Lmcc Main Study

main symptoms
- fever (high - sudden onset)
- myalgias
- fatigue

2° symptoms (urti sx)
- H/A
- sore throat
- nasal d/c / nasal decongestion
- non-productive cough

An anti-viral that has very little evidence of benefit in treating influenza A + B.

Must be taken <48hrs of symptoms, otherwise no benefit. The benefit is only reduction of symptoms by 24 hours at most.

Prescription: (uncomplicated flu)
Tamiflu: Take 75mg po bid M: 5d

Mononucleosis (also called "kissing disease"), is a disease most commonly caused by the Epstein-Barr virus (EBV). EBV affects the lymphocytes which are white blood cells involved in the adaptive immune system. Mononucleosis can also be caused by cytomegalovirus (HCMV), a herpes virus most commonly found in body fluids. While CMV can cause mononucleosis, 85% of the cases are associated with EBV. The disease can be found in anyone but is most commonly contracted by adolescents and young adults ages 15–35.

Avoid all contact sports (possibility of spleen rupture if enlarged); however, even if not palpable on exam, recommend avoiding all contact sports.

In the f/u visit, if the patient says that they feel all better, it is important to recheck the spleen at this point to clear them.

1. monospot (70-92% sensitive and 96-100% specific)
2. CBC (to look for atypical lymphocytes, inc. lymphocytes and leukocytes)

3. EBV titres (not needed, monospot is a relatively good test)

Note: for monospot tests, a positive test is very likely to rule mononucleosis to be the case; whereas, a negative test cannot rule it out

LFTs

Viral

Used to relieve nasal congestion in babies and children, also adults. Different products available:
Easydose Vials: newborns and infants
Ultra-Gentle mist: babies (<2 yrs)
Gentle mist: adults and children 2 yrs and older
Medium stream: adults and children 2 yrs and older
Full stream: adults and children 12 yrs and older
Congestion relief: adults and children 12 yrs and older

note: it is advisable to use a nasal applicator
Website: www.hydrasense.ca/en

True

In pregnancy, pseudoephedrine may cause vasoconstriction of the uterine arteries, which reduces fetal blood supply. This may cause the link between pseudoephedrine use in the first trimester and the development of gastroschisis. In this anomaly, a fissure develops in the fetus' abdomen, perhaps allowing protrusion of the intestines.

Using decongestants while breast-feeding may cause irritability, insomnia, and tachycardia in the baby. Further, pseudoephedrine has been shown to reduce mean milk volume by 24%.

Avascular necrosis (especially in younger patients); however, patients of any age should be warned of this possibility even though rare.

Write a script saying:
Physiotherapy at therapist's discretion
Dx: stress incontinence

And tell the patient to book at appointment with Carolyn Vandyken for Kegel training.
1. Physiotherapy Associates of Cambridge
163 Hespeler Road, Cambridge, ON N1R 3H7
phone no. 519-624-8798

Metformin

NOT clomiphene citrate (as its benefit is very modest and risk of harmful s/e is much greater).

NOTE: patients with PCOS continue to ovulate; however, rate of ovulation is less than patients w/o PCOS.

1. Epley maneuver (performed by M.D.)
2. Brandt-Daroff exercises (performed by patient
3. anti-emetics for N/V
4. SERC 24mg (have with meal as it may cause GI upset)
Take 1 tablet po BID M: 7d

Metronidazole (flagyl) 500mg BID x 7d

Avoid alcohol until 3d after Rx; metronidazole blocks the breakdown of alcohol leading to the accumulation of acetaldehyde --> facial flushing, headaches, palpitations and nausea

A post-viral cough is a lingering cough that follows a viral respiratory tract infection, such as a common cold or flu, and lasting up to eight weeks.

One possible cause for post-viral cough is that the receptors that are responsible for stimulating the cough during the respiratory tract infection are up-regulated by respiratory tract infection and continue to stimulate after the virus has disappeared.

Prescribe Trazodone 50mg
Take 1 tablet po qhs M: 30d (f/u in 1 months time; if stable prescribe 3 months + 1 repeat)

or Melatonin (3mg, 6mg, 9mg, 12mg)

Now after a few followups the patient continues to complain of insomnia + depression; can consider adding any of the following:
- doxepin (10-50mg) qhs
- seroquel 25mg qhs
- amitriptyline (10-50mg) qhs
- remeron (15-->30mg-->45mg) qhs (major s/e is wt gain)
- zopiclone 5mg qhs prn M:14d (avoid more than this; if needed longer term, then avg. 3 tabs per week prn)

depression + insomnia

remeron
15mg qhs
(note: can go up to 30mg qhs, then 45mg qhs (max dose))
(dose must be tapered gradually when discontinuing)

note: however, a major S/E of Remeron is weight gain. Weight gain may be a desired effect if the pt has anorexia or weight loss

3 months if uncontrolled diabetes ('diabetes long' requisition should be given and done 1-2 wks before next visit)

4 month if almost stable but not quite ('diabetes long' requisition should be given and done 1-2 wks before next visit)

6 months if controlled diabetes ('diabetes long' requisition should be given and done 1-2 wks before next visit)

NOTE: Diabetes long requisition includes FBS, HbA1C, urine, AC ratio

Just write " glucometer x 1" on the prescription (handwritten) or put in PSS system (however, it will crowd the medication history)

TEST STRIPS:
Ascensia contour strips
100 strips + 10 repeats

PLAN

1. Metformin 500mg tablet
Take 1 tablet po od x 1wk, then take 1 tablet BID M: 3 months
2. BW_diabetes (long) in ~ 3 months
3. f/u in 3 months time after bw

NOTE: this is diabetes_inadequately controlled and therefore, a 3 mo f/u is arranged.

Calculate his Framingham risk score for CAD.
If severe risk, prescribe:

Crestor
Take 10mg po od M: 6 wks (initially)
F/U in 6 wks with repeat LFTs, then if things are stable, prescribe:

Crestor
Take 10 mg po od M: 3 months
f/u in 3 months with LFTs, then if things stable prescribe q6 months (3 months + 1 repeat) to q12 months (depending on patient)


(NOTE: if moderate risk (10-19% 10 yr risk), then you want LDL <3.5

- diabetes mellitus

- psychogenic polydipsia
- diabetes insipidus (central vs. peripheral)

1. osteoporosis, postmenopausal: 35mg po qwk or 150mg po qmo

2. osteoporosis, steroid-induced: 5mg po od for tx and prevention in pts on >7.5mg/d prednisone or equiv

3. osteoporosis, male: 35mg po qwk

(take with water >30mins before first meal, remain upright x 30 mins; Ca and Vit D supplementation recommended if inadequate intake

Fosamax 70mg: Take 1 tablet po qweekly M: 3 mo + 1 repeat

Same prescription for postmenopausal women if they're not tolerating Actonel well.

Rare circumstance:

A patient who has a hx of using 'nitro' meds should not be taking PDE5-inhibitors such as cialis, viagra, or levitra.

B/c the effects of cialis last much longer than viagra, it is risky in a patient who may end up taking nitro. This may cause severe hypotension. Viagra would be a better choice in this circumstance.

Cialis 10mg: Take 1 tablet po prior to sexual activity prn M: 10 or 15 tablets + 1 repeat

Viagra 50mg: Take 1 tablet po 1 hr prior to sexual actvity prn M: 10 or 15 tablets + 1 repeat
(if pt >65 start at 25mg tablet od)



note: Viagra should be taken on an empty stomach; this does not apply to cialis.

0-1: Do not culture; do not treat
2-3: culture: Rx only if positive culture
4+: Rx, don't bother doing culture

For scores < or = to 3, recommend gargling with lukewarm salt water, tylenol/advil, and/or offer tantum

tantum 0.15% liquid
gargle and spit 15mL q2h prn M: 250mL

1. check FOBT vs colonscopy dates
2. increase fibre intake; benefibre (otc) vs. metamucil (otc); consider stool softener
3. tylenol prn
4. sitz baths
5. Nitroglycerin

Prescription (in pss):
Medication: nitroglycerin
Instructions:
0.2% ointment; apply perianally BID M: 15g repeat: 1

BMD testing should be done for any patient who has been on prednisone 7.5mg x 3 mo or equivalent.

Treatment with Actonel (bisphosphonate) should be strongly considered in a patients taking prednisone 7.5mg x 2 years.

Counsel: diet, exercise, weight loss (if obese)
(note: you can expect conservative management to reduce cholesterol / LDL by about 20%, consideration for a statin (crestor) should be taken into account.

So if this patients cholesterol is reduction from his prev. cholesterol level, then you can wait and see what his next cholesterol level is. If its the same or higher, consider crestor; otherwise, conservative management.

Now if this patient had other RFs such as heart disease, HTN, diabetes, smoking, it is best to be more aggressive in bringing his cholesterol levels lower. NOTE: use the framingham cardiovascular risk calculator to calculate is 10yr risk of CAD. If high risk, err towards treating with statin. Moderate risk ... can be watched.

alcohol
tobacco
caffeine

fatty foods
spicy foods
citrus fruits

peppermint
chocolate

i. pariet ec
ii. nexium (esomeprazole)
backup option is: tecta 40mg od

Prescriptions:
------------------------------------------------------------
PPIs:

1. pariet ec 20mg tablet
1 tablet daily M: 30 days
(for hypersecretory conditions max of 120mg od)

2. nexium 20mg tablet
1 tablet daily M: 30 days
(for hypersecretory conditions, max of 120mg bid)

-------------------------------------------------------------
h2 antagonist:

1. ranitidine 150mg
1 tablet bid
-------------------------------------------------------------

non-medical strategies for gerd:
- weight loss
- elevating head of bed
- avoid trigger foods: alc, tabacco, caffeine, chocolate, peppermint, spicy foods, fatty foods, citrus fruits

Avoid all triggering foods

Prescription:
1. pariet ec
take 20mg tablet po od M: 30 days

No, it should be prescribed for 1 month with instructions to the patient to f/u if symptoms recur. If they recur, she may need to be started on a PPI for a longer duration, eg. 3 months + 1 repeat.

F/U prescription durations:
1 month --> 3 months --> 6 months (lifelong 3mo + 1 rpt)

Advise the patient on diet management (avoidance of caffiene, spicy foods, fatty foods, citrus juices etc)

May want to consider sending the patient for an endoscopy if any red flags are present; if symptoms controlled on medication, don't bother scoping them

1. GERD
2. Refer for laryngoscopy to r/o
- malignancy
- polyps
- papules on vocal cords

NOTE: this patient should be scoped by default; unless, you are certain he has GERD

On history, ask about
1. RFs: alcohol, smoking, radiation
2. constitutional symptoms
3. reflux symptoms (heart burn, dyspepsia, cough, sob)
4. ROS: dysphagia, odynophagia
5. excess voice use

Check her bp and make sure its not elevated (protein was 1+ although this is quite common)

The 2+ leuks indicate a potential UTI. UTI in asymptomatic pregnant patients must be treated. Therefore, do a urine culture and send it to the lab. If positive treat for UTI.

A f/u culture in 3-4 wks is recommended after treatment initiation.

NOTE: nitrofurantoin / macrobid is CONTRAINDICATED between 36-42 wks GA, and during labour due to the possibility of hemolytic anemia.

NOTE: septra is contraindicated in the 1st trimester b/c it may limit availability of folic acid to the fetus as well as the last 6 wks of pregnancy as it may cause kernicterus

For the contraindications, consider amoxicillin 500mg tid x 7d or keflex 500mg qid x 7d

~20-30 lbs close to delivery

mothers often gain ~ 1 lbs every month in the 1st and 2nd trimester and ~ 1 lbs qweekly from week 30-40 (approximately)

Bacterial conjunctivitis is more common in children (~50-75% than viral)

Viral conjunctivitis is more common in adults

1. erythromycin ointment 0.5% opthalmic
2. fucithalmic 1% drops (note this is actually a viscous paste; not drops)
3. garamycin 0.3% drops
4. moxifloxacin 0.5% drops


1. erythromycin oph ointment 0.5%: Apply to affected eyes QID (duration 5-7d) M: 1 bottle

2. fucithalmic 1% drops: apply 1 drop BID to affected eye(s) (duration 5-7d) M: 1 bottle

3. garamycin 0.3% drops: apply 2 drops TID in affected eyes(s) (duration 5-7d) M: 1 bottle

4. [for contact lens wearers, corneal involvment, Rx failure]
moxifloxacin 0.5% drops: apply 1 drop TID in affected eye(s) (duration 5-7d) M: 1 bottle

NOTE: also use warm compresses to clean the affected eye(s) and maintain good hand hygiene

NOTE: if you're on the edge between viral and bacterial conjunctivitis, then you can opt for polysporin drops (OTC).

