YEPSA Objectives by wuyunyi

VIEWS: 62 PAGES: 190

									                                     YEPSA Review



                      YEPSA:
                    OBJECTIVES
                                 Spring 2008
                                     last updated 6/5/2008




                                      Christopher B. Kolar
                                       cbkolar@wisc.edu


This study guide has been created in the course of my studies at the University of Wisconsin
School of Medicine and Public Health. It is intended as an exam review of the required learning
objectives. It references a variety of course materials, including lecture, Power Point, assigned
readings, and sometimes outside sources. While I have attempted to make it as thorough, specific,
and accurate as possible, I cannot guarantee this, so use it at your own risk. If you have any
questions or comments, or have found an error within the text, please feel free to contact me.




                                                             COLOR KEY:
                                                             • red:    diseases
                                                             • blue:   medications
                                                             • orange: enzymes and compounds
                                                             • pink:   microorganisms
                                                             • gray:   supplemental information

                                                             FORMAT KEY:
                                                             • margins: 1”
                                                             • tab stops: 0.25”
                                                             • font:      Times New Roman
                                                             • size:      10
                                                                                          YEPSA: Objectives (page 2 of 190)




Basic Skills
                                                                                                       BASIC SKILLS


1.   Exhibit professionalism throughout the exam.

- professionalism
   - definition:      commitment to carrying out professional responsibilities in an ethical and sensitive manner
   - requirements:    professionalism requirements of the Accredication Council for Graduate Medical Education:
                      - demonstration of respect, compassion, integrity, responsiveness, and accountability
                      - demonstration of commitment to excellence and ongoing professional development
                      - demonstration of ethical principles related to provision of care, confidentiality, and consent
                      - demonstration of sensitivity and responsiveness to patients’ culture, age, gender, disabilities


2.   With regards to verbal communication, be able to:
             • greet patient appropriately and convey respect
             • establish and maintain rapport
             • prioritize patient and physician concerns (set an agenda)
             • elicit patient concerns without interruption
             • gather information appropriately using open and closed-ended question
             • facilitate patient’s self disclosure of explanations, concerns, expectations
             • assess compliance non-judgmentally
             • recognize emotional cues, acknowledge and explore patient's feelings
             • offer support and collaboration
             • deliver diagnostic assessments in language patient can understand
             • work effectively with a trained interpreter
             • acknowledge patient ideas of management preferences, including culture and SES
             • check patient understanding and acceptance of plans
             • identify barriers to implementing treatment plans
             • negotiate management consistent with physician and patient expectations
             • communicate uncertainty appropriately
             • break bad news
             • obtain informed consent
             • consider interdisciplinary / team interactions


- greeting the patient, conveying respect, and establishing rapport
   - function:        improves patient-doctor relationship and permits for better trust
   - method:          begin each visit with a smile, hand washing, handshake, and the following questions:
                      - “Hello, my name is ________ , and I am a medical student.”
                      - “Is it okay if I speak with you today prior to the physician seeing you?”
                      - “Would you prefer to be addressed as…?”


- eliciting patient concerns and agenda-setting
   - function:         establishment of an outline for an efficient patient-doctor encounter
   - method:           begin each visit with:
                       - “What brings you in here today?”
                       - “Before we continue, are there any other concerns you would like to address?”
                       - “Unfortunately, we do have a limited time. What are the 2 or 3 most important issues?”
                       - “I would be happy to schedule you for another visit to address your other concerns.”


- using open-ended questions and facilitating self disclosure
                                                                                          YEPSA: Objectives (page 3 of 190)



  - function:          use of more broad-based questions that are better able to:
                       - uncover patient priorities and values
                       - avoid socially-desirable responses
  - method:            use questions that, by their nature:
                       - call for descriptive answers
                       - encourage patients to say what is important to them
                       - elicit contextual information
  - examples:          regarding quitting smoking:
                       - “Would you like to quit smoking?”           (direct question)
                       - “How do you feel about your smoking?” (open-ended question)


- nonjudgmental assessment of compliance
   - function:      understanding of execution of treatment plan while maintaining patient-doctor relationsihp
   - method:        questioning in a normalizing, non-judgmental manner, while looking to the future:
                    - “Regularly scheduled medications can be difficult for many patients.”
                    - “What have been the barriers that have been preventing you from doing this?”
                    - “How can I help you?”


- assessing health literacy
   - function:          permits tailoring of assessment and plan to the patient
   - method
      - Rx test:        pull out a bottle the patient has not seen, “Tell me how you would take this.”
      - nutrition test: pull out a nutrition label, “Tell me some information about this.”
      - pt. profile:    “How happy are you with the way you read?”
      - brown bag:      assessment of medication; read labels vs. open bottle
      - experience:     direct questioning about health care experience
                        - “It is important to me that I explain things in an understandable way.”
                        - “I would like to know if I am not clear.”
                        - “Have you had experiences in the past where things have not been clear?”
                        - “Are their ways doctors have used that have worked well for you?”


- using appropriate language
   - function:          delivery of medical information in a manner understandable to an individual patient
   - method:
      - consolidation: limit amount of information and repeat it
      - simplification: use plain, non-medical language
      - use of visuals: show or draw pictures (models, posters)
      - summarization: use teach-back or show me technique
                        - “Do you understand?” is insufficient (lends to socially acceptable answer)
                        - ask patients to explain or demonstrate
                        - reteach using alternative approach if patient understanding is inadequate
      - speed:          slow down
      - understanding: create a shame-free environment


- communicating effectively through an interpreter
   - function:      improved medical services for limited English speakers, who generally report:
                    - less likelihood of receiving preventive services
                    - fewer physician visits
                    - poorer experiences in the ED, with less satisfaction and less willingness to return
                    - more difficulties understanding medication instructions

  - method:            in communicating through an interpreter:
                                                                                           YEPSA: Objectives (page 4 of 190)



                       - use qualified interpreters
                       - have a brief pre-interview meeting with the interpreter
                       - speak directly to the patient, not the interpreter
                       - speak at an even pace, in normal voice, in relatively short segments
                       - do not hold the interpreter responsible for what the patient does or does not say
                       - avoid jargon or technical terms
                       - expect that everything will be interpreted
                       - avoid patronizing the patient
                       - encourage the interpreter to alert you to potential cultural misunderstandings
                       - be patient

  - clinical:          qualified interpreters include those that are:
                       - fluent in two languages
                       - trained as a medical interpreter
                       - not the patient’s family, friend, or child

                       clues to a bad interpreter include:
                       - response to physician question without talking to the patient
                       - response seems insufficient or excessive relative to the length of the patient’s speech


- cultural sensitivity, checking understanding, identifying barriers, and negotiating management
   - function:          improved compliance
   - method:            ascertain patient understanding
                        - “What is your understanding of your disease?”
                        - “Explain the management plan back to me.”
                        ascertain anticipated barriers
                        - “What concerns do you have regarding implementing the treatment plan?”
                        - “What barriers do you see that will prevent you from being successful?”
                        - “What do you think will work in helping to overcome those barriers?”
                        involve the patient in the management plan
                        - “What parts of this will be most difficult for you?”
                        - “What would you prefer?”
                        - “For now, let’s focus on this aspect… Next time, we’ll discuss the rest.”


- obtaining informed consent and communicating uncertainty
   - definition:     “The willing acceptance of a medical intervention by a patient after adequate disclosure by
                     the physician of the nature of the intervention, its risks and benefits, and also its alternatives
                     with their risks and benefits.”
   - function:       legal and ethical obligation to patient autonomy
   - method:         informed consent should include the following:
                     - current medical condition and likely course if no treatment is provided
                     - interventions that might aid prognosis, including risks, benefits, probabilities, uncertainties
                     - alternatives
                     - recommendations for therapy based on physician’s best medical judgment

    BOX: Problems and Pitfalls with Informed Consent
      • information:              medical information is often statistical
      • communication:            medical information can be slanted
      • understanding:            patient understanding can be limited
      • desperation / anxiety:    patient may make uncharacteristic decisions in the context of fear / anxiety
      • time / urgency:           obligations differ in different situations
      • clinical uncertainty:     medical information is often incomplete
                                                                                            YEPSA: Objectives (page 5 of 190)




         • practitioner bias:       recommendations for therapy often depend on skills of practitioner
         • patient preferences:     patients differ in personal preference




- breaking bad news
   - function:      delivery of bad news in a sensitive and empathetic manner

     - method
       - setting:        establish the setting and create an appropriate environment
                         - ensure comfort and privacy
                         - ask if family or others should be present
       - perception:     assess the understanding of the patient and family regarding the issue at hand
       - invitation:     assess the desire of the patient regarding level / manner of information delivered
       - knowledge:      deliver the news
                         - use language the patient will understand
                         - deliver information in small pieces
       - empathy:        react and respond appropriately to emotions (including reassurance, tissues, and even silence)
       - strategy:       establish a plan, considering goals and follow-up

     - clinical:         avoid the SPIKES of bad bedside manner


3.     Demonstrate written communication (SOAP note, orders, and prescriptions)
4.     Demonstrate oral communication (oral presentation of patient history, exam, assessment and plan)

- anatomy of a SOAP note
   - Subjective:    patient description              (CC, HPI, FH, PP, and relevant ROS)
   - Objective:     physician observation            (physical exam and lab diagnostics)
   - Assessment:    diagnosis                        (statement of the problem, DD x / status, and clinical reasoning)
   - Plan:          intended action                  (diagnostics, therapeutics, patient education, follow-up)


- subjective
   - first sentence:     statement of relevant identifying information and PMH
                              “[patient name] is a [age] y/o [gender] with a PMH significant for [relevant information]
                              who presents to the clinic today with a [duration] history of [chief concern].”

     - 1st paragraph:    HPI

     - 2nd paragraph:    pertinent FH, PP, and relevant ROS

- objective
   - physical exam:      vital signs, I/O’s, general status, physical findings
   - laboratory:         laboratory findings
   - imaging:            imaging findings
   - other:              results of other procedures

- assessment
  - acute concern
     - statement:        statement of the problem
     - differential:     list of hypotheses, usually presented from most to least likely
     - reasoning:        rationale for or against each hypothesis using data from history, PE, and labs
                                                                                               YEPSA: Objectives (page 6 of 190)



       - example:         “Cough of 4 weeks duration. The most likely diagnosis is post nasal drip because of the
                          duration and timing with seasonal allergies. Pneumonia is unlikely due to lack of fever and
                          SOB. GERD seems unlikely due to lack of association with meals, though association with
                          lying recumbent is supportive. This could be the onset of asthma, though would expect more
                          SOB and relationship to activity.”

       - chronic concern
          - statement:   statement of the problem
          - status:      well-controlled, poorly controlled, resolved, improving, worsening, persistent, etc.
          - reasoning:   rationale for status statement using data from history, PE, and labs
          - example:     “Diabetes, well controlled with diet and weight loss. There are no symptoms of
                         hyperglycemia and blood work confirms good glucose control.”

- plan
   - outline:             step by step outline of what is being done


5.     Perform appropriate physical exam

- physical exam
   - general:           sex, race, state of health, stature, development, dress, hygiene, affect
   - vital signs:       blood pressure, pulse, respirations, temperature, SpO2, weight, height, BMI
   - skin:              skin scars, rashes, bruises, tattoos, hair consistency, nail pittingin, stippling
   - head:              size, shape, trauma
   - eyes:              pupil size, shape, reactivity, conjunctival injection, scleral icterus, fundal papilledema,
                        hemorrhage, lids, extraocular movements, visual fields, acuity
     - ears:            shape / symmetry, tenderness, discharge, external canal / tympanic membrane inflammation,
                        gross auditory acuity
     - nose:            symmetry, tenderness, discharge, mucosal / turbinate inflammation, frontal / maxillary sinus
                        tenderness
     - mouth / throat:  hygiene, dentures, erythema, exudate, tonsillar enlargement
     - neck:            masses, range of motion, spine / trachea deviation, thyroid size
     - breasts:         skin changes, symmetry, tenderness, masses, dimpling, discharge
     - cardiovascular: rate, rhythm, murmurs, rubs, gallops, clicks, precordial movements
     - pulmonary:       chest symmetry with respirations, wheezes, crackles, vocal fremitus, whispered pectoriloquy,
                        percussion, diaphragmatic excursion
     - abdominal:       shape, scars, bowel sounds, consistency (soft / firm), tenderness, rebound, masses, guarding,
                        spleen size, liver span, percussion (tympany, shifting dullness), costovertebral angle (CVA)
                        tenderness
     - genitourinary:   male: rashes, ulcers, scars, nodules, induration, discharge, scrotal masses, hernias
                        female: external genitalia, vaginal mucosa, cervix, inflammation, discharge, bleeding, ulcers,
                        nodules, masses, internal vaginal support, bimanual and rectovaginal palpation of cervix,
                        uterus, and ovaries
     - rectal:          sphincter tone, prostate consistency, masses, occult stool blood
     - musculoskeletal: muscle atrophy, weakness, joint range of motion, instability, redness, swelling, tenderness,
                        spine deviation, gait
     - vascular:        carotid, radial, femoral, popliteal, posterior tibial, dorsalis pedis pulses, carotid bruits, jugular
                        venous distension (JVD), hepatojugular reflux (HJR), edema, varicose veins
     - lymphtic:        cervical, supra / infraclavicular, axillary, trochlear, inguinal adenopathy
     - neurologic:      cranial nerves, sensation, strength, reflexes, cerebellum, gait


- neurological exam
   - mental status
     - attention:   date, current president, serial backward tasks
     - language:    fluency of speech, repetition, comprehension of commands, naming objects, reading, writing
                                                                                             YEPSA: Objectives (page 7 of 190)



    - memory:            three words in 5 minutes
    - visuospatial:      drawing clock, copying complex figures
    - neglect:           line bisection, double simultaneous stimulation, picture description
    - frontal lobe:      generating word lists, learning a motor sequence

  - cranial nerves
     - CN I:             non-noxious stimulus in separate nostrils (not usually tested)
     - CN II:            visual acuity, visual fields, pupils, fundoscopic exam
     - CN III, IV, VI:   extraocular movements
     - CN V:             facial sensation (V1, V2, V3)
     - CN VII:           facial movement (temporal, zygomatic, buccal, mandibular, cervical)
     - CN VIII:          hearing (finger rub, tuning fork, Rinne, Weber)
     - CN IX, X, XII:    palate and tongue movement
     - CN XI:            shoulder shrug

  - motor
    - bulk:              palpation for atrophy
    - tone:              evaluation for rigidity, spasticity
    - power:             confrontation testing, observational tests (pronator drift, walking on heels / toes)

  - reflexes
     - DTRs:             biceps, brachioradialis, triceps, patellar, Achilles
     - Babinski:         lateral foot stroke

  - sensory
     - pain:             pinprick
     - temperature:      cold tuning fork
     - two point:        distinction between 1 or 2 points
     - vibration:        vibrating tuning fork
     - joint position:   joint movements (especially first finger, big toe)

  - coordination
     - accuracy:         finger-to-nose, heel-to-shin
     - rhythm:           rapid alternating movements, rhythmic finger movements

  - gait
     - stance:           narrow or wide base
     - Romberg sign:     evaluation for steadiness with feet together and eyes closed
     - gait:             evaluation for leg movement, arm swing
     - ataxia:           tandem walk


- Folstein Mini-Mental Status Exam (MMSE)
   - orientation:   (5) year, date, day, month, season
                    (5) state, county, city, building, floor
   - registration:  (3) repeat three objects
   - attention:     (5) serial 7 subtraction from 100, or spelling of “world” backwards
   - recall:        (3) repeat the three previous objects
   - language:      (2) identification:      identify two objects (e.g. pencil, watch)
                    (1) repetition:          repeat the following: “No ifs, ands, or buts”
                    (3) command:             follow a 3 step command
                    (1) reading:             CLOSE YOUR EYES
                    (1) writing:             write a sentence (must have subject, verb)
                    (1) copying:             copy a design (two embedded pentagons)
                                                                                            YEPSA: Objectives (page 8 of 190)



- musculoskeletal exam
  - inspection:      general inspection of affected joints for erythema, deformity, obvious defects
  - palpation:       palpation of joints, including bony structures, soft tissues, tendons, and temperature
  - ROM:             active and passive range of motion
  - strength:        graded strength against resistance / gravity
                     - 0:      paralysis
                     - 1:      visible contraction
                     - 2:      full ROM with gravity eliminated
                     - 3:      full ROM against gravity
                     - 4:      full ROM with decreased strength
                     - 5:      full ROM with normal strength
  - laxity:          joint stability with strain
  - special tests:   special tests for a given joint


6.     Order and interpret diagnostic tests (ECG, chest X-ray, etc.)

- diagnostic tests
   - laboratory:         hematology, chemistry, urinalysis, cultures, etc.
   - imaging:            CXR, CT/MRI, EKG, etc.
   - procedures:         colonoscopy, bronchoscopy, tilt table test, etc.


7.     Recognize the importance of patient gender in evaluation and treatment of common medical and surgical
       conditions.

                Gender is important in evaluation and treatment of common medical and surgical conditions.


8.     Be able to use a computer to obtain patient data and search the medical literature


     • Ebling Library for the Health Sciences:
                http://ebling.library.wisc.edu/


evidence-based medicine websites
  • BMJ Clinical Evidence:
            http://www.clinicalevidence.com

     • DynaMed:
              http://www.ebscohost.com/dynamed/

     • Essential Evidence Plus [formerly InfoRetriever] (UW Remote Access)
                 http://ezproxy.library.wisc.edu/login?url=http://www.infopoems.com/irsearch/irsearch.cfm

     • MD Consult (UW Remote Access):
              http://digital.library.wisc.edu/1711.web/mdconsult

     • PubMed (UW Remote Access):
               http://www.ncbi.nlm.nih.gov/sites/entrez?myncbishare=uwisclib&otool=uwisclib

     • SUMSearch:
              http://sumsearch.uthscsa.edu

     • TRIP Database:
                                                                                            YEPSA: Objectives (page 9 of 190)



                   http://www.tripdatabase.com


9.     For clinical questions of therapy (Evidence-Based Medicine), be able to:
                • assess evidence for validity
                • interpret evidence for magnitude and precision of treatment effect (including ARR, RRR, NNT)
                • apply evidence to patient scenarios

evidence-based medicine
- evidence-based medicine (EBM)
   - definition:     the use of scientific evidence in making clinical decisions

     - importance:         evidence becomes necessary with:
                           - new therapy or diagnostic test
                           - internet or media claims
                           - controversial issue
     - method
       - define:           define clinical questions that can be answered using evidence-based resources.
       - find:             effectively and efficiently find evidence
       - assess:           assess the meaning and results of your search
       - apply:            apply the answers to patient care
       - discuss:          communicate evidence to patients

     - barriers:           barriers to EBM include:
                           - quicker to ask a colleague or look at an online database
                           - easy to rely on expert opinion
                           - many clinical questions lack evidence
                           - fear that “evidence” will take the place of patient choice and common sense

- PICO format
   - function:             definition of an answerable clinical question

     - method:             PICO format involves:
                           - P:    patient / problem
                           - I:    intervention
                           - C:    comparison
                           - O:    outcome

     - examples:           breast cancer and chemotherapy (therapy)
                           - P:     In women with breast cancer,
                           - I:     does the use of chemotherapy and surgery
                           - C:     compared to surgery alone
                           - O:     result in improved survival?

                           osteoporosis and raloxifene (prevention)
                           - P:    In a woman with osteoporosis,
                           - I:    does raloxifene
                           - C:    compared to no medicine
                           - O:    result in reduced vertebral fractures?

     - clinical:           types of answerable clinical questions include:
                           - diagnosis:     How do I diagnose what my patient has?
                           - prevention:    How can a certain outcome be prevented?
                           - therapy:       Will this treatment make my patient better?
                           - prognosis:     What will happen?
                           - harm:          Is this harmful to my patient
                                                                                          YEPSA: Objectives (page 10 of 190)




- resources
   - background information
      - definition:   general clinical information regarding a topic such as etiology, presentation, or treatment
      - clinical:     questions answered using “background” resources such as:
                      - textbooks (print, electronic)
                      - narrative reviews

  - foreground information
     - definition:   specific clinical information regarding a specific patient
     - clinical:     questions answered using “foreground” resources such as:
                     - primary sources (journal articles)
                     - secondary sources (systematic reviews, synopses, meta-analyses)


calculations
- incidence (absolute risk)
   - definition:       ratio of new occurrences of an event to total number in group, within a given time interval
                                    number of new events
   - calculation:       incidence 
                                       number in group

- prevalence
   - definition:       ratio of total occurrences of an event to total number in group, at a specific time
                                        total events
  - calculation:       incidence 
                                     number in group

- relative risk (RR)
   - definition:       incidence in one group compared to the other (generally experimental vs. control)
                              I experiment
                        RR 
                                           al
  - calculation:                              | risk of experimental therapy relative to control therapy
                                 I control

- absolute risk reduction (ARR)
   - definition:       difference in incidence between control and experimental treatment
   - calculation:       ARR  I control  I experim ent
                                                      al

  - implications:      substantial differences in baseline risk can substantially alter ARR

- relative risk reduction (RRR, efficacy)
   - definition:        reduction in risk of the experimental treatment relative to the control treatment
                                   I control  I experiment
   - calculation:       efficacy 
                                                          al

                                            I control

- number needed to treat (NNT)
   - definition:      number of experimental treatments to prevent a single adverse outcome (relative to control)
                               1             1
   - calculation:      NNT        
                             ARR I control  I experim ent
                                                         al

   - clinical:        large RR reductions can be quite insignificant if the risk was small to begin with
                      number needed to harm (NNH) calculated if experimental therapy causes increased risk


validity testing
- sensitivity
   - definition:       probability of a positive test result in patients who have a disease
                                                                                            YEPSA: Objectives (page 11 of 190)



                                       () results in diseased patients
  - calculation:       sensitivity 
                                        number of diseased patients

- specificity
   - definition:       probability of a negative test result in patients who do not have a disease
                                      () results in nondiseased patients
  - calculation:       specificit y 
                                       number of nondiseased patients

- positive predictive value (PPV)
   - definition:        of those testing positive, the proportion having the disease
                                () results in diseased patients
   - calculation:       PPV 
                                  number of positive results

- negative predictive value (NPV)
   - definition:       of those testing negative, the proportion not having the disease
                               () results in nondiseased patients
   - calculation:       NPV 
                                   number of negative results

- positive likelihood ratio (LR+)
   - definition:        likelihood of positive test result in diseased individuals compared to nondiseased individuals
   - calculation:                 sensitivity
                        (LR  ) 
                                1  specificit y

- negative likelihood ratio (LR–)
   - definition:       likelihood of negative test result in nondiseased individuals compared to diseased individuals
   - calculation:                1  sensitivity
                        (LR ) 
                                  specificit y


  TABLE: Derivation of Validity-Testing Equations (Sensitivity, Specificity, PPV, and NPV)
                  disease                   non-disease
   test (+)                   a                         b                              a
                                                                               PPV 
                          (true +)                  (false +)                         ab
   test (–)                   c                         d                              d
                                                                               NPV 
                          (false –)                  (true –)                         cd
                                           a                              d                       ac
                          sensitivity                   specificity            prevalence 
                                          ac                            bd                    abcd




interpreting validity testing

  TABLE: Effect of Changing Prevalence on Validity Testing
                                      PPV               NPV                    effect on results
   with increasing prevalence…          ↑                 ↓                    positive results more informative
   with decreasing prevalence…          ↓                 ↑                    negative results more informative


