌﺘﻬﺎ دورﻱﺎ‬
‫وﻓﻖ اﻟﺤﺎﺝﺔ و هﻲ ﻗﺎﺋﻤﺔ ﻋﻠﻰ ﺑﺮاهﻴﻦ وﺑﺎﺋﻴﺔ )‪ (Evidence Based‬أﺙﺒﺘﻬﺎ اﻟﻤﺆﻟﻔﻮن ﻓﻲ ذﻱﻞ آﻞ ﻡﺪاﺧﻠﺔ ‪.‬‬
‫وﻗﺪ ﻟﺠﺄت وزارة اﻟﺼﺤﺔ و ﻥﻘﺎﺑﺔ اﻷﻃﺒﺎء و اﻟﺠﻤﻌﻴﺎت اﻟﻌﻠﻤﻴﺔ ﻟﻬﺬا اﻷﺱﻠﻮب ﺑﻬﺪف ﺕﺤﺪﻱﺪ ﺕﺒﺎﻱﻦ أﺱﺎﻟﻴﺐ‬
‫اﻟﻌﻤﻞ و اﻟﻌﻼج ‪ .‬ﻓﻜﻤﺎ هﻮ ﻡﻌﻠﻮم ﻡﻦ ﺧﻼل اﻟﺪراﺱﺎت اﻟﺘﻲ ﻗﺎﻡﺖ ﺑﻬﺎ وزارة اﻟﺼﺤﺔ ﻓﻲ ﻟﺒﻨﺎن و اﻟﺪراﺱﺎت‬
‫اﻟﻌﺎﻟﻤﻴﺔ ﻓﺎن ﺕﺒﺎﻱﻦ ﻃﺮق اﻟﻌﻼج و ﻡﻘﺎرﺑﺔ اﻟﻤﺮض ﺕﺆدي إﻟﻰ زﻱﺎدة اﻟﻜﻠﻔﺔ اﻟﻄﺒﻴﺔ ﻋﻠﻰ اﻟﻔﺮد واﻟﻤﺠﺘﻤﻊ ‪.‬‬
‫ﻥﺎهﻴﻚ ﻋﻦ اﺡﺘﻤﺎﻻت رداءة اﻟﺨﺪﻡﺔ اﻟﻄﺒﻴﺔ اﻟﺘﻲ ﻗﺪ ﺕﺨﺘﺒﺊ وراء ﺱﺘﺎر "ﻓﻦ اﻟﻄﺐ" أو "ﺡﺮﻱﺔ اﻟﻤﻤﺎرﺱﺔ"‪.‬‬
‫اﺧﺘﻴﺮت هﺬﻩ اﻟﺤﺎﻻت وﻓﻖ اﻹﺡﺼﺎءات اﻟﻤﻨﺸﻮرة ﻓﻲ اﻟﻤﺠﻠﺔ اﻟﻄﺒﻴﺔ اﻟﻠﺒﻨﺎﻥﻴﺔ و ﺑﺎﻻﺕﻔﺎق ﻡﻊ ادارة اﻟﻤﺮاآﺰ‬
‫اﻟﺼﺤﻴﺔ ﻓﻲ وزارة اﻟﺼﺤﺔ اﻟﻌﺎﻡﺔ‪ .‬وﻗﺎم ﺑﻮﺽﻌﻬﺎ ﻡﺠﻤﻮﻋﺔ ﻡﻦ أﺱﺎﺕﺬة اﻟﺠﺎﻡﻌﺎت ﻓﻲ ﻟﺒﻨﺎن ﺙﻢ راﺝﻌﻬﺎ‬
‫وﻥﻘﺤﻬﺎ أﺱﺎﺕﺬة وأﻋﻀﺎء ﻓﻲ اﻟﺠﻤﻌﻴﺎت اﻟﻌﻠﻤﻴﺔ ﻟﻨﻘﺎﺑﺔ اﻷﻃﺒﺎء وﺡﺮرﺕﻬﺎ ﻟﺠﻨﺔ اﻟﺘﻌﻠﻴﻢ اﻟﻄﺒﻲ اﻟﻤﺴﺘﻤﺮ ﻓﻲ‬
‫اﻟﺠﻤﻌﻴﺔ اﻟﻌﻠﻤﻴﺔ ﻟﻄﺐ اﻟﻌﺎﺋﻠﺔ وﺕﻢ ﻋﺮﺽﻬﺎ ﻟﻠﻤﻨﺎﻗﺸﺔ ﺽﻤﻦ ‪ ٣‬ورﺵﺎت ﻋﻤﻞ ﻟﻠﻨﻘﺎش اﻟﻌﺎم ﺽﻤﺖ اﻃﺒﺎء‬
‫ﻋﺎﻡﻠﻴﻦ ﻓﻲ اﻟﻤﺮاآﺰ اﻟﺼﺤﻴﺔ و ﻡﻤﺜﻠﻴﻦ ﻋﻦ ﺑﻌﺾ اﻟﺠﻤﻌﻴﺎت اﻟﻌﻠﻤﻴﺔ‪ .‬ﻟﺬﻟﻚ ﻓﻬﻲ ﻥﺘﺎج اﻷﻃﺒﺎء ﻟﻸﻃﺒﺎء ﻟﺘﻜﻮن‬
‫ﻡﻘﻴﺎﺱﺎ ﻟﻬﻢ ﻱﻘﻴﻬﻢ ﺽﻐﻮﻃﺎت اﻟﺒﺮوﺕﻮآﻮﻻت اﻟﻘﺎﺋﻤﺔ ﻋﻠﻰ ﻡﺒﺪأ ﺧﻔﺾ اﻟﻜﻠﻔﺔ دون اﻋﺘﺒﺎر ﻥﻮﻋﻴﺔ اﻟﺨﺪﻡﺔ‬
‫اﻟﻄﺒﻴﺔ وﻱﺴﺎﻋﺪهﻢ ﻋﻠﻰ اﺧﺘﻴﺎر اﻟﻮﺱﻴﻠﺔ اﻷﻥﺠﺢ ﺹﺤﻴﺎ وإﺡﺼﺎﺋﻴﺎ وﻡﺎدﻱﺎ ﻟﻤﺼﻠﺤﺔ اﻟﻤﺮﻱﺾ وﻡﻦ وﺝﻬﺔ‬
‫ﻥﻈﺮﻩ وإﻡﻜﺎﻥﻴﺘﻪ ‪.‬‬
‫اﻟﻄﺒﻴﺐ ﻏﺴﺎن ﺡﻤﺎدة‬
‫اﻟﻤﺤﺮر اﻟﺮﺋﻴﺲ‬
‫اﺱﺘﺎذ ﻡﺸﺎرك ﻓﻲ ﻃﺐ اﻟﻌﺎﺋﻠﺔ‬
‫اﻟﺠﺎﻡﻌﺔ اﻻﻡﺮآﻴﺔ ﻓﻲ ﺑﻴﺮوت‬
‫‪4‬‬
Common acute problems
5
Abdominal pain evaluation
Definition and Epidemiology
Pain, acute or chronic, affecting the abdomen, that is most commonly due to a functional or
pathologic problem of the gastro-intestinal tract, but it can also originate from organs of other systems
and from extra-abdominal sites.
Etiologies
1. Acute pain
a. Gastro-intestinal and intraperitoneal causes:
i. Inflammation/infection
1. Peritoneum: Chemical/non-bacterial peritonitis: perforated ulcer; gallbladder; ovarian
cyst; mitelschmerz. Bacterial peritonitis: primary pneumococcal/ streptococcal/
tuberculous; perforated hollow viscus: stomach/ intestine/ biliary tract
2. Hollow intestinal organs: appendicitis; cholecystitis; peptic ulceration; gastroenteritis;
regional enteritis; Meckel’s diverticulum; colitis (ulcerative; bacterial; amebic);
diverticulitis.
3. Solid viscera: pancreatitis; hepatitis.
4. Mesentery: lymphadenitis
5. Pelvic organs: pelvic organ disease; tubo-ovarian abscess; endometritis.
ii. Mechanical (obstruction/acute distention)
1. Hollow intestinal organ: intestinal obstruction ( adhesions; hernia; tumor; volvulus;
intussusception) ; biliary obstruction ( calculi; tumor; choledochal cyst;
hematobilia)
2. Solid viscera: acute splenomegaly; acute hepatomegaly (e.g. cardiac failure)
3. Mesentery: omental torsion
4. Pelvic organs: ovarian cyst; fibroid torsion or degeneration; ectopic pregnancy
iii. Vascular:
1. Intraperitoneal bleeding: ruptured liver, spleen, mesentery, ectopic pregnancy, or
aneurysm (aortic, hepatic, splenic)
2. Ischemia: mesenteric thrombosis; hepatic infarction; splenic infarction; omental
ischemia
iv. Miscellaneous: endometriosis
b. Extraperitoneal Causes:
i. Cardiopulmonary: pneumonia; empyema; myocardial ischemia;
ii. Blood: leukemia; sickle-cell crisis
iii. Neurogenic: spinal cord tumors; spine osteomyelitis; herpes zoster
iv. Genito-urinary: cystitis, vaginitis, nephritis; pyelitis; perinephric abscess; ureteral
obstruction (calculus; tumor); prostatitis; seminal vesiculitis; epididymitis.
v. Vascular: aortic aneurysm dissection, rupture or expansion
vi. Metabolic: uremia; diabetic keto-acidosis; porphyria; Addisonian crisis
vii. Toxins: bacterial (tetanus); insect bites; venoms; lead poisoning
viii. Abdominal wall: intramuscular hematoma
ix. Psychogenic
c. Pediatric acute abdomen differential diagnosis:
i. Infants: viral enteritis; intussusception; gastroenteritis; GE reflux; bacterial enterocolitis;
pneumonitis; appendicitis; pyloric stenosis; testicular torsion; mesenteric cyst;
ruptured tumors; pancreatitis; Meckel’s diverticulitis; Hirschprung’s disease;
strangulated hernia; poisoning; trauma (child abuse)
6
ii. Children: Meckel’s diverticulitis; cystitis; viral enteritis; appendicitis; Crohn’s disease;
Bacterial enterocolitis; pneumonitis; pancreatitis; ruptured tumors; poisoning;
pyelonephritis; trauma (child abuse)
iii. Adolescents: pelvic inflammatory disease; appendicitis; Mittelschmerz; Crohn’s disease;
pancreatitis; pneumonia; bacterial enterocolitis; viral enteritis; peptic ulcer;
poisoning; trauma; ectopic pregnancy; pregnancy; appendicitis; cholelithiasis;
psychosomatic.
2. Chronic pain
a. Look for pain pattern:
i. Bouts of pain with normal intervals: intermittent porphyria; internal hernias;
endometriosis.
ii. Pain present most of the time: chronic pancreatitis; pancreatic or colonic malignancy.
b. Pain not reflecting pathophysiologic abnormality: non-ulcer dyspepsia and irritable bowel
syndrome.
c. Look for pain arising from the abdominal wall: peripheral nerve injury; hernias; pain of spinal
origin; spontaneous rectal sheath hematoma.
d. Look for psychiatric disorders: primary affective disorders; somatization; psychogenic
(conversion) pain; anxiety state; substance abuse; hypochondriasis; schizophrenia;
malingering…
History
Although individualization should be the rule, the following symptom screening questioning may be
very useful:
1- Provoking: What makes the pain worse? Does it hurt more when you move, take a deep
breath or cough? (peritoneal irritation)
2- Palliating: What makes your pain improve?
3- Quantity: On a scale of 1 to 10, how bad is the pain?
4- Quality: Could you explain what this pain feels like?
5- Region: Where is the pain located?
6- Radiation: Does the pain radiate (e.g. back, shoulders, genitals..)?
7- Severity: Is the pain sufficiently severe to disrupt activities of daily living?
8- Temporal Issues:
a. - Was the onset sudden or gradual?
b. Does the pain come and go or is it constant
9- Is this the first time you have had the pain?
Objective Findings
1. Physical Examination:
• General: blood pressure (? shock); temperature (high, infection; low, septic shock);
pulse…
• Check body habitus and facial expression:
-Unwilling to change position ? peritonitis
-Hip and knee flexion / shallow breathing ? peritoneal irritation
-Intense movement to alleviate pain interrupted by restful intervals ? colic
• Inspection: hernial bulges; masses; distention…
• Auscultation: Bowel sounds, abdominal bruits, Lower lung fields (lower lobe pneumonia)
• Palpation: Gentle superficial palpation of all quadrants, start from the least to the most
symptomatic and use gentle deep palpation
• Percussion test is preferred to rebound tenderness test to check for peritoneal irritation
• Pelvic examination to rule out pelvic organ pathology in females
• Rectal examination to rule out a significant ano-rectal pathology
7
2. Laboratory Evaluation:
• Basic tests: CBC, urine analysis, amylase (and, if elevated, lipase) , pregnancy test(or BHCG) if pregnancy is a possibility
• Optional tests (requested if needed only): electrolytes, BUN, creatinine, glucose, EKG
and liver function tests.
3. Radiological evaluation:
Is not always needed, yet sometimes maybe of prime importance:
• Plain X-rays: of the chest (whenever chest infection is suspected) and abdomen (in which
pneumoperitonium, gas-fluid levels, fecaliths, gallstones, urinary stones, ascitis and
obliteration of the psoas shadows should be checked). The yield of plain films is 10%.
• Other studies: Ultrasound, upper GI endoscopy, colonoscopy, contrast gastrointestinal or
urological studies, laparoscopy, CT scan and arteriography. These maybe requested in
special conditions.
Management options
Depends on the cause. In chronic or recurrent pain, always remember psychogenic causes such as
anxiety, depression or Irritable Bowel Disease. Pain of chronic un-treatable conditions (e.g.
unresectable pancreatic carcinoma and chronic pancreatitis), may need both pharmacologic Rx plus
behavioral Rx.
Sources
1. Schwartz Principles of Surgery. McGraw Hill. 6th edition. pp 1016-1020
2. Primary Care Medicine. Lippincot. 2nd Edition. pp 261-269.
3. Lake AM. Chronic abdominal pain in childhood: diagnosis and management. Am Fam Physician
1999 Apr 1;59(7):1823-30
4. Decadt B. et al. Randomized clinical trial of early laparoscopy in the management of acute nonspecific abdominal pain. Br J Surg 1999 Nov;86(11):1383-6
8
Acne
Definition and Epidemiology
Acne Vulgaris is a chronic inflammatory disorder of the pilosebaceous follicles, particularly those of
the face, chest and back. It is generally a self limited condition characterized by the presence of
comedones, papules, pustules, cysts, and scars. It affect mostly adolescents, but may be found in
neonates, prepubescent children and adults. It results from obstruction of follicles by excessive
amounts of keratinaceous material and sebum, and the production of chemical mediators leading to
inflammation by the skin resident anaerobe (Propionebacterium acnes).
In early adolescence, acne affects more boys than girls; later in life, however, the sex prevalence is
reversed. Nearly 85% of the 12- 24-year-old age, 8% of 25-34 year old, and 3% of 35-44 have acne.
Acne Vulgaris tends to be familial, although its exact inheritance pattern remains undetermined.
CLASSIFICATION: Acne is classified according to the predominant lesions into:
1. Stage 1: Comedonal Acne.
2. Stage 2: Papular Acne.
3. Stage 3: Pustular Acne.
4. Stage 4: Nodulo-cystic Acne.
Acne is also classified according to the severity into:
1. Mild: Small papules and comedones.
2. Moderate: papules predominate, with few nodules and rare cysts.
3. Severe: Nodules and cysts predominate.
History
1. Initial visit:
a. Ask about duration of the condition, location, relationship to seasonal variation and
stress A family history of acne should be established.
b. Ask about other skin diseases, drug allergies, general health, intake of any
medications and previously used acne therapies. In females ask about menstrual
history, use of oral contraception, pregnancy status, use of cosmetics, abnormal hair
growth and voice changes. This is important to establish the diagnosis, Identify the
possible causes, and institute therapy.
2. Follow up:
a. Ask about response to treatment, compliance with therapy and side effects of
medications.
Objective Findings
1. Initial visit:
Describe the number, location (Face, upper chest, back, other sites) and morphology of lesions as
follows:
i. Closed comedone or whitehead: Whitish, slightly pa1pable pinhead sized 1-3
mm in diameter
ii. Open comedone or blackhead: Flat or slightly raised, brownish or black
measuring up to 5 mm in diameter.
iii. Papules: Red, may be tender, elevated lesions as large as 5 mm in diameter.
iv. Pustules: Superficial papules containing pus.
v. Nodules: Solid, inflammatory lesions that exceed 5 mm in diameter deep in
the dermis.
vi. Cysts: Large nodules that are suppurated.
vii. Scars: Sequelae of inflammation, may appear as atrophic or hypertrophic
9
2. Follow-up:
Number and location of lesions.
Diagnostic Considerations
•
•
•
•
Acne Rosacea: Occurs in middle-age, gradual onset, exacerbated by cold temperature, hot or
spicy food and stress, not associated with plugged sebaceous follicle or comedone formation,
and most common complaint is skin redness and / or flushing.
Gram-negative Folliculitis: Papules and superficial pustules are present, associated with
long-term antibiotics use.
No tests are indicated unless Isotretinon is used, then the following tests are necessary:
o Serum pregnancy test one week before starting course.
o Complete blood count before starting course.
o Lipid profile and liver function tests before starting course, at two weeks then
monthly until response to medication is established.
In females with severe acne and virilizing symptoms and/or irregular menses, diagnostic tests
include free testosterone, androstenedione, DHEAS, FSH, and LH.
Management options
The treatment goal is to prevent new lesions and scarring, improve the physical appearance, and
preserve the psychosocial well-being and well being which can be impaired by the presence of
disfiguring lesions.
1. Mild Acne:
a. Start with Tretinoin (Retin-A) 0.025% cream or 0.01% gel at night for two weeks.
b. Add either Benzoyl peroxide 5%, 10% (Oxy 5, Oxy 10) in the morning,
or topical antibiotics such as erythromycin, or clindamycin twice daily,
or both.
2. Moderate Acne:
a. Add to the above regimen any of the following oral antibiotics:
i. Doxycycline 100 mg bid.
ii. Erythromycin 500 mg bid.
iii. Minocycline 50 mg bid
b. Consider adding an oral contraceptive containing 0.035 mg of ethinyl estradiol
combined with the triphasic regimen of norgestimate (Ortho Tri-Cyclen) in women
with no known contraindication to oral contraceptive therapy
3. Severe Acne: same as for moderate plus/or any of the following:
a. Isotretinoin 0.5-2 mg/kg/day.
b. Refer for Intralesional injection of Triamcinolone.
c. Refer for surgical comedone removal.
10
Therapeutic choices
Topical
agents
Used in mild to moderate acne – first line treatment
Comedolytic
agents
Benzoyl peroxide
2%, 5% and 10% concentration.
Antibiotics
Clindamycin
1% lotion or gel
Erythromycin
2% gel
20% cream
Azeleic Acid
(Azelex, Fostex)
Tretinoin
(Retin-A)
Systemic
agents
Liquid and cream forms are less irritating,
gel is better for oily skin.
Apply to clean dry skin, twice a day or
only at bedtime
Applied twice daily
Applied twice daily
Apply bid, less irritating than others
0.01, 0.025, 0.5% creams,
0.01 and 0.025% gel
0.05% liquid
Especially good for open and closed
comedones
Apply daily
Start with lowest strength available and
increase dose every 2 to 3 weeks if
necessary
May be combined as benzoyl peroxide in
AM, Retin A in PM
Used in moderate and severe acne
Antibiotics
Systemic Retinoids
- Isotretinoin
(Accutane®, 13cis-retinoic acid)
Hormonal Therapy
Tetracycline
Kills P. acnes and inhibits neutrophil
250 mg PO QID or 500 BID
migration
Erythromycin
May not work with pustular acne
250 mg QID
Minocycline
May cause dizziness or color changes
50 mg BID or 100 mg daily
Trimethoprim/Sulfamethoxazole Used for refractory cases
•
Synthetic vitamin A derivative for severe acne
•
Dramatic clearing with prolonged periods of remission in severe
acne
•
Reduction of sebum, anti-inflammatory, and corrects altered
keratinization
•
Side Effects: dry skin and mucous membranes, decreased night
vision, hair loss, liver function abnormalities, hyperlipidemia, vertebral
hyperostoses
•
Major Teratogen - full contraception is absolutely required; no
effects on sperm
•
Serum beta HCG must be done to rule out pregnancy before
prescribing
•
Informed consent required and adequate contraception must be used
anti-androgens (e.g. oral contraceptives with spironolactone
When to Refer
Refer severe acne
Advice about therapy or combination therapy
Starting or following up oral isotretinoin
11
Patient Education
Prevention
No evidence of any specific measure to prevent acne exists. However, it is believed that
environmental factors such as humidity, excessive sweating or scrubbing, use of harsh soaps, some
cosmetics and medications may cause or make acne worse.
Treatment and compliance
1. Explain causes and pathogenesis of acne.
2. Explain purpose of treatment: ‘ control rather than cure’.
3. Give “general care measures” instructions:
a. Limit face washing to twice daily
b. Do not pick face or squeeze comedones
c. Avoid make-up, but if necessary, use only water-based ones and wash them of in the
evening
4. Instruct about proper use of topical agents:
a. More is not better.
b. Apply agent 20 min. after gently washing and thoroughly drying the face, and 30 min.
before going to bed.
5. Explain possible side effects
6. Give oral and written instructions.
7. Emphasize that improvement may not be noticed before 4-8 weeks.
8. Try to enhance compliance.
9. Answer questions and correct myths:
a.
Acne is not a sign of poor hygiene.
b.
Acne is not an infection.
c.
Diet does not affect acne.
d.
Sunlight may affect acne.
e.
Take the opportunity to talk with adolescents about other health issues: sex, smoking,
drug and alcohol abuse, accidents and violence.
Sources
Acne-Net: www.derm-infonet.com
American academy of dermatology: guidelines of care of acne vulgaris. J Am Acad Dermatol 22:676680, 1990
12
Low back pain
Definition and Epidemiology
Low back pain affects most people with a lifetime incidence of 60-90%. It occurs most often between
the ages 45 and 65 years. Although most episodes of acute back pain (80-90%) recover spontaneously
within 4 to 8 weeks irrespective of treatment, 10% of patients develop chronic low back pain and
many more have recurrent acute episodes. Patients with chronic pain utilize the majority of resources
expended on low back pain and are the most difficult to treat.
Back pain can be classified as:
• Mechanical
1.
Acute soft tissue injury or lumbosacral sprain (of less than 6 weeks duration)
2.
Acute discogenic with or without nerve root infringement
3.
Chronic mechanical pain (symptoms present for more than 12 weeks)
• Non-mechanical
1. Rheumatologic diseases
2. Infection
3. Tumor
4. Metabolic and endocrinologic disorders
5. Referred pain
History
Determine mechanism of injury, onset, duration, distribution and relation to position.
Occupational history and risk factor history including:
• Previous episodes
• Hard physical labor
• Activity that increases physical stress on the spine
• Psychological stress
• Osteoporosis
• Physical inactivity
Red flags in the history that should prompt immediate attention and possible referral include:
1. History of cancer
2. Unexplained weight loss
3. Immunosuppression
4. Prolonged use of steroids
5. Intravenous drug use
6. Urinary tract infection
7. Pain that is increased or unrelieved by rest
8. Fever
9. Significant trauma related to age (e.g. fall from a height or motor vehicle accident in a young
patient, minor fall or heavy lifting in a potentially osteoporotic or older patient or a person
with possible osteoporosis)
10. Bladder or Bowel incontinence
11. Urinary retention (with overflow incontinence). In absence of urinary retention, the likelihood
of a cauda equina is less than 1 in 10000.
13
Objective Findings
Physical examination
1. Gait and Posture:
• Observe the gait of the patient and check for scoliosis.
2. Range of motion:
• Check flexion, extension, lateral flexion and lateral rotation of low back.
• Pain increased by flexion reflects mechanical causes usually
• Pain precipitated by extension is indicative of spinal stenosis.
3. Palpation or percussion of the spine:
• Point tenderness may indicate fracture or infection.
• Para-spinal tenderness indicates muscle spasm.
4. Palpation of the sciatic notch:
• Tenderness over the sciatic notch with radiation to leg indicates nerve root compression.
5. Heel-Toe Walk, Squat and Rise:
• Inability to walk Heel-Toe, Squat and rise may indicate Cauda - Equina Syndrome or
neurologic compromise.
6. Straight leg raising:
• Pain occurring between the angle 30-60% is a provocative sign of nerve root compression.
Pressure over the popliteal region when performing the maneuver should worsen the pain
(popliteal compression test).
• Flexion of the ankle increases the pain.
• Straight leg raising is positive in 95% of patients with proven disc disease but it can be
positive in80-90% of patient without disc disease. In contrast, crossed straight leg raising is
less sensitive but much more specific for disc herniation.
7. Reflexes, motor and sensory testing:
Root Reflex
Motor
Sensory
L3-L4 L4 Knee Inversion
Medial Ankle
L4-L5 L5 none Extend 1st toe Foot Dorsum
L4-S1 S1 Ankle Eversion
Lateral Foot
• An altered reflex does not suggest the need for invasive management because it is generally
transient and fully reversible. Items to be checked:
• Checking the above items with the straight leg-raising maneuver allows the detection of the
most clinically important radiculopathy related to disc disease.
8. Findings that should prompt for immediate action / consultation or referral include:
• Saddle anesthesia
• Loss of anal sphincter tone
• Major motor weakness in lower extremities
• Fever
• Vertebral tenderness
• Limited spinal range of motion
• Neurologic findings persisting beyond one month
Laboratory tests
1.
2.
3.
CBC, ESR
HLA B27 antigen in case of suspected ankylosing spondylitis.
Serum protein electrophoresis if multiple myeloma is in the differential diagnosis.
14
Radiographic Assessment:
X-Rays are not recommended as a routine in low back pain, unless the history and physical exam are
suggestive of a suspicious cause. Selective indications for radiography in acute low back pain include:
1. Age > 50 years
2. Significant trauma
3. Neuromotor deficits
4. Unexplained weight loss (5 kg or more in six months)
5. Suspicion of ankylosing spondylitis
6. Drug or alcohol abuse
7. History of Cancer
8. Use of Corticosteroids
9. Temperature > = 37.8C
10. Recent visit (within 1 month ) for same problem and no improvement
11. Patient seeking compensation for back pain
12. CT or MRI are recommended if the patient has red flags suggestive of cauda equina syndrome or
progressive motor weakness or, if after one month of treatment, symptoms persist.
13. CT better for bone and MRI better for Vascular / Soft Tissue.
14. Nearly 20% of patients without symptoms having a herniated disk by CT or MRI.
Diagnostic Considerations
The goal in the initial evaluation of acute low back pain is to exclude systemic disease, identify
neurologic deficits and differentiate mechanical from non mechanical pain. Physicians should check
for red flags for potentially serious conditions:
Differential diagnosis of low back pain
Primary mechanical
Ligamentous strain
derangements
Muscle strain or spasm
Facet joint disruption or degeneration
Intervertebral disc degeneration or
herniation
Vertebral compression fracture
Vertebral end-plate micro fractures
Metabolic disease
Osteoporosis
Osteomalacia
Inflammatory
Ankylosing spondylitis
rheumatologic
Reactive spondyloarthropathies
disorders
(including Reiter’s syndrome)
Infection
Epidural abscess
Vertebral osteomyelitis
Referred Pain
Abdominal or retroperitoneal visceral
process
Retroperitoneal vascular process
Nonspecific
Bacterial endocarditis
manifestation of
Influenza
Systemic illness
Primary fibromyalgia
Neoplasia
Epidural or vertebral carcinomatous
metastases
Multiple myeloma, lymphoma
15
Spondylolisthesis
Spinal stenosis
Diffuse idiopathic skeletal
hyperostosis
Scheuermann’s disease
(vertebral epiphyseal aseptic
necrosis)
Hemochromatosis
Ochronosis
Psoriatic arthropathy
Polymyalgia rheumatica
Septic discitis
Pott’s disease (tuberculosis)
Herpes Zoster
Retroperitoneal malignancy
Psychogenic pain
Malingering
Primary epidural or intradural
tumors
Paget’s disease of bone
Management options
Non-Pharmacological Management:
1.
2.
3.
4.
5.
Reassure patient that acute episodes are self limiting
Educate about back hygiene and exercises
Complete bed rest is NOT necessary
Allow patients to achieve maximum functioning and regular activity.
Exercise program is to prevent debilitation related to inactivity and improve activity
tolerance.
Approach
Bed rest
Exercise
Mobilization & manipulation
Acupuncture
Educational & motivational programs
TENS
Massage therapy
Biofeedback
Heat/Cold
Back support
Surgery
Benefit
No evidence of efficacy
Improves recovery
May help some patients
May help some patients
May help some patients
Limited evidence of efficacy
Provides short-term symptomatic relief
No evidence of efficacy
Provides brief symptomatic relief
May prevent some low back injuries
May help some patients
In chronic low back pain exercise should be encouraged provided:
• Program is tailored to the individual patient
• Impact on comorbid conditions (e.g., coronary heart disease) is considered
• A regular and consistent program is adhered to
• Program is supervised by a physiotherapist or trainer, and includes a combination of aerobic and
resistance training
• The patient is motivated
Pharmacologic Treatment:
Goals of pharmacologic treatment of LBP
Acute Low Back Pain
Achieve pain control
Improve or restore range of motion
Return to normal daily activities
Minimize adverse drug effects
Chronic Low Back Pain
Optimize pain control
Improve function
Resume daily activities
Minimize adverse drug effects
In acute episodes:
1. Acetaminophen 325-1000 mg every 6 hours may be used for pain.
2. Non Sterioidal Anti infalmmatory Drugs (NSAID) can be used and are all relatively
comparable: Ibuprofen 400-800 mg every 6 to 8 hours can be used with food. Other COX II
inhibitors may be less irritant to the stomach. Consider treatment for up to two weeks.
3. Avoid muscle relaxants, tramadol and narcotics; they do not provide any more benefit than
acetaminophen or NSAIDs.
4. Reserve tramadol and naroctic analgesics for severe pain
In chronic pain, although a number of different drugs are used empirically for chronic low back pain,
the efficacy of most medications has not been demonstrated by controlled trials. Pharmacologic
16
treatment should be part of a multi-disciplinary approach. The physician must consider the presence
of comorbid conditions, medications adverse effects when selecting the most appropriate drug.
Outcomes
60% of patients will return to work within one month and 90% within 3 months. Most patients will
recover within the first week. Job satisfaction is the single most reliable predictor of return to work.
Not to be missed
Besides major organic conditions heralded by “red flags” above, non-organic factors are sometimes
important contributors to the symptoms of acute low back pain with depression a common cause in
chronic LBP. Other psychosocial factors can be economical or social such as job satisfaction, work
compensation claims or marital stressors.
To check for non-organic factors, physicians can use the Waddell’s tests:
Waddell’s Tests for Non-organic Physical Signs where 3 or more inappropriate responses of the
following suggest complicating psychosocial issues in patients with low back pain.
Test
Inappropriate Response
Tenderness
Superficial, non-anatomic tenderness to light touch
Simulation
Axial loading
Vertical loading on a standing patient’s skull produces LBP
Rotation
Passive rotation of shoulders and pelvis in same plane causes pain
Distraction
Discrepancy between findings on sitting and supine straight leg
raising tests
Regional Disturbances
Weakness
“Cogwheel” (give-way) Weakness
Sensory
Non-dermatomal sensory loss
Overreaction
Disproportionate facial expression, verbalization or tremor during
examination
When to Refer
Refer for physical therapy and exercise instruction
Refer to orthopedist when a neurologic deficit is detected or spinal stenosis suspected or in cases of
severe or recurrent pain.
Patient Education
Resume usual activities as soon as possible with light activity.
Sleep on firm back supporting mattress
Avoid unnecessary lifting or carrying
Education about proper lifting techniques and posture
Instruction on home exercises
Encourage low impact aerobic exercise
Quality of care indicators
1. Proper use of conservative approach as first- line treatment.
Percentage of acute and chronic low back pain and acute and chronic sciatica patients with a referral
for surgical consult six to eight weeks after presenting to the clinic for a new episode.
2. Avoid unnecessary imaging studies.
17
Percentage of patients with acute low back pain receiving lumbosacral spine Xrays within a week
from presentation
Percentage of patients with acute low back pain receiving CT or MRI.
3. Proper referral to specialists
Percentage of chronic low back pain patients assessed for psychosocial factors for disability and
chronic pain.
Sources
1. Acute lower back pain in adults. Clinical practice guideline No. 14. Rockville, MD, Agency for
Health Care Policy and Research, 1994 (AHCPR No. 95-0642).
2. Robert Bratton M.D.: Assessment and Management of acute low back pain. AFP Nov. 18, 1999.
3. George Ruoff M.D.: Management of low back pain for the family physician, Lecture during the
scientific assembly of AAFP: Orlando Sept., 1999
4. Deyo RA, et al. Lumbar spine films in primary care. J Gen Int Med 1986; 1:20-5.
5. Waddell G, et al. Nonorganic physical signs in low back pain. Spine 1980;5:117-25.
18
Acute bronchitis
Definition and Epidemiology
•
•
It is an inflammatory condition of the tracheobronchial tree , characterized by productive
cough and usually caused by a viral infection.
It is most often self limited, lasting 1-2 weeks and occuring mostly during the winter months.
Attacks are worsened by cold, damp weather, pollution and cigarette smoking.
History
Symptoms vary depending on the etiologic agent and coexisting pulmonary disease and whether the
patient smokes.
1. Cough usuallly persistent after a simple upper respiratory tract infection
2. Character of sputum
3. Fever – low grade. The presence of chills should raise the possibility of pneumonia
4. Chest pain may be present with congesion
5. Smoking history
6. History of asthma
Objective Findings
Lung exam may be useful but it is not diagnostic . Wheezing , rhonchi a pronlonged expiratory phase
or other obstructive signs may be present .
Diagnostic Considerations
Diagnosis is purely clinical , no available test can provide a definitive diagnosis of acute bronchitis
1. When pneumonia is suspected CXR may be useful in making the diagnosis especially if there is
no improvement after supportive treatment for 1 week
2. Microscopic exam or culture of sputum in healthy adults with acute bronchitis is generally not
healpful
3. Cough can be the result of :
a.
Upper respiratory tract infection & sinusitis .
b.
Sputum in this case is from deep pharynx & has accumulated from post nasal
drainage .
c.
Asthma & allergic bronchospastic disorder .
d.
There is evidence of reversible airway obstruction even when no infection is
present .
e.
Congestive heart failure .
f.
There might be wheezing , shorttness of breath & orthopnea . Symptoms are
often worse at night .
g.
Reflux esophagitis with chronic aspiration , may also have wheezing .
Symptoms are intermitted & worse when lying down .
h.
Pneumonia suspected on basis of the presense of high fever , constitutional
symptoms , severe dyspnea & certain physical findings or risk factors
i.
Bronchogenic tumors : cough is usually chronic & they may produce
obstructive symptoms , constitutional symptoms & sometimes hemoptysis
19
Therapeutic choices
1. Paracetamol ( panadol ) for fever
2. Bronchodilators if there is bronchospasm
•
Salbutamol 4 mg PO Qid
•
Salbutamol - 2 puffs by MDI 4 times daily
3. Cough suppression with a codeine based antitussive
4. Expectorants/Mucolytics are widely prescribed but do not alter course of disease (Rhinathiol,
Fluibron, Mucosolvan, etc…. used at 1 tsp tid as needed for symptomatic relief)
5. Evidence does not support the use of antibiotics in acute bronchitis unless symptoms persist
longer than 7 days or sputum becomes thick with constitutional symptoms and fever within 3 to 5
days of illness onset
• Commonly used antibiotics:
• Amoxicillin 500 mg PO TID for 7 days
• Erythromycin 250 mg PO QID for 10 days
• Augmentin 1000 mg BID for 7 days
Patient Education
1. About etiology , transmission & prognosis
2. Stop smoking & increase fluid intake
3. Return if no better in 5 days
Sources
1. Acute bronchitis , AFP , March 15 , 1998 , p 1270 - 1282
2. Koster F , Respiratory Tract Infections , Principles of Ambulatory Medicine , 4 th edition , p 329 336
3. Orr PH, et al. Randomized placebo controlled trials of antibiotics for acute bronchitis. J Fam
Practice 1993; 36(5):507-12.
20
Burns
Definition and Epidemiology
Exposure to temperature extremes, certain chemicals, electricity causing injury to skin tissues and
blood vessels, thus resulting in burns.
Burn wounds can be classified into six groups according to the mechanism of injury.
1.
Scalds: caused by liquid, grease or stream.
2.
Contact burns: divided into immersion or spill.
3.
Fire: divided into flash / flame.
4.
Chemical
5.
Electrical
6.
Radiation
History
•
•
•
•
•
•
•
•
•
Age
Causative, agent
Time of exposure
Extent of exposure
Medical status (trauma, illness, allergic)
Time, location (open vs. closed space)
Extent of injury
Treatment given
Tetanus immunization history
Objective Findings
•
•
•
•
Assessment of airway breathing circulation
Full Physical exam, Neurological status
Depth and extent of injury
o Extent surface area: rule of nines (See figure)
o Depth classification: see assessment.
CBC, electrolytes, BUN, or glucose levels, CPR, arterial blood gazes, CX Ray, urine analysis,
and urine myoglobin.
21
Diagnostic Considerations
Surface area of injury (Rule of nines)
The body is divided into anatomic regions that represent 9% or multiple of 9% of the total body
surface. The infant's or young child's head represents a larger proportion of the surface area and the
lower extremities a lesser proportion than an adult.
Depth of injury
1st degree
2nd degree
3rd degree
Skin red, dry, warm, sensitive to touch
Mild pain + swelling
Epidermis affected
Superficial partial thickness:
Pink, soft, moist, tender
Thin walled, filled blisters
Epidermis +superficial dermis
Deep partial thickness
Mixture of red and blanched white
Thick walled blisters (ruptured)
Epidermis +reticular dermis
Full thickness
White leathery appearance, clotted vessels, black
Epidermis and dermis affected
22
PLAN
First degree burn
•
•
•
•
•
•
1st degree burns heal naturally over several days
Verify tetanus status and give tetanus prophylaxis if needed
Wash burn with surgical soap and apply sterile non adherent dressing
Use analgesics as necessary
Protect from environment with daily clean dressing
If signs of infection or no healing in two weeks refer to specialist
Second & third degree burns
Emergency Department Management:
1.
2.
3.
4.
5.
Assess and Monitor airway, breathing and circulation
Apply O2, intubate: if necessary
NG tube and feeding for serious burns
If chemical burn remove soaked clothing, irrigate with water.
Assess extent and size of burn.
Hospital admission
Burn patients with the following circumstances require impatient care:
1. Those between 10 and 5 years of age with partial-thickness burns of greater than 15 percent total
body surface area (TBSA) or deep partial-thickness burns or full-thickness burns of greater than 5
percent TBSA.
2. Those less than 10 years or greater then 50 years of age with partial-thickness burns greater than
10 percent TBSA or deep partial-thickness burns greater than 3 percent TBSA.
3. Any patient with partial-thickness to full-thickness burns of the face, hands, feet, or perineum or
burns across major joints or circumferential limb burns.
4. Electrical burns.
5. Chemical burns.
6. Burns with inhalation injury.
7. Burns in-patient who have underlying medical problems or who are immunocompromised.
8. Burns associated with other trauma.
Specialized burn centers needed in case of
1. Major partial-thickness burns with a TBSA of great 25 percent in the 10- to 50-year-old age group
or great than 20 percent in children less than 10 years and adults older than 50 years.
2. Any full-thickness burn greater than 10 percent TBSA.
3. Burns involving the hands, face, feet, or perineum; circumferential limb burns; or burns across
major joints.
4. Major or moderate burns complicated by fractures or other trauma.
5. Electrical burns.
6. Burns in infants or the elderly.
7. Major or moderate burns in-patients who are poor risk due to underlying conditions.
8. Transfer to a burn unit should be considered for any patient where long-term social or emotional
support is needed or where there is going to be a long, difficult rehabilitation and/or recovery
period.
23
For extremities burn:
1.
2.
Assess the status of distal circulation: check for cyanosis, impaired capillary refilling time or
progressive paresthesias…
Escharotomy in case of circulatory embarrassment.
Fluid Resuscitation
Insert IV and start lactated Ringers according to estimation of requirements.
First 24 hours post-burn:
• 2-4 ml of LR/Kg body weight/% body surface burned.
• Infuse 1/2 calculated dose within first 8 hours post-burn; second half over next 16
hours.
• Adjust IV rate to maintain urine output at 30-50 ml/hr in adults.
• Make decreasing adjustments of IV rate gradually (10% increments q 1hr).
• Use of diuretics makes urine output an invalid measure of circulatory status.
Second 24 hours post-burn:
• 5% albumin in LR at 0.5ml/ Kg / % burn (200 cc of salt-poor albumin placed in 800
cc of LR).
Plus:
• D5W (OR 1/4 Normal saline (1/4 NS) primarily for children) to yield same, hourly
infusion rate as first 24 hours.
• Adjust DSW or the 1/4 NS rate, not the 5% albumin solution in order to maintain
urine output at 30-50 ml/hr.
Sources
24
Constipation
Definition and Epidemiology
Definitions of constipation usually include elements related to alterations in frequency, size,
consistency or ease of passage of stools.
It is defined commonly as infrequent difficult passage of stools. This may mean two or fewer bowel
movements per week, or excessive difficulty and straining at defecation, or both. A change from a
regular pattern with respect to frequency of and/or difficulty in defecation may also be called
constipation.
Etiologies
While in adults, new onset constipation can be a warning sign for a serious illness or malignancy
especially in the elderly; in children, the most common cause is “functional” constipation with no
neurologic or anatomic problems.
Other causes of constipation include problems related to:
Examples
Diet
Insufficient bulk in diet, excessive intake of cow’s milk,
dehydration.
Medication
Iron supplements, codeine cough syrup, some
antihypertensives, tricyclic antidepressants or antacids.
Painful defecation
Anal fissures, rectal prolapse, atresia or stenosis, hemorrhoids.
Mechanical
Anal atresia or stenosis in children, colorectal cancer in elderly,
difficulties
hernias, diverticulitis, torsion, adhesions, or irritable bowel
syndrome (IBS).
Metabolism
Hypothyroidism, hypercalcemia, renal tubular acidosis
Neurologic deficits Diabetes mellitus, Hisrchsprung’s disease, multiple sclerosis.
History
History is aimed at confirming the presence of constipation using the definition elements and then
excluding serious organic causes.
Individualization is important but the following should be considered while taking the history:
a. Frequency, consistency and caliber of stools
b. Painful defecation
c. Rectal bleeding
d. Relation to diarrheic episodes
e. Abdominal pain or distention
f. Duration of symptoms
g. Constitutional symptoms: Fever, chills, malaise, weight loss, nausea or vomiting
h. Dietary habits: use of fibers/fluid intake
i. Activity level
j. Current medications: Analgesics; antacids; anti-cholinergic; anti-depressants; anticonvulsants; anti-parkinsonian drugs; Bismuth; diuretics; iron; NSAID’s; opiates;
psychotherapeutic agents; laxatives, calcium channel blockers.
k. Psychological status
l. Others: symptoms of diabetes, hypothyroidism, hyper-calcemia, pregnancy, scleroderma,
cerebro-vascular disease, CNS tumors etc..