NOTE: difference btwn fucithalmic vs garamysin eyedrops is that garamysin covers pseudomonas (contact lens wearers); in addition moxifloxacin drops have pseudomonas coverage.

- vision changes / acuity / fields
- eye pain
- photophobia
- eye trauma
- contact lens

1. SSRIs (1st line)
more specifically Zoloft (sertraline)
Prescription:
Zoloft 50mg tablet
Take 1 tablet po od (regularly) x 3 weeks; then 3-4 hrs prn prior to sexual activity M: 30 tablets

2. Clomipramine (2nd line)

1. behaviour modification
2. Kegel exercises
3. Vesicare

Prescription (vesicare)
Vesicare
Take 5mg po od
NOTE: starting dose is 5mg od; max dose is 10mg od

Note: oxybutynin was used for urge incontinence; however, vesicare has fewer S/Es and is much less likely to cause "dizziness" / falls. Both oxybutynin and vesicare are anti-cholinergic agents.

1. postnasal drip
2. reflux

Nasonex 50mcg nasal spray
Take 2 sprays in each nostril od M: 1 device

Note: for nasal sinus congestion, the prescription for nasonex would be
Take 2 sprays in each nostril bid (never prn, because steroids take a while to start working)

Keflex 500mg
Take 1 tablet po qid M: 7d

NOTE: Keflex has a <5% chance of cross-reactivity with penicillin. Given that the patient has a questionable anaphylactic reaction to penicillin, it would be appropriate to prescribe:

Biaxin 500 mg tablet
Take 1 tablet po bid M: 7d

If this patient just had a mild allergic reaction to penicillin, then keflex would be a reasonable choice.

1. epinephrine
2. benedryl (anti-histamine) 50mg IM/IV q4-6h
3. methylprednisone 50-100mg IV

4. (ventolin - nebulized if bronchospasm)
5. (glucagon (for those on β-blockers w/ resistant hypotension and/or cardiac disease)

1. cetirizine 10mg po OD x 3d (H1 antagonist)
2. ranitidine 150mg po OD x 3d (H2 antagonist)
3. prednisone 50mg po OD x 3d (corticosteroid)

6 weeks

For the periodic_bw avoid checking ck and lfts, unless there are indications for checking these.

Baseline ck and lfts can be done prior to starting a pt on a statin; however, followup ck and lfts are no longer required.

MOST COMMON (ROCS and in order of most potent to less potent)
- Risperidone
- Olanzapine (zyprexa, zydis)
- Clozapine (Clozaril)
- Quetiapine (seroquel)

LESS COMMON
- Ziprasidone (Zeldox)
- Aripiprazole (Abilify)

NOTE: ALL OTHERS ARE TYPICALS including Haloperidol (Haldol), Pimozide (Orap), Chlorpromazine

When starting someone on a new medication such as Lithium, Epival, BP meds, it is important to do bloodwork (generally AHE_BW) to see if the levels (including electrolytes) are okay.

? prescribe mood stabilizers
? refer to psychiatrist

True.

Screening for a family history of bipolar disorder
is critical. A positive family history among first degree
relatives increases the likelihood of bipolar II disorder by 8–18 times compared to those with no family history.

True

True

True

Therefore must rule out pregnancy before initiating lithium therapy

NOTE: lithium toxicity can present even at therapeutic levels. Common causes include:
- overdose
- Na or fluid loss
- concurrent medical conditions

CLINICAL PRESENTATION:
- GI: severe N/V + diarrhea
- Cerebellar: ataxia, incoodination, slurred speech
- Cerebral: drowsiness, myoclonus, seizures, delirium, coma, parkinsonian movements

MANAGEMENT:
- discontinue Li for several doses, begin again at a lower dose
- serum Li, Cr, BUN, lytes
- saline infusion
- hemodialysis if Li > 2mmol/L, coma, shock, severe dehydration, failure to respond to treatment after 24 hrs, or deterioration

SIDE EFFECTS of LITHIUM:
GI: N/V, diarrhea, stomach pain, weight gain
GU: polyuria, polydipsia, GN, renal failure, nephrogenic DI
CNS: fine tremor, lethargy, fatigue, H/A
HEMATOLOGICAL: reversible leukocytosis
OTHER: teratogenic (Ebstein's anomaly), edema, psoriasis, hypothyroidism, hair thinning, acne, muscle weakness, ECG changes

LONG TERM may cause:
- nephropathy
- diabetes insipidus

INVESTIGATIONS:
- ahe_periodic, lytes, tsh, β-hcg
- urinalysis
- ECG (if patient >45 yrs old or CV risk)

Before initiating Lithium therapy: must screen for:
1. pregnancy
2. thyroid disease
3. seizure disorder
4. neurological, renal, CV disease

1. bilateral custom orthotics M: 1 pair; Dx: mechanical feet pain
2. custom back support x 1; Dx: back strain
3. graded compression stockings. Below knee. Pressure 20-30mmHg M: 1 pair

NOTE: its best to write these prescriptions separately so that the patient can submit these for insurance purposes.

pediatric aerochamber M: 1 unit

True

B-blockers, ACEi, ARBs, and aldosterone antagonists increase serum potassium levels

furosemide (lasix) and thiazides decrease serum potassium levels

1. Qualia Counseling Services
16 Andrew St
Kitchener, ON N2H 5R2
(519) 742-0500

2. KW Counselling Services
480 Charles St. East,
Kitchener, ON N2G 4K5
P: 519-884-0000

3. Mosaic Counselling and Family Services
400 Queen Street South
Kitchener, ON
N2G 1W7
519-743-6333

Nortriptyline is better tolerated than Amytriptyline

causes:
1. cad (60-70%)
2. htn
3. idiopathic (often dilated cardiomyopathy)
4. valvular (eg. AS, AR, and MR)
5. alcohol (dilated cardiomyopathy)


precipitants:
1. HTN
2. Arrhythmia
3. Infection/Ischemia/Infarction
4. Dietary indiscretions
5. Failure to take meds

l. heart failure

i. bw_ahe, tsh, ferritin
ii. ecg
iii. echo
iv. cxr

True.

Do not skip meals. They should be regular. Otherwise, they can run into hypoglycemic spells

An Ace-inhibitor

INDICATIONS:
-------------------------
HTN
2.5-20mg/d po (divided od-bid)
start at 2.5mg po od

CHF, post-MI
5mg po bid
Start at 2.5mg po bid

Cardiovascular event protection
10mg po od
start 2.5mg po x 1 wk, then
5.0mg po x 3 wk, then
10.0mg po od

NOTE: Ace-i are renally excreted

PLAN:
1. Ramipril 5mg po od x 2 wks; then 10mg po od x 3 months (if pt has diabetes, kidney disease); otherwise chlorthalidone 12.5mg po od x 3 mo
2. BW - Cr, lytes in 2 weeks time (imp. b/c you want to see if anything has changed after starting them on an ACEi
3. f/u in 1 months time for repeat BP

Initially, inc. freq of visits
f/u 2-3 wks; if this is stable, then
f/u in 3 months, if this is stable
f/u in 6 months (therefore when giving prescription, give 3 months + 1 repeat)

Now for elderly frail patients, may need to f/u in 3 months (do take into consideration that it may be hard for them to get to your office in which case f/u in 6 months.

For someone, who is young (42) reliable, checks BP at home, watches their diet, may even f/u in 1 year

True

Ace-inhibitors
B-blockers
CCBs
Diuretics

A with C / D
B with C/ D
C with A / B
D with A / B

Therefore, A is not combined with B,
C is not combined with D.

NOTE: however, in patients with CHF (with or without HTN), ACEi are combined with B-blockers (mortality benefit)

- refractory HTN
- suspected secondary cause
- worsening renal failure

NOTE: hospitalization is required for malignant HTN
i.e. BP often >200/140, papilledema, retinal hemorrhages, bulging discs, mental status changes, inc. creatinine

For elderly patients (>60yrs) with isolated diastolic/systolic HTN, B-blocker monotherapy or combination of ACEi with an ARB are both not recommended.

If she has never had the flu shot before, then she needs to get a booster flu shot 1 month following the first flu shot. Subsequently after this, they do not require boosters.

note: boosters only apply for 1st time flu shot recipients ages 6 months to 9 years.

Ciprodex
4 drops in affected ear BID x 7d M: 1 bottle

Other option is:
garasone otic solution
3 drops in affected ear TID x 7d M: 1 bottle

NOTE: for a pt getting recurrent episodes of otitis externa may use diluted vinegar (1/2 vinegar) 1-2 drops in each ear (this is shown to prevent infections) if tm is intact and not perforated.

1. Naproxen (if minimal relief with advil)
2. physiotherapy/massage therapy
3. icing/heat therapy
4. flexiril (cyclobenzapril) at qhs (sedating, can make pt drowsy)

Prescription for flexiril:
Flexiril 10mg tablet
Take 1 tablet po qhs M: 14 tablets
*note: max dose: flexiril 30mg / day

Flexeril (cyclobenzaprine), is a muscle relaxant medication used to relieve skeletal muscle spasms and associated pain in acute musculoskeletal conditions.

Pulmicort 200
Inhale 2 puffs BID M: 1 inhaler

oral B12
Prescription: none required - this is OTC
Vitamin B12 1000mcg tablet (OTC)
Take 1 tablet po od

NOTE: you need a prescription for vitamin b12 injections
Prescription:
Vitamin B12 1000 mcg/mL Amp
Administer 1cc IM qmonthly M: 1 + 1 repeat

NOTE: foods rich in b12 include meats, eggs, dairy products

b12 levels <300 (as per bloodwork in pss)

Symptoms:
- weakness
- numbness
- paresthesias
- lack of dexterity
- impaired memory
- irritability

This may be interstitial cystitis; but we can't make this diagnosis yet..

Patients can get dysuria with irritation from caffeine. (NOTE this patient drinks ++ coffee)

MANAGEMENT:
- lots of fluids
- cranberry juice
- advil
- send urine for cultures; will treat if positive
- abstain from caffeine x 1 mo to see if there is resolution of Sx
- if recurrent dysuria; then need to completely abstain from coffee (not a drop of coffee) [note: other triggers may include alcohol, artificial sweeteners, and hot pepper]

** INTERSTITIAL CYSTITIS is a diagnosis that should be made by a urologist, so if abstinence from caffiene, or other triggers does not provide relief a referral should be sent. Rx for interstitial cystitis includes: elmiron (pentosan polysulfate), low dose amitriptyline (see TO notes for other management options)

Twinrix (hep A and B)
normal course: 0, 1, 6 months (3 shots)
rapid course: 0, 7d, 21d, 12 months (in case patient is leaving in 2 weeks)

Prescription:
Twinrix: to be injected in office M: 1 vial + 2(3) repeats

- hypotension (lightheadedness)
- H/A
- facial flushing

Discontinue bisoprolol, and start the patient on Cardiazem cd (diltiazem) 120mg po od as directed

Note if unstable angina, send them to the ER.

For stable angina:
1. bw: Hb, fasting glucose and lipids, tsh (in practice: ahe + tsh + ferritin)
2. ekg + 48hr holter, cxr, echo
3. stress test (if really old and you think they can't run on the treadmill, opt for nuclear stress test)
4. +/- angiography

acute management:

(BEMOAN)
B-blocker
Enoxaparin
Morphine
Oxygen
ASA
Nitrates
------------------------------------------------
chronic management:

i. asa 81mg od
ii. ace-i
iii. statin
iv. β-blocker

NOTE:
- for ace-i: coversyl (start 4mg od, double in 2wks to 8mg od (target dose), if able to tolerate; w/ elderly pts start at 2mg od x 1wk, then 4mg od x 1wk, then target dose of 8mg od)
- for statin: crestor 10mg od; may go upto 40mg od if lipids not at target
- for β-blocker: bisoprolol 5mg od (starting and target dose)

MOST LIKELY
1. deconditioning
2. exercise induced asthma

LESS LIKELY
3. anemia (inquired with the patient, periods normal, no blood in stool)
4. CVS problem (no chest pain, no palpitations, color normal)
5. Respiratory problem (not smoking, no drugs, no blood with cough, no fever)

MANAGEMENT (provided physical exam unremarkable)
- reassurance: gradual inc. in intensity to build stamina
- trial of ventolin: 2 puffs before exercise
- if improvement with ventolin, (dx: exercise induced asthma, otherwise deconditioning is the likely dx and it is then important r/o anemia, CVS problem vs resp problem - rtc for further investigations)
- B/W: cbc, ferritin (to do if no improvement with puffer)
- rtc if symptoms ongoing or worsen

They should avoid nsaids (especially in the 3rd trimester); advise patient to avoid it all together to avoid confusion.