  TABLE: Effect of Sensitivity and Specificity on Validity Testing
                                     false tests           LR 1                effect on results
   sensitive, but not specific test high false +         low LR+               negative result more informative
                                                        low LR –
                                                                                           YEPSA: Objectives (page 12 of 190)



      specific, but not sensitive test    high false –         high LR+       positive result more informative
                                                              high LR –
     1
       recall that a low value for LR– suggests a better negative predictive value


     TABLE: Effect of Likelihood Ratios on Validity Testing
                                            posttest probability             effect on results
      high LR+ test, (+) result           dramatically increased             positive result more informative
      low LR– test, (–) result            dramatically decreased             negative result more informative


     TABLE: Usefulness of Likelihood Ratios
                             LR+          LR –
      conclusive             > 10         < 0.1
      moderately helpful     5-10        0.1-0.2
      possibly helpful       2-5         0.2-0.5
      not helpful            1-2         0.5-1.0




Dermatologic Problems
                                                                                                   MISCELLANEOUS


1.     Be able to diagnose and manage common dermatologic problems.

                (based partially on objectives written by Grace Chiang)

     TABLE: Differential Diagnosis of Common Dermatolgic Lesions
      lesion                              differential diagnosis
      papules                             • acne
        (raised, palpable, < 1 cm)        • achrodordon (skin tags)
                                          • cherry angioma
                                          • flat wart / plantar wart
                                          • molluscum contagiosum (umbilicated)
                                          • nevi
                                          • scabies (often between fingers, pruritic)
                                          • scarlet fever (diffuse, innumerable)
                                          • seborrheic keratosis

      plaques                                   • eczema
        (raised, flat, > 1 cm)                  • psoriasis
                                                • seborrheic dermatitis
                                                • stasis dermatitis
                                                • tinea corporis (annular, heaped edges)

      nodules                                   • basal cell cancer (pearly)
        (raised, solid, > 1 cm)                 • squamous cell carcinoma
                                                • melanoma
                                                • hemangioma (purple, early in development)
                                                                                           YEPSA: Objectives (page 13 of 190)




   pustules                                    • candidiasis (beefy central plaque, macular satellite lesions)
     (circumscribed, elevated, with pus)       • hand-foot-mouth disease (summer/fall, from coxsackievirus)
                                               • impetigo (honey-crusted, from GABHS and S. aureus)

   vesicles                                    • chicken pox (spread from trunk to extremities)
     (raised, clear fluid, < 1 cm)             • contact dermatitis
                                               • herpes simplex (grouped vesicles, erythematous base)
   bullae                                      • herpes zoster
     (raised, clear fluid, > 1 cm)

   wheals                                      • hives
    (upper epidermis edema)                    • angioedema




dermatologic lesions
- primary skin lesions
   - macule:             circumscribed, flat, nonpalpable discoloration of size < 1 cm
   - papule:             superficial elevated solid lesion of size < 1 cm
   - patch:              circumscribed, flat, nonpalpable discoloration of size > 1 cm
   - plaque:             superficial elevated solid lesion of size > 1 cm
   - nodule / tumor:     raised solid lesion with indistinct borders and a deep palpable portion, size > 1 cm
                         - subcutaneous: skin moves freely over nodule
                         - dermal:          skin does not move over nodule
  - vesicle:             circumscribed collection of free fluid, size < 1 cm
  - bulla:               circumscribed collection of free fluid, size > 1 cm
  - cyst:                raised lesion containing a palpable sac filled with liquid or semisolid material
  - pustule:             vesicle containing pus
  - wheal:               tense, edematous, transitory plaque secondary to extravasation into the dermis




               FIGURE: Primary Skin Lesions


- secondary skin lesions
   - scale:            epidermal thickening
   - crust:            dried serum
   - fissure:          crack or split
   - erosion:          loss of epidermis (superficial)
   - ulcer:            loss of epidermis and dermis (deeper)
   - lichenification: thickening (especially epidermis) with skin line accentuation
   - scar:             thickening, fibrous tissue
                                                                                      YEPSA: Objectives (page 14 of 190)



  - atrophy:           loss of substance (thinning)
  - excoriation:       linear erosion




             FIGURE: Secondary Skin Lesions


dermatologic descriptors
- papule contour
   - flat topped       (e.g. lichen planus)
   - dome-shaped       (e.g. lymphomatoid papulosis)
   - slightly elevated (e.g. panniculitis)
   - acuminate         (e.g. acute spongiotic dermatitis)
   - papillated        (e.g. intradermal nevus)
   - digitated         (e.g. wart-like)
   - umbilicated       (e.g. molluscum contagiosum)




             FIGURE: Contour


- shape and configuration
   - margination:     sharp vs. ill-defined
   - circinate:       round, circular
   - arciform:        partial circle
   - annular:         round or circular with central clearing
   - iris / target:   bullseye lesions, annular with central internal activity zone
   - serpiginous:     meandering (serpent-like)
                                                              YEPSA: Objectives (page 15 of 190)



  - gyrate:            connecting arcs
  - linear:            straight
  - zosteriform:       dermatomal distribution




             FIGURE: Shape




             FIGURE: Configuration


- distribution
   - localized:        grouped into specific areas
   - generalized:      dispersed all over
   - symmetric:        bilateral
   - asymmetric:       unilateral or lacking randomness
   - discrete:         separate
   - grouped:          clustered
   - confluent:        coalescing smaller into larger
   - cleavage plane:   arranged along lines of skin tension
                                                                                  YEPSA: Objectives (page 16 of 190)




             FIGURE: Distribution



pediatric dermatology
- erythema toxicum
   - disorder:      common benign rash of newborns
   - etiology:      idiopathic
   - morphology:    erythematous papules / pustules associated with multiple erythematous macules
   - location:      commonly on face, trunk, proximal extremities
   - management:    self-limiting, will resolve within several weeks




             FIGURE: Erythema Toxicum


- transient neonatal pustular melanosis
   - disorder:        common benign rash of newborns
   - etiology:        idiopathic
   - morphology:      vesicles, superficial pustules, and pigmented macules
   - location:        commonly on face, palms, and soles
   - management:      self-limiting
                                                                YEPSA: Objectives (page 17 of 190)




             FIGURE: Transient Neonatal Pustular Melanosis


- stork bite lesion
   - disorder:        benign vascular birthmark
   - etiology:        blood vessel malformation
   - morphology:      flat, vascular lesion
   - location:        nape of neck
   - management:      observation, laser therapy




             FIGURE: Stork Bite Lesion


- port wine stain
   - disorder:        benign vascular birthmark
   - etiology:        blood vessel malformation
   - morphology:      darker, red blue, flat vascular lesions
   - location:        often seen on the head
   - management:      observation, laser therapy




             FIGURE: Port Wine Stain
                                                                                            YEPSA: Objectives (page 18 of 190)




- hemangioma
   - disorder:          vascular birthmark
   - etiology:          blood vessel malformation and proliferation of endothelial cells
   - morphology:        raised vascular lesion
                        - enlarge in first 6-9 months of life, begin to flatten
                        - most flatten to skin level prior to 10 years of age
  - location:           nonspecific
  - management:         observation, laser therapy
                        - more aggressive treatment required with obscured vision or airway
                        - may require antibiotic therapy (commonly against S. aureus) if they ulcerate




                 FIGURE: Hemangioma


- diaper dermatitis
   - disorder:          rash of the diaper region
   - etiology:          secondary to combined effects of:
                        - skin wetness
                        - pH elevation of the diaper-covered skin (urease activation)
                        - friction of the diaper against the skin
  - morphology:         large erythematous patch, sometimes with peripheral erythematous red papules
  - location:           diaper region
                        - contact dermatitis: frequently avoids skin folds
                        - candidiasis:           located in skin folds, associated with peripheral papules
  - management:         topical lubricants, topical corticosteroids, topical antifungal agents (e.g. nystatin)




                 FIGURE: Diaper Dermatitis (Candida)


- acne
   - disorder:          common pediatric rash
                        - generally seen with onset several years prior to adolescence
                        - occasionally seen in infants at age 2-6 weeks
  - etiology:           obstruction of sebaceous follicles leading to infection and inflammation
  - morphology:         blackheads, papules, and pustules
                                                                                         YEPSA: Objectives (page 19 of 190)



  - location:         face, upper chest, upper back
  - management:       treatment depends on severity
                      - mild:       peroxide, topical retinoic acid
                      - moderate: peroxide, topical retinoic acid, topical / oral antibiotics
                      - severe:     topical retinoic acid, referral to dermatologist
                      not affected by diet or scrubbing




             FIGURE: Neonatal Acne


- atopic dermatitis (eczema)
   - disorder:        pruritic, excoriating rash of allergic origin
   - etiology:        allergic
   - morphology:      excoriated lesions
   - location:        face and other body sites
   - differential:    differentiate from contact dermatitis and scabies
                      - contact dermatitis: history of exposure to poison ivy or oak; initial vesicular lesions
                      - scabies:              worse in hands and feet, often seen in other family members
   - management:      environmental controls, skin hydration, topical corticosteroids




             FIGURE: Atopic Dermatitis


- seborrheic dermatitis
   - disorder:       scale rash of physiologic origin
   - etiology:       physiologic overproduction of sebum
   - morphology:     greasy scale on a base of erythema
   - location:       sebum-producing areas of scalp, face, and trunk
   - management:     mineral oil prior to washing hair; topical steroids
   - clinical:       cradle cap: seborrheic dermatitis involving scalp of infants
                                                                                         YEPSA: Objectives (page 20 of 190)




             FIGURE: Seborrheic Dermatitis

- guttate psoriasis
   - disorder:        patchy rash secondary to inflammation and excessive skin production
   - etiology:        may occur secondary to streptococcal infection
   - epidemiology:    uncommon in children
   - morphology:      guttate lesions (small papules 2-4 mm in size)
   - location:        central trunk with extension to proximal, then distal extremities
   - management:      topical steroids, topical tar preparation, topical vitamin D analog, UV light therapy




             FIGURE: Guttate Psoriasis


- pityriasis rosea
   - disorder:        common “pine tree” skin condition seen in children and adolescents
   - etiology:        idiopathic
   - morphology:      small, oval-shaped erythematous papules and plaques with scale
   - location:        seen on back parallel to lines of skin stress, giving a “pine tree” appearance
   - management:      self-limiting in 6-10 weeks; topical steroid or moistures if symptomatic
                                                                                          YEPSA: Objectives (page 21 of 190)



             FIGURE: Pityriasis Rosea


- urticaria (hives)
   - disorder:        allergic reaction forming raised skin welts
   - etiology:        allergic response to insect bites, infection, drugs, food, cold, trauma, heat, or exercise
   - morphology:      central wheal with surrounding flare of erythema
   - location:        non-specific
   - management:      avoidance of causative agent; antihistamines




             FIGURE: Urticaria (Hives)


- palpable purpura
   - disorder:        purpura secondary to small vessel inflammation
   - etiology:        inflammation and bleeding of small skin vessels; may be bacterial or viral in origin
   - morphology:      erythematous, non-blanching papules
   - location:        nonspecific
   - management:      may signal severe disease (e.g. Henoch-Schönlein purpura) and should be investigated




             FIGURE: Palpable Purpura
                                                                                      YEPSA: Objectives (page 22 of 190)



- vitiligo
   - disorder:       autoimmune depigmentation
   - etiology:       autoimmune destruction of melanocytes
   - morphology:     localized areas of absence of pigmentation, with sharp demarcation from surrounding skin
   - location:       generally symmetrical involvement of arms, legs, or trunk
   - management:     potent topical steroids, UV therapy; difficult to treat adequately




              FIGURE: Vitiligo


- alopecia areata
   - disorder:       acute hair loss
   - etiology:       autoimmune destruction of hair follicles
   - morphology:     complete hair loss in a local area
   - location:       usually on the scalp
   - differential:   tinea capitis (would give positive fungal smear)
   - management:     spontaneous regrowth in 95% of cases; steroids, contact sensitization helpful




              FIGURE: Alopecia Areata


- nevi
   - disorder:       pigmented lesion of the skin
   - etiology:       sun-induced
   - morphology:     brown to tan macules
   - location:       sun-exposed areas
   - differential:   melanoma (ABCD)

                     BOX: Melanoma
                      The features concerning for malignant melanoma can be remembered by the mnemonic
                                                                                        YEPSA: Objectives (page 23 of 190)




                          ABCD:

                          • asymmetry
                          • border irregularity
                          • color variation
                          • diameter > 6 mm


  - management:       basic sun protection
                      - keep infants < 6 months of age out of direct sunlight
                      - use minimum SPF 15 sunscreen for infants and children > 6 months of age
                      - wear protective clothing
                      - avoid sun exposure between 10 a.m. and 4 p.m.




             FIGURE: Dysplastic Nevus



infectious dermatology
- bacterial infections
   - etiology:         cuts and injuries secondarily infected with S. aureus or S. pyogenes
   - morphology:       numerous manifestations, including:
                       - small fluid-filled vesicles that rupture easily
                       - erosions developing a honey-colored thick crust (as in impetigo)
                       - diffuse, innumerable papules (as in scarlet fever)
   - location:         areas of previous injury
   - management:       topical mupirocin, oral antistaphylococcal antibiotics
                                                                   YEPSA: Objectives (page 24 of 190)




             FIGURE: Scarlet Fever




             FIGURE: Impetigo


- fungal infections
   - etiology:        frequently secondary to Candida albicans
   - morphology:      localized erythematous plaques with scale
   - location:        named based on location of rash
                      - tinea corporis: infected skin
                      - tinea capitis:   infected scalp
  - management:       topical antifungal agents, close follow-up




             FIGURE: Tinea Corpora
                                                                                      YEPSA: Objectives (page 25 of 190)




- scabies
   - disorder:       pruritic skin infestation, may be shared among multiple members of a family
   - etiology:       Sarcoptes scabiei
   - morphology:     pruritic, excoriated areas
   - location:       most intense on hands and feet, but seen in other areas
   - management:     whole body permethrin cream, fumigation




              FIGURE: Scabies


- head lice
   - disorder:       pruritic scalp infestation, may pass from child to child
   - etiology:       Pediculosis capitis
   - morphology:     often asymptomatic, but may be pruritic
   - location:       scalp, primarily occipital regions
   - management:     topical permethrin, malathion




              FIGURE: Head Lice Nits


- viral infections
   - disorder:       viral rash
   - etiology:       viral infection
   - morphology:     nonspecific morbilliform eruption (macules, papules) of the trunk, face, and extremities
                     specific morphologies may include:
                     - measles: associated with fever, cough, rhinitis, conjunctivitis
                     - rubella:     faint, pink macules on the face (somewhat nonspecific)
                     - varicella: papules → vesicles (tear drop) → crusts; multiple stages of healing
                     - HSV:         grouped vesicles on an erythematous base, usually on mouth or hand
                     - HPV:         discreet, raised thickening of skin (warts)
                     - molluscum: umbilicated lesions from 0.5-8 mm in size
  - management:      resolution of viral illness
                                                                                            YEPSA: Objectives (page 26 of 190)




                FIGURE: Nonspecific Viral Rash




Geriatric Problems
                                                                                                    MISCELLANEOUS



     BOX: Important Issues in Geriatric Medicine
      While many of the medical concerns are similar, certain issues take on added importance in elderly patients.
       These include:

        • advanced directives:     important even in healthy patients
        • driving status:          may cause patient-doctor or patient-family conflict
        • elder abuse / neglect:   more common than generally thought
        • hospitalization:         should be avoided as much as possible due to iatrogenic issues, rapid declines




1.     Evaluate and be able to differentiate among dementia, delirium, and depression in an older adult.

                (based partially on objectives written by Sonia Luthra)

     TABLE: Clinical Features in Delirium, Dementia, and Depression
      presentation                          implied diagnosis                common etiologies
      • memory impairment                   dementia                         • Alzheimer’s disease
      • functional impairment in executive                                   • Parkinson’s disease
        function or basic ADLs                                               • frontal lobe dementia

      • stepwise deterioration in cognition     cerebrovascular disease      • vascular dementia
      • episodes of confusion, aphasia,
        slurred speech, or focal weakness

      • acute cognitive impairment              delirium                     •   hypo / hyperglycemia
      • clouded sensorium                                                    •   hypo / hypernatremia
      • difficulty with hypersomnolence                                      •   UTI
                                                                             •   URI / pneumonia
                                                                             •   skin infections
                                                                                       YEPSA: Objectives (page 27 of 190)



                                                                          • EtOH / sedative withdrawal
                                                                          • low perfusion states
                                                                          • toxin ingestion

   • complaints of memory loss,            depression                     • major depressive disorder
     decreased concentration, or                                          • dysthymic disorder
     impaired judgment                                                    • depression from medical condition
   • worse in morning
   • feelings of hopelessness




- delirium
   - disorder:       disturbance of consciousness with reduced ability to focus, sustain, or shift attention
                     - not accounted for by dementia, develops over a short time
                     - frequently the first manifestation of an underlying physical disorder

  - pathogenesis:    secondary to general medical condition (common pathway of many potential causes)

  - differential:    metabolic disturbances
                     - infection
                     - febrile illness
                     - hypoxia
                     - hypoglycemia
                     - drug intoxication or withdrawal states
                     - hepatic encephalopathy

                     central nervous system (CNS) disturbances
                     - brain abscesses
                     - stroke
                     - traumatic injuries
                     - postictal states

                     new onset arrhythmias
                     - atrial fibrillation
                     - cardiac ischemia

                     environmental factors

  - epidemiology
     - prevalence:   10-15% of patients in a hospital setting
     - mortality:    relatively high
                     - 3 month mortality: 33%
                     - 1 year mortality:   50%

  - risk factors:    risk factors include:
                     - post-surgical patients
                     - elderly patients, especially older than 80 years
                     - young children
                     - preexisting brain damage (including dementia)
                     - bone fractures
                     - history of alcoholism
                     - history of sensory impairment (e.g. blindness)
                     - malnutrition
                     - systemic infections
                                                                                            YEPSA: Objectives (page 28 of 190)



                      - use of narcotics or antipsychotics

  - presentation:     confusion, particularly in hospital setting
                      specific factors suggesting delirium may include:
                      - acute presentation with more global confusion and attention impairment
                      - hallucinations, when present, are generally visual or tactile (as opposed to auditory)
                      - less likely to have a history of psychiatric illness

  - diagnosis
     - history:       common symptoms include:
                      - rapid development of disorientation, confusion, and global cognitive impairment
                      - alteration of consciousness, cognition, and perception
                      - disturbances in sleep-wake cycle, with symptoms worsening at night
                      - disorientation to place, date, or person
                      - incoherence
                      - restlessness
                      - agitation or excessive somnolence

     - examination:   important physical findings include:
                      - focal neurologic signs
                      - papilledema
                      - frontal lobe release signs

     - laboratory:    laboratory tests to consider (based on findings / history) include:
                      - blood and urinalysis
                      - chest X ray
                      - CT scan or MRI of the brain
                      - electrocardiogram (ECG)
                      - lumbar puncture
                      - toxic screen
                      - blood gases
                      - electroencephalogram

     - laboratory:    laboratory testing may include:
                      - CBC with differential
                      - serum electrolytes, BUN, Cr, glucose
                      - LFTs
                      - serology for syphilis and HIV
                      - thyroid function tests
                      - serum vitamin B12, folate
                      - urinalysis and urine drug screen

     - imaging:       imaging studies may include:
                      - electrocardiogram (ECG)
                      - chest X ray
                      - brain CT or MRI

  - differential:     distinguish from other functional confusion states
                      - schizophrenia
                      - mood disorder

  - management:       treatment of the underlying cause


- dementia
   - disorder:        syndrome characterized by memory impairment and one or more of:
                                                                                       YEPSA: Objectives (page 29 of 190)



                   - aphasia:           language disturbance
                   - apraxia:           inability to perform complex motor activities in absence of paralysis
                   - agnosia:           failure to recognize or identify objects despite intact sensory function
                   - ↓ executive fxn:   disturbance in higher level function (planning, organizing, abstracting)

- etiology:        most common causes include:
                   - Alzheimer’s disease
                   - vascular disease
                   - dementia with Lewy bodies

- epidemiology:    prevalence increases with age
                   - less than 65 years old: uncommon
                   - 65 to 75 years old:      10%
                   - 75 to 85 years old:      25%
                   - 90 years old:            50%

- pathogenesis:    acquired disorder
                   - impairment distinguishes from mild memory change that occurs during normal aging
                   - generally irreversible, but progression can often be controlled by therapeutic interventions
                   - 3% may fully resolve

- presentation:    early phase:
                   - subtle personality changes
                   - decreased interests
                   - apathy
                   - labile or shallow emotions
                   - noticeable cognitive impairment

                   intermediate phase:
                   - more pronounced cognitive impairment
                   - loss of social skills
                   - psychotic symptoms

                   late phase:
                   - functional loss (self feeding, personal hygiene)
                   - incontinence
                   - extreme emotional lability

                   end stage:
                   - mute and unresponsive
                   - death typically follows within a year

- diagnosis:
   - general:      diagnosis of exclusion (gold standard is biopsy, but oddly enough, is not routinely performed)

  - history:       complete history
                   - functional impairment (decreased task completion abilities, increased reliance on others)
                   - emotional / behavioral changes (delusions, hallucinations, dysphoria, aggression, anxiety)

  - examination:   thorough physical examination, including neurological examination
                   - mental status examination (MSE)
                   - Mini-Mental State Exam (MMSE) can be administered in place of a more formal exam

                   BOX: Mini Mental State Exam (MMSE)
                                                                                      YEPSA: Objectives (page 30 of 190)




                    The Mini Mental State Examination is a 5-10 minute exam that tests cognitive ability across
                      several dimensions, and does so in a standardized way that can be followed on multiple
                      visits. Interpretation is as follows:

                      • MMSE 25-30:        normal
                      • MMSE 20-24:        suggestive of impairment
                      • MMSE <20:          indicative of impairment

                      Interpretation should also take into account age and previous functioning (i.e. a middle
                      aged physician physician scoring a 26 would be somewhat concerning)



   - laboratory:   laboratory testing (to rule out other causes) may include:
                   - CBC with differential
                   - serum electrolytes, BUN, Cr, glucose
                   - LFTs
                   - serology for syphilis and HIV
                   - thyroid function tests
                   - serum vitamin B12, folate
                   - urinalysis and urine drug screen

   - imaging:      imaging studies (to rule out other causes) may include:
                   - electrocardiogram (ECG)
                   - chest X ray
                   - brain CT or MRI

   - procedures:   other tests may include:
                   - neuropsychological testing
                   - cerebral blood flow (i.e. single PET)
                   - lumbar puncture

 - management:     hospitalization indicated for:
                   - evaluation and treatment of behavioral and psychological complications
                   - suicidal threats or behaviors
                   - rapid weight loss
                   - acute deterioration without an apparent cause

                   TABLE: Delirium vs. Dementia
                                           delirium                                 dementia
                    etiology               physical illness                         cognitive deficit
                    onset                  abrupt, precise                          gradual
                    symptoms
                    - consciousness        clouded                                  normal
                    - disorientation       early onset                              late onset
                    - attention            short                                    normal
                    - agitation            frequent                                 infrequent
                    urgency                medical emergency                        quality of life issues


- pseudodementia
   - disorder:     dementia-like illness sometimes accompanying depressive illness
   - symptoms:     poor memory
                   poor cognition, with frequent complaints of lost abilities and skills
 - differential:   mood symptoms often more prominent
                                                                                           YEPSA: Objectives (page 31 of 190)



     - clinical:         include in differential, as it is often much more treatable than dementia
                         for more on dementia in general, see Psychiatry, Objective 1

                         TABLE: Clinical Features Distinguishing Dementia From Pseudodementia
                                                   pseudodementia                 dementia
                          duration                 short duration                 long duration
                          cognitive loss           frequent complaints            few complaints
                                                   - detailed                     - imprecise
                                                   - insightful                   - unconcerned
                          memory effects           specific periods or events     more generalized, if present
                          attention                preserved attention            faulty concentration
                          concentration            preserved concentration        faulty concentration
                          responsiveness           “don’t know” answers           near miss answers
                          simple tasks             tasks performed with little    struggle with tasks
                                                   effort
                          accomplishments          highlight failures             delight in trivial tasks
                          social skills            early loss                     frequently retained
                          mood change              pervasive                      shallow, labile affect
                          psychiatric Hx           psych history common           psych history uncommon


- assessments of mental status
   - Folstein Mini-Mental Status Exam (MMSE): 50-70% sensitive when followed over time
      - orientation:  (5) year, date, day, month, season
                      (5) state, county, city, building, floor
      - registration: (3) repeat three objects
      - attention:    (5) serial 7 subtraction from 100, or spelling of “world” backwards
      - recall:       (3) repeat the three previous objects
      - language:     (2) identification:      identify two objects (e.g. pencil, watch)
                      (1) repetition:          repeat the following: “No ifs, ands, or buts”
                      (3) command:             follow a 3 step command
                      (1) reading:             CLOSE YOUR EYES
                      (1) writing:             write a sentence (must have subject, verb)
                      (1) copying:             copy a design (two embedded pentagons)

     - animal fluency test
        - method:         name as many animals as possible in under a minute
        - sensitivity:    <12 animals is nearly 100% sensitive for significant cognitive impairment

     - clock test
        - method:        draw a clock at a given time (e.g. 10 minutes to 2)
        - sensitivity:   rapid test with high sensitivity for some form of cognitive impairment



2.     Recognize the usefulness of the functional assessment (e.g. ADL and IADL) in making medical decisions
       related to the health status of older adults.