25
Objective Findings
1. On presentation:
i.
Abdominal examination: Look for gross deformities; abdominal tenderness;
tympanicity; abdominal masses; increased bowel sounds, hernias.
ii.
Rectal examination: Look for hemorrhoids; fissures; peri-anal abscess; digitally
felt rectal tumors; rectal prolapse.
iii.
General: Look for signs of systemic diseases such as hypothyroidism, diabetes,
malnutrition, parkinsonism, abnormal neurologic examination…
2. On follow-up:
i.
Abdominal examination
Diagnostic Considerations
Constipation: Functional versus organic
1. Initial tests
a. Stool for occult blood 3: if there is history of rectal bleeding, dark stools or if patient is
>50 years of age
b. Complete blood count if anemia of chronic diseases or secondary to GI bleeding is
suspected
c. TSH if hypothyroidism is suspected
d. Calcium serum level if hyperparathyroidism is suspected
e. Serum creatinine, electrolytes and BUN if uremia is suspected
2. Later testing
a. Flexible procto-sigmoidoscopy and barium enema or colonoscopy if patient has: Positive
stool occult blood; anemia; is above 50; has rectal bleeding; had no response to
conservative treatment; has small caliber stools; has weight loss and other constitutional
symptoms; has recent and otherwise unexplainable constipation.
Management options
1.
Functional constipation:
Non-pharmacological measures:
i.
High fiber diet e.g. vegetables and bran
ii.
Regular exercises e.g. walking
iii.
High fluid intake
iv.
Avoiding or altering possible causative agents such as medications
b.
Pharmacological measures: Laxatives:
i.
Bulk agents such as
• Psyllium (=Metamucil) 1tsp/d up to 1 tablespoon tid; Methyl cellulose 2g one to
three times daily (both are natural fibers);
• Polycarbophil 1g once to 4 times daily (artificial fiber)
ii.
Osmotic laxatives such as non-absorbable sugars e.g. sorbitol and lactulose
(=Duphalac) 1 tablespoon 1 to 3 times daily;
iii.
Magnesium hydroxide (=Milk of magnesia) 15 to 30 ml daily
iv.
Stool surfactant agents such as docusate sodium 50 to 200 mg daily orally or
rectally
c.
In acute constipation lasting for several days after: medical/surgical illness, travel,
dietary changes, medications, one can use the following:
i.
Cathartic laxatives such as cascara sagrada 4 to 8 ml daily orally, bisacodyl
(=Dulcolax) 5 to 15 mg orally or 10mg suppository, castor oil 15 to 45 ml orally ,
or
ii.
Osmotic laxatives such as magnesium citrate 18gms, magnesium sulfate 10 to
30gms, sodium phosphate 15 to 30gms and balanced polyethylene glycol 1 to 4 L
lavage solution or 1 powder sachet 1 to 4 times daily (=Movicol), or
a.
26
iii.
d.
2.
3.
Enemas such as saline enemas (non-irritating), pure water enema (irritating) and
oil retention enema (for impacted stools).
Fecal impaction, if resistant to pharmacological measures or enemas: use digital
disruption of fecal impacted material.
Constipation due to other causes (non-functional constipation): Treat the original cause,
medical or surgical.
In children, Corn syrup or Senna Syrop (Senokot) can be used.
Patient Education
a.
b.
c.
d.
e.
f.
Explain the cause of constipation
Explain the prognosis
Stress the importance of high fiber and high fluid diet
Advise regular exercise
Advise regular daily bowel habits after meals
Advise against overuse of laxatives
Sources
1.
2.
3.
4.
Akdamar K, Maumus L. Management of constipation in the elderly. Geriatrics 1981; 31:81-83
Barker L, et al. Principles of Ambulatory Medicine. Williams and Wilkins, 1986
Johnson A, et al., Constipation: is it functional or not? Patient Care, 18:128-147
Loening-Baucke L. Management of chronic constipation in infants and toddlers. Am Fam Phys
1994;49:397-406.
5. Leung AKC, Chan PYH, Cho HYH. Constipation in children. Am Fam Phys 1996;54:611-8.
27
Dyspepsia
Definition and Epidemiology
Dyspepsia is a broad term that covers a variety of symptoms including fullness, bloating, belching,
abdominal discomfort, heart burn, and nausea for at least one month. These symptoms may be
intermittent or continuous in nature and can vary in severity and duration. Bowel habits generally do
not change.
Prevalence vary between 20-69% of the adult population.
History
Usual symptoms are episodic, post prandial, upper abdominal discomfort or heartburn or
regurgitation. Burning epigastric pain which may awaken the patient may suggest a peptic ulcer.
Alarm symptoms include:
• Dysphagia – especially if progressive.
• Involuntary weight loss (3 kg or more over 1 month)
• Persistent anorexia, nausea, vomiting, early satiety or bowel habit changes.
• Gastro-intestinal blood loss (e.g. coffe ground emesis, hematemesis or melena)
• Upper abdominal mass.
• Iron deficiency anemia.
• New onset dyspepsia in a 50 year old person or older.
• Persistence of symptoms after 8 weeks despite treatment.
Inquire about use of medications including aspirin, NSAID, corticosteroids, alcohol, caffeine and
tobacco. Types of treatment used and duration.
Objective Findings
General physical for evidence of hepatobiliary disease, anemia or lymphadenopathy.
Abdominal examination for masses and tenderness.
Stools for occult blood
Diagnostic Considerations
The most common causes are:
• Non-ulcer dyspepsia
• Peptic ulcer disease
• Gastro esophageal reflux disease (GERD).
• Hepatobiliary disease.
The majority of cases (65-70%) are “functional” with investigations revealing no organic cause.
Gastric cancer is rare and is usually at an advanced stage when diagnosed. In the absence of warning
symptoms the need to exclude cancer should not drive investigations.
Patients <50 years with no alarming signs and symptoms may be treated empirically for up to 6-8
weeks without prior investigation. In the presence of alarming signs, refer for upper GI endoscopy;
other diagnostic tests may be needed:
• Diagnostic study to detect H. pylori
• Esophagogastrodudenoscopy (EGD)
• Ultrasonography of the abdomen if you suspect hepatobiliary problem.
28
Most physicians reserve these studies for patients with atypical symptom(s), or symptoms persisting
longer than 2 weeks despite empiric therapy.
Endoscopy is entertained in the following situations:
• When it is necessary to establish an anatomic diagnosis, endoscopy is a more reliable test than
upper GI barium series.
• Patients with dyspepsia with specific warning symptoms.
• To confirm a diagnosis of non-ulcer dyspepsia in patients:
o
Who are H. pylori seronegative and have persisting troublesome symptoms
o
With recurrent symptoms after antibiotic therapy for H. pylori
Management options
Most cases will resolve with lifestyle changes and empirical treatment with cimetidine.
Only 10% of patients will require another H2 blocker because they are allergic to or intolerant of
cimetidine or at risk for a drug interaction. Patients with dyspepsia which recurs despite lifestyle
changes and H2 blockers should be tested for H. Pylori, be scoped or undergo other testing.
Two options are commonly adopted:
1. Many guidelines recommend treating H. pylori positive patients with recurrent dyspepsia,
using triple antibiotic therapy. In such an approach, the number needed to treat to benefit one
patient aged <50 years is 4.
2. Another acceptable approach is to perform endoscopy, establish a definitive diagnosis, and
treat with antibiotics only if a peptic ulcer is identified.
The choice between these two alternatives should be made jointly with the patient. There is no
evidence that patients with non-ulcer dyspepsia or gastro esophageal reflux benefit from antibiotic
therapy to eliminate H. pylori. Many Lebanese gastro enterologists prefer the second approach: treat
H Pylori only after confirming presence of mucosal disease (gastritis, duodenitis or ulcers)
Therapeutic choices
1. Life style changes that may be of help include:
• Stress management
• Smoking cessation if the patient smokes
• Avoidance or decrease of alcohol intake
• Avoid chocolate and caffeinated drinks (coffee, tea, some soft drinks) and ‘decaf’
coffee
• Avoid anti-inflammatory drugs
2. Medication options include:
• H2 – receptor antagonists, namely cimetidine as a first line drug from the essential
drug list (400-600 mg. bid)
• Cisapride (Prepulsid) 5 mg tid. can be tried if no improvement is noted on H2 –
receptor antagonists after 2 weeks. Metoclopramide is as effective as Cisapride; the
latter may have less side effects. It is advised to continue Cisapride for one month at
least once started. Cisipride is contraindicated if the patient is receiving
erythromycin, clarithromycin, fluconazole and similar drugs, as it may cause
ventricular arrhythmias (including torsades de pointes)
• Triple drug therapy if infected with H. pylori.
29
When to Refer
Warning signs present
Failure of therapy
Algorithm
Dyspepsia
Non-Ulcer dyspepsia = 6570%
Reflux = 20 %
Peptic Ulcer = 10-16 %
Gastric cancer < 0.5 %
Early gastric cancer < 0.1 %
Warning symptoms:
Weight loss > 5%
Dysphagia
Anemia
Vomiting
Hematmesis
Melena
Consult GI
Yes
NO response
No
Simple measures:
Stop smoking
Stop caffeine and alcohol
Stop NSAID, ASA
Use Cimetidine 400-600 mg bid for 2 weeks OR
Ranitidine to avoid side effects or drug drug interactions
Improved
Yes
Continue Cimetidine
for 6 weeks
Yes
Continue Prokitenic
for a total of 4 weeks
No
Try a Prokitenic x 2
weeks
Improved
Preferred regimen
Lansoprazole 30 mg b.i.d +
clarithromycin 500 b.i.d +
Metronidazole 250 mg q.i.d or Amoxicillin 1 g b.i.d
All for 14 days
Then continue Cimetidine 400- 600 mg b.i.d for 6 weeks
No
H.pylori test or
refer for scope
Present
No response
No
Consult GI
Yes
Triple drug therapy
Sources
1. Graham D, et al. Practical advice on eradicating Helicobacter pylori infection. Post Graduate
Medicine 1999; 105:137-148.
2. Bytzer P et al. Empirical H2 blocker therapy or prompt endoscopy in management of
dyspepsia. Lancet. 1994;343:811-816.
3. Goulston KJ, et al. Use of H2 receptor antagonists in patients with dyspepsia and heartburn: a
cost comparison. Med J Aust. 1991;155:20-26.
4. De Boer W, et al. Randomized study comparing 1 with 2 weeks of quadruple therapy for
eradicating Helicobacter pylori. Am J Gastroenterol. 1994;89:1993-1997.
5. Management issues in the treatment of upper G.I. Disorders. International Primary Care
Group.
6. Soll AH. Medical treatment of peptic ulcer disease: practice guidelines. JAMA 1996
(275):622-9.
30
Dysuria
Definition and Epidemiology
Painful urination, typically referred to the tip of the penis in men or to the urethra in women
Accounts for up to 2% of all visits to primary care and is mostly due to urinary tract problems.
History
•
•
•
Dysuria that begins after voiding has begun (external dysuria) suggests genital tract problems.
Other symptoms of genital irritation may be present including itching, discharge or swelling.
Internal dysuria (occurs before voiding) is associated with the urinary tract system and
accounts for about 2/3 of dysuria cases. Other symptoms of urinary tract irritation may be
present and include urgency and hesitancy.
Systemic symptoms of infection may also be present.
Objective Findings
•
•
Vital signs, abdominal, testicular and pelvic examinations can guide to the source of this
complaint.
Rectal exam in males may need to be done to rule out prostatitis & prostate cancer. It should
be done carefully in suspected prostatitis because of hypothetical risk of seeding the blood
stream with bacteria.
Diagnostic Considerations
1. Cystitis:
• The patient presents with frequency, urgency, dysuria, & may have hematuria. There may
be a history of recent sexual intercourse. Physical exam will show that some patients will
have suprapubic tenderness but no CVA tenderness, urine analysis will show pyuria.
• In men, urine culture growing more than 1000 colony forming unit / ml, is a best sign of
UTI.
2. Sub clinical pyelonephritis :
• The patient presents with symptoms of cystitis but there is renal parenchymal
involvement found in 30 % of women presenting with symptoms of cystitis. It should be
suspected in patients with symptoms of cystitis & having one or more of the following
risk factors :
a. Symptoms present for more than one week
b. Diabetes mellitus
c. Immunocompromised patients
d. Pregnancy
e. Anatomic anomaly of the urinary tract
f. Vesicoureteral reflux
g. Relapse of symptoms within three days of treatment for acute cystitis
h. Urethral obstruction
i. History of acute pyelonephritis within one year
• Urine analysis is positive for pyuria. Urine culture usually shows more than 105 colony
forming unit per ml. Renal cortical scintigraphy is usually positive.
3. Acute pyelonephritis :
• The patient usually presents with fever, nausea, emesis, sepsis, back or flank pain
• On physical exam, there is costovertebral angle tenderness, deep right or left upper
quadrant tenderness. Urine analysis usually shows pyuria with casts of WBC. The urine
culture & sensitivity should be obtained.
31
4. Vaginitis:
a. Candidal :
Patients usually present with dysuria, vaginal pruritis & discharge usually worsen just before
menstruation. KOH smear may reveal mycelia.
b. Trichomonas :
Symptoms usually increase during & immediately after menstruation. Normal saline vaginal smear
may show motile trichomonas.
c. Bacterial vaginosis
d. Herpes simplex
Patients present with dysuria, fever, headaches, myalgia, neck pain, photophobia & sometimes vaginal
discharge. The patent is usually sexually active.
On physical exam, grouped vesicles are usually found on the cervix, pubic area & vaginal area with
tender inguinal adenopathy.
e. Atrophic vaginitis
Patients usually present with decreased vaginal discharge, vaginal tenderness, dyspareunia &
sometimes vaginal spotting, especially after intercourse.
f. Other causes of vaginitis
These include vaginal & urethral trauma, including sexual abuse & intervention of a
foreign body. Soaps douches, lubricants, spermicidal jellies, contraceptive foams,
sponges, tampons, sanitary napkins, perfumed soaps & toilet papers.
5. Urethritis (Non-gonococcal)
• Patients usually present with history of unprotected intercourse. Urethral swab is usually
positive for WBC. Gram stain may detect intracellular gram negative diplococci ( N.
gonorrhea )
6. Interstitial cystitis
• Inflammation of the bladder with unknown etiology. The characteristic symptoms are
suprapubic pain with nocturia, frequency of at least 8 times a day for at least 9 months.
• The majority of the patients have dyspareunia & 20 % have gross hematuria, patients are
older than 18 years, bladder capacity less than 350 ml & there is an urge at 150 cc. No
history of bacterial UTI in the last 3 months & no alternative explanation ( tumors,
chemical agents, T. B, radiation, etc ), bladder biopsy may be used to rule out other
etiologies as carcinomas. Urodynamic study is used to demonstrate a reduced bladder
capacity.
Management options
1. Urine analysis :
a. Pyuria indicates urethritis, prostatitis or other urinary symptoms.
b. White blood cells casts suggest acute pyelonephritis.
c. The first 10 cc of the first morning specimen should be examined in patients
suspected to have trichomonas infections.
2. Gram stain :
Gram stain of any urethral discharge should be part of the initial evaluation of patients suspected to
have urethritis. It directs the physician in choosing the initial empiric antibiotics.
3. Urine cultures & sensitivities :
a. To identify the causative organism in all patients suspected to have urinary infection
b. Greater than 100 colony forming unit per ml is significant, if symptoms of cystitis are
present.
4. Vaginal smears :
Potassium hydroxide ( KOH ) smears may reveal mycelia indicating fungal infection Saline smears
may reveal trichomonas.
5. Renal ultrasound or CT scan :
Is done for evidence of urinary obstruction or abscess.
32
Treatment options
1. Urinary tract infection (Cystitis, acute and subacute pyelonephritis)
a. Oral therapy should be considered in women with mild to moderate symptoms who
are compliant with therapy & can tolerate oral antibiotics but do not have other
significant conditions (such as pregnancy & gastrointestinal upset). Oral
fluoroquinolones should be considered in regions where the resistance exceed 15 % to
trimethoprim - sulfamethoxazol which is often considered the treatment of choice.
• Trimethoprim sulfamethoxazol ( Bactrim forte or Septrin DS ), one tablet 2X /
day for 3 days in cystitis and up to 14 days in pyelonephritis.
• Norfloxacin 400 mg ( Noroxin, Urobacid ), one tablet 2X / day for 3 days in
cystitis and up to 14 days in pyelonephritis.
• In pregnant women Amoxil 250 mg, 3X / day for 3 to 7 days.
b. Patients who are too ill to take oral antibiotics or who are unable to take them should
be initially treated with parenterally administered single agent.
• Ceftriaxone ( Rocephin ) one gram per day
• Ciprofloxacin 400 mg IV 2X / day
• Ofloxacin 400 mg IV 2X / day
• Gentamicin 3 mg / Kg / day divided tid
2. Vaginitis:
a. Candidal :
• Nystatin ( Daktarin ) 100,000 unit, vaginal tablets for 14 days
• Clotrimazol 10 mg, vaginal suppositories for 7 days
• Miconazole 2 % cream or 100 mg vaginal suppositories for 7 days
• Fluconazol 150 mg ( Diflucan ) orally in single dose
b. Trichomonas :
• Metronidazole ( Flagyl, Supplin ) 500 mg, 2X /day for 7 days or 2 grams as a
single dose. In case of failure, give Metronidazole one gram, 2X / day for 7 days.
Both partners should be treated simultaneously.
c. Bacterial vaginosis
• Metronidazole 500 mg, 2X / day for 7 days or 2 grams orally as a single dose or
Clindamycin 300 mg, orally, 2X / day for 7 days
d. Herpes simplex
• For the first clinical episode :
o
Acyclovir ( Zovirax ) 200 mg PO, 5X / day or 800 mg 3X /day for 5 to 10
days
o
Valcyclovir 1000 mg 2X / day or Famcyclovir 250 mg, 3X / day for 5 to 10
days
• Most cases of recurrent herpes do not require intermittent treatment & the benefit
from treatment is minimal in most patients
e. Atrophic vaginitis
• Topical estriol vaginal cream
3. Non gonococcal Urethritis
• Ceftriaxone 250 mg I. M once for gonorrhea
• Ofloxacin 400 mg once or ciprofloxacin 500 mg once for N. gonorrhea
• Doxycyclin 100 mg 2X / day for 10 days for C. trachomatis
• Ofloxacin 300 mg 2X / day for 10 days for Chlamydia trachomatis
4. Interstitial cystitis
• Pentosan polysulfate ( Elmiron ) 300 mg per day
• Amitriptyline ( Triptizol ) 25 mg / increasing 25 mg every 1 week up to 150 mg
per day at bed time
• Hydroxyzine ( Atarax ) 25 to 50 mg at bed time
33
Patient Education
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Explain pathogenesis & prognosis
Good hygiene
Generous fluid intake every day
Urination after sexual activities
Avoid unprotected intercourse & multiple partners
Stop using diaphragms with spermicides
Avoid heat, moisture & occlusive clothing
In menopausal women, estrogen replacement therapy, may reduce the frequency of UTI
Report to your doctor as soon as possible
Proper follow up
Sources
1. Ornstein Robert. Urinary tract infections in adults. AFP 1999. Vol 59, N. 5, p 1225 - 1234.
2. Kurowshi Kurt, MD. The woman with dysuria. AFP 1998. vol 57, N. 9, p 2155 - 2163.
3. Presti Joseph, MD. Current medical diagnosis & treatment 1999, 38th edition, p 894 - 895.
34
Headache
Definition and Epidemiology
Headache is a subjective feeling of pain referable to a variety of intracranial & extra cranial structures.
Less than 1% of headaches are caused by potentially dangerous problems. Up to 80% of headaches
seen in primary care are due to tension or muscular contraction type. Vascular headaches (migraine
and cluster) account for the majority of the remaining 20 to 30% of cases.
History
1. Identify headache characteristics (table)
2. Past medical history for similar headaches or chronic illness (hypertension, diabetes, cancer,
medications, etc..)
3. Psychosocial history: depression, stress, family and job satisfaction
4. Family history of headaches
Objective Findings
Physical examination:
1.
2.
3.
4.
Vital signs: Blood pressure and temperature
Neurologic examination
Optic fundi exam to rule out papilledema.
Face and ENT examination to rule out eyes, ears, throat, sinuses diseases. Check temporal
artery.
5. Neck exam to rule out muscle contraction, osteoarthritis or neck deformity.
Laboratory tests
1. Unnecessary for most patients with chronic, recurring headaches & for low risk patients
(young, prior history of headache or family history of headache, improving, no focal
neurologic signs, alert & oriented, with no worrisome symptoms or signs).
2. CBC may be asked in febrile patients.
3. E.S.R is indicated in older patients with new headaches to rule out temporal arteritis
4. Lumbar puncture is mainly performed if meningitis is suspected. It should not be performed
when increased intracranial pressure is suspected.
5. E.E.G may be useful in patients with chronic headaches who do not respond to therapy to
ensure no seizure disorder is present.
Imaging studies:
1. Acute headache:
a. CT scan is more sensitive in detection of hemorrhage
b. Focal neurologic signs or papilledema – r/o space occupying lesion
c. Severe headache (like no headache before) with sudden onset – r/o subarachnoid
hemorrhage
d. Severe headache following trauma r/o subdural or epidural hemorrhage
e. Symptoms of increasing intracranial pressure
2. Chronic headache:
a. CT or MRI
b. Focal neurologic signs or papilledema – r/o space occupying lesion
c. Worsening headaches: more frequent, more severe or uncontrollable
d. Warning signs present: Nausea/vomiting, weight loss
35
3. Special headaches:
a. X - ray of sinuses if sinusitis is suspected.
b. X - ray of temporomandibular joint if a dysfunction is suspected.
Diagnostic Considerations
A simple approach to headache consists of 3 steps:
I.
Classify the headache:
1. Acute
A. Generalized
1. Infections (CNS or systemic)
2. Metabolic (electrolyte imbalance, hypoglycemia, drug or toxin
induced)
3. Traumatic
4. Vascular (Embolism, arterial dissection or hemorrhage)
B. Localized
1. ENT related (Sinusitis, otitis, temporomandibular joint dysfunction)
2. Eye problems
C. Recurrent
1. Tension
2. Migraine
3. Cluster
2. Chronic
A. Progressive
1. Space occupying lesion (Tumor, abscess, hematoma)
B. Non-progressive
1. Tension
2. Migraine-tension complex
3. Analgesic rebound headache
II.
Check for warning signs:
1. New asymmetric neurologic deficits
2. Transient loss of vision
3. New onset headache after age 55
4. Deterioration of a previously stable headache
5. Headache described as most severe in a patient’s life
6. Signs of meningitis
7. Symptoms of increased intracranial pressure
8. History of cancer
9. New onset migraine during pregnancy
III.
Proceed to aborting the attack
Not to be missed
1. Urgent headaches: Subarachnoid hemorrhage, bacterial meningitis and giant cell arteritis.
2. Chronic progressive headaches which awaken patient at night and are made worse by cough
or straining or associated with vomiting or nausea – space occupying lesion
When to Refer
1. Uncertain about diagnosis
2. Suspected serious neurologic or underlying diseases
3. Patients requiring chronic treatment for migraine or with narcotics
36
Patient Education
1.
2.
3.
4.
5.
6.
Explain pathogenesis & prognosis of headache
Explain aims & side effects of treatment
Avoid physical & emotional stress
Regular meals & sleeping hours
Exercise
Avoid precipitating factors such as alcohol, travel, certain medications (such as nitroglycerin,
oral contraceptives), certain food preservatives, certain food such as chocolate cheese & wine
Sources
1. Noble S, Moore DK. Drug treatment of migraine. American Family Physician 1997; 56(9):
2279-86
2. Fagarty JP. Headache. Ambulatory Medicine, the Primary Care of Families. Appleton &
Lange 1993; pp 163 -170.
3. Frishber BM The utility of neuro imaging in the evaluation of headache in patients with
normal neurologic examination. Neurology 1994;44:1191-7..
37
Common Headaches
Tension (> 50 %)
Type
Occipital, frontal or band like
Characteristics 1.
2.
3.
4.
5.
6.
7.
Associated
features
1.
2.
Acute or
abortive
treatment
1.
2.
a.
b.
3.
Prophylactic
treatment
Develops gradually
Worsens through the day
Not aggravated by routine
physical activity
Stressors present
Lasts half an hour up to 1 week
If more than 10 episodes with
more than a total of 180 days per year =
chronic
Depression
Psychosocial stressors
1.
Massage, relaxation, hot baths
Analgesics
Acetaminophen
NSAID
Muscle relaxants
Tricyclic antidepressants (e.g.
imipramine 25 to 150 mg at bedtime)
2.
Beta blockers (e.g. nadolol at 20
mg daily up to 80 mg)
Migraine (30-40%)
1.
Frontal, temporal
2.
Often unilateral
3.
Throbbing or pulsating
4.
Intense
5.
Aura occurs in about 20% of all migraines and lasts less than 1
hour
6.
Prodrome with photophobia or sonophobia
7.
Nausea / vomiting
8.
Classic migraine with aura lasts 6 to 12 hours
9.
Common migraine without aura lasts hours or days
1.
Family history
2.
Menses related
3.
Diet triggers (chocolate, alcohol, cheese, Canderel)
1.
Analgesics as in tension
Cafergot (Ergotamine tartarate + Caffeine)
2.
1 to 2 tab taken at onset, then one Q 30 min PRN up to 6
tab per attack & 10 tab per week.
3.
4.
Sumatriptan 25 - 100 mg PO 2X / day
Antiemetic for nausea & gastric stasis: metoclopramide
(primperan) 10 mg IV, 10 mg PO, 20 mg supp.
5.
Narcotics: codeine 30 mg may benefit some patients (risk of
habituation & rebound headache)
If more than two to three attacks a month
1.
Beta blockers
2.
Tricyclic antidepressants or SSRIs (Fluoxetine)
3.
Cyproheptadine (Periactine) 12-20 mg/day
4.
Calcium channel blockers (mainly in patients unable to take
Beta blockers)
a.
Verapamil 60-160 mg 2-4 times/day
b.
Diltiazem 30-90 mg 2-3 times/day
c.
Nifedipine may increase headache
5.
Carbamazepine (Tegretol) 100 mg - 200 mg twice daily
38
Cluster (< 7%)
1.
Orbital, temporal
2.
Unilateral
3.
Sharp and intense
4.
20 to 30 minutes or an hour
5.
Sudden pain
6.
Red eyes
7.
Runny nose
8.
Occasional miosis or ptosis
1.
2.
3.
1.
Young males with family history
Alcohol trigger
Very intense pain
100% oxygen by mask at rate of 710 l/min for 15 min.
2.
Inhaled ergotamine, one puff Q 5
min for maximum of 5 puffs.
3.
Sublingual nifedipine 10-20 mg Q
6-8 hrs (do not use with ergotamine).
4.
Sumatriptan or dihydroergotamine
1.
2.
Methysergide 2-8 mg/day
Lithium 300 mg tid (monitor level
weekly)
3.
Prednisone 40-60 mg per day for 5
days then taper over 10 14 days
4.
Calcium channel blockers
5.
Propranolol Amitryptyline,
Cyproheptadine are found to be effective.
39
Hematuria
Definition and Epidemiology
Hematuria is the presence of red blood cells in the urine.
Work-up of hematuria is recommended when:
1. More than 3 RBCs/high power field are found on two or 3 clean catch specimens
2. One episode of gross hematuria
3. One episode of large microhematuria (>100 RBCs/hpf)
History
1. Genitourinary (GU) symptoms
a. Symptoms of cystitis or infection: dysuria, frequency, urgency
b. Symptoms of vaginal infection or penile discharge
c. GU trauma or surgery
d. Symptoms of stone passage: flank pain, past history
2. Pain
a. Painful hematuria occurs in: UTI, renal stones, obstruction, glomerulonephritis,
endometriosis or papillary necrosis.
b. Painless hematuria occurs n : Bladder tumor, polycystic kidneys, staghorn calculus,
hydronephrosis, sickle cell, hypercalciuria and bleeding disorders.
3. Stage
a. Initial hematuria in distal urethral involvement
b. Terminal hematuria in bladder neck or prostatic urethra problems
c. Total hematuria in upper tract or bladder disease
4. Presence of clots
a. Small stringy clots originate from upper tract
b. Large clots originate from bladder
5. Family history
Polycystic kidneys, stones, sickle cell or bleeding disorders
6. Medications
Non steroidal anti inflammatory drugs, aspirin, warfarin
7. Cancer risk
a. Age above 40
b. Smoking
c. Aniline dyes exposure
d. Family history
e. Schistosomiasis
Objective Findings
Physical examination
1. Appearance, vital signs and blood pressure
2. Abdominal exam (suprapubic tenderness suggests cystitis, abdominal mass suggests tumors
or polycystic kidneys )
3. Back exam (costovertebral angle tenderness suggests pyelonephritis or renal colic)
4. Digital rectal exam ( in benign prostatic hypertrophy, prostate exam shows enlarged firm
lateral lobes. In acute prostatitis, the prostate is enlarged, boggy occasionally, with increased
warmth to the touch. In prostatic carcinoma, the prostate may be stony hard or nodular).
5. Genital exam to R / O urethral pathology.
40
6. Skin exam : ecchymoses, abrasion may be present post trauma. Rash suggests secondary
glomerulonephritis.
7. Heart exam : murmurs suggest endocarditis, atrial fibrillation suggest possible renal emboli &
infarction.
8. Nail exam to R / O splinter hemmorrhage
9. Joint exam to R / O arthritis.
Laboratory tests :
1. Urine analysis
a. Pyuria & WBC casts suggest infection
b. Proteinuria & RBC casts suggest glomerular disease
c. May want to obtain urine culture and gram stain
2. Blood screen including
a. Renal function tests (Creatinine, BUN, electrolytes, calcium and uric acid).
b. PSA levels if indicated
c. Complete blood count: to evaluate for systemic involvement
Radiology:
1. I.V.P: It is the most effective method for the evaluation of the anatomy & function of the
upper urinary tract. Indicated for hematuria with negative culture. It is important in the
evaluation of urolithiasis, renal tumors, renal trauma, bladder carcinoma & BPH. (only 75 %
of bladder carcinoma are seen on IVP ) It is contraindicated in allergy to dye & diminished
renal function.
2. Ultrasonography: It is not effective as IVP in evaluating urolithiasis & carcinoma of the
bladder. It is helpful, if the patient is allergic to dye or has compromised renal function of if a
cystic lesion of the kidney is suspected.
3. Abdominal radiography for stones ( it will detect 80 % of kidney stones)
4. CT scan: to evaluate small lesions of the kidney, especially the solid staging of bladder
carcinoma.
Cystoscopy:
1. If active bleeding is present at the time of the evaluation, it is the best initial study.
2. It should be used in all patients over the age of 40 yrs who present with microscopic
hematuria, who have negative urine culture, IVP or sonography.
3. It is important for further evaluation of filling defect in the ureter or the renal pelvis with
retrograde pyelogram & lavage
Pathology
1. Renal biopsy : it is indicated when history & lab data suggest that glomerulonephritis is the
cause of hematuria, when other diagnostic tests have yielded little information & hematuria
persists.
2. Cytology is indicated when cancer is suspected
Diagnostic Considerations
Hematuria’s differential diagnosis is long.
A.
Anatomic abnormalities such as cysts, AV malformations, obstruction and
benign prostatic hypertrophy.
B.
Boulders: stones, hypercalciuria, hyperuricosuria
C.
Cancer: renal cell, bladder, prostate, leukemia or Wilm’s tumor in children
41
D.
E.
F.
G.
H.
I.
Drugs
Exercise: march hematuria, contact sports
Foreign body: catheters, trauma
Glomerulonephritis
Hematological causes: hemoglobinopathies or coagulopathies
Infections
Consider red urine not due to RBC’s: Pseudohematuria due to:
1. Hemoglobinuria, myoglobinuria, bilirubin, urobilinogen, porphyrins,
2. Food ( beets, blackberries, rhubarb or food coloring ),
3. Drugs : Phenothiazine, Phenazopyridine ( Pyridium ), Phenolphthalein, Rifampin ( Rifadin ),
Anthraquinone containing laxatives, Chloroquine, Deferoxamine ( Desferal ), Doxorubicin (
Adriamycin ), Metronidazol (Flagyl), Phenytoin ( Dilantin ), Ibuprofen ( Bruffen ), Levodopa
( Larodopa, Dopar ), Methyldopa ( Aldomet ), Nitrofurantoin ( Furadantin ),
Sulfamethoxazole, Phenacetin.
Management options
1. Asymptomatic microscopic hematuria
a. Obtain urine analysis and laboratory studies
b. If all negative, repeat analysis in 3 months
c. If persistent, obtain IVP or U/S or urologic consult
2. Asymptomatic gross hematuria
a. Obtain urine analysis, laboratory studies and IVP or U/S
b. Consider referral
Not to be missed
Urologic cancer
• Found on follow-up in 1-3% of patients with microscopic hematuria and 18% of those with
recurrent gross hematuria
• If work-up is negative
o Repeat urine analysis and cytology every 6 months as longs as hematuria persists
o IVP and cystoscopy annually
Sources
1. Restrepo NC, Carey PO : Evaluating hematuria in adults. Am Fam Physician 1989 ; 40 : 149.
2. Fuselier HA Jr, Rous SN, Sullivan JW: A practical workup for hematuria. Patient Care 1990 ; 24 :
159.
3. Presti J Jr MD, Stoller M MD. Current Medical Diagnosis & treatment 1999 ; 38 th ed. : 915 917, 898 - 899.
4. Morgan L MD, PHD. Ambulatory Medicine, The primary Care of Families 1993; 1st ed. : 174 180.
42
Pharyngitis
Definition and Epidemiology
Pharyngitis is the infection or inflammation of the oro-pharynx & of the surrounding tissues.
The causes are :
1. Respiratory viruses: most commonly rhinovirus or adenovirus but also Epstein-Barr virus with
significant exudative tonsillitis and constitutional symptoms.
2. Bacterial agents including:
a. Streptococcal species which can be isolated in up to 30% of adults presenting with sore
throat and up to 50% of children
b. Other infrequent agents such as Neisseria gonorrhea, H. influenza - type B especially in
children, C. Diphteria and M. pneumonia
3. Candida albicans
4. Trauma, irritants ( smoke & chemicals ), dehydration, chronic cough ( often associated with post
nasal drip), vomiting & gastro esophageal reflux ( usually with laryngitis ).
History
Sore throat, rhinorrhea, cough, fever, duration of illness, occupation.
Objective Findings
Throat exam for signs of inflammation, follicles, petechiae. Cervical nodes exam for enlargement.
Liver & spleen examination for hepatosplenomegaly. Complete blood count with smear examination
and a monospot test are done if mononucleosis is suspected.
Diagnostic Considerations
1. Streptococcal and viral sore throat are difficult to distinguish clinically; throat cultures are often
necessary for diagnosis confirmation.
2. Viral pharyngitis ( most common ) is suggested by rhinorrhea, cough, hoarseness, conjunctivitis
& diarrhea.
3. Streptococcal pharyngitis is suspected based on some risk factors:
• High probability:
Exudate (age >2), tender anterior cervical nodes, palatal petechiae, excoriated nares (age<2 ),
contact with streptococcus, scarlet fever & temperature > 39C ( oral ).
• Low probability:
Cough, rinorrhea, conjunctivitis, hoarseness, diarrhea, pharyngeal ulcers or absence of all high risk
factors.
• Moderate probability
Absence of high & low risks factors & fever <39C and / or exudate age <2.
4. Throat cultures have their own flaws
• No accepted criteria differentiate carriers from new infection
• Poor technique can result in false negative results
• Waiting for results may delay treatment
• They are being replaced by rapid strep antigen assays with equal (if not better) sensitivity and
specificity.
5. The goal of initiating therapy is to decrease the chance of secondary complications (including
rheumatic fever). Therapy can initiated up to 9 days after onset of symptoms and still be effective.
Complications of streptococcal pharyngitis are :
• Peritonsillar abscess
• Retro pharyngeal abscess
• Scarlet fever
43
6.
7.
8.
9.
10.
11.
• Acute rheumatic fever
• Glomerulonephritis
Throat culture onto a single blood agar plate, has a sensitivity of 70 - 80 %. Rapid office latex
agglutination or Eliza ( 85 % sensitive, 95 % specific ).
Strep throat culture of family contacts, if there are recurrent strep infections.
Gonococcus throat culture, if urethritis or cervicitis (on Thayer - Martin medium).
Candida is identified with the use of KOH preparation.
Do monospot test, if posterior cervical lymphadenitis to rule out mononucleosis.
Antistreptolysin O confirms past infection in patients with acute rheumatic fever or acute
glomerulonephritis but is NOT useful for diagnosis of pharyngitis.
Management
1. Hydration, antipyretics (acetaminophen or ibuprofen), gargle with warm salt water,
2. If there is a high risk for strep, positive antigen or positive culture use one of the following :
a. Penicillin V ( ospen ), 50 mg / Kg / d up to 2 grams / day in 2 - 4 doses × 10 days
b. Benzathin penicillin ( Extencillin )
< 27 Kg - 600000 U.I.M
27 Kg - 1200000 U.I.M
c. Amoxicillin (Ospamox, Amoxil, Hiconcil ) 50 mg / Kg / day in 3 doses, for 10 days. The
adult dose, 500 mg tid for 10 days.
3. If there is penicillin allergy or recurrent strep, use
a. Erythromycin 40 mg / Kg / d, up to 2 gm / d in 2 - 4 doses X 10 days
b. Cephalexin ( Keflex, Ibilex, Ospexin ), 50 mg / Kg / d, up to 2 gm / d in, 2 - 4 doses X
10 days ( or other Cephalosporins )
c. Azithromycin ( Zithromax ), 500 mg ( 10 mg / Kg in children ), once daily for 3 days is
an alternative to Erythromycin.
4. For Candida, Nystatin 5 cc po, wash & spit, 4 - 6 times / day or use Fluconazol oral ( if
immunocompromised ).
5. For mononucleosis, oral glucocorticoids to prevent airway compromise ( e.g., Prednisone, 40 mg
po daily for 3 - 5 days. Steroids may also be used to decrease painful lymphadenopathy.
6. Treatment of Group A strep carriers
a. Penicillin V 50 mg / Kg / d, up to 2 gm / d in 2 - 4 doses X 10 days, plus Rifampin 10 20
mg / Kg /day, up to 600 mg / d for the last 4 days of Penicillin therapy OR
b. Erythromycin 40 mg / Kg / d up to 2 gm in 2 - 4 doses X 10 days OR
c. Cephalexin 50 mg / Kg / d up to 2 gm / d in 2 - 4 doses X 10 days ( or other
cephalosporins )
When to Refer
•
•
•
•
Severe mononucleosis requiring steroids
Peritonsillar abscess
Recurrent infections : Five or more documented episodes of strep pharyngitis in one year or three
documented episodes in two consecutive years
Suspected tonsillar neoplasia
Patient Education
•
•
•
•
Explain about etiology of symptoms and prognosis
Explain that antibiotics are not helpful for viral infections
Advise to return for recheck if not better after 3 days
Advise to take antibiotics for 10 days for strep infection and to discontinue treatment when
symptoms improve
44
Management and treatment tips
1. Untreated, streptococcal pharyngitis resolves on its own. Antibiotic treatment is necessary,
however, to prevent complications.
2. Children can return to school 24 hours after therapy is initiated
3. Mono spot tests help diagnose infectious mononucleosis in young adults who can also have
posterior neck lymphadenopathy, prolonged course of symptoms or splenomegaly.
Sources
1. Perkins, A. An approach to diagnosing acute sore throat. Am Fam Physician 1997, 55 : 131, 141.
2. Brodsky, L. Modern assessment of tonsils & adenoids. Pediatric Clinics of North America
December 1989, 36 :6
3. McCracken G . Diagnosis & management of children with streptococcal pharyngitis Ped. Inf.Dis.
November - December 1986, 5 : 754 - 759.
4. McMillan J. A Sore throat in teens : strep& beyond. Contemporary Pediatrics, March 1988, 5 : 20
- 30.
5. White C. B et al Streptococcal pharyngitis - Comparison of latex agglutination & throat culture.
Clinical Pediatrics September 1988 : 431 - 433.
6. Yu P. K et al. Evaluation of test pack strep A for the detection of group A streptococci in throat
swabs. Mayo Clin. Proc. 1988, 63 : 33 - 36.
45
Community acquired pneumonia
Definition and Epidemiology
Community acquired pneumonia (CAP) is commonly seen in practice. It is a leading cause of death
with a mortality of 2/1000. Causative organisms are identified only in 50% of cases. Gram stain
sensitivity is 62% and that of sputum culture is only 50%. Blood cultures are positive in around 20%
of cases. The difficulty in isolation of causative bacteria is due to the easy & frequent contamination
of sputum collections. This is why treatment is frequently empirical.
Common causative agents
(A) Viral:
• Accounts for 2-15% of cases. Most common viruses are Influenza virus A, B. RSV
is encountered in children below the age of 2 years.
(B) Bacterial:
• Streptococcus Pneumonia is the most frequent cause of CAP, accounting for up to
70% of cases.
• H. Influenza accounts for 5-10% of cases. Most commonly encountered in children,
smokers, elderly and with COPD.
(C) Atypical:
• Mycoplasma pneumoniae: more common in young adults.
• Chlamydia pneumoniae
• Legionella pneumophilia: rare but should be considered in seriously ill individuals
above 40 years who may be immunocompromised or do not respond to beta-lactam
antibiotics or have low serum sodium (less than 130 mEq/L).
Less common agents in CAP in adults
•
•
•
•
Moraxella catarrhalis
Has increased incidence in smokers.
Staphylococcus aureus
Mostly seen in hospitals, nursing homes or in heavy alcohol users
Anaerobes
May be under diagnosed as a cause of pneumonia and this is due to difficulty in culture. It is
seen mostly in individuals with high risk for aspiration such as: alcoholics or debilitated, bed
ridden, comatose or post stroke individuals.
Mycobacterium Tuberculosis:
Should be suspected in the presence of chronic cough, hemoptysis, weight loss, night sweats
or other tuberculosis risk factors.
46
Clinical presentation
Typical Pneumonia
S. Pneumoniae
H. Influenzae
K. Pneumoniae
Mixed anaerobes
Aerobic gram-negative bacilli
S. Pyogenes
S. aureus
(Legionella species)
Atypical pneumonia
M. Pneumoniae
Legionella species
Viruses
Subjective findings
Objective findings
Fever/rigors
Productive cough
Pleuritic chest pain
Pulmonary rales &
consolidation
Positive Gram stain and sputum
culture
Leukocytosis, toxic granulations
Lobar consolidation on chest
radiograph
Upper respiratory infection
Symptoms
Fever (rigors not common)
Nonproductive cough
(Pleuritic chest pain rare)
Headache
Myalgia
Scattered rales, (consolidation
rare)
Mild leukocytosis
Negative sputum Gram stain
Negative sputum/blood cultures
Interstitial infiltrates on chest
radiograph
Management options
The most important critical decision is whether to treat at home or admit the patient to hospital.
Risk factors for death from CAP are:
1.
2.
3.
4.
5.
6.
Age > 65 yr.
Co-existence of a co-morbid illness Diabetes, chronic renal failure, congestive heart failure.
Hospitalization of pneumonia during the past year.