Can cause premature closure of the ductus arteriosus in the fetus

note: the ductus arteriosis should close shortly after birth. In the fetal stages it allows oxygenated blood to bipass the lungs as blood moves from the r. ventricle straight to the aorta. If the ductus arteriosis closes prematurely, blood cannot go from the pulmonary artery to the aorta and instead forces its way into the lungs and puts reverse pressure on the r. side of the heart. This leads to:
- r. heart hypertrophy and subsequently failure
- lung damage

Call ENT on call

DDx:
- viral neuritis
- CVA (affecting nerve)

NOTE:
This patient will probably get a steroid injection in the middle ear. An audiogram must be done before the patient is sent in to the ENT specialists office.

Allergic conjunctivitis features:
* eyelid + conjunctival: erythema + swelling
* almost always bilaterally
* pruritis
* tearing / watery discharge
* burning
* photophobia
* other allergic sx

NOTE:
- allergic conditions are often accompanied by significant itch, whereas this is not very common in infection

MANAGEMENT:

General:
- do not rub eyes
- avoid contact with known allergen
- Refresh eye drops for concomitant dry eyes

Prescription (for patients with frequent episodes)
Pataday 0.2%
Apply 1 gtt in affected eye od M: 1 bottle

OTC option if infrequent episodes:
Visine-A

Most likely allergic conjunctivitis,

- could also be dry eyes (unlikely b/c patient had been using eyedrops).


Treatment:
- Pataday eye drops (for allergic conjunctivitis)
- Refresh tear drops for dry eyes


If it is an allergic conjunctivitis, patients symptoms are likely to resolve within 2-3 days. Otherwise, regular use of Refresh tear drops will resolve his dry eyes within a month


note: it is unlikely that this patient has a corneal abrasion, because both eyes are affected, he would be in ++ pain, symptoms would likely not last 3 months

Other DDx:
- viral/bacterial conjunctivities: unlikely b/c symptoms don't last 3 months

Prescription:
Ciprofloxacin 500mg tablet
Take 1 tablet po BID x 3 days. To take only with development of diarrhea (4 or more unformed stools/d, fever, blood/pus in stool M: 6 tablets

For any patient travelling to Asia, latin america, Africa (except S. Africa) you should recommend the following:
- safety precautions and medical insurance
- travel's diarrhea
- prevention: dukoral
- Rx: ciprofloxacin
- typhoid
- hep A/B (twinrix)

Dukoral (non-prescription) is available at most pharmacies; used for prevention of Traveller's diarrhea

A full immunization requires 2 doses taken 1 week apart, with the last dose taken at least 1 week before travel.

Effective once taken last dose for 3 months

Dosing: Adult Immunization:

Oral: (Vivotik)

Primary immunization: One capsule on alternate days (day 1, 3, 5, and 7) for a total of 4 doses; all doses should be complete at least 1 week prior to potential exposure

Booster immunization (with repeated or continued exposure to typhoid fever):

Repeat full course of primary immunization every 7 years
--------------------------------------------------------
I.M. (Typherix)

Initial: 0.5 mL given at least 2 weeks prior to expected exposure

Reimmunization:
Typherix® 0.5 mL every 3 years

≥ 5 attacks meeting each of the following criteria
* 4-72h duration
* 2 of the following: unilateral, pulsating, moderate-severe, aggravated by routine physical activity
* 1 of the following: N/V, photophobia/phonophobia/osmophobia

NOTE: important to ask about aura with migraines

1st Line: Tylenol
2nd Line: Advil
3rd Line: Axert (almotriptan)

Prophylaxis:
1st Line: B-blockers (propanolol)
2nd Line: TCA (amitriptyline, nortriptyline)

Axert (almotriptan) 12.5mg tablet
Take 1 tablet po od prn, may repeat x 1 after 2 hrs prn (max: 2 tabs in 24hr) M: 20 tablets

Axert (almotriptan) is a 'triptan' used for migraines

Prescription:
Axert 12.5mg tablet
Take 1 tablet po od w/ H/A prn, may repeat x 1 after 2 hrs prn M: 10 tablets

1. B-blocker (propanolol)
2. TCA (amitriptyline / nortriptyline)
3. CCB (verapamil)
4. anticonvulsants (divalproex, gabepentin)
-----------------------------------------
1. B-blocker: propanolol
Prescription:
Propanolol
Take 40mg po BID M: 90 tablets (45 days / 6 wks)
rtc if no improvement or minimal improvement;
can increase by 40mg / dose qmonthly upto a max of 160-240mg / d
NOTE: B-blockers should not be used in patients >60yrs or smokers. If they're 60 or more and have an indication to use B-blockers such as a recent MI, then sure.

2. TCA: amitriptyline
Prescription:
Take 10mg po qhs M: 45 tablets
(usual dose 150mg; can increase by 10-25mg qwkly)
Note: if migraines recur after the 45 tablets, long term prophylaxis of 3 months + 1 repeat is acceptable

Others:
CCB: verapamil 80mg po TID

NOTE: for a patient with chronic migraines, at some point it is worthwhile to consider a head CT/MRI (avoid CT if pt young due to radiation harm)

NOTE: For TCA prophylaxis, you can choose between amitriptyline vs nortriptyline. The main difference is that amitriptyline is much more sedating. So if a patient says that they're having difficulty sleeping, then amitriptyline is a better choice. Both TCAs should be prescribed at night time.

NOTE: Nortriptyline is better tolerated than amitriptyline.

Celebrex (celecoxib)
Prescription:
Take 200mg po od M: 90 tablets + 1 repeat

Mobicox (meloxicam)
Prescription
Initial: take 7.5mg po od (may increase upto 15mg/d) M: 90 tablets + 1 repeat

NOTE: these two medications are NSAIDs and patient should be counseled about nsaid use (eg. take not on an empty stomach, renal impairment?, prev GI bleeds?

NOTE: celebrex and mobicox are long acting anti-inflammatories so there isn't much sense in prescribing them prn

Use of the PERC (Pulmonary Embolism Rule-out Criteria) rule can significantly decrease work-up for pulmonary embolism.

To apply this rule, the clinician must first use clinical gestalt to classify the patient as low risk. The PERC rule, which consists of eight clinical criteria including history, physical and vital signs, can then be used. If both of these criteria are met, then there is less than a 2 percent risk that this patient has a PE and no further work-up is needed.

PERC Rule
Age > 50 years
Pulse > 100 bpm
SaO2 < 94% (r. air)
unilateral leg swelling
hemoptysis
recent trauma or surgery
prior PE or DVT
hormone use
*score 1 for each question; a score 0/8 means pt has <1.6% chance of having a pe and avoids further investigation; if any one of these is pos. require further investigations for pe.

1. Well's criteria
2. PERC
------------------------------------
Well's criteria:
i. 3.0 clinical sx of dvt (leg swelling, pain w/ palpation)
ii. 3.0 other diagnosis less likely than PE
iii. 1.5 hr > 100
iv. 1.5 immobilization (≥3d) or surg. in prev 4 wks
v. 1.5 previous dvt/pe
vi. 1.0 hemoptysis
vii. 1.0 malignancy
score ≥5; pe likely
score ≤4; pe unlikely
-------------------------------------

PERC Rule
Age > 50 years
Pulse > 100 bpm
SaO2 < 94% (r. air)
unilateral leg swelling
hemoptysis
recent trauma or surgery
prior PE or DVT
hormone use
*score 1 for each question; a score 0/8 means pt has <1.6% chance of having a pe and avoids further investigation; if any one of these is pos. require further investigations for pe.

perc rule:
- high NPV (when test is negative, that is likely true)
- poor PPV (when test is pos, we're not sure its true)

On DRE:

- smooth
- rubbery
- symmetrically enlarged

MEDICAL MANAGEMENT:

Prescription
Flomax 0.4mg tablet
1 tablet od (30 mins after same meal) M: 90d +/- 1 repeat

If this fails, try substituting or adding
Proscar 5mg tablet
1 tablet od M: 90 tablet + 1 repeat

If both these fail, patient should see a urologist. Note: prior to sending the patient to a urologist a urinalysis, Cr, BUN, PSA, and renal U/S should be done

note: combination of a α-adrenergic antagonist (Flomax aka tamsulosin) and a 5-α reductase inhibitor (Proscar aka finasteride) is shown to be synergistic

note: onset of action for proscar is about 6 months for bph. Proscar is mainly effective when the prostate is large, otherwise it's not very useful

note: 5-α reductase inhibitors stop the conversion of testosterone to the more potent dihydrotestosterone.

1. orthostatic hypotension (pts need to get up slowly or else they may feel lightheaded)
2. H/As

Sexual dysfunction (not common)
- dec. libido
- erectile dysfunction

True

Inc. dose to 32 mg po od.

NOTE: dose effect. It needs to be doubled for it to benefit. Increasing the dose to 20mg won't do much for her HTN

True

Breast milk has very little Vit D in it. Formula includes Vitamin D drops. So if they're getting formula, then they don't need the Vit D drops; however, best to recommend that they can stop taking Vit D drops between 6 months to 1 year; as they'll be getting more solid foods around 6 months and if they're formula feeding.

2 or more Major symptoms are present:

1. nasal congestion / purulent discharge / postnasal drainage
2. facial pressure / pain
3. hyposmia / anosmia

Additionally, the symptoms have become worse after 5d of Sx onset or remained the same after 7d of Sx onset
----------------------------------------------------------

MANAGEMENT
- fluids
- NS rinse (Netipot)
- decongestants (not more than 2d; long acting)
- nasonex
- amoxicillin

Prescription:
1. Nasonex 50mcg
Inhale 2 puffs each nostril BID M: 1 device/inhaler
2. Amoxicillin 500mg tablet
Take 1 tablet po TID M: 5-10d

note: antihistamines are NOT recommended

note: decongestants may raise bp

In chronic sinusitis, Abx do not usually play a major role, For recurrent (4 or more episodes per yr) or signs of chronic sinusitis (8 wks or more of eg: nasal d/c / facial pressure / dec. ability to smell), refer them to ENT to r/o possibility of anatomical abnormalities that may require surgery.

NOTE: you only send them to ENT if they've failed abx treatment. Once the diagnosis of chronic sinusitis is made they should be referred to ENT. Antibiotics such as clavulin (augmented penicillin) or biaxin may be tried for 3-6wks for chronic sinusitis.

In summary, management:
- trial of abx - clavulin (augmented penicillin) or biaxin
- ns rinse
- decongestants (2 or less days; not more)
- intranasal steroid (nasonex)
- referral to ent

Amitriptyline is much more sedating than nortriptyline. Also, nortriptyline is better tolerated than amitriptyline

- sedating, confusion, dec. memory
- dizziness
- h/a
- dry mouth

- inc. appetite
- wt. gain

note: nortriptyline is better tolerated than amitriptyline. amitriptyline is more sedating than nortriptyline

Depomedrol 40mg/mL vial
To be injected in office
M: 1 Days: 1 (this way it will autodiscontinue)

Ativan 0.5mg tablet
Take 0.5-1 tablet po BID prn M: 15 tablets

tylenol elixir with codeine
Take 10mL PO q6h prn M: 4.5L
pharmacy instructions: dispense 1.5L every month

STOOL SOFTENER
PEG stool softener

FIBRE PILLS:
- bene-fibre
- metamucil

eGFR is 'estimated' GFR

NOTE: eGFR tends not to be very accurate at high numbers (eg. 75-90); however, at lower numbers (eg. 32-40) it is quite a reliable estimate. For clinical purposes, we consider an eGFR to mean adequate renal function.

Colace 100mg
1 tablet od M: 3 months repeat: 1

d/ to discontinue Altace (ace-inhibitor)
- contraindicated in pregnancy

usually pregnancy safe HTN meds include:
- labetalol (most common)
- α-methyldopa
- (nifidipine)

note: HCTz is considered safe; however, not as effective

note: The following anti-hypertensives are not appropriate in pregnancy (teratogens)
- ACEi
- diuretics
- propanolol

PRESCRIBE:
Aldara (imiquimod) 5% cream packets
Apply to affected area 3x / week at hs, then wash off in am
M: 3 months

Avoid aldara cream if you can and stick w/ liquid nitrogen or try other options for plantar warts including:
- salicylic acid (compound W)
- cantharidin

BuSpar (buspirone):

buspar
take 7.5mg bid
(can inc. by 5mg/d q3d; max of 60mg/d)

Unfortunately dandruff cannot be entirely cured.

However, to get rid of it,
Nizoral shampoo (OTC)
Apply twice weekly x 8 wks prn; f/u prn

Prescription:
Valisone 0.1% scalp lotion
Apply od prn x 1 bottle R: 1

Cold sores are painful blisters that form on or near the lips and inside the mouth. They are caused by an infection with a virus called “herpes simplex virus.” There are two types of herpes virus. Type 1 causes most cases of cold sores. Type 2, also called genital herpes, usually affects the penis or vagina. Once you have the virus, you're stuck with it for the rest of your life.