- functional assessment in older adults
   - function:       importance includes:
                     - prioritization of management decisions
                     - maintenance of independent living
                     - prevention of substantial medical complications that may occur

     - methods:          Activities of Daily Living (ADLs):
                                                                                           YEPSA: Objectives (page 32 of 190)



                         - bathing
                         - continence
                         - dressing
                         - feeding
                         - toileting
                         - transferring

                         BOX: Barthel’s Index for ADLs
                          ADLs can be scored using the Barthel’s Index, a 100 point scale that incorporates feeding,
                           transfers, hygeine, toileting, bathing, movement on level surfaces, movement up and
                           down stairs, dressing, bowel continence, and bladder continence.



                         Instrumental Activities of Daily Living (IADLs)
                         - food preparation
                         - shopping
                         - housework
                         - money management
                         - medication management
                         - transportation management

     - clinical:         can be among the most important assessments in geriatric medicine


3.     Create a differential diagnosis for falls in older adults; understand that falls are an important threat to the
       independence of older persons.

- recurrent falls
   - disorder:           repeated episodes of falls, generally in older patients

     - epidemiology
        - incidence:     30% incidence in people over age 65, with 5% resulting in fracture or hospitalization
        - age:           incidence increases with age
        - economics:     results in 6% of medical spending on people over age 65

     - risk factors:     individual risk factors include:
                         - muscle weakness
                         - balance deficit
                         - gait deficit
                         - visual impairment
                         - mobility limitation
                         - cognitive impairment
                         - postural hypotension
                         - impaired functional status

                         other risk factors include:
                         - h/o fall in the last year
                         - age > 80 years
                         - use of assistive device (e.g. cane)
                         - arthritis
                         - depression

                         medication risk factors include:
                         - psychotropic medications (benzodiazepines, antidepressants, antipsychotics)
                                                                                            YEPSA: Objectives (page 33 of 190)



                     - antihypertensives
                     - anticonvulsants

- presentation:      injuries secondary to fall
                     direct questioning (many older people will not volunteer that they are falling)

- differential
   - neurologic:     gait deficits, visual impairment, cognitive deficit, muscle weakness
   - metabolic:      pernicious anemia, thyroid disorders, diabetes mellitus
   - cardiologic:    postural hypotension, arrhythmia
   - functional:     home safety, poor functional status
   - medications:    psychotropic medications, antihypertensives, anticonvulsants
   - psychosocial:   elder abuse

                     TABLE: Etiology and Prevalence of Falls
                       etiology                                         proportion
                       accidents / environmental hazards                   31%
                       gait and balance disorders / weakness               17%
                       dizziness, vertigo                                  13%
                       drop attack                                          9%
                       confusion                                            5%
                       postural hypotension                                 3%
                       visual disorder                                      2%
                       syncope                                             0.3%
                       other specified causes 1                            15%
                       unknown                                              5%
                     1
                        arthritis, acute illness, drugs, alcohol, pain, epilepsy, falling from bed, etc.

- diagnosis
   - history:        important considerations include:
                     - number of falls, patterns, changes
                     - precipitating factors
                     - patient activity at the time
                     - any loss of consciousness
                     - post-fall status
                     - visual symptoms
                     - current medications
                     - witness accounts

  - examination:     important examination includes:
                     - mental status
                     - visual examination
                     - cardiovascular examination
                     - neurologic examination
                     - musculoskeletal examination

  - laboratory:      common laboratory testing includes:
                     - CBC
                     - electrolytes
                     - LFTs
                     - thyroid function tests
                     - vitamin B12
                     - random blood glucose
                     - urinalysis
                                                                                            YEPSA: Objectives (page 34 of 190)



       - imaging:        ECG

       - referral:       visual assessment by ophthalmologist or optician

     - management:       treatment of underlying cause

     - complications:    complications include:
                         - loss of self confidence and independence
                         - fractures (esp. with background of preexisting osteoporosis)
                         - loss of independence requiring admission to a residential home

     - web resource:     Patient UK: Recurrent Falls
                              (http://www.patient.co.uk/showdoc/40001796/)




Gastrointestinal Problems
                                                                                                    MISCELLANEOUS


1.     Evaluate, diagnose, and manage common causes of diarrhea.

                 (partially based on objectives written by Ryan Johnson)

- acute diarrhea
   - disorder:           defined as:
                         - production of > 200 g/day of stool in adults
                         - production of > 20 g/kg/day of stool in children
                         - frequent liquid stools

     - etiology
        - infectious:    common infectious causes include:
                         - viruses (30-40% of episodes)
                         - bacteria and parasites (20-30% of episodes)
                         - other infectious diseases

                         BOX: Infectious Bloody Diarrhea
                           The five most common bacterial causes of bloody diarrhea include:

                             • Campylobacter jejuni       (most common bacteria)
                             • Clostridium dificile       (concern in hospital setting)
                             • E. coli 0157:H7            (30% of infectious bloody stool)
                             • Salmonella
                             • Shigella

                           They can be remembered by the mnemonic SUCCESS.



       - noninfectious: common noninfectious causes include:
                        - intestinal obstruction
                                                                                         YEPSA: Objectives (page 35 of 190)



                    - toxic ingestion and food-related
                    - inflammatory and allergic conditions
                    - psychologic causes
                    - drug-induced

- pathogenesis
   - osmotic:       increased osmotic load
                    - ingestion of large amounts of hexitols
                    - overconsumption of certain fruits

  - secretory:      increased secretion of fluid and electrolytes
                    - bacterial toxins (e.g. cholera)
                    - enteropathogenic viruses
                    - bile acids (e.g. s/p ileal resection)
                    - unabsorbed dietary fat            (e.g. steatorrhea)
                    - drug-induced                      (e.g. anthraquinone cathartics, castor oil, prostaglandins
                    - peptide hormones                  (e.g. VIP from pancreatic tumor)

  - inflammatory: mucosal inflammation, ulceration, or tumefaction resulting in outpouring of fecal content
                  - regional enteritis
                  - ulcerative colitis
                  - tuberculosis
                  - lymphoma
                  - cancer

  - absorptive:     decreased absorptive time
                    - large or small bowel resection
                    - gastric resection
                    - pyloroplasty
                    - vagotomy
                    - surgical bypass of intestinal segments
                    - drugs (Mg-containing antacids, laxatives)
                    - humoral agents (prostaglandins, serotonin)

                    increased transit time and small bowel bacterial proliferation, as seen in:
                    - strictured segments
                    - sclerodermatous intestinal disease
                    - postsurgical stagnant loops

                    malabsorption (osmotic or secretory)
                    - fat malabsorption
                    - carbohydrate malabsorption
                    - celiac sprue

  - functional:     oozing around fecal impaction from constipation
                    - children
                    - debilitated / demented adults

- classification:   based on mechanism and stool characteristics
                    - watery:       stool with large amounts of water present (secretory or osmotic diarrhea)
                    - inflammatory: stool with pus or blood present
                    - fatty:        stool that is large, greasy, frothy, pale, and malodorous

- risk factors:     risk factors include:
                    - recent travel to endemic area
                    - foodborne illness
                                                                                       YEPSA: Objectives (page 36 of 190)



                   - waterborne illness
                   - day care exposure
                   - high risk sexual behavior
                   - recent antibiotic use
                   - immunosuppression

- complications:   complications include:
                   - dehydration
                   - electrolyte loss (Na+, K+, Mg2+, Cl-)
                   - vascular collapse (esp. in young, old, debilitated, or cholera patients)
                   - metabolic acidosis

- diagnosis
   - history:      detailed history, including PMH
                   - circumstances of onset (recent travel, food ingested, source of water, medication use)
                   - duration and severity
                   - association of abdominal pain or vomiting
                   - blood in the stool or change in color
                   - frequency and timing of bowel movements
                   - consistency of stool
                   - evidence of steatorrhea
                   - associated changes in weight or appetitis
                   - rectal urgency

  - examination:   full examination with attention to:
                   - vital signs and fluid status
                   - abdominal exam
                   - rectal exam

  - laboratory:    possible labs include:
                   - stool cultures
                   - stool ova & parasites
                   - fecal leukocytes
                   - stool antigens (C. dificile, giardia, rotavirus)
                   - serum electrolytes

  - procedures:    other procedures include:
                   - endoscopy:              chronic diarrhea or suspected inflammatory casues
                   - fecal fat measurement: suspected malabsorption
                   - pancreatic assessment: if still unknown

- evaluation:      community-acquired, traveler’s diarrhea, or dysentery
                   - stool cultures (Salmonella, Shigella, Campylobacter, E. Coli 0157:H7)
                   - C. dificile toxins
                   - antibiotics if not Shiga toxin (quinolone for Shigella, macrolide for Campylobacter)

                   nosocomial diarrhea
                   - C. dificile toxins
                   - community-acquired labs
                   - d/c antibiotics when possible
                   - consider metronidazole (Flagyl) if persistent or worsening

                   persistent diarrhea > 7 days
                   - fecal WBCs
                   - parasite panel (Giardia, Cryptosporidium, Cyclospora, Isospora balli)
                   - opportunistic infections (Microsporidia, Mycobacterium avium intracellulare)
                                                                                             YEPSA: Objectives (page 37 of 190)




     - management:       antidiarrheal agents in non-bloody diarrhea
                         - bismuth (Pepto Bismol, Kaopectate)
                         - loperamide (Imodium)
                         - diphenoxylate with atropine (Lomotil)
                         - difenoxin with atropine (Motofen)
                         - codeine
                         - aluminum

                         rehydration and electrolyte replacement
                         - oral rehydration therapy (glucose, electrolyte preparations)
                         - IV rehydration
                         - restriction of PO intake if nausea / vomiting prominent

                         dietary adjustment

     - web resource:     FP Notebook: Acute Diarrhea
                             (http://www.fpnotebook.com/GI16.htm)


pharmacologic management of diarrhea
- bismuth subsalicylate
   - function:       antidiarrhetic agent
   - mechanism:      antisecretory, antiinflammatory, antimicrobial effects
   - clinical:       active ingredient in Kaopectate, Pepto Bismol

     - Pepto Bismol
        - function:      antidiarrheal agent
        - mechanism:     bismuth subsalicylate derivative
        - indications:   prevention and treatment of traveler’s diarrhea
                         common antibacterial used in treatment of H. pylori
       - adverse:        black tongue, black stools in some users

     - Kaopectate
       - function:       antidiarrheal agent
       - mechanism:      bismuth subsalicylate derivative
                         - contains clays (kaolin, other silicates) that bind water avidly
                         - may also bind enterotoxins
       - indications:    mild diarrhea

- opioids / opioid agonists
   - agents:          agents include:
                      - loperamide       (Imodium)
                      - diphenoxylate (Lomotil)
                      - difenoxin        (Motofen)
                      - codeine
   - function:        antidiarrheal agents
   - indications:     diarrhea
   - mechanism:       µ-opioid receptor agonists
                      - bind and stimulate µ receptors in the gut
                      - those indicated for diarrhea are generally too insoluble to penetrate the blood brain barrier
   - clinical:        loperamide available OTC


2.     Evaluate, diagnose, and manage common causes of constipation.
                                                                                         YEPSA: Objectives (page 38 of 190)



              (partially based on objectives written by Ryan Johnson)

- chronic constipation
   - disorder:        defined as:
                      - unsatisfactory defecation characterized by infrequent stool and/or difficult stool passage
                      - symptoms present ≥ 3 months

  - epidemiology
     - prevalence:     common problem in the Western world
     - gender:         females > males
     - age:            affects all age groups, but more prevalent in those ≥ 60
     - economics:      5.7 million physician visits per year (6th leading outpatient GI complaint)
                       $800 million dollars spent annually on laxatives

  - classification:    primary constipation
                       - slow transit constipation
                       - pelvic floor dysfunction
                       - normal transit & pelvic floor

                       secondary constipation

  - differential
     - psychosocial:   OCD, functional constipation, dietary / fiber influences
     - metabolic:      hypercalcemia, uremia
     - hematologic:    porphyria
     - secondary:      neurologic (parkinsonism, CVA, tumor, spinal cord injury)
     - vascular:       chronic ischemia
     - infectious:     gross infection
     - inflammatory:   inflammatory bowel disease (IBD)
     - neoplastic:     stricture, tumor
     - degnerative:    loss of autonomic innervation
     - anatomic:       motility disorders
     - endocrine:      hypothyroidism, diabetic (autonomic degeneration)
     - drugs:          secondary to drugs, including:
                       - aluminum hydroxide, bismuth salts, iron salts, cholestyramine
                       - anticholinergics
                       - opioids
                       - ganglionic blockers
                       - tranquilizers / sedatives

  - presentation:      concern over lack of consistent bowel movement or difficult stool passage

                       BOX: Constipation and Difficult Stool Passage
                        Despite the common physician perception, difficult stool
                         is actually a more common symptom than infrequency.
                         Difficult stool passage includes:

                          • straining
                          • hard, lumpy stool
                          • difficulty passing stool
                          • incomplete evacuation
                          • prolonged time to stool
                          • need for manual maneuvers to pass stool
                                                                                     YEPSA: Objectives (page 39 of 190)




- diagnosis
   - general:      must rule out more serious causes in constipation workup

  - criteria:      clinical criteria for chronic constipation include:
                   - straining > 25% of the time
                   - hard stools > 25% of the time
                   - incomplete evacuation > 25% of the time
                   - bowel movements < 3 times per week

  - history:       symptoms may include:
                   - rectal pain, cramps
                   - passage of watery mucus
                   - abdominal pain
                   - nausea
                   - nonspecific (fatigue, anorexia)

  - examination:   full physical examination with rectal (may reveal hard stool in rectal vault)

  - laboratory:    common initial labs include:
                   - CBC
                   - TSH
                   - fasting glucose
                   - electrolytes

  - procedures:    colonoscopy for patients with resistant, prolonged, or unusual symptoms

                   TABLE: Constipation Red Flags
                    type                 finding
                    history              • older onset (age ≥ 50 years)
                                         • family history of colon cancer or IBD
                                         • unintentional weight loss ≥ 10 lb
                                         • hematochezia
                                         • symptoms of underlying disorders (e.g. hypothyroidism)

                   physical examination       • abnormal rectal exam
                                              • abdominal mass

                   laboratory findings        • ↓ Hb
                                              • ↑ WBC count
                                              • guaiac-positive stool


- management
  - general:       general regimen (not necessarily evidence-based) includes:
                   - fiber 25-35 g/day
                   - fluids 40-60 oz/day
                   - adequate caloric intake
                   - exercise

  - medications:   pharmacologic treatments (should be used judiciously) include:
                   - fiber supplements:          psyllium, methylcellulose, calcium polycarbophil, guar gum
                   - wetting / softening agents: docusate, mineral oil
                   - osmotic laxatives:          PEG, lactulose, sorbitol, magnesium salts
                   - stimulant laxatives:        bisacodyl, senna, casarca, castor oil
                                                                                             YEPSA: Objectives (page 40 of 190)



                        - new agents:                      tegaserod, lubiprostone

                        TABLE: Laxative Effect and Latency in Usual Clinical Dosage
                         indication           latency      agents
                         softening of feces   1-3 days     bulk-forming laxatives
                                                           • bran
                                                           • psyllium preparations
                                                           • methylcellulose
                                                           • calcium polycarbophil

                                                                   surfactant laxatives
                                                                   • docusates
                                                                   • poloxamers
                                                                   • lactulose

                            soft / semifluid stool   6-8 hours     stimulant laxatives

                                                                   diphenylmethane derivatives
                                                                   • bisacodyl

                                                                   anthraquinone derivatives
                                                                   • senna
                                                                   • cascara sagrada

                            watery evacuation        1-3 hours     osmotic laxatives 1
                                                                   • sodium phosphates
                                                                   • magnesium sulfate
                                                                   • milk of magnesia
                                                                   • magnesium citrate

                                                                   castor oil
                        1
                            high dose for cathartic (evacuative) effect, low dose for laxative effect

       - impaction:     fecal impaction treated with:
                        - enema
                        - manual disimpaction




Medicine
                                                                                          DIAGNOSIS & TREATMENT


1.     Be able to evaluate, diagnose, and manage sepsis.

               (based partially on objectives written by Deb Thompson)

- definitions
   - bacteremia:        presence of bacteria in bloodstream detected by BC’s

     - SIRS:            systemic inflammatory response syndrome
                                                                                      YEPSA: Objectives (page 41 of 190)



                     - response to inflammation or injury, infectious or non-infectious
                     - criteria-based diagnosis

                     DIAGNOSTIC CRITERIA: Systemic Inflammatory Response Syndrome (SIRS)
                      ≥ 2 of the following, in absence of alternative explanation:

                      A:   temperature >38.0°C (100.4°F) or <36°C (96.8°F)
                      B:   heart rate > 90/min
                      C:   respiration rate > 20/min or arterial blood PaCO2 < 32 mmHg
                      D:   leukocyte counte > 12,000/µL or <4,000/µL with 10% bands



  - sepsis:          SIRS in response to confirmed infectious process

  - severe sepsis:   sepsis associated with organ dysfunction, hypoperfusion, or hypertension
                     resultant abnormalities may include:
                     - lactic acidosis
                     - oliguria
                     - acute alteration in mental status

  - septic shock:    sepsis-induced hypotension and perfusion abnormalities despite adequate fluid resuscitation


- sepsis
   - disorder:       SIRS in response to confirmed infectious process

  - etiology:        Gram positives > Gram negatives
                     - Gram-pos:      S. aureus, coag-neg Staph, S. pneumo, S. pyogenes, enterococci.
                     - Gram-neg:      E. coli, Klebsiella, Pseudomonas, Proteus, Serratia, Neisseria meningitidis.
                     - other:         opportunistic fungi, viral, rickettsia, protozoa

  - risk factors:    includes hospitalization, illness, invasive procedures

                     Gram positive infections
                     - indwelling IV catheters
                     - indwelling mechanical devices
                     - IV drug use/abuse
                     - burns

                     Gram negative infections
                     - diabetes mellitus
                     - cirrhosis, biliary disorders, alcohol abuse
                     - burns
                     - cancer
                     - total parenteral nutrition (TPN)
                     - urinary disorders
                     - immunosuppression (steroids, chemotherapy)
                     - GI infections

                     fungal septicemia
                     - immunosuppressed
                     - neutropenic
                     - prolonged broad-spectrum antibiotics
                                                                                        YEPSA: Objectives (page 42 of 190)



                    splenectomy patients
                    - S. pneumoniae
                    - H. influenzae
                    - N. meningitidis

- presentation:     presentation can vary
                    - early:      fever, chills, tachypnea
                    - late:       mental status changes, cold and clammy extremities, oliguria

- diagnosis
   - history:       review medical record for:
                    - medications (antibiotics, immunosuppressants)
                    - recent surgeries or dental procedures
                    - previous illnesses and surgeries (e.g. splenectomy)
                    - HIV risk factors
                    - IVDU

  - examination:    note vital signs, input / output, systemic symptoms, mental status changes

  - laboratory:     metabolic studies
                    - electrolytes with glucose, BUN / Cr
                    - liver function tests
                    - arterial blood gases (ABGs)

                    infection studies
                    - cultures from infection sites (blood, sputum, urine, skin, CSF)
                    - urinalysis with culture

                    blood studies
                    - CBC with differential (evaluate WBCs)
                    - coagulation studies (concern for DIC)
                    - ESR / CRP

                    BOX: Notable Findings in Sepsis Blood Studies
                     Blood studies are important with sepsis. Notable findings include:

                       CBC with differential:
                       • leukocytosis with left shift or leukopenia
                       • toxic granules, Dohle bodies, or intracytoplasmic vacuolization in PMNs

                       coagulation studies:
                       • thrombocytopenia
                       • increased fibrin degradation products, decreased fibrinogen
                       • increased PT



  - procedures:     if suspected, abdominal ultrasound or CT to look for:
                    - bowel perforation
                    - ischemic bowel
                    - cholecystitis
                    - diverticulitis

- management
  - source control: initial broad spectrum antibiotics, narrow spectrum when sensitivities obtained
                                                                                             YEPSA: Objectives (page 43 of 190)



       - respiratory: keep O2 > 92%, consider ventilator for progressive hypoxia
       - hemodynamic: monitor and adjust fluid status
                      - keep MABP > 60 mmHg with IVNS
                      - keep CVP < 10-12 cm H2O, PCWP 14-18 mmHg to avoid pulmonary edema
       - pressor:     start pressors of patient fails volume resuscitation (norepinephrine, dopamine, dobutamine)
       - other:       activated protein C (APC) in patients with end organ failure (absolute mortality reduction 6%)


2.     Be able to evaluate, diagnose, and manage pneumonia.

                   (based partially on objectives written by Miguel Gamez)

- pneumonia
   - disorder:             inflammation of the pulmonary parenchyma

     - etiology:           typical CAP
                           - Streptococcus pneumoniae (most common cause in adults)
                           - Moraxella catarrhalis
                           - Haemophilus influenzae

                           atypical CAP
                           - Mycoplasma pneumoniae
                           - Legionella pneumophila
                           - Clamydia pneumoniae

                           pneumonia with specific risk factors
                           - Chlamydia psittaci:               bird exposure
                           - Pneumocystis carinii:             AIDS / immunosuppression
                           - Mycobacterium tuberculosis:       previous history, predisposition

                           nosocomial infection
                           - E. coli
                           - Pseudomonas aeruginosa

     - epidemiology:       highest mortality in people > 65
                           mortality increases with:
                           - comorbidity (neoplasia, renal insufficiency, CHF, cirrhosis, diabetes, influenza)
                           - prior bouts of pneumonia
                           - hospitalization in previous year