Temperature > 38.3c.
Presence of immunosuppresion: steroids-chemotherapy during the past 6 months.
High risk pneumonia: Staph. aureus or gram negative aspiration or presence of bronchial
obstruction.
47
Hospitalization score
The following table helps in deciding on hospitalization. A score of 70 or more should prompt serious
consideration of hospitalization.
Characteristic or finding
Male
Female
Nursing home resident
Cancer present
Liver disease
Congestive heart failure
Cerebrovascular disease
Renal disease
Altered mental state
Respiratory rate above 30 per minute
Systolic blood pressure less than 90
Temperature < 35 or > 40 degrees C
Pulse above 125 per minute
pH less than 7.35
BUN > 10.7 mmol/L
Na < 130 mEq/L
Glucose > 13.9 mmol/L
Hematocrit < 30%
PO2 < 60 mmHg
Pleural effusion present
Points assigned
= to age in years
= to age in years minus 10
+ 10
+ 30
+20
+ 10
+ 10
+ 10
+ 20
+ 20
+ 20
+ 15
+ 10
+30
+ 20
+ 20
+ 10
+ 10
+ 10
+ 10
Therapeutic choices
Treatment is empirical most of the time due to the low yield of cultures because of frequent
contamination. This treatment, should always cover streptococcus pneumonia because it is the most
common causative organisms. The age of the patient and presence of co-morbidity can help choose
the antibiotic:
Patient Category
Less than 60 yr old without
comorbidity
More than 60 yr old with
comorbidity
•
Likely infecting organisms
Streptococcus pneumoniae
Mycoplasma pneumoniae
Respiratory viruses
Chlamydia pneumoniae
Haemophilus influenzae
S pneumoniae
Respiratory viruses
H influenzae
Aerobic gram-negative bacilli
Staphylococcus aureus
Empirical treatment
Macrolide (Erythromycin or
Azithromycin or
Clarithromycin)
Amoxicillin-clavulonic
Second generation
cephalosporin or
trimethoprim-sulfamethoxazole
Add a macrolide (if concerned
about Legionella)
Examples of regimens:
Erythromycin 500 mg qid for 10 to 14 days
Clarithromycin (Klacid) 500 mg bid for 10 days
Azithromycin (Zithromax) 500 mg daily for 3 days
Amoxicillin-clavulonic acid (Augmentin) 1000 mg twice daily for 10-14 days
Cefuroxime (Zinnat) 500 mg twice daily for 10 days
Cefixime (Suprax) 400 mg once daily for 10 days
48
•
•
•
Note that 25% of strep pneumonias are resistant to Penicillin.
In case of Influenza virus epidemic, you should cover Staph aureus in the treatment regimen.
Clinical response to treatment must be closely monitored in the initial 48 to 72 hours. X-rays
are not helpful for monitoring and may look worse early on treatment and may not clear up to
4 weeks after illness.
When to Refer
•
•
Using the scoring table above, the primary care physician should consider transferring the
patient to a pulmonary specialist whenever the scores are above 90.
Non resolving pneumonia or poor clinical improvement within 48-72 hours of treatment.
Patient Education
Upon recovery, Pneumococcal vaccine and annual influenza vaccine should be offered to the patient.
Sources
1. British Thoracic Society: Guidelines for the management of community, acquired pneumonia in
adults admitted to hospital. BM J. Hosp. Med 1993;49: 346-350.
2. Fine MJ, Auble TE, Yealy DM, et al: A prediction rule to identify low-risk patients with
community-acquired pneumonia. NEJM 1997; 336:243-250
3. Infectious diseases society of America: Community acquired pneumonia in adults: Guidelines for
management. Clin Infect Dis 1998;26:811-838
4. American thoracic society. Guidelines for the initial management of adults with communityacquired pneumonia. Am Rev Respir Dis 1993;148:1418-1426
49
Peptic Ulcer Disease
Definition and Epidemiology
Peptic ulcer disease (PUD) refers to gastric (GU) and / or duodenal ulceration (DU). It occurs usually
in young and middle aged men and women with a seasonal symptoms exacerbation
Helicobacter pylori infection is detected in more than 90 percent of duodenal ulcers and about 70
percent of gastric ulcers. However, only a small percentage of infected people develop peptic ulcer
disease.
History
•
•
•
•
•
•
Pain in the epigastric area, gnawing or burning in nature on hunger that may be relieved by
food intake and awakens patient at night .
Epigastric pain on fasting
o Duodenal ulcer symptoms decreased by eating
o Gastric ulcer symptoms usually increased with eating
Dyspepsia - feeling of fullness , bloating, and belching, or heart burn.
Nausea & vomiting
Gastrointestinal bleeding.
o Stool negative for occult blood in most cases (except with acute bleed)
Smoking common
Objective Findings
Physical examination findings usually negative
Epigastric tenderness.
Melena may be detected by color of stools on gloves after a rectal exam.
Laboratory Test
CBC
Stool Guaiac.
Barium studies (Upper GI)
Gastroduodenoscopy
Diagnostic Considerations
Other entities to be considered in the evaluation for peptic ulcer disease include:
1. Functional dyspepsia.
2. Gastroesophageal reflux.
3. Hepato-biliary tract disease.
4. Pancreatitis.
5. Upper gastrointestinal infections; e.g. giardiasis .
6. Cancer of the stomach, lymphoma.
50
Management options
If the patient is on NSAIDs:
• High likelihood that NSAIDs are cause of symptoms
• Stop NSAIDs, and treat with proton pump blocker or H-2 blocker for 4-8 weeks
• If NSAIDs cannot be stopped,
o May try a COX-2 specific NSAID (e.g. VIOXX) OR
o Use anti-acid therapy ± misoprostol (Cytotec) can be added OR
o Add a PPI (proton pump inhibitor, e.g. lanzoprazole or omeprazole)
• If symptoms recur, consider endoscopy and biopsy
If the patient is not on NSAID:
1) Initial therapy
a) Indications - either of these:
i) Duodenal or gastric ulcer demonstrated by x-ray or endoscopy.
ii) Upper abdominal pain with suspicion of ulcer disease. (see dyspepsia chapter)
b) Medications
i) H2-receptor antagonists – see table below.
H2-receptor antagonists have equal efficiency in equivalent doses. Start with cimetidine 400 mg. bid.
for 6-8 weeks. If drug interaction is a problem ,can use Ranitidine or Nizatidine 150 mg. bid. or 300
mg. qhs for 8 weeks. Healing rate of H2RA is 90-95 percent at 8 weeks.
ii) Proton pump inhibitors result in healing rate of 80-100 percent at four weeks. Omeprazole
is given 20-40 mg. daily.
• Require ~48 hours to begin activity; acid environment needed to activate drug
• Allow for rapid healing of NSAID induced ulcers, even during NSAID therapy
• Relieve pain and heal ulcers more rapidly than H-2 blockers
c) Duration of therapy
i) Duodenal ulcer - 4 to 8 weeks. If persistent ulcer confirmed after therapy, continue
another 4-6 weeks or evaluate for H Pylori.
ii) Gastric ulcer - 4 to 12 weeks. If persistent, refer for EGD and biopsies.
2) Maintenance therapy
a) Indications:
i) Over 65 years old
ii) Previous complications
iii) Heavy smoker who persists in smoking
iv) History of frequent recurrence
v) Coincident therapy with non-steroidal anti-inflammatory drugs or KCl.
vi) Concomitant serious diseases such as cardiac, renal, respiratory or hepatic failure.
b) Duration of therapy - up to 5 years or longer.
c) Medications - any of the following:
i) Antacids 75-80 meq of acid-neutralizing capacity at bedtime.
ii) H2-receptor antagonists - any of these:
(1) Cimetidine 400 mg hs
(2) Ranitidine 150 mg hs
(3) Famotidine 20 mg hs
(4) Nizatidine 150 mg hs
3) Surgical referral - if intractable pain, persistent bleeding, penetration, perforation or obstruction.
51
Therapeutic choices
Famotidine
(Gastrodomina,
Pepcidine)
Ranitidine
(Rantag, Zantac)
Cimetidine
(Tagamet,
Neutronorm
Nizatidine
(Axid)
Omeprazole
(Risek, Gastrimut,
Losec, Sanamidol)
Lanzoprazole
(Lanzor, Takepron)
Acute
duodenal ulcer
20 mg BID or 40 HS
x 6-8 weeks
Maintenance
duodenal ulcer
20 mg HS
Acute
gastric ulcer
40 HS or 20 BID
x 6-8 weeks
150 mg BID or 300 HS
x 6-8 weeks
400 mg BID or 800 HS
x 6-8 weeks
150 mg HS
150 mg BID or 300 HS
x 6-8 weeks
800 HS or 400 BID
x 6-8 weeks
150 mg BID or 300 HS
x 6-8 weeks
20 mg QD
x 4-8 weeks
150 mg HS
30 mg QD
x 4-8 weeks
15 mg QD
400 mg HS
20 mg QD
300 HS or 150 BID
x 6-8 weeks
20-40 mg QD
x 4-8 weeks
30 mg QD
x 4-8 weeks
Selected H. pylori treatment regimens
Regimen
BMT
MOC
AOC
Medication
Bismuth
Metronidazole
Tetracycline
Omeprazole
Amoxicillin
Metronidazole
Omeprazole
Clarithromycin
Amoxicillin
Omeprazole
Clarithromycin
Dose
2 tabs
250 mg
500 mg
20 mg
1000 mg
500 mg
20 mg
500 mg
1000 mg
20 mg
500 mg
Frequency
Duration
3x before meals
& at bed time
2 weeks
BID w meals
2 weeks
BID w meals
2 weeks
Not to be missed
Perforation
Malignancy especially when gastric ulcers are suspected.
When to Refer
1) Gastric ulcer with clinical or x-ray suspicion of malignancy or non-healing
2) Acute UGI hemorrhage.
3) Peptic ulcer symptoms with negative or equivocal UGI.
4) Refractory or recurrent ulcer symptoms.
Refer for surgical management :
1) Intractable to medical therapy
2) Perforation
3) Obstruction (due to stricture formation)
4) Hemorrhage
52
Patient Education
1.
2.
3.
4.
5.
6.
Explain the pathogenesis of ulcer disease.
Explain the prognosis.
Advise smokers to stop smoking.
Advise to avoid alcohol and caffeine.
Advise to avoid aspirin and other non-steroidal anti-inflammatory drugs.
Explain aims and side effects of treatment.
Prevention
Patients at high risk to develop bleeding secondary to NSAIDS may be given:
1. Misoprostol (Cytotec) 200 micrograms qid.; lower dosages of 200 micrograms two to three
times daily may be effective with fewer patients withdrawing from therapy because of side
effects.
2. Omeprazole 20-40 mg. daily.
3. Lanzoprazole 30 mg daily
Sources
1. Graham DY, et al. Practical advice on eradicating Helicobacter pylori infection. Postgraduate
Medicine 1999;105:137-148.
2. Ament P, Childers S. Prophylaxis and treatment of NSAID-induced gastropathy. Am Fam
Physician 1997; 1323-1332.
3. Graham DY, et al. Recognizing peptic ulcer disease. Postgraduate
4. Medicine 1999; 105:113-128.
5. Graham DY, et al. Scope and consequences of peptic ulcer disease. Postgraduate Medicine
1999; 105:100-108.
53
The red eye
Definition and Epidemiology
Inflammation in the eye that causes vasodilatation of the vessels
History
a. Redness
b. Discharge
c. Pain
d. Itching
e. Photophobia
f. Decrease in visual acuity
g. Trauma
h. Associated symptoms: headache, nausea and vomiting
Objective Findings
a. Conjunctival exam
b. Corneal inspection
c. Pupil size and reactivity
d. Color of discharge and appearance
Diagnostic Considerations
a. Conjunctivitis
1. Viral
2. Bacterial
3. Allergic
b. Corneal abrasion or Foreign body
c. Subconjunctival hemorrhage
d. Uveitis
e. Keratitis
f. Episcleritis, scleritis
g. Acute angle closure glaucoma
Management options
Culture of conjunctival discharge if:
a) Diagnosis in doubt
b) No response to multiple antibiotics
Therapeutic choices
1. Viral conjunctivitis:
a) Warm compresses
b) Irrigation with water
2. Bacterial conjunctivitis
Topical antibiotics 1 to 2 drops q 2-4 hours * 5-7days
1) Chloramphenicol (Chloroptic; Chloromycetin)
2) Gentamicin (Cidomycin, Garamycin)
3) Fusidic acid (Fucithalmic) 1 drop twice daily
4) Neomycin-polymyxin-bacitracin (Neosporin)
54
3.Allergic conjunctivitis-use any of these
a) Topical decongestants, alone or in combination with topical antihistamines
1) Naphzoline (Vasocon) 1-2 drops q 4h
2) Phenylephrine (Isopto Frin) 1-2 drops q 6h
3) Naphcon A (Decongestant + Antihistamine) 1-2 drops q 6h
b) Sodium cromoglycate (Opticrom) 1-2 drops bid* 3-4 weeks
4.Foreign body:
Removal with a sterile needle with the use of a topical anesthetic.
Topical antibiotic ointment should be placed in the eye, firmly patched for24h.
If no improvement in 24 h or foreign body cannot be easily removed, referral is indicated
5.Episcleritis and scleritis:
Referral to ophthalmologist because recurrences are common
6.Keratitis and iritis:
Urgent referral is needed
7.Angle-closure glaucoma:
Urgent referral to ophthalmology after Diamox 500 mg IV
Algorithm
Red Eye
Pain
Yes
Blurred vision
NO
Yes
Ophthalmology
Referral
Yes
Photophobia
No
Discharge
NO
Itching
NO
Yes
Yes
Purulent
Watery
Bacterial Conjunctivitis
Viral or Allergic Conjunctivitis
Allergic Conjunctivitis
NO
Refer
R/O episcleritis
Viral Conjunctivitis
No
Itching
Yes
Sources
Mengel M. et al., Ambulatory Medicine. Appleton and Lange 1993
Morrow G., Conjunctivitis. American Family Physician, February 15, 1998, 57:4.
55
Sinusitis
Definition and Epidemiology
Acute sinusitis is an infection of the mucosal lining of the paranasal sinuses characterized by fever,
purulent nasal discharge, facial pain for less than three weeks. It is the leading ambulatory care
diagnosis for which an antibiotic is prescribed.
History
1.
2.
3.
4.
Purulent nasal discharge
Maxillary toothache
Nasal obstruction
Prolonged “cold” (> 10 days) or “double-sickening” (an upper respiratory tract infection that
initially improves and then worsens)
5. Cough secondary to post nasal drip
6. Facial fullness and headache
Objective assessment for suspected sinusitis
1.
2.
3.
4.
5.
6.
7.
Take the body temperature- rectal if possible
Examine the nasal mucosa for color, edema, and character of nasal secretions. Purulent
secretions, particularly when seen coming from middle meatus, suggest sinusitis.
Check the structure of the nasal septum.
In a completely darkened room, transilluminate the maxillary sinuses by placing a
penlight over the infraorbital rim. Look for light transmission through the hard palate.
Normal and equal light transmission from side to side makes sinusitis less likely.
Decreased transmission on either side makes sinusitis more likely, other possibilities are
polyps or a hypoplastic sinus.
Percuss the maxillary teeth with a tongue blade to check for dental pain associated with
sinusitis.
Palpate for facial tenderness.
Examine the throat for post nasal drip.
Diagnostic Considerations
Sinusitis is usually diagnosed clinically. The most common conditions that may mimic sinusitis are
common cold, allergic and vasomotor rhinitis as well as rhinitis medicamentosa and deviated nasal
septum.
The following five clinical findings are the best predictors of acute bacterial sinusitis. When <2 of
these findings support sinusitis, it is usually absent; however, when >3 are confirmatory, the
likelihood of sinusitis is high. When 2 or 3 findings are confirmatory, a Waters view may be useful:
1.
Maxillary toothache
2.
Poor response to decongestants
3.
A history of colored nasal discharge
4.
Purulent nasal secretion
5.
Transillumination result (useful only if negative)
When considerable uncertainty persists after the clinical evaluation or when the patient fails an initial
course of therapy, diagnostic testing may be useful.
1.
Conventional radiographs are useful for confirming acute maxillary sinusitis. A single
waters view is less expensive and correlates highly with standard four-view sinus series.
56
Conventional radiography is about 90% sensitive and 75% specific in detecting acute
maxillary sinusitis.
Sinus computed tomography is more sensitive (90 % - 100%) and images the ethmoid
sinuses well but may have poor specificity (60%).
CT scans are not cost effective and should not be used routinely to diagnose acute
sinusitis (level II evidence).
2.
3.
Management options
1.
•
•
•
•
2.
•
3.
•
4.
•
Antibiotics
The evidence that antibiotic therapy of acute maxillary sinusitis is beneficial is not
that strong. Most studies are either inadequate to reach a conclusion or give conflicting
conclusions. The common practice, however, is to prescribe antibiotics if acute sinusitis is
suspected.
There may be a slight-to-moderate benefit of penicillins, cephalosporins, macrolides
and sulfonamides in acute maxillary sinusitis, and differences between antibiotics appear
to be small.
First-line therapy should be a 10-day course of amoxicillin or trimethoprimsulfamethoxazole and a decongestant.
Second-line agents include any agent with an approved indication for acute bacterial
sinusitis other than amoxicillin and TMPSMX. They are indicated for non responders to
first line agents and for patients with recurrent episodes of acute sinusitis who have been
assessed and found not to have anatomic anomalies.
Antihistamines
Antihistamines are not beneficial in the management of acute sinusitis.
Steroids
Glucocorticosteroids have not been shown to be of any notable benefit in treating
acute sinusitis.
Irrigation
Irrigation of the nasal cavity may provide symptomatic relief. This is done by an
ENT specialist.
Therapeutic choices
1. Pharmacologic
a. Antimicrobials x 10-14 days:
i. Children - any of the following:
• Amoxicillin 50 mg/kg/d. up to 500 mg tid
• Trimethoprim - sulfamethoxazole 8/40 mg/kg/d. up to 160/800 mg
bid.
• Cefaclor 50 mg/kg/d. up to 500 mg tid.
• Erythromycin - sulfisoxazole 40/120 mg/kg/d. up to 200/600 mg qid.
• Amoxicillin - K+ clavulanate 50 mg/kg amoxicillin/d. up to 500 mg
tid.
• Cefixime 8 mg/kg/d. up to 400 mg qd.
ii. Adults - any of the following:
• Amoxicillin 250-500 mg tid.
• Cephalexin 250-500 mg qid.
• Cefaclor 250-500 mg tid.
• Cefuroxime 250-500 mg bid.
• Erythromycin 250-500 mg qid.
• Cefixime 400 mg qd.
b. Nasal decongestants - either of the following:
57
i. Topical - use for no longer than 5 days in people over 6 years of age. Use
either of the following or others:
• Oxymetazoline - 2 sprays or drops each nostril bid.
• Phenylephrine - 2 sprays or drops each nostril tid.
ii. Oral - either of the following:
• Pseudoephedrine 30-60 mg tid.
• Phenylpropanolamine 6.25 mg tid.
c. Analgesics - any of the following or others:
• Acetaminophen 600 mg q4h.
• Codeine 30-60 mg q6h.
• Ibuprofen 400 mg q6h.
• Naproxen 250 mg q8-12h.
2. Non-pharmacologic - any of these:
a. Heated mist
b. Steam baths
c. Hot showers
d. Saline nose drops
3. Refer to ENT for irrigation of sinuses - if fail to respond to treatment or severe pain.
4. Hospitalization - if orbital, intracranial or bone complications occur.
When to Refer
1.
2.
3.
4.
Patients with sinusitis that recurs 3 times a year should be referred to an otolaryngologists.
If symptoms persist for more than 6 weeks.
If gross obstructive pathology is seen in the nose.
If there is associated bleeding.
Patient Education
The patient should be instructed to implement the following comfort and prevention measures:
1.
Maintain adequate hydration (drink 6– 10 glasses of liquid a day to thin mucus)
2.
Steamy shower or increase humidity in your home
3.
Apply warm facial packs (warm wash cloth, hot water bottle, or gel pack for 5– 10
minutes 3 or more times per day)
4.
Analgesics (acetaminophen, ibuprofen, ASA as needed)
5.
Saline irrigation: 1/ 4 teaspoon salt dissolved in 1 cup of water; use bulb syringe or
dropper
6.
Decongestants (topically or orally)
•
pseudoephedrine HCL (e. g., Sudafed) 60 mg. q 4- 6 hours, not to exceed 4 doses per
24 hours.
•
decongestant nasal sprays for no longer than 3 days, e. g., oxymetazoline (e. g. Afrin),
phenylephrine HCl (Neosynephrine)
7.
Adequate rest
8.
Saline nasal drops/ spray: commercial (e. g., Ocean, Salinex, Nasal)
9.
Sleep with head of bed elevated
10.
Avoid cigarette smoke and extremely cool or dry air
Educate about treatment:
1.
Substantial improvement occurs after 5-6 days of effective therapy. Follow up is
recommended if there is no response to treatment.
2.
Emphasize that prolonged use of tropical decongested is harmful.
3.
In allergic patient efforts to avoid environmental allergic may be helpful.
4.
When prescribing nasal steroids, instruct the patient that it may take 1-2 weeks to achieve
maximal effect.
58
Prevention
1.
2.
Appropriate treatment of allergies and viral upper respiratory infections may prevent the
development of sinusitis.
Environmental factors which affect the sinuses include cigarette smoke, pollution,
swimming in contaminated water, and barotrauma.
Management and treatment tips
1.
2.
3.
4.
5.
6.
7.
8.
9.
Treatment aims at improving drainage of the sinuses and eradicating the bacterial
infection.
Paracetamol is preferred for pain control.
Oral decongestants, may result in subjective symptomatic relief; however, data supporting
clinical benefit in acute sinusitis are limited. Local decongestants should not be used for
more than 5 days (to avoid rhinitis medicamentosa).
Antihistamines can be used in allergic conditions but should be discouraged in acute
sinusitis secondary to infection because they may thicken nasal secretions.
Mucolytics may thin secretions and promote sinus drainage and Guaifenesin may speed
recovery.
Nasal steroids help in patients with underlying allergic rhinitis (in chronic sinusitis).
Nasal saline or steam may decrease nasal crusting and liquefy secretions, thus facilitating
sinus drainage.
Antibiotics are of use when bacterial sinusitis is suspected.
Evidence suggests that Amoxicillin is as effective as more expensive antibiotics for the
initial treatment of uncomplicated acute sinusitis.
• Amoxicillin 50 mg/kg/d. up to 500 mg Q8 hours for 10 days result in cure of acute
sinusitis in 80-90 % of the cases.
• If b-lactamase- producing H. influenzae is suspected (no improvement on amoxicillin
after 5-6 days), use amoxicillin/ clavulanate, or Cefaclor. Amoxicillin/ clavulanate
dose is as Amoxicillin. Cefaclor dose is 50mg/kg/d up to 500 mg. Q 8 hrs.
59
Algorithm
1.Maxillary toothache
2.Poor response to decongestants
3.Colored nasal discharge
4.Purulent nasal secretion
5.Transillumination
< 2 findings
Reconsider DX
2 or 3 findings
Sinus X-Ray
> 3 findings
Sinusitis very likely
Recovery
Extend RX for 14
days
Partial Response
No Response
Further X-Ray
(CT ?)
Recovery
Partial or No
Response
Refer
FIRST LINE RX
Amoxicillin
500 mg TID x 10d
OR
TMP/SMX DS
BID x 10 d
SECOND LINE RX
Amoxicillin/clavulonate
875 mg TID x 14d
OR
Second generation
cephalosporins
10-14 days
OR
Macrolides
OR
Ciprofloxacin
500 mg BID
Quality of care indicators
1.
2.
3.
4.
5.
6.
7.
Percentage of patients with an office visit for acute sinusitis given a first line antibiotic
when an antibiotic is prescribed.
Percentage of patients with acute sinusitis who receive an antibiotic other than first line
for whom one of the following contraindications is documented:
• allergies to first line antibiotics
• failure to respond to first line antibiotics.
Percentage of patients with a sinus x- ray after an initial visit for acute sinusitis.
Percentage of patients referred to ENT for acute sinusitis who have not received three
weeks of continuous antibiotic treatment
Percentage of patients referred to ENT for acute sinusitis who do not have any factors
documented. complications
Percentage of patients seen for acute sinusitis who have documentation that they have
been educated about treatment.
Percentage of patients seen for acute sinusitis where symptoms have been present for less
than 7 days and there is documentation of patient demand for antibiotics.
Sources
1.
2.
3.
4.
Rakel RE. Saunders Manual of Medical Practice. Saunders 1996.
Redington J. Acute Sinusitis: Diagnosis and Management. Primary Care Case Review
1998; 1: 61-69.
De Ferranti et al. Are Amoxicillin and folate as effective as other antibiotics for acute
sinusitis? A meta analysis. BMJ Middle East 1998; 5 (55): 52-59.
Fagnan LJ. Acute sinusitis: A cost-effective approach to diagnosis and treatment. Am
Fam Physician 1998; 58: 1795-1802.
60
Thyroid Nodule
Definition and Epidemiology
One of the commonest thyroid abnormalities is the presence of nodules. These become palpable
when they exceed 1 cm in size. The prevalence of nodules increases with age, averaging 6.4% in
females and 1.5% in male over their lifetime. Many palpable nodules are thought to be solitary but in
fact they are part of a multinodular goiter which has a lower malignancy probability. 90% of solitary
nodules are benign cysts or adenomas.
History
Most nodules are discovered by the patient or incidentally by a physician or a dentist. Initially the
physician should determine:
1. The duration of awareness of the nodule.
2. The growth of the nodule, whether this is a rapidly or slowly growing nodule.
3. Presence of pain
4. Presence of hoarseness
5. Symptoms of hyperthyroidism, weight loss, sweating, palpitation, presence of exophthalmos,
abnormal menses in females…..
6. Symptoms of hypothyroidism: constipation, weight loss, depression….
7. Symptoms of previous, thyroid diseases: thyroiditis or multi-nodular goiter.
8. History of neck or chest or irradiation because the presence of any radiation given to that
regions will increase the incidence of malignant neoplasm of thyroid.
Factors that increase the risk of malignancy include:
1. Rapidly growing thyroid nodule.
2. Presence of tenderness or hoarseness.
3. History of radiation to neck.
4. Being a male patient.
Objective Findings
In the physical exam, physician should check the following:
1. Location of the nodule.
2. Size of the nodule.
3. Presence of others thyroid nodules.
4. Consistency of the nodule whether this is a hard nodule or a cystic nodule.
5. Fixation of the nodule to the surrounding structures: Movable or non-movable.
6. Presence of cervical lymphadenopathy.
Diagnostic Considerations
The primary care physician should try to identify the presence of other nodules.
• Ultrasound of thyroid is helpful in two things:
1. To identify other nodules that are not palpable.
2. To differentiate between cystic lesions or solid lesions. In case of the cystic
lesion, it can be aspirated and this may be curative. The aspirated fluid should be
submitted for cytologic examination.
If a solitary nodule is highly suspected or confirmed by ultrasound:
• Obtain TSH and FT4 in the presence of symptoms of hyperfunciton
• Refer for FNA if not trained to perform it.
61
When to Refer
If unable to perform FNA in presence of a solitary nodule
Algorithm
•
Identify if other nodules exist
1. If multinodular -> assess function and treat accordingly
2. If solitary nodule
i. Cannot do FNA -> refer
ii. Can do FNA
1. Positive cancer -> send to surgeon
2. Negative cancer -> suppression therapy and follow up every 6
months
3. Unsure -> repeat FNA or do thyroid scan or try suppression therapy
and if no response do surgery
Sources
1. Ridguary EC: Clinician’s evaluation of a solitary thyroid nodule – J.Clin. Endocrinologic Metab
74,231,1991.
2. Rifat SF. Management of thyroid nodules. Am Fam Phys. 1994; 50(4):785
62
Urinary incontinence in the elderly
Epidemiology
Urinary incontinence affects 15-30% of elderly people living at home. Medically it predisposes to
perineal rashes, pressure ulcers, urinary tract infections, urosepsis, falls and fractures.
Psychologically, it is associated with stigmatization, isolation, embarrassment, depression and the risk
of institutionalization.
New onset or exacerbation of incontinence in an elderly, is often due to problems outside the lower
urinary tract amenable to medical intervention. Reversal of the precipitant may restore continence
without necessarily correcting the underlying lower urinary tract abnormality. If not, urinary
incontinence is established and generally due to lower urinary tract abnormality
Anatomy & physiology of micturition
1. Muscle groups and their innervation:
a. Detrusor surrounding the bladder
i. Cholinergic innervation causes contraction and voiding
b. Sphincter surrounding the bladder neck and at the urethral angle
i. Cholinergic innervation causes relaxation and voiding
ii. Adrenergic innervation increases tone and continence
2. Pharmacology
a. Anticholinergics and adrenergic agents increase continence
b. Alpha blockers decrease sphincter tone and ease urination.
3. Age related changes
a. Involuntary bladder contractions increases
b. Post voiding residual volume increases to 50-100 ml.
c. There is also a decrease in inhibitory ability, bladder capacity, contractility and
bladder closure pressure.
d. In addition, the elderly excretes most of their fluid intake at night, even in the
absence of renal disease edema or prostatism.
e. This leads to 1 or 2 episodes of nocturia in most healthy old people.
f. None of the changes causes incontinence but predispose to it.
Evaluation process
1.
2.
3.
Identify transient and established causes of incontinence
Classify disorder
a. Storage disorder:
i. Detrusor instability (urge incontinence): bladder contracts involuntarily as in
cortical insults (stroke, Alzheimer) or local irritation in the bladder (cystitis,
bladder ca..)
ii. Stress incontinence: urethral pressure is low as in women following childbirth
or radical prostatectomy in men
b. Evacuation disorder:
i. Detrusor under activity (overflow incontinence): detrusor does not contract
when or as well as it should. Usually idiopathic but can be neurogenic as in
diabetes, pelvic surgeries, alcohol, herniated disc
ii. Outlet obstruction: more common in men (prostate) but can occur in women
who have undergone bladder neck suspension or severe prolapse.
Exclude any serious underlying condition: Brain or cord lesion, bladder ca,
hydronephrosis
63
History
Mechanism
History
Post void residual
Urge
Detrusor instability
Normal
Stress
Outlet inadequacy
Overflow
Detrusor hypotonia
Functional
Does not reach toilet
on time
Nocturnal wetting
Urgency followed by incontinence
May be triggered by running water
Increased intrabdominal pressure
(cough, laughter, sneeze) causes
incontinence
Dribbling
Frequent leaking
Ill patient
Impaired mobility
DIAPPERS symptoms (see below)
Type
•
•
•
•
•
•
•
Normal
Large (> 450 ml)
Normal
Frequency and pattern: periodic /constant, day/night, with stress/at rest
o Morning only incontinence may be due to diuretics
o Night only may be due to postural diuresis associated with congestive heart failure
Urgency present or absent
Need to strain to void interrupted stream
History of retention, sense of incomplete emptying
Functional assessment ( mentation and manual dexterity)
List of all medications and medical problems
DIAPPERS symptoms. Usually associated with transient incontinence
o D : Delirium/acute confusion
o I : Infection (symptomatic UTI)
o A : Atrophic vaginitis/ urethritis
o P : Pharmaceuticals
i. sedatives/hypnotics- flurazepam, diazepam, alcohol
ii. potent diuretics- furosemide, ethacrynic acid,
iii. anticholinergics – psychotropics, antispasmodics, antiparkinsonian meds (not
Sinemet) , antiarrhythmics, antihistamines, antidiarrheals
iv. adrenergic agents- alpha adrenoreceptor agonist in males and antagonists in
females
v. calcium channel entry blockers
vi. ACE inhibitors ( cough stress incontinence)
o P : Psychological: severe depression or behavioral disturbances
o E : Excess urine output (excess intake, diuretics, metabolic, edema)
o R : Restricted mobility
o S : Stool impaction
Objective Findings
Targeted exam:
1.
Orthostatic BP, mental status, general exam, peripheral edema
2.
Leakage when upright, relaxed/bladder full/cough
3.
Bladder palpable after voiding
4.
Pelvic exam: atrophic urethritis/vaginitis, uterine prolapse, cystocele, mass
5.
Rectal: anal wink/ bulbocavernosus ( sacral reflexes), perineal sensation, sphincter resting
tone and volitional control, fecal impaction- prostate size ( large prostate does not mean
obstruction is the cause)
6.
Neurologic: sensation, strength, tone, reflexes, plantar in lower extremities
64
Diagnostic Considerations
1.
2.
3.
4.
5.
6.
7.
8.
Voiding diary: check voided and total volumes, frequencies, and pattern for 48-72 hours.
Urine analysis, culture
When indicated: blood sugar, calcium, BUN, Creatinine
Residual volume determination- by catheter or ultrasound- if post void residue is more
than 450 ml think of overflow incontinence
Renal sonography, if post void residue in a male is more than 200 ml,
Urine cytology if sterile hematuria or pain
Cystoscopy
Voiding cystourethrogram and not IVP
Management options
General :
• Discontinue potentially offending drugs (including diuretics)
• Treat infections
• Pads/diapers/ condoms
Timed-voiding bladder training
• Bladder training-works in 75 % of the cases with detrusor instability
• Urinate in a receptacle at least half of the time
• Determine interval time leading to incontinence by using voiding charts
• Set frequency of voiding to 1 hour before expected incontinent time OR
• Start by voiding every 2 hours while awake and every 2-4 hours at night
• Extend period by half an hour every week until voiding every 4 hours or an acceptable time.
• Ask patient to void on schedule:
o If needs to void earlier, make every effort to hold it until scheduled time
o If feels no urge to void on schedule, make an effort to void on time
Catheterization
• Condom catheters are helpful for men but cause skin breakdown and decrease motivation to
become dry.
• Indwelling catheters may exacerbate the condition. If they must be used, a small catheter with
a small balloon is preferred.
• Intermittent catheterization for motivated patients with neuropathic or hypotonic bladders
with large post void residual volume. Usually individuals need at least four catheterizations
per 24 hours period
Kegel pelvic muscle exercises
• 10-25% of women with stress incontinence become continent.
• Ask patient to identify floor muscles: they are the ones that start and stop flow.
• Practice 5 times a day or with each void
• Hold floor muscles tight as if stopping urine for 5 seconds – relax – repeat 10 times
• Needs motivation
65
Patient instructions
Possible treatment
Urge
Timed-voiding bladder training
Avoid xanthines
Stress
Kegel exercises
Keep bladder empty
Tampon
Overflow
Timed-voiding
Intermittent catheterization
Surgery to relieve obstruction
Functional
Remove cause
Oxybutynin (Ditropan) 2.5 – 5mg TID
Flavoxat (Urispas) 100-200 mg TID
Imipramine (Tofranil) 10-25 mg TID
Estrogen replacement
Estrogen replacement
Imipramine (Tofranil) 1o-25 mg QD- TID
Phenylpropanolamine 25 mg QD-QID
Pseudoephedrine (Sudafed) 60 mg Q8hrs
Exclude fecal impaction, large cystocele
Decompress for 10-14 days
Refer to exclude obstruction
Finasteride (Proscar) 5 mg QD for 6 months
Doxazosin (Cardura) 1 mg QD
Family support
Type
When to refer
1.
2.
3.
4.
5.
6.
Unsure about management
Unsure about diagnosis
Hematuria in the absence of pyuria or infection
Stress incontinence in men
Surgical treatment needed
Elevated post void residual > 150 ml.
Sources
1.
2.
3.
4.
Resnick. Urinary Incontinence. Lancet 1995; 346:94-99
Bladder Function, Pathophysiologic Principles of Urology- 1997
Urinary incontinence guideline panel. Clinical practice guidelines N0 2, 1996 Update AHCPR
March 1996
Resnick, Geriatric Medicine. Harrison’s Principles of Internal Medicine 1997
66
Viral Upper Respiratory Tract Infection (Common Cold)
Definition and Epidemiology
Viral upper respiratory tract infection (VURI) is a self-limited illness lasting typically 5 to 14 days.
It is mostly caused by one of the many strains of rhinovirus and is manifested by rhinorrha, cough and
fever.
Incidence peaks during the winter season when crowding indoors is the rule, most frequently 1 to 2
days after inoculation with the virus through inhalation of coughed material or hand to hand contact.
A main problem physicians face in dealing with VURI is inability to refrain from over prescribing,
particularly antibiotics. Care can be significantly improved with proper patient education and
conservative physician approach
History
Patients usually report:
Sore throat (usual presenting symptom)
Rhinorrhea (watery or mucoid; may become purulent at a later stage)
Cough (dry or slightly productive)
Fever less than 39C for less than 72 hours
Malaise, myalgias, weakness.
Objective Findings
Pertinent physical examination includes the following:
• Throat exam: to check for hyperemia, tonsillar enlargement, follicle/exudates
• Nose exam: to check for watery versus purulent discharge
• Ear exam: to check for acute otitis media especially in the pediatric age group
• Cervical lymph nodes
• Chest exam: to check for lower respiratory tract complications such as bronchitis or
pneumonia
• Sinus tenderness
• Temperature measurement
Diagnostic Considerations
Physician’s initial concern is to rule out presence of serious illness manifested usually by;
1.
Respiratory distress: grunting, retractions, rapid respiratory rate, dyspnea or cyanosis
2.
Decreased responsiveness in a child or an old person, flaccidity, lethargy, altered mental
state and loss of appetite.
3.
Meningeal signs: stiff neck, persistent vomiting or sever headache
4.
Dehydration: reduced wet diapers or absence of urine for more than 6 to 8 hours in a
child under one year or absence of urine for more than 12 hours in an older child or adult.
Other respiratory conditions must also be entertained, such as:
1.
Otitis media (see chapter on otitis)
2.
Lower respiratory tract conditions (see chapters on asthma, pharyngitis, pneumonia and
bronchitis)
3.
Sinus infection: (nasal discharge of any type >10- 14 days, cough persisting beyond 7- 14 days
and not improving and/ or worsening, cracked, crusted or bleeding sores around nares,
purulent nasal discharge, fever, and seems ill, moderate periorbital swelling with red or
blue discoloration).
4.
Allergic rhinitis: Here symptoms of rhinorrhea occur usually in the morning , are not
associated with fever or body aches, are seasonal/chronic and correlated with exposure to
a certain antigen.
67
5.
Vasomotor rhinitis: Here symptoms are perennial and not associated with fever or body
aches and respond with difficulty to anti-histamines - decongestants.
6.
Acute bacterial tonsillo-pharyngitis: In this condition there is high grade fever, usually
sudden onset of symptoms mostly of severe sore throat, with tender submandibular
lymphadenopathy.
7.
Nasal polyps: persistent discharge with nasal obstructive symptoms in a patient with
allergic rhinitis.
8.
Rhinitis medicamentosa: History of prolonged use of topical decongestants; symptoms of
nasal pain, purulent discharge and inflamed nasal mucosa.
9.
Infectious mononucleosis: sore throat - usually severe, many enlarged lymph nodes,
fatigue, temperature elevated longer than usual for VURI
10.
Asthma / allergy: cough, wheezing, dyspnea, chest tightness, bronchitis sputum
production
Elderly patients or those with multiple complicating chronic diseases should be identified and
attended to.
Therapeutic choices
Symptomatic relief can provided using any one or a combination of the following to be used
sparingly:
1.
Oral decongestants
e.g. Sudafed (= pseudoephedrine): 1 tab tid for adults and 5 cc tid for children
2.
topical decongestants
e.g. Duration and Afrin (=oxymetazolin) nasal drops: tid for 3 to 4 days: caution against prolonged
use.
3.
Oral antihistamines-decongestants combinations
e.g. Actifed (= triprolidine + pseudoephedrine; 1 tab tid for adults and 5 cc tid for
children); Disophrol (= dexbropheniramine + pseudoephedrine; 1 tab bid); Clarinase
(=loratidine + pseudoephedrine; 1 tab bid); Dimetapp (=brompheniramine +
phenylpropanolamine; 2 tsp tid)
4.
Antipyretics
e.g. Tylenol (=acetaminophen supp; 1 supp q 6 hrs prn) or Panadol (= paracetamol syrup; 5 to 10 cc q
6 hrs prn) for children; Aspirin (=Acetyl-salicylic acid; 2 tab q 6 prn); Panadol (= paracetamol; 2 tab
q 6 hrs) or Tylenol (=acetaminophen; 2 tab q 6 hrs) for adults
5.
Throat sprays or lozenges - Locabiotal 2 sprays q 4 hrs.
6.
Cough syrups
e.g. Mucosolvan/Fluibron (=mucolytics: 5 cc tid in children; 15 cc tid for adults); Rhinathiol with or
without promethazine( also mucolytic: 5cc bid in children up to 15 cc tid in adults)
Patient Education
1.
2.
3.
4.
5.
6.
7.
Explain the etiology of colds
Encourage fluid intake
Advise relative rest
Explain the usual course of colds
Explain that cold is contagious and that precautions should be taken to avoid
transmission to contacts
Explain that antibiotics are not helpful and that they may be harmful .
Ask patient to report back if symptoms do not improve in one week time or if significant
deterioration occurs before that period
68
Quality of care indicators
1. Percentage of patients visiting for URI who have had symptoms for more than 7 days with
proper home treatment but no relief
2. Percentage of patients with URI who had symptoms less than 7 days and are given antibiotics
3. Percentage of records with documentation about URI proper care
Sources
1.
2.
3.
4.
5.
6.
Work group Members. Viral URI in children and adults. Institute for Clinical Systems
Integration, 1998
JAMA 1993. 270 (10); 1242
Rakel R. E., Textbook of Family Practice, 5th Ed., 1995, 389-90 and 462.
Rakel R. Conn’s Current Therapy, 1986
Everrett MT, Upper respiratory illness in perspective. Practitioner, Mar 1981,225:379-391
69
Common chronic problems
70
Asthma
Definition and Epidemiology
Bronchial asthma is a chronic inflammatory disorder characterized by variable and usually reversible
airway obstruction related to airway hypersensitivity.
Prevalence of asthma is estimated at 10-12 % of the population with only about 6% actually labeled
asthmatics and up to 80% of those being under treated. Around 20 % of identified asthmatics have
fairly severe disease, 40% moderate, 20 % mild and 20% variable severity.
History
History taking in asthma aims at confirming diagnosis, identifying severity of illness and assessing the
patient and family’s familiarity and coping skills about the disease.
Severity :
• Symptoms: Wheezing, breathlessness, cough, chest discomfort
• Pattern of Symptoms: Perennial/ seasonal, episodic/ continual, diurnal
• Severity of Symptoms: Number of symptom episodes per week, number of nocturnal
symptoms per week, change in activity associated with symptoms, hospitalization and
emergency room visits.
Confirmation of condition:
• Previous physical examinations consistent with diagnosis.
• Previous spirometry.
• Response to therapy consistent with symptoms.
• Triggers: Viral respiratory infections, allergens, exercise, temperature, humidity,
occupational irritants, perfume, tobacco smoke, drugs (Aspirin, NSAID, beta blocker) and
food (sulfites)
• Associated symptoms (rhinitis, sinusitis, GERD)
Knowledge and compliance:
• Previous treatment and response, side effect from treatment.
• Difficulties in compliance with treatment.
• Handling of attacks.
• Family or emotional problems.