MANAGEMENT:
- usually required for 1st time episodes and when symptomatic
Rx:
Valtrex 2000mg po BID M: 2 tablets (1 day)
Start with symptom onset (effectiveness dec. with delay)

For suppression:
Valtrex 500mg tablet
Take 1 tablet po od
(reassess treatment need in 4 months)

Gingivostomatitis (also known as primary herpetic gingivostomatitis) is a combination of gingivitis and stomatitis, or an inflammation of the oral mucosa and gingiva. Herpetic gingivostomatitis is often the initial presentation during the first ("primary") herpes simplex infection. It is of greater severity than herpes labialis (cold sores) which is often the subsequent presentations. "Primary herpetic gingivostomatitis is the most common viral infection of the mouth"

The first time a person gets cold sores, the symptoms can include:

Painful blisters on the lips, mouth, nose, or throat, which eventually pop and form scabs
Mouth and throat pain
Swelling in the neck
Fever, body aches, and feeling ill
After the first time, pain and blisters can come back, but the other symptoms do not usually happen again. Plus, the symptoms are usually milder and don’t last as long.

- estrogen in the combo ocps reduces breast milk secretion so that would not be beneficial in this case
- a progesterone only pill "Micronor" would be reasonable

PRESCRIPTION:
Micronor 0.35mg tablet
Take as directed M: 6 months

NOTE: prescription not given for 1 month with repeats b/c cost of dispensing fee each time. Better to give 6 months or 3 months + 1 repeat. The pharmacy will never dispense more than 1 month the first time for a new med. But thats their problem. Most likely, they'll give 1 month, and the 2 months worth, and then the 3 month refill.

-------------------------------------------------------------

PRESCRIPTION (Domperidone)
Domperidone 10mg tablet
Take 3 tablets po TID x 3 wks; then dec. by 1 tablet/dose q4days until finished M: 270 tablets

bw
- cbc, inr, ferritin
- tsh, prl, lh, fsh, progesterone, NOT estrogen (no indication)
- (β-hcg)

pelvic u/s (r/o mass, fibroids, polyps)



-----------------------------------------------------------------------
note: it is important to do a pelvic exam on this pt; before doing a pelvic exam you have to make sure the pt is NOT pregnant b/c if she is pregnant then placenta previa needs to be RULED OUT by u/s.

note: pt should be treated / referred based on results. If no obv. cause a trial of OCPs is reasonable.

Shouldice Hospital is the global leader in hernia repair. They have a 99.5% lifetime success rate for primary inguinal hernias.

It is a private institution; bed is ~$250 a day.

Reasons for very high success rate are:
- thats all they do (practice makes perfect)
- they're selective about the pt population (generally healthy pts)

It is important because:

A patient who used to smoke and quit ≥10 years has the same risk of CAD as a patient who never smoked.

However, once a patient has a 20 pack smoking hx, lungs are effected, and this is permanent.

NOTE: in PSS (under risk), write smoking vs no smoking (enter quit date and smoking hx)

- order CXR (if not already ordered) - do the Xray at GRH, so that incase you need to refer them to peds, they have the results on their system.
- even if the fever is improving, but is present on the 5th day, more investigations such as urine dip need to be done
- refer them to pediatrics

NOTE: fever is counted as number of days minus 1 (do not include the 1st day)

NOTE: if on Day 4, the Xray results show pneumonia and pleural effusion, they need to be referred to pediatrics

Males: ≤2.0

Females: ≤2.0

There is some evidence that cranberry juice can help prevent UTIs, but not treat the infection once you have it.

PDE-5 inhibitors: (think all in the head + dyspepsia)
- H/A
- nasal congestion / rhinitis
- facial flushing
- dyspepsia

Nitrates:
- H/A
- hypotension (orthostatic, advise to get up slowly)
- facial flushing

Flomax
- H/A
- hypotension (orthostatic, advise to get up slowly)

If severe shortness of breath, she needs to go to the ER; otherwise prescribe:
Lasix
Take 40mg po bid M: 30d

Have them f/u in 1 month, earlier prn;
- at 1 month visit symptoms have improved. Do NOT discontinue lasix altogether; dec. dose

PRESCRIPTION:
Lasix
Take 40mg po od, if wt inc. by 2-3 lbs, take 40mg po bid M: 100 tablets R: 1
- return to clinic prn, worsening shortness of breath

CHF:
Bisoprolol
Initially: take 1.25mg po od; double dose q2wks to target dose of 10mg

Chronic stable angina:
Take 5mg tablet po od (range: 5-20mg)

MORE COMMON
- endometriosis (most common)
- adenomyosis
- PID
------------------------------------------

LESS COMMON
- polps (uterine)
- fibroids (uterine)
- anomalies (uterine)
- intrauterine synechiae
- ovarian cysts
- cervical stenosis
- imperforate hymen, transverse vaginal septum
- IUD - copper
- foreign body

Treatment of dysmenorrhea

Prescription:
Ponstan 250mg capsule
Take 2 capsules at onset of period; then 250mg QID prn
M: 3 days (14 tablets)
NOTE: (take with food)

note: if ponstan does not do much, a trial of naproxen is reasonable.

Prescription
Naproxen
Take 500mg tablet po BID prn M: 30 tablets

Ventolin Hfa 100mcg inhaler
Take 1-2 puffs q4-6h prn M: 1 inhaler repeat: 2

A diabetic pt is automatically placed as high risk for cad (≥20%). Therefore, this pt would be on a statin to lower his/her ldl

PLAN:

1. Prescription
Crestor
10mg od M: 3 months

2. bw_lipids, LFTs (ast, alt), ck in 6wks
3. f/u in 6-7 wks time after bw

Based on the LDL levels, adjustments can be made on the crestor dosage. Max: crestor 40mg od

- vision change / acuity / fields
- eye pain
- photophobia
- no trauma
- ? contact lens

note: important to do an eye exam for PERLA (pupils equal and reactive to light and accommodation)

note: fucithalmic / erythromycin does not cover pseudomonas (contact lens wearers), whereas moxifloxacin drops does cover pseudomonas

Recurrent UTI:
≥ 2 episodes in 6 months
≥ 3 episodes in 12 months

PRESCRIPTION:
Macrobid 100mg
1 tablet po qhs or post-coital M: 90 tablets + 1 repeat

note: drug of choice should be based on urine cultures (therefore you may want to give prescription "90 + 1 repeat" after culture results come back)

patients should be re-assessed following 6 months of therapy. About 50% of women may experience recurrence by 3 months after discontinuation of the prophylactic antimicrobial. If this occurs, prophylaxis may be reinstituted for as long as 1-2 years and remain effective. Women having frequent recurrences, despite prophylaxis, may require genitourinary investigation.

yes

1. viral urti (scuffing of nasal mucosa)
2. dry mucosa (winter time)

Other common causes of epistaxis in kids include:
- nose picking (very common)
- foreign body
- coagulopathies
- trauma

MANAGEMENT:
- humidifier
- nasonex (note this is a steroid, that can be used in kids >2yrs; however, like all steroids this one can make the mucosa dry, so its important to warn parent to use humidifier, and apply moisturizer/vaseline

dec. exercise tolerance initially (1-2 wks), then improvement

MANAGEMENT
- avoid freq. hand washing unless required
- use moisturizers
- apply barrier cream (otc) at work

Prescription:
Elocom 0.1%
Apply to affected areas OD M: 100g + 1 repeat

- the incidency of shingles is 1 in 3
- zostavax dec. the risk of developing shingles by 50%

note: zostavax can be given in anyone ≥50 yrs; it is not covered by ohip and costs about $200-250 per vaccine

- onset (4h-72h)
- unilateral vs. bilateral
- moderate to severe intensity?
- ? throbbing
- ? photophobia / ? phonophobia
- nausea / vomiting
- does activity make h/a worse
- does resting in a quiet dark room relieve the migraine ?

Any Speech and Language Pathologist

Can easily look up a number of places in the KW region

Pupils Equal and Reactive to Light and Accommodation

Evra 200 Mcg-35 Mcg/24Hr Patch
apply 1 patch qwk x 3wk, off x 1wk M: 3 months

- Instructions to pt: start on day 1 of menstrual cycle or 1st sunday after onset of menses

- restart >2wk after surgery w/ VTE risk
- restart >3wk postpartum or >6wk postpartum if breastfeeding

You start fentanyl at 25mcg/hr patch. For this they must be at an equivalent of at least 60mg of morphine daily.

That fentanyl patch in Canada is called "Duragesic". The patch is not for "acute" pain. It must be changed q3days

For a patient with an MI (myocardial infarction), the guidelines recommend β-blockers; however, the benefit of β-blockers is only till the first 3 years post an MI.

For congestive heart failure (CHF), the guidelines recommend Ace-I and β-blockers for mortality benefit; however, evidence shows that these 2 drugs have mortality benefit only in systolic CHF with an ejection fraction of <40%.

There is no benefit in diastolic heart failure.

spirometry is part of PFTs (pulmonary function tests)

PFT equals:
i. spirometry
ii. lung volume assessment
iii. diffusion capacity calculation

PFTs are more useful when you're suspicious of a restrictive lung disease. If you're just concerned between distinguishing COPD from asthma, then spirometry is sufficient.

- hormonal imbalance
- fibroids
- adenomyosis
- uterine polyps
- copper IUD

- β-hcg
- cbc, lytes, inr, ferritin
- lh, fsh, tsh, prl, (estrogen), progesterone, (dhea)

Prazosin
Initial: 1mg po qhs
Titrate: by 1mg po every 3 days upto a max dose of 15mg daily

i. cbt
ii. medications
- SSRIs
- benzos (avoid due to strong addictive potential)
- atypical antipsychotics (quetipine, olanzapine, risperidone)
iii. EMDR (eye movement desensitization and reprocessing)

NOTE: for ptsd-related nightmares and sleep disruption, the following is used:

Prazosin
Initial: 1mg po qhs
Titrate: by 1mg po every 3 days upto a max dose of 15mg daily

No

They both function to inc. the amount of incretins
- januvia works by inhibiting dpp-4 (enzyme that eats away at the incretins released by the GI tract) and by delaying gastric emptying
- victoza = injecting incretins SC - get absorbed into the blood

Similarly insulin should not be used w/ diamicron. No point as diamicron is a secretagogue.

note: for practical purposes advise/prescribe the following creams tid (3x/d)

i. polysporin (otc)
apply to affected areas od-tid

ii. fucidin 2% cream M: 30g repeat: 1
apply to affected areas bid-qid (duration usually 10d)

iii. Fucidin H cream
(fucidic acid 2% - hydrocortisone 1%)
Apply to affected areas tid M: depends
(duration usually 10d)

iv. bactroban 2% cream
Apply to affected areas tid M: 30g R:1
(NOTE: how much you give depends on the area)
(duration usually 10d)

note: fucidin H cream is 2% fucidin and 1% HC. This should be prescribed for treating an infection + inflammation. Fucidin H cream is prescribed TID

In a CHF exacerbation, patients may have severe sob. If the patient is palliative, then an opioid will reduce the respiratory drive (the need to breath) and provide some relief for their sob.

inc. risk of seizure

It decreases your seizure threshold. Hence, you are more likely (odds are still quite low) to get a seizure

lightheadedness

People should not be put on januvia and victoza together. Both increase amount of incretin in blood stream. Victoza does this directly and Januvia inhibits the enzyme dpp-4 (enzyme that breaks down incretins secreted by the GI tract)

True

osteoarthritis (knee)

- minimal benefit for pain relief based on trials
- dose studied was 500mg TID
- should not be given to patients w/ shellfish allergy
- also comes in a combination of glucosamine (500mg) + chondroitin (400mg) taken TID

note: COX 1 and 2 are key enzymes in the inflammatory cascade of the body. When these two enzymes are inhibited, the production of arachidonic acid is blocked, thereby decreasing the amount of prostaglandin G2 (PGG2). As a result of decreased PGG2, there is a decrease in the production of prostaglandins, important factors in inflammation, pain and fever, as well as a decrease in the production of thromboxanes which normally activate platelets and cause constriction of blood vessels.

ADVIL is a non-selective nsaid that inhibits cox1 and cox2 enzymes. It is the shortest acting of the three drugs (can be taking q4h prn).