     - pathogenesis:       pulmonary parenchymal infection secondary to:
                           - defects in host defenses protecting the lung
                           - inhalation of a large inoculum
                           - hematogenous infection

     - presentation:       clinical presentation can aid in diagnosis, but is not specific
                           - typical vs. atypical
                           - viral vs. bacterial

                           TABLE: Typical vs. Atypical Presentation
                            “typical” presentation 1                          “atypical” presentation 2
                            • sudden onset                                    • insidious onset
                            • fever                                           • dry cough
                            • productive cough                                • extrapulmonary symptoms
                            • rust-colored sputum                                - headache
                            • pleuritic chest pain                               - myalgia
                                                                                   YEPSA: Objectives (page 44 of 190)



                                                                     - sore throat
                                                                   • CXR worse that auscultation
                  1
                      most characteristic of S. pneumoniae
                  2
                      most characteristic of M. pneumoniae

                  TABLE: Bacterial vs. Viral Presentation
                   bacterial pneumonia                             viral presentation
                   • abrupt onset cough, fever                     • prodromal rhinorrhea, cough, fever
                   • chest pain                                    • pharyngitis
                   • chills                                        • tachypnea, tachycardia
                   • hypoxia                                       • mild hepatosplenomegaly
                   • toxic appearing



- diagnosis
   - general:     combined clinical and radiologic findings, with empiric treatment

  - laboratory:   common initial lab studies include:
                  - CBC with differential
                  - chest radiograph (bacterial more commonly lobar; viral more commonly diffuse)
                  - pulse oximetry

                  studies indicated for atypical or urgent presentations
                  - blood culture
                  - sputum (children > 12) for Gram stain, culture, acid fast smear and culture
                  - direct viral examination of nasopharyngeal specimens
                  - M. pneumoniae IgM and IgG
                  - pulse oximetry

  - imaging:      certain findings on CXR suggest specific causes
                  - diffuse interstitial infiltrates: viral, P. carinii
                  - bilateral apical infiltrates:     M. tuberculosis
                  - cavitation:                       S. aureus, tuberculosis, Klebsiella

                  serial CXR generally not required as resolution takes > 4 weeks; only indicated for:
                  - no clinical improvement
                  - presence of pleural effusion
                  - necrotizing infection (cavitation)

- differential:   DDx for cough includes:
                  - asthma
                  - chronic GERD
                  - repeated aspiration
                  - chronic bronchitis
                  - bronchiectasis
                  - bronchial carcinoma
                  - tuberculosis
                  - medications (e.g. ACE-inhibitors)

- management
  - principles:   general principles of management include:
                  - determine likely etiology from history and physical findings
                  - stratify risk to determine inpatient vs. outpatient
                                                                                     YEPSA: Objectives (page 45 of 190)



                   - treat empirically, unless specific diagnosis indicated
                   - follow up closely

  - admission:     based on risk stratification

                   TABLE: High Risk Findings in the History and Physical
                    history                                     physical exam findings
                    • age > 50 years                            • altered mental status
                    • h/o cancer                                • tachycardia (≥ 125 bpm)
                    • congestive heart failure (CHF)            • tachypnea (> 30 breaths / min)
                    • coronary vascular disease (CVD)           • hypotension (< 90 mmHg systolic)
                    • renal, liver disease                      • hypothermia (< 95°F or 35°C)
                                                                • hyperthermia (> 104°F or 40°C)


  - antibiotics:   regarding antibiotic use:
                   - when possible, obtain spugum Gram stain and culture, and blood culture, prior to antibiotics
                   - initiate empiric treatment within 8 hours, then switch to pathogen-specific

                   TABLE: Pathogen-Specific Antibiotics
                    pathogen                        treatment
                    S. pneumoniae (PCN sensitive)   • amoxicillin
                                                    • cefuroxime, cefproxil (2nd gen. cephalosporin)
                                                    • ceftriaxone, cefotaxime (3rd gen. cephalosporin)

                   S. pneumoniae (PCN resistant)          • gatifloxacin, levofloxacin (quinolones)
                                                          • vancomycin
                                                          • linezolid


                   H. influenzae                          • doxycycline
                                                          • cefuroxime, cefproxil (2nd gen. cephalosporin)

                   S. aureus                              • ceftriaxone, cefotaxime (3rd gen. cephalosporin)
                                                          • vancomycin (MRSA)

                   Legionella                             • azithromycin
                                                          • levofloxacin x2w

                   Chlamydia, Mycoplasma                  • azithromycin
                                                          • doxycycline x1-2w

                   anaerobes                              • clindamycin
                                                          • amoxicillin-clavulanate (Augmentin)
                                                          • ampicillin-sulbactam (Unasyn)
                                                          • piperacillin-tazobactam (Zosyn)

                   HSV                                    • acyclovir

                   CMV                                    • ganciclovir



BOX: Aspiration Pneumonia vs. Aspiration Pneumonitis
                                                                                          YEPSA: Objectives (page 46 of 190)




      Aspiration pneumonia and aspiration pneumonitis are frequently confused. In general:

      • Aspiration pneumonia is an infectious process caused by inhalation of oropharyngeal secretions colonized
        by bacterial pathogens. This occurs during normal sleep, but patients with impaired immune defenses
        (coughing, ciliary transport) are susceptible to development of pneumonia. It is treated with antibiotics.

      • Aspiration pneumonitis is an inflammatory response to a chemical injury to the lungs secondary to
        aspiration of gastric contents. This occurs most commonly secondary to diminished consciousness, and is
        treated with observation.




- pneumonia severity index (PSI)
   - function:        identify predictors of mortality to assess for prognosis, as well as aid in triage
   - method:          summation of point values assigned to various risk factors
   - interpretation:  five point classification system

     TABLE: Calculation of Pneumonia Severity Index (PSI)
      category              factor                                   points
      demographic factors   • age (– 10 for women)                   + age (years)
                            • nursing home resident                  + 10

      comorbidities           • neoplastic disease                   + 30
                              • liver disease                        + 20
                              • congestive heart failure (CHF)       + 10
                              • cerebrovascular accident (CVA)       + 10
                              • renal disease                        + 10

      physical examination    • altered mental status                + 20
                              • respiratory rate ≥ 30                + 20
                              • systolic BP < 90                     + 20
                              • temperature < 35 or ≥ 40             + 15
                              • pulse > 125 bpm                      + 10

      laboratory findings     • pH < 7.35                            + 30
                              • BUN > 10.7, sodium < 130             + 20
                              • glucose > 13.9                       + 10
                              • hematocrit < 30                      + 10
                              • pO2 < 60 or SpO2 < 90%               + 10
                              • pleural effusion                     + 10


     TABLE: Classification of PSI Patients
      points            class                mortality           treatment
      0 points          class I              0.1% mortality      outpatient
      < 70 points       class II             0.6% mortality      outpatient
      71-90 points      class III            2.8% mortality      outpatient
      91-130 points     class IV             8.2% mortality      inpatient
      > 130 points      class V              29.2% mortality     inpatient



3.     Be able to evaluate, diagnose, and manage acute myocardial infarction.
                                                                                          YEPSA: Objectives (page 47 of 190)




                (based partially on objectives written by Michelle Yao)

- acute myocardial infarction
   - disorder:       necrosis secondary to insufficient O2 supply to an area of the heart

  - etiology:           causes include
                        - coronary atherosclerosis (vast majority)
                        - coronary artery spasm
                        - coronary embolism
                        - periarteritis
                        - MI with normal coronaries (MINC syndrome)
                        - hypercoagulable states
                        - trauma
                        - radiation

  - risk factors:       modifiable risk factors:
                        - hypertension
                        - hyperlipidemia (high LDL, low HDL)
                        - diabetes mellitus
                        - tobacco use

                        non-modifiable risk factors:
                        - age
                        - male gender
                        - family history (male < 55, female < 65)
                        - personal history of CAD

  - pathogenesis:       acute coronary syndromes (ACS)
                        - stable angina:         activity-related chest pain secondary to ischemic disease
                        - unstable angina:       unpredictable chest pain secondary to ischemic disease
                        - non ST-elevation MI:   MI without ST elevation
                        - ST-elevation MI:       MI with ST elevation (0.1 mV in ≥ 2 contiguous leads)

                        significance of the Q wave
                        - non Q-wave MI:           infarction limited to inner myocardial wall
                        - Q-wave MI:               transmural infarct

  - presentation:       may be painless in 20% of patients, particularly:
                        - diabetes mellitus
                        - elderly

                        typical presentation includes:
                        - crushing substernal chest pain (longer than 20 min, not relieved by nitroglycerin or rest)
                        - radiation (arms, jaw, neck, shoulder, abdomen)
                        - non-pleuritic pain

                        associated symptoms may include:
                        - dyspnea
                        - diaphoresis
                        - dizziness
                        - nausea / vomiting
                        - feeling of impending doom

  - diagnosis
     - general:         diagnosis based on 2 of 3 criteria
                                                                                    YEPSA: Objectives (page 48 of 190)



                    - typical symptoms
                    - ECG findings
                    - cardiac enzymes

  - examination:    physical findings may include:
                    - skin:       sympathetic response
                    - lungs:      rales (indicative of CHF)
                    - heart:      systolic murmurs, S3 (systolic dysfunction), S4 (LV noncompliance), arrhythmia

  - laboratory:     cardiac enzymes
                    - CK:       general indicator of muscle damage
                    - CK-MB: more specific to myocardium
                    - TnI:      highly specific cardiac marker, begins elevation within 6 hours of damage
                    - TnT:      high levels associated with high mortality

                    cardiac cath studies
                    - clotting studies (aPTT, INR)
                    - kidney function (BUN, Cr)

  - ECG:            temporal progression in an untreated Q-wave MI:
                    - peaked T waves           (hyperacute)
                    - ST elevation             (acute; represents myocardial injury)
                    - T wave inversion         (hours to days)
                    - Q wave development       (weeks to months; represents scar tissue)

- management
  - immediate:      immediate measures include:
                    - bed rest
                    - ASA
                    - O2 (2-4 L/min)
                    - nitrates
                    - morphine (or other pain control)

  - thrombolytic:   choice of thrombolytic therapy guided by ECG, time of presentation
                    - heparin drip within 12 hours of onset
                    - add tPA for STEMI

  - interventional: percutaneous transluminal coronary angioplasty (PTCA)

  - prophylactic:   adjuvant therapies that reduce mortality include:
                    - β blockers to all patients with evolving MI if no contraindications
                    - ACE-I / ARB initiation within several hours unless hypotensive or h/o ACE-I angioedema

                    long term secondary prevention
                    - smoking cessation
                    - patient education
                    - statin treatment to < 100 mg/dL

  - other:          other measures in the acute setting include:
                    - stool softener
                    - NPO until stable
                    - anxiolytics

                    TABLE: Management of Suspected Acute Coronary Syndrome (ACS)
                     time              management
                     at t = 0…         • patient presentation to hospital
                                                                                   YEPSA: Objectives (page 49 of 190)




                   by t = 5 minutes…        • stat 12 lead EKG

                   by t = 15 minutes…       • ASA 325 mg PO
                                            • 2 peripheral IVs
                                            • supplemental O2
                                            • nitroglycerin sublingual or IV PRN chest pain
                                            • metoprolol 5 mg IV q 5 min x3
                                                  (hold if SBP < 100 or HR < 60)
                                            • thrombolysis
                                               - NSTEMI:       heparin
                                               - STEMI:        heparin + tPA

                   by t = 30 minutes…       • labs (CKMB, troponin, CBC, metabolic panel, Mg, INR)
                                            • imaging (CXR)
                                            • apply radiolucent EKG leads / defib patches from kit
                                            • groin prep (both) using clipper
                                            • cardiology consult / transfer to ICU


                   BOX: Management of Suspected Acute Coronary Syndrome
                    The most important steps in initial management of a suspected acute coronary
                      syndrome can be remembered through the use of the mnemonic BEMOAN:

                      • β-blocker
                      • EKG
                      • morphine
                      • oxygen
                      • aspirin
                      • nitroglycerine



- complications:   complications of MI include:
                   - arrhythmia
                   - mitral regurgitation
                   - RV infarct
                   - ventricular septal defect (VSD)
                   - myocardial rupture
                   - systemic embolism
                   - Dressler’s syndrome
                   - pulmonary embolism
                   - LV aneurysm


TABLE: Contraindications to Thrombolytic Therapy
 absolute contraindications                               relative contraindications
 • major surgery / trauma within past 2 weeks             • blood pressure > 180/110 on ≥ 2 readings
 • aortic dissection                                      • bacterial endocarditis
 • active internal bleeding (excluding menses)            • diabetic retinopathy with recent bleed
 • pericarditis                                           • severe hepatorenal disease
 • h/o cerebral tumor, hemorrhage, AVM                    • chronic warfarin therapy
 • prolonged, traumatic resuscitation                     • stroke / TIA within last 12 months
 • bleeding diasthesis
 • allergy to agent / prior reaction
                                                                                       YEPSA: Objectives (page 50 of 190)



      • cerebral hemorrhage within last 12 months
      • pregnancy
      • h/o uncontrolled HTN
      • recent hepatic / renal biopsy




4.     Be able to evaluate, diagnose, and manage congestive heart failure.

                   (based partially on objectives written by Budd Droese)

- congestive heart failure (CHF)
   - disorder:         inability of the heart to meet metabolic needs of the body under normal ventricular pressures

     - etiology:           myocardial injury
                           - adriamycin
                           - alcohol use
                           - cocaine
                           - myocardial infarction / ischemia
                           - dysrhythmia
                           - rheumatic fever / systemic infection
                           - viral myocarditis

                           chronic pressure overolad
                           - aortic stenosis
                           - systemic hypertension

                           chronic volume overload
                           - anemia
                           - mitral regurgitation
                           - pregnancy

                           acute outflow obstruction
                           - acute valvular dysfunction
                           - pulmonary embolism

                           infiltrative diseases
                           - amyloidosis
                           - hemochromatosis

                           BOX: Etiology of Congestive Heart Failure
                             Common causes of heart failure include:

                               • myocardial injury
                               • chronic pressure overload
                               • chronic volume overload
                               • acute outflow obstruction
                               • infiltrative diseases



     - pathogenesis:       two components to heart failure
                           - forward (systolic):     low cardiac output
                           - backward (diastolic):   increased filling pressure
                                                                                        YEPSA: Objectives (page 51 of 190)




- classification:   from New York Heart Association (NYHA) functional classification
                    - based on exercise tolerance
                    - best predictor of mortality

                    TABLE: NYHA Functional Classification
                     class     function                                                                  mortality
                     class I   no limitation of ordinary physical activity                                 ---

                        class II       slight limitation of physical activity                                ---
                                          (fatigue, dyspnea with moderate exertion)
                        class III      marked limitation of physical activity                               20%
                                          (symptomatic with even light activity)
                        class IV       symptomatic at rest                                                  60%

                    1
                        annual mortality numbers; not available for class I and II

- presentation:     presenting symptoms include:
                    - lightheadedness
                    - decreased exercise tolerance
                    - orthopnea
                    - angina-like chest pain

- diagnosis
   - examination:   varies with mechanism of heart failure, though both are often present concomitantly

                    TABLE: Common Signs in CHF
                     forward (systolic) failure                         backward (diastolic) failure

                        hypoperfusion                                   pulmonary edema
                        • exertional dyspnea                            • orthopnea
                        • cool, clammy skin                             • inspiratory crackles (“wet”)
                        • vasoconstriction 1                            • systolic murmur
                        • delayed capillary refill                      • tachypnea 2
                        • mental status changes
                        • decreased urinary output                      RHF
                                                                        • hepatojugular reflux
                                                                        • S3 gallop
                                                                        • dependent edema

                                                                        nocturia 3
                    1
                      can be the cause of “normal” blood pressure
                    2
                      most common sign of CHF
                    3
                      mediated by BNP

  - laboratory:     lab findings include:
                    - respiratory alkalosis
                    - azotemia
                    - decreased ESR
                    - increased creatinine
                    - hyponatremia (dilutional)

  - imaging:        CXR may demonstrate:
                    - increased heart size
                                                                                          YEPSA: Objectives (page 52 of 190)



                        - pleural effusion
                        - Kerley B lines (lines above costophrenic recesses indicating interstitial edema)

                        cardiac echo can indicate the size, function, and direction of flow

       - procedures:    cardiac catheterization gives measurements of pressure related to function

     - management
       - goals:         goals of treatment are:
                        - symptomatic relief
                        - reduction of mortality risk

       - principles:    general principles of management include:
                        - correct any correctable causes
                        - administer supplemental O2 to reduce hypoxia
                        - utilize anti-embolism stockings
                        - restrict fluids and sodium (may require compromise with nephrology)
                        - watch electrolytes carefullly for K+ imbalances

       - medications:   afterload reduction
                        - ACE-I, ARBs (improve mortality)
                        - β blockers (improve mortality)
                        - nitrates (improve mortality)

                        preload reduction
                        - diuretics (furosemide, metolazone, spironolactone)
                        - fluid and sodium restriction
                        - vasodilators (morphine sulfate)

                        contractility agents
                        - digoxin (improves symptoms, but not mortality)

       - surgical:      based on underlying causes
                        - valvular replacement / valvuloplasty
                        - coronary artery bypass graft


5.     Be able to evaluate, diagnose, and manage abdominal pain.

                (Based partially on objectives written by Mike Grinney. For the diagnostic workup of the acute
                abdomen, please see Surgery, Objective 6)

- irritable bowel syndrome (IBS)
   - disorder:        recurrent abdominal pain or discomfort with no identifiable organic cause

     - epidemiology
        - prevalence:   most common functional GI disorder
                        20-22% of US population have symptoms consistent with IBS
       - gender:        females > males (2-3 : 1)

     - symptoms:        symptoms may include:
                        - abdominal pain, burning, discomfort
                        - visceral hypersensitivity
                        - abdominal bloating (distension vs. sensation)
                        - diarrhea, constipation (alone, mixed, or alternating )
                        - fecal urgency
                                                                                    YEPSA: Objectives (page 53 of 190)



                  - fecal incontinence
                  - passage of mucous
                  - rectal dissatisfaction (incomplete evacuation)

                  syndrome is associated with:
                  - rheumatological symptoms:     66% of patients
                  - fibromyalgia:                 60%
                  - genitourinary symptoms:       50-60%
                  - sexual dysfunction:           24-83%
                  - sleep disturbance:            50% (71% in functional dyspepsia patients)
                  - psychiatric diagnosis:        “high prevalence”

- diagnosis
   - general:     ROME II Diagnostic Criteria

                  ROME II Criteria: Irritable Bowel Syndrome (IBS)
                   A: 12 weeks in preceding 12 months of abdominal discomfort with 2 of 3:
                      1.) relieved with defacation
                      2.) onset associated with change in frequency of stool
                      3.) onset associated with change in form or appearance of stool

                   B: not better explained by a structural or biochemical etiology

                   supporting symptoms:
                   • abnormal stool frequency            (< 3 BMs / week, > 3 BMs / day)
                   • abnormal stool form                 (lumpy / hard, loose / watery)
                   • abnormal stool passage              (straining, urgency, feeling of incomplete evacuation)
                   • passage of mucus
                   • bloating, feeling of distension


  - laboratory:   general labs (to rule out other disorders) include:
                  - CBC, ESR
                  - stool tests for WBCs, blood, pathogens

                  labs specific to subtype include:
                  - constipation-dominant: FOBT, CBC, TSH
                  - diarrhea-dominant:        glucose, stool O&P, lactose-hydrogen breath test, anti-gliadin Ab

  - imaging:      imaging studies include:
                  - plain films             (r/o obstruction)
                  - transvaginal ultrasound (if new onset, increased frequency / severity)

  - endoscopy:    colonoscopy or flexible sigmoidoscopy ± barium enema
                      (age >45, age >40 with family history of colon cancer)

- management:     lifestyle modifications include:
                  - frequent office visits
                  - reduction of stressors
                  - adequate fluid intake
                  - bulk agents
                  - avoid provocative agents
                       (caffeine, alcohol, legumes, dairy, carbonated beverages, fatty meals, spicy foods)
                                                                                             YEPSA: Objectives (page 54 of 190)




- inflammatory bowel disease (IBD)
   - disorder:     non-specific, non-infectious, chronic inflammation of the intestinal tract
                   - group of inflammatory conditions of the large (and sometimes small) intestine
                   - shares underlying features, mechanisms, and therapies with some rheumatoid disorders

                     manifests as any one of the following:
                     - Crohn’s disease (ileocolitis, colitis, small bowel, perianal, etc.)
                     - ulcerative colitis
                     - ulcerative proctitis
                     - indeterminate colitis

  - etiology:        environmentally triggered immune dysregulation in a genetically susceptible individual
                     - precise etiology is currently unknown
                     - thought to be secondary to ubiquitous, commensal intestinal bacteria

                     effect of environmental factors
                     - smoking:                 worsens Crohn’s disease, protective against ulcerative colitis (UC)
                     - appendectomy:            protective against UC
                     - NSAIDs:                  worsens both Crohn’s, UC
                     - oral contraceptives:     effect is debatable
                     - breastfeeding:           protective against both Crohn’s, UC
                     - hygiene hypothesis:      increasing incidence of IBD may be secondary to better hygiene

  - epidemiology
     - geography:    more common in Western civilizations (North America, UK, Scandinavia)
     - prevalence:   1-2 million IBD patients in the U.S.
     - incidence:    10,000 new cases/year in the U.S.
                     - since 1960, U.S. incidence of UC has been stable, but Crohn’s has increased 8-10x
                     - currently, incidence of ulcerative colitis and Crohn’s disease is equal in the U.S.
    - ethnicity:     more common in Jewish people

  - genetics:        non-Mendelian inheritance
                     - 10-30% of patients with IBD have a positive family history of IBD
                     - stronger genetic association for Crohn’s than for ulcerative colitis

                     involved genes
                     - NOD2 (CARD15): susceptibility to fibrostenosing Crohn’s (chromosome 16)
                     - IL-23 receptor: associated with IBD (important role in activating inflammation)

  - pathogenesis:    tissue damage secondary to inappropriate, ongoing immune response
                     involved cells known to originate outside the gut because:
                     - marrow transplant can cure IBD
                     - Crohn’s disease recurs in transplanted bowel

  - symptoms:        common symptoms include:
                     - abdominal pain
                     - vomiting
                     - diarrhea
                     - hematochezia
                     - weight loss

  - diagnosis
     - laboratory:   stool studies to look for lower GI bleeding causes
                     - stool cultures for C. difficile, Campylobacter, Shigella, Salmonella, E. coli
                     - stool O&P
                                                                                         YEPSA: Objectives (page 55 of 190)



                     - fecal leukocytes
                     - FOBT

                     CBC, CRP, albumin to determine severity of disease

    - imaging:       imaging studies may include:
                     - abdominal x-ray            (may show signs of obstruction)
                     - air contrast barium enema  (may show narrowing, fistulas, and/or string sign)
                     - CT abdomen

    - endoscopy:     sigmoidoscopy or colonoscopy (need endoscopy with mucosal biopsy for diagnosis)

  - management:      goals of therapy include:
                     - induce and maintain remission
                     - avoid toxicity from medications
                     - provide adequate quality of life

                     lifestyle modifications include:
                     - well-balanced, low fat diet
                     - diet high in fiber (diarrhea dominant)
                     - diet low in roughage (constipation dominant)
                     - limit intake of caffeine, gas-producing vegetables