Objective Findings
Objective assessment must include a focused pulmonary examination at each visit and (whenever
available) a peak flow value. Peak flow meters are available in Lebanese pharmacies and are
inexpensive.
Physical examination
Lung sounds, respiratory rate, retractions, nasal flaring, skin color, clubbing, pulsus
paradoxus.
71
Laboratory evaluation
•
•
Oxygen saturation may be helpful in severe disease especially in emergency management.
Spirometry is recommended in every patient > 5 years of age at the time of initial
diagnosis. Measurements (FEV1, FVC, FEV1/FVC) before or after the patient inhales a
short-acting bronchodilator should be undertaken for patients in whom the diagnosis of
asthma is being considered. Airflow obstruction is indicated by reduced FEV1 and FEV1/
FVC values relative to reference or predicted values. Significant reversibility is indicated
by an increase of more than 12 percent and 200 ml in FEV after inhaling a short-acting
bronchodilator.
Peak expiratory flow (PEF) home monitoring values can be very useful in following
illness. All patients age 5 and older who have moderate or severe asthma should be
encouraged and taught how to use a peak flow meter. PEF recordings by patients can
help:
1. Decide if medication plan is successful or needs modification.
2. Involve patient in his/her own care and learn when to seek emergency care and
identify attack triggers.
PEF is best done upon awakening each morning. A “personal best” must be identified
during periods of good control.
•
•
How to Use a Peak Flow Meter
1.
2.
3.
4.
5.
6.
7.
Personal Best Peak Flow Number
Place the indicator at the base of the
numbered scale.
Stand up and take a deep breath.
Place the meter in your mouth and close
your lips around the mouthpiece. Do not
put your tongue inside the hole.
Blow out as hard and fast as you can.
Write down the number you get.
Repeat steps 1 through 6 two more times.
Write down the highest of the three
numbers achieved.
Every day for 2 weeks while patient is feeling
good without any symptoms
Record PEF twice a day mornings and evenings
Each time before and after taking inhaled beta2agonist (if on treatment)
“Personal best” is the highest reading achieved
during these 2 weeks
Diagnostic Considerations
Additional studies done should be based on each patient’s need and availability of facilities:
• Allergy testing, chest radiography (to exclude other diagnosis), sinus x- rays or CT scan,
gastro esophageal reflux evaluation, CBC with eosinophils, total IgE and sputum exam.
• Eosinophil count is believed to correlate with severity and to be a good index to follow
response (keep below 80/mm3)
72
Management
1. Classify asthma severity
Mild
Intermittent
Symptoms
Signs
Symptoms <= 2 / week
Asymptomatic in
between the brief
exacerbations which last
few hours - few days
Nighttime symptoms
<=2 / month
FEV1 or PEF > = 80%
predicted
PEF variability < 20%
Mild
Persistent
Symptoms > twice /
week
But < once per day
Exacerbations affect
activity
Nighttime symptoms >2
/ month
FEV1 or PEF > = 80%
predicted
PEF variability 20% 30%
Moderate
Persistent
Severe
Persistent
Daily symptoms
Daily use of short acting
b2 agonists
Exacerbations affect
activity but occur more
than 2 a week and may
last days
Nighttime symptoms >1
/ week
FEV1 or PEF 60%80% predicted
PEF variability > 30%
Continuous symptoms
Limited physical
activity
Nighttime symptoms frequent
FEV1 or PEF <= 60%
predicted
PEF variability > 30%
2. Choose medications based on severity (Stepped care approach)
Daily
Controller
medications
Step1
Mild
Intermittent
None
Step 2
Mild
Persistent
Low dose inhaled
corticosteroid (200-500
mcg /d of
triamcinolone) OR
Step 3
Moderate
Persistent
Medium dose inhaled
corticosteroid (500800mcg /d of
triamcinolone) OR
Combination:
Low-med (or med-high
if needed) inhaled
steroid + long acting
bronchodilator
+/--
Quick Relief
medications
Short acting inhaled b2
agonist as needed for
symptoms, less than
once per week.
B2 agonist or Cromolyn
before exercise.
Short acting inhaled b2
agonist.
73
Cromolyn OR
Nedocromil OR
Leukotriene modifier OR
Theophylline SR
If needed more than 3-4
times per day - reassess
control.
Step 4
Severe
Persistent
High dose inhaled
corticosteroid (8002000 mcg /d of
triamcinolone or more)
+
Long acting
bronchodilator
+/-steroid tablets or syrup
+/--
3. For acute exacerbations – teach patient what to do at home and when
to come to emergency
1. Home treatment
A. Measure peak expiratory flow (PEF) : If < 50% personal best or predicted, this
means a severe exacerbation
B. Start treatment with an inhaled short acting beta agonist (see table below) up to 3
treatments of 2-4 puffs each at twenty minutes interval (or use one single nebulizer
treatment).
• Assess response
∗ Good: Mild episode
⇒
PEF > 80 %, No wheezing, response sustained for 4 hours
⇒
Continue beta agonist every 3-4 hours for 48 hours
⇒
If on inhaled steroid, double dose for 10 days
⇒
Follow up by doctor within a week
∗ Incomplete response: Moderate episode
⇒
PEF 50-80%, persistent wheezing
⇒
Add an oral corticosteroid
⇒
Follow up by doctor same day
∗ Poor response: Severe episode
⇒
PEF < 50%, marked wheezing
⇒
Repeat beta-agonist
⇒
Add oral corticosteroid
⇒
Immediate emergency medical attention
2. Emergency room treatment
A. Usual initial treatment is with short-acting nebulized agonist (Albuterol, Terbutaline)
2.5- 5 mg q 20 min up to 3 doses.
B. Alternatives
• Epinephrine
∗ Adult: 0.3- 0.5 mg sc q 20 min up to 3 doses
∗ Peds: 0.01 mg/ kg up to 0.3- 0.5 sc q 20 min up to 3 doses
• Terbutaline
∗ Adult: 0.25 mg sc q 20 min up to 3 doses
∗ Peds: 0.01 mg/ kg sc q 20 min up to 3 doses
C. Anticholinergic therapy should be added to beta2-agonist therapy in severe and lifethreatening cases and may be considered in cases of mild to moderate asthma.
Aminophyline is not recommended for use in the first 4 hours of therapy.
D. Assess Response
• Good response
∗ PEF>70% predicted normal, no wheezing on auscultation
∗ Send home on home treatment
• Incomplete response
∗ PEF 50- 70% predicted normal, mild wheezing
∗ Consider hospitalization, particularly for high risk patients who:
⇒
Had hospitalization or an emergency visit for asthma in the past month
⇒
Had two or more hospitalizations for asthma in the past year
⇒
Had three or more emergency visits for asthma in the past year
⇒
Had prior intubation for asthma
⇒
Have past history of sudden severe exacerbation
⇒
Use more than 2 canisters per month of inhaled short-acting beta2-agonists
⇒
Currently use systemic corticosteroids or recently stopped them
74
⇒
Have co morbid conditions such as cardiovascular, psychiatric or chronic
obstructive airway disease
⇒
Have difficulty perceiving airflow obstruction or its severity
• Poor response
∗ PEF<50% predicted normal, no improvement in respiratory distress
∗ Strongly consider hospitalization
∗ Continue inhaled beta-agonist q 60 minutes
∗ Consider starting prednisone
⇒
Adult: short course 40-60 mg/day in one or 2 divided doses for 3 to 10
days
⇒
Child: short course 1-2 mg/kg/day, maximum 60 mg/ day for 3 to 10
days
E. All patients should be considered candidates for systemic corticosteroid therapy at
discharge from emergency room and should be given WRITTEN clear instructions
for follow-up care.
Desired outcomes
•
•
•
•
•
•
Minimize need for emergency care
Prevent troublesome symptoms night and day
Require little or no relief medications
Provide optimal pharmacotherapy with minimal adverse effects
Have as close to normal as possible a lung function
Have a productive, physically active life
Not to be missed
•
•
•
Sinus disease
Gastro esophageal reflux
Acute attacks in adolescents
Follow up
The exact frequency of clinician visits is a matter of clinical judgment.
Severity
Regular follow- up visit
Mild Intermittent
6- 12 months
Mild Persistent
6 months
Moderate Persistent
3 months
Severe Persistent
1 to 2 months and as often as needed to establish control
When to Refer
•
•
•
Refer to allergist for skin testing –if needed to determine role of allergy in symptoms,
symptoms poorly responsive to treatment or severe symptoms
Refer to pulmonologist: patients in whom the diagnosis is in doubt, patients with possible
occupational asthma, patients who present problems in their management or those with
atypical symptoms suggesting anatomic abnormality or foreign body
Refer to ENT with sinus x-ray –I f persistent daytime and nighttime cough and wheeze
unresponsive to bronchodilators
75
Therapeutic choices
Group
Generics
Brands
Usual Dosage
Remarks
Short acting
b2 agonists
Albuterol
Ventolin, Proventil
Syrup: 2 mg/5 ml
Terbutaline
Pirbuterol
Albuterol
Brethine
Maxair
Volmax
2 puffs Q4-6hrs
PO: 0.1 mg/kg up to 2
mg TID
2 puffs q4-6hrs
Salmeterol
Beclomethasone
Serevent
Beclovent, Vanceril,
Becotide, Clenil
2 puffs BID
1-2 puff tid-qid
Triamcinolone
Azmacort, Kenacort
1-2 puff tid-qid
Prednisolone
Prednisone
Pediapred, Delta-cortef
Deltasone, Cortancil
Methylprednisolon
e
Dexamethasone
Medrol
Long acting
b2 agonists
Inhaled
steroids
Oral steroids
Inhaled
NSAID
Leukotriene
modifiers
Methyl
Xanthines
Anticholinergi
cs
Cromolyn
Oradexon (0.025
mg/ml)
Decadron (0.05
mg/ml)
Intal
Nedocromil
Zafirlukast
Tilade
Accolate
Montelukast
Singulair
Zileuton
Theophylline
Zyflo
Theo-Dur
Ipratropium
Atrovent
4 or 8 mg tab PO BID
Each puff is 42 mcg
Max adult: 840 mcg/d
Max child 6-12y: 420 mcg/d
Under 6 – avoid
Each puff is 100 mcg
Max adult: 1600 mcg/d
Max child 6-12y: 1200 mcg/d
Under 6 – avoid
1-2 mg/kg/d
Up to 60 mg/d adult
0.15-0.3 mg/kg/d
2-4 puffs QID
100 mg PO BID for
children
200 mg QID for adults
2 puffs QID
20 mg PO BID between
meals
5 to 10 mg PO once
daily
600 mg PO QID
10 mg /kg/ dose BID up
to around 600 mg per
day or monitor blood
levels
2-3 puffs QID
Adults only
5 mg chewable at bedtime for
children above 6y old
Adults only, Hepatotoxicity
Use sustained release
formulation especially for
night symptoms relief
Patient Education
•
•
•
•
•
•
•
•
•
Influenza vaccine to be offered to all asthmatics in September and October every year
Explain the aims and side effects of treatment
Advise stop smoking and /or avoid second-hand smoke
Instruct about environmental control
Instruct on use of metered-dose inhaler
Instruct on use of home peak flow meter
Instruct about plan for treatment of an acute wheezing episode including criteria to start any
medication and when to call doctor or go to emergency
Explain that asthma can be fatal if high-risk factors present
Advise regular exercise
76
Management and treatment tips
•
•
•
•
•
•
Check compliance with controller medications, particularly if control is poor or treatment is to
be increased.
Check inhaler technique.
Oral treatment should be considered as second line therapy to inhaled treatment.
Use the cheapest delivery device the patient can use and comply with effectively.
For uncontrolled asthma: treat with prednisolone 30-40mg daily until symptoms settle and
PEF normal. Consider using Leukotriene modifiers to decrease need for steroids
Lifestyle education: establish smoking status, advise smokers to stop, offer education about
condition and its management
Algorithm
Asthma suspected
(Dyspnea, cough,
wheezing, etc..)
Confirm diagnosis
Assess severity
•History and physical
•Measure pulmonary
function
-spirometry
-PEFR
Step Care of
Pharmacologic
Treatment
•mild intermittent
•mild persistent
•moderate persistent
•severe persistent
Education
• written action plan
• home PEFR
• inhaler technique
Quality of care indicators
1. Proper follow up and monitoring as evidenced by:
Proportion of patients who receive an annual pulmonary function test
Proportion of patients who have good symptoms control as evidenced by decreased use of
short acting b2 among receivers of steroids
Proportion of patients who use of anti-inflammatory agents
2. Good patient education and participation in one's own care:
Proportion of patients educated on use of inhalers, spacers and peak flow meter
Proportion of patients who have a written plan of what to do in exacerbations
Proportion of patients with documented goals as to degree of functionality, activities, freedom
from symptoms (day and night) and the best possible lung peak expiratory flow.
Sources
1. National Heart, Lung, and Blood Institute: National Asthma Education and Prevention
Program: Highlights of the Expert Panel Report 2; Guidelines for the Diagnosis and
Management of Asthma. U.S. Department of Health and Human Services, NIH Publication
No 97-4015A, Bethesda, MD; National Institutes of Health, May 1997.
2. Web site: www.nhlbi.nih.gov/nhlbi/nhlbi.htm
77
Congestive Heart Failure
Definitions
Heart failure is a dysfunction of the myocardium resulting in decreased cardiac output. This
dysfunction leads to compensatory mechanisms which cause symptoms and signs recognized as the
syndrome of heart failure.
Heart failure has many descriptions often useful in clinical practice:
1. Congestive is applicable when there are signs and symptoms of pulmonary or systemic
volume overload.
2. Acute failure manifests usually by pulmonary edema (abrupt onset of breathlessness and
evidence of alveolar edema by physical and radiological examination). The prototype is the
patient who suddenly develops a large myocardial infarction or rupture of a cardiac valve.
3. Chronic failure is typically observed in patients with dilated cardiomyopathy or multivalvular
heart disease that develops or progresses slowly. This type can usually be managed in an
ambulatory setting and is the subject of this guideline.
4. Systolic: Inability of the heart to contract normally and expel sufficient blood
5. Diastolic: Inability of the heart to relax and fill normally then expel sufficient blood.
6. High output: Seen in hyperthyroidism, anemia, pregnancy and arteriovenous fistulas.
7. Low output: Occurs secondary to ischemic heart disease, hypertension, dilated
cardiomyopathy, and valvular and pericardial disease.
8. Left-sided: Patients in whom the left ventricle is mechanically overloaded (aortic stenosis), or
weakened (post myocardial infarction), develop dyspnea or orthopnea as a result of
pulmonary congestion which is referred to as left-sided failure.
9. Right-sided: When the underlying abnormality affects the right ventricle (pulmonary valvular
stenosis or pulmonary hypertension), symptoms of edema, congestive hepatomegaly and
systemic venous distention develop which is referred to as right-sided heart failure.
History
Ventricular dysfunction can be asymptomatic, and occult heart failure can be diagnosed incidentally
on chest radiography. However, when symptoms are present, they may be secondary to insufficient
output, or to congestion. History is the initial step to identify the patient with heart failure and should
include questions related to symptoms of left as well as right ventricular failure:
Right ventricular heart failure
History of weight gain.
History of increased abdominal girth.
Anorexia, nausea, and bloating.
Fluid retention: Ascites and edema.
Left ventricular heart failure
Symptoms of insufficient output:
Weakness and fatigue.
Reduced exercise capacity.
Decrease concentration and mental function.
Symptoms of congestion:
Exertional dyspnea.
Orthopnea.
Paroxysmal nocturnal dyspnea.
Nocturnal cough.
History should also include
• Information about possible underlying etiology:
History of hypertension, angina or myocardial infarction, and presence of heart murmur
during childhood.
78
•
Possible precipitating factors:
Arrhythmias, hypoxia, anemia, alcohol intake, noncompliance with low salt intake, systemic
infection, psychological stress, exercise in extremes of heat or humidity, adding or
discontinuing drugs, tachycardias, heavy alcohol consumption, and thyrotoxicosis.
Objective Findings
The following physical signs need to be evaluated to assess severity of failure:
• Systemic signs: Edema, cachexia, petechiae/ecchymoses, rash
• Neurologic signs: Mental status abnormalities.
• Cardiovascular signs: Neck vein distention, abdomino-jugular neck vein reflex, cardiomegaly
on percussion/palpation, gallop rhythm on auscultation (S3, S4), diminished S1, S2,
prominent P2, friction rub.
• Pulmonary signs: Rales, ronchi, friction rub, wheezes, dullness to percussion.
• Abdominal signs: Ascites, hepatosplenomegaly, pulsatile liver, decreased bowel sounds,
ileus.
Laboratory investigations:
• Blood tests: Kidney and liver function need to be evaluated. If the patient is older than 65
years, has an arrhythmia or symptoms or signs of thyroid disease, TSH and T4 should be
included. Other tests are performed as indicated by the history and physical findings.
• Electrocardiography: Assess for signs of infarction, arrhythmias, conduction delay, chamber
enlargement, or hypertrophy.
• Chest radiography: can show: Increased cardiothoracic ratio, specific chamber enlargement,
pulmonary vascular redistribution or edema, Kerley’s B lines, or pleural effusion.
• Assessment of ventricular function: Heart failure is most cost effectively diagnosed by the
measurement of the ejection fraction (EF) by echocardiography.
o An EF of 40% or less reflects significant systolic dysfunction
o In diastolic dysfunction EF could be high, normal or low.
o Echocardiography can also evaluate chamber dimensions, ventricular wall thickness,
valvular abnormalities, and check for the presence of focal wall motion abnormalities
which imply underlying coronary artery disease.
• Holter monitor may be indicated if there are symptoms or signs that suggests either
arrhythmias or ischemia.
• Exercise testing: can provide objective evidence of functional impairment or screen for
ischemic heart disease. It is only indicated if the patient is stable.
• Cardiac catheterization should be considered in whom an etiological and anatomical diagnosis
has not been made by noninvasive techniques.
Cardiac limitation classification
Based on the history and the severity of heart failure; the functional status of patients is classified
according to the New York Heart Association (NYHA):
Class I:
Class II:
Class III:
Class IV:
Cardiac disease without symptoms or limitation of ordinary physical activity.
Slight limitation of physical activity-comfortable at rest, but ordinary physical
activity results in fatigue, dyspnea, or anginal pain.
Marked limitation of physical activity- comfortable at rest, but less than ordinary
physical activity cause fatigue, palpitation, dyspnea, or anginal pain.
Inability to carry on any physical activity without discomfort or symptoms at rest.
79
Management options
1. Inpatient vs. outpatient
Once the diagnosis of heart failure is made, hospitalization (and cardiology consultation) should be
considered with any of the following findings:
• Clinical or electrocardiographic evidence of acute myocardial ischemia
• Pulmonary edema or severe respiratory distress
• Severe complicating medical illness (e. g., pneumonia)
• Generalized edema
• Heart failure refractory to outpatient therapy
• Thromboembolic complications requiring interventions
• Significant arrhythmias
• Inadequate social support for safe outpatient management
2. Management strategies:
• Identify precipitating factors.
• Treat reversible underlying or precipitating causes
i. Hypertension control.
ii. Refer to surgery for valvular disease.
iii. Refer for possible mechanical revascularization for patients with coronary artery
disease and left ventricular dysfunction.
• Reduce cardiac work load
• Control excessive retention of salt and water
• Enhance myocardial activity.
3. Management choices:
• Nonpharmacological:
Sodium restriction, weight reduction, stop smoking, adequate rest, programmed exercise, avoidance
of physical and psychological stress.
• Pharmacological:
A summary of the usual dosing and potential side effects of the common pharmacological agents used
to treat patients with heart failure is shown below.
• Choices of therapy are usually determined by the presence of either systolic or diastolic
dysfunction which can be distinguished using the following parameters.
Parameter
History
Coronary artery disease
Hypertension
Diabetes
Valvular heart disease
Paroxysmal dyspnea
Physical examination
Narrow pulse pressure
Cardiomegaly
Soft heart sounds
S3 gallop
S4 gallop
Mitral regurgitation
Edema
Jugular venous distention
Systolic
Diastolic
++++
++
+
++++
++
+
++++
+++
-+++
+++
+++
++++
+++
+
+++
+++
+++
-+
+
+
+++
+
+
++
Parameter
Chest radiography
Cardiomegaly
Pulmonary congestion
Electrocardiogram
Low voltage
Left ventricular hypertrophy
Left ventricular dilatation
Q-waves
Echocardiogram
Low ejection fraction
Left ventricular dilatation
Atrial dilatation alone
Left ventricular hypertrophy
Mitral regurgitation
80
Systolic
Diastolic
+++
+++
+
+++
+++
++
+++
+++
-++++
-+
++++
+++
-++
+++
--+++
++++
++
Desired outcomes
The goals of therapy include:
1. Reduction of symptoms
2. Prevention of progression of ventricular dysfunction
3. Prolongation of life
The frequency of follow-up visits for CHF patients should be based on the severity of the CHF, the
age of the patient, and whether the patient has other associated medical problems. Class I or II CHF
patients should be seen every three to four months. Class IV CHF patients or patients with other
complicated medical conditions may need to be seen every two to four weeks.
Not to be missed
Common errors that can deprive patients of some of the benefits of treatment include:
• Not recognizing heart failure.
• Improper dosage of diuretics.
• Inadequate dosage of ACE inhibitor.
• Failure to use hydralazine and isosorbide dinitrate.
• Use of potentially harmful drugs: antiarrythmics, NSAID, calcium antagonists.
• Failure to assess the quality of life.
• Failure to consider long term therapeutic goals.
When to Refer
•
•
•
Class III or IV symptoms patients.
Rapidly progressive symptoms in spite of maximal medical management.
Calcium channel or β-blockers are to be considered.
Therapeutic choices
1. ACE Inhibitors
Are the cornerstone of the pharmacological management in systolic failure. They improve
hemodynamics by afterload reduction, and improve symptoms and quality of life. The progression
of heart failure is slowed by ACE inhibitor therapy, providing a survival benefits and reducing
hospitalization. They also delay the onset of symptoms in left ventricular dysfunction.
2. Diuretics
Are used when patients have symptoms or signs of systemic congestion due to volume overload.
Although these drugs have not been shown to prolong life, however, they relieve symptoms and
improve function in most patients, by promoting excretion of sodium and water. Thiazide
diuretics should be used if fluid retention is mild, but are effective only when the glomerular
filtration rate is greater than 30 ml/min. If congestion is moderate or severe then a loop diuretic
becomes the mainstay of therapy.
3. Digitalis
May help restore cardiac compensation by increasing the contractility of cardiac muscle. Digoxin
has been shown both to improve function and quality of life and not to increase mortality in
patients with heart failure. Because digoxin is indicated only for patients with systolic
dysfunction, it is ordinarily used with a diuretic and ACE inhibitor.
4. Hydralazine/ nitrates
Are used in combination in patients intolerant to ACE inhibitors, and in persistent heart failure
symptoms or hypertension in spite of ACE inhibitor therapy.
81
5. Other drugs
Calcium channel blockers and β- blockers are used in patients with diastolic dysfunction and
adequate ejection fraction, and always in consultation with a cardiologist.
Commonly used medications in heart failure
Drug
Thiazide diuretics
Hydrochlorothiazide
Initial dose
Maximum dose
Major adverse reactions
25 mg/day
50 mg/day
Postural hypotension, hypokalemia,
hyperglycemia, hyperuricemia, rash.
10-40 mg/day
240 mg bid
Same as thiazide diuretics
25 mg/day
100 mg bid
Amiloride
ACE inhibitors
Enalapril
5 mg/day
40 mg/day
Hyperkalemia, especially with ACE
Inhibitors, rash, gynecomastia
Hyperkalemia, rash
2,5 mg bid
20 mg bid
captopril
Lisinopril
Other agents
Digoxin
6.25-12.5 bid
5 mg/day
100 mg tid
40 mg/day
0.125 mg/day
Hydralazine
10-25 mg tid
100 mg tid
Isosorbide dinitrate
10 mg tid
80 mg tid
Loop diuretics
Furosamide
Potassium-sparing
diuretics
Spironolactone
Hypotension, hyperkalemia, renal
insufficiency, cough, skin rash,
angioedema, neutropenia
Same as above
Same as above
Cardiotoxicity, confusion, nausea,
dizziness, tachycardia, lupus-like
syndrome
Headache, nausea, dizziness
tachycardia, lupus-like syndrome
Headache, hypotension, flushing
Patient Education
General counseling
Explanation of heart failure and reasons for symptoms.
Symptoms of worsening heart failure and what to do if symptoms worsen
Self monitoring with daily weights
Explanation of treatment/care plan
Clarification of patient’s responsibilities
Role of family members or other caregivers in treatment/care plan
Importance of obtaining vaccination against influenza and pneumoccocal diseases
Prognosis
Life expectancy
Advice for family members in the event of sudden death
Activity recommendation
Recreation, leisure and work activity
Exercise
Sex, sexual difficulties and coping strategies.
Dietary recommendations
Sodium restriction
Avoidance of excessive fluid intake and fluid restriction if required
Alcohol restriction
Medications
Effects of medications on quality of life and survival
Dosing
Likely side effects and what to do if they occur
Coping mechanisms for complicated medical regimens
82
Availability of lower cost medications
Importance of compliance with the treatment/care plan
Quality of care indicators
1. Optimal use of ACE inhibitors as first line management.
Proportion of adult patients with CHF who are on an ACE inhibitor.
2. Proper assessment of left ventricular (LV) function during initial evaluation.
The proportion of CHF patients who have an evaluation of left ventricular function.
3. Proper assessment for secondary causes of CHF.
The proportion of patients with CHF who have documentation of assessment of secondary causes by
history, physical findings or appropriate laboratory testing.
83
Algorithm
Signs and symptoms of heart failure
123-
Determine etiology and correct if possible
Identify precipitating cause and treat
Correct ischemia and hypertension
Signs and symptom persist
Systolic dysfunction
Dilated LV and
RV/RA
Diuretic
Vasodilator
( ACE
inhibitor)
Diastolic dysfunction
Dilated LV
only
Decreased
exercise
tolerance
LV not
dilated
No
symptom
Diuretics
Calcium
channel
blockers
? β blockers
Dilated
LV
Diuretics
Calcium channel
blockers
ACE inhibitor
Inadequate response
ACE inhibitor
Digoxin
Β blocker
Inadequate response
Diuretics
Vasodilator ( ACE
inhibitor)
Digoxin
Consider
hospitalization
Sources
1. Institute for Clinical System Integration; Health care guidelines: Congestive Heart Failure in
Adults. September 1998.
2. American College of Cardiology/American Heart Association Task Force Report: Guidelines for
the evaluation and management of heart failure. J. Am. Coll. Cardiol. 26:1376-1398, 1995
3. Konstam, M.A., Dracup, K., Baker, D.W., et al.: Heart failure: Evaluation and care of patients
with left-ventricular systolic dysfunction. Clinical Practice Guideline no. 11. AHCPR publication
no. 94-0612. Rockville, MD, Agency for Health Care Policy and Research, Public Health Service,
U.S. Department of Health and Human Services, June 1994.
4. Stevenson, L.W.: Therapy tailored for symptomatic heart failure. Heart Failure 11:87-107, 1995.
84
5. Lee T.H.: Practice guidelines in cardiovascular medicine. In Braunwald, E. (ed.): Heart Disease.
5th ed. Philadelphia, W.B. Saunders, 1997, pp. 1939-1996.
6. Vasan, R.S., Benjamin, E.J., and Levy, D.: Prevalence, clinical features and prognosis of diastolic
heart failure: An epidemiologic perspective. J. Am. Coll. Cardiol. 26:1565-1574, 1995.
7. Cohn, JN. The management of chronic heart failure. N. Engl. J. Med. 335, No. 7:490-498: 1996.
85
Depression
Definition and Epidemiology
Major depression is characterized by a sustained dysphoric mood and at least five of the following
symptoms for at least two weeks: poor appetite, insomnia or hypersomnia, loss of interest or pleasure
in usual activities, psychomotor retardation or agitation, loss of energy, feelings of worthlessness,
diminished ability to think or concentrate and recurrent thoughts of death or suicide.
It is one of the most common diseases encountered in primary care setting and is often unrecognized
or maltreated. The lifetime prevalence of major depression in the general population varies widely
from 4% to about 30%, with a 1.5 to 2 ratio of women to men. Clinically significant depressive
syndromes may be detected in 12- 36% of patients with general medical disorders and up to 70 % of
individuals identified with clinical depression do not receive proper treatment..
It is a costly disease due to treatment cost and significant impairment of daily activities.
History
The primary care physician should probe for possibility of depression or anxiety disorders in patients
presenting with multiple somatic or vague complaints. Two simple clinical questions are helpful in
EXCLUDING depression:
1. "During the past month, have you often been bothered by feeling down, depressed or
hopeless?"
2. "During the past month, have you often been bothered by little interest or pleasure in doing
things?"
A positive answer requires confirmation using the DSM-IV criteria which require five symptoms for
at least two weeks including depressed mood or loss of interest.(Criteria can be remembered using the
mnemonic D-SIG-E-CAPS):
D
S
I
G
E
C
A
DEPRESSED
SLEEP
INTEREST
GUILT
ENERGY
CONCENTRATION
APPETITE
P
S
PSYCHOMOTOR
SUICIDALITY
Depressed mood most of the day
Insomnia or hypersomnia.
Markedly diminished interest or pleasure in all or almost all activities.
Feeling of worthlessness or inappropriate guilt.
Fatigue or loss of energy.
Diminished concentration or indecisiveness.
Significant (> 5% body weight) weight loss or gain or decrease or
increase in appetite.
Psychomotor agitation or retardation.
Recurrent thoughts of death or suicide.
The style of the interview is as important as its content and should convey support, trust and respect
for confidentiality. The doctor will benefit from making an effort to:
• Put the patient at ease.
• Use open-ended questions.
• Use language the patient can understand.
• Listen and observe reactions during the interview
• Demonstrate concern about the feelings of the patient.
86
A known depressed patient on treatment is followed up by asking about the status of the above
symptoms (severity, frequency), compliance with treatment and side effects of medication.
Objective Findings
A documented complete physical examination helps to discover any new problems or contraindications to medications and to reassure the patient.
Depression questionnaire such as “Beck’s inventory ” or “Hamilton Rating Scale” and may be useful
if the physician wishes to have a quantitative score of the severity of depression. Arabic versions are
available.
Diagnostic Considerations
The diagnostic work up requires assessing for potential associated mental or physical problems and
for suicide risk. If suicide potential, schizophrenia or acute mania exist, psychiatric evaluation must be
done the same day.
Diagnostic dilemmas face the primary care physician when:
1. Not all criteria for major depression are met:
If the physician still perceives depressive symptoms, the possibility of “dysthymia” (depressed mood
for 2 years or more with 2 or more of major depression symptoms on a near daily basis) should be
entertained. “Depression not otherwise specified” is also another “minor” form of depression (shorter
duration and less severe presentation). Both entities are DSM-IV diagnoses. A newly identified entity
is “Recurrent brief depression” lasts for 3 to 4 days and can be quite severe with high risk of suicide.
Evidence exists that many of these patients might benefit from specific pharmacologic treatment.
2. Bereavement
In bereavement, symptoms are less severe, work or school functions are not incapacitated, no guilt
feelings exist and the duration rarely extends beyond 6 months. It can, however, be incapacitating and
interfere with daily life. In such situations, some experts recommend treatment as in depression.
3. Somatic complaints raise the possibility of other psychiatric problems:
Psychiatric conditions that have somatic complaints as presenting symptoms can be differentiated by
history:
Condition
Somatization
disorder
Panic disorder
Generalized
anxiety
Depression
Hypochondriasis
Distinguishing Feature
Distressing physical symptoms or pain with no diagnosable medical condition
that has spanned over several years and begun before age 30.
Symptoms occur primarily during panic attacks.
Focus of anxiety and worry not limited to physical complaints.
Symptoms always in context of depression and remit with treatment of
depression.
Somatic preoccupation which can’t be accounted for by one of the above
conditions.
4. Other physical problems exist and can “explain” depression:
Depression coexists frequently with other diseases such as stroke or myocardial infarct. This does not
preclude its management as a separate “true” illness. This is particularly true in the elderly where
physicians may be preoccupied with somatic problems and ignore mental issues, especially patients
report only somatic complaints or attribute their “sadness” to old age.
87
5. Other co-existing mental problems exist
Dementia in the elderly can sometimes be distinguished from depression by the following tips:
Onset
Neurologic symptoms
Memory Loss
Cognitive defects
Dementia
Chronic
Present
Severe
May try to mask
Depression
Acute
Absent
Present
Apathy
Generalized anxiety disorders (GAD) often co-exists with depression. However, patients with GAD
do not have suicidal thoughts nor guilt feelings and they usually seek help and are worried about the
future. DSM- IV criteria for diagnosis of GAD
A. Excessive anxiety and worry about a number of events (which causes clinically significant
distress or impairment in functioning) occurring more days than not for at least six months.
B. The person finds it difficult to control the worry.
C. Associated with at least three of the following:
1.
Restlessness, feeling "on edge."
2.
Fatigue.
3.
Difficulty concentrating.
4.
Irritability.
5.
Muscle tension.
6.
Sleep disturbance.
Management options
The initial decision for a newly diagnosed depressed individual is hospitalization when suicidality,
drug abuse, acute mania or psychosis exist. If outpatient management is selected, the following
modalities of treatment are available.
1. Pharmacologic Management.
2. Formal psychotherapy
3. Electro-Convulsive-Treatment (ECT)
Pharmacologic Treatment:
Initial antidepressant choice
A simple classification of antidepressants divides them into 4 groups: Tricyclics (TCA), Serotonin
Reuptake Inhibitors (SSRI), Monoamine Oxidase Inhibitors(MAOI) and Others. Table 1 shows some
common antidepressants. Each primary care physician should familiarize him/herself with 3 or 4
medications especially the ones listed in the ministry of public health essential drug list.
In the US, the Agency for Health Care and Policy and Research (AHCPR) divides treatment of
depression into 3 phases: an acute phase (6-12 weeks), continuation phase (4-9 months) and
Maintenance (1 or more years). It recommends starting with an SSRI or a tertiary amine TCA
awaiting for response and remission then continuing treatment through recovery (Figure)
88
All anti-depressants have similar success rate (around 70%), the main difference among them is
related to their side effects and cost. Selection of an antidepressant in a particular patient is now more
based on:
• Side effects
• Cost
• Physician’s experience
• Patient’s preference and age
o Co-existence of other medical illnesses: Heart diseases, epilepsy.
o Compliance potential - impact of the drug on the lifestyle of the patient
o Prior positive/negative response to antidepressant medications in the patient
or in a first degree relative
Tricyclic antidepressants (TCA) (amitriptyline; clomipramine; desipramine; imipramine;
nortriptyline, doxepin) have not been shown in all studies to be more effective than placebo in the
treatment of depression in children and adolescents. They should not be used as a first line of
treatment in this target group. In adults, however, imipramine (TCA) was shown to be as costeffective as or more cost-effective than the serotonin-specific reuptake inhibitors. In general, no
difference in clinical outcomes was found between fluoxetine, desipramine, and imipramine when
used for mild to moderate depression in adults diagnosed by family physicians.
Recovery
Severity
Normalcy
Remission
Relapse
X
X
Recurrence
Relapse
Symptoms
Syndrome
Treatment
Phases
Response
X
Acute
6-12 weeks
Continuation
4-9 months
Maintenance
1 or more years
Time
Dosage adjustment and follow-up
If tricyclic antidepressants (TCAs) are chosen, begin low (25 - 50 mg QHS) and increase to goal
dosage (150-300 mg/day except for nortriptyline 75-150 mg/day) every three days over 1 - 3 weeks.
There is no pharmacologic rationale for prescribing most TCAs in divided doses since most have halflives of about 24 hours, and once daily dosing (at bedtime) often minimizes side effects.
Selective serotonin reuptake inhibitors (SSRIs) should be given in the morning, and most patients
respond to the initial starting dose (50 mg sertraline, 20 mg paroxetine, 20 mg fluoxetine). For
patients with depression and co-existing anxiety/panic disorder, it may be necessary to start with 1/2
the usual antidepressant dosage (25 mg sertraline, 10 mg paroxetine, 10 mg fluoxetine) and titrate to
89
the goal dosage as tolerated. If patients only partially respond to the usual initial starting dosage, it
may be increased in 6-8 weeks.
Patients should be seen every 1-2 weeks for the first 6 - 8 weeks of therapy, at which time medication
efficacy can be evaluated.
If antidepressant dosages are increased too quickly, side effects may emerge. However, patients
should be told that side effects may decrease within several weeks of beginning medication.
Providing patient support and education optimizes adherence, facilitates dosage adjustments,
minimizes side effects and allows monitoring of clinical response.
Continuation and maintenance
The prevention of relapse is of primary importance in the treatment of Major Depression. From 50
to 85% of people who suffer an episode of major depression will have a recurrence, usually within
two or three years. Patients who have had three or more episodes of major depression are at 90%
risk of having another episode.
After four months, the dose may be gradually tapered and discontinued by the sixth month. If
symptoms re-emerge, medications should be restarted at the previous dose and continued for an
additional six months followed by another attempt to taper off the medication. Attempting to taper
medications off may not be appropriate in certain patients, specifically those with a high recurrence
potential.
Maintenance therapy using the successful antidepressant agent at the dosage effective in the acute
phase of treatment for prolonged periods of 5 years or more should be considered in consultation with
the psychiatrist in people who have had:
1.
Three or more episodes of major depressive disorder.
2.
Two episodes of major depressive disorder and:
a)
family history of bipolar disorder,
b)
history of recurrence within one year after previously effective medication was
discontinued,
c)
family history of recurrent major depression,
d)
early onset (before age 20) of the first episode,
e)
both episodes were severe, sudden or life-threatening in the past three years.
Lifetime treatment may be indicated for patients:
1. Aged 50 at first episode
2. Aged 40 with 2 episodes
3. Had 3 episodes of major depression
Psychotherapy:
It is considered as 1st line treatment in case of mild depression and with the absence of psychotic or
melancholic features or whenever there is a history of chronic psychosocial problems.
Referral for formal psychotherapy can be helpful. Cognitive behavioral therapy has been shown in
some studies to be equally effective to pharmacotherapy and best results are when both are combined
in non hospitalized patients.
Many primary care physicians are trained in basic counseling skills and should exercise these skills to
help clients early in their illnesses. However, it is essential for physicians who choose to practice
counseling to be recognize complex conditions and refer them early for specific and intensive therapy.
90
Electro convulsive Therapy (ECT):
Remains a very effective and safe treatment for a selected group of patients like:
• Patients with severe or psychotic features who are suicidal and dangerous or in case when
medical conditions prohibit the use of drugs.
• Severely depressed patients with significant neurovegetative symptoms or psychomotor
disturbances who do not respond to a trial of medications.
• Patients in life-threatening situation that require rapid respond ex., high risk of suicide or
refusal to drink or to eat.
Desired outcomes
•
•
•
Control of symptoms
Tolerable drug side effects
Prevention of relapse
Not to be missed
Approximately 15% of patients hospitalized for depression eventually commit suicide, 50% of them
are seen by a physician in the previous month and given medications. In case the risk exists, the
patient should be queried:
1. Do you feel that life is worth living?
2. Do you wish you were dead?
3. Have you thought about ending your life?
4. If yes, have you gone so far as to think about how you would do so?
A positive response should prompt for hospitalization and psychiatric consult
When to Refer
Consider involving Mental Health same day for:
1. Suicidal thoughts and/ or plans which make the clinician uncertain of the patient’s safety.
2. Assaultive or homicidal thoughts and/ or plans which make the clinician uncertain about the
safety of the patient or others.
3. Loss of touch with reality (psychosis).
4. Significant or prolonged inability to work and care for self/ family.
5. In case of personal or family history of manic depressive illness (Bipolar affective disorder)
Elective referral can be made when:
1. Inadequate response despite optimal treatment.
2. Uncertain diagnosis.
3. Severe depressive episode with suicidal thoughts.
4. Upon the wish of the patient.
5. In case of concomitant medical illness, that may be contraindication to the use of antidepressant.
Patient Education
1. Explain the pathogenesis and prognosis of depression.
2. Explain the aims and side effects of treatment and instruct the patient to:
a. Take the medication daily.
b. Antidepressants must be taken for two to four weeks for a noticeable effect to start
showing.
c. Do not stop taking antidepressant without with checking with your doctor
d. Contact your provider if you have questions about your medication.
e. Advise which foods and drugs to avoid if use MAO inhibitors.
91
3. Advise regular exercise.
Table I
A selected list of antidepressants for general information
Name
Starting dose
(range)
Selective Serotonin
Reuptake Inhibitors
(SSRI)*
Fluoxetine (Prozac)
Can cause anorgasmia, agitation, nausea, headache, insomnia; non- lethal in
overdose; blood levels not useful; several drug-drug interactions can occur due
to cytochromes inhibitions.
10- 20 mg
long half- life, anorexia
(10- 80 mg qd)
50 mg
(100- 300 mg qd)
10- 20 mg
somnolence, dry mouth, constipation
(10- 50 mg qd)
25- 50 mg
Loose stools, anorexia
(25- 200 mg qd)
20 mg
(10-40 mg qd)
Use caution in advanced atrio- ventricular delay, potentially lethal in overdose,
blood levels useful. Can cause dry mouth, constipation, blurred vision, urinary
retention, postural hypotension, tachycardia, somnolence, weight gain.
25- 50 mg
Secondary amine - relatively more activating
(25- 300 mg qd)
10- 25 mg
secondary amine - relatively more sedating
(10- 150 mg qd)
Tertiary amine – Use in absence of serious medical
illnesses, including cardiac disease that preclude use;
need for rapid sedation
Tertiary amine
Fluvoxamine (Faverin)
Paroxetine (Seroxat)
Sertraline (Zoloft)
Citalopram (Cipram)
Tricyclic Antidepressants
(TCA)
Desipramine
(Norpramin)
Nortriptyline
(Nortrilene)
Amitriptyline
(Tryptizol)
Imipramine
(Tofranil)
Predominant effects
Doxepin
(Sinequan, Quitaxon)
Others
Bupropion
(Wellbutrin)
Trazodone (Desyrel)
Nefazadone (Serzone)
Mirtazapine
(Remeron)
Milnacipran (Ixel)
Venlafaxine (Effexor)
Include quaternary amines, mixed serotonin and norepinephrine reuptake
inhibitors or other mechanisms of action
75 mg
dizziness, nausea, dry mouth, constipation, sweating,
(150- 300 mg qd)
headache, agitation seizures have been reported
25- 50 mg qhs drowsiness, dizziness, dry mouth, fatigue priapism has
insomnia
been reported
(25- 150 mg qhs)
50-75 mg bid –
depression
(100- 600 mg qd)
100 mg bid
headache, dry mouth, somnolence, nausea
(200- 600 mg qd)
Drowsiness
37.5 mg bid
(75- 225 mg qd)
nausea, headache, insomnia, sweating, nervousness,
significant hypertension has been reported
92
Algorithm
Presentation suggestive
of an emotional Problem:
Multiple complaints
Fatigue
Frequent visits
Screen for
Depression by
interview or
questionnaire
Suicide Risk
Yes
Immediate psychiatirc
opinion &/or
hospitalization
No
Apply DSM IV criteria to
diagnose depression and
rule out/in anxiety
disorders mania (ever) or
schizophrenia
Discuss treatment plan
with the patient and
family
Increase medication dose
and monitor weekly until
response
Obtain a psychosocial
history and perform a full
physical evaluation
Response
Yes
No
Continue treatment until
recovery
(4-9 months)
No
No
Increase dose
Switch medication
Refer
Quality of care indicators
1.