NAPROXEN is v. similar to advil in that it inhibits both cox1 and cox2. Main difference is that naproxen is longer acting ie. an intermediate-acting nsaid (taken bid prn)

CELEBREX (mobicox is similar) is a selective inhibitor of COX2. It does not inhibit COX1 and therefore is less likely than advil or naproxen to cause adverse gastric S/Es such as bleeding. It is a long acting nsaid (taken od prn)

- osteoarthritis (200mg od)
- rheumatoid arthritis (100-200mg bid)
- ankylosing spondylitis (200mg od)
- dysmenorrhea (200mg bid)
- acute pain (200mg bid)

- impaired renal function
- gastric / peptic ulcers
- cardiovascular disease inc. heart failure
- nsaid allergy
- ongoing treatment w/ anticoagulants / coagulopathy
- pregnancy (may lead to premature closure of DA)
- caution in pts > 80 yrs
- caution in asthmatics

---------------------------------------------------------------------------------

So if a patient needs NSAIDs and they have some inflammatory condition like a bursitis, you give them alternatives, like icing and tylenol (inflammation subsides on its own), or you give them NSAID + PPI or a combination pill (vimovo), or a topical anti-inflammatory such as Voltaren gel.

Best option is corticosteroid injection (not typically done the GP office)

Other option is prednisone (eg. prednisone 50mg od po M: 5d (short duration; no tapering required)
NOTE: make sure to mention rare possibility of avascular necrosis

DO NOT prescribe allopurinol for an acute gouty flare as this can makes things worse.

An acute gouty attack may mimic cellulitis; however, joint mobility is preserved in cellulitis.

Gout is a clinical diagnosis

However, investigations include:
i. serum uric acid levels
ii. joint aspirate --> crystals of monosodium urate (negatively berefringent, needle shaped)
iii. xray (may show punched out lesions)

NOTE: serum uric acid is good for baseline; however, cannot diagnose or rule out gout as normal levels appear w/ acute flare ups

DRUGS (pneumonic = fact)
furosemide
asa / alcohol
cytotoxic drugs
thiazide diuretics

FOODS (pneumonic = salt)
shellfish
anchovies
liver / kidney
turkey
sardines (a type of fish)

Gout is also associated in pts with
- htn
- dm
- obesity
- starvation
- dehydration
- trauma, illness, and surgery

True

To prevent tolerance, the main strategy would be to use it intermittently w/ adequate nitrate-free intervals.

NOTE: tolerance would not be a problem for nitroglycerin spray or SL; however, the patch would cause tolerance

nitroglycerin SL (tablet)
take 0.3mg tablet SL q5minutes prn; maximum 3 doses within 15 minutes M: 30 tablets

nitroglycerin spray
take 0.4mg/dose spray q5minutes prn; maximum of 3 sprays within 15 mintues M: 1 device + repeat: 1

nitro-dur (patch)
apply 0.2(0.4)mg/hr patch for 12 hours on, then 12 hours off M: 90 patches (check what the Mitte should be ?????)
note: max is 0.8mg/hr patch

note: for acute stable angina, the tablet (SL) and spray would be more effective than the patch (nitro-dur); however, for angina prophylaxis the patch would be a better option OR the nitroglycerin SL tablet / nitroglycerin spray can be taken 5 minutes prior to strenuous activity.

transmission:
- parenteral (transfusion, iv drug use, sexual)

management:
- prevention: no vaccine
- Rx: α-interferon SC injection wkly and ribavarin po bid (only 50-80% success rate, s/e common)

prognosis:
- chronicity 80%; 20% of these develop cirrhosis
- hepatocellular carcinoma in 2-5% of cirrhosis / yr
- may develop b-cell non-Hodgkin lymphoma

transmission:
- fecal-oral route

management:
- general hygiene
- treat close contacts (w/ anti-HAV Ig)
- prophylaxis for high risk grps unless immune

prognosis:
- no chronicity
- virus clears up on its own

transmission:
- parenteral (transfusion, iv drug use, sexual)
- vertical

management:
- prevention: HBV vaccine and / or hep b Ig (HBIG) for needlestick, sexual contact, infants of infected mothers unless already immune
- for chronic hep b: minimize alcohol, and Rx w/ interferon, adefovir etc (see. toronto notes/uptodate)

prognosis:
- chronic in 20% of pts

- blurry vision
- dry mouth
- difficulty urinating
- constipation

for 1°, 2°, early latent:
- PenG 2.4M U IM x 1

for 3°, late latent:
- benzathine PenG 2.4M U IM wkly x 3

if allergic to penicillin: doxycycline 100mg po bid x 14d

note: neurosyphilis requires PenG 18-24M U/d IV x 10-14d

ODB = Ontario Drug Benefit program that covers most of the cost of 3,800 prescription drug products, some nutrition products and some diabetic testing agents. The list of products covered by the ODB program is called the "Formulary". Some products listed on the Formulary will only be funded in limited circumstances and/or for a limited duration in time.

As well, under special circumstances the Exceptional Access Program may cover most of the cost of an additional 850 prescription drug products that are not on the Formulary for people in the ODB Program. Your doctor must apply on your behalf. Approval must be given by the ministry before a drug will be funded by the program if it is not on the Formulary.

To qualify, an Ontario doctor or other authorized prescriber must prescribe the drugs and you must buy them from either:

an accredited Ontario pharmacy OR
an Ontario doctor who is licensed to sell prescription drug products and is linked to the ministry’s Health Network System.

-----------------------------

You are eligible for ODB program benefits if you live in Ontario, you have a valid Ontario health card and at least one of these statements applies to you :

- 65 years of age or older
- live in a Long-Term Care Home or a Home for Special Care
- enrolled in the Home Care program
- have high drugs costs relative to my income and are registered in the Trillium Drug Program
- receive social assistance through Ontario Works or the Ontario Disability Support Program.

NOTE: nitrofurantoin / macrobid is CONTRAINDICATED between 36-42 wks GA, and during labour due to the possibility of hemolytic anemia.

NOTE: septra is contraindicated in the 1st trimester b/c it may limit availability of folic acid to the fetus as well as the last 6 wks of pregnancy as it may cause kernicterus

For the contraindications, consider instead using amoxicillin 500mg tid x 7d or keflex 500mg qid x 7d

stage I: GFR≥90 ml/min
stage II: GFR 60-89 ml/min
stage III: GFR 30-59 ml/min
stage IV: GFR 15-29 ml/min
stage V: GFR <15 (or dialysis)

prescription:

- cefixime 400mg tablet
2 tablets (800mg) x 1 M: 2 tablets
AND
- doxycycline 100mg bid M: 14 days

Note: this is reportable and any partners must be treated

MUST HAVE:
- lower abdo pain
- CMT
- adnexal tenderness

PLUS 1 or more of:
- fever
- mucopurulent cervical d/c
- high risk partner
- positive culture for N. gonorrhea or C. trochomatis, E. coli or vaginal flora
- leukocytosis
- cul-de-sac fluid, pelvic abscess or inflammatory mass on u/s or bimanual
- elevated crp or esr

cefixime 800mg x 1
PLUS
azithromycin 1g x 1

Note: this is reportable and any partners must be treated

azithromycin 1g x 1

Note: this is reportable and any partners must be treated

cefixime 400mg x 1
PLUS
azithromycin 1g x 1

Note: this is reportable and any partners must be treated

- anticholinergic s/e: blurry vision, dry mouth, constipation, urinary retention
- antihistaminic s/e: sedation, drowsiness
- antiadrenergic s/e: postural hypotension, impotence, failure to ejaculate

- metabolic s/e - weight gain, hyperglycaemia, hyperlipidemia (NOTE these are not typically present in TYPICAL antipsychotics)

---------------------------------------------------

Distinguishing s/e of ROCS (atypical antipsychotics)

- Risperidone (Risperdal): EPS (more likely)

- Olanzapine (Zyprexa, Zydis): ++ wt gain compared to the others (assoc with diabetes and hyperlipidemia)

- Clozapine (Clozaril): 1% risk of agranulocytosis (required to do weekly blood counts for at least 1 month, then biweekly)

- Quetipine (Seroquel): Most sedating

1. check FOBT vs colonscopy dates
2. increase fibre intake; benefibre (otc) vs. metamucil (otc); consider stool softener
3. tylenol prn (if pain)
4. sitz baths
5. anusol HC 1%

NOTE: anusol hc comes in 0.5% (otc), 1%, and 2.5% (avoid the 2.5% cream because the rectal skin area is quite thin; the 1% cream is ideal.

Prescription (in pss):
Medication: Anusol HC
1% cream; apply to affected area tid and after bowel movement prn M: 15g repeat: 1

Nystatin
- topical antifungal
- not absorbed systemically

Prescription:
Nystatin 100,000/mL suspension orally 1mL qid M: 7 days

NOTE: it is best to treat the mum as well, because she may have thrush on the nipple(s) and can pass it on to the baby after it's treated.

Prescription (mum):
Nystatin 100,000 units/gram cream
apply tid x 7 days M: 15 grams

daughters - Amy 1986, Lisa 1988, husband Spencer (job)

ahe bw **given** (or ahe 04/14)
fobt **given** (or 'no fobt b/c age >75')
pap 03/14 (or write 'no pap b/c hyst 1990' or 'no pap b/c age>70')
bmd 04/14
mammo 08/14 (or 'no mammo given age>75')



note: if the pt is >70 and has had 3 or more normal paps in the last 10 years, then paps can be stopped; however, they should be continued if they've had 1 or more abnormal paps

i. framingham risk calculators
http://www.framinghamheartstudy.org/risk-functions/index.php

ii. 10yr risk of having a heart attack
http://cvdrisk.nhlbi.nih.gov/calculator.asp
note: this risk assessment tool assumes the pt is free of coronary heart disease, intermittent claudication and diabetes, and is between ages 30-79
Variables include: age, gender, total cholesterol, hdl, smoking status, SBP, yes/no for htn Rx

iii. 10yr risk of developing 'general' cardiovascular disease (coronary death, MI, coronary insufficiency, angina, ischemic stroke, hemorrhagic stroke, transient ischemic attack, peripheral artery disease, heart failure); this is for individuals aged 30-74 and w/o cardiovascular disease at baseline examination.
http://www.framinghamheartstudy.org/risk-functions/cardiovascular-disease/10-year-risk.php#
- once at this site scroll down and choose --> risk score calculator --> interactive --> using lipids
Variables include: age, gender, sbp, yes/no for htn Rx, smoking status, diabetes status, hdl, total cholesterol

iv. cholesterol conversion:
http://www.onlineconversion.com/cholesterol.htm

-------------------------------

NOTE: the 10 yr risk of developing 'general' cardiovascular disease should probably be used for determining management of pts' risk factors such as lipids, bp, smoking etc. as this tool is more inclusive; whereas, the 10yr risk of having a heart attack is very specific and underestimates the probability of general heart disease

NOTE: in PSS, the calculator resembles the 10yr risk of developing 'general' cvd; therefore that is a good option as well.

NOTE: the PSS calculator for predicting 10yr risk of cvd includes the following predictors: age, gender, hdl, total cholesterol, sbp, diabetes status, smoking status, established cvd (stroke, mi, angina, claudication), yes/no for htn Rx, 1° relative w/ CAD before 55

30%

Therefore, if a patient has a 10 yr risk of 6% you're reducing the risk by 1-2%. So even if the LDL is 5.05 which is >5, why put them on a statin unless they have familial hyperlipidemia.

In someone with a 10 yr risk of 30% you would be reducing the risk by 9% by using statins; therefore much more useful in this group.

Before deciding whether or not to put a pt on a statin (s/e of myalgias and liver toxicity) use the framingham 10yr general cvd risk assessment tool to see if the pt is a mild, mod, or high risk of developing cardiovascular disease.

Diane-35 is indicated for acne control; however, other ocps like Alesse and Tri-cyclen Lo have some benefit for improving acne.

note: Diane is not typically marketed as an ocp, it is more for acne control; however, in theory it should be an effective ocp.

i. HIV
ii. Gonorrhea
iii. Chlamydia
iv. Syphilis
v. Hep B,C,D

False. Metformin is NOT associated w/ weight gain.

Insulin is associated with more rapid weight gain. Its a viscous cycle. The fatter you get the more insulin resistance you get and you require more insulin. The more insulin you take the fatter you get.

True

stress

6-12 months: if 1st or 2nd episode

2 years:
- if third episode
- elderly
- psychotic features
- refractory depression
- >2 episodes in 5 years

HRT Benefits:
- protect against colon cancer
- protect against osteoporotic #s

HRT Risks:
- invasive breast cancer (no inc. risk w/ 1st 5 yrs of use)
- coronary heart disease
- stroke
- DVTs or PEs
- Dementia and mild cognitive impairment: women taking estrogen-alone before the age of 65 were less likely to develop dementia, however there was a 50% inc. risk of developing dementia when taken after 65 yrs of age (those taking combined HRT were at even greater risk)

- can be given orally or transdermally (eg. patch, gel)

- TRANSDERMAL is preferred in women with hypertriglyceridemia or impaired hepatic function
- must be given in lose doses

Osteoporosis is the single most important health hazard associated with menopause.