  - clinical:        the most common inflammatory bowel disorders are ulcerative colitis and Crohn’s disease
                     - ulcerative colitis: tends to affect the colon proximally from the rectum
                     - Crohn’s disease:    tends to affect any part of the digestive tract (regional enteritis)


  TABLE: Clinical Features of Inflammatory Bowel Disease (IBD)
                          ulcerative colitis                          Crohn colitis
    distribution          distribution continuous with rectum         segmental distribution
    rectal involvement    usually involves rectum (98%)               commonly involves rectum (80%) 1
    terminal ileum        ---                                         usually involves terminal ileum
    mucosa                diffuse involvement of mucosa               mucosa with ulcers, fissures, cobblestone
    serosa                ---                                         congested, thickened serosa
    fistulas              ---                                         fistulas
    pseudopolyps          pseudopolyps                                pseudopolyps
    strictures            ---                                         structures
    inflammation          diffuse mucosal, submucosal inflammation patchy, transmural inflammation
    ulceration            mucosal, submucosal ulcers                  deep ulcers
    crypt abscess         crypt abscesses                             crypt abscesses
    granulomata           ---                                         granulomata common (60%)
    fibrosis (serosal)    ---                                         serosal fibrosis common
  1
    though previously believed otherwise, Crohn colitis commonly involves the rectum



- cholecystitis
   - disorder:       inflammation of the gall bladder

  - etiology:        causes include:
                     - cholelithiasis (gallstones)
                     - acalculous cholecystitis (seen in debilitated, trauma patients)

  - symptoms:        common symptoms include:
                                                                                        YEPSA: Objectives (page 56 of 190)



                      - RUQ pain, referred to R flank or scapula
                      - low grade fever
                      - nausea / vomiting

  - diagnosis
     - laboratory:    initial laboratory studies include:
                      - CBC
                      - metabolic studies (AST/ALT, ALP, bilirubin, amylase, lipase)

    - imaging:        regarding imaging studies:
                      - ultrasound:    gold standard (presence of stones, thickening of GB wall)
                      - scintigraphy: nonvisualization of GB is a positive sign
                      - CT:            not a good test

    - endoscopy:      endoscopic retrograde cholangiopancreatography (ERCP)
                      - can be diagnostic, can also remove stones
                      - associated with risk of perforation or pancreatitis


- acute pancreatitis
   - disorder:       acute inflammatory process of the pancreas

  - etiology:         common causes include:
                      - obstructive:  gallstones, tumor, choledochocele, parasites, trauma, pancreas divisum
                      - toxins:       alcohol, various medications, scorpion venom
                      - metabolic:    hypertriglyceridemia, hypercalcemia
                      - idiopathic:   unknown

                      memory device: pancreatitis is some BAD SHIT
                      - b: biliary
                      - a: alcohol
                      - d: divisum, drugs
                      - s: surgery (post-ERCP)
                      - h: hypertriglyceridemia, hypercalcemia, hereditary
                      - i: infection, iatrogenic, idiopathic, ischemic
                      - t: tumor, trauma, Trinidad scorpion

                      90% of acute pancreatitis is secondary to biliary obstruction or alcohol use

  - pathogenesis:     tissue damage and cell death secondary to:
                      - autodigestion and localized inflammation of the pancreas
                      - release of systemic factors, vasoactive substances, cytokines

                      disease may be initiated by:
                      - ductal obstruction
                      - pancreatic ischemia
                      - premature activation of zymogens and pancreatic enzymes within the pancreatic acinar cells

  - symptoms:         symptoms may include:
                      - epigastric pain radiating to the back
                      - nausea, vomiting

  - diagnosis
     - examination:   abdominal distension, tenderness, guarding, hypoactive bowel sounds

    - laboratory:     findings may include:
                                                                                       YEPSA: Objectives (page 57 of 190)



                      - ↑ amylase, lipase, urine trypsinogen-2
                      - ↑ ALT, AST, bilirubin (gallstone etiology)

    - imaging:        regarding imaging modalities:
                      - abdominal CT: most accurate (necrosis, pseudocyst)
                      - x-ray:         may show pleural effusion, sentinel loops, colon cutoff sign
                      - ultrasound:    consider if gallstones suspected

    - endoscopy:      ERCP has no diagnostic role in acute pancreatitis

  - management
    - mild:           pancreatic rest (replace fluids, provide pain relief)
    - severe:         aggressive supportive care, ICU monitoring
                      - imipenem with evidence of necrosis on CT scan
                      - enteral nutrition may actually be more beneficial
    - gallstone:      endoscopic sphincterotomy, stone extraction


- chronic pancreatitis
   - disorder:        chronic inflammatory condition of the pancreas characterized by fibrosis

  - etiology:         similar to acute pancreatitis, but with different prevalence
                      - 70-80% is alcohol-related, 10-30% is idiopathic
                      - obstruction, hyperparathyroidism, and hyperlipidemia are rare causes

  - pathogenesis:     recurrent bouts of acute pancreatitis, leading to:
                      - chronic pancreatic inflammation and obstruction
                      - recurrent ductal obstruction, fibrosis, and necrosis
                      - ductal changes, strictures, and fibrosis in larger ducts

  - symptoms:         diarrhea, weight loss, steatorrhea, and vitamin deficiencies
                      - exocrine defects are not apparent until >90% destruction is present
                      - endocrine defects are not apparent until >80-90% destruction is present

  - diagnosis
     - history:       diagnostic triad includes:
                      - pain                 (ductal pressure, inflammation)
                      - malabsorption        (exocrine insufficiency)
                      - diabetes             (endocrine insufficiency)

    - laboratory:     can have normal to increased amylase / lipase

    - imaging:        regarding imaging modalities:
                      - abdominal CT:     30-40% sensitivity, showing pancreatic calcifications
                      - abdominal x-ray:  may show calcifications
                      - ultrasound:       70% sensitivity, showing heterogeneity, ductal dilation, calcifications

    - endoscopy:      ERCP most accurate (95% sensitive), but risky (only attempt if CT, US are nondiagnostic)

  - management
    - pain:           oral narcotic analgesia

    - malabsorption: administration of pancreatic enzymes
                     - inhibits pancreatic CCK stimulation
                     - replaces enteric function
                                                                                        YEPSA: Objectives (page 58 of 190)



    - obstruction:     therapies for obstruction include:
                       - endoscopic dilation
                       - stone removal
                       - sphincter ablation
                       - pancreatojejunostomy (Puestow procedure)

    - local disease:   therapies for localized disease include:
                       - distal pancreatectomy
                       - removal of pancreatic head (Whipple procedure)

    - lifestyle:       lifestyle modifications include:
                       - treat episodes of acute pancreatitis
                       - abstain from alcohol
                       - avoid fatty meals
                       - treat hypertriglyceridemia

  - clinical:          alcohol is a direct pancreatic toxin


- gastroesophageal reflux disease (GERD)
   - disorder:       reflux of gastric contents backward into the esophagus

  - epidemiology
     - prevalence:     high in the adult population (33% have episodes at least once per year)
     - age:            elderly
     - ethnicity:      Caucasians
     - geography:      Western societies

  - pathogenesis:      motility disorder (insufficiency of the LES)

  - symptoms:          common symptoms include:
                       - regurgitation (acid brash)
                       - heartburn (pyrosis)
                       - chest pain
                       - increased salivation (water brash)
                       - epigastric pain

  - complications:     possible complications include:
                       - esophagitis
                       - strictures
                       - esophageal cancer
                       - pulmonary disease / chronic cough

  - diagnosis
     - history:        symptomatic history generally sufficient
                       - combination of heartburn, regurgitation 90% sensitive for reflux
                       - further evaluation reserved for red flag symptoms
    - laboratory:      24 hour pH monitoring
    - imaging:         barium swallow (look for inflammation, ulceration, stricture)
    - endoscopy:       upper endoscopy (look for mucosal damage, Barrett’s esophagus)

  - management
    - goals:           goals of managing GERD include:
                       - symptomatic relief
                       - healing of underlying erosive esophagitis
                       - treatment / prevention of complications
                                                                                          YEPSA: Objectives (page 59 of 190)



                       - prevention of recurrence

    - lifestyle:       lifestyle changes include:
                       - elevate head of bed 30°
                       - stop smoking, decrease alcohol consumption
                       - reduce fat intake
                       - decrease size of meals, avoid bedtime snacks
                       - reduce aggravating foods (tea, coffee, citrus, chocolate, mint, tomato juice, cola)

    - pharmacology: pharmacotherapy includes:
                    - proton pump inhibitors (PPIs)
                    - H2 receptor blockers
                    - antacids
                    - promotility agents

  - clinical:          severity of symptoms does not correlate with severity of damage

  BOX: GERD Red Flags
   Gastroesophageal reflux disease is a common disorder affecting millions of Americans. In most cases, history
    alone is sufficient for diagnosis and evaluation. However, a need for further testing is suggested by the
    following:

      • dysphagia
      • vomiting
      • odynophagia (painful swallowing)
      • wheezing, other pulmonary symptoms
      • GI bleeding
      • unexplained iron deficiency anemia




- peptic ulcer disease (PUD)
   - disorder:         ulceration in the lining of the stomach or small intestine

  - epidemiology
     - prevalence:     10% of men, 5% of women
     - incidence:      500,000 new cases / year (1.8%), with 4,000,000 recurrences / year
     - morbidity:      hospitalization has decreased, bleeding rates have increased (direct correlation with NSAIDs)
     - mortality:      low (< 15,000 per year), but increases with age above 65
     - cost:           > $7 billion per year
     - trends:         decreasing in males, increasing in females due to tobacco and NSAID use

  - pathogenesis:      imbalance of protective and damaging factors
                       strong correlation with presence of H. pylori

                       TABLE: Pathogenesis of Ulcer Formation 1
                        protective          damaging
                        • prostaglandins    • acid
                        • mucus             • NSAIDs
                        • bicarbonate       • H. pylori
                        • blood flow        • pepsin
                        • growth factors    • smoking
                        • cell renewal      • ethanol
                                                                                          YEPSA: Objectives (page 60 of 190)



                                                • ischemia
                                                • hypoxia
                                                • genetics
                       1
                         bold indicates strongest effects

                       terminology
                       - gastritis / duodenitis:   superficial erythema, with erosions of surface mucosa
                       - gastric / duodenal ulcer: deeper mucosal destruction, possible perforation

  - symptoms:          symptoms and signs may include:
                       - episodic epigastric pain (with eating, gastric worsens while duodenal improves)
                       - pain radiating to back (25%)
                       - response to antacids (early disease)

  - diagnosis
     - history:        history generally sufficient, supported by relief from empiric H 2 blocker or PPI therapy
     - laboratory:     urea breath test, serology for H. pylori
     - imaging:        CT (assess possible perforation)
     - endoscopy:      upper endoscopy, gastroscopy (visualize ulcer, look for gastric cancer; reserved for red flags)

  - management
    - acid inhibitors: proton pump inhibitors, H2 blockers (excessive use can actually increase colonization)

    - antibiotics:     amoxicillin + clarithromycin (10-14 day course) to remove H. pylori

    - lifestyle:       lifestyle modifications include:
                       - avoid gastric irritants (aspirin, NSAIDs, alcohol, coffee, tobacco, corticosteroids)
                       - avoid bland diets (may increase gastric acid production)
                       - Maalox / Mylanta before meals, bedtime


- bowel obstruction
   - disorder:      mechanical or functional obstruction of the intestines

  - classification:    based on location
                       - small bowel obstruction (SBO)
                       - large bowel obstruction (LBO)

  - etiology
     - vascular:       ischemia
     - inflammatory:   Crohn’s disease
     - neoplastic:     abdominal neoplasm, carcinoid
     - drugs:          medications
     - iatrogenic:     recent surgery, adhesions from previous abdominal surgery
     - congenital:     intestinal atresia
     - anatomic:       foreign bodies, volvulus, intussusception, hernia, impaction, diverticular disease
     - traumatic:      abdominal trauma

  - symptoms:          signs and symptoms include:
                       - abdominal pain
                       - abdominal distension
                       - nausea / vomiting
                       - constipation

  - diagnosis
     - laboratory:     CBC (elevated WBCs), serum amylase
                                                                                          YEPSA: Objectives (page 61 of 190)




    - imaging:         flat and upright abdominal x-ray
                       - SBO:             loop distension, air-fluid levels, absence of large bowel gas
                       - LBO:             colonic distension
                       - perforation:     free air under diaphragm suggestive

                       abdominal CT (can see intussusception, volvulus, strangulated bowel, extraluminal mass)

    - endoscopy:       not indicated

  - management
    - self-limiting:   some cases resolve spontaneously
    - conservative:    conservative management involves:
                       - nasogastric (NG) tube
                       - correction of dehydration and electrolyte abnormalities
                       - analgesics
                       - antiemetics
    - surgical:        required for complete obstructions; commonly necessary in adults

  - clinical:          “clearing from above” generally contraindicated


- appendicitis
   - disorder:         inflammation of the appendix

  - epidemiology
     - incidence:      lifetime incidence of 5-10%, peak incidence in 20s, 30s
     - prevalence:     most common surgical emergency of the abdomen

  - pathogenesis:      inflammation secondary to:
                       - orifice obstruction, secondary distension and bacterial invasion (absent in 33%)
                       - gangrene, perforation within 24-36 hours

  - symptoms:          symptoms include, often in sequence:
                       - abdominal pain (initially periumbilical, shifts to RLQ)
                       - anorexia, nausea, vomiting (95%)
                       - fever

  - complications:     complications include:
                       - perforation (risk increases quickly after 24 hours; most common at extremes of age)
                       - peritonitis, abscess
                       - pylephlebitis (inflammation of the portal vein; rare)

  - diagnosis
     - general:        can often be made on history and exam, but imaging frequently ordered to supplement

    - laboratory:      initial laboratory workup includes:
                       - CBC w/ diff, ESR          (elevated WBC)
                       - urinalysis                (r/o urinary tract infection)
                       - hCG                       (r/o pregnancy)

    - imaging:         imaging modalities include:
                       - abdominal contrast CT (gold standard)
                       - ultrasound              (useful if CT unavailable)

    - endoscopy:       not indicated
                                                                                            YEPSA: Objectives (page 62 of 190)




  - differential:        diagnoses to rule out include:
                         - gastroenteritis
                         - acute salpingitis
                         - ruptured ectopic pregnancy
                         - ureteral colic
                         - Meckel’s diverticulitis
                         - sigmoid diverticulitis

  - management:          surgical resection


- diverticulitis
   - disorder:           inflammation of the peridiverticular area
                         - diverticulosis: acquired herniation of colonic mucosa / submucosa through muscularis
                         - diverticulitis: peridiverticular inflammation

  - etiology:            secondary inflammation in the context of diverticular disease

  - pathogenesis:        peridiverticular inflammation
                         - fecalith (inspissated stool) in a tic causing abrasion, resulting in low grade inflammation
                         - can result in micro- or macroperforation

  - presentation:        “left-sided appendicitis”
                         - pain in LLQ
                         - fever
                         - increased WBCs

  - complications:       possible complications include:
                         - generalized peritonitis
                         - abscess
                         - fistula
                         - scarring, fixed sigmoid colon

  - diagnosis
     - laboratory:       ↑ WBC, ESR
     - imaging:          helical CT with rectal contrast, contrast enema
     - procedures:       endoscopy (r/o malignancy, IBS, ischemia; not during active disease)

  - management
    - antibiotics:       metronidazole, ciprofloxacin
    - hospitalization:   close follow-up and management
    - surgical:          patients with recurrence or complications; must remove from rectum through disease extent
    - lifestyle:         lifestyle modifications include:
                         - high fiber diet
                         - avoid high residue foods (seeds, corn, nuts)


- ectopic pregnancy
   - disorder:      implantation of the fertilized ovum in a location outside the uterine cavity

  - etiology:            any process impairing migration of the embryo

  - epidemiology
     - incidence:        1-2% of all pregnancies
     - prevalence:       increasing (6x from 1970-1992)
                                                                                      YEPSA: Objectives (page 63 of 190)



                      - more accurate diagnosis
                      - increased incidence of STIs
                      - earlier diagnosis of PID
                      - increase in assisted reproductive technologies
    - mortality:      responsible for 9% of all maternal pregnancy deaths

  - pathogenesis:     ectopic implantation occurs most commonly in the tubes
                      - ampulla:        80%
                      - isthmus:        12%
                      - infundibula:    5%
                      - interstitium:   2%
                      - other:          <1%

  - risk factors:     risk factors include:
                      - Hx of PID or other STDs
                      - prior ectopic pregnancy
                      - Hx of tubal surgery
                      - Hx of pelvic or abdominal surgery
                      - endometriosis
                      - exogenous hormone use (estrogen, progesterone)
                      - assisted reproduction
                      - congenital abnormalities
                      - IUD use

  - diagnosis
     - history:       early pregnancy, pelvic / abdominal pain, vaginal bleeding

    - physical:       tender adnexal mass, SGA uterus, cervical bleeding, shock

    - laboratory:     β-human chorionic gonadotropin (β-hCG)
                      - doubles every 48 hours in early pregnancy
                      - falls 33% every 48 hours after spontaneous abortion
                      - changes in β-hCG levels other than these occur in 70% of ectopic pregnancies

    - imaging:        pelvic / abdominal ultrasound
                      - adnexal mass or extrauterine pregnancy
                      - exclusion of normal intrauterine pregnancy, heterotopic pregnancy
                      - β-hCG levels of 1500-2000 mIU/mL should allow visualization of gestational sac
                      - β-hCG levels of >5000 mIU/mL should allow visualization of fetal heartbeat

    - endoscopy:      diagnostic laparoscopy only if necessary (low hCG, no findings on US)

  - management
    - expectant:      serial monitoring of β-hCG levels, ultrasound, and symptoms (reliable patients only)
    - medical:        methotrexate IM (single or multiple dose regimens)
    - surgical:       stabilization and surgical resection


- pelvic inflammatory disease (PID)
   - disorder:       serious infection of the female genital tract, secondary to STI complication

  - etiology:         common causes include:
                      - N. gonorrhoeae
                      - C. trachomatis
                      - Mycoplasma hominis
                      - facultative / anaerobic organisms
                                                                                     YEPSA: Objectives (page 64 of 190)




- epidemiology
   - incidence:    170,000 cases of acute PID, with 100,000 cases of infertility
   - mortality:    150 deaths / year

- pathogenesis:    invasion and scarring of the fallopian tubes

- risk factors:    risk factors include:
                   - h/o sexually transmitted infection (STI)
                   - h/o pelvic inflammatory disease (PID)
                   - young onset of sexual intercourse
                   - multiple sex partners, partner with multiple sex partners
                   - douching
                   - insertion of an intrauterine device (IUD)

- symptoms:        frequently asymptomatic in early stages
                   - diagnosis missed ⅔ of the time due to asymptomatic infection
                   - associated with silent pathology of the reproductive organs

                   common signs and symptoms may include:
                   - lower abdominal pain
                   - fever, nausea, vomiting
                   - unusual vaginal discharge (may have a foul odor)
                   - painful intercourse
                   - pain on urination
                   - irregular menstrual bleeding
                   - pain in the RUQ (rare)

- diagnosis
   - general:      criteria-based (do not delay treatment while waiting for labs)
   - laboratory:   inflammatory markers (CBC, ESR, CRP)
   - studies:      endometrial biopsy, transvaginal ultrasound, CT / MRI pelvis, laparoscopy

                   DIAGNOSTIC CRITERIA: 2002 CDC Criteria for Pelvic Inflammatory Disease
                    A: major criteria (required)
                       1.) either of:
                           i.) uterine or adnexal tenderness to palpation
                           ii.) cervical motion tenderness
                       2.) no other apparent cause

                    B: minor criteria (supporting but not required)
                       1.) fever > 101°F (38.3°C)
                       2.) abnormal discharge per cervix or vagina
                       3.) WBCs on Gram stain or saline of cervical swab
                       4.) Gonorrhea or Chlamydia testing positive
                       5.) increased ESR or CRP
                       6.) PID findings on diagnostic study



- management
  - general:       principles of treatment
                   - remove IUD
                   - treat patient’s sexual contacts within last 60 days
                   - start empiric therapy if minimal criteria present, and do not delay treatment
                                                                                              YEPSA: Objectives (page 65 of 190)



                           - patients should abstain from sexual intercourse until 7 days after initiation of treatment
                           - utilize an empiric, broad spectrum coverage of likely pathogens

       - outpatient:       initial treatment with any of:
                           - cefoxitin 2 g IM for 1 dose + probenecid 1 g PO for 1 dose
                           - ceftriaxone 250 mg IM for 1 dose
                           - other third generation cephalosporin

                           outpatient course of:
                           - ofloxacin 400 mg PO bid for 14 days
                           - levofloxacin 500 mg PO daily for 14 days

                           consider anaerobic coverage
                           - clindamycin 450 mg PO QID for 14 days
                           - metronidazole 500 mg PO bid for 14 days

       - inpatient:        indications for hospitalization
                           - surgical emergencies
                           - pregnancy
                           - non-responsiveness to oral antimicrobial therapies
                           - inability to follow or tolerate an outpatient oral regimen
                           - severe illness, nausea, vomiting, or high fever
                           - presence of a tubo-ovarian abscess

     - complications:      permanent damage to female reproductive organs
                           - chronic pain
                           - ectopic pregnancy
                           - infertility
                           - increased susceptibility to HIV infection (5x more likely if exposed)

     - prevention
        - avoidance:       avoid STIs
                           - abstinence
                           - long-term mutually monogamous relationship with a confirmed uninfected partner
                           - latex male condoms

       - screening:        screen for chlamydia
                           - all sexually active women age 25 or younger
                           - older women with risk factors for chlamydial infection (new partner, multiple partners)

     - web resource:       FP Notebook: Pelvic Inflammatory Disease
                               (http://www.fpnotebook.com/Gyn/ID/PlvcInflmtryDs.htm)


6.     Be able to evaluate, diagnose, and manage diabetic ketoacidosis.

                   (based partially on objectives written by Brad Manning)

- diabetic ketoacidosis
   - disorder:        clinical syndrome of severe insulin deficiency resulting in the triad of:
                      - anion gap metabolic acidosis
                      - ketosis
                      - hyperglycemia

     - etiology:           precipitating events include:
                           - infections such as pneumonia, UTI (most common overall)
                                                                                      YEPSA: Objectives (page 66 of 190)



                   - new onset diabetes mellitus
                   - inadequate insulin therapy in known diabetic
                   - physical or emotional trauma
                   - surgery
                   - myocardial infarction
                   - cerebrovascular accident
                   - drug and alcohol abuse

- epidemiology:    < 5% mortality when properly treated

- presentation:    typical presentation may include:
                   - nausea, vomiting, abdominal pain (severe, prominent)
                   - polyuria, polydypsia, polyphagia
                   - abdmonial pain
                   - altered mental status

- diagnosis
   - history:      findings in the history may include:
                   - recent unintentional weight loss
                   - recent infection
                   - history of diabetes mellitus

  - examination:   physical exam findings include:
                   - fever
                   - tachycardia, tachypnea
                   - Kussmall respirations (deep, rapid breathing)
                   - dehydration (hypotension, dry membranes)
                   - abdominal pain (may resemble acute abdomen)
                   - acetone breath

  - laboratory:    laboratory findings include:
                   - hyperglycemia
                   - acidosis
                   - elevated anion gap
                   - ketonemia

                   BOX: The Anion Gap and High Anion Gap Metabolic Acidosis
                    The anion gap is a measurement of the negatively-charged ions not regularly measured in
                      metabolic studies. It is calculated by the following equation:

                           anion gap = [Na+] – ([Cl-] + [HCO3-])

                    In general, there are four general causes of high anion gap metabolic acidosis

                      • lactic acidosis:          global tissue hypoxia, CO, cyanide
                      • ketoacidosis:             diabetic, alcoholic, starvation
                      • toxins:                   ethylene glycol, methanol, salicylates
                      • renal failure:            acute, chronic



- management
  - goal:          restoration of metabolic homeostasis, correction of precipitating events
                   - resolution of ketoacidosis (most important)
                   - glucose 150-250 mg/dL
                                                                                           YEPSA: Objectives (page 67 of 190)




      - principles:      general principles of management include:
                         - admission (to ICU if pH > 7.0 or if patient is unconscious)
                         - replacement of fluid losses, improvement of circulatory volume
                         - correction of hyperglycemia (and thus plasma osmolarity)
                         - replacement of electrolyte losses
                         - clearance of serum ketones
                         - identification, treatment of precipitating cause and complications

      - methods:         fluid replacement
                         - initial 1-2 L bolus NS over 1-2 hours
                         - ½ NS at 250-500 mL to correct total body water deficit
                         - add D-10 once blood glucose < 300 mg/dL (correct ketosis before glycemia)

                         insulin therapy
                         - 0.1 U/kg bolus of insulin
                         - 0.1 U/kg/hr until glucose <250 mg/dL
                         - addition of D-10 to fluid therapy, continued insulin until ketoacidosis corrected
                         - subcutaneous insulin 30 min before d/c IV insulin
                         - begin long-term insulin therapy once patient starts eating

                         electrolytes
                         - K+ to keep serum K+ > 5 mEq/L (cardiac monitoring)
                         - Phos to keep serum phosphate > 1 mg/dL
                         - Ca2+, Mg2+ as needed

                         bicarbonate therapy: do NOT use unless other indications
                         - cardiac instability
                         - severe hyperkalemia

        - monitoring: monitoring should include:
                      - glucose Q1-2H
                      - anion gap Q4H
                      - strict vitals and I/Os


     BOX: General Concepts in DKA
      In the management of DKA,

        • all patients are volume-depleted
        • all patients have a total body potassium deficit, despite initial serum levels
        • glucose normalizes before ketones, so coadministration of glucose and insulin is necessary
        • cerebral edema may result from overly rapid correction




7.    Be able to evaluate, diagnose, and manage asthma.

                 (based partially on objectives written by Tara Lang)

- asthma
   - disorder:           reversible obstructive lung disease
                                                                                       YEPSA: Objectives (page 68 of 190)



- epidemiology
   - prevalence:    4-7% of the general population
   - incidence:     increasing, with onset generally in childhood

- pathogenesis:     cell-mediated inflammatory cascade characterized by:
                    - reversible airway obstruction
                    - airway hyperresponsiveness
                    - airway inflammation and remodeling

                    common triggers include:
                    - allergic reactions (dust mites, cockroaches, cats, seasonal pollens)
                    - exercise
                    - upper respiratory infections
                    - smoke
                    - occupational exposures
                    - medications
                    - circadian variations (night-time sleep)

- presentation:     common presentations include:
                    - chronic cough (may be the only symptoms)
                    - wheezing, shortness of breath
                    - exercise intolerance

- classification:   stratified based on severity of symptoms (see below)

- diagnosis
   - general:       clinical diagnosis

  - history:        findings in history may include
                    - coughing, wheezing, shortness of breath
                    - intermittent symptoms
                    - family history of asthma

  - examination:    findings on physical examination may include
                    - wheezing
                    - nasal mucosa swelling
                    - increased nasal secretions, nasal polyps
                    - eczema / atopic dermatitis

  - laboratory:     CXR to rule out pneumonia, other serious causes
                    additional studies may include:
                    - CBC
                    - sputum allergen test
                    - ECG

  - studies:        pulmonary function test (PFT) showing reversible obstruction
                    - obstruction:   FEV1 < 80% predicted, FEV1 / FVC < 65% or below lower limit of normal
                    - reversibility: FEV1 increases ≥ 12% or ≥ 200 mL after a short-acting inhaled β2 agonist
                    - provocation:   can use provoking agent (methacholine) to show FEV1 decrease ≥ 20%

- differential:     differential diagnosis includes:
                    - COPD
                    - bronchiectasis
                    - interstitial lung disease (ILD)
                    - lung cancer
                    - broncholithiasis
                                                                                        YEPSA: Objectives (page 69 of 190)



                      - pulmonary embolism
                      - heart failure
                      - GERD
                      - recurrent aspiration
                      - vocal cord dysfunction
                      - respiratory deconditioning
                      - muscle weakness

                      BOX: Differential Diagnosis of Chronic Cough
                        In a non-smoking immunocompetent individual not taking ACE-inhibitors, the three most
                          common causes of chronic cough are:

                          • postnasal drip
                          • asthma
                          • gastroesophageal reflux disease (GERD)



  - management
    - medication:     quick relief medications
                      - short-acting β2 agonists (albuterol)
                      - anticholinergics (iproatropium)

                      long-term control
                      - inhaled corticosteroids (budesonide, fluticasone)
                      - long-acting β2 agonists (salmeterol, formoterol)
                      - leukotriene modifiers (montelukast, zafirlukast)
                      - histamine release inhibitors (cromolyn sodium, nedocromil sodium)
                      - methylxanthines (theophylline, aminophylline)

    - prevention:     preventative measures include:
                      - patient education
                      - removal of environmental risk factors

  - prognosis:        gradual, mild loss of function over time; more pronounced in smokers

  - clinical:         the presence of normal lung function testing does not exclude asthma


classification and treatment of asthma

  TABLE: NAEPP Classification of Asthma
                                       days                 nights                FEV1                   FEV1
                                 with symptoms          with symptoms                                  variability
   step 1:                          ≤ 2 / week           ≤ 2 / month              ≥ 80%                  < 20%
      mild intermittent
   step 2:                         3-6 / week            3-4 / month              ≥ 80%                 20-30%
      mild persistent
   step 3:                             daily             ≥ 5 / month          > 60% - <80%               > 30%
      moderate persistent
   step 4:                          continual              frequent               ≤ 60%                  > 30%
      severe persistent
  - patients should be assigned to the most severe step in which any feature occurs
  - individual classification may change over time
  - patients at any level of severity of chronic asthma can have mild, moderate, or severe exacerbations
                                                                                        YEPSA: Objectives (page 70 of 190)



  - patients with ≥ 2 exacerbations / week tend to have moderate-to-severe persistent asthma


  TABLE: NAEPP Treatment of Asthma 1
                      quick relief                                         long term control
  step 1:             short-acting bronchodilator PRN                      none
    mild intermittent
  step 2:             short-acting bronchodilator PRN                      either of the following:
    mild persistent                                                        • low dose inhaled corticosteroid
                                                                           • cromolyn
                                                                           • nedocromil

  step 3:                     short-acting bronchodilator PRN              either of the following:
    moderate persistent                                                    • medium dose inhaled corticosteroid
                                                                           • low dose steroid + long-acting β2 agonist

  step 4:                     short-acting bronchodilator PRN              all of the following:
    severe persistent                                                      • high dose inhaled corticosteroid
                                                                           • long-acting β2 agonist
                                                                           • corticosteroid tablets or syrup
                                                                              (2 mg/kg/day, not to exceed 60 mg/day)
  1
      note that specific treatment recommendations may vary significantly by age



quick relief agents
- β2 adrenergic agonists
   - agents:          albuterol (Proventil)
   - function:        short-acting bronchodilator
   - mechanism:       stimulates β2 receptors on airway smooth muscles, causing relaxation
   - adverse:         may include:
                      - tremor, hyperactivity
                      - tachycardia, palpitations
                      - headache, tinnitus, insomnia
                      - hypokalemia, muscle cramps
   - clinical:        can be administered through metered dose inhalers (MDIs) or nebulizers
   - cost:            $40 per Proventil inhaler (90 mcg/act, 6.7 g total)

- anticholinergics
   - agents:            ipratropium (Atrovent)
   - function:          short-acting bronchodilator
   - mechanism:         non-selective muscarinic antagonist
   - adverse:           “dry as a bone, hot as a hare, red as a beet, blind as a bat, mad as a hatter”
                        - hyperthermia
                        - dry skin, dry mouth
                        - flushing, tachycardia, hypertension
                        - mydriasis
                        - delirium
  - clinical:           do not have substantial acute bronchodilatory effects; should be given with epinephrine
  - cost:               $90 per Atrovent inhaler (17 mcg/dose, 12.9 g total)


long term control
- corticosteroids
                                                                                           YEPSA: Objectives (page 71 of 190)



  - agents:            corticosteroid agents include:
                       - inhaled:          budesonide (Pulmicort), fluticasone (Flovent)
                       - systemic:         methylprednisolone
  - function:          long-term anti-inflammatory agents
  - mechanism:         varied effects include:
                       - inhibit recruitment of inflammatory cells
                       - inhibit generation of pro-inflammatory cytokines from lymphocytes (IL-4, IL-5, IL-13)
                       - inhibit components of the repair process
                       - result in eosinophil apoptosis
  - adverse:           adverse effects may include:
                       - candidiasis
                       - pharyngitis, hoarseness
                       - cushingoid features (adrenal suppression, osteoporosis, hirsutism)
                       - upper respiratory infection
                       - cough
  - clinical:          oral, parenteral steroids show little efficacy and significant adverse effects
  - cost:              $120 per Pulmicort inhaler (180 mcg/dose)
                       $90-$200 per Flovent inhaler (44 mcg/dose to 220 mcg/dose, 12 g total)

- long-acting β2 adrenergic agonists
   - agents:          salmeterol, formoterol
   - function:        bronchodilation
   - mechanism:       stimulates β2 receptors on airway smooth muscles, causing relaxation
   - adverse:         similar to short-acting agents, may include:
                      - tremor, hyperactivity
                      - tachycardia, palpitations
                      - headache, tinnitus, insomnia
                      - hypokalemia, muscle cramps
   - clinical:        always given in conjunction with other medications (inhaled steroids, leukotriene modulators)
                      some studies suggest increased mortality associated with use in asthma
   - cost:            $130 per salmeterol inhaler (50 mcg/dose, 60 doses)

- leukotriene modifiers
   - agents:           montelukast (Singulair), zafirlukast (Accolate)
   - mechanism:        interfere with cysteinyl leukotriene receptor interactions, resulting in:
                       - mild anti-inflammatory effects
                       - bronchodilation and reduced airway edema
   - adverse:          minimal toxicity
   - clinical:         used in treatment of asthma and allergic rhinitis
                       not as effective as corticosteroids, but exceedingly safe

- histamine release inhibitors
   - agents:           cromolyn sodium (Intal), nedocromil sodium (Tilade)
   - mechanism:        prevent release of histamine, inhibiting mast cell degranulation, reducing hyperresponsiveness
   - adverse:          minimal toxicity
   - clinical:         infrequently used due to low efficacy

- methylxanthines
  - agents:            theophylline, aminophylline
  - function:          bronchodilation
  - mechanism:         adenosine receptor antagonist
  - adverse:           adverse effects may include:
                       - cardiovascular toxicity
                       - CNS toxicity
  - clinical:          rarely used due to low efficacy, high adverse effects, narrow therapeutic index
                                                                                          YEPSA: Objectives (page 72 of 190)




OB/GYN
                                                                                      DIAGNOSIS & TREATMENT


1.     Be able to evaluate, diagnose, and manage bleeding in the first trimester.

                   (based partially on objectives written by Tony Rutkowski)

- first trimester bleeding
   - definition:         bleeding during the first trimester of pregnancy (0-12 weeks)

     - differential:       differential diagnosis includes:
                           - spontaneous abortion
                           - ectopic pregnancy
                           - extrusion of molar pregancy
                           - postcoital bleeding
                           - vaginal / cervical lesions or lacerations

                           other disorders may include:
                           - cervical: severe cervicitis, polyps, neoplasms (benign or malignant)
                           - vaginal:   lacerations, varices, neoplasms (benign or malignant)
                           - other:     hemorrhoids, congenital bleeding disorder, abdominal / pelvic trauma


- spontaneous abortion
   - disorder:       miscarriage with gestational age < 20 weeks and weight < 500 grams

     - etiology:           causes of spontaneous abortion include:
                           - autosomal trisomy
                           - chromosomal triploidy or monosomy
                           - uterine anomaly (e.g. leiomyoma, DES exposure)
                           - incompetent cervix
                           - progesterone deficiency
                           - environmental risk factors

     - epidemiology:       first trimester bleeding in 15-25% of all pregnancies
                           miscarriage in 50% of bleeding cases
                           half of all conceptions miscarrying in first 12 weeks

     - classification:     abortion may be defined as:
                           - inevitable:    bleeding and rupture of gestational sac < 20 weeks, with:
                                            - cervical dilation
                                            - menstrual type cramping
                                            - no products of conception expelled yet
                           - missed:        retained nonviable products of conception (POC) up to 4 weeks
                           - septic:        incomplete abortion with secondary maternal infection
                           - incomplete:    incomplete evacuation of products of conception
                           - complete:      complete evacuation of products of conception
                           - threatened:    uterine bleeding with closed cervix (50% risk of complete abortion)
                                                                                      YEPSA: Objectives (page 73 of 190)



- risk factors:    risk factors include:
                   - advanced maternal age
                   - cigarette smoking
                   - alcohol abuse
                   - ilicit drug use
                   - caffeine intake > 100 mg/day
                   - occupational chemical exposure
                   - previous miscarriage
                   - increasing gravidity
                   - incompetent cervix
                   - uterine surgeries / anomalies
                   - fever > 100°F
                   - trauma

- presentation:    presenting symptoms may include:
                   - vaginal bleeding
                   - cramping
                   - abdominal pain
                   - decreased symptoms of pregnancy

- diagnosis
   - general:      must rule out ectopic pregnancy

  - history:       history should include:
                   - quantity, rate of blood loss
                   - pelvic pain or cramping
                   - symptoms of pregnancy
                   - positive pregancny test
                   - fever

  - examination:   examination should include:
                   - vital signs (temperature, orthostatic blood pressure, pulse)
                   - assessment of pregnancy (dating, FHT, uterine size)
                   - abdominal exam (peritoneal signs, abdominal distension)
                   - vaginal exam (cervical motion tenderness, nonuterine bleeding, dilation, blood / tissue at os)

  - laboratory:    laboratory analysis may include:
                   - quantitative β-hCG (anticipate doubling q48 hours)
                   - serum progesterone
                   - CBC, blood type, and Ab screen
                   - gonorrhea culture / chlamydia screen
                   - urinalysis

                   BOX: Diagnostic Tests in Spontaneous Abortion
                    Quantitative β-hCG is a useful test for assessing growth in pregnancy. During weeks 4-8
                     of the pregnancy, it is expected to double every 48 hours in a normal intrauterine
                     pregnancy (IUP). Deviation from this suggests:

                      • less than 2x:       ectopic pregnancy
                      • more than 2x:       gestational trophoblastic disease (GTD)

                    Serum progesterone is also useful in predicting pregnancy outcome before 10 weeks.
                      • > 25 ng/mL:    live IUP
                      • < 5 ng/mL:     ectopic pregnancy, spontaneous abortion
                                                                                       YEPSA: Objectives (page 74 of 190)




    - imaging:        transvaginal ultrasound
                      - gestational sac by β-hCG 1800 mIU/mL on transvaginal
                      - gestational sac by β-hCG 3500 mIU/mL on transabdominal
                      - fetal cardiac activity by β-hCG 20,000 mIU/mL

  - management        general management includes:
                      - RhoGAM 50 mcg (if Rh negative)
                      - management of friable cervix if present
                      - obstetrics surgical consult if β-hCG < 1800-2000 (presumed ectopic pregnancy)

                      threatened abortion
                      - hydration (IV, oral if tolerated)
                      - bed rest
                      - pelvic rest / NPV (including no intercourse)

                      inevitable, incomplete, or complete abortion
                      - general measures (hydration, evaluation for septic abortion)
                      - follow serial quantitative hCG until 0

                      - observation:    for stable patients and GA < 8 weeks
                      - D&C:            for GA 8-14 weeks with excessive bleeding, pain, or symptoms
                      - induction:      for GA 14-20 weeks (pitocin, prostaglandin, or misoprostol)

  - web resource:     Family Practice Notebook: First Trimester Bleeding
                         (http://www.fpnotebook.com/OB10.htm)


- ectopic pregnancy
   - disorder:      implantation of the fertilized ovum in a location outside the uterine cavity

  - etiology:         any process impairing migration of the embryo

  - epidemiology
     - incidence:     1-2% of all pregnancies
     - prevalence:    increasing (6x from 1970-1992)
                      - more accurate diagnosis
                      - increased incidence of STIs
                      - earlier diagnosis of PID
                      - increase in assisted reproductive technologies
    - mortality:      responsible for 9% of all maternal pregnancy deaths (2nd most common cause)

  - pathogenesis:     ectopic implantation occurs most commonly in the tubes
                      - ampulla:        80%
                      - isthmus:        12%
                      - infundibula:    5%
                      - interstitium:   2%
                      - other:          <1%

  - risk factors:     risk factors include:
                      - Hx of PID or other STDs
                      - prior ectopic pregnancy
                      - Hx of tubal surgery
                                                                                  YEPSA: Objectives (page 75 of 190)



                  - Hx of pelvic or abdominal surgery
                  - endometriosis
                  - exogenous hormone use (estrogen, progesterone)
                  - assisted reproduction
                  - congenital abnormalities
                  - IUD use

- presentation:   presenting symptoms include:
                  - pelvic / abdomninal pain   (97% of ectopic pregnancies)
                  - vaginal bleeding           (70% of ectopic pregnancies)

- diagnosis
   - history:     early pregnancy, pelvic / abdominal pain, vaginal bleeding

  - physical:     tender adnexal mass, SGA uterus, cervical bleeding, shock

  - laboratory:   β-human chorionic gonadotropin (β-hCG)
                  - doubles every 48 hours in early pregnancy
                  - falls 33% every 48 hours after spontaneous abortion
                  - changes in β-hCG levels other than these occur in 70% of ectopic pregnancies
                  CBC, blood type, and Ab screen
                  UA

  - imaging:      pelvic / abdominal ultrasound
                  - adnexal mass or extrauterine pregnancy
                  - exclusion of normal intrauterine pregnancy, heterotopic pregnancy
                  - β-hCG levels of 1500-2000 mIU/mL should allow visualization of gestational sac
                  - β-hCG levels of >5000 mIU/mL should allow visualization of fetal heartbeat

  - endoscopy:    diagnostic laparoscopy only if necessary (low hCG, no findings on US)

- differential:   differential diagnosis includes:
                  - appendicitis
                  - threatened abortion
                  - ruptured ovarian cyst
                  - pelvic inflammatory disease
                  - nephrolithiasis
                  - ovarian torsion
                  - urinary tract infection
                  - diverticulitis

- management
  - expectant:    serial monitoring of β-hCG levels, ultrasound, and symptoms (reliable patients only)
  - medical:      methotrexate IM (single or multiple dose regimens)
  - surgical:     stabilization and surgical resection, indicated for:
                  - failed / contraindicated nonsurgical management
                  - nondiagnostic transvaginal ultrasound with β-hCG > 1500
                  - hemoperitoneum
                  - diagnosis unclear
                  - advanced ectopic pregnancy
                  - noncompliant patient
                  - unstable vital signs

- web resource:   FP Notebook: Ectopic Pregnancy
                      (http://www.fpnotebook.com/OB1.htm)
                                                                                        YEPSA: Objectives (page 76 of 190)




- gestational trophoblastic disease (GTD)
   - definition:     abnormal proliferation of trophoblastic (placental) tissue
   - classification: disorders include:
                     - molar pregnancy (complete mole, partial mole)
                     - persistent gestational trophoblastic neoplasia
                     - placental site tumors

  - molar pregnancy
    - disorder:     implantation and proliferation of trophoblastic tissue containing a nonviable embryo

    - etiology:       embryonic genetic abberation

    - epidemiology: 1 in 1,000-1,500 pregnancies in North America (higher in less developed nations)

    - pathogenesis:   complete mole
                      - 46XX or 46XY (paternally derived)
                      - fertilization of empty egg and duplication, or two sperm fertilization of empty egg (rare)
                      - complete hydatiform transformation, with no evidence of fetal vessels
                      - marked proliferation, higher risk for malignant change

                      partial mole
                      - 69XXX or 69XXY (maternally and paternally derived)
                      - fertilization of normal egg by two sperm
                      - incomplete hydatiform transformation, with nonviable fetus or fetal vessels
                      - moderate proliferation, with less risk of malignant change

    - risk factors:   risk factors include:
                      - prior molar pregnancy
                      - extremes of reproductive age (< 20 years, > 45 years)
                      - twin gestation
                      - high parity
                      - malnutrition

    - presentation:   common presenting symptoms include:
                      - vaginal bleeding or passage of grapelike villi
                      - abdominal pain

    - diagnosis
       - history:     symptoms include:
                      - vaginal bleeding (esp. 3rd, 4th month)
                      - hyperemesis gravidarum
                      - passage of grapelike villi from the uterus
                      - abdominal pain early in pregnancy
                      - pallor or dyspnea (anemia)
                      - anxiety or tremor (thyroid stimulation by β-hCG)

      - examination: signs include:
                     - excessive uterine enlargement
                     - ovarian enlargement
                     - early onset of hypertension

      - laboratory:   quantitative β-hCG (excessive elevations; may exceed 1,000,000 IU)
                      CBC (anemia, decreased platelets)
                      LFTs, TSH
                                                                                    YEPSA: Objectives (page 77 of 190)



    - imaging:      pelvic ultrasound
                    - “snowstorm” pattern
                    - absent fetal heart tones (first auscultated at 16-20 weeks)
                    - absent fetal parts on US

  - management:     evacuation of uterine contents (D&E, D&C) and diagnosis
                    serial monitoring of β-hCG
                    - weekly for several months, then monthly for 6-12 months
                    - chemotherapy if rise or failure to fall to 0

  - prognosis:      recurrence rate of complete mole is 20%
                    recurrence rate in future pregnancies is 1-2%

  - web resource:   FP Notebook: Hydatiform Mole
                        (http://www.fpnotebook.com/OB/Hemeonc/HydtdfrmMl.htm)


- choriocarcinoma
   - disorder:    malignant transformation of trophoblast

  - etiology:       causes include:
                    - molar pregnancy (50%)
                    - spontaneous / elective abortion (25%)
                    - postpartum delivery of viable fetus (20%)
                    - ectopic pregnancy (5%)

  - epidemiology:   1 in 25,000 pregnancies

  - diagnosis:      as in molar pregnancy

  - management:     surgical removal
                    - surction curretage with administration of oxytocin
                    - hysterectomy if > 40 years old

                    chemotherapy
                    - methotrexate or actinomycin D
                    - combination therapy for metastases

                    serial monitoring of β-hCG
                    - q2 weeks x 2 months
                    - q1 month x 3 months
                    - q 2 months x 6 months
                    - q 6 months thereafter

  - complications: dissemination
                   - local spread to the vagina or pelvic organs
                   - distant metastases to the liver or lungs

  - prognosis:      100% 5 year survival in low risk patients:
                    - under 4 month history suggesting metastatic disease
                    - serum β-hCG < 50 mIU/mL
                    - no signs of liver or CNS metastases

                    50% 5 year survival in high risk patients:
                    - over 4 month history of metastatic disease
                    - serum β-hCG > 50 mIU/mL
                                                                                    YEPSA: Objectives (page 78 of 190)