2.
3.
4.
Percentage of patients with a new diagnosis of fatigue, sleep disorder or irritable bowel
syndrome, whose charts contain documentation of screening for depression.
Number of visits per year of patients with depression
Average duration of treatment of individuals started on antidepressants
Frequency of documentation of signs of depression
Sources
1. U. S. Department of Health and Human Services Public Health Service. Agency for Health
Care Policy and Research. Depression in Primary Care. AHCPR publications 93-0550,1,2,2.
April 1993.
2. Group Health Cooperative of Puget Sound. Adult depression guideline. 1998
3. Cross-National Collaborative Group. Cross-National Comparison: The changing rate of major
depression. JAMA 1992; 268(21):3098-3105
4. Karam E. The nosological status of bereavement related depressions. Br J Psych 1994; 15:4852.
93
Diabetes
Definition and Epidemiology
Diabetes mellitus (DM) is a disorder of carbohydrate metabolism characterized by inappropriate
hyperglycemia and glycosuria and resulting from defects in insulin secretion, action or both. Diabetes
is classified as Type 1, with pancreatic beta cells destruction leading to absolute insulin deficiency
and Type 2, which may range from predominantly insulin resistance with relative insulin deficiciency
to a predominantly secretory defect with insulin resistance.
The estimated prevalence of DM in Lebanon and in the US is around 5 % for all age groups and up to
15 % in adults above 30 years. In the US half of all diabetics go undiagnosed and untreated.
Definition of Type 2 Diabetes
The criteria for diagnosis of diabetes mellitus in a non-pregnant adult are summarized in the following
table:
Test
Diagnosis
Diabetes
Impaired Glucose
tolerance (IGT)
Fasting Plasma Glucose
(FPG) *
FPG ≥ 126 mg/dl
(7.0 mMol/l)
FPG ≥110 and < 126
mg/dl (7.0 mMol /l)
Casual Plasma Glucose
(CPG)
CPG ≥ 200 mg/dl (11.1
mMol /l) + symptoms**
Oral Glucose Tolerance Test
(OGTT)
Two-hour plasma glucose
(2hPG) ≥ 200 mg/dl***
2hPG ≥ 140 (7.8/l) and < 200
mg/dl (11.1 mMol /l)
*The FPG is the preferred test for diagnosis, but any one of the three listed is acceptable. In the absence of unequivocal
hyperglycemia with acute metabolic decompensation, one of these three tests should be used on a different day to confirm
diagnosis. Fasting is defined as no caloric intake for at least 8 hours.
**Casual = any time of day without regard to time since last meal; symptoms are the classic ones of polyuria, polydipsia,
and unexplained weight loss.
***OGTT should be performed using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.
The OGTT is not recommended for routine clinical use.
In the absence of unequivocal hyperglycemia associated with acute metabolic decompensation, the
results should be confirmed by repeat testing on a different day.
At the present time, glycosylated HbA1c is not used to diagnose diabetes.
History & Objective Findings
THE INITIAL OFFICE VISIT:
A. Medical History
Family history of diabetes
Other endocrine disorders
History of gestational diabetes
Drug intake history
Other past medical and surgical history
Life style habits, including smoking ,exercise and dietary habits
Cultural, psychological, economic, educational and occupational factors
Vaccination status
94
Specific symptoms related to diabetes:
Polyuria
Polydipsia
Polyphagia
Weight loss
Fatigue
Paresthesias
Recurrent skin infections
Foot ulcer
Leg or chest pain
Diarrhea / constipation
Urinary incontinence
Impotence
Blurred or decreased vision
Treatment history (if applicable):
Current medications
Previous treatment for diabetes
Frequency and timing of hypoglycemic reactions
History of diabetic ketoacidosis
B. Physical Examination
An initial complete physical examination should be done with emphasis on:
Height, Weight and body mass index (BMI = wt (kg)/ ht2 (m))
Blood Pressure (including orthostatic measurement)
Oral exam
Thyroid size
Foot exam
Pulses exam
Neurologic exam
Ophthalmologic exam
C. Laboratory Testing
Fasting Plasma Glucose (FPG), to be done at every follow up check visit
HbA1C at 3-6 months interval
Urine analysis
Fasting Lipid Profile - yearly
Serum creatinine – yearly
24 hour urine microalbumin or Albumin / Creatinine ratio on a spot urine sample.
Baseline EKG and stress EKG depending on risk factors
Other tests as necessary or recommended for health maintenance (e.g. PAP test, Fecal
Occult Blood,...)
ONGOING CARE:
Following the initial visit and each follow-up visit:
• Glycemic control (optimal, acceptable, poor)
• Complications and their status of control
• Other problems and their status of control
Follow-up visits should take place at least every 3 months, and more often if glycemic goals
are not achieved and should include:
Targeted annual history and physical exam
1. The history should assess:
• Results of self monitoring blood glucose; validate results at least once a year (i.e.,
check patient's glucose meter against an office random capillary glucose)
• Current medications
• Adjustments by the patient of the therapeutic regimen
• Problems with adherence to therapeutic regimen
• Frequency, causes, and severity of both hyperglycemia and hypoglycemia
• Symptoms suggesting development or progression of the complications of
diabetes
95
• Documentation of eye care specialist exam results.
2. The targeted physical exam should assess:
• Weight and body mass index calculation
• Blood pressure
• Cardiovascular - evaluation of preexisting problems;
• Feet (nails, web spaces, calluses, ulcers, structural deformities, protective
sensation and shoes).
Management options
NON-PHARMACOLOGIC MANAGEMENT
A. Dietary Therapy
•
•
•
•
•
•
•
•
•
May be used alone initially if fasting glucose < 200 mg/dl.
Should be tailored to fit the individual’s needs
Should take into account the presence of concomitant disease such as hypertension,
proteinuria and dyslipidemia
Should take into account food preferences, life style, cultural and socioeconomic background
Should take into account therapeutic regimens used, especially insulin
Meals should be spaced throughout the day to reduce the carbohydrate load in any one meal
Advise high fiber content for its overall nutritious benefits however, it is unlikely to improve
glycemic control.
Preferably involve a dietitian to meet with the patient and appropriate family members
periodically.
Generally:
Reduce total caloric intake by limiting total amount of carbohydrates and fats:
Limit high sugar foods such as regular soft drinks, and large desserts.
Carbohydrate percentage based on nutrition assessment
Total amount of carbohydrate is more important than the type or amount of starch or
sugar.
No advantage or disadvantage of other nutritive sweeteners such as fruit juice
concentrates, fructose, sorbitol, and mannitol, over sucrose.
Non nutritive sweeteners such as aspartame (Canderel) are safe to use in moderation
during pregnancy.
Fat percentages based on weight and lipid state:
Step I diet in cases of normal weight and lipids: < 30% calories from fat, < 10% saturated
fats, & < 300 mg cholesterol
Step II diet in elevated LDL-cholesterol: Reduce saturated fat < 7% calories, cholesterol <
200 mg
Elevated triglycerides: improve blood glucose control; lose weight; increase exercise;
avoid alcoholic beverages; moderate carbohydrate and fat intake.
Protein percentage - 10-20% of the total calories and adjust according to renal function
B. Exercise Program
•
•
•
Exercise is a corner stone of diabetes therapy
30 minutes of daily aerobic exercise in order to increase and maintain insulin
sensitivity
Before undertaking an exercise regimen, the patient should be evaluated for
hypertension, neuropathy, and silent ischemic heart disease. (An exercise stress test may
also be needed)
96
•
•
Patients should be instructed to wear comfortable, protective foot wear and to
examine their feet after exercise to look for pressure areas that may be prone to blistering
or callus formation.
Education of how to avoid hypoglycemia during exercise
PHARMACOLOGIC MANAGEMENT
Pharmacologic therapy should be initiated if 2 to 4 months of diet and exercise have not resulted in
improved glycemic control. Patients should be reminded that pharmacologic therapy is an adjunct to
diet and exercise, and not a substitute. A variety of pharmacologic agents are available from different
classes with different mechanisms and sites for action. In determining which pharmacologic
alternative is best, consider the following:
• Weight & age of the patient
• Severity of the patient's disease (i.e. degree of hyperglycemia, presence of symptoms);
• Preferences of the patient on the use, expected therapeutic effects, and possible side effects of
oral agents & insulin.
A. Oral agents
•
•
•
•
•
All oral agents have been approved for initial therapy
Oral agents have other metabolic effects that should be considered
The single best choice for oral agent therapy for type 2 diabetes has not been determined.
Metformin may offer advantages in monotherapy for obese patients with type 2 diabetes.
Sulfonylureas are inexpensive and generally well tolerated with no adverse effects on longterm outcomes. Sulfonylureas are a good choice for monotherapy.
1. Sulfonylureas
Generic
Glipizide
Gliclazide
Glyburide /
Glibenclamide
Glimiperide
•
•
•
Brand
Name
Minidiab
Diamicron
Daonil
Euglucon
Gliboral
Amaryl
Usual
Maximum effective dose
starting dose per day
5mg/day
15 mg/day
80 mg/day 240 mg/day
2.5 mg/day 15 mg/day
1-2 mg/day 6 mg/day
The dose should be increased every 1 or 2 weeks until satisfactory glycemic control or the
maximum dose is reached.
There are no major differences in sulfonylureas on effectiveness in controlling
hyperglycemia. Switching from one to another is rarely beneficial in improving
hyperglycemia.
Hypoglycemia risk increases with impaired renal function.
Contraindications to Sulfonylureas:
•
Pregnancy & lactation
•
Allergy to sulfonylurea or sulfa drugs
•
Severe hepatic or renal disease
2. Metformin
Name
Usual starting dose Maximum dose per day
Metformin (Glucophage or Stagid) 500 mg q d/or bid 850 mg tid
97
•
•
•
•
Major effect may be reducing hepatic glucose production.
Enhances insulin action. It does not stimulate insulin secretion therefore when used alone
does not cause hypoglycemia.
May have unpleasant side effects such as metallic taste, diarrhea, nausea, and anorexia. These
may be transient.
May be more effective in obese patients because weight gain is less common.
Contraindications to Metformin:
•
Pregnancy & lactation
•
Hepatic disease or renal disease because of possible lactic acidosis.
•
Severe COPD or CHF or alcohol abuse.
•
Allergy to biguanides
3. Other oral agents
In some instances sulfonylureas or metformin may not be tolerated or may be contraindicated. In
those cases the other oral agents can be used effectively with appropriate patient monitoring.
A. Acarbose (Glucobay)
Usual starting dose is 25 mg daily titrated upward every 2-4 weeks depending on GI tolerance up to
300 mg daily.
• Delays carbohydrate absorption which reduces postprandial blood glucose and insulin levels.
• Does not cause hypoglycemia.
• Abdominal cramping pain, flatulence, and diarrhea are common side effects. Tolerance
develops, so start with low dose and gradually increase.
• Approved for use in combination therapy.
• Must be taken at beginning of meal to be effective.
Contraindications to Acarbose
•
Age less than 18
•
Pregnancy or breast feeding
•
Creatinine > 2.0 mg/dl
•
Abnormal baseline liver function test
•
Inflammatory bowel disease
B. Troglitazone (Rezulin, Novonorm)
•
•
•
•
•
•
Improves insulin action in peripheral tissues, particularly muscle
Rare instances of severe idiosyncratic hepatotoxicity have resulted in death or need for liver
transplantation. The frequency of the hepatotoxicity is uncertain. Patients with abnormal (>
1.5 times upper normal limit) baseline ALT or AST should not receive Troglitazone. ALT
should be monitored monthly for the first 8 months of therapy and then every other month
until 1 year and periodically thereafter. Troglitazone should be stopped if the liver function
tests become > 3 times upper limit of normal and checked weekly if > 1.5 times upper limit of
normal.
Does not stimulate insulin secretion therefore when used alone will not cause hypoglycemia
Can be used alone or in combination with sulfonylureas or insulin. Has been reported to be
effective in combination with metformin
Consider in patients with clinical evidence of severe insulin resistance who are not candidates
for or don't tolerate metformin
May take > 4 weeks for response
98
•
•
•
Most patients require 400 to 600 mg daily
Non-responder rate is at least 20% and HbA1c decrease average 1.4%
Not a first choice drug because of expense and unknown long-term safety of this new class of
medication
Contraindication to Troglitazone
•
Abnormal baseline liver function tests
C. Repaglinide (Prandin)
Duration (hrs) Usual starting dose (mg)
Maximum dose per day
1-4
0.5 mg/meal if HbA1c < 8% or no previous treatment 4 mg/meal 16 mg/day
1 or 2 mg/meal if HbA1c > 8% or on other oral agent
•
•
•
•
•
•
•
•
Mechanism of action similar to sulfonylureas, stimulates insulin secretion
Short duration of action
Usually taken 15 min before meals (0 to 30 min)
Skip dose if meal not eaten
Approved for use as monotherapy or in combination with metformin
Can be used with renal function impairment but increase dose cautiously
Hypoglycemia major side-effect, may be less common than with sulfonylureas
Interaction with other drugs metabolized by cytochrome P450 is possible. These
include Troglitazone, rifampicin, barbiturates, and carbamazepine, ketoconazole and
miconazole.
B. Insulin therapy
•
•
•
•
•
•
•
Indications for the use of insulin:
Type I diabetes
Periods of acute injury, stress, infection, or surgery
Pregnancy
Failure to achieve treatment goals with oral agents
The use of insulin carries a higher risk of hypoglycemia than the use of oral agents,
however severe hypoglycemia is rare in type 2 diabetics.
Insulin should be dosed according to a patient’s weight, be individualized based on
blood glucose monitoring and synchronized with food intake.
The recommended starting dose is 0.5 units/kg per day with the average dose between
0.6-0.8 units / kg body weight per day
If despite a good fasting blood sugar the daytime glucose control is inadequate, a second
dose of insulin is required
The most common regimen used is the “split-dose”, which consists of prebreakfast and
predinner injections of a combination of intermediate- and rapid-acting insulins.
Generally the total insulin dose is split with two thirds of the dose being injected before
breakfast and one third injected before dinner.
99
•
Time course of action of insulin preparations:
Preparation
Onset of Action
Lispro (Humolog)
Short acting (regular)
Intermediate acting
(NPH or lente)
Long acting (ultralente)
Mixtures (70/30, 50/50)
Peak Action
Duration of Action
15 min
30 min
1-3 h
30-90 min
2-5 h
6-12 h
2-4 h
5-8 h
16-24 h
4-6 h
30 min
8-20 h
2-12 h
24-28 h
16-24 h
This table summarizes the typical time course of action of various insulin preparations. These values are
highly variable among individuals. Even in a given patient, these values vary depending on the site and
depth of injection, skin temperature, and exercise.
Lispro (Humalog) insulin should not be taken more then 15 minutes before meals in contrast
to regular insulin which should ideally be taken at least 30 minutes before a meal to better
match the insulin peak action with post-meal hyperglycemia.
Patients who are testing their blood glucose before meals and adjusting insulin doses to match
meals may find Lispro insulin to be more effective although generally studies have not
shown an improvement in HbA1c.
Effective use of Lispro insulin may require adjustment of the basal intermediate or long-acting
insulin and more frequent doses of basal insulin.
C. Combination therapy of oral agent and insulin
A bedtime dose of intermediate-acting NPH or lente insulin is generally used, often in combination
with an oral agent that is effective during the day.
This regimen has high patient acceptance because insulin is injected only once daily, at bedtime.
Desired outcomes
Control for diabetes is defined as follows:
Value
Optimal
Absent
Acceptable
Absent
Poor
Present
80-120 (4.5-6.7)
90-145 (5-8)
100-140
<6%
<200(5.2)
<150(1.7)
> 45
< = 100 if CHD
<140 (8)
<160 (10)
< 160
<7%
<250(6.5)
<200(2.2)
> 35
< = 130 NO CHD
<135/85
<140/90
>160 (9)
>180 (10)
> 180
>8%
>250(6.5)
>200(2.2)
< 30
> 130 no CHD
> 100 if CHD
>160/90
< 25
< 24
25-27
24-26
> 27
> 26
Symptoms
Plasma glucose level in mg/dl (mMol/l)
Fasting
Postprandial
Bedtime
Glycosylated Hb level (HbA1C)*
Total cholesterol level in mg/dl (/l)
Triglyceride level in mg/dl (/l)
HDL
LDL
Blood pressure (mm Hg)
Body Mass Index
Male
Female
*Medical centers need to know what the standard is for HbA1c and glycosylated hemoglobin in their
labs and make the appropriate conversions.
100
Frequency and timing of glucose self monitoring:
Therapy
Non-pharmacologic or oral agent
Simple insulin regimens (1 or 2 shots
intermediate daily)
Complex insulin regimens
Frequency and Timing
Before breakfast and evening meal at least 2-3 days per week
Postprandial may be helpful
Before breakfast and evening meal at least 3-4 days per week
Daily for type I
Before breakfast, lunch, and supper and bedtime daily, especially
for type I
Not to be missed
Urine Protein Assessment
Urinalysis and urinary protein excretion annually by a microalbuminuria method. If proteinuria is
above normal, serum creatinine or urea nitrogen concentrations should be measured.
If the dip stick or urine analysis test is negative for protein, then a more sensitive early screening test
is indicated. A qualitative urinary microalbumin screen can be used to detect urinary microalbumin.
If qualitative is positive, a quantitative must be performed.
Another option is a timed collection of urine (24 hr. or overnight), but this is not always necessary
with the availability of the albumin:creatinine ratio test.
A microalbumin screening test should be done each year on patients with diabetes mellitus (after 5
years of disease in type I, and at onset of illness in type II) up to age 70. If positive (exceeds 30
mg/gm), it should be repeated twice in the next 3 months. If 2 out of 3 of these screening
microalbuminuria tests are positive, the individual has microalbuminuria and interventions should be
considered. A negative finding should be followed yearly; a positive finding should be followed a few
times per year to see if the interventions are effective in diminishing the albuminuria.
Comprehensive foot exam with risk assessment and follow-up
Patients with one or more risk factors for foot complications should be educated about their risk
factors and appropriate measures taken to avoid complications. Measures may include selfmanagement education, more intensive follow-up, and/or referral to appropriate specialist. Risk
factors for foot complications include:
• Loss of protective sensation
• Peripheral vascular disease (absent pedal pulse, history of claudication or ischemic skin
changes);
• Structural deformities (bunion, hammertoes, Charcot deformity, limited joint mobility or prior
amputation);
• Skin disorders (nail deformity, callus, fissure, tinea or ulceration);
• Footwear (excessively worn, ill fitting or inappropriate shoes).
When to Refer
A working relationship with an endocrinologist and diabetes team is of utmost importance and should
include a mechanism to assure that patients can receive adequate diabetes education.
REFERRAL CRITERIA:
• Nephrologist: for proteinuria or elevated serum creatinine > 2.5 mg/dl.
• Podiatrist, orthopedist: Neuropathic ulcer.
• Vascular surgeon: Vascular insufficiency or complicated ulcer.
101
•
•
•
Ophthalmologist: On initial visit and every year, and if there is retinopathy or decreased
visual acuity.
Diabetologist: Consistently poor control.
Nutritionist: On initial visit, every year, and as necessary if poor control.
Patient Education
Take every opportunity to educate the patient about:
• The pathophysiology of diabetes mellitus and the psychosocial impact of living with chronic
disease
• Patient responsibilities for self care
• Risks for complications of the disease
• Diet and meal planning
• Regular physical activity and exercise
• Medication adherence
• Regular appointments with medical provider(s)
• Advise about symptoms and treatment of hypoglycemia.
• Self monitoring of blood glucose and ketones in urine
• Instruct about insulin injections.
• Update vaccination status
• Foot Care education should be tailored to patient's current knowledge, individual needs and
risk factors. Patients should be aware of their risk factors and appropriate measures to avoid
complications.
• Inspect feet daily for cuts, bruises, bleeding, redness and nail problems
• Wash feet daily and dry thoroughly including between the toes
• Do not soak feet unless specified by a health care provider
• Be careful of hot water
• Don't walk barefoot
• Check shoes each day for objects that may have fallen inside, excessive wear or areas that
may cause irritation
• Avoid injuries from cutting toenails, avoid self-cutting calluses or corns
• Seek care immediately for new foot problems
Management and treatment tips
•
•
•
•
•
Patients starting or having a major change in their treatment program (such as initiating
insulin therapy) may need to be in contact with their care provider as often as daily until
glucose control is achieved, the risk of hypoglycemia is low, and the patient is competent to
conduct the treatment program.
Contact with the patient after a major modification of the treatment plan (such as introducing
a new medication) should not be delayed > 1 week.
Regular visits should be scheduled for insulin-treated patients at least quarterly and for other
patients at least semiannually. More frequent visits may be necessary if treatment goals are
not achieved.
Cardiovascular disease is the primary cause of morbidity and mortality in people with Type 2
diabetes. The risk of coronary artery disease is approximately doubled in men and quadrupled
in women with diabetes.
Initiate low dose aspirin therapy (81-325 mg daily) in patients over 40 unless there is a
contraindication to aspirin therapy.
102
Algorithm
Therapy Level
Nonpharmacologic therapy
Intervention
Lifestyle modifications:
Nutrition therapy with a dietitian consult
Physical activity
Stop smoking
Education:
Diabetes self care
Blood sugar self monitoring
If individualized goals for control not achieved within 2-4 months, reassess life style intervention to
maximize benefits.
Advance to next level of therapy
Oral agent monotherapy
Choice of agent tailored to individual:
Alpha glucosidase inhibitor
If FPG > 10 mmol/L, use sulfonylurea or
Biguanides
biguanides
Sulfonylurea
Biguanides are associated with less weight gain
and lower frequency of hypoglycemia. They are
contraindicated in renal or hepatic failure
In the elderly start with lower doses
If individualized goals for control not achieved within 2-4 months, reassess life style intervention to
maximize benefits.
Advance to next level of therapy
Oral combination therapy
Multiple agents used until the maximum dose of
an agent of each class is reached
If individualized goals for control not achieved within 2-4 months, reassess life style intervention to
maximize benefits.
Advance to next level of therapy
Bedtime insulin +/- oral agent (BIDS)
May be used at the beginning of Insulin addition
to oral therapy. This approach may result in better
control with a smaller insulin dose and induce
less weight gain than insulin alone
Insulin (1 to 4 times per day)
To be used when all other modes no longer work.
May also use acarbose, metformin or troglitazone
to improve response.
Quality of care indicators
1.
2.
3.
4.
5.
6.
7.
8.
9.
Percentage of patients attaining pre-set desired outcomes (e.g. with HbA1c < 8%)
Percentage of patients with HbA1c measured every 6 months.
Percentage of patients with a lipid profile every 12 months.
Percentage of patients with microalbumin tested within the last 12 months.
Percentage of patients with eye examination documented within the last 12 months.
Percentage of patients with foot examination documented within the last 12 months.
Percentage of patients without contraindications who regularly use aspirin.
Percentage of patients with tobacco use documented.
Percentage of current tobacco users given advice to quit.
Sources
1. American Diabetes Association. Report of the Expert Committee on the diagnosis and
classification of diabetes mellitus. Diabetes Care. 1998; 21 (suppl 1):S5-S9
2. World Health Organization. Management of diabetes mellitus. Standards of care and clinical
practice guidelines. Geneva, 1994.
103
3. American Diabetes Association. Standards of medical care for patients with diabetes mellitus.
Diabetes Care. 1998; 21 (suppl 1):S23-S31.
4. Implications of the United Kingdom Prospective Diabetes Study. American Diabetes Association.
Diabetes Care 1999; 22(Suppl 1) S27-S31.
5. Canadian medical association. 1998 clinical practice guidelines for the management of diabetes in
Canada. CMAJ 1998; 159(8Suppl) S1-S38.
6. Purnell JK and Hirsh IB. New oral therapies for type2 diabetes. Am Fam Phys. 56:1835-1842.
7. Skyler JS. Insulin Therapy in type II diabetes. who needs it, how much of it, and for how long?
Postgrad Med. 1997;101:85-96.
104
Hyperlipidemia
Definition and Epidemiology
Hyperlipidemia is a major modifiable risk factor for coronary heart disease with plasma lipoprotein
(lipids) levels influenced by genetics, concomitant disease, medications and lifestyle. It is believed
that more than 25% of the adult population in wealthy nations have a level of cholesterol that warrants
medical advice. The situation in Lebanon is most likely similar.
Plasma Lipoproteins Types
1. Atherogenic
a. Chylomicron remnants
b. Very Low Density lipoproteins (VLDL) remnants
c. Intermediate density lipoproteins (IDL)
d. Low Density Lipoproteins (LDL) - usually includes IDL, LDL and Lp(a)
e. Lipoprotein(a) (Lp(a)) - similar to LDL, but with added protein, apoplipoprotein a
2. Anti-atherogenic - High Density Lipoproteins (HDL), only certain subclasses
3. Nonatherogenic Lipoproteins
a. Chylomicrons (intact)
b. VLDL (intact)
Classification of Hyperlipidemia
The primary care doctor is mostly interested in hyperlipidemia as a risk factor for cardiovascular
disease, however, familiarity with the various types is helpful in management and selection of patients
for referral to the specialist.
Type
Hypercholesterolemia
(Type IIa)
Laboratory findings
Elevated total (300-500),
LDL (>250) cholesterol.
Combined Hyperlipidemia
(Type IIb)
Elevated total (250-350),
LDL, and VLDL cholesterol
and/or elevated TG.
Hypertriglyceridemia
(Type IV)
Severe Polygenic
Hypercholesterolemia
Chylomicronemia
(Type I-younger, V-older)
Dysbetaliproteinemia
(Type III)
Elevated total cholesterol,
TG, and VLDL. LDL low.
Elevated LDL (>220)
Defective Apolipoprotein B
Levels similar to
Hypercholesterolemia (IIa)
Elevated TG (700-10,000),
VLDL, chylomicrons
Elevated total cholesterol
(300-600), TG (400-800).
Characteristics
10% of all hyperlipoproteinemias
LDL receptor defect.
Premature coronary heart disease (CHD), tendon xanthomas,
arcus senilis
40% of all hyperlipoproteneinemias
Different patterns in different family members
VLDL overproduction by the liver.
Premature CHD, xanthelasma, arcus senilis.
45% of all hyperlipoproteneinemias
Delayed VLDL catabolism.
Multifactorial
5% of all hyperlipoproteneinemias
Serum lipemic, pancreatitis, eruptive xanthomas.
< 1% of all hyperlipoproteneinemias
Abnormal apolipoprotein E.
In addition to genotype, need other factors to express (DM,
obesity, hypothyroidism).When patients lose weight, lipids
may normalize.
Premature CHD, palmar xanthoma, PVD in nonsmokers.
Decreased LDL receptor affinity.
Premature CHD, tendon xanthomas.
History and Objective Findings
Hyperlipidemia is a laboratory diagnosis made usually during screening for coronary heart disease
(CHD) risk factors. As such, history and physical are geared at evaluating all cardiovascular risk
factors and include the following:
105
Coronary Heart Disease risk factors
• Age: M>45yr, F>55yr or premature menopause without Estrogen Replacement
Therapy
• Family History of premature CHD
• Smoking
• Hypertension
• Diabetes and possibly Insulin Resistance Syndromes)
• HDL Cholesterol <35mg/dL (0.9mMol) – if available
• Diabetes
• Central Obesity (increased waist to hip ratio)
• Hyperhomocysteinemia
An initial evaluation of:
• Dietary habits
• Exercise habits
• History of thyroid or coronary heart disease
• Previous levels of cholesterol
• Current medications
• Cardiovascular examination
A follow-up for:
• Compliance with diet.
• Compliance with exercise.
• Compliance with medications.
• Side effects from medications.
• Serum cholesterol - at 4-6 weeks, then q3 months x 1 year, then q6 months.
LDL is calculated using the Friedenwald equation if triglyceride level is less than 400 mg/dL:
LDL = total cholesterol – HDL – triglycerides/5. If triglyceride level is above 400, the blood sample
has to be subjected to a non routine special ultra centrifugation technique.
Diagnostic Considerations
Usually, a non fasting total and HDL cholesterol levels are obtained in screening (see prevention
section for screening indications). To minimize the adverse effects of misclassification resulting from
biological variance or laboratory error*, an average of at least two blood test results is often
recommended to provide a more accurate measure of the true concentration of total cholesterol; three
tests are recommended if the difference between the first two tests is greater than 30 mg/dL (0.80
mmol/L). Repeat testing is usually done between 1 and 8 weeks of the initial test.
A fasting (> 12 hours) lipid profile including LDL, HDL and triglyceride levels is recommended if:
a.
Blood cholesterol > 240 mg/dL
b.
Borderline-high blood cholesterol (200-239 mg/dL) with definite CHD or two other
risk factors.
c.
HDL – cholesterol is less than 35 mg/dL
A general chemistry screen is necessary if diabetes, renal or liver disease are suspected. Thyroid
function tests should be requested based on clinical judgment.
* Different laboratories may report different values; a report in the Medical Letter in 1987 (29:41) showed results of 197 to 367 mg/dL on
the same cholesterol blood sample from different labs. Cholesterol levels should be measured on venous samples and are usually 10% higher
in winter compared to summer
106
Management options
When the diagnosis is confirmed as above, the decision to treat is based on presence of coronary heart
disease (CHD) risk factors and LDL level. Treatment options include dietary and pharmacologic
therapy together with advice regarding other cardiovascular risk factors.
Dyslipidemia
LDL: 100-129 mg/dL
LDL: 130-159 mg/dL
General Diet
None
All
LDL: 160-189 mg/dL
Phase I diet
If CHD present
If CHD or 2 risk factors for
CHD are present
All
LDL: 190-220 mg/dL
LDL: >=220
Triglycerides 200-500
Triglycerides > 500
All
Medication
None
If CHD present
If CHD or 2 risk factors for
CHD are present
All men above 35 y or
postmenopausal women
All
Evaluate other risks
All
Follow up and goals of treatment:
Risk factor
NO CHD &
NO risk factors
No CHD &
Less than 2 CHD risk factors
No CHD &
2 or more CHD risk factors
OR Diabetes
CHD present
•
•
•
Cholesterol level
Less than 240
Follow up
Recheck cholesterol in 1 year
LDL goal
< 190
More than 240
Less than 240
Recheck 3-6 months
Recheck cholesterol in 1 year
< 190
< 160
More than 240
Any level
Recheck 3-6 months
Recheck in 3 months
< 160
< 130
Any level
Recheck in 3 months
< 100
In patients without CHD, when rechecking for improvement, total cholesterol alone may be
checked to reduce the cost of monitoring. (A cholesterol of 200 approximates an LDL of 130 and
240 cholesterol approximates 160 LDL)
In isolated hypertriglyceridemia, therapy depends on the triglyceride level. Patients with
triglycerides > 500 mg/dL are at increased risk of developing acute pancreatitis. This risk
increases very significantly as triglycerides increase to > 1000 mg/dL. Although triglycerides may
not normalize with the commonly used treatments, the risk of pancreatitis is reduced.
In patients with moderate hypertriglyceridemia (200-500 mg/dL) who have two or more CHD risk
factors, an HMG reductase inhibitor may be considered for first line therapy.
Efficacy of Treatment
1. Primary prevention of coronary events
1. Cardiovascular events are reduced ~2-3% for every 1% drop in cholesterol
2. Overall mortality appears to be decreased by cholesterol reduction
3. No current proof that reduced cholesterol affects total mortality in healthy women
2. Secondary prevention
1. Definite benefits on cardiovascular event reduction
2. Absolutely recommended for all patients with previous cardiac event
3. Cardiac event risk reduction ~1.5-2% for every 1% decrease in cholesterol
3. Mechanisms
1. Decreased cholesterol ~20% on average leads to 1-5% reduction in angiographic
stenosis per year
2. Improves endothelial dilatory responses independent of cholesterol decreases
107
Therapeutic choices
Nonpharmacologic Therapy
1. Stop Smoking
2. Diet
• General diet advice: Reduce saturated fat and substitute if necessary with monosaturated
and polyunsaturated fats; reduce total calories to maintain ideal body weight.
• Step I (10% of calories saturated fat): cholesterol <300mg/d, total fat <30% of calories
• Step II (7% of calories saturated fat): cholesterol <250mg/d, total fat <30% of calories
• Note that diet may not change TChol:HDL ratio, or may increase the ratio
• Probably indicated in all young persons with increased cholesterol
• Most effective in patients with higher than average fat intake
• Alcohol (EtOH) probably does not alter HMG CoA reductase inhibitor activity
• Alcohol increases HDL fraction when taken alone, and may reduce overall mortality
• Dietary Fiber - Soluble Fiber probably more effective than Insoluble Fiber
3. Exercise
• 20 minutes of aerobic activity at least 3 days a week
Pharmacologic Therapy
Drugs
HMG CoA Reductase
Inhibitors or Statins:
Atorvastatin (Lipitor)
Cerivastatin (Baycol)
Fluvastatin (Lescol)
Lovastatin (Mevacor)
Pravastatin (Lipostat)
Simvastatin
(Zocor)
Lipid Effect
Most potent agents.
Lower cholesterol, LDL and
TG.
Minimal increase HDL
Little effect on VLDL
Mild reduction in TG
Often considered firs line of
treatment
Indicated in type IIa, IIb,
high LDL and primary
hypercholesterolemia
Dosing
Evening doses-more effective
due to higher cholesterol
synthesis
LDL reduction
Dose percent (range in
mg%)
10 mg qd 32% (37-40)
20 mg qd 45% (43-46)
40 mg qd 50% (50-53)
0.2 mg qd 25%
0.3 mg qd 30% (28-30)
0.4 mg qd 35%
20 mg qd 20% (16-18)
40 mg qd 28% (22-25)
start
10 mg qd 20%
20 mg qd 25% (23-25)
40 mg qd 35% (30-35)
10 mg qd 22% (18)
20 mg qd 26% (22-24)
40 mg qd 30% (30-32)
5 mg qd 24%
10 mg qd 30% (26-28)
20 mg qd 34% (32-35)
40 mg qd 39% (39-41)
20mg (10-80mg) qd
(better with food)
(range)
10mg (10-80mg) qd
0.3 mg (0.3 mg)
20mg (20-80mg) qd
80 given as 40 bid
20mg (10-40mg) qd
20mg (5-80mg) qd
108
Monitoring
Fasting lipid panel, serum
transaminases, CPK at base line
Fasting lipid panel, at 6–12
weeks after start or elevation in
dose, then periodically approx.
every 6 months.
If the transaminases are
increased they should be
followed until the abnormality
resolves. If transaminases
increase more than 3 times
normal, and persist stop med.
Check CPK if muscle symptoms
develop.
LFT baseline, 6 and 12 weeks
after initiation or dose increase
then every 6 months
LFT baseline, 6 and 12 weeks
after initiation or dose increase
then every 6 months
LFT baseline, 6 and 12 weeks
after initiation or dose increase
then every 6 months
LFT baseline, 6 and 12 weeks
after initiation or dose increase
then every 6 months
LFT baseline and 12 weeks after
initiation or dose increase
LFT baseline and 6 months
after initiation or dose increase
for first year
Nicotinic Acid
Niacin
Niacin sustained
release SR (Niaspan)
(Nicobid)
(Enduracin)
Bile Acid
Sequestrants (BSA)
Cholestyramine
Powder (Questran)
Colestipol
Powder/Tabs
(Colestid)
Fibric Acids
Gemfibrozil
(Lopid)
Fenofibrate (Tricor)
Lower LDL (10-35%),
Lower TG (20-50%),
moderate increase in HDL
(5-40%), decrease
lipoprotein A up to 50%
Indicated in elevated
cholesterol with high LDL
and low HDL
SR form reduces
triglycerides better and is
better tolerated but causes
more LFT abnormalities
IR form increases HDL
better
Decreases LDL up to 20%,
increase HDL 3-5%, no
effect or may increase TG
Improves Chol:HDL ratio
good for combination
therapy
Decrease TG (20-50%) &
Increase HDL (10-15%)
variable effect on LDL but
usually reduces VLDL and
LDL synthesis.
Used especially in type 2b
with triad of high LDL, low
HDL and high TG
Drugs
Statins:
Contraindications
Active Liver disease
Pregnancy
Lactation
Relative contraindications alcohol abuse, primary
biliary cirrhosis.
Nicotinic Acid
Active liver disease
Active Peptic Ulcer
Pregnancy/Lactation
Arterial hemorrhage
Alcohol abuse
Relative contraindications:
history of gout,
diabetes mellitus or glucose
intolerance glaucoma, renal
dysfunction
Complete biliary
obstruction.
Do not use as sole therapy in
patients with trig >
200mg/dL.
Bile Acid
Sequestrants
Relative contraindication:
Pt. on Warfarin - close
monitoring of INR with
Start with 100 mg tid with
meals and increase by 100 mg
per dose every 3 days over 2
weeks, observe then keep
slowly increasing as needed to
1-2 g tid.
Moderate dose is 1.5 g daily
Crystalline niacin 1-3 gm/day
Take with food; avoid hot
beverages and alcohol at time
of dosing; may take 160 mg to
325 mg aspirin 30 minutes
before niacin dose.
5-10 mg with meals
Tolerance may be improved by
titrating dose slowly ½ scoop
or 1-2 tbs with a meal increase
slowly to 1 scoop or 2-4 tbs bid
Powder must be mixed with
liquid or foods with high water
content prior to ingestion.
To improve palatability mix
and leave in fridge over night
Gemfibrozil 600mg bid
Fenofibrate 67 mg/day with
food. maximum dose 201
mg/day
Dosage reduction may be
necessary in patients with
impaired renal function.
Drug/Food Interactions
Cyclosporine
Fibric acid, macrolide
antibiotics, niacin, azole
antifungals, Nefazadone,
grapefruit juice increase risk of
myopathy*
rhabdomyolysis may occur.**
Warfarin - anticoagulant effect
may be increased monitor INR
closely.
Statins-risk of myopathy
appears increased but true
incidence is probably low.
Documented decrease in
absorption of digoxin,
warfarin, levothyroxine,
thiazide diuretics. Any drug
should be separated from the
sequestrant by taking it either 1
hour before or 4 hours after the
sequestrant.
109
Fasting lipid panel, fasting
glucose, transaminases and uric
acid at baseline.
Fasting lipid, glucose and
transaminases every 6-12 weeks
the first year and with dosage
increases, then periodically
aprox. q 6months.
If transaminases increase more
than 3 times normal, and persist
stop med.
Uric acid if symptoms of gout.
Side effects are their major
problem – 42 % discontinuation
rate in first 5 years of treatment
Fasting lipid panel at 6-12
weeks, on initiation or with dose
increases, then periodically
approximately every 6 months..
Fasting lipid panel and
transaminases at baseline then at
6-12 weeks after start or
elevation in dose, then
periodically approximately
every 6 months. (Occurrence of
liver abnormalities is not
common with Gemfibrozil but
has been reported more with
Fenofibrate.)
Potential Side Effects
Mild GI complaints, headache,
insomnia,
Myopathy-rare with
monotherapy (0.1%) appears
dose dependent, risk is increased
with combination therapy.
Hepatotoxicity-appears dose
dependent with occurrence
estimated at 0.1% to 2.3%
Flushing, transient pruritis,
acanthosis nigracans
GI upset (more common with
SR forms)
Increase uric acid , glucose
Hepatotoxicity-rare with usual
doses of crystalline niacin
risk increased with SR forms
appears dose related most
occurring at 2 or more gms/day
Not absorbed so limited to GI
tract.
Constipation most commonminimize by increasing fluid,
fiber and exercise or adding
fiber laxative or stool softener to
regimen
Bloating
Belching-sip slowly through
Drugs
Fibric Acids
Contraindications
initiation, change in dose or
d/c of med
History of gallstones or
cholelithiasis
Hepatic impairment
Severe renal impairment.
Relative contraindication:
Pt. on Warfarin - monitor
INR with initiation, change
in dose or d/c of med.
Drug/Food Interactions
Warfarin increased
anticoagulant effect-monitor
INR
HMG reductase inhibitors
increase risk of myopathy
Nephrotoxic drugs i.e.,
cyclosporine increase risk of
severe myopathy
Potential Side Effects
straw to minimize air
swallowed.
GI most common, dyspepsia,
abdominal pain, diarrhea, skin
reactions
Rarely anemia, leukopenia,
gallstones, atrial fibrillation,
myopathy ( incidence appears
increased when used with
statins) .
*Myopathy defined as muscle pain &/or weakness plus elevation of CK to 10 times normal. Patients should be asked to
report promptly any unexplained muscle aches or weakness, especially if malaise or fever is present; also flu-like symptoms
(without upper respiratory infection).
** Highest risk of myopathy seems to occur when patients are taking other drugs that are metabolized by or inhibit the CYP
450 enzymes particularly 3A4. Neither fluvastatin or pravastatin is significantly metabolized by CYP 3A4. Pravastatin has
been allowed to change its product labeling to reflect this. Stating a lack of significant interaction potential has been shown
with known CYP450 3A4 inhibitors such as diltiazem and itraconazole..
When to Refer
•
•
•
•
Refer to dietitian or nutritionist for Step-Two Diet or another 3 month trial of Step-One Diet if goal not reached after 3 months on Step-One Diet.
Consult endocrinologist if unsure about diagnosis or treatment protocol or patient does not
respond to initial drug therapy
Refer to endocrinologist if considering combination therapy or alternative agents.
Refer to endocrinologist in all cases of familial hyperlipidemias
Patient Education
1.
2.
3.
4.
5.
6.
7.
Explain the increased risk of coronary heart disease with increased blood cholesterol.
Instructions about low cholesterol, low saturated fat diet.
Advise regular exercise.
Advise smokers to stop smoking.
Tell patient his/her cholesterol level.
Explain the target cholesterol level.
Explain side effects of medications.
Screening Guidelines
•
•
•
The US National Cholesterol Education Program (NCEP) expert panel recommends routine
lipid screening for men ages 35- 75 and women ages 45- 75 and discussing uncertainty
surrounding lipid screening benefit with men between the ages of 20- 34 years, women
between the ages of 20- 44 years, and men and women after age 75. Individuals in the latter
groups should be screened on the basis of their cardiovascular risk profile and treatment
availability after discussion of patient preference and risks and benefits of treatment.
Complete fasting lipid profile : Total cholesterol, low and high density lipoproteins, and
triglycerides should done if cholesterol is above 240, between 200 and 239 in a patient with
CHD or 2 risk factors for CHD or has an HDL < 35mg/dL.
Elevated triglycerides (greater than 200 mg/ dL) lose most of their ability to predict coronary
artery disease when other lipid risk factors are taken into account. However, elevated
triglycerides are usually associated with low HDL cholesterol levels. (Borderline high are
defined as 200- 400 mg/ dL, and High as > 400 mg/ dL.). An LDL to HDL ratio of greater
than 5 to 1 serves as a good predictor of coronary artery disease under these circumstances.
110
•
Measurement of a non-fasting serum total cholesterol is recommended for children and young
adults who have either a primary relative with a history of CHD prior to the age of 55 years or
a parent with a history of a total cholesterol > 300 mg/ dL. The NCEP guideline recommends
chemical screening if parental levels are higher than 240 mg/ dL. A primary relative is a
parent, grandparent or sibling. CHD event at an early age includes occurrence prior to the age
of 55 in men or prior to the age of 65 in women. If the family history is unobtainable
clinicians may wish to test the patient.