Cardiovascular disease is the leading cause of death post-menopause.

vasomotor instability

- HRT should be prescribed at the lowest effective dose (0.3mg Premarin) and the duration of treatment should be short (<5 yrs)

ABSOLUTE CONTRAINDICATIONS

ABCD

- Acute liver disease
- undiagnosed vaginal Bleeding
- Cancer (breast/uterine)
- DVT (thromboembolic disease)
---------------------------------------------------


RELATIVE CONTRAINDICATIONS

Relative contraindications include:
- pre-existing uncontrolled HTN, familial hyperlipidemias, migraine H/As
- DM (w vascular disease)
- gallbladder disease, hypertriglyceridemia, impaired liver function (consider transdermal estrogen)
- uterine fibroids and endometriosis
- fibrocystic disease of breasts

- abnormal uterine bleeding
- mastodynia (breast tenderness)
- edema, bloating, heartburn, nausea
- mood changes (progesterone)

It is given in combo with estrogen for women with intact uterus to prevent development of endometrial hyperplasia or cancer.

A women who has had a hysterectomy can be given unopposed estrogen.

period of time surrounding menopause (2-8 yrs preceding + 1 yr after last menses) characterized by fluctuating hormone levels, irregular menstrual cycles, and symptom onset

relative risk is 1.3, therefore periodic surveillance and counselling is required. However, the absolute risk is very very low.

The 1.3 risk is associated with only the estrogen + progesterone HRT, but not with estrogen-only HRT

note: there is no inc. risk at <5 years. The risk mentioned above applies to women taking HRT >5yrs

i. physiological (average age 51 - follicular atresia)
ii. premature ovarian failure, before age 40 (autoimmune disorder, turner's syndrome, infection)
iii. iatrogenic - (surgical/radiation/chemo)

note: menopause is defined as absense of menses for 1 yr

- erythema
- pain
- warmth
- swelling
- bleeding/pus/fever

Food triggers for IBS include:
- milk products
- egg yolks
- fatty foods
- spicy foods
- beans and lentils

NOTE: it is often hard to pinpoint what the trigger food for one particular individual is; therefore, a food diary is very beneficial in isolating the cause.

HbA1C

Therefore is a patient comes in and says that his/her BG levels have been ranging from 5-7; but his/her HbA1C comes out to 11, be very skeptical.

This patient will likely have to go on insulin; b/c each of the antiglycemic agents reduce HbA1C from 1-2%.

NOTE: All of the above being said, HbA1C can be misleading sometimes. An HbA1C can be 7 is a pt is having sugars that are lows half the time, and highs the other half to balance the HbA1C to a nice middle number such as 7. Therefore, be cautious of a good HbA1C reading if the pts blood sugars are in the extremes. It is beneficial to look at the pts sugar diary.

- Discuss not to pop or scratch lesions otherwise there is a risk of permanent scarring

Must always wash, rinse, and dry area before applying cream/gels

1. Benzoyl peroxidase Gel 5-10% apply to affected areas bid M: 30g with 1 repeat (Must tell patient that this may cause bleaching of clothes sheets); if patient does not want to try this then try Stievamycin

2. Stievamycin mild gel apply to affected areas qhs M: 30g with 1 repeat

- recent hospitalization
- recent antibiotic use
- age > 65
- immunosuppression

Patients:
- must have regular activity levels
- must have meals at consistent times (eating regularly); b/c if you miss a meal, you run the risk of hypoglycemia

Ace-I and ARBs

- Ace-inhibitors is better for vascular and renal protection
- ARBs work equally well but have been studied less than Ace-i

i. What is the most likely problem?
ii. What are the alternatives (DDx)?
iii. What must I not miss?

No. studies show that there is no added benefit

The only case where ARBs are given with ACE-inhibitors is CHF (the benefit is not for mortality; only for hospitalization)

Chlorthalidone

90% of pharyngitis is viral; if suspicious of bacterial pharyngitis, then:

amoxicillin 40 mg/kg/day divided BID / TID; note: (max 3g/day) M: 10d

β-blockers

- to r/o electrolyte imbalances

90% of pharyngitis is viral; if suspicious of bacterial pharyngitis, then:

penicillin V 600mg po BID M: 10d

b-blockers

True

This is b/c a switch from depression to mania can occur.

When prescribing anti-depressants, it is very important to be particularly vigilant over the first 2 weeks of therapy as neurovegetative Sx may start to resolve while emotional and cognitive Sx may not (patients may be particularly at risk for suicidal behaviour during this time)

r/o pyelonephritis

Check for
- suprapubic tenderness
- check for CVA tenderness

Must r/o fever

ciprodex otic suspension 4 drops BID M: 7d

ONSET OF EFFECT:
- neurovegetative Sx: 1-3 wks
- emotional/cognitive Sx: 2-6 wks

amoxicillin 80mg/kg/day divided BID / TID (max 3g/day)
M: 5d in children ≥ 2 yrs
M: 10d in children < 2 yrs or recurrent otitis media

True

ciprodex otic solution 4 drops bid M: 7d

amoxicillin 500mg tid M: 5d

- Diuretics eg. chlorthalidone

NOTE: both diuretics and Ace-inhibitors are equally effective; however, diuretics are cheaper, so we use these in younger patients.

cellulitis of the face or diabetic foot

i. common migraine: no aura
ii. classic migraine: with aura
iii. complicated migraine: with severe/persistent sensorimotor deficits

If it shows >15 apneic episodes / hr of sleep with arousal

NOTE: apneic episodes can last from 20 seconds to 3 minutes; can have 100-600 episodes/night

MILD
Keflex 500mg po QID M: 7d with f/u prn

MODERATE
For moderate cellulitis M:10d with f/u prn
---------------------------------------------
In children:
Keflex 50-100mg/kg/day divided q6h (upto a max of 2000mg/day
M:7 (mild) M: 10 (moderate) with f/u prn

- sleep on side (position therapy)
- weight loss
- nasal dilators
- tongue-retaining devices
- mandibular advancement devices

- genetic predisposition
- advanced age
- obesity (for knee OA)
- female
- trauma

RFs for DM type I:
- personal or family hx of autoimmune disease

DM type II:
- first degree relative with DM
- age >40
- obesity, HTN, hyperlipidemia, vascular disease
- prior GDM, macrosomic baby
- PCOS
- hx of impaired glucose tolerance or impaired fasting glucose
- presence of complications assoc. with diabetes
- members of high risk populations (SE Asian, hispanic, Africans, Aboriginals)

Antibiotics:

i. erythromycin ophthalmic 0.5% ointment Apply 1 cm ribbon tid to affected eye x 7 days M: 3.5g + 1 repeat

ii. Fucithalmic 1% eye drops Apply bid x 7 days M: 1 bottle

Analgesia:
- Ketorolac ophthalmic 0.5% 1 gtt in eye qid x 7 days M: 1 bottle

Photophobia:
- homatropine 5% solution Apply 1-2 gtt q3-4 h x 4d M: 1 bottle

True

INDICATIONS

Diagnostic:
- CNS infection (meningitis, encephalitis)
- Inflammatory disorder (MS, Guillain-Barre, vasculitis)
- Subarachnoid hemorrhage (if CT negative)
- CNS neoplasm (neoplastic meningitis)

Therapeutic:
- to administer anesthesia
- chemotherapy
- contrast media
- to decrease ICP (pseudotumour cerebri, normal pressure hydrocephalus)
_________________________________________________

CONTRAINDICATIONS

- mass lesion causing increased ICP - could lead to cerebral herniation (requires CT first)
- infection over lumbar puncture (LP) site
- low platelets or treatment with anticoagulation (high INR or aPTT)
- uncooperative patient

- Deep, labored breathing often associated with severe metabolic acidosis particularly diabetic ketoacidosis (DKA).

asymmetrical

Screen every 3 years starting at age 40; if one or more RF can screen earlier.

L sided heart failure

- x ray* (most important and relevant)

other tests include:
- CBCs and ESR (should be normal)
- RF and ANA (should be negative)
- synovial fluid analysis: should be non-inflammatory

i. sexual dysfunction (upto 90% incidence) - dec. libido, potency (males), ejaculation and orgasm
ii. GI s/e: n/v, diarrhea, bloating, cramps
iii. h/a, tremor, insomnia, sedation
iv. dry mouth, sweating

Low potency:
- anticholinergic: dry mouth, blurred vision, constipation, urinary retention
- antiadrenergic: orthostatic hypotension, impotence, failure to ejaculate
- antihistaminic: sedation

High potency:
- EPS (dystonia, akathisia, pseudo-parkinsonism, dyskinesia)
- neuroleptic malignant syndrome (allergic rxn)

BP <130/80

Lipids:
- LDL <2.0 M
- TC/HDL <4.0 M

History:
- any urinary changes, blurry vision, energy levels, numbness or tingling sensation anywhere?
- any hypoglycemic spells: confusion, sweating, tremors, chills, palpitations, seizures?
- have you been monitoring your BG levels? how often? Taking meds regularly
- currently smoking? If BP high ask: headaches, dizziness
- diet, exercise
- last time seen by ophthalmologist

Physical exam:
- Vitals: BP, weight, BMI, WC
- CVS (N S1 and S2, any murmurs?)
- Feet: sensation, pinprick, vibration sense, pulses, ulcers
- Fundus (normal/abnormal)

Investigations:
- fasting blood sugars
- fasting lipids: cholesterol, TG, LDL, HDL
- microalbumin:creatinine ratio
(yearly ECG if age>35, yearly urinalysis)
- yearly eye exam (optometrist)

- elevated levels indicated uncontrolled DM
- an indicator of subclinical CV disease
- marker of vascular endothelial dysfunction
- an important prognostic marker for kidney disease (in DM, HTN, post streptococcal glomerulonephritis)
- a RF for venous thromboembolism

severe esophagitis

- post-menopausal decline in estrogen (worsens with age): most common cause

- corticosteroid therapy: second most common cause of osteoporosis. (note: individuals receiving ≥7.5 mg of prednisone daily for over 3 months should be assessed for bone-sparing therapy)

OTHER MEDS:
- ASA - for all diabetics unless contraindicated
- Statins: as required to attain target lipid profile
- ACEi: all HTsive patients with DM, elevated microalbuminuria (30-300mg albumin in 24h), overt nephropathy (>300mg albumin in urine in 24h). NOTE: ARBs are 2nd line for these conditions

r sided heart failure

- 2 uncomplicated UTIs within 6 months OR

- ≥ 3 positive urine cultures in the prior 12 months

In an elderly patient if there is no back pain midline, then the patient is unlikely to have a compression fracture. Must document specifics of back pain eg. lower right buttock.

NOTE: when doing a back exam on an elderly pt c/o of back pain, its important to check for midline back tenderness as they may have a compression fracture.

Contraindications (absolute):
- moderate to severe liver dysfunction
- moderate renal dysfunction
- cardiac dysfunction

Anemia (possible upper GI bleed)

True

otc
Ca 1200mg od
Vit D 2000iu od

ANTI-RESORPTIVE THERAPY
- bisphosphonates (risedronate [actonel], alendronate [fosamax])
- monoclonal Ab (denosumab)
- estrogen (1st line in women with menopausal Sx)
- SERM (raloxifene)

BONE FORMATION THERAPY
- PTH (teriparatide)

OTHER DRUGS
- HRT
- calcitonin

NOTE: severe esophagitis is a major side effect of bisphosphonates

EXCEPT during pregnancy and / or pre-op GU procedures, there are NO indications for screening or therapy for asymptomatic UTI (including the elderly)

-------------------------------------------------------------------------

i. Macrobid 100 mg BID (contraindicated in pregnant patients at term (36-42 wks GA), during labour and in neonates due to the possibility of hemolytic anemia)
ii. Amoxicillin 500mg TID

- GU procedure: immediately before procedure and for its duration, unless there is an indwelling catheter present
- Pregnancy: If positive, treat with 3-7d course therapy

All men and women ≥ 65 should get bone mineral density testing.

Its a combination steroid cream that is used for hemorrhoids.

0.5% - otc
1-2% - prescription (usually favor the 1% b/c area of thin skin)

Prescription:
anusol hc 1% cream
apply to affected area tid and after bowel movement prn

1. height loss >3cm (Sn 92%)
2. weight <51 kg
3. kyphosis (Sp 92%)
4. tooth count <20 (Sp 92%)
5. grip strength
6. armspan-height difference > 5cm (Sp 76%)
7. wall-occiput distance >0cm
8. rib-pelvic distance ≤2 finger breaths (Sn 88%)

i. TMP/SMX 5-10mg/kg/day divided q12h x 7d
ii. Nitrofurantoin 5-7mg/kg/day divided q6h. Should not be used in infants <1mo of age; M: 7d

NOTE:
- in pss, when searching for septra,
- type in "trimeth" and you'll see a suspension form
---------------------------------------------------

Septra (note in pss, you can't search for septra so you have to type it in manually as follows)

Prescription:
Septra DS
1 tablet bid M: 5 days (even though guidelines say 3d)

True

What their BP is. Elevated BP could mean pre-eclampsia

Also would wanna know if:
- any edema, h/a, blurry vision, n/v, lightheadedness

True

Viral

Viral: rhinovirus, influenza, parainfluenza

Bacterial: s. pneumoniae, H. influenza, m. catarrhalis, anaerobes (dental)

NOTE:
- acute viral rhinosinusitis lasts <10d
- if symptoms increase after 5d or persist >10d, then consider bacterial etiology

Screening should be with full fasting lipid profile in males > age 40, females > 50 or who are menopausal, or any adults at any age with additional CAD RFs EVERY 1-3 years.