                         - liver or CNS metastases
                         - tumor development follows term pregnancy
                         - failure of chemotherapy

       - web resource:   FP Notebook: Choriocarcinoma
                             (http://www.fpnotebook.com/OB64.htm)


2.     Be able to evaluate, diagnose, and manage vaginal discharge / vaginitis.

                 (based partially on objectives written by Tracy Capes)

- vaginal discharge
   - disorder:           abnormal discharge from the vagina

     - differential:     vulvar causes include:
                         - vulvitis
                         - bartholinitis
                         - vulvar carcinoma

                         vaginal causes include:
                         - senile vaginitis
                         - foreign body
                         - vaginal carcinoma
                         - fistulas (vesicovaginal, rectovaginal, enteric)

                         cervical causes include:
                         - cervicitis / endocervicitis
                         - cervical polyps
                         - carcinoma

                         uterine causes (commonly bloody) include:
                         - endometritis
                         - polyp
                         - carcinoma

                         salpingal causes include:
                         - salpingitis (mucopurulent)

     - evaluation:       initial diagnostic tests should include:
                         - wet prep                        (Trichomonas)
                         - KOH prep                        (candida)
                         - smear and culture               (chlamydia, gonorrhea)

                         other workup may include:
                         - CBC and ESR                    (PID)
                         - VDRL                           (syphilis)
                         - rectal culture                 (gonorrhea)
                         - vaginal / cervical cytology    (carcinoma)
                         - ultrasound / laparoscopy       (PID)
                         - antibiotic trial               (chlamydia, gonorrhea)

     - web resource:     Wrong Diagnosis: Vaginal Discharge
                            (http://www.wrongdiagnosis.com/)
                                                                                       YEPSA: Objectives (page 79 of 190)



vulvitis
- vulvitis
   - definition:        inflammation of the vulva (external genitalia)
   - differential:      differential diagnosis based on lesion characteristics
                        - ulcerated:       syphilis, herpes, chancroid, LGV, cancer
                        - non-ulcerated: HPV, molluscum contagiosum, candida, cancer

  TABLE: Ulcerated Vulvar Lesions
                    syphilis                     herpes                 chancroid               LGV
   incubation       7-14 days                    2-10 days              4-7 days                3-12 days
   primary lesion   papule (chancre)             vesicle                papule / pustule        papule / vesicle
   # of lesions     single                       multiple               1-3 (occ. more)         single
   size             5-15 mm                      1-3 mm                 2-20 mm                 2-10 mm
   pain             painless                     painful                painful                 painless
   diagnosis        VDRL (screen)                viral culture          Gram stain:             complement fixation
                    FTA-ABS (confirm)            Tzank smear 1            “school of fish”
   management       penicillin G                 acyclovir              ceftriaxone or          doxycycline
                                                                          azithromycin
  1
      demonstrates multinucleated giant cells

  TABLE: Nonulcerated Vulvar Lesions
                   condyloma acuminata                  molluscum contagiosum           candidiasis
   etiology        HPV                                  poxvirus                        Candida
   lesion          raised papillomatous lesions         domed, umbilicated papule       pruritic vulvar erythema
                                                                                        satellite lesions
      evaluation         clinical diagnosis             clinical diagnosis              clinical diagnosis
                                                                                        r/o malignancy if chronic
      management         cryotherapy                    excision                        topical antifungal
                         CO2 laser                      self-limiting



vaginitis
- bacterial vaginosis
   - disorder:        non-specific vaginitis

  - etiology:           commonly attributed to Gardnerella vaginalis

  - epidemiology:       most common vaginal infection in women of childbearing age
                        - occurs in 16% of pregnant women
                        - varies by race (lower in Asians and Caucasians, higher in Hispanics and African Americans)

  - pathogenesis:       marked reduction in normally predominant lactobacillus, leading to imbalance in flora

                        TABLE: Comparison of Normal Vaginal Environment to Bacterial Vaginosis
                                    normal environment           bacterial vaginosis
                        pH          acidic (pH = 4-4.5)          more alkaline (pH > 4.5)
                        respiration facultative anaerobes        strict anaerobes
                        flora       Lactobacilli predominant     mixed population
                                                                 - more anaerobes
                                                                 - more Gram negative
                        factors     hydrogen peroxide            presence of volatile amines
                                                                 - putrescine
                                                                 - cadaverine
                                                                                       YEPSA: Objectives (page 80 of 190)



                                                                    - trimethylamine

- risk factors:    risk factors include:
                   - new sex partner, multiple sex partners
                   - use of douching
                   - use of intrauterine device for contraception

- presentation:    frequently asymptomatic

                   common symptoms include:
                   - unpleasant (“fishy”) odor, especially after intercourse
                   - white or gray stringy, pearly discharge
                   - burning during urination, itching in the vaginal area

- diagnosis:       Amsel’s criteria

                   DIAGNOSTIC CRITERIA: Bacterial Vaginosis
                    Amsel’s Criteria for bacterial vaginosis requires 3 of 4:

                    A:   vaginal pH > 4.5
                    B:   clue cells present on > 20% of cells
                    C:   positive whiff test (amine test)
                    D:   discharge (thin, non-clumping, gray-white, adherent)



- management
  - general:       principles of treatment
                   - male partners generally do not need treatment, but female partners should be treated
                   - treatment is especially important for pregnant women

  - nonpregnant:   regimens for nonpregnant women include:
                   - metronidazole (Flagyl) 500 mg PO bid for 7 days
                   - metronidazole (MetroGel) 0.75% 5 g PV QHS for 5 days
                   - clindamycin cream 2% 5 g PV QHS for 7 days

  - pregnant:      regimens for pregnant women (avoid in first trimester if possible) include:
                   - metronidazole (Flagyl) 250 mg PO TID for 7 days
                   - clindamycin 300 mg PO bid for 7 days

- complications:   general complications include:
                   - increased susceptibility to transmitting / receiving HIV
                   - increased susceptibility to PID following certain surgical procedures (e.g. hysterectomy)

                   complications in pregnant women include:
                   - increased frequency of premature or low birth weight (LBW) babies
                   - increased frequency of infertility / ectopic pregnancies (secondary to PID risk)
                   - pregnant women may be at increased risk for complications in general

- prevention:      preventative measures include:
                   - limit the number of sex partners
                   - avoid the use of douches
                   - use all prescribed medication for treatment, even if signs and symptoms go away

- clinical:        NOT spread through contact with toilet seats, doorknobs, eating utensils, etc.
                                                                                     YEPSA: Objectives (page 81 of 190)




  - web resource:     FP Notebook: Bacterial Vaginosis
                          (http://www.fpnotebook.com/Gyn/ID/BctrlVgns.htm)


- vaginal moniliasis (yeast infection)
   - disorder:        vaginitis secondary to yeast infection

  - etiology:         Candida albicans (45% of vaginitis)

  - risk factors:     risk factors include:
                      - diabetes mellitus
                      - medications (corticosteroids, immunosuppressants, antibiotics, OCP)
                      - heat- and moisture-retaining clothing
                      - pregnancy
                      - obesity

  - presentation:     asymptomatic in 20-50% of women
                      signs and symptoms include:
                      - intense pruritis
                      - vulvar burning, soreness, or irritation
                      - odorless adherent “cottage cheese” discharge (50% sensitive, 90% specific)
                      - dysparenuia
                      - dysuria

  - diagnosis
     - general:       history, discharge
     - examination:   odorless adherent “cottage cheese” discharge in vagina
     - laboratory:    KOH prep showing filamentous fungal forms (50% sensitive)

  - differential:     other diagnoses to consider include:
                      - other vaginitis (bacterial, trichomonas)
                      - infectious cervicitis
                      - allergic vaginitis or vulvitis
                      - vulvodynia

  - management
    - topical:         miconazole (Monostat), clotrimazole, Nystatin
    - oral (2nd line): fluconazole

  - web resource:     FP Notebook: Candida Vulvovaginitis
                          (http://www.fpnotebook.com/Gyn/ID/CndVlvgnts.htm)


- vaginal trichomoniasis
   - disorder:       common protozoal STI

  - etiology:         Trichomonas vaginalis

  - epidemiology
     - prevalence:    most common curable STI in young, sexually active women
     - incidence:     5 million in men and women (United States)

  - pathogenesis:     transmitted via sexual contact
                      - women:      generally infects vagina, acquired from men or women
                      - men:        generally infects urethra, usually acquired from women
                                                                                       YEPSA: Objectives (page 82 of 190)




  - presentation:    symptoms in women usually include:
                     - frothy, yellow-green vaginal discharge with strong odor
                     - discomfort during intercourse and urination
                     - irritation and itching of the groin
                     - lower abdominal pain (rare)

                     men generally asymptomatic (90%)

  - diagnosis
     - general:      history, discharge, wet mount
     - laboratory:   wet mount showing motile protozoa with flagella

  - management
    - general:       principles of treatment include:
                     - untreated, asymptomatic men can continue to infect female partners
                     - both partners should be treated at the same time to eliminate the parasite

    - antibiotics:   treatment regimens include:
                     - metronidazole 2 g PO (single dose)
                     - metronidazole 500 mg bid for 7 days
                     - tinidazole 2 g PO (single dose)

  - complications:   increased susceptibility to transmitting / receiving HIV

  - prevention:      preventative measures include:
                     - abstinence
                     - long-term mutually monogamous relationship with a confirmed uninfected partner
                     - latex male condoms

  - web resource:    FP Notebook: Trichomonal Vaginitis
                         (http://www.fpnotebook.com/Gyn/ID/TrchmnlVgnts.htm)


  TABLE: Everything You Ever Wanted to Know About Vaginal Infestation
                   bacterial (Gardnerella)  parasitic (Trichomonas)              fungal (Candida)
   discharge       pearly, “stringy”        green, “frothy”                      thick, “cheesy”
   pH              pH > 4.5                 pH > 4.5                             pH < 4.5
   whiff test      positive                 positive                             negative
   wet prep        clue cells               motile protozoan cells               filamentous fungal forms



chlamydia, gonorrhea, and PID
- chlamydiosis
   - disorder:     chlamydia infection

  - etiology:        Chlamydia trachomatis

  - epidemiology
     - prevalence:   most common cause of bacterial STI in the United States
     - incidence:    3 million infections per year
                     - underreporting is common due to mildness of primary infection
                     - because women are generally asymptomatic, reported prevalence higher in men
                                                                                       YEPSA: Objectives (page 83 of 190)



- pathogenesis:   transmission includes:
                  - sexual (vaginal, anal, oral sex)
                  - childbirth

- presentation:   often asymptomatic in women, frequently symptomatic (50%) in men

  - genital:      symptoms of genital infection may include:
                  - abnormal penile / vaginal discharge
                  - pain on urination
                  - burning / itching of the urethral meatus
                  - lower abdominal or lower back pain
                  - nausea, fever
                  - pain during intercourse
                  - bleeding between menstrual periods
                  - NOTE: painful or swollen testicles are not common

  - oral:         inflammation of the throat

  - anal:         rectal pain, discharge, bleeding

- risk factors:   higher risk associated with:
                  - teenage girls                      (immature cervix)
                  - men who have sex with men          (anal, oral transmissibility)

- diagnosis
   - general:     advantages to modern methods include:
                  - simple to perform                (vaginal swab in women, simple voided urine in men)
                  - good sensitivity and specificity (in general, > 90%)

  - collection:   collection methods include
                  - tissue collection
                  - urine specimen

  - analysis:     analysis methods include:
                  - tissue culture with direct fluorescent antibody (gold standard)
                  - enzyme immunoassay (EIA)
                  - polymerase chain reaction (PCR)
                  - ligase chain reaction (LCR)

- management
  - goals:        goals of treatment include:
                  - prevent transmission to sex partners
                  - prevent reinfection of index patient, infection of others

  - principles:   principles of treatment include:
                  - evaluate sex partners for 60 days preceding onset of symptoms
                  - patients should abstain from sexual intercourse until 7 days after initiation of treatment

  - treatment:    treatment regimens may include:
                  - azithromycin 1 g orally, single dose
                  - doxycycline 100 mg orally, bid for 7 days        (contraindicated in pregnancy)
                  - amoxicillin 500 mg orally, tid for 7 days        (when doxycycline is contraindicated)

- complications
   - STIs:        increased susceptibility to other sexually transmitted infections
                  - nonspecific urethritis (NSU)
                                                                                         YEPSA: Objectives (page 84 of 190)



                     - mucopurulent cervicitis
                     - pelvic inflammatory disease (PID)
                     - endometritis
                     - epididymitis
                     - lymphogranuloma venereum (LGV; serotypes L1-L3)

     - ocular:       problems with eye infections
                     - ophthalmia neonatorum
                     - trachoma

     - pregnancy:    chlamydial infection in pregnant women can lead to:
                     - premature delivery
                     - neonatal pneumonia (leading cause)
                     - neonatal conjunctivitis (leading cause)

     - other:        other complications may include:
                     - reactive arthritis (Reiter’s syndrome: can’t see, can’t pee, can’t climb a tree)
                     - cervical cancer

  - prevention
     - general:      methods of prevention include:
                     - abstinence
                     - long-term mutually monogamous relationship with a confirmed uninfected partner
                     - latex male condoms

     - screening:    screening recommendations include:
                     - annual screening for sexually active women ≤ 25 years old
                     - annual screening for older women with a new sex partner or multiple sex partners
                     - pregnant women


- gonorrhea
   - disorder:       “flow of seeds”

  - epidemiology
     - prevalence:   relatively common infectious disease, but less so than chlamydia
     - incidence:    600,000 in the United States (only half reported to CDC)

  - pathogenesis:    methods of transmission include:
                     - sexual contact (penis, vagina, mouth, anus)
                     - vaginal childbirth

  - risk factors:    higher rates associated with:
                     - sexually active teenagers
                     - young adults
                     - African Americans

  - presentation
     - general:      frequently asymptomatic (esp. in women), and symptoms may take 30 days to develop
     - genital:      pain on urination, discharge, bleeding
     - oral:         sore throat, asymptomatic
     - anal:         discharge, anal itching, soreness, bleeding, painful bowel movements

  - complications:   general complications may include:
                     - Bartholin gland infection
                     - Fitz-Hugh-Curtis syndrome (infection of the liver capsule)
                                                                                            YEPSA: Objectives (page 85 of 190)



                      - pelvic inflammatory disease (PID)
                      - ectopic pregnancy
                      - epididymitis
                      - disseminated gonococcal infection (DGI)

                      neonatal complications from vaginal childbirth include:
                      - conjunctivitis
                      - blindness
                      - septic arthritis
                      - neonatal sepsis

  - diagnosis
     - collection:    regarding sample collection:
                      - should include all sites of sexual contact (cervix, urethra, rectum, and/or throat)
                      - best urethral sample is obtained in the morning, prior to voiding

    - analysis:       methods of analysis include:
                      - Gram stain (≥ 5 WBC / oil immersion field, with intracellular Gram negative diplococci)
                      - urine analysis for proteins or genetic material

  - management
    - goals:          goals of treatment include:
                      - prevent transmission to sex partners
                      - prevent reinfection of index patient, infection of others

    - principles:     principles of treatment include:
                      - drug resistance is increasing, so full course of prescribed medications is essential
                      - due to frequent coinfection, presumptive treatment for C. trachomatis is appropriate
                      - evaluate sex partners for 60 days preceding onset of symptoms
                      - patients should abstain from sexual intercourse until 7 days after initiation of treatment

    - treatment:      treatment regimens include 1
                      - ceftriaxone 125 mg IM, single dose
                      - cefixime 400 mg orally, single dose
                      - ciprofloxacin 500 mg orally, single dose 2
                      - ofloxacin 400 mg orally, single dose 2
                      - levofloxacin 250 mg orally, single dose 2
                          1
                              if chlamydia is not ruled out, additional regimens include:
                                  - azithromycin 1 g orally, single dose
                                  - doxycycline, 100 mg orally bid for 7 days
                          2
                              due to higher rates of drug resistance, quinolones should not be used in:
                                 - men who have sex with men
                                 - history of recent foreign travel
                                 - infections acquired in Pacific Rim areas (California, Hawaii)

  - prevention:       prevention methods include:
                      - abstinence
                      - long-term mutually monogamous relationship with a confirmed uninfected partner
                      - latex male condoms


- pelvic inflammatory disease (PID)
   - disorder:       serious infection of the female genital tract, secondary to STI complication
                                                                                    YEPSA: Objectives (page 86 of 190)



- etiology:        common causes include:
                   - N. gonorrhoeae
                   - C. trachomatis
                   - Mycoplasma hominis
                   - facultative / anaerobic organisms

- epidemiology
   - incidence:    170,000 cases of acute PID, with 100,000 cases of infertility
   - mortality:    150 deaths / year

- pathogenesis:    invasion and scarring of the fallopian tubes

- risk factors:    risk factors include:
                   - h/o sexually transmitted infection (STI)
                   - h/o pelvic inflammatory disease (PID)
                   - young onset of sexual intercourse
                   - multiple sex partners, partner with multiple sex partners
                   - douching
                   - insertion of an intrauterine device (IUD)

- presentation:    frequently asymptomatic in early stages
                   - diagnosis missed ⅔ of the time due to asymptomatic infection
                   - associated with silent pathology of the reproductive organs

                   common signs and symptoms may include:
                   - lower abdominal pain
                   - fever, nausea, vomiting
                   - unusual vaginal discharge (may have a foul odor)
                   - painful intercourse
                   - pain on urination
                   - irregular menstrual bleeding
                   - pain in the RUQ (rare)

- diagnosis
   - general:      criteria-based, do not delay treatment while waiting for labs
   - laboratory:   inflammatory markers (CBC, ESR, CRP)
   - studies:      endometrial biopsy, transvaginal ultrasound, CT / MRI pelvis, laparoscopy

                   DIAGNOSTIC CRITERIA: 2002 CDC Criteria for Pelvic Inflammatory Disease
                    A: major criteria (required)
                       1.) either of:
                           i.) uterine or adnexal tenderness to palpation
                           ii.) cervical motion tenderness
                       2.) no other apparent cause

                    B: minor criteria (supporting but not required)
                       1.) fever > 101°F (38.3°C)
                       2.) abnormal discharge per cervix or vagina
                       3.) WBCs on Gram stain or saline of cervical swab
                       4.) Gonorrhea or Chlamydia testing positive
                       5.) increased ESR or CRP
                       6.) PID findings on diagnostic study
                                                                                            YEPSA: Objectives (page 87 of 190)



     - management
       - general:        principles of treatment
                         - remove IUD
                         - treat patient’s sexual contacts within last 60 days
                         - start empiric therapy if minimal criteria present, and do not delay treatment
                         - patients should abstain from sexual intercourse until 7 days after initiation of treatment
                         - utilize an empiric, broad spectrum coverage of likely pathogens

       - outpatient:     initial treatment with any of:
                         - cefoxitin 2 g IM for 1 dose + probenecid 1 g PO for 1 dose
                         - ceftriaxone 250 mg IM for 1 dose
                         - other third generation cephalosporin

                         outpatient course of:
                         - ofloxacin 400 mg PO bid for 14 days
                         - levofloxacin 500 mg PO daily for 14 days

                         consider anaerobic coverage
                         - clindamycin 450 mg PO QID for 14 days
                         - metronidazole 500 mg PO bid for 14 days

       - inpatient:      indications for hospitalization
                         - surgical emergencies
                         - pregnancy
                         - non-responsiveness to oral antimicrobial therapies
                         - inability to follow or tolerate an outpatient oral regimen
                         - severe illness, nausea, vomiting, or high fever
                         - presence of a tubo-ovarian abscess

     - complications:    permanent damage to female reproductive organs
                         - chronic pain
                         - ectopic pregnancy
                         - infertility
                         - increased susceptibility to HIV infection (5x more likely if exposed)

     - prevention
        - avoidance:     avoid STIs
                         - abstinence
                         - long-term mutually monogamous relationship with a confirmed uninfected partner
                         - latex male condoms

       - screening:      screen for chlamydia
                         - all sexually active women age 25 or younger
                         - older women with risk factors for chlamydial infection (new partner, multiple partners)

     - web resource:     FP Notebook: Pelvic Inflammatory Disease
                             (http://www.fpnotebook.com/Gyn/ID/PlvcInflmtryDs.htm)


3.     Be able to do a routine prenatal visit.

     TABLE: Overview of Prenatal Visits
      visit          frequency     evaluation
      first OB visit anytime       the first OB visit should include:
                                   • history and physical
                                   • blood work (CBC, blood type, Rh)
                                                                                          YEPSA: Objectives (page 88 of 190)



                                       • infections (GC/Chl, RPR, HBsAg, HIV, urine cx)
                                       • gynecologic (Pap smear)

      each OB visit     every time     each OB visit should include:
                                       • fundal height (once palpable)
                                       • presentation (once palpable)
                                       • fetal heart rate (once detectable)
                                       • presence of fetal movement
                                       • presence of preterm labor signs (contractions, cramps, leaking)
                                       • maternal weight / edema
                                       • urinalysis

      6-26 weeks        q 4 weeks      ultrasound dating (6-12 weeks) 1

                                       1st trimester screen (11-13 weeks) 2
                                       • PAPP-A, bHCG
                                       • nuchal translucency on US

                                       2nd trimester screen (15-20 weeks)
                                       • Triple Screen (β-HCG, estriol, MSAFP)
                                       • Quad Screen (β-HCG, estriol, MSAFP, inhibin A)
                                       • less accurate than triple screen

                                       fetal anatomic survey (18-22 weeks)

      26-28 weeks                      OB visit during 26-28 weeks should include:
                                       • blood work (CBC, Ab screen; if Rh negative, give Rhogam)
                                       • infection (RPR)
                                       • glucose tolerance test (GTT)

      28-36 weeks       q 2 weeks      discussion of perinatal issues
                                       • birth control
                                       • breastfeeding
                                       • pediatrician
                                       • circumcision

      36-40+ weeks      q week         CG / Chl / GBS

  1
      assessment by crown hump length
  2
      either 1st or 2nd trimester screen is recommended


common pregnancy evaluations
- fundal height
   - function:       monitoring of normal fetal growth
   - method:         measurement from pubic symphysis to top of fundus
                     - non-palpable: < 10 weeks gestation
                     - at umbilicus: ~ 20 weeks gestation
   - interpretation: measurement (in cm) correlates with gestational age from 16-36 weeks
   - differential:   for fundal height less than expected:
                     - incorrect dating
                     - hydatidiform mole
                     - fetal growth restriction
                     - oligohydramnios
                     - intrauterine fetal demise
                                                                                           YEPSA: Objectives (page 89 of 190)



                         for fundal height greater than expected:
                         - incorrect dating
                         - multiple pregnancy
                         - macrosomia
                         - hydatidiform mole
                         - polyhydramnios

- fetal heart activity
   - function:           monitoring of continued fetal viability
   - method:             direct auscultation or Doppler ultrasonography
   - interpretation:     normal fetal heart rate 120-160 bpm

- biophysical profile
   - function:        assessment of fetal well-being
   - method:          ultrasonographic measurement of 5 indicators, with 2 points for the presence of each:
                      - amniotic fluid volume, qualitative
                      - breathing movements
                      - gross body movement
                      - reactive fetal heart rate
                      - tone

                         BOX: Components of the Biophysical Profile
                          The components of a biophysical profile can be remembered by the mnemonic “ABG by
                            RT” (Arterial blood gas by respiratory therapy).