Management and treatment tips
•
•
•
•
•
•
•
HMG CoA Reductase Inhibitors (Statins) are generally considered first line therapy for high
LDL. Niacin is effective, lower cost, but poorly tolerated
Most patients with LDL >160mg/dL require >1 agent to reduce LDL to <130mg/dL
• Combinations of agents (Statins + BAS) may be needed to achieve goal, especially if
cholesterol above 300 mg/dL
• Combinations may also allow use of lower doses of each agent with reduced side effects
HDL >35mg/dL should be and additional goal in patients at risk or post-MI
• Low HDL can best be increased with Niacin or gemfibrozil (Lopid).
Treatment of Hypertension and Hypercholesterolemia
• Beta-blockers, thiazides and related agents increase total cholesterol
• Beta-blockers with intrinsic sympathomimetic activity decrease total cholesterol
• ACE inhibitors and alpha-adrenergic blockers reduce total cholesterol
Familial hypercholesterolemia patients should usually be referred to a specialist and be treated
aggressively at any age.
Education and nonpharmacologic therapy preferred for young men, premenopausal women
Long term effects of pharmacologic therapy are not known
111
Algorithm
Health Maintenance visit
Less than 20 years
Males 20- 34, > 75
Females 20- 44, > 75
Primary relative with CHD
at an early age
OR
Parent with pre-treatment
cholesterol > 300
Understand that there may
be no benefit from early
detection and treatment but
desire testing any way
Yes
No
Yes
No
Measure total cholesterol and HDL
Reconfirm abnormality within 8 weeks
Males 35-75
Females 45 -75
Previous screen in 5 years
Clinical conditon that
would make lipid profile
of futile value in
management
Yes
No
Appropriate health advice for age
No
HDL < 35
OR Cholesterol > 240
Cholesterol 200 to 239
No
No
Yes
Known CHD with
more than 2 years life
expectancy
Yes
No
2 or more CHD risk
factors
Yes
Yes
Total fasting lipid profile
Classify risk and management choice based on Age, CHD
risk factors and LDL level
(see text)
General diet and health
advice
Phase I and II diets
112
Diet + Medication
Quality of care indicators
•
•
•
•
•
•
•
•
•
Percentage of men aged 35-75 with a cholesterol screen in the last 5 years.
Percentage of women aged 45-75 with a cholesterol screen in the last 5 years.
Decrease in percentage of adults without history of hyperlipidemia with a serum cholesterol
test whose last test within the last 3 years was normal.
Percentage of children receiving serum cholesterol screening who are at risk for familial
hypercholesterolemia.
Percentage of patients with diagnosed coronary artery disease who have LDL- cholesterol less
than 100 mg/ dL.
Percentage of patients with diagnosed coronary artery disease who have LDL- cholesterol less
than 130 mg/ dL.
Percentage of patients who are on lipid lowering medications, within each of three starting
LDL and risk factor levels, who achieve the goal range for LDL for the group.
Percentage of patients with referral for individual diet instruction or class.
Percentage of patients on lipid lowering medication who may have a fasting lipid panel every
six to twelve months.
Sources
1. http://www.nhlbi.nih.gov/nhlbi/cardio/chol/prof/atp2/atp_ii.htm
2. National Heart, Lung, and Blood Institute: National Cholesterol Education Program (NCEP).
U.S. Department of Health and Human Services, NIH Publications No 95-3530, 97-3794,
Bethesda, MD; National Institutes of Health, Sept 1997.
3. National Cholesterol Education Program (NCEP). 1993. JAMA. 269(23):3015
4. Oster, G., Borok, G.M., Menzin, J. et al. 1996. Arch Intern Med. 156(7):731
5. U.S. Department of Health and Human Services, Report of the Expert Panel on Detection,
Evaluation and Treatment of High Blood Cholesterol in Adults, Jan, 1989.
6. Grundy SM, et al. "Summary of the Second Report of the National Cholesterol Education (NCEP)
Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol Pro-gram in
Adults (Adult Treatment Panel II)." JAMA 269( 23): 3015- 3023, 1993
7. Levy D. "The Framingham Heart Study. A Multifactorial Approach to Coronary Disease Risk
Assessment." Clin and Exper Hypertension 15( 6): 1077– 1086, 1993.
8. Burke GL, Sprafka JM, Folsom AR, Hahn LP, Luepker RV, Blackburn H. Trends in serum
cholesterol levels from 1980 to 1987 -- the Minnesota Heart Survey. NEJM 1991; 324 (14):941
113
Hypertension
Definition and Epidemiology
Hypertension is the most common chronic condition seen by primary care physicians.
About 5 % of patients have a specific cause for elevated blood pressure or “secondary” hypertension
(chronic alcoholism, renovascular hypertension, kidney disease, primary hyperaldosteronism,
pheochromocytoma, coarctation of the aorta, Cushing, hyperthyroidism, and drugs); the remaining
95% have “ primary”, “idiopathic”, or essential hypertension.
The prevalence of hypertension varies among nations, with higher rates in industrialized countries. In
addition, the measured prevalence of hypertension may be higher in countries with well-organized
health care system that are better able to detect hypertension.
Epidemiological studies show that morbidity and mortality rates rise progressively as both or either
the systolic or diastolic pressure increase. Without treatment, approximately 70% of hypertensive
patients will die of coronary artery disease or heart failure, 15% of cerebrovascular disease, and 10%
of renal failure. Fortunately as a result of blood pressure education, awareness, and control, the
mortality rates from coronary heart disease and stoke have decreased by 50 and 57% respectively.
Baseline Evaluation
Baseline evaluation for hypertension has 4 objectives:
1. Establish presence of hypertension and grade it
Patient should:
• Rest for 5 minutes before measurement.
• Refrain from smoking or drinking coffee for 30 minutes prior to test
• Be seated with feet flat on floor, back and arm supported, arm at heart level.
Clinician should:
• Use the appropriate size cuff for the patient; the bladder should encircle at least 80
percent of the upper arm.
• Use calibrated or mercury manometer.
• Average two or more readings, separated by at least 2 minutes.
Optimal
Normal
High
Normal
Stage I
Stage II
Stage III
Systolic
(mmHg)
< 120
< 130
130-139
Diastolic
(mmHg)
< 80
< 85
85-89
140-159
160-179
>= 180
90-99
100-109
>=110
2. Rule out the possibility of secondary causes
3. Assess target organ damage (TOD) or presence of cardiovascular disease (CCD)
4. Evaluate the patient for other cardiovascular risk factors (RF)
114
Recommended baseline evaluation of patients with sustained high blood pressure.
Reason for obtaining information
TOD
Secondary
Treatment
Factors
causses
selection
modified
by
treatment
Information obtained
History
Age and race
X
X
Blood pressure levels
X
X
X
Previous BP treatment
X
X
Family history
X
X
Congestive heart failure
X
X
Angina
X
X
History of TIA or CVA
X
Renal disease
X
X
X
Comprehension of hypertension
X
X
Diet (Na, K, Fats)
X
X
X
Exercise habits
X
Current medications
X
X
X
Alcohol use
X
X
Tobacco use
Current life stress
X
X
Coexisting conditions
X
X
CCD and
RF
X
X
X
X
X
X
Physical examination
Height and weight
Blood pressure reading
Heart rate and rhythm
Eye exam
Peripheral pulses
Heart
Lungs
Abdomen
Neurological
Laboratory tests
Complete blood count
Calcium level
Creatinine level
Potassium level
Sodium level
Fasting blood sugar
Cholesterol (total HDL)
Uric acid
Urinalysis
ECG
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Management strategies
Encourage patients to make healthy lifestyle choices:
• Quit smoking
• Lose weight if indicated
• Restrict sodium intake to less than 100 mmol per day
• Limit alcohol intake to less than 1-2 drinks per day
115
X
X
X
X
X
X
X
X
X
• Aerobic activity daily for 30-45 minutes or more
• Maintain good potassium intake of 90 mmol per day
• Maintain calcium and magnesium intake
Set a clear goal of therapy based on patient’s risk. Control blood pressure to below:
• 140/90 if uncomplicated and lower if there is target organ damage or other cardiovascular
disease
• 130/85 if there is diabetes
• 125/75 if there is renal failure with proteinuria greater than 1 g/24 hrs
Stepped care management:
• Begin with lifestyle modifications for all patients. Be supportive.
• Add medications if pressure remains uncontrolled
• Start with diuretic or beta blocker unless there are compelling indications to use others. Use
low dose and titrate upward. Consider low dose combinations.
• If no response try a drug from another class or add a second agent from a different class (if
diuretic is not already used)
Monitor compliance and insure adherence with treatment:
• Encourage lifestyle modifications for all patients. Be supportive.
• Educate patient and family about disease
• Keep care inexpensive and simple
• Favor once daily, long acting formulations
• Use combination tablets, when needed
• Consider using the less expensive generic or essential drug list formulations
When to Refer
1. Uncertain about diagnosis
2. Failure to control blood pressure despite use of a three medications regimen
3. Suspicion of secondary hypertension
Quality of care indicators
1. Percentage of hypertensive patients with blood pressure in control.
2. Percentage of staff with documented initial and annual education on correct blood pressure
measurement technique.
3. Percentage of hypertensive patients on medication with a documented follow-up plan.
4. Percentage of hypertensive patients presenting in clinic within the last month for whom
patient education about modifiable risk factors has been documented in medical record.
Sources
1- The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure. Arch Intern Med 1997; 157:2413-46.
2- 1999 World Health Organization-International Society of Hypertension Guidelines for the
Management of Hypertension.
116
Risk stratification and treatment recommendations (JNC-VI)
•
•
•
•
•
Determine blood pressure stage.
Determine risk group by major risk factors (RF) & target organ damage (TOD) or clinical cardiovascular disease
(CCD)
Determine treatment recommendations from table below
Determine goal blood pressure
Select any specific recommendations.
TOD / CCD
Major risk factors
Heart diseases
Stroke or TIA
Smoking
Dyslipidemia
LVH
Nephropathy
Diabetes
Age > 60
Angina / prior
Peripheral artery
Gender
Family history
MI
disease
Men
Women < 65
Prior CABG
Hypertensive
Postmenopausal
Men < 55
Heart failure
retinopathy
women
Blood pressure stages
Risk Group A
Risk Group B
Risk Group C
(mm Hg)
No major RF
One or more RF
Diabetes &/or TOD/ CCD
No TOD/CCD
No TOD/CCD
irrespective of RF
High normal
Lifestyle modification
Lifestyle modification
Drug therapy if heart failure,
130-139 /
diabetes or renal
85-89
insufficiency.
Lifestyle modification
Stage 1
Lifestyle modification
Lifestyle modification (up to Drug therapy
140 – 159 /
(up to 12 months)
6 months)
Lifestyle modification
90 – 99
Recheck every 2 months
May start with drug therapy
if multiple risk factors
present
Stages 2 and 3
Drug therapy
Drug therapy
Drug therapy
> = 160 /
Lifestyle modification
Lifestyle modification
Lifestyle modification
> = 100
Recheck monthly or weekly
for stage 3
< 140/90 mm Hg
< 130/85 mm Hg
< 125/75 mm Hg
Goal Blood Pressure
Uncomplicated hypertension, risk groups A or B.
Risk group C without the following
Diabetes, renal failure or heart failure
Renal failure with proteinuria > 1 g / 24 hours
Specific treatment recommendations
Lifestyle modification is indicated for ALL patients
Pharmacologic therapy is additional to lifestyle modifications
Initial drug choices
•
Start with low dose of a long acting once daily drug, and titrate dose
•
Low-dose combinations may be appropriate
Uncomplicated Hypertension
Compelling indications
Diuretics
Diabetes type 1 (IDDM)
Start with ACE inhibitor if proteinuria
Beta blockers
present
Heart failure
Start with ACE inhibitor or diuretic
Myocardial infarct
Beta blocker (non-ISA)
ACE inhibitor for LV dysfunction
Isolated systolic hypertension (older
Diuretics (preferred) or long acting
patients)
dihydropiridines (DHP) calcium
channel blockers
117
Obesity
Definition and Epidemiology
Obesity is an excess of body fat above the norm for age and sex with a mean weight more than 20%
above ideal body weight. Severity is defined as frankly obese if 20-50% above ideal body and
grossly obese if more than 50% above ideal body weight.
Obesity is associated with increased mortality rate in most age groups as well as hypertension,
diabetes, stroke, lipid disorders, gallbaldder disease, osteoarthritis and sleep apnea.
Distribution of Body Fat
a. Often characterized as centrally vs. peripherally located fat distribution
b. Central obesity is characterized by an "android" or "apple" shape
•
Central obesity is more common in men and is a strong risk factor for several diseases
•
Ratio of waist (umbilicus) to hip (pubic symphysis) >0.85 is a risk factor (central form)
•
This ratio also correlates (r=0.4) with elevated serum triglyceride and low HDL
c. Peripherally distributed ("gynecoid" or "pair" shape) is more common in women
•
Although not completely benign, peripheral (non-central) obesity appears to be less of a
risk factor for cardiovascular disease than central obesity
History
A. INITIAL ENCOUNTER
1. Duration of obesity
2. Eating habits
3. Activity habits
4. Hour dietary recall
5. Previous weight loss attempts
6. Assess patient readiness
7. Weight loss expectations
8. Family history of obesity
9. Presence of comorbid conditions
Any condition associated with obesity that usually worsens as the degree of obesity increases:
• Hypertension
• Cardiovascular disease
• Dyslipidemia
• Type 2 diabetes
• Sleep apnea \ obesity hypoventilation syndrome
• Osteoarthritis
• Lower extremity venous stasis disease
• Gastro-esophageal reflux
• Urinary stress incontinence
B. FOLLOW-UP
Eating and activity habits
118
Objective Findings
A. INITIAL ENCOUNTER
1. Measure Body Mass Index (BMI). This is a reliable index to evaluate the body fat. It is measured
as Kg / m2 and available quick measurement in nomogram.
2. General physical examination including: Waist circumference and body habitus
B. FOLLOW-UP
BMI Measurement
Diagnostic Considerations
1. Determine the BMI-related health risk (table below)
BMI category
Health Risk Based on BMI
<25
25 - <27
27 - <30
30 - <35
35 - <40
≥ 40
Minimal
Low
Moderate
High
Very High
Extremely High
Risk Adjusted for Presence of Comorbid
Conditions and/or Other Risk Factors
Low
Moderate
High
Very High
Extremely High
Extremely High
2. Perform needed tests to rule out obesity related illnesses
• T3, T4 – if suspect hypothyroidism
• FBS – if suspect diabetes
• Serum cholesterol
• Dexamethasone suppression test – if suspect Cushing’s syndrome
Management steps
1. Select weight reduction treatment option based on the determined health risk:
Health Risk
Minimal and Low
Moderate
High
Very High
Extremely High
Treatment option(s) available
- Healthful eating and or moderate deficit diet
- Increased physical activity
- Lifestyle changes strategies
- All the above PLUS low calorie diet
- All the above PLUS very low calorie diet
- All the above PLUS pharmacotherapy
- All the above PLUS surgical intervention
2. Determine weight reduction exclusion: Pregnancy, lactation, osteoporosis, anorexia nervosa,
unstable medical condition or terminal illness
3. Together with the patient, select a target BMI that the patient is willing to maintain
4. Create an energy balance between the energy consumed in food and daily physical activity
5. Establish permanent life style change strategies
a. Eating Behavior Modification is essential but probably not sufficient
i. Reduce total caloric intake by 500 Kcal per day to lose 1 kg per week
ii. Keep records of food intake
iii. Eat regular meals
b. Exercise is necessary in all cases
119
6. Some medications are temporarily helpful as adjunct to reduced calorie diet especially in
patients with BMI above 30 or 27 with other cardiovascular risk factors.
a. Sibutramine (Reductyl, Meridia): a mixed neurotransmitter reuptake inhibitor which
helps curb appetite. Start at 10 mg once daily then increase to 15 mg daily in 4 weeks.
b. Selective Serotonin Reuptake Inhibitors - Fluoxetine (Prozac) at 20 mg daily –
decreases appetite
c. Certain stimulant compounds including Methylphenidate (Ritalin) – decreases
appetite
d. Orlistat (Xenical): Lipase inhibitor - decreases fat absorption.. 120 mg capsule taken
during or up to 1 hour after each of 3 daily meals. If a meal contains no fat,
medication is skipped.
7. Re-evaluate weight reduction need and progress periodically
Desired outcomes
Weight not more than 20% greater than norm for height.
When to Refer
1) Refer all to registered dietician for implementation of prescribed diet
2) Refer to “obesity treatment center” or endocrinologist if uncertain about diagnosis or patient
desires multidisciplinary treatment or if BMI > 40 or BMI > 35 with significant co-morbidity
Patient Education
1)
2)
3)
4)
5)
6)
Explain the cause of obesity
Explain the prognosis
Advise about the complications of obesity
Advise to avoid fad diets
Advise to avoid self prescribed diet pills
Advise about the exercise program
Sources
1. NIH: Clinical guidelines on the identification, evaluation, and treatment of overweight and
obesity in adults. Rockville, MD 1998.
2. American Obesity Association: Guidance for treatment of adult obesity. 1996.
3. Robinson BE, Gjerdingen DK, Houge DR. A move from a traditional to more patient-oriented
management. J Am Board Fam Pract. 1995.88:99-108.
4. Ciliska D. Women and obesity. Canadian Family Physician. 1993.39:145-152.
5. Menotti A, Descovich GC, Lanti M et al. Indexes of obesity and all-causes mortality in Italian
epidemiological data. Prev Med 1993. 22:293-303.
6. Carpenter N. and Brunton S., Adult obesity: evaluating weight loss programs and the role of
exercise. Family Practice Recertification, October 1988, 10:10.
7. Fuller E., Helping your patient lose weight. Patient Care, June 15, 1986.
120
Panic Disorder
Definition and Epidemiology
Anxiety disorders are common in primary care. They include: Generalized anxiety disorder (GAD),
panic disorder (PD), obsessive compulsive disorder (OCD), mixed anxiety and depression (MAD) and
phobic disorders. Panic is the most common among these and will be emphasized in this guide.
PD consists of a mixture of characteristic signs and symptoms that persist for at least one month. The
symptoms include recurrent panic attacks and persistent concern about having another attack or worry
about the implications and consequences of the attacks.
Panic attacks are discrete periods of intense fear or discomfort, accompanied by at least four of the 13
somatic or cognitive symptoms defined by DSM-IV (palpitations, tachycardia, sweating, trembling,
shortness of breath, choking sensation, chest pain, nausea, dizziness, derealization, depersonalization,
fear of losing control or of dying, paresthesias, chills, hot flushes). An attack has an abrupt onset and
reaches a peak of usually within 10 minutes. It is often accompanied by a sense of imminent danger
and an urge to escape. Panic attacks occur much more frequently than PD.
PD has lifetime prevalence of 0.4 to 2.9% with the mean age of onset in early to middle adulthood.
History
Initial history should assess the possibility of an organic illness underlying the panic attacks. Mainly,
ruling out hyperthyroidism, excessive caffeine intake, unstable angina and substance abuse.
Frequency, duration and precipitating factors of attacks should be noted.
Objective Findings
A complete physical examination is necessary initially with careful cardiac evaluation and
documentation of findings.
Laboratory testing for TSH and T4 if suspect hyperthyroidism and blood sugar or blood count may be
done. Echocardiogram if mid-systolic click is heard. EEG or CT of brain may be done if any
neurologic condition is suspected.
Diagnostic Considerations
Diagnosis of PD is made when:
1. Recurrent unexpected panic attacks
2. At least one attack has been followed by 1 month or more of at least one of the following:
persistent concern about additional attacks, worry about the implications of the attack, or a
significant change in behavior related to the attacks
3. With or Without agoraphobia
4. No direct psychological effect of a substance or medication can be identified
5. No other mental disorders can explain the attack
Diagnosis of GAD is made when:
1. Excessive anxiety and worry occur more days than not for at least 6 months
2. Patient cannot control worry
3. Worry is associated with at least 3 of the following: muscle tension, restlessness, fatigue,
difficulty concentrating, irritability or sleep disturbance.
4. There is significant distress or impairment in social, occupational, or other important
functions.
121
5. No psychological effect of a substance, medication or general medical condition can explain
the symptoms.
Management options
1. Remove exacerbating factors: caffeine, tobacco, drugs.
2. Discuss previous therapies (psychotherapies or drugs) the patient may have used and explore
their interests and choices of treatment
3. Offer brief therapy in your office if you are trained or suggest referral psychological
counseling with cognitive or group psychotherapy.
4. Pharmacotherapy may be used first line, especially in PD in acute setting.
Therapeutic choices
1. Anxiolytics
a. Benzodiazepines
Used most often in acute attacks and for short periods only because of their potential for abuse and
dependence. Efficacy of long term use (beyond 4 months) has not been shown. Drowsiness, dizziness
and headache are common side effects.
Alprazolam (Xanax) 0.25 mg-0.5 mg TID, dose can be adjusted every 3-5 days until desired effect is
reached
Diazepam (Valium) 2-20 mg PO BID – QID
Clonazepam (Rivotril) 0.5 mg PO BID (and up to 10 mg/day) – long acting
b. Non-Benzodiazepines
Buspirone (Buspar) 5 mg TID (up to 60 mg per day) does not have the sedative, withdrawal or abuse
potential seen with the benzodiazepines but its effect may take several weeks to be evident.
2. Selective Serotonin Reuptake Inhibitors (SSRI)
More and more commonly used as initial treatment for PD
a. Sertraline (Zoloft): begin 25 mg PO QAM for 1-2 weeks then increase up to 20 mg
daily
b. Fluoxetine (Prozac): begin 10 mg PO QAM for 1-2 weeks then increase up to 40 mg
daily
c. Citalopram (Cipram)
3. Tricyclic antidepressants agents (TCA)
a. Start at low dose and gradually increase until panic attacks diminish or stop.
b. Imipramine can be started at 10 mg daily and increased 10 mg every 2-3 days till
there is response.
c. Effect may not be seen until 4 weeks of treatment.
d. Other medications used are described in the section on depression.
4. Other medications
Propranolol may be used to control vegetative symptoms, particularly palpitations, trembling,
restlessness or motor tension. Start with 10 mg TID up to 80 mg daily as needed.
When to Refer
1. Uncertainty about diagnosis
2. For psychotherapy
3. Phobias or mixed disorders
Sources
1. American psychiatric association: Diagnostic and statistical manual of mental disorders, 4th
edition. Washington, DC, American psychiatric association, 1994.
122
2. Saeed SA, Bruce TJ. Panic disorder: effective treatment options. Am Fam Phys 1998;
57:2405-12.
3. Walley EJ, et al. Management of common anxiety disorders. Am Fam Phys 1994; 50:174553.
4. Cross-National Group. The cross-national epidemiology of panic disorder. Arch Gen Psych
1997; 54:1.
123
Tuberculosis
Definition and Epidemiology
•
•
•
Tuberculosis is spread primarily through respiratory droplets. By 6 to 12 weeks, most exposed
people, develop cell mediated immunity which stops the infection spread.
Tuberculous infection: persons who were exposed to Mycobacterium Tuberculosis but do not
have symptoms of tuberculosis
Tuberculous disease: persons who have symptoms of tuberculosis
History
Symptoms of initial disease may include:
1. Productive cough (>3 weeks)
2. Hemoptysis
3. Chest pain
4. Chills with fever an night sweats
5. Weight loss
Other relevant information to assess risk and prognosis includes:
1. History of previous tuberculosis or treatment of TB
2. Country of origin and prevalence of TB in that country
3. Occupation
4. Intravenous drug or alcohol abuse
5. Homelessness
6. Underlying medical conditions that could impair immunity: HIV infection, chronic renal
failure, diabetes mellitus, post-gastrectomy, steroid therapy.
Objective Findings
1. Chest X-ray- if signs and symptoms and /or positive reaction to TB skin test
2. Sputum smear and culture- if Chest X-ray is suggestive and every two weeks to one month till
culture negative.
3. Liver enzymes - baseline and every two months if on drug treatment.
4. Serum uric acid - baseline and every two months if treated with Pyrazinamide
5. BUN, creatinine - baseline if on drug treatment
6. CBC, platelet count - baseline if on drug treatment
7. Visual acuity - baseline if treated with Ethambutol
8. HIV- antibody titer- should be considered if high risk for HIV or extra pulmonary TB.
Skin testing
1. Skin testing is useful for examining a person who is not ill but may be exposed & infected
with M. tuberculosis. The TB skin test is the only way to diagnose TB infection before
progression to TB disease
2. It is useful for examining a patient who has symptoms suggestive of TB.
3. Mantoux test is the standard skin test method. The area of induration (palpable swelling)
around the site of injection should be measured, and not the erythema (redness). It must be
read 48-72 hours after injection.
4. The measurement should be reported as 1 number indicating the width of the induration in the
transverse plane. Positive or Negative report is NOT sufficient.
5. The test becomes positive 8-12 weeks after exposure to tuberculous disease.
124
6. A “negative” skin test does NOT exclude infection especially in immunocompromised
individuals.
7. Significant tuberculin reaction:
5 mm induration or greater
1. Recent close contacts with a case of infectious TB
2. Patients who have fibrotic radiographs consistent with healed TB
3. Persons with HIV status
10 mm induration or greater
1. Diabetes mellitus
2. Prolonged therapy with corticosteroids
3. Immunosuppressive therapy
4. Hematologic/ reticuloendothelial diseases that are associate with decreased
cellular immunity (i.e., Hodgkin’s disease, leukemia)
5. Injection drug user known HIV-negative
6. Substantial weight loss or malnutrition
7. Foreign-born, from a country with incidence of tuberculosis
8. Medically underserved, low-income population
9. Residents of correctional, mental, or extended-care facilities
10. Infants and children under 4 years of
15 mm induration or greater
All others without above risk factors
8. Booster phenomenon:
• Repeat testing with PPD does NOT sensitize individuals to the test substance
• Delayed sensitivity or positive reaction to PPD may wane and decrease over time.
Some individuals who may have exposed to TB many years previously (and should test positive) may
show false negative test results: in these, a repeat test within a week may show positive result which is
a booster phenomenon (indicating a remote infection) and NOT a recent conversion.
•
Repeat testing is usually done in the initial screening for individuals who will
receive annual skin testing so that a positive PPD is known as a boosted reaction
and not a recent infection.
9. Tuberculin skin-test conversion is an increase of at least 10mm within a period of 2
years.
10. Prior BCG vaccination does not alter the guidelines for interpreting skin test results.
Management
1. Chemoprophylaxis
• Rule out the possibility of active TB (with a medical history and chest X-ray)
• Question for a history of treatment for TB infection or disease, or history of BCG
vaccination
• Check for contraindications for preventive therapy, and if patient is high risk for adverse
reactions
a- Indications:
1. Persons who have been in close contact with potentially infectious tuberculosis cases.
2. Persons who inject drugs and who are known to be HIV negative (10mm or greater)
3. Persons who had tuberculosis in the past but did not receive adequate therapy.
4. Persons with significant reactions to tuberculin skin test except when 15mm reaction
(no risk factors) and > age 35 years.
5. Patients with certain medical conditions (10mm or greater)
125
b - Medications:
1. Isoniazide 10mg/kg up to 300 mg once daily for at least 6 months (9months for
children, 12 months for HIV infected persons)
2. Pyridoxine 25-50 mg once daily-in adults
2. Chemotherapy:
1. Isoniazide, Rifampin and Pyrazinamide for two months, followed by Isoniazide and
Rifampin alone for four months. Ethambutol or Streptomycin should be included in
the initial regimen until drug susceptibility are available.
2. Isoniazide and Rifampin for nine months-Again, Ethambutol or Streptomycin should
be included in the first two months if INH resistance is not < 4% PLUS
3. Refer to specialist for further management and follow up.
DOTS
Directly Observed Treatment, Short-course (DOTS) is a comprehensive strategy promulgated by
WHO with the goal of controlling the TB epidemic. Essential to this strategy is the close follow up
and direct observation of treatment for at least the first two months. This follow up is usually through
specialized management units supported by governments. The ministry of public health (MoPH) in
Lebanon has such a unit and program. It is therefore essential for physicians identifying patients with
positive smears to inform the MoPH and to refer the patient to TB units for free medications and close
follow up.
Patient Education
1.
2.
3.
4.
5.
Explain the significance of a positive TB.
Explain prognosis
Advise that household contacts should be screened for tuberculosis.
Advise patients on the importance to adhere to treatment.
Educate patients about signs and symptoms of hepatitis; instruct about avoiding alcohol
intake and acetaminophen.
6. Refer to Ministry of health.
7. Complete epidemiological surveillance unit (ESU) form and fax to the Ministry.
Sources
1. Mccolloster P, Neff N. Outpatient Management of Tuberculosis. American Fam Phys 1996;
53:1579-1586
2. Montana Department of Public Health and Human Services. CDC/DTBE – Core Curriculum
on Tuberculosis. U.S. Department of Health and Human Services. 1994. 3rd edition.
3. American Thoracic Society. Treatment of tuberculosis and tuberculosis infection in adults
and children. Am J Crit Care Med.1994;149: 1359-1374.
4. Communicable Diseases Cluster Prevention and Control Country Support. What is DOTS.
World Health Organization. 1999. WHO/CDS/CPC/TB99.270.
126
Women’s health
127
Amenorrhea
Definition
The absence of menses (amenorrhea) is divided into two groups:
• Primary: No menstrual period by age 14 in the absence of growth or development of
secondary sex characteristics, or no menstrual period by age 16 regardless of the presence of
normal growth and development of secondary sex characteristics.
• Secondary (more common): The absence of menses for the equivalent of 3 previous cycle
intervals or 6 months in a woman with prior regular menses or 12 months for those with prior
oligomenorrhea.
History
History addressing amenorrhea includes a review of medical conditions affecting the endocrine and
reproductive system as well as use of medications and psychosocial issues. Prior to any evaluation,
pregnancy must be excluded.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
Last menstrual cycle
Normal menstrual cycle: interval, regularity, duration, ovulation pain, and dysmenorrhea
Pregnancy history, sexual activities
Galactorrhea
Prior episodes of amenorrhea
Weight changes (loss or gain),
Current and/or chronic diseases
Exercise habits
Emotional stress
Hot flashes, vaginal dryness
Hirsutism, acne
Increased libido, deepening of voice, frontal alopecia
Vision, headache
Medication intake
Objective Findings
a. Pregnancy test
b. Pelvic exam
c. Sexual maturity (Tanner stage)
Diagnostic work up
Exclude pregnancy with a pregnancy test
Serum prolactin
Thyroid function tests
a) If PRL elevated and TSH increased
• Hypothyroidism
b) If PRL elevated and TSH is normal
• MRI of sella turcica to differentiate between pituitary tumor and idiopathic
hyperprolactinemia
• If pituitary adenoma by CT scan or MRI:
(1) Refer to neurosurgeon if size > 10mm
(2) Refer to endocrinology if size < 10mm
128
c) If normal PRL and TSH:
• Progesterone challenge test with 10 mg medroxyprogesterone (Provera) r5 days
(1) If positive (any bleeding within 2-7 days of 5th tablet), anovulatory cycle
(a) If pregnancy desired consult gynecologist
(b) If not, consider oral contraceptives
(2) If no withdrawal bleeding:
o Estrogen-Progesterone challenge with conjugated estrogen (Premarin) 1.25mg.
daily r 21 days plus Provera 10 mg days 16 to 21; and REPEAT another cycle
of no bleeding by day 28 on first cycle.
(a) If still no withdrawal bleeding after 2 cycles, uterine outflow tract abnormality,
refer
(b) If withdrawal bleeding after the estrogen-progesterone challenge, obtain serum
LH , FSH level after 2 weeks from bleeding
(i) If both FSH,LH high , ovarian failure
(ii) If both FSH, LH low or normal, hypogonadotropic hypogonadism
1. do CT or MRI of brain to R/O hypothalamic or pituitary mass
2. refer to gynecologist if pregnancy desired
(iii) If FSH is high and LH low or normal, consider gonadotropin secreting
adenoma. Refer to endocrinologist
Sources
1. Kinningham RB, Apgar BS, Schwenk TL. Evaluation of amenorrhea. Am Fam Physician
1996;53:1185
2. Baird DT. Amenorrhea, Lancet 1997;350:275
3. Reilly B. Practical Strategies in Outpatient Medicine, Saunders, 1991
4. McIver B. Evaluation and management of amenorrhea, Mayo Clinic Procedures 1997;72:1161.
129
Breast nodule
Definition and Epidemiology
The primary care physician has to be able to act promptly on the finding of a breast lump or an
abnormal mammogram. This is a serious compliant among women. Although the majority of these
cases are benign, 90per cent of breast cancers are discovered by the patient herself. 75 per cent of
women newly diagnosed to have breast cancer, have no identifiable risk factor.
History
Patient is by definition asymptomatic. The physician should ask about duration of symptoms and their
relation to menstrual cycle. Inquire about nipple discharge, pain, last mammogram done and result.
Risk factors for breast cancer should be obtained with the most obvious risks including:
1. Age related-incidence
2. Family history
Any first-degree relative (mother, sister and daughter) with breast cancer. Patient with one
first degree relative with premenopausal breast cancer has 3-4 fold greater risk of developing
breast cancer. If the relative has bilateral cancer than the risk will be 8-10 times more.
If a woman has a personal history of breast cancer the risk of developing new primary breast
cancer is 0. 5-1 per cent per year for the remaining life.
3. Other risk factors:
a. No children or first child after the age of 35.
b. Early menarche and late menopause.
In case of any nipple discharge, the risk of cancer is increased in spontaneous, unilateral or bloody
discharge or associated with a mass in an older patient. Bilateral milky discharge is usually due to an
endocrine, central nervous system or medication side effect problems.
Objective Findings
Principles to be followed in breast examination are:
1. Adequate patient privacy.
2. Examination gowns should be adjusted to minimize unnecessary and unintended exposure of
the patient.
3. Examine the patient in upright and supine positions.
4. Doctor should define the size, location, mobility, and consistency of the nodule. It is
important to note if a mass is dominant and discrete, soft or hard, cystic or solid, movable or
fixed and to identify its borders.
5. Check for skin changes or nipple changes.
6. Check for nipple discharge.
7. Do not forget to examine the axillae for lymph nodes. The number and fixation of the lymph
nodes should be mentioned.
Diagnostic Considerations
In presence of discharge, check for blood using heme occult test. If positive, refer to surgeon
immediately. If no blood, obtain mammogram and evaluate for endocrine causes (TSH and Prolactin
level to start) or medication side effect or lactation.
130
1-MAMMKOGRAPHY
Any palpable solitary or dominant discrete breast nodule should be evaluated by a mammography
and/or ultrasound. Keep in mind that the purpose of the mammography is to screen the rest of the
breast tissue and not to make a diagnosis of the palpable mass.
The usefulness of mammography in young female is limited by the increased density of the breast. If
a woman is below the age of 30 years, mammography should not be done routinely because of the
rarity of breast cancer except if the mass is suspicious and the woman is high risk. Normal
mammogram of any age does not eliminate the need for further evaluation of any palpable mass.
2-ULRASONOGRAPHY
The value of the ultrasound is to differentiate between solid and cystic mass or for further evaluation
of a mass poorly or partially seen by mammography. Because of the inconsistent detection of micro
calcifications, ultrasound is not used as a screening method.
3-FINE NEEDLE ASPIRATION
Every palpable breast mass should be considered for needle aspiration. FNA is a treatment for cysts
and can be diagnostic for solid mass by aspirating tissue for cytologic evaluation .The false positive
result does not exist, but false negative rate may be as high as 15%-20%. After aspiration any residual
mass should be evaluated and excised if needed.
When to Refer
Immediately if suspect malignancy or if unable to do FNA when indicated as above.
Patient Education
Women should be encouraged to have periodic mammograms. Several organizations recommend
mammography every 1-2years for women 40-49 years of age. However, evidence of community and
epidemiologic benefit is available only for annual screening between the age of 50-74 years.
Controversy exists about screening after the age of 75.
Breast examination should be part of any physical exam done for women above the age of 30 years.
The role of breast self examination (BSE) in early detection of breast cancer is not clear. Breast exam
should be encouraged if the patient values the role of BSE. If the woman finds a mass during BSE she
should be seen promptly and evaluated.
Quality of care indicators
Timeliness of follow up
a. Percentage of abnormal mammograms that are followed by either biopsy or ultrasound.
b. Percentage of patients with benign biopsy results (other than fibroadenoma) with repeat
mammogram in six months.
131
Algorithm
Palpable Mass
Mammography
Benign Probably
Suspicious
Highly Suggestive of
Malignancy
U/S
Cystic
Solid
b
Benign
Follow-up
FNA
Or
Core Biopsy
Malignant
Surgery
Surgery
Insufficient or
Unconclusive
Biopsy
Sources
1.
Cady B, et. al: Evaluation of common breast problems: Guidance for primary care providers.
Guidelines. Cancer 1998; 48:49-63. (Prepared by the US center for disease control and prevention
with collaboration of the society of surgical oncology)
132
Contraception counseling
Aim
1.
2.
3.
4.
5.
Provide adequate counseling regarding the use of appropriate methods to avoid unwanted
pregnancy
Identify medical and personal factors that impact on contraceptive selection
Discuss the available contraceptive choices
Delineate contraceptive and non contraceptive benefits of each method
Enhance patient selection of the most appropriate contraceptive method
History
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Patient’s age: avoid oral contraceptives (OCP) if above 40 years
Marital status: if she or her partner has multiple partners, avoid intrauterine devise (IUD)
Menstrual history- if irregular cycles, avoid IUD
Smoking history- avoid OCP if above 35 years of age
Child bearing potential: fertility returns sooner upon discontinuation of oral contraceptive
pill (OCP) and implants but can take more than 12 months to return after a depomedroxyprogesterone acetate (DMPA) injection.
Life style: women who cannot take OCPs at the same time on a daily basis may not be
appropriate OCP candidates
Income
Religious beliefs
Recent or recurrent pelvic inflammatory disease: avoid IUD
History of any of these absolute contraindications to oral contraceptives: thromboembolic
disease, stroke, atherosclerotic heart disease, liver disease or tumor or other estrogendependent malignancy
History of any of these relative contraindications to oral contraceptives: severe migraine
headaches, hypertension, diabetes, gall bladder disease, undiagnosed vaginal bleeding.
Medical history: acne (better use triphasic norgestimate/ethinyl estradiol formulation),
obesity, hypercholesterolemia (use less androgenic OCPs), hypertriglyceridemia (avoid
OCP), anemia (avoid IUD)
Objective Findings
1.
2.
3.
Initial assessment should include a general physical exam and documentation of:
a. Blood Pressure, weight
b. Thyroid exam
c. Breast mass
d. Pelvic exam with PAP smear
e. Extremities check for phlebitis or varicosities
Annual follow up
a. Breast exam
b. Pelvic exam
Diagnostic work up
a. Pap smear annually
b. HIV Ab If multiple sexual partners
c. Chlamydia antigen- (when available) if multiple sexual partners or age less than 30
years
d. GC culture (when available) if multiple sexual partners or age less than 30 years
133
Therapeutic choices
1. Combined Oral Contraceptives
• 0ne year pregnancy rate in the average user: 2%
• Non contraceptive benefits include reduction in the menstrual cramps, decreased menstrual
flow, and regulation of menstrual cycle. It also provides protection against ovarian and
endometrial cancers and reduces the risk of PID.
• Post pill amenorrhea is rare; fewer than 1 % have amenorrhea lasting more than 12 months
after discontinuing the pill. Neither spontaneous abortion nor congenital anomalies occur
more frequently in pregnancies after discontinuance of the pill.
• Initial therapy: either of these
1) Norethindrone 1mg/ethinyl estradiol 0.035 mg
2) Norethindrone 0.5 mg, 0.75 mg, 1 mg/ethinyl estradiol 0.035 mg (triphasic)
• Advise the patient to take the pill on the same time each day. If the pills are prescribed after
an abortion, the pill should be started immediately to prevent ovulation. After a pregnancy,
allow 2 weeks before starting, due to the risk of thromboembolism and possible decreased
breast milk production.
• It is recommended that women experiencing nuisance effects on a formulation wait for three
cycles before switching to another formulation, as the majority of these side effects
spontaneously resolve within 3 months.
• Side effect management - if significant side effects occur, switch to different combination as
follows, based when appropriate on these relative effects of progestins:
Problem
Suggested action
Early spotting
Increase estrogen potency
Late spotting
Increase progestin potency
No withdrawal bleeding
Make sure no pills were missed, perform a
pregnancy test, if negative increase progestin
potency. If that fails to produce withdrawal
bleeding, increase estrogen dose
Heavy bleeding
Use stronger progestin, if that fails, increase
estrogen.
Nausea
Change time of day pill is taken (better in evening)
or have the patient take it with food. If fails,
decrease progestin potency
Cyclic fluid retention
Decrease estrogen potency
Oily skin or hirsutism
Decrease androgen potency
Hyperpigmentation
Decrease estrogen , stay out of sunlight or use sun
block.
Depression
Decrease estrogen potency or increase progestin.
Headaches
Lower dose combined pill
Hypertension, severe
Progestin only mini pill if no other suitable method
headaches, leg cramps
Androgenic effect
Norethynodrel
0
Ethynodiol diacetate
1.0
Norethindrone
1.6
Norethindrone acetate
2.5
Norgestrel
17.5
Levonorgestrel
15.0
Progestational effect
Norethindrone
1.0
Norethynodrel
1.1
Norethindrone acetate
2.0
Ethynodiol diacetate
15.0
Norgestrel
30.0
Levonorgestrel
60.0
134
2. Progestin-only options
• For lactating women, women with cardiovascular or liver disease, women over age 35 who
smoke, or women at increased risk of thromboembolism, or developed complication of
combined pill, hormonal contraception without estrogen may be the most appropriate choice.
• There are three: progestin only products:
• Progestin only mini-pill
0ne year pregnancy rate in the average user: 2.5%
Women using the mini-pill must take their pills at the same time every day for as long
as they remain on this method. This may result in irregular bleeding or amenorrhea.
•
Hormonal subdermal implants
0ne year pregnancy rate in the average user: 2.5%
Usually inserted into the arm and remain effective for up to 5 years.
Irregular bleeding is the most common reason women cite for discontinuation within
the first 2 years. Fertility may return as early as 3 days after removal of the implants
•
Depomedroxyprogesterone acetate injections
0ne year pregnancy rate in the average user: 0.25%
This involves injecting depomedroxyprogesterone acetate every 12 weeks. Irregular
bleeding is very common. Amenorrhea occurs within 6 months to one year in 50% of
the users. An average weight gain of 16 pounds over 5 years may occur. The
androgenic effects of DMPA injections are to be discussed with the patient. Fertility
may return within 2 weeks but may require 12 to 22 months after the last injection.
Long term use (>5 years) may have a negative effect on bone mineral density
particularly among adolescents and young women who did not achieve their peak
bone mass.
3. Barrier methods
•
Barriers are advised in individuals with multiple partners, short term users, postpartum,
lactating, coming off pill, perimenopausal, IV drug user or homosexual,.