These RFs include:
- diabetes
- smoking
- HTN
- obesity
- family hx of premature CAD
- clinical signs of hyperlipidemia (xanthelasma, xanthoma, arcus cornealis)
- evidence of atherosclerosis
- rheumatoid arthritis, SLE, psoriasis
- HIV infection on highly active antiretroviral therapy
- chronic kidney disease (estimated GFR <60 ml/min
- erectile dysfunction

Screen children with a family hx of hypercholesterolemia or chylomicronemia

note: other causes of dyslipidemia include:
- hypothyroidism
- alcohol abuse

Bacteria (~90% of otitis externa)

- most common organism is Pseudomonas, which is why otitis externa is treated w/ ciprodex.

i. mild/moderate acute prostatitis

ciprofloxacin 500mg BID x 14d

After 14d re-assess, once acute symptoms have resolved, an addition 2-4 wks of oral therapy (based on C+S) is indicated.

If no / incomplete resolution of Sx after 6 wks of total treatment, a referral to urology is indicated.

---------------------------------------------------------------------

ii. severe acute prostatitis

These pts need to be admitted and treated with:

- ampicillin IV 1-2g q4-6h PLUS gentamicin IV 6mg/kg q24h

metronidazole 2g [single dose]

NOTE: must treat partners as this is sexually transmitted

NOTE: treatment is NOT recommended for asymptomatic pregnant women

- result of long term topical nasal decongestant abuse
- loss of vasomotor tone so nasal mucosa is swollen, with clear rhinorrhea
- rebound swelling of mucosa when topical decongestant is stopped
- if abuse continues, nasal mucosa becomes thin, irritated, red, and may bleed
- Treatment: stop the abuse: sometimes saline/topical steroid helps the patient while they are trying to break this habit
- if not successful and late stage disease occurs then nasal hydration with saline sprays and ointments is all we have to offer them

ASYMPTOMATIC PATIENTS:
- Treatment is unnecessary unless high risk pregnancy (eg. prior pre-term delivery), prior to IUD insertion, gynecological surgery, induced abortion, or upper tract instrumentation

SYMPTOMATIC PATIENTS:
- metronidazole 500mg BID x 7d

NOTE: no treatment is needed for male sexual partner

Pathologic skin picking (PSP) is the repetitive manipulation of the skin, with or without instrumentation, resulting in visible tissue damage and impairment in social functioning. Patients with PSP may present with features of impulse control disorder, obsessive compulsive disorder, or both. Multiple psychiatric comorbidities are associated with PSP, including depression, bipolar disorder, obsessive compulsive disorder, alcohol abuse or dependance, and trichotillomania.

PSP appears as excoriated, polymorphic lesions of variable size in all stages of evolution, localized most frequently on the face. PSP should be differentiated from the excoriations seen in subgroups of patients with primary pruritic skin conditions, chronic pruritus associated with systemic diseases, or other psychocutaneous diseases.

Psychiatric referral is appropriate for patients with PSP, although many patients will not accept it. Patients with PSP should be either comanaged by a mental health specialist and dermatologist, or managed by a specialist who has experience in both psychiatric and dermatologic disorder.

For patients with associated intense pruritus, we suggest POTENT topical corticosteroids or intralesional triamcinolone acetonide (Grade 2C). For patients with acne excoriée, aggressive treatment of the underlying acne should be initiated. Patients with skin infections should be treated with topical and/or systemic antibiotics.

We suggest pharmacotherapy for patients with skin picking behavior whose severity interferes with daily functioning (Grade 2C). When pharmacotherapy is selected for the treatment of PSP, we suggest an SSRI antidepressant (Grade 2C). Evidence is limited, but we typically initiate treatment with fluoxetine 20 mg per day, titrating the dose up every two to four weeks as needed and tolerated. In patients presenting with features of delusional disorder, antipsychotic medications are indicated. Pimozide or olanzapine are options, but have only been reported in case studies. For patients accepting mental health professional referral, we suggest cognitive behavioral-therapy or habit reversal therapy (Grade 2C).

In summary medical management includes:
i. potent steroid (elocom 0.1% / topicort 0.25%)
ii. ssri (fluoxetine 20mg, titrate q2wks as tolerated
iii. cbt
iv. specialist involvement: psychiatry / dermatology

Prescription:

Calcitonin-salmon nasal spray
- 200 units/spray

1 spray in one nostril od x 1 month (may switch to bisphosphonates such as actonel earlier if pain abates)

--------------------------------------------------

NOTE: calcitonin is mainly used for acute bone pain in a pt w/ osteroporosis. It should not be used long term as it is:
- expensive
- ++ s/e including n/v, flushing
- develop resistance
- better alternatives for osteoporosis are present (actonel/fosamax)

True

Use moderate potency topical steroid

- Elocom 0.1% apply to affected areas od M: 60g
- if this does not work, try
- Topicort 0.25% cream: apply to affected areas bid M: 60g

Calcitonin is a valid option for the therapy of established osteoporosis, since it increases spine bone density and may decrease vertebral fracture risk. It is especially attractive when back pain is a problem. It is not usually used as first-line therapy because of its expense, the relative inconvenience of nasal or parenteral administration, frequent side effects, and the possible development of resistance. In addition, more effective drugs are available for prevention of bone loss and reduction of fracture risk (bisphosphonates - actonel/fosamax)

We often administer calcitonin if pain from an acute osteoporotic fracture is a prominent problem, and then switch to other agents such as bisphosphonates once the pain has abated.
--------------------------------------------------------------------------------------

Calcitonin binds to osteoclasts and inhibits bone resorption.

Calcitonins from many species are effective in humans, but salmon calcitonin is the one most widely used. It has 40 times the affinity of human calcitonin and is much more potent.

The administration of salmon calcitonin frequently is associated with side effects such as nausea, vomiting, and flushing; these side effects are much less common with the nasal route.

Calcitonin has a beneficial short-term effect on acute pain relief in patients who have sustained a vertebral fracture, as illustrated by the findings of a meta-analysis of 10 trials comparing calcitonin (nasal or parenteral) with placebo in patients with acute (onset <10 days) or chronic (>3 months) pain due to an osteoporotic compression fracture. Calcitonin was not effective for patients with chronic pain.

The main concern about treatment with calcitonin is that more effective drugs (eg, bisphosphonates) are available for the prevention of bone loss and reduction of fracture risk.

i. Macrobid 100mg BID x 5d (contraindicated in pregnant patients at term (36-42 wks GA), during labour and in neonates due to the possibility of hemolytic anemia)
ii. Cephalexin 500mg QID x 7d

Encopresis (aka paradoxical diarrhea) is involuntary fecal soiling in adults and children who have usually already been toilet trained. Persons with encopresis often leak stool into their undergarments.

macrobid 100mg BID x 7d (relatively contraindicated in patients with renal impairment, i.e. CrCl <60mL/min)

- usually don't do any investigations as it is a clinical diagnosis
- x rays are warranted only when the diagnosis of sinusitis is in doubt
- CT scans are not cost-effective and should not be used routinely to diagnosis sinusitis.

B12 is as important as folate in preventing neural tube defects. Normal b12 as per CFFM's bw is considered levels >300.

Complicated UTI includes patients with:

structural abnormalities:
- solitary kidney, polycystic kidney(s)
- duplicated collecting system
- vesicoureteral reflux
- recent instrumentation, catheter use, ureteral stent
- pyelonephritis

obstruction
- ureteral obstruction (tumor, fibrosis, stricture)
- enlarged prostate
- neurogenic bladder
- calculi

medical
- immunocompromised (incl. dm, ckd)
- recent hospitalization/nursing home

male sex

------------------------------------------------------------

Mild to moderate lower tract (bladder)
- ciprofloxacin 500mg bid M:7d (7-10)

Upper tract (kidney) or systemic (high fever, sepsis, vomiting):
- ciprofloxacin 500mg bid M:10d (10-14)

-------------------------------------------------------------

Severe:
- ampicillin IV 1g q6h plus gentamicin IV 6mg/kg q24h

Ciprofloxacin 500mg BID x 7d (7-10)

Aminoglycosides such as gentamycin because of risk of ototoxicity.

- sudden onset of severe h/a
- worst h/a ever
- new h/a after age 50
- h/a present on awakening
- impaired mental status
- fever
- neck stiffness
- seizures
- focal neurological deficits
- jaw claudication
- scalp tenderness
- worse with exercise, sexual activity or valsalva

ORAL
fluconazole 150mg capsule
1 tablet po M: 1 capsule

CREAM
clotrimazole (canestan) 10% cream
one applicatorful intravaginally [single dose]

- palpation of Achilles tendon
- resisted dorsiflexion

- r/o compression fracture

- must do an xray (ap and lateral in this case); also check to see if bmd is up to date

note: lateral allows for better visualization of compression fractures

Sciatic pain typically radiates with numbness and tingling all the way down to the foot. Pain that is localized above the knee may be either mechanical back pain or sciatic pain.

1. bacterial vaginosis (rx w/ flagyl 500mg bid x 7d)
2. vulvovaginal candidiasis (rx w/ fluconazole 150mg x 1; canestan cream; monistat cream)
3. trichomoniasis (sexually transmitted) (rx w/ flagyl 2g x 1)

- bisphosphonates
- calcitonin (good for pain + osteoporosis)

- pain meds as needed

- family history
- obesity (especially abdominal)
- alcohol consumption
- stress
- sedentary lifestyle
- smoking
- male gender
- age > 30
- excessive salt intake/fatty diet
- African American ancestry
- dyslipidemia

Consider getting a BP true (i.e. 5 readings, then avg is taken, considered very accurate)

Topical nystatin cream

Prescription:
Nystatin 100,000 units/g cream Apply to affected areas bid M:30g R:1

valtrex (valacyclovir) 1000mg po tid x 7d
- works for severe pain and ophthalmic involvement

Other drugs: [famcicyclovir and acyclovir] x 7d

Salbutamol (ventolin) or albuterol (ventolin) is a short-acting β2-adrenergic receptor agonist used for the relief of bronchospasm in conditions such as asthma and chronic obstructive pulmonary disease.

Fluticasone (Flovent), Budesonide (Pulmicort) are inhaled corticosteroids. The combination of fluticasone and salmeterol as Advair.

Salmeterol is a long acting b-agonist used for maintenance treatment (prevention of bronchospasm in COPD, asthma)

Advair - combination long acting b-agonist (salmeterol) and inhaled corticosteroid (flovent)

Atrovent - aka ipratropium bromide: anticholinergic (short acting) that acts as a bronchodilator in COPD, bronchitis, and emphysema

Spiriva aka tritropium bromide: anticholinergic (long acting) that acts as a bronchodilator in COPD, bronchitis and emphysema

- food
- sleep disturbance
- stress
- weather
- hormonal
- alcohol
- AGGRAVATED by physical activity

1. daytime symptoms <4x/wk
2. night time symptoms <1x / wk
3. normal physical activity
4. mild, infreq exacerbations
5. no asthma related absense from work/school
6. B2 agonist used <4x / wk

- O2 sat
- CXR
- ABGs
- PFTs

- stress
- heat/cold
- allergies
- URTI
- allergens (pets, carpets)
- irritants (cigarette smoke)
- drugs (NSAIDs, B-blockers)

- fatigue, weakness, exercise intolerance
- syncope, palpitations, H/A, postural dizziness
- dyspnea
- irritability
- feeling cold
- confusion/loss of concentration

- pallor
- brittle hair, brittle nails (may have koilonychia (spoon-shaped)

- very sore nipples, with burning, itching, or redness
- shooting pains in the breasts during feeding
- shiny or flaky skin around the nipples

asthma
copd
CHF
bronchiectasis
mechanical obstruction of airways

Flovent is an inhaled corticosteroid

Prescription
Flovent HFA 50mcg(or 125mcg depending)/spray
2 puffs bid M: 1 device

- advise patient to allow toe nail to grow and cut more horizontally.
- pain meds as needed
- if signs of infection (erythema, discharge, pus), then dip in warm water
- if severe infection, patient can apply Polysporin bid x 7 days or come back for further assessment

Dyspepsia, also known as upset stomach or indigestion, refers to a condition of impaired digestion. It is common and is often assoc. with GERD or gastritis. In a small minority it may be the first symptom of peptic ulcer disease (an ulcer of the stomach or duodenum) and occasionally cancer. Hence, unexplained newly onset dyspepsia in people over 55 or the presence of other alarming symptoms may require further investigations.