  - interpretation:      test interpreted as follows:
                         - score 8-10:            normal
                         - score 6:               equivocal, requires further evaluation
                         - score 4 or less:       requires immediate intervention
  - differential:        based on abnormality
                         - low amniotic fluid: cord compression
                         - other:                 generally CNS abnormalities


- common questions in pregnancy
   - employment:    traditionally 4 weeks before, 6 weeks after
                    - may be modified by pregnancy, emplyer, heath care system, and patient desires
                    - recent trends have reduced this time

  - exercise:            modest exercise can be continued during pregnancy
                         - avoid overly strenuous activity
                         - avoid activities that risk abdominal trauma
                         - discontinue activity with discomfort, dyspnea, or pain in the chest / abdomen

  - nutrition:           recommendations for total weight gain based on prenatal BMI
                         - underweight (≤ 19.9): 30-40 lb
                         - normal (20-24.9):       25-35 lb
                         - overweight (25.0-29.9): 15-25 lb
                         - obese (≥ 30.0):         15 lb
                         - twin gestation:         35-40 lb

  - breastfeeding:       breastfeeding is strongly encouraged for multiple reasons
                         - give consideration to pumps, milk storage if mothers resistant due to time constraints
                                                                                       YEPSA: Objectives (page 90 of 190)



                      - do not make women feel guilty about not breastfeeding

  - tobacco/alcohol: no safe dose!

  - intercourse:      not prohibited in normal pregnancy
                      - may consider advice about positional changes during later pregnancy
                      - may be prohibited in high risk cirucmstances (placenta previa, PROM, h/o preterm labor)

  - travel:           not prohibited during pregnancy
                      - advisable to avoid in last month (solely to avoid away from home delivery)
                      - should carry copy of obstetric record


- common symptoms in pregnancy
   - headaches:   treatment with acetaminophen is generally adequate

  - N/V:              particularly in the morning
                      - smaller, more frequent meals to avoid empty stomach
                      - ingestion of crackers or other bland carbohydrates
                      - hospitalization and rehydration if necessary

  - reflux:           especially postprandially
                      - smaller, more frequent meals
                      - avoidance of spicy foods
                      - avoidance of eating prior to sleep
                      - antacids as necessary

  - constipation:     physiologic due to increased transit time, increased water absorption, decreased bulk
                      - increased lfuid intake
                      - increased bulk (fruits, vegetables)
                      - bowel softeners (docusate)
                      - supplemental fibers (psyllium)

  - fatigue:          generally first trimester
                      - adjustment of schedule as necessary / possible
                      - reassurance that it is self-limiting

  - leg cramps:       particularly in the calves
                      - massage
                      - rest

  - back pain:        particularly in late pregnancy
                      - heat, massage
                      - limited analgesia
                      - avoidance of high heels or platforms

  - groin pain:       round ligament pain, particularly as pregnancy advances
                      - reassurance
                      - modification of activity

  - varicose veins:   not caused by pregnancy, but may first appear during the course of gestation
                      - support hose (symptomatic only, does not change appearance)
                      - sitz baths and local preparations (hemorrhoids)
                      - postpartum surgical correction if involution does not occur by 6 months

  - discharge:        normal increase in secretions, must rule out other causes
                                                                                           YEPSA: Objectives (page 91 of 190)



                          - vaginitis:      presents with itching, malodor
                          - SROM:           presents with thin, clear fluid


4.     Be able to evaluate, diagnose, and manage adnexal masses.

                 (based partially on objectives written by Steve Klos)

- adnexal masses
   - disorder:            mass in the region of the pelvis including the ovary, fallopian tube, and broad ligament

     - differential:      ovarian masses
                          - benign ovarian neoplasm
                          - malignant ovarian neoplasm (ovarian cancer)

                          salpingeal masses (generally associated with pain)
                          - ectopic pregnancy
                          - salpingitis / hydrosalpingitis / tuboovarian abscess
                          - endometriosis
                          - paraovarian cysts, paratubal cysts (hydatids of Morgagni)
                          - primary fallopian tube CA (usually adenocarcinoma)
                          - metastatic fallopian tube CA (more common than primary tubal CA)

                          non OB/GYN masses
                          - ptotic (downwardly-displaced) kidney
                          - acute appendicitis
                          - inflammatory bowel disease
                          - sigmoid diverticular disease
                          - rectosigmoid carcinoma

     - evaluation
        - history:        presenting symptoms, associated symptoms
        - examination:    bimanual rectovaginal examination
        - laboratory:     pregnancy and tumor markers include:
                          - β-hCG
                          - CA-125 levels (ovarian CA; low specificity, sensitivity)
                          - α-fetoprotein (testicular cancer, ovarian cancer, malignant teratoma, HCC)
       - imaging:         imaging studies include:
                          - transvaginal ultrasound (high sensitivity for ovarian tumors, low specificity for ovarian CA)
                          - CT pelvis / abdomen



cysts
- follicular cyst
   - disorder:            follicular overgrowth
   - etiology:            failed ovulation
   - epidemiology:        most common ovarian cyst
   - presentation:        generally asymptomatic, but may cause acute pelvic pain if hemorrhagic
   - diagnosis
      - history:          asymptomatic vs. pelvic pain
      - imaging:          ultrasound
                          - size:      3-8 cm in diameter
                          - shape:     round or oval
                          - structure: thin-walled, anechoic
     - management
                                                                                       YEPSA: Objectives (page 92 of 190)



    - observation:    if generally asymptomatic, will resolve on its own
    - surgery:        laparoscopic removal (or open laparotomy) and pathologic diagnosis indicated if:
                      - severe pain
                      - not resolving
                      - suspicious on ultrasound
  - web resource:     FP Notebook: Follicular Cyst
                           (http://www.fpnotebook.com/GYN91.htm)

- corpus luteum cyst
   - disorder:       cyst associated with corpus luteum
                     - corpus hemorrhagicum: ruptured follicle, stage immediately before corpus luteum
                     - theca lutein:            form resulting from fertilized, implanted egg
   - presentation:   generally asymptomatic, but may cause acute pelvic pain if hemorrhagic
   - diagnosis:      ultrasound
                     - size:        3 to 11 cm
                     - structure: thin-walled, unilocular cyst with circumferential vascularity on color Doppler
   - management:     observation


neoplasms
- benign ovarian neoplasm
   - epidemiology:
      - incidence:  more common than malignant tumors of the ovary in all age groups
      - age:        most common in reproductive years

  - pathogenesis:     bilateral in 15-20%

  - classification
     - epithelial:    serous tumors (benign and malignant)
                      - serous cystadenoma (most common epithelial tumor of the ovary)
                      - serous cystadenoma with proliferating changes
                      - serous cystadenocarcinoma

                      mucinous (benign and malignant)
                      - mucinous cystadenoma (2nd most common epithelial tumor of the ovary)
                      - mucinous cystadenoma with proliferating changes
                      - mucinous cystadenocarcinoma

                      endometrioid (benign and malignant)
                      - endometrioid benign cysts
                      - endometrioid tumors with proliferating changes
                      - adenocarcinoma

                      Brenner tumor

    - germ cell:      benign cystic teratoma (dermoid cyst / dermoid)

    - stromal cell:   types include:
                      - granulosa-theca cell tumors (female type [estrogenic], with feminizing characteristics)
                      - Sertoli-Leydig cell tumors (male type [androgenic], with virulization and hirsutism)
                      - ovarian fibroma             (no sex steroid secretion, but leads to ascites)

  - management:       surgical excision (due to potential for malignancy)
                      - preoperative assessment with pelvic imaging, including US or CT
                      - may be conservative for benign tumors, esp. if future reproduction desired
                                                                                       YEPSA: Objectives (page 93 of 190)



- malignant ovarian neoplasm (ovarian cancer)
  - epidemiology
     - incidence:    lifetime incidence 1%
     - prevalence:   5th most common of all cancers in women in the US
     - age:          most common presentation during 5th, 6th decades

  - risk factors:     risk factors include:
                      - low parity / nulliparity
                      - decreased fertility
                      - delayed childbearing
                      - family history
                      - cancer history (endometrial, colon, breast cancer)
                      - BRCA1 and BRCA2 carrier (10% of ovarian CA, BRCA1 confers 44% lifetime risk)

  - classification
     - epithelial:    most common (90%)
                      - serous cystadenocarcinomas        (Psammoma bodies, 30% bilateral)
                      - mucinous cystadenocarcinoma       (large, > 20 cm, with mucinous ascites)
                      - endometrioid tumor                (2nd most common epithelial ovarian tumor)
                      - hereditary cancer syndrome        (BRCA1, BRCA2, Lynch II syndrome)

    - germ cell:      less than 5% of malignant ovarian tumors, most common in women < 20 years old
                      - dysgerminoma                     (assoc. with gonadal dysgenesis, 5 yr survival 90-95%)
                      - immature teratoma                (2nd most common germ cell CA, 5 yr survival > 80%)
                      - mixed germ cell tumor            (composed of several histologic forms)
                      - endodermal sinus tumor           (uncommon, childhood / adolescent, 5 yr survival > 60%)
                      - embryonal tumor                  (uncommon, childhood / adolescent, 5 yr survival > 60%)

    - stromal cell:   hormone-producing (functional) tumors
                      - granulosa cell tumor            (most common form, estrogen-secreting)
                      - Sertoli-Leydig cell tumor       (rare, testosterone-secreting, usually in older patients)
                      - fibrosarcoma                    (malignant form of fibroma
                      - malignant thecoma               (exceedingly rare)

    - metastatic:     Krukenberg tumor                    (from GI tract, breast, and endometrium)

  - presentation:     nonspecific symptoms
                      - abdominal fullness
                      - urinary urgency
                      - pelvic discomfort / pain

  - diagnosis
     - history:       presence of symptoms
     - examination:   bimanual rectovaginal examination
     - laboratory:    CA-125 levels (low specificity, sensitivity; generally for monitoring rather than diagnosis)
     - imaging:       imaging studies include:
                      - transvaginal ultrasound (high sensitivity for ovarian tumors, low specificity for ovarian CA)
                      - CT pelvis / abdomen

  - screening:        no effective screening modality available

  - staging
     - stage I:       ovary only
     - stage II:      pelvic extension
     - stage III:     peritoneal implants
     - stage IV:      distant metastasis
                                                                                            YEPSA: Objectives (page 94 of 190)




     - management
       - surgical:     radical surgical resection
       - chemotherapy: adjuvant chemotherapy with platinum, taxane agents

     - prognosis:        5 year survival of 40% (20% with advanced ovarian CA)
                         predictors of worse outcome include:
                         - age > 75
                         - residual tumor > 1 cm
                         - FIGO stage 4

     - web resource:     FP Notebook: Ovarian Cancer
                             (http://www.fpnotebook.com/Gyn/Hemeonc/OvrnCncr.htm)


5.     Be able to evaluate a patient for labor.

- evaluation and management of labor
   - presentation:  patients should come to the hospital for the following reasons:
                    - contractions every 5 minutes for at least 1 hour
                    - sudden gush / constant leakage of fluid
                    - significant bleeding
                    - significant decrease in fetal movement

                         TABLE: True vs. False Labor
                          true labor                                          false labor (Braxton Hicks Contractions)
                          • regular intervals, increasing frequency           • irregular intervals and duration
                          • increasing intensity                              • intensity unchanged
                          • cervical dilation occurs                          • no cervical dilation
                          • back and abdominal discomfort                     • lower abdominal discomfort
                          • no relief from sedation                           • relief from sedation


     - evaluation
        - history:       focused history including:
                         - nature, frequency of contractions
                         - possibility of SROM or significant bleeding
                         - change in maternal or fetal status

       - examination:    limited general physical exam including:
                         - vital signs
                         - auscultation of fetal heart tones (particularly following contractions)
                         - abdominal exam and Leopold maneuvers

                         pelvic examination
                         - contraindicated with bleeding due to concerns of placenta previa
                         - sterile speculum exam if SROM unclear or suspected
                         - digital exam to determine cervical status

     - management
       - general:        initial management includes:
                         - maternal vital signs q30 minutes
                         - NPO
                         - CBC, type and screen, platelet count, urinalysis
                         - catheterization if bladder becomes distended
                                                                                          YEPSA: Objectives (page 95 of 190)



    - position:        based on patient preference, status of pregnancy, and plan developed with physician
                       - seated or reclining position: most common
                       - lateral recumbent position: enhancement of uterine blood flow in difficult delivery
                       - ambulatory:                   enhancement of cervical maturation in difficult delivery

    - fetal monitor:   common monitoring includes:
                       - Doppler ultrasound of fetal heart rate (vs. auscultation q15 min or after contractions)
                       - external tocometer

                       more invasive monitoring may include:
                       - internal pressure monitoring
                       - internal heart monitoring (scalp electrode)

    - cervix:          serial sterile pelvic examinations

    - analgesics:      generally limited to active phase of labor
                       - narcotics            (pain of labor)
                       - pudendal block       (pain of labor)
                       - epidural block       (pain of labor)
                       - spinal anestetic     (abdominal delivery)
                       - local block          (episiotomy or tear)
                       - general anesthesia (only for difficult operative deliveries)

    - AROM:            indicated for prolonged active labor

    - delivery:        delivery involves:
                       - modified Ritgen maneuver             (simultaneous perineal and vertex pressure)
                       - delivery of anterior shoulder        (downward traction on head)
                       - delivery of posterior shoulder       (upward traction on head)
                       - cradling and suction                 (head down to maximize drainage)
                       - umbilical cord cutting               (clamp on either side, cut in middle)
                       - newborn care                         (rapid, thorough drying and warm blankets)
                       - APGAR assessment                     (to evaluate need for further management)

    - placenta:        placental delivery includes:
                       - abdominal pressure
                       - moderate traction on umbilical cord
                       - rotation of placenta as it is removed


- stages of labor
   - first stage:      interval between onset of labor and full cervical dilation
                       - latent phase: cervical effacement and early dilation (0-4 cm)
                       - active phase: more rapid cervical dilation (4-10 cm)
  - second stage:      complete cervical dilation through delivery of the infant
  - third stage:       after delivery of the infant through delivery of the placenta
  - fourth stage:      immediate postpartum period through 2 hours after placental delivery

                       TABLE: Phases and Stages of Labor: Normal Characteristics
                                                           nulliparous                            multiparous
                                                      mean         upper limit               mean         upper limit
                        latent phase (hr)              6.5            20.0                    5.0            13.5
                        active phase (hr)              4.5            12.0                    2.5             5.0
                        maximum dilation (cm/hr)       3.0             1.0                    6.0             1.5
                        second stage (hr)              1.0             3.0                    0.5             1.0
                                                                                        YEPSA: Objectives (page 96 of 190)




- mechanism of labor (cardinal movements)
  - engagement:        descent of the biparietal diameter of the head below the pelvic inlet
                       - nulligravida: may be days / weeks prior
                       - multigravida: commonly at onset of labor
  - flexion:           head flexion, permitting smaller diameter of head to present to the maternal pelvis
  - descent:           movement of the presenting part through the birth canal
  - internal rotation: head rotation within the birth canal (commonly transverse to anterior or posterior)
  - extension:         head extension, generally at the introitus
  - external rotation: head rotation outside the birth canal (commonly to “face forward”)


- induction of labor
   - definition:     induction vs. augmentation
                     - induction:        stimulation of uterine contractions before spontaneous onset of labor
                     - augmentation: stimulation of uterine contractions that are too infrequent or too weak
   - function:       indicated if anticipated benefits of delivery exceed risks of allowing pregnancy to continue
   - method:         ROM, cervical ripening, and induced contractions
                     - ROM:              sterile hooked instrument
                     - ripening:         intravaginal prostaglandin (dinoprostone)
                     - contractions: IV oxytocin (Pitocin)
   - clinical:       maternal risks of prolonged labor include:
                     - infection
                     - exhaustion
                     - lacerations
                     - uterine atony (with possible hemorrhage)
                     fetal risks of prolonged labor include:
                     - asphyxia
                     - trauma
                     - infection
                     - meconium aspiration syndrome

                      TABLE: Induction of Labor: Indications and Contraindications
                       indications                                 contraindications
                       • postterm pregnancy                        • placenta or vasa previa
                       • major maternal medical illnesses          • cord presentation
                       • fetal demise                              • abnormal / unstable fetal lie
                       • suspected fetal compromise                • presenting part above inlet
                       • severe pregnancy-induced hypertension     • prior classical uterine incision
                       • premature ROM (at term)                   • prior uterine incision of unknown type
                       • chorioamnionitis                          • active genital herpes


  - Bishop Score
    - function:       evaluation of cervix for induction of labor
    - method:         13 point score based on dilation, effacement, station, consistency, and position
    - interpretation: scored as:
                      - 0-4 points:     high likelihood of failed induction
                      - 9-13 points:    high likelihood of successful induction

                      TABLE: Bishop Score for Cervical Status
                                              0                  1                       2                      3
                       dilation            closed             1-2 cm                  3-4 cm                 ≥ 5 cm
                       effacement          0-30%              40-50%                  60-70%                 ≥ 80%
                                                                                           YEPSA: Objectives (page 97 of 190)



                            station                  -3                -2, -1               0                +1, +2, +3
                            consistency             firm              medium               soft                 -----
                            position              posterior             mid              anterior               -----



6.     Be able to evaluate, diagnose, and manage postmenopausal bleeding.

                   (based primarily on objectives written by Ember Ewings)

- postmenopausal bleeding
   - disorder:      defined as:
                    - bleeding after 12 months of amenorrhea in a middle-aged woman
                    - bleeding in a younger person with premature ovarian failure after 12 months of amenorrhea

     - etiology:           differential diagnosis includes:
                           - exogenous hormones
                           - vaginal atrophy and vaginal / vulvar lesions
                           - endometrial disorders (uterine fibroids, endometrial cancer)
                           - cervical disorders (polyps, cervicitis, cancer)
                           - blood dyscrasias
                           - non-gynecologic causes (hemorrhoids, fissures, rectal prolapse, lower GI tumors)

     - epidemiology:       most common causes are HRT and atrophic vaginitis

     - diagnosis
        - general:         indications for detailed workup include:
                           - postmenopausal bleeding without hormone replacement
                           - postmenopausal bleeding on hormone replacement > 6 months
       - history:          detailed history
       - examination:      examination should include:
                           - inspection of external genitalia
                           - speculum exam with Pap smear
                           - rectal exam with stool GUIAC
       - laboratory:       CBC for heavy bleeding
       - imaging:          imaging may include:
                           - hysteroscopy
                           - ultrasound
                           - dilation and curettage (D&C)
       - procedures:       other procedures may include:
                           - colposcopy and cervical biopsy
                           - endometrial biopsy
                           - vulvar / vaginal biopsy

     - management:         for non-endometrial causes:
                           - GI causes:                   referral to GI
                           - lacerations:                 repair of the laceration
                           - vaginal atrophy:             estrogen cream

                           for endometrial causes:
                           - simple hyperplasia:          observation and repeated biopsy
                           - atypical hyperplasia:        progestin therapy
                           - progressive hyperplasia:     hysterectomy
                           - endometrial polyps:          hysteroscopic removal or D&C
                           - endometrial cancer:          hysterectomy with or without chemotherapy or radiation
                                                                                          YEPSA: Objectives (page 98 of 190)



     - web resource:     FP Notebook: Postmenopausal Bleeding
                             (http://www.fpnotebook.com/Gyn/Menses/PstmnpslBldng.htm)


7.     Be able to perform contraceptive counseling.

- contraceptive counseling
   - function:       prevention of pregnancy in those who desire it or for whom it is indicated
   - epidemiology:   55% of pregnancies in the US are unintended, and of these:
                     - 43% result in live births
                     - 13% result in miscarriages
                     - 43% resulte in elective abortions
   - counseling:     varied methods, ranging from medical to surgical
                     counseling individualized to failure rates and indications / contraindications

     TABLE: Overview of Contraceptives
                                 theoretical      actual            advantages                      disadvantages
                                  efficacy 1    efficacy 1
      none                         15.0 %        15.0 %                  -----                            -----
        (sexual intercourse prn)

      natural family planning       99.0 %       75.0 %      • cheap                         • requires motivated users
                                                             • no contraindications
                                                             • no ethical difficulties

      withdrawal                    96.0 %       80.0 %      • no intervention required      • requires motivated users

      diaphragm                     94.0 %       82.0 %      • female control                • requires prescription
                                                                                             • refit required with
                                                                                               weight change (± 10 lb)

      male condom                   97.0 %       86.0 %      • readily available             • loss of sensation
                                                             • help prevent some STIs

      oral contraceptive (OCP)      99.9 %       95.0 %      • high efficacy                 • interactions with meds
                                                             • decreased cancers             • risk for DVT, HTN, MI
                                                               (ovarian, endometrial)

      intrauterine device (IUD)     98.5 %       98.0 %      • multiparous women             • can cause scarring
        (copper IUD)                                           who can’t take pill
        (Mirena IUD)                                         • protection against
                                                               ectopic pregnancy 2

      female sterilization          99.5 %       99.5 %      • permanent                     • permanent
        (tubal ligation)                                                                     • chance of ectopic
                                                                                               pregnancy (tubal)
                                                                                             • surgical procedure

      injectable contraceptive      99.7 %       99.7 %      • effective                     • weight gain (5 lb / yr)
        (Depo-Provera)                                       • only every 3 months           • irregular bleeding

      female sterilization          99.7 %       99.7 %      • effective                     • high one-time cost
        (Essure)                                             • simple office visit
                                                               (vs. tubal ligation)
      implantable contraceptive     99.9 %       99.9 %      • highly effective              • high one-time cost
                                                                                            YEPSA: Objectives (page 99 of 190)



        (Norplant)                                               • little upkeep
                                                                 • reversible

      male sterilization               99.9 %        99.9 %      • permanent                   • permanent
       (vasectomy)                                               • simple office visit
                                                                   (vs. tubal ligation)

  1
      percent without pregnancy after 1 year
  2
      higher rate of ectopic pregnancy in those that occur with IUD in place, but lower rate overall



natural family planning
- natural family planning (NFP)
   - method:         calendar method:
                     estimation of ovulation based on previous menstrual cycles
                     - ovulation occurs 9-17 days prior to onset of next menses
                     - couple must refrain from intercourse 5 days prior to ovulation and thereafter
                     less effective than other methods of NFP

                           basal body temperature:
                           charting of morning body temperature prior to getting out of bed
                           - temperature drops 1-2 days prior to ovulation, rises 1-2 days after
                           - couple must refrain from intercourse until 3 days of temperature over “cover line”




                           FIGURE: Basal Body Temperature Chart

                           cervical mucus method (Billings)
                           direct observation, feeling, and recording of mucus
                           - after menses:        initially dry, amount increases; becomes thick, cloudy, sticky
                           - before ovulation:    elastic, stretchy, slippery, thin, and clear
                           - after ovulation:     opaque, sticky
                                                                                  YEPSA: Objectives (page 100 of 190)




                  FIGURE: Billings Circle

                  symptothermal (BBT + cervical mucus)
                  - combined monitoring
                  - can include physical signs of ovulation (breast tenderness, abdominal pain)
                  - most effective of all NFP methods

                  hormonal monitoring
                  measured presence of LH in urine
                  - available OTC
                  - can link with a computer to monitor

 - efficacy:      75% in general, 99% with perfect use


barrier methods
- male condom
  - method:       barrier protection (male or female)
  - efficacy:     male condoms are 86% in general, 97% with perfect use
                  - female condoms are somewhat less effective (~80% in general)
                  - failure rate of polyurethane condoms is greater than for latex
 - clinical:      only contraceptive that also protects against STIs
                  male and female condoms cannot be used together




                  FIGURE: Condom Failure Rates