•
Use any of the listed barriers either alone or in conjunction with other methods of
contraception as appropriate to provide high degree of protection against pregnancy:
•
Diaphragm or Cervical cap
0ne year pregnancy rate in the average user: 13-18%
when available, inserted up to 6 hours prior to intercourse and must remain in place
for 6 hours after the last intercourse. Should not remain in place for more than 24
hours for risk of toxic shock syndrome.
•
Condom
0ne year pregnancy rate in the average user:10%
both male and female condoms offer some protection from STDs although this
protection is not fool proof.
•
Vaginal spermicide
0ne year pregnancy rate in the average user: 18%
•
Sponge when available
0ne year pregnancy rate in the average user: 10-20%
4. Intrauterine device
•
0ne year pregnancy rate in the average user: 5%
•
There are two types IUD available: the copper and the progesterone containing
IUDs
•
Both are T shaped with a mono-filament tail.
•
The progesterone IUD is better suited for women who have dysmenorrhea, heavy
periods or significant premenstrual syndrome, but often causes breakthrough bleeding
and must be removed and replaced on an annual basis.
•
The copper IUD has a life span of 10 years It is the most cost effective method
available.
135
•
The ideal candidate is a parous woman who is in a stable mutually monogamous
relationship, and therefore is at minimal risk for STDs or PID. This includes women who
have completed their childbearing, cannot or prefer not to use hormonal contraception and
want reversible contraception.
•
The IUD is inserted into the patient uterus during menses when slight cervical
dilatation makes insertion easier. Few women have several days of bleeding, cramping or
backache after insertion. Time and prostaglandin inhibiting drugs lessen these symptoms.
During the first few months, spotting between periods can occur and the period itself
becomes heavier. The position of the IUD is checked at 1 month follow up visit; major side
effects would have subsided then.
•
IUD is NOT to be advised to women with
• Confirmed or suspected pregnancy
• Women who have enlarged uterus or physical uterine abnormalities
• Acute episode or history of PID
• Postpartum endometritis or infected abortion within past 3 months
• Confirmed or suspected uterine or cervical malignancy
• Undiagnosed genital bleeding
• Untreated acute cervicitis or vaginitis
• Patient or partner has multiple sex partners
• Diagnosed Wilson’s disease or known allergy to copper
• Increased susceptibility to infections
5. Natural family planning
• 0ne year pregnancy rate in the average user: 24%
• Requires a significant amount of motivation , and knowledge of when the woman is most
fertile.
6. Sterilization
• 0ne year pregnancy rate in the average user: 0.4%
• Refer to gynecologist
Patient Education
1.
2.
3.
4.
5.
6.
Explain mechanism of action of method used
Explain effectiveness
Explain side effects and danger signs
Instructions on use of chosen method
Explain alternative method
Advise about safe sex
Sources
1.
2.
3.
4.
Health net Community health centers and Methodist Hospital of Indiana Guidelines
Contraceptive Choices: Helping Your Patients Decide; AAFP CME program; September
1999
Contraception, Essentials of Family Medicine, Second Edition.1993. Sloane P, Slatt L.,
Curtis P., chapter 24
Family Planning Williams Obstetrics 19th edition. Cunningham, Macdonald, Gant, Leveno,
Gilstrap. Chapters 60,61.
136
Dysmenorrhea & Premenstrual Syndrome
Definition and Epidemiology
Dysmenorrhea refers to painful menstruation.
• Primary dysmenorrhea is painful menstruation without detectable pelvic disease. It
usually occurs within a year or 2 of the menarche.
• Secondary dysmenorrhea has a pathologic cause such as endometriosis, adenomyosis,
fibroids or pelvic inflammatory disease (PID), usually occurs 2 years after onset of
menarche and is characterized by new onset of pain or worsening of usual pain.
• Dysmenorrhea can affect up to 50% of menstruating women and is caused by an
increased endometrial prostaglandin production with increased uterine tone and pain.
Discomfort and pain resolve at the end of menses.
Premenstrual syndrome (PMS) is a condition with multiple physical and non-physical complaints
interfering with normal functioning, occurring in the premenstrual period and resolving at the onset of
menses.
• PMS occurs in up to 8% of menstruating women.
• Up to 50% of women presenting to the doctor with premenstrual complaints will meet
criteria for PMS.
Signs & symptoms
Dysmenorrhea is associated with:
Abdominal cramping which begins hours prior to menstruation, is worst in the first day and may last
up to 3 days. Fatigue, nausea, vomiting, back ache and diarrhea may also be present.
PMS manifests 10 to 14 days prior to menses with a multitude of symptoms including:
1. Affective changes: Emotional lability, irritability or depression
2. Behavioral changes: Aggression, altered libido or food cravings
3. Cognitive changes: Confusion, poor concentration or forgetfulness
4. Physical symptoms: Headache, fatigue, mastalgia, bloating, fluid retention or insomnia
In both conditions, the physician needs to explore:
1. How severity interferes with daily living or function
2. Possibility of other physical (genito urinary) or psychological problems
3. Secondary gain issues at work or relationship
4. A pelvic examination and ultrasound may be necessary to rule out genital infections, masses
or leiomyomas. Pregnancy test if suspected
Management options
Dysmenorrhea
Dysmenorrhea’s first line treatment of choice are Non Steroidal Anti Inflammatory Drugs (NSAID).
They should be started BEFORE the onset of pain for maximum effect.
Examples include:
Ibuprofen (Motrin) 400mg QID for 3-4 days
Mefenamic acid 250mg QID for 2-3 days
Naproxen (Proxen) 500mg BID for 2-3 days
If inadequate response to one agent after three cycles, it should be discontinued.
137
Oral contraceptives (OCP): in patients requiring both contraception and relief of dysmenorrhea
If no improvement occurs after using OCP for 3 months, a NSAID should be added for the next 3
months.
PMS
NO universal treatment for PMS is known. Education and reassurance of the patient are crucial.
Some women improve on a 60% carbohydrate, 20% protein and 20% fat diet supplemented with
vitamin E or B6. Other women benefit from aerobic exercise and adequate sleep.
The use of Selective Serotonin Reuptake Inhibitors has become more frequent in PMS. Fluoxetine
(Prozac) at 20 mg daily has been studied most but most SSRI are probably equally effective.
When to Refer
1. Refer dysmenorrhea to gynecologist
a. if endometriosis is suspected
b. If failure to respond to NSAID for 6 cycles or OCP
c. If the combination of NSAID and OCP provides no relief after 6 months, laparoscopy
should be performed.
2. Refer PMS
a. For counseling if indicated
b. To see gynecologist if no improvement after lifestyle changes or 2 months trial of
SSRI.
Patient Education
1. Explain pathogenesis of symptoms
2. Explain prognosis
3. Instruction on life style changes: diet, exercise, stop smoking and vitamins.
Sources
1. Mengel M. Ambulatory Medicine. Appleton & Lange 1995
2. Baker et al., Principles of Ambulatory Medicine. Williams & Wilkins 1996
3. Novak's et al. Gynecology. Mass publication 1996
138
Menopause, hormone replacement & osteoporosis
Definition
Menopause is the cessation of menses for 12 continuous months due to permanent loss of ovarian
responses to gonadotropins. The average range is 40-55 years with the median around 51 years.
Osteoporosis is a progressive disease with decrease in the density of normal bone. WHO defines it as
a bone mineral density 2.5 standard deviations below the mean for normal healthy adults aged 30-40
years. Osteopenia is when BMD falls between 1 and 2.5 standard deviations.
Hormonal replacement therapy
Several changes are observed after menopause: accelerated bone loss, reduction in HDL cholesterol
and increase in total cholesterol, cardiovascular disease, hot flashes, atrophic vaginitis, and decrease
in libido and mood changes. Many of these changes can be reduced or eliminated with hormonal
replacement therapy (HRT).
The goal of HRT is not to normalize the follicle stimulating hormone value but to use the minimum
effective dose to suppress vasomotor reactions, to treat urogenital atrophy, to prevent trabecular and
cortical bone loss, to provide cardiac risk factor reduction, possibly improve mood , energy and
memory and possibly reduce risk of colon cancer.
Risks associated with HRT include growth acceleration of an already preformed breast cancer,
increase of endometrial cancer (if estrogen is unopposed), premenstrual syndrome (when used
cyclically), increased incidence of gallbladder disease.
Recommendation: in the absence of contraindications, all women should be advised to use HRT, more
strongly for women at high risk (white, thin, oriental, smokers; women at increased risk of coronary
disease or had an early or surgical menopause).The therapy should be started close to menopause and
continued indefinitely
History
•
•
Menopause begins with skipped periods, increased or decreased interval, variation in frequency or
amount of menses.
Symptoms include vasomotor changes (hot flashers, sweating), insomnia, mood changes and
urogenital symptoms. History should assess untoward symptoms of menopause and the benefits
and risk of HRT. It therefore, should include:
1.
Recent menstrual history- unexplained vaginal bleeding is a contraindication – may do
endometrial biopsy first
2.
Smoking history
3.
Calcium intake
4.
Alcohol intake
5.
Hysterectomy and /or oophorectomy
6.
History of breast cancer: contraindication to HRT regardless of receptor status of tumor.
A strong family history of breast cancer is a controversial contraindication
7.
History of uterine cancer; usually with hysterectomy, concern for worsening metastatic
disease
8.
History of liver disease, gallstones – may worsen
9.
History of thromboembolic disease / coagulopathy/ pulmonary embolism- HRT contraindicated. A
remote history of deep venous thrombosis is not a contraindication to HRT.
10.
History of migraine- may worsen
139
Work up
Pap smear- annually as long as on HRT
Mammogram- annually
Objective Findings
Physical exam:
1.
BP: HRT is associated with a lowering of the mean diastolic blood pressure.
Occasionally, a woman may increase may increase her BP in response to HRT
2.
Breast exam: any palpable mass should be evaluated first
3.
Pelvic exam: uterine leiomyomatas are not absolute contraindication to HRT
Work up
1.
2.
3.
4.
5.
6.
7.
8.
Urine pregnancy test
Serum FSH- may be needed to confirm diagnosis
Lipid profile (HRT may worsen hypertriglyceridemia),
Liver function tests
Pap smear as long as woman is on HRT
Mammogram - annually
Endometrial biopsy – when abnormal vaginal bleeding is present
Lipid profile- annually : LDL-C is decreased by 7-10%, triglycerides are increased by 67%, HDL-C is increased by 4%
Diagnostic Considerations
1. Confirmation of menopause
a. If patient has 3 months of amenorrhea
i. Obtain FSH level
1. If above 35 mIU/mL – menopause
2. If less than 35 mIU/mL – not menopause, consider endometrial sampling
(with curette by gynecologist or pipelle) to exclude malignancy. If clean,
cycle with Provera 10 mg daily for 7 days per month.
ii. Withdrawal bleeding: Give Provera 10 mg daily for 7 days
1. If NO bleeding – repeat test in 3 months – if same – menopause
2. If there is bleeding – NOT menopaused.
b. If patient has symptoms and is not amenorrheic and FSH is above 20 mIU/mL – she
is in transitional phase & menopause is expected within few years.
c. If patient is on oral contraceptives, measure FSH on 6th day of pill free interval and if
FSH more than 30 mIU/mL - consider switch to HRT
d. If patient is showing irregular heavy menses for 3-4 months – refer for dilatation &
curettage
2. When to do a bone mineral density (BMD) measurement
a. Menopaused or peri-menopaused woman with hip, vertebral or other fracture by Xray or clinically
b. Menopauses woman reluctant about HRT
c. Women with high risk for osteoporosis (low trauma fracture after 45 years, maternal
history of hip fracture, above 65 years, thin body build, early menopause, prolonged
amenorrhea, chronic steroid use, thyroid and parathyroid disease, prolonged
immobilization).
d. Woman with concern about osteoporosis
140
Therapeutic choices
Available HRT preparations
d.
Estrogens- given either in oral tablet form or transdermal patches.
a.
Conjugated estrogens 0.625 mg/d
b.
Ethinyl estradiol 0.02 mg/d
c.
Micronized estradiol 1mg /d
Transdermal patches of 0.05/0.1 mg /patch to be used twice weekly
Progesterone- any of the following,
a.
medroxyprogesterone 5 mg
b.
norethindrone 0.25-1.25 mg
Regimen
When estrogen + progesterone are to be given , any of the following is equally effective ; but if the
uterus is absent, estrogen is given alone
Regimen
Estrogen
Progesterone
Cyclic/sequential
1-25d
13-25d/mo
Continuous/sequential
qd
1-14d/mo
Continuous/combined
qd
qd
Cyclic/combined
1-25d
1-25d/mo
Continuous repetitive
qd
3d on/3d off
Combined pills are available in the market, they are more costy but equally effective
If ERT is contraindicated may use any of these for the hot flashes
a.
b.
c.
medroxyprogesterone 10 - 20 mg/d
norethindrone 0.25-1.35 mg
clonidine 0.1 mg bid
Osteoporosis prevention / treatment
Elemental Calcium – 800 to 1500 mg/d (equivalent to 1 liter of milk a day) with Vitamin D
400-800 IU daily
Alendronate (Fosamax) has been shown to stabilize bone, increase its density and decrease fracture
risk when given for 3 consecutive years.
Given as 10 mg daily to women who show osteoporosis on BMD or as preventive dose of 5
mg daily; both with calcium and vitamin D supplements
Calcitonin (Miacalcic) is considered second line after alendronate in the treatment of BMD
confirmed osteoporosis. Given intranasally as 200 u daily or as intra muscular injection.
Estrogen replacement decreases risk of fracture if continued for 5 years at least.
Patient Education
1.
2.
3.
4.
5.
Explain pathogenesis of menopausal symptoms
Explain prognosis
Explain side effects: bloating, weight gain (controversial), irritability and depression may
occur. Symptoms are usually mild in most women and do not require discontinuation of
therapy. They may improve with dose reduction
Explain risks versus benefits of estrogen therapy
Explain that periods may occur with estrogen therapy when taken cyclically
141
6.
Advise to report any abnormal vaginal bleeding: unpredictable endometrial bleeding occurs in
30 to 50 % of women on combination therapy during the first 6 to 8 months. Subsequently,
bleeding is generally light and stops in most women when uterine atrophy occurs
Sources
123456-
Lobo, Rogerio. Treatment of Postmenopausal Woman: Basic and Clinical Aspects. Raven
Press 1994
Estrogen Replacement: the evolving Role of Alternative Delivery Systems. XIV FIGO World
Congress, Canada . Suppl. to Am J Obstet Gyneco 1995; 173
Patient Specific Decisions about Hormone Replacement Therapy in Postmenopausal Women.
JAMA. 1997;277:1140-1147
Menopause. Primary Care. 1997;24:1 205-221
Post Menopausal Hormone Prophylaxis –US Preventive Health Task Force –Guide to
Clinical Preventive Services, ed 2. Baltimore, Williams and Williams, 1996, 829
Counseling Postmenopausal Women About Preventive Hormone Therapy. American
Geriatric Society Clinical Practice Guidelines- JAGS, 1996 44: 1120-22
142
Prenatal care
Schedule of prenatal care
Prenatal care has played an important role in the reduction of maternal and infant mortality. It
includes continuous risk assessment, education, counseling, and intervention when problems are
identified.
A first prenatal visit should occur at 6-8 weeks gestation. For healthy women, the recommended
schedule for prenatal follow up is monthly visit until 32 weeks then biweekly at 32 and 34 weeks, and
weekly through delivery.
Initial visit
•
•
Establish pregnancy (if visit is within the first trimester) with a pregnancy test (the commercial
tests sold in pharmacies are highly sensitive, specific and inexpensive)
Estimate the date of confinement: 40 weeks from last period (LMP)
o Use the commonly available tables or wheel or
o Add 7 days to the LMP and count back 3 months
o Quickening, occurring at 16-18 weeks in multigravida and at 19-20 weeks in
primigravida, is commonly used in dating but vary by +or-2 weeks.
o A pelvic bimanual exam can help determine the gestational age: at 7 weeks the uterus is
the size of a hen’s egg, at 10 weeks of an orange and at 12 weeks a grapefruit. Uterine
fundal height at the umbilicus is for 20 weeks gestation.
o Ultrasound for dating is commonly used when a woman can’t recall her last menstrual
cycle, has irregular periods, has recently used oral contraceptives or there is size date
discrepancy. Ultrasound in the first trimester can establish gestation within a +or- 4 days
of accuracy; alternatively, a single ultrasound at 18 weeks can confirm dating within +or1.5 weeks in addition to scanning for anomalies.
o Fetal heart rate is usually heard by Doppler ultrasound at 10-12 weeks gestation and by
fetoscope at 18-20 weeks.
History
•
•
•
•
•
•
•
Age: if more than 35 years, advise amniocentesis
Medical history: hypertension, diabetes, pyelonephritis, asthma, others.. recent exposure to
infectious diseases as rubella or toxoplasma.
Essential but potentially teratogenic medications are to be changed to lowest risk category.
Reproductive history: previous pregnancy complications, previous method of delivery, newborn
weight ... History of premature labor, premature delivery, second trimester loss (suggestive of
cervical incompetence), gestational diabetes, hypertensive disorder, postpartum hemorrhage
makes the pregnancy high risk and a referral is to be considered. Short inter pregnancy interval
place the pregnancy at nutritional risk.
Behavior history: substance abuse, promiscuity in the mother or partner increase the chance of
HIV and premature labor and may need referral, smoking and alcohol intake have adverse effects
and discontinuation is to be advised
Social history: marital status, education, employment (strenuous activity, excessive hours, toxic or
radiation exposure are associated with less favorable outcome), support system (family and
partner)…
Family history: diabetes, congenital malformations, mental retardation, hemoglobinopathies,
multiple births in relatives
143
Physical exam
The first prenatal visit should include a thorough physical examination with special attention directed
toward the size of the uterus, the configuration of the bony pelvis (clinical pelvimetry) and the
patient’s baseline blood pressure, height and weight.
Lab testing
•
•
•
•
•
•
•
Blood type: to assess the risk of developing D(Rh) or ABO incompatibility. Most authorities
obtain indirect Coomb’s test (Antibodies to other blood group antigens)..
o Rh negative women should be questioned regarding the use of anti D in prior pregnancies,
including spontaneous or therapeutic abortions, breech version, or other possible
occurrence of fetal -maternal hemorrhage. Unless the father of the pregnancy is known to
be D-negative, anti D is given at the time of the amniocentesis, at 28 weeks, and within
72 hours of birth for all D negative mothers who tested negative on indirect coombs test.
Hemoglobin or hematocrit: to screen for anemia. Hemoglobin less than 10 g/dl (hematocrit<30) is
associated with poor outcome (prematurity, low birth weight and fetal demise).
Serology screen: rubella antibody IgG and hepatitis B surface antigen testing are indicated. Non
immune women should receive the vaccine postpartum. HIV and VDRL are encouraged
particularly for women with behaviors that place them at a higher risk for infection.
Urinalysis for protein and glucose
Urine culture recommended between 12 and 16 weeks gestation to screen for asymptomatic
bacteriuria (higher risk of maternal pyelonephritis, preterm delivery and low birth weight).
Pap smear if she did not have in the past year.
Gestational diabetes screen when the mother has any of the following: previous gestational
diabetes, prior history of stillborn infant, one with congenital anomalies or one weighing more
than 4000gms, history of neonatal death associated with traumatic delivery, family history of
diabetes mellitus, repetitive pregnancy loss, history of recurrent prematurity, toxemia, hydramnios
maternal age more than 35 years
Plan:
Medication:
1. Folic acid 0.4-0.8 mg per day has been shown to reduce the risk of neural tube defects.
2. Iron supplementation is not necessary in the first 4 months of pregnancy because the
requirements are slight. Starting the second trimester, 30 mg of iron supplied in the form of a
simple iron salt such as ferrous fumarate , sulfate or gluconate taken regularly once a day
provided for the iron requirement of pregnancy. The supplementation should continue
throughout lactation. If the pregnant woman is large, has twin pregnancy, takes iron
irregularly or has a depressed hemoglobin, she may benefit from 60 to 100 mg of iron.
3. Calcium supplementation: 1200 mg of calcium are needed each day to meet the requirements
of the developing fetal skeleton. Three or 4 servings of milk can meet this additional
need…several calcium preparations are also available in the market.
4. Vitamin B12 : 2 micrograms are needed for complete vegetarians.
Patient education:
Instruct the patient about diet, relaxation and sleep, bowel habits, exercise, bathing, clothing,
recreation, sexual intercourse, smoking, drug and alcohol ingestion, and follow up visits. Also instruct
the woman to report immediately about any the following warning signals: vaginal bleeding, swelling
of the face and fingers, severe or continuous headache, dimness or blurring of vision, abdominal pain,
persistent vomiting, chills or fever, dysuria, escape of fluid from the vagina, marked change in
intensity or frequency of fetal movements.
144
Follow up visits:
History
History taking should focus on continuous risk assessment. Symptoms of pregnancy or medical
complications, including nausea, headache, altered vision, bleeding, discharge, contractions, and
dysuria should be elicited on each visit. Fetal movement and preterm labor are important part of the
history taking as the pregnancy progresses
Physical exam
Maternal
• Weight: the average weight gain is 0.7 lb/wk from 8 to 20 weeks and about 1 lb/week from 20
to delivery.
• Blood pressure: actual and extent of change
• Peripheral edema.
• Cervical examinations are not necessary or useful until induction is being considered or there
is a question about fetal position or preterm labor.
Fetal
• Fetal cardiac activity
• Presenting part
• Fetal size: determine the fundal height by measuring the length in centimeters from the pubis
to the top of the fundus: between 20 and 31 weeks, the fundal height in centimeters equaled
the gestational age in weeks
Lab testing
•
•
•
•
Urine dipstick for protein and glucose in all visits
Hemoglobin or hematocrit repeated at 24 to 28 weeks
Diabetes screening at 24 to 28 weeks (1 hr 50 gm glucose tolerance test). If level is above 140
mg/dl, 3 hour 100 gm glucose test is performed.
Indirect coombs testing and anti D is administered at this visit if indicated.
Health promotion activity
The health care provider should educate the woman and her family about the physiologic changes,
sexuality, and common problems as well as comfort measures for discomforts. In the third trimester,
more information on fetal development, family adjustments, childbirth and parenting classes is
appropriate. During the last month or two, information regarding labor and birth should be covered.
•
•
•
Nutrition: emphasize food rather than supplements. Encourage women to eat generous
amounts of fruits and vegetables, whole grain bread and cereal, calcium rich dairy products, and
moderate amounts of protein rich foods such as legumes, fish, poultry, lean meat. Avoid alcoholic
beverages.
Nausea and vomiting : common complaints in the first half of pregnancy. Starts between the
first and second missed menstrual period and continue until about the time of the fourth missed
period. Eating small feedings at more frequent intervals but stopping short of satiation is of value.
Heartburn: symptoms are relieved by frequent small meals, avoidance of bending over and
lying flat. Antacid preparations may provide considerable relief. Aluminum or magnesium
hydroxides are preferred to sodium bicarbonate.
145
•
•
Exercise: it is not necessary for the pregnant woman to limit exercise, provided she does not
get fatigued excessively or injure herself. The recommendation is that women accustomed to
aerobic exercise should be allowed to continue this during pregnancy. Caution against starting
new aerobic exercise programs or intensifying training efforts. With some pregnancy
complication like pregnancy induced hypertension, intrauterine growth retardation, multiple
pregnancies, the woman and her fetus may benefit from sedentary existence
Coitus: whenever abortion or preterm labor threatens, coitus should be avoided.
Sources
1. Content of Prenatal Care. Handbook of pregnancy and perinatal care in Family Practice: science
and practice. 1996 Ratcliffe, Byrd , Sakornburt
2. Prenatal Care, Helton. Primary Care March 1997
3. Prenatal Care, Wiliams Obstetrics. 19th edition
4. Nutrition During Pregnancy and Lactation, Primary Care September 1993
5. Obstetric Risk Assessment, Primary Care September 1993
146
Approach to a patient with vaginal discharge
Definition
The normal vaginal discharge consists of desquamated vaginal epithelial cells, lactic acid, and
secretions from cervical cells. There is an individual variation in the amount and character of the
normal discharge. A discharge notable for its amount, odor or color is abnormal.
The initial evaluation of vaginal discharge is based on distinguishing “normal” from “abnormal
discharge”. Abnormal discharge may result from infection (bacteria, yeast or parasite), atrophy
secondary to estrogen deficiency, foreign bodies, trauma, recent surgery, alteration of vaginal flora
secondary to antibiotic use, chemical irritants, and rarely neoplasms. It is associated with skin lesions,
itching, bad odor, change in the color or consistency and dyspareunia
History
•
•
•
•
•
•
•
Information is collected to distinguish normal from abnormal discharge and point to a specific
organism.
History of previous episodes: was diagnosis confirmed or an empirical treatment given?
Sexual history: if the patient is sexually active inquire about new spermicidal agents,
condoms, symptoms in the partner (s).
Dysuria accompanies infection in approximately one fifth of the cases. Usually the pain is felt
externally with urination. Additional urinary symptoms with vaginal discharge favor
Trichomonas or Chlamydia
Recent use of antibiotic, oral contraceptives, corticosteroids, douching or spermicides may
favor candidal infection.
Systemic conditions: poorly controlled diabetes, menopause, AIDS
Gardnerella infections (bacterial vaginosis) cause slight change in normal discharge and little
itching but the odor is more pronounced after intercourse
Objective Findings
•
•
•
•
Check urethra, labia and vulva for ulcerations, warts, tears, cysts, lesions and edema.
Inspect vagina for color, lesions and edema. Normal vaginal mucosa is pink with moist folds.
o A fiery red weepy mucosa with a clear exudate is a sign of inflammation ( douching,
spermicides, condoms).
o Cheesy white exudates with plaques adherent to the vaginal wall speaks for yeast
infection.
o A yellow green and bubbly discharge with “strawberry” vagina (red with petechiae)
favor trichomonal infection.
o A normal looking mucosa with a thin gray discharge is associated with bacterial
infection.
o A pale thin mucosa in postmenopausal women is consistent with atrophic vaginitis.
Observe the cervical os: Using a large cotton swab, clean all discharge and observe for 10
seconds, if a purulent discharge appears at the os it is an indicator of upper pelvic infection.
Check for polyps, erosion or eversion of the cervix.
Perform a bimanual exam to assess adnexal tenderness or masses.
147
Diagnostic tests
•
Smear:
o Prepare 2 wet mounts using 10% KOH and normal saline and view them under the
microscope using low (10X) and high (40X) power. Fluid should be examined as
soon as possible after it is obtained as Trichomonas is fragile and may die quickly.
o After inserting the vaginal speculum, a plain cotton tipped applicator is swept into the
vaginal fluid, withdrawn with a clump of discharge and placed into a small container
with 1 ml of saline.
o Take the cotton applicator from the tube and place a drop of fluid on two slides, one
for saline and one for KOH preparation.
o A drop of 10% KOH is placed on one slide. Smell it immediately for a fishy odor
then place a cover slip and allow the slide to sit for few minutes before looking for
hyphae.
Under low power, find a clumped area, go to high power and focus on the
edges of the clump where you may find hyphae.
The sensitivity of the KOH smear is 40%
o Examine the saline slide with a cover slip under low power. Search for motion of
cells, sheets of epithelial cells or clue cells (epithelial cells studded with bacteria).
These can be present normally in up to 10% of the field; however, a preponderance of
them especially when combined with a fishy odor on the KOH smear supports the
diagnosis of bacterial vaginosis. Then shift to the high power and check for T.
vaginalis ( motile triangular cells with long moving tails).
o The sensitivity of the saline smear is 25%.
•
Other lab studies:
• The discharge should be cultured for Gonococci and Chlamydia (if the media are
available) . Otherwise the yield from the culture is low.
• CBC and ESR are indicated if PID is suspected.
• A clean urine for analysis is obtained when there is a concurrent dysuria.
• Pap smear is indicated but may be deferred until vaginitis has been treated since it
may be abnormal in the presence of inflammation.
• If the workup reveals no reason for the patient’s symptoms, consider an overgrowth
of the acidophilic Doderlein lactobacilli especially if the symptoms are cyclic in
nature ( in the luteal phase of the cycle) and worse after douching with the
conventional acidic environment.. The smear may show the presence of cells with
moth-eaten appearance (pseudoclue cells) with few WBCs .
Management options
•
•
•
•
•
Resist the urge to perform shotgun or even empiric treatment
Encourage patient to finish course of therapy despite symptom resolution.
Choose the shortest regimen possible and make sure the patient understands the side effects,
route of usage, and use of medication during menses.
Negotiate with the patient the best time to begin treatment and inform her of the possibility of
recurrence or treatment failure.
Clarity about sexual transmission is important and advise use condoms or abstain from
intercourse during treatment.
Therapeutic choices
•
Trichomonas- treat partner(s) at the same time
o Metronidazole 2 gm single dose or 500 mg bid for 7 days
o If recurred, retreat with metronidazole 2 gms in a single dose daily for 3-5 days.
148
•
•
•
•
Bacterial vaginosis
o Metronidazole 500 mg bid for 7 days or Clindamycin 300 mg qid for 7 days.
Candidiasis
o Candida albicans is the cause of yeast infections in >90% of cases, occasionally
Torulopsis glabrata can cause resistant yeast infection
o Use topical antifungal treatment (ovules with cream if vulvitis is present) in pregnants
or for the first attack of vaginal candidosis. Nystatin is a well established treatment ,
two ovules intravaginally for 14 nights. Other preparations are available for shorter
duration.
o Use oral antifungal in women who do not accept inserting cream applicators or
vaginal suppositories or have multiple attacks. Itraconazole 200 mg twice daily or
fluconazole 150 mg single dose can be used.
Atrophic vaginitis
o Conjugated estrogen cream 2-4 gm intravaginally at bedtime 21 days a month
In case of recurrence or persistence of symptoms
o Start over with the history , emphasizing compliance to previous therapy and focusing
attention on details of diet, clothing and irritants.
o Question the patient about use of new tampons, pads, or other agents.
o Explore the relation to tight clothing, exercise gear
o On some occasions, the only cause of leukorrhea is an eroded cervix secondary to the
use of oral contraceptive pill.
Sources
1. USDHS. 1998 guidelines for the treatment of sexually transmitted diseases. Morbidity &
Mortality Weekly Report. Jan 23, 1997;47(RR-1):1-116
2. Vaginal discharge : Decision Making in Medicine -Greene 1997
3. Approach to the patient with abnormal vaginal discharge: Primary care 1996
4. Vaginitis: Novak ‘s Gynecology- 1996
5. Nonmalignant vulvovaginal and cervical disorders: Principles of ambulatory medicine, 1999
6. Bacterial vaginosis: An update article Am Fam Phys Mar 15 98
149
Children health
150
Bronchiolitis
Definition and Epidemiology
An inflammatory process involving the bronchi and bronchioles. It is the most common form of lower
respiratory tract infection characterized by rhinorrhea, moist cough, dyspnea and wheezing. The
illness is caused mainly by respiratory syncytial virus (RSV), occurs mainly in winter and affects
children under the age of 2 years with a peak incidence at 6 months.
History & Objective Findings
1.
2.
3.
4.
5.
6.
7.
Sore throat, cough and coryza
Difficulty Feeding
No previous episodes of wheezing
Temperature less than 39
Expiratory wheezing and inspiratory rales, hyper resonance of chest upon percussion
Apnea can be the initial presenting symptom, it occurs in approximately 20 to 25%
Otitis media may be present
Diagnostic Considerations
Diagnosis is made when all the following are met:
1. First episode of acute wheezing in a child less than 24 months
2. Symptoms are associated with viral infection (cough, fever, coryza)
3. Pneumonia is ruled out
Possibility of foreign body aspiration, congestive heart failure should be considered.
Degree of severity is defined as follows: (RR = respiratory rate)
Mild:
Moderate:
Moderately severe:
Severe:
RR < 50, no or mild retractions
RR 50-60, subcostal and intercostal retractions
RR 60-70, sternal and supraclavicular retractions
RR > 70, poor air entry
Criteria for Hospitalization
• O2 saturation <93% on room air
• Any significant underlying illness
• Any history of previous need for intubation with wheezing
• Age <3 months
• Retractions or Tachypnea
• Toxic appearance, dehydration or tachycardia out of proportion of fever
• Recent history of apnea or cyanosis
• Social situation that makes follow-up or adequate home care unlikely
• Decreased fluid intake
151
Management options
Mild Attack:
1. Observe at home with small frequent feedings and monitor fluid intake
2. Good hydration
3. No smoking around child: (maternal smoking increases in frequency 36-60%)
4. Avoid kerosene heaters or wood stove heaters which can pollute the air.
5. Recheck by doctor in 48 hours
6. Symptomatic relief:
7. Antipyretic: acetaminophen
8. Bronchodilator: Albuterol 0.1 mg/kg/dose tid or other beta2 agonists.
Moderate attack
1. Epinephrine 1:1000 0.01 cc/kg or terbutaline 0.01 cc/kg subcutaneous and/or,
2. Albuterol 0.01-0.03cc/kg in 3 cc normal saline by aerosol (may be repeated q 1-2 hours)
3. If adequate response to injection or aerosol, start oral or aerosol beta-2 agonist .
4. If inadequate response to injection or aerosol, refer for hospitalization.
Moderately severe, severe or high-risk factors - hospitalize
Not to be missed
Foreign body aspiration
Pneumonia
When to Refer
Severe attack or doubt about management
Patient Education
•
•
•
•
Explain pathogenesis & bronchiolitis and course
Recurrent episodes may indicate asthma
Avoid smoking around the child .
Avoid exposure to other children: incubation period 4-6 days
Management and treatment tips
•
•
1 child in 50 will require hospitalization due to RSV bronchiolitis, of these, 3-7% develop
respiratory failure and 1% die.
Antibiotics should be withheld unless a bacterial etiology is suspected.
Sources
1. Wohl J. Bronchiolitis- Ped Annals 1986; 15:4.
2. Adcock PM, Sanders CI, Marshall GS. Standardizing the care of Bronchitis. Arch Pediatr Adolesc
Med. 1998; 152: 739-744
3. Levy BC, Graber MA. Respiratory syncytial virus infection in infants and young children J Fam
Prat 1997; 45: 473-481.
4. Horst PS. Bronchiolitis. Am Fam Phys 1994;49:1449
152
Croup
Definition and Epidemiology
Croup (also known as laryngotracheobronchitis) is an inflammatory condition of the upper airways
characterized by a barky cough, inspiratory stridor, hoarseness and signs of respiratory distress. It
includes viral laryngotracheitis, spasmodic croup and bacterial tracheitis, and affects children 6
months to 6 years (peak 1-2 years). Most frequently in autumn-early winter. Parainfluenza virus type
is the most common cause of croup.
History
A gradual onset of symptoms preceded by a prodrome of upper respiratory tract infection for 6 to 7
days and mild fever. Symptoms include: stridor, barking cough, hoarseness, low grade fever.
Objective Findings
1. Skin color (look for cyanosis)
2. Assess respiratory status and check for: Respiratory rate, presence of retractions, inspiratory
stridor
3. Lung exam-decreased air entry, presence of wheeze
4. Pharyngeal exam
5. Mental Status
Diagnostic Considerations
Diagnosis of croup is usually clinical. Severe presentations require evaluation to rule out:
1. Epiglottitis,
• Croup is ~10 times more common
• Much less pain upon swallowing ( odynophagia) with croup
• Younger patients typically have croup
• Patients with croup are usually less toxic appearing than those with epiglottitis
• Drooling is a serious sign and suggests epiglottitis
2. Bacterial tracheitis
3. Retropharyngeal abscess
4. Anatomical airway obstruction.
5. Foreign body obstruction of upper airway way.
This is usually facilitated by:
PA and lateral neck x-rays (whenever unsure of diagnosis) to rule out epiglottis
White blood cell count, usually less than 10,000 per mm3 with lymphocytic predominance
153
Severity of the attack is scored based on symptoms and signs:
Croup score: (A score of > 4 indicates moderate attack)
Sign
Condition
Score
Conscioussness
Normal
0
Disoriented
5
Cyanosis
None
0
With agitation
4
At rest
5
Stidor
None
0
With agitation
1
At rest
2
Air entry
Normal
0
Decreased
1
Marked
2
Retractions
None
0
Mild
1
Moderate
2
Severe
3
Management options
a. Mild attack (see algorithm)
- Humidified mist
b. Moderate to severe
•
Nasal oxygen
•
Minimal disturbance and position of comfort
•
Aerosolized epinephrine every 1-2 hours (1/1000 –0.5 ml/kg, max. 5 ml) or racemic
epinephrine aerosol every 1-2 hours (2.25 % -0.05 ml/kg, max. 1.5 ml) PLUS
•
Dexamethasone (Decadron) 0.6 –1.0 mg/kg IM, IV or Oral
•
Keep patient 2 hours under observation after aerosolized epinephrine for fear of rebound
effect.
•
Discharge home if sure of improvement and reliable home, otherwise hospitalize.
c. Severe / Hospitalize
• Degree of stridor
• Severity of retractions
• Evidence of cyanosis
• Toxicity
• Adequacy of follow-up
When to Refer
•
•
Severe attack
Unsure of diagnosis
Patient Education
•
•
•
•
Explain Pathogenesis of symptoms and prognosis
Instructions on using vaporizers
Advise that child should be minimally disturbed
Instruct about follow-up if symptoms worsen
154
Algorithm
Mild
Suspected Croup
Toxic appearance
Tachypnea
Retractions
Significant stridor
at rest
Dehydration
Oxygen
saturation less
than 95%
No
Humidification
Aerosolized Epinephrine
&
Dexamethasone (0.6 mg/
kg) IM or PO single dose
No
Positive
response
Yes
Yes
Home
Severe
Yes
Positive
response
Yes
Reliable
HOME
Negative response
& unreliable home
Yes
No
Admit to hospital
Sources
1. Gagliano N. et al. Coping with croup. Patient care 1988
2. Mauro R, and Pool s. Is it croup? A guide to diagnosis and treatment. Contemporary Pediatrics;
October 1988
3. Bank D, Krug S. New Approaches to Upper Airway Disease. Emerg Med Clin NA 1995; 13 :
473-490.
155
Diarrhea in children
Definition
It is usually defined as the passage of loose or watery stools three times or more during a
day. Stools are usually foul smelling and are passed quickly.
It can be acute, starting suddenly and lasting for few days. It can also be chronic.
History
Presence of fever, duration.
Frequency of stools.
Consistency of stools, smell, colors.
Presence of blood.
Presence of pus.
Presence of mucous.
Urgency.
Cramps, abdominal pain.
Vomiting.
Cough.
Food ingested prior to episodes.
Diet: bottle vs. breast.
Hygiene measures.
Urine and voiding frequency.
Objective Findings
Fontanelles in infants.
Skin turgor
Mucous membranes.
Tears.
Mental status.
Vital signs: temperature. Heart rate, BP.
ENT exam.
Respiration
Weight.
Stood microscopy.
Stood Wright stain.
Stood culture.
BUN, creatinine, electrolytes.
CBC, blood culture, urine analysis and culture if specific.
Diagnostic Considerations
Diarrhea can be caused by:
Infections: bacterial, or viruses, parasites, fungi.
Dietary causes: sorbitol, malnutrition, overfeeding.
Extraintestinal infections: otitis, UTI, sepsis pneumonia.
Toxins.
156
Pharmacologic effects.
Anatomic defects.
Absorption disorders cystic fibrosis, Celiac disease.
Metabolic defects.
Endocrine problems.
Neoplastic diseases.
Immunologic defects.
Neurologic disorders.
Management
1.
2.
Assess if acute or chronic.
Acute
A. Decide on presence /or degree of dehydration.
No dehydration
Ask
Look
Feel
Stools
< 5 x/d watery
Mild dehydration
(2 or more of signs)
< 5-10 x/d watery
Vomiting
Thirst
Urination
General
status
Eyes
Mucous
membranes
Respiration
Skin turgor
No or little
Normal
Normal
Good, conscious
Some
Normal
Little, dark
Sleepy, irritable
Normal
Normal, wet
Sunken
Dry
Dry and sunken
Normal
Normal
Fast
Skin slowlygoes
back when pinched
Fast
Sunken, depressed
Loss of 50-100 g per
Kg
Rapid and shallow
Skin goes back very
slowly when pinched
Very fast and weak
Very depressed
Loss > 100 g per Kg
Pulse
Fontanelles
Weight
Temperature
Decision
Normal
Normal
Unchanged
Plan A
Plan B
Severe dehydration
(2 or mor e of signs)
>10 x/d watery or with
blood and mucous
A lot
Cannot drink
No Urind for 6 hours
Very sleepy, lethargic
High fever 39C
Plan C
B. Select plan commensurate with degree of dehydration
a. Plan A – No dehydration
• Continue feeding especially if breast fed
• Dilute formula milk
• Give yogurt
• Focus on protein rich food (chicken soup cereals)
• Teach the mother to look for signs of dehydration
• Give ORS (ready, or homemade)
b. Plan B – Mild dehydration
• Start with ORS (give based on weight and age)
• Patient not rehydrated go to Plan C
• Patient rehydrated
o Maintenance therapy
o Resume feedings
157
•
Patient receiving medicines ?
o Consider medication associated diarrhea
o Stop medication or change it
• Possible toxin ingested ?
o Toxin induced diarrhea
o Evaluate and treat
• Evidence of food poisoning
o Supportive care
o Prevention for contacts
• No infective causes identified
o Supportive treatment
o Hydrate
o Stool culture
o Ova and parasites
o Treat as needed
• No specific cause
o Continue supportive management
C. Plan C – Severe dehydration
• Start with ORS
• Refer to hospital for IV hydration or NG hydration
• When stable – Plan B
3.
Chronic
Work up for chronic diarrhea
Patient dehydrated
Y
Treat as for acute
diarrhea
Malnourished / failing to
thrive
Y
Evaluate for
malabsorption
N
Consider overflow
incontinence
History of constipation?
Infectious cause
Fecal leukocytes, Ova
parasites, Giardia
Negative
Treat constipation
Recent history of infectious
diarrhea
Carbohydrate
malabsorption
Stool PH
Stool for reducing substances
Negative
Fat malabsorption
Fetal fat assay
Beta carotene
Negative
Cystic fibrosis
Sweat test
Negative
Prolonged infectious diarrhea
Post enteritis entreopathy
Food allergy
Consider chronic nonspecific dairrhea
Allergy skin (and other) tests
Negative
Celiac disease
Antigladin andtibodies
Negative
No specific
etiology
Sources
158
Nutritional support
159
Childhood Exanthems
Definition
An exanthem is an eruption on the skin associated with a systematic illness. Most are benign, selflimited viral diseases
History
-
Onset of rash.
Distribution and progress.
Fever, and onset of rash.
Duration of fever.
Prodrome: runny nose, cough
Appetite.
Activity.
Contact with ill persons.
Itching.
Objective Findings
-
General status.
Temperature.
Rash distribution, type.
ENT exam (mouth).
Neurologic exam.
Lung exam.
Lymph nodes.
Sources
160
Assessment and Plan:
Measles
Scarlet fever
Chicken pox
Rubella
Roseola
Temperature
Starts low grade then
peaks and on 5th day
Rash appears.
High-grade 12-48 hours
then drops slowly.
- high-grade 1-2 days
- Sometimes no fever
with the rash.
Mild fever if any.
Sudden onset high
lasting for 3-4 days.
Rash
1st day rash is discrete,
then behind ears and
spread from head to
feet over 3 days
erythematous, maculopapular, then confluent.