Defined as one or more the following symptoms:
- postprandial fullness / bloating
- early satiety
- epigastric pain or burning
- (some definitions include heart burn)
- (can be accompanied by nausea)

- Functional dyspepsia (previously called non-ulcer dyspepsia) is dyspepsia without evidence of an organic disease that is likely to explain the symptoms

Approximately 25 percent of patients with dyspepsia have an underlying organic cause. However, up to 75 percent of patients have functional (idiopathic or nonulcer) dyspepsia with no underlying cause on diagnostic evaluation.

Organic etiology (not limited to):
- peptic ulcer disease (nsaid, h.pylori, stress induced)
- gerd
- gastroparesis (delayed stomach emptying)
- biliary pain
- pancreatitis
- esophageal / stomach Ca
- chr. abdo wall pain
- stemi, other cardiac causes
- meds including: oral abx, nsaids, narcotics, glucocorticoids


NOTE:
--> h. pylori tests include serology and urea breath test

NOTE: better to check serology first b/c urea breath test can be more involving

Weigh them and see if that has changed from the previous measure.

You can weigh them and check their previous weight

- seizure disorder (bupropion lowers seizure threshold; therefore good idea to ask about alcohol abuse --> more likely to get seizures with alcohol withdrawal)
- eating disorder (b/c of inc. risk of seizures due to electrolyte imbalances)
- MAOI use in the past 14d

note: bupropion is used for:
i. smoking cessation
ii. depression

Varenicline (Champix)

However in pregnancy only bupropion should be used between the 2. This is b/c the safety of varenicline has not been studied in pregnancy

Also Varenicline should be used with caution in patients with pre-existing psychiatric condition. One major s/e of varenicline is night terrors.

True

there is no need to do mammography in patients > 75

True

True

True

- cigarette smoking (most important RF)
- DM
- HTN
- hyperlipidemia

- esophageal strictures (scarring can lead to dysphagia (solids))
- ulcer
- bleeding
- Barrett's esophagus
- esophageal carcinoma

True

Proactiv (has a component of benzoyl peroxidase)

1. NOCICEPTIVE PAIN - Examples include sprains, bone fractures, burns, bumps, bruises, inflammation (from an infection or arthritic disorder), obstructions, and myofascial pain (which may indicate abnormal muscle stresses).

Nociceptors are the nerves which sense and respond to parts of the body which suffer from damage. They signal tissue irritation, impending injury, or actual injury. When activated, they transmit pain signals (via the peripheral nerves as well as the spinal cord) to the brain. The pain is typically well localized, constant, and often with an aching or throbbing quality. Visceral pain is the subtype of nociceptive pain that involves the internal organs. It tends to be episodic and poorly localized.

Nociceptive pain is usually time limited, meaning when the tissue damage heals, the pain typically resolves. (Arthritis is a notable exception in that it is not time limited.) Another characteristic of nociceptive pain is that it tends to respond well to treatment with opioids.

2. NEUROPATHIC PAIN - Examples include post herpetic (or post-shingles) neuralgia, reflex sympathetic dystrophy / causalgia (nerve trauma), components of cancer pain, phantom limb pain, entrapment neuropathy (e.g., carpal tunnel syndrome), and peripheral neuropathy (widespread nerve damage). Among the many causes of peripheral neuropathy, diabetes is the most common, but the condition can also be caused by chronic alcohol use, exposure to other toxins (including many chemotherapies), vitamin deficiencies, and a large variety of other medical conditions--it is not unusual for the cause of the condition to go undiagnosed.

Neuropathic pain is the result of an injury or malfunction in the peripheral or central nervous system. The pain is often triggered by an injury, but this injury may or may not involve actual damage to the nervous system. Nerves can be infiltrated or compressed by tumors, strangulated by scar tissue, or inflamed by infection. The pain frequently has burning, lancinating, or electric shock qualities. Persistent allodynia, pain resulting from a nonpainful stimulus such as a light touch, is also a common characteristic of neuropathic pain. The pain may persist for months or years beyond the apparent healing of any damaged tissues. In this setting, pain signals no longer represent an alarm about ongoing or impending injury, instead the alarm system itself is malfunctioning.

Neuropathic pain is frequently chronic, and tends to have a less robust response to treatment with opioids, but may respond well to other drugs such as anti-seizure and antidepressant medications. Usually, neuropathic problems are not fully reversible, but partial improvement is often possible with proper treatment.

Avascular necrosis; patient may eventually suffer from arthritis.

- immediate post-MI
- serious/worsening angina
- serious arrhythmia


--------------------------------------------------------------------

note: nicotine:
- It increases the heart rate
- It causes the heart muscle cells to squeeze harder with each beat
- It causes blood vessels in the heart to constrict to a smaller diameter

All of these effects are temporary, however, because a person's body quickly becomes tolerant to the effects of nicotine; this is why nicotine is one of the most highly addictive substances known. Because of this tolerance to nicotine, for someone who chews tobacco regularly, the long-term heart effects are probably minimal.

low mood
insomnia
irritability
anxiety
difficulty concentrating
restlessness
decreased HR
increased appetite

NO

- advise to quit w/o pharmacotherapy (+/- counseling)
- if that does not work, then nicotine replacement therapy (NRT) in the form of patches should be made available
- Use bropropion (no evidence of fetal or reproductive harm)
- Do not use varenicline (champix) as it has not been studied in pregnancy; therefore should not be used by pregnant women.

Prescription:

Hp-pac kit (includes lansoprazole 30mg, amoxicillin 500mg(x2), clarithromycin 500mg) M: 7 days
--------------------------------------------------------------------------------
i. lansoprazole 30mg bid
ii. amoxicillin 1g bid
iii. clarithromycin 500mg bid

*confirmation of eradication is required for complicated (bleeding, perforation, stricture) or refractory ulcers, but is controversial after the medical management of uncomplicated ulcers in pts who remain asymptomatic.

NOT to take alcoholic beverages during treatment w/ metronidazole and for 48h post-treatment to prevent disulfiram-like reaction.

A disulfiram like reaction means that the alc. dehydrogenase enzyme is inhibited thereby preventing the enzyme acetaldehyde dehydrogenase thereby leading to the accumulation of high levels of acetaldehyde. This makes the pt feel like they're having a hangover w/ symptoms of: flushing of the skin, accelerated heart rate, shortness of breath, nausea, vomiting, throbbing headache, visual disturbance, mental confusion, postural syncope, and circulatory collapse.

The most common chronic causes are:

i. gerd
ii. asthma
iii. post-nasal drip
iv. post-viral
v. ACEi

------------------------------------------------------

Other causes of cough include:

1. A/W irritants: smoke, dust, fumes, allergens

2. A/W disease: COPD, neoplasm, bronchiectasis, acute/chronic bronchitis, URTI

3. Parenchymal disease: pneumonia, lung abscess cancer

4. Cardiac: CHF

- activity modification (avoid aggravating activity)
- NSAIDs (regularly for first few days then prn)
- Icing: 4 x 15 mins / day
- physiotherapy

1. lifestyle:
- sleep
- exercise
- diet (omega 3 fatty acids)

2. counselling (CBT) (ask if they have coverage, if not the CFFM can provide 8 free sessions)

3. Medications such as SSRIs. (This is the 3rd step b/c once a patient is put on SSRIs, they're committed to about 1 year, and SSRIs are not without S/Es)

This pt probably has post-concussion syndrome.

ADVISE:
- AVOID physical and mental stimulation.
- they should not even read or watch TV till they get better. B/c any mental exertion can worsen their symptoms.

*note: you can monitor sx of post-concussion syndrome using the SCAT2 tool

Zostavax [indicated for patients 50 and above]. Since most people >50 have had chicken pox, they are all at risk of developing shingles.

Zostavax is a live vaccine developed by Merck & Co. that has been shown to reduce the incidence of herpes zoster (known as shingles) by 51.3% in a study of 38,000 adults aged 60 and older who received the vaccine. The vaccine also reduced by 66.5% the number of cases of postherpetic neuralgia and reduced the severity and duration of pain and discomfort associated with shingles, by 61.1%. Local reactions at the injection site were generally mild.

NOTE: tell pts that risk of getting shingles is 1 in 3 and zostavax cuts the risk in half.

NOTE: Zostavax is not covered typically and costs about $200-250. Also it needs to be kept below a certain temperature to remain effective.

Dermatological
- xerosis (dry skin)
- atopic dermatitis
- psoriasis
- cutaneous infections
- cutaneous T-cell lymphoma

Systemic
- chronic renal failure
- liver disease
- hematologic or proliferative disease
- malignancy

Neurologic
- MS

Psychogenic
- depression
- anxiety
- psychogenic excoriation

True

Pain may persist or recur for months, years, or for life

1. Kidsability (about a 6 month wait)

2. BlueBalloon

In PAD, patients get intermittent claudication (pain) with exertion.

In vascular insufficiency, patients get edema of the extremities (usually legs).

Prescription meds:
- Flexiril (NOT covered by ODB)
- Baclofen (covered by ODB)

OTC meds:
- Robaxacet
---------------------------------------------

Prescription for Flexeril:
Flexiril 10mg
1 tablet qhs prn M: 15 tablets

Prescription for Baclofen:
Baclofen 5mg
1 tablet tid prn M: 30 tablets
[max per day 80mg]

The biggest difference is that you have ++ pain with herpes zoster, not so much with contact dermatitis.

True

One can offer baseline PSA screening to men at 40 with at least 10 yrs life expectancy, especially if at high risk (family hx, African descent)

These pts will need a stress test at either:

CardioPulmonary Services (KW)

Cambridge cardiac care centre (Cambridge)
- Dr. Pandey

When a baby comes in with oral thrush, it is important to r/o if the mother has the infection on her breasts, i.e. cracked nipples. If the mother is feeding the baby, she may have the candida infection as well, so you have to make sure that both the baby and the mother have the medication (that is nystatin).

Nystatin
- topical antifungal
- not absorbed systemically

Prescription:
Nystatin 100,000/mL suspension orally 1mL qid M: 7 days

note: it is best to treat the mum as well, because she may have thrush on the nipple(s) and can pass it on to the baby after it's treated.

Prescription (mum):
Nystatin 100,000 units/gram cream
apply tid x 7 days M: 15 grams

a skeletal muscle relaxant (prescription). It is covered by odb whereas flexiril is not

Prescription
Baclofen 10mg
1 tablet tid prn M: 30 tablets

i. bilirubin
ii. amylase

4F's

fat
female
fertile
forties

abdominal ultrasound

True. Colicky pain is severe, often fluctuating pain in the abdomen. Biliary colic is non-colicky pain. Biliary colic is constant pain.

formation of gallstones

- bw_abdo set typically, more specifically, bilirubin, amylase, lipase, LFTs, cbc (possibly elevated wbc)
- U/S (diagnostic procedure of choice)
- ERCP - endoscopic retrograde cholangiopancreatography (diagnostic and therapeutic)
- MRCP - magnetic retrograde cholangiopancreatography (only diagnostic)

True

BILIARY COLIC
- rehydration
- analgesia
- elective cholecystectomy

ACUTE CHOLECYSTITIS
- antibiotics (ciprofloxacin 400mg IV q12h + metronidazole 500mg IV q8h)
- early laparoscopic cholecystectomy

A) Recurrent, intermittent epigastric abdo pain that occurs approximately 1 hr after meals
B) Daily postprandial abdo pain, assoc with 40 lb weight loss
C) Chronic, persistent abdo pain and back pain of 1 month duration and a 10 lb weight loss
D) diarrhea that occurs following fatty meals, steatorrhea, and chronic epigastric and back pain



ANSWERS: 1D 2C 3A 4B

- acute or chronic cholecystitis in the absence of stones

- typically due to gallbladder stasis --> sludge forms in gallbladder

right subscapular pain that can be present in cholecystitis

True

True

biliary colic:
- analgesia, hydration, and elective cholecystectomy

acute cholecystitis
- antibiotics and early cholecystectomy

Champix (Varenicline)
0.5mg qam x 3d; then
0.5mg bid x 4d; then
1mg bid x 3mo repeats: 1

Instructions: continue to smoke (if smoking) for 1st week of treatment, then completely stop.

contraindications:
- preexisting pysch condition (not strict contraindication but be cautious)
- pregnancy

S/E:
- night terrors
- insomnia
- h/a
- n/v
- constipation