- cough
- conjunctivitis
- coryza
- Koplik’s spots
- photophobia
- otitis media
- pneumonia
- encephalitis
9-12 days
Rough to touch (sand
paper), noticed on groin,
axilla, antecubital, area
Circumference pallor,
flushed cheeks
lasts 4-5 days.
- Sore throat
- chills
- Peeling of skin over next
2 weeks.
Rapid progression form
Macules to papules to
vesicles to scabs
Profuse on trunk sparse
distally pruritic.
Small discrete pink
maculo-papular
coalescing on trunk
fading in 3rd day.
Faint, pink maculopapular
Rash sometimes itchy
Resolves in 48 hours.
Prodrome of rhinorrhea,
cough.
- Prodrome: malaise
conjunctivitis coryza
Lymphadenopathy.
Occurs 6 months to 3
years.
Rheumatic fever.
Pneumonia encephalitis.
Congenital rubella.
Febrile seizures.
11-21 days
14-21 days.
5/15 days.
No treatment
antipyretics bed rest
Oral penicillin or
erythromycin
- anti-histamine
- local anti pruritic
- antipyretics
Supportive treatment..
Antipyretic.
Other signs and symptoms
Complications
Incubation period
Infectivity period
Management
161
Erythema
Infectiosum
No fever.
Sudden rash bright red
cheats (slapped)
Then maculo-papular
faint pink over trunk,
extremities fades over
several days.
Fetal plastic anemia
Miscarriage arthralgia,
arthritics.
4 days- weeks.
162
Fever without a source under 3 years
Definitions
An acute febrile illness with a rectal temperature of 38.0C in which the etiology of fever is not
apparent after careful history and physical examination.
• High risk febrile infants are those who are toxic looking: Lethargic, signs of poor perfusion,
marked hypoventilation, hyperventilation or cyanosis.
• Low risk febrile infants are those who were previously healthy, have no evident focal
infection on physical exam and do not look toxic.
History
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Degree of fever, measurement of fever patterns.
Duration of fever, response to antipyretics.
Level of activity.
Appetite and feeding.
Runny nose.
Cough.
Vomiting.
Diarrhea.
Abdominal pain.
Contact with sick persons.
Previous medical history.
Current medications.
Immunization status.
Objective Findings
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
General state.
Vital signs (especially rectal temperature) HR, RR.
ENT exam.
Surgical lymph nodes.
Meningeal signs.
Heart exam.
Lung exam.
Abdominal exam.
Skin exam.
Extremities exam.
Neurological exam.
Diagnostic Considerations
Scales to identify the risks of serious illness in a child: can be used in the fever assessment.
1.The Yale observation scale
Observation Item
Quality of cry
Color
Normal
Strong cry and normal tone OR
content and not crying
Cries briefly then stops OR content
and not crying
If awake stays awake OR is
asleep and stimulated wakes up
quickly
Pink
Hydration
Skin normal, eyes normal, AND
Reaction to parent
stimulation
State variation
163
Moderate Impairment
Whimpering OR sobbing
Cries off and on
Eyes close briefly
awake OR awakes with
prolonged stimulation
Pale extremities OR
acrocyanosis
Skin normal, eyes
Sever Impairment
Weak OR moaning OR
high-pitched
Continual cry OR hardly
responds
Falls to sleep OR will not
rouse
Pale OR cyanotic OR
mottled OR ashen
Skin doughy OR tented
Response (talk, smile
(anxiety to social
overtures
mucous membranes moist
normal, AND mouth
slightly dry
Smiles OR alerts (<=2mo)
Brief smile OR alerts
briefly <=2mo)
AND dry mucous
membranes AND/OR
sunken eyes
No smile, face dull
expressionless OR no
alerting (2<mo)
2. The Rochester criteria (modified)
Goal
History
Physical examination
Laboratory
Stool WBC (if diarrhea is present)
Defines febrile infant at low risk of serious bacterial infection if
following criteria are met
Previously healthy
Term infant, normal perinatal course, no antibiotics no medical
conditions, no hospitalizations
Well appearing
No focal bacterial infections
White blood cell count (WBC) 5000-15,000
Band count (immature neutrophils)
Urinalysis:
cells/high-power field on spun urine sediment)
< 5 WBC/high-power field
3. The Young Infant Observation Scale (YIOS) was designed to assess seriousness of infection in
febrile infants aged 4-8 years.
Variable
1. Affect
Smiles or not irritable
Irritable, consolable
Irritable, not consolable
2. Respiratory Status/Effort
No impairment, vigorous
Mild-moderate compromise (tachypnea, retractions, grunting)
Respiratory distress or inadequate effort (apnea, respiratory failure)
3. Peripheral Perfusion
Pink, warm extremities
Mottled, cool extremities
Pale, shock
Score
(1)
(3)
(5)
(1)
(3)
(5)
(1)
(3)
(5).
Therapeutic choices
Ceftriaxone 50 mg/kg IM (maximum dose 1 gram) can be given as empiric antibiotic therapy until
specific diagnosis made and after all cultures are obtained and proper close follow up ensured, if (see
algorithm):
1.
Low risk between 1 and 3 months old with WBC count > 15000
2.
Low risk 3-36 months old with WBC count > 15000 and temperature > 39 C
When to Refer
1.
2.
If in doubt of management steps
Signs of toxicity present
164
Algorithm
Fever with
no identifiable source
Toxic
Yes
NO
Adequate social
situation for follow up
3 -36 months
Refer to specialist
OR
Blood, CSF & urine
cultures &
hospitalize
NO
1 - 3 months
< 1 month
Risk
High
Low
Risk
Temperature
>= 39C
YES
LOW
CBC
Urine culture
CBC w differential
Urine culture
NO
Comfort
Recheck if clinical
change or fever
persists > 48 hours
HIGH
WBC > 15000
OR
Positive urine
(male < 6 months or
female < 2 years)
Stool culture
NO
(bloody or mucoid stools)
Chest X Ray
(ipulmonary symptoms
present)
Blood culture
(if WBC > 15000)
Yes
Close observation
Obtain blood and CSF
cultures before any
empiric antibiotic
treatment
Doubt
OR
No improvement
Sources
1.
2.
Baraff LJ, Bass JW, Fleisher GR, et al. Practice guideline for the management of infants
and children 0 to 36 months of age with fever without source. Pediatrics 1993; 92(1):110.
Daaleman TP. Fever without a source in infants and young children. Am Fam Phys
1996;54:2503-12.
165
Acute otitis media
Definition and Epidemiology
•
Acute otitis media (AOM) is an inflammation of the middle ear characterized usually by the
rapid onset of symptoms and specific findings on physical examination. Almost 85% of
children have one episode of acute otitis media by age 3.
It is associated with respiratory syncytial virus, influenza virus and adenovirus infections, which result
in auditory tube edema, and is caused mostly by Streptococcus pneumoniae (38%), followed by
Haemophilus influenzae (27%), Moraxella (Bordetella) catarrhalis (10%) and Group A beta hemolytic
strep (3%).
• Persistent otitis media (POM) is unresolved otitis media after 6 days of antibiotics or
recurrence of otitis within few days of completion of a 10 days course. It occurs in about 25%
of patients after an initial course of treatment
• Recurrent otitis media (ROM) occurs whenever the patient has three or more attacks in the
preceding six months or four or more attacks in the preceding twelve months with at least one
in the past six months.
History
Under 3 years old:
•
Non-specific symptoms: irritability, fever, night waking, poor feeding, coryza.
Above 3 years old: (percentage of children with otitis who have symptoms)
•
•
•
•
•
Earache (47-83%)
Fever (22-69%)
Associated respiratory symptoms (94%)
Ear pulling (12%)
Irritability (56%)
Objective Findings
Use of pneumatic otoscopy is highly recommended and encouraged to make a good diagnosis and
evaluation of the tympanic membrane (TM):
• Cloudy TM has 80% positive predictive value (PPV) for otitis
• Distinclty red TM has 65% PPV
• Slightly red TM has only 16% PPV
• Bulging TM has 89% PPV
• Immobile TM by pneumatic otoscopy has 78% PPV
• Absence of effusion has a 77% negative PPV
Combining these findings allows identification of criteria for diagnosis:
• Acute otitis media (AOM):
Middle ear effusion by vision or pneumatic otoscope + either local signs of inflammation
(redness, bulging) or symptoms : otalgia, otorrhea, irritability, poor feeding, fever.
• Otitis media with effusion (OME):
Middle ear effusion on exam or pneumatic otoscopy without signs or symptoms of
inflammation (the eardrum may look opaque or yellow, neutral or retracted, with decreased
mobility or with air fluid level).
166
Diagnostic Considerations
In persistent OM, evaluate patient for mastoiditis, meningitis or sinusitis.
In recurrent OM, consider sinusitis, allergy, immuno deficiencies or tumors of the nasopharynx.
Management options
A- AOM:
•
•
•
•
First line antibiotics are the initial choice in management.
Second line antibiotics are indicated when there is:
1. failure to respond to 1st line drugs
2. history of failure of 1st line drugs
3. hypersensitivity to 1st line drugs
4. culture proven resistant organism
5. coexisting illness requiring 2nd line medication
Duration of antibiotic treatment is 10 days except for low risk children in whom 5 days may
be enough. Low risk children include those:
1. >2 years
2. negative history of OM
3. intact tympanic membranes
Parents must be told to call back if symptoms persist; child is inconsolable or symptoms get
worse.
B- Resistant AOM:
•
Persistent symptoms after 3-5 days of antibiotic therapy with bulging tympanic membranes
on exam:
1.
choose a second antibiotic.
2.
Refer to ENT specialist if symptoms persist for 4-5 days after starting the second
antibiotic.
C- Persistent AOM:
•
Start another course of a different antibiotic.
D- Recurrent AOM:
•
•
•
•
Prophylactic antibiotic course following a therapeutic course.
Prophylactic antibiotics:
o Amoxicillin 20mg/kg daily
o Sulfisoxasole 50mk/kg/d for 2-6 months.
This will reduce the frequency of AOM by 40-50% but will not eliminate its occurrence.
Follow-up in 3-4 weeks for : all children <5 years; children>5 years with risk factors (tubes;
ear surgery; speech delay).
Therapeutic choices
First line antibiotics:
1. Amoxicillin (Amoxil, Amodex, Ospamox, Flemoxin, Hiconcil) 40-80mg/kg/d in 3 divided
doses.
2. Trimethoprim/sulfa (Bactrim, Septrin) 1 cc/kg/d in 2 doses (or 10-12 mg TMP/kg/day bid)
167
Second line antibiotics:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Amoxicillin/clavulanate (Augmentin/Curam) 50mg of Amoxicillin/kg/d in 3 divided doses.
Cefaclor (Ceclor) 40mg/kg/d in 3 divided doses
Clarithromycin (Klacid) 15 mg/kg in 2 divided doses
Azithromycin (Zithromax) 10 mg/kg single dose on first day then 5 mg/kg single dose per day
for 5 days.
Cefprozil (Cefzil) 30 mg/kg/d in 2 doses
Cefixime (Suprax) 8mg/kg/d in 1-2 doses
Cefuroxime (Zinacef) 20-30 mg/kg/day in 2 doses
Cefpodoxime (Vantin) 10 mg/kg.day PO in 2 doses
Ceftriaxone (Rocephin) every other day for 3 intramuscular doses of 150 mg each.
Some factors affecting choice of antibiotic
Factor affecting choice
Streptococcus pneumoniae
Hemophilus Influenzae
Mycoplasma Catarrhalis
Broadest spectrum
Least diarrhea side effect
Best taste
No refrigeration
Least cost
Possible antibiotics
Amoxicillin, Amoxicillin/clavulanate, Cefprozil
Cefixime, Amoxicillin/clavulanate, Cefpodoxime
Cefixime, Cefpodoxime
Cefpodoxime
Cefaclor, Cefprozil
Cefixime, Cefpodoxime
Cefixime, Trimethoprim/sulfa
Amoxicillin, Trimethoprim/sulfa
Outcomes
Effusion persists in 70% after 2 weeks, 40% at 4 weeks, 20% at 2 months and 10% at 3 months.
1. AOM Resolved: no further management
2. OME can be handled by:
a. Watchful waiting
i. 90-95% of OME resolve in 3-4months
ii. Continued follow-up is appropriate because of the possibility of hearing loss.
b. Referral
i. Ventilating tubes are to be considered if there is no improvement after a trial of
10 day course of antibiotics.
When to Refer
Referral for consideration of ventilating tubes insertion, in the following conditions:
1. Recurrent AOM which fails medical management (3 or more episodes / 6 months or 4 or
more episodes /year) with either:
a. Failure of prophylaxis (= 2 recurrences on prophylaxis in a 2-6 months time period),
or
b. High risk categories(= craniofacial anomalies [Down’s syndrome; cleft palate];
speech delay).
2. Refractory AOM with moderate to severe symptoms unresponsive to at least 2 antibiotics.
3. Bilateral or unilateral OME persisting for at least 3 months with hearing threshold of 20dB or
worse.
4. Development of advanced middle ear disease involving tympanic membrane atrophy,
retraction pockets, ossicular erosion or cholesteatoma.
5. Medical treatment failure secondary to multiple drug allergy or intolerance.
6. At least 2 recurrences of AOM within 2-3 months of ventilation tube extrusion with failed
medical management.
168
7. Impending or existing OM complication(s): Mastoiditis; facial paralysis; lateral sinus
thrombosis; meningitis; brain abscess; labyrinthitis.
8. History of 6 months of OME in the past 12 months.
Patient Education
Encourage breast feeding.
Avoid passive smoking
Limit exposure to URTI’s
Avoid pacifier beyond 10 months of age.
Adult careful hand washing before manipulating children.
Algorithm
Symptoms
suggestive of otitis
media
Consider prophylactic
regimen
Yes
Meets diagnostic
criteria
Yes
Yes
Acute otitis media
Otitis media with
effusion
Select treatment
Select treatment
Exam suggestive of
otitis media
Recurrent AOM
3 episodes/6 months
or 4 episodes/year
NO
Follow up in 3-4 weeks
AOM resolved
Follow up in 3-4 weeks
NO
Criteria for ENT met
NO
OME resolved
Yes
Refer
Quality of care indicators
1. Increase appropriate antibiotic usage for otitis media infections.
a. Percentage of children with a diagnosis of acute otitis media who were prescribed first
line antibiotics.
b. Percentage of children with a diagnosis of acute otitis media who were prescribed second
line antibiotics who met the indications for second line antibiotics.
2. Increase the timely and appropriate clinical follow- up for patients with a diagnosis of otitis
media:
a. Percentage of children referred to ENT meeting the criteria for referral.
b. Percentage of children with a diagnosis of acute otitis media who had an appropriate
routine follow- up visit within the recommended time interval.
169
Sources
1. Bloomington (MN): Institute for Clinical Systems Integration; 1998 Oct 24 (ICSI health care
guidelines; no. 10/98)
2. Weiss JC, et al. Acute otitis media. Am Fam Phys 1996;53:1200-6.
3. Agency for health care policy and research. Managing otitis media with effusion in children. Am
Fam Phys 1994;50:1003-10.
170
Preventive health
171
Well child health supervision
Definition and Epidemiology
The objective of supervising health of children is to detect and manage problems at an early stage,
prevent disease and promote healthy behavior and lifestyles.
It includes monitoring physical growth, motor and psychological development, counseling,
anticipatory guidance, screening and immunizing.
History
History during health supervision must include:
Interval history.
Prenatal history.
History about growth.
Nutritional history: breast/formula, diet, vomiting.
Developmental history: speech, motor…
Family history of genetic diseases.
Immunization history.
Psychological history.
Sleep patterns.
Objective Findings
-
Growth: Ht, weight and head circumference parameters, and fontanelles.
Head, ENT exam.
Heart, lungs, abdomen.
Genitalia.
Vision.
Hearing.
Vital signs (BP).
Developmental milestones (Denver's chart).
Neurological exam.
CBC (at certain ages) see chart.
Urine analysis.
PPD (at certain ages).
Other tests (see chart).
Diagnostic Considerations
1. Growth patterns and deviations (failure to thrive, obesity)
Definitions of failure to thrive:
Attained growth:
Weight < 3rd percentile on NCHS growth chart
Weight for height < 5th percentile on NCHS growth chart
Weight 20% or more below ideal weight for height
Triceps skin fold thickness < 5 mm
Rate of growth:
Depressed rate of weight gain.
< 20 g/d from 0-3 mo of age.
< 15 g/d from 3-6 mo of age.
Falloff from previously established growth curve:
Downward crossing of>2 major percentiles on NCHS growths chart.
Documented weight
172
2. Developmental milestones (delay in development) using Denver charts
3. Screening:
• Neonatal screening (at birth)
- Congenital hypothyroidism, phenylketonuria and galactosemia.
• Developmental screening.
- Vision screening: * Gross eye inspection
- Evaluation of red reflex
- Pupillary light reflect
- Ability to follow an object
- Ocular alignment
• Vision acuity testing (Snellen chart or other, at 3 years), yearly for school aged.
• Hearing:
- At birth.
- Selective screening for newborns at visits.
- Screen at 3 months for babies with:
1. Positive family history.
2. History of congenital infection.
3. Anatomic malformations of head neck or ears.
4. Birth weight of less 1500.
5. History of hyperbilirubinemia (over exchange levels).
6. APGAR 0-4 at 1 minute or 0-6 at 5 minutes.
7. History of bacterial meningitis.
8. Significant exposure to ototoxic medication.
9. Prolonged mechanical ventilation.
• Blood pressure:
- Routinely at least once a year for children aged 3 years and older.
• Cholesterol and lipids:
- Selective screening based on high-risk family history.
• Iron deficiency anemia:
- Selective screening
- At 9-15 months
- For adolescents.
- Risk factors include during infancy:
1. Prematurity.
2. Low birth weight.
3. Introduction of cow's milk before 12 months of age.
4. Insufficient non-intake.
- Low socioeconomic status.
4. Psychological problems
Parent Education
Counseling and anticipatory guidance should be part of every visit. The Ministry of Public Health’s –
Parent Held Handbook (PHH) includes check lists and basic information to be discussed with the
parents. Of particular importance are injury prevention and breast feeding.
Injury prevention:
• Safe baby furniture.
• Car safety.
• Water thermostats set.
• Bath safety.
• Sun exposure.
• Protection from falls, burns.
• Small objects.
173
• Electrical outlets.
• Ingestions.
• Playground safety.
• Bicycle safety.
Nutrition:
• Breast vs. bottle feeding.
• Weaning.
• Introduction of solids, cereals, fruits.
• Discouraging non-nutritive snacks.
• Balanced diet.
Sources
1. Overby, Kim: Health Supervision in Rudolph’s fundamentals of Pediatrics, 2nd edition, Chapter
1, pp1-49
2. Unti, Sharon: The critical first year of life, in Pediatrics Clinics of North America vol41,#5,
Oct1994, pp 859-873
3. Ministry of Public Health. Parent held handbook. 1996
174
Guidelines for Health Supervision in children
Infancy
Early Childhood
New
born
By
1mo
History: initial/interval
Growth parameters
Height & Weight
Head circumference
Tanner staging
Physical examination
Development surveillance
Screening Newborn
metabolic
Newborn
hemoglobinopathies
Vision
•
•
Hearing 2
Late Childhood
•
•
2
m
o
•
•
4
m
o
•
•
6
m
o
•
•
9
m
o
•
•
12
m
o
•
•
15
m
o
•
•
18
m
o
•
•
24
m
o
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
S
S
S
S
S
S
S
S
S
S
O
S/o
S
S
S
S
S
S
S
S
S
S/
o
S/
o
•
O
Adolescence
3y
4y
5
Y
6
Y
8
Y
10Y
11Y
12Y
13Y
14Y
15Y
16Y
17Y
18Y
19Y
20Y
21Y
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
O
S
S
O
S
O
S
S
O
S
S
O
S
S
S
O
S
S
O
S
O
S
S
O
S
S
O
S
S
S
•
Blood pressure
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Cholesterol 3
Lead 4
•
•
Hematocrit/ hemoglobin
5
PPD 6
STD screening 7
PAP/pelvic 8
Anticipatory guidance
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Immunizations 9
•
•
•
•
•
•
•
Initial dental referral
•
• = To be performed; = To be performed for patients at risk; S= Subjective, by history, O= Objective, by a standard testing method; •
= range during which a service may be provided, with the dot
indicating the preferred age; PAP= Papanicolaou smear; PPD= Purified protein derivative for tuberculosis testing.
Adapted from American Academy of Pediatricians (AAP) Committee on Practice and Ambulatory Medicine Recommendations 1995.
Goal of universal objective hearing assessment of birth to 3 months supported by AAP. Until effective technologies/programs are in place to accomplish this, a selective screening strategy based on the presence of
risk factors is recommended;
Selective screening at 24 months based on presence of risk factors; subsequent screening interval determined by same; universal screening at 18-21 years (see section on screening).
Universal screening at 12 and 24 months; earlier and more frequent screening based on presence of risk factors.
Selective screening at 9/15 months and during adolescence based on presence of risk factors.
Selective screening based on presence of risk factors; subsequent screening interval determined by same.
All sexually active patients should be screened for STDs at least annually; more frequently if high risk.
All sexually active females should have a pelvic examination. A pelvic examination and routine PAP smear should be offered as part of preventive health maintenance between the ages of 18 and 21 years.
Refer to national guidelines for immunizations
175
Periodic Health Examination
Definitions
Periodic examinations of children, adults and the elderly are based on recommendations of
professional organizations. These recommnedations sometimes disagree depending on:
1. Population targeted and the prevalence of the subject of recommendation
2. The subjectivity of the decision analysis in the choice of cut off points for decsion making
3. The use of explicit criteria in screening programs
4. The clinical significance of the intervention.
5. The methodology with which the evidence is evaluated
Screening can be viewed along two broad lines:
1. Formal screening – the health providers reach out to the population
This is usually done in campaigns or systemic outreach to the population served by a provider
2. Opportunistic screening (Case finding) – the patient comes to the health provider
In this method, the health provider takes the opportunity of the patient’s visit for some ailment, to
discuss preventive and health promotion issues.
The decision to include a condition in screening and set the frequency with wich it is checked is based
on a cost benefit analysis that may vary from one population to antoher. The variables taken into this
decision process include:
1. Attributes of the condition: common, important, diagnosable and has a latent interval which
allows effective interventional treatment.
2. Attributes of the intervention (or test): Acceptable to the users, inexpensive, effective, safe
and has high sensitivity and specificity to minimize false results.
Lebanon lacks vital statistics that enable us to give sound recommendation on some preventive issues.
The information presented here is derived mainly from the US Preventive Services Task Force
(USPSTF).
USPSTF graded recommendations based on presence and strength of evidence as follows:
A: There is good evidence to support the recommendation that the condition be specifically
considered in a periodic health examination.
B: There is fair evidence to support the recommendation that the condition be specifically
considered in a periodic health examination.
C: There is insufficient evidence to recommend for or against the inclusion of the condition
in a periodic health examination, but recommendations may be made on other grounds.
D: There is fair evidence to support the recommendation that the condition be excluded from
consideration in a periodic health examination.
E: There is good evidence to support the recommendation that the condition be excluded
from consideration in a periodic health examination.
Sources
1. U.S. Preventive Services Task Force. Guide to clinical preventive services:
http://odphp.oash.dhhs.gov/pubs/guidecps
2. American Academy of Family Physicians. Age charts for periodic health examination. Kansas
Ciy, MO: AAFO, Aug. 1993.
3. Hayward RS, el al. Preventive care guidelines. Ann Intern Med 1991;114:758-783.
176
Screening recommendations for asymptomatic individual
Remarks (USPSTF grading)
Service
Physical examination
Blood pressure
Height & Weight
Vision
Glaucoma
Hearing
Sex
Age
Frequency
MF
MF
MF
MF
MF
2 – 5 years
1 – 2 years
2 years
2 years
2 years
Clinical breast examinaiton
Pelvic exam
F
F
> 3 – 65
>3
> 60
> 50
2-6 years
> 65 years
40 – 69
> 40
Testicular examinaiton
Prostate digital rectal exam
M
M
13-18 years
50 – 70
?
Annually
Laboratory test
Anemia
MF
1- 2, 5-10
?
Encouraged in high risk infants, children
and pregnant (B)
F
MF
MF
MF
MF
MF
F
MF
M
F
M
F
2-6
18-65
50-80
1-12
> 50
> 35?
50-70
40-69 (75)
13-18
35-65
45-65
> 50
> 45
2-3 years
Annually
Annually
?
?
10 years
1-2 years
5 years
5 years
5 years
?
?
Upper age limit is uncertain
No consensus as to benefit
MF
> 30
?
No strong recommendation (C)
MF
F
MF
MF
MF
0-16
> 12
> 18
> 65
> 65
Once
10 years
Annually
Once
MF
> 18
F
F
> 18
> 40
Urine analysis
PAP smear
Stool occult
PPD
TSH
FBS
Sigmoidoscopy
Mammography
Cholesterol
PSA
Annually
?
For ovarian cancer
No strong recommendation (D) unless
high risk (C)
No strong recommendation (C)
Combine with PSA
No consensus as to benefit
With family history (C)
With family history
Controversial
High risk or unsure about HRT
Bone mineral density
Rourine EKG or stress test
Immunizations
Childhood vaccination
Rubella
Tetanus
Influenza
Pneumococcal vaccine
Counseling
Nutrition
Exercise
Smoking
Skin cancer
Dental hygiene
Injury prevention
Breast self examination
Hormone Repalcement Therapy
At each visit
177
See vaccination schedule
Check serology if vaccinated
Immunizations
Lebanese national vaccination schedule approved in 1998.
Age
Vaccine
Birth
Hepatitis B*
1 month
Hepatitis B*
2 months
OPV, DTP
3 months
OPV, DTP
4 months
OPV, DPT, Hepatitis B*
10 months
Measles
15 months
Measles, Mumps, Rubella
18 months
OPV, DTP
4 to 5 years
OPV, DTP
5 to 6 years
Measles, Mumps, Rubella
10 to 12 years
OPV, TD
OPV = Oral polio vaccine, D = Diphtheria, P = Pertussis, T = Tetanus
Poliomyelitis
Polio vaccine has decreased dramatically the annual number of reported cases of paralytic
poliomyelitis but still continues to be a problem in developing countries. The World Health
Organization has established a goal of global eradication of poliomyelitis by the year 2000.
Vaccine types:
Two types are available: live oral poliovirus vaccine (OPV) and enhanced-potency inactivated
poliovirus vaccine (IPV). Both vaccines contain antigens to poliovirus types I, II, and III and are
highly effective.
Schedule:
Poliovirus vaccine is administered at ages 2, 3 and 4 months, followed by two doses at ages 12-18
months and 4-6 years.
IPV is given at the same schedule wherever health authorities have included it in the national
schedule. OPV remains the vaccine of choice for mass vaccination campaigns to control outbreaks of
wild poliovirus.
Dosage and Administration:
OPV is supplied in a disposable pipette containing a single dose of 0.5 mL. It is administered orally,
either directly or mixed with distilled water, chlorine-free tap water or milk. If a substantial amount of
OPV is regurgitated or spit out within 5-10 minutes of administration, it may be re-given. If the repeat
dose is also lost, re-administration should be attempted at the next visit.
The dosage of IPV is 0.5 mL, given subcutaneously in the thigh in infants and in the deltoid area for
older children.
Adverse Reactions:
There is an extremely small risk of paralysis in recipients after OPV use. In immunologically normal
recipients, the risk is 1 case per 6.8 million doses.
178
IPV does not induce paralysis and its side effects are minor - such as local pain and swelling at the
injection site.
Contraindications:
Diarrhea is not a contraindication to OPV.
Persons infected with HIV, with household contacts infected with HIV, or with known altered
immunodeficiency should receive IPV rather than OPV.
Vaccine Storage and Handling:
OPV should be stored at temperatures low enough to keep it solidly frozen. This may require
temperatures below -14 C. The vaccine must be completely thawed before use. A container of vaccine
may be subjected to a maximum of ten cycles of thawing and refreezing as long as the temperature of
the vaccine does not exceed 8 C and the total cumulative time thawed is not greater than 24 hours. If it
is thawed for more than 24 hours it should not be refrozen, but stored at 2 to 8 C and used within 30
days.
IPV should be stored at 2 to 8 C and should not be frozen.
Diphtheria, Tetanus, and Pertussis
Vaccine Types:
Two types are now available in Lebanon, DTP and DTaP with preparations of diphtheria and tetanus
toxoids in which the pertussis portion of the vaccine is whole-cell or acellular respectively. DT and Td
contain only the diphtheria and tetanus toxoids, with Td containing fewer flocculating units of
diphtheria toxoid dose per dose than DT. If a child under 7 years of age has a contraindication to
pertussis vaccine, DT should replace DTP or DTaP in the immunization schedule. Only Td should be
used to immunize children 7 years of age and older.
Schedule:
Routine immunization with DTP or DTaP at 2, 3, and 4 months of age. The fourth vaccination is
recommended at 15-18 months of age. The fifth vaccination should be given at 4 to 6 years of age.
Booster immunizations with Td should be given every 10 years; for children immunized according to
the recommended schedule, the first booster will be needed at 14 to 16 years of age.
Dosage and Administration:
The recommended dosage of DTP, DTaP, DTP-Hib, DT, Td is 0.5 mL, given intramuscularly in the
anterolateral thigh in infants and the deltoid area in older children.
DTP and DTaP may be given simultaneously with other childhood vaccinations. It is preferable to
avoid giving other vaccinations in the same limb with DTP or DTaP.
Adverse Reactions:
Local side effects (redness, swelling, or pain) and mild systemic reactions (fever >38 C, drowsiness,
fretfulness, vomiting, or anorexia) are fairly common. These side effects occur somewhat less
frequently with the use of the acellular DTaP vaccine. The following moderate-to-severe systemic
events have rarely occurred after DTP and DTaP vaccination, and are considered precautions for
further vaccination:
• Severe allergic hypersensitivity.
• Fever ³40.5 C within 48 hours.
179
•
•
•
Collapse or shock like state (hypotonic-hyporesponsive episode) within 48 hours.
Persistent, inconsolable crying for 3 hours or more, or an unusual, high-pitched cry within 48
hours.
Seizure within 3 days of receiving the previous dose of DTP/DTaP
Acetaminophen, given in a dose of 15 mg/kg at the time of DTP or DTaP vaccination and 4 hours
later, may help prevent or relieve minor side effects (e.g., fever, pain) of the vaccine.
Contraindications for DTP/DTaP Vaccination:
Persons who developed an encephalopathy within 7 days of administration of a previous dose of DTP
or DTaP should not receive further doses of DTP or DTaP.
Measles, Mumps, and Rubella
Vaccine Types:
Measles, mumps, and rubella are live attenuated vaccines. They are available as single antigen
preparations and as combination.
Schedule:
Measles vaccine at 8-10 month.
A primary measles-mumps-rubella (MMR) immunization should be given at 12-15 months of age. A
booster dose should also be given at 4-6 years of age. MMR may be given simultaneously with other
childhood immunizations.
Dosage and Administration:
0.5 mL given subcutaneously in the deltoid.
Adverse Reactions:
The measles component may cause a transient rash in 5% of vaccinees. Fever greater than 39.4 C
develops in 5% to 15% of individuals susceptible to measles, beginning 5 to 12 days after
immunization and usually lasting 1 to 2 days (up to 5 days). Because of the late onset of fever,
acetaminophen prophylaxis may not be practical in preventing febrile seizures.
The rubella component is associated with the development of a mild rash lasting 1 to 2 days and mild
pain and stiffness in the joints 1 to 2 weeks after the immunization, usually lasting up to 3 days. The
joint problem affects 1% of children.
Contraindications and Precautions:
•
•
•
•
•
Anaphylactic reaction to a prior dose or to any vaccine component or to eggs
Pregnancy or possible pregnancy within next 3 month
Immunosuppressed patients due to cancer, leukemia, lymphoma, immunosuppressive drug
therapy ( including high-dose steroids).
HIV positivity is NOT a contraindication to MMR except for those who are severely
immunocompromised.
Measles vaccination may temporarily suppress tuberculin reactivity. If testing cannot be done the
day of MMR vaccination, the test should be postponed for 4-6 weeks.
Haemophilus influenzae Type b
Haemophilus influenzae type b (Hib) is one of the leading causes of invasive bacterial disease in
children under 5 years of age, and it is the leading cause of meningitis in this age group. The peak
180
incidence of Hib infection occurs between 6 and 12 months of age, and 75% of all illness occurs in
children younger than 24 months of age. Hib conjugate vaccines given as a primary series in infancy
have high efficacy (in some studies over 90%) in preventing disease.
Vaccine Types:
Two types of conjugate vaccines are licensed for use in Lebanon, and are now considered
interchangeable for primary as well as booster vaccination. A combined DTP-Hib vaccine is also
licensed for single-injection vaccination of children against diphtheria, tetanus, pertussis, and
Haemophilus influenzae type b (Hib).
Schedule:
All children should receive a primary series at 2, 4, and 6 months of age. Children who start the
primary series at 7-11 months of age should receive a primary series of 2 doses of the vaccine.
Children beginning the primary series at 12-14 months of age should receive a primary series of 1
dose.
A booster dose should be given at 12-15 months of age.
Children beginning the Hib vaccine series at 15-59 months of age should receive one dose only.
In general, Hib vaccine should not be given after the fifth birthday, except in certain special
circumstances (such as asplenia or sickle cell anemia) that may make a child particularly vulnerable to
Hib infection.
Dosage and Administration:
0.5 mL, given intramuscularly in the anterolateral thigh in infants and in the deltoid area in older
children. Hib vaccines may be given simultaneously with other childhood vaccinations at different
sites.
Precautions:
There are no known specific contraindications to the Hib vaccination.
Adverse Reactions:
The side effects from Hib vaccination are minor and limited to mild fever and redness and/or swelling
at the injection site.
Hepatitis A
Vaccine Types:
Contains inactivated Hepatitis A virus and is available in two formulations that differ in dosage
according to patient's age
Schedule:
Given in a two dose schedule
Dosage and Administration:
Adults: 1ml IM repeated in 6 to 12 months
2 to 18 years: 0.5 ml given IM in the deltoid and repeated in 6 to 12 months
181
Hepatitis B
Infection with the hepatitis B virus (HBV) is a major health problem worldwide. People with chronic
infection are at increased risk of death from chronic liver disease and cancer. Vaccination is highly
effective (up to 95%) in preventing HBV infection in susceptible patients.
Vaccine Types:
There are currently three licensed HBV vaccines. All are produced by recombinant DNA technology.
Pooled sera HBV may still be available in the market and shout NOT be used. Always confirm that
the vaccine you are using is a recombinant DNA product.
Schedule:
All children should receive a complete series of three doses of hepatitis B immunizations during the
first 18 months of life. Infants born to HBsAg-positive mothers should begin receiving these
immunizations at birth.
The schedule recommended is: at birth (before hospital discharge), 1 to 2 months, and 6 to 18 months
of age. Do not restart series, no matter how long since previous dose
Dosage and Administration:
0.5 mL, given intramuscularly in the anterolateral thigh in infants and in the deltoid area in older
children.
Precautions:
There are no known specific contraindications to the HBV vaccination.
Adverse Reactions:
The side effects of HBV vaccination are relatively minor in children. These include pain at the
injection site (3% to 29%) and temperature greater than 38C.
Varicella Immunization
Although chickenpox is usually a self-limited illness in children, it is often more severe in infants,
adolescents, adults and immuno-compromised persons, and carries a higher risk of complications. in
children 12 months through 12 years of age. The Advisory Committee on Immunization Practices
(ACIP) and other major authorities are likely to recommend its use for all susceptible children 12
months through 12 years of age and for some high-risk older persons. Preliminary information on the
vaccine and its use follows.
Vaccine Type.
The single vaccine available is a live, cell-free preparation that is highly effective.
Schedule.
Healthy children aged 12 months through 12 years of age who lack a reliable history of chickenpox.
Dosage and Administration.
The recommended dosage in children aged 12 months through 12 years is 0.5 mL in a single
vaccination. In persons 13 years of age or older, two injections of 0.5 mL are given four to eight
weeks apart. The injection should be given subcutaneously into the anterolateral thigh in infants and
in the deltoid area in older children.
182
Precautions.
It is contraindicated in persons with a history of an anaphylactic reaction to neomycin. It should not
be given to persons with blood dyscrasias, leukemia, lymphomas, primary or acquired
immunodeficiency (including AIDS), those on immunosuppressive therapy, or women who are
pregnant or intend to become pregnant within three months.
Children receiving the vaccine should avoid use of salicylates for six weeks following vaccination,
due to the theoretical risk of developing Reye's syndrome.
Adverse Reactions.
The vaccine is well tolerated. Pain and redness at the injection site is reported by up to 20 percent of
vaccinees. A mild rash, either local or generalized, has also been reported. Inadvertent administration
of vaccine to individuals immune to varicella has not resulted in an increase in any adverse reactions.
Contraindications and Misconceptions
True contraindications, applicable to all vaccines, include a history of anaphylactic or anaphylacticlike reactions to the vaccine or a vaccine constituent and the presence of a moderate or severe illness
with or without a fever.
Some conditions are often inappropriately regarded as contraindications to vaccination. Among the
most important are diarrhea and minor upper- respiratory illnesses with or without fever, mild to
moderate local reactions to a previous dose of vaccine, current antimicrobial therapy, and the
convalescent phase of an acute illness.
Routine physical examinations and measuring temperatures are not prerequisites for vaccinating
infants and children who appear to be healthy. Asking the parent or guardian if the child is ill and then
postponing vaccination for those with moderate to severe illness, or proceeding with vaccination if no
contraindications exist, are appropriate procedures in childhood immunization programs.
BCG vaccine
BCG vaccine is not currently recommended by any authority in Lebanon and should not be given
before having recommendation from the Ministry of Health
PPD test for Tuberculosis should be done every 1-2 years starting from the first birthday.
General contraindication to vaccination:
Anaphylactic reaction to a prior dose or to any vaccine component
Moderate or severe acute illness. Don’t postpone for minor illness
183
Alternative schedule of vaccination approved by ACIP (reference 2)
Recommended Childhood Immunization Schedule January-December 2000
1
This schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines as of
11/1/99. Additional vaccines may be licensed and recommended during the year. Licensed combination vaccines may be
used whenever any components of the combination are indicated and its other components are not contraindicated. Providers
should consult the manufacturers' package inserts for detailed recommendations.
2
Infants born to HBsAg-negative mothers should receive the 1st dose of hepatitis B (Hep B) vaccine by age 2 months.
The 2nd dose should be at least one month after the 1st dose. The 3rd dose should be administered at least 4 months after the
1st dose and at least 2 months after the 2nd dose, but not before 6 months of age for infants.
Infants born to HBsAg-positive mothers should receive hepatitis B vaccine and 0.5 mL hepatitis B immune globulin
(HBIG) within 12 hours of birth at separate sites. The 2nd dose is recommended at 1 month of age and the 3rd dose at 6
months of age.
Infants born to mothers whose HBsAg status is unknown should receive hepatitis B vaccine within 12 hours of birth.
Maternal blood should be drawn at the time of delivery to determine the mother's HBsAg status; if the HBsAg test is
positive, the infant should receive HBIG as soon as possible (no later than 1 week of age).
All children and adolescents (through 18 years of age) who have not been immunized against hepatitis B may begin the
series during any visit. Special efforts should be made to immunize children who were born in or whose parents were born in
areas of the world with moderate or high endemicity of hepatitis B virus infection.
3
The 4th dose of DTaP (diphtheria and tetanus toxoids and acellular pertussis vaccine) may be administered as early as 12
months of age, provided 6 months have elapsed since the 3rd dose and the child is unlikely to return at age 15-18 months. Td
(tetanus and diphtheria toxoids) is recommended at 11-12 years of age if at least 5 years have elapsed since the last dose of
DTP, DTaP or DT. Subsequent routine Td boosters are recommended every 10 years.
4
Three Haemophilus influenzae type b (Hib) conjugate vaccines are licensed for infant use. If PRP-OMP (PedvaxHIB® or
ComVax® [Merck]) is administered at 2 and 4 months of age, a dose at 6 months is not required. Because clinical studies in
infants have demonstrated that using some combination products may induce a lower immune response to the Hib vaccine
component, DTaP/Hib combination products should not be used for primary immunization in infants at 2, 4 or 6 months of
age, unless FDA-approved for these ages.
5
To eliminate the risk of vaccine-associated paralytic polio (VAPP), an all-IPV schedule is now recommended for routine
childhood polio vaccination in the United States. All children should receive four doses of IPV at 2 months, 4 months, 6-18
months, and 4-6 years. OPV (if available) may be used only for the following special circumstances:
1. Mass vaccination campaigns to control outbreaks of paralytic polio.
2. Unvaccinated children who will be traveling in <4 weeks to areas where polio is endemic or epidemic.
3. Children of parents who do not accept the recommended number of vaccine injections. These children may receive
OPV only for the third or fourth dose or both; in this situation, health-care providers should administer OPV only
after discussing the risk for VAPP with parents or caregivers.
184
4.
During the transition to an all-IPV schedule, recommendations for the use of remaining OPV supplies in
physicians' offices and clinics have been issued by the American Academy of Pediatrics (see Pediatrics, December
1999).
6
The 2nd dose of measles, mumps, and rubella (MMR) vaccine is recommended routinely at 4-6 years of age but may be
administered during any visit, provided at least 4 weeks have elapsed since receipt of the 1st dose and that both doses are
administered beginning at or after 12 months of age. Those who have not previously received the second dose should
complete the schedule by the 11-12 year old visit.
7
Varicella (Var) vaccine is recommended at any visit on or after the first birthday for susceptible children, i.e. those who
lack a reliable history of chickenpox (as judged by a health care provider) and who have not been immunized. Susceptible
persons 13 years of age or older should receive 2 doses, given at least 4 weeks apart.
8
Hepatitis A (Hep A) is shaded to indicate its recommended use in selected states and/or regions; consult your local public
health authority. (Also see MMWR Oct. 01, 1999/48(RR12); 1-37).
Sources
1. Ministry of Public Health. National vaccination schedule, 1996. Decree 287/1. Ministry of Public
Health of Lebanon. (March 27, 1996).
2. CDC. Recommended childhood immunization schedule--United States, January-December 200,
American Family Physician, January 2000.
3. American Academy of Pediatrics, Committee on Infectious Diseases. Recommended childhood
immunization schedule--United States, January-December 1999. Pediatrics 1999; 103:182-5.
4. CDC. Pertussis vaccination: use of acellular pertussis vaccines among infants and young children.
Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR
1997;46(No. RR-7):1-25.
5. CDC. Recommendations for use of Haemophilus b conjugate vaccines and a combined diphtheria,
tetanus, pertussis, and Haemophilus b vaccine. Recommendations of the Advisory Committee on
Immunization Practices (ACIP). MMWR 1993;42(No. RR-13):1-15.
6. American Academy of Family Physicians. Combination vaccines for childhood immunization:
recommendations of the Advisory Committee on Immunization Practices (ACIP), American
Academy of Pediatrics (AAP) and American Academy of Family Physicians (AAFP). Am Fam
Physician 1999;59:2565-74.
7. Madlon-Kay DJ, Harper PG. Too many shots? Parent, nurse, and physician attitudes toward
multiple simultaneous childhood vaccinations. Arch Fam Med 1994;3:610-3.
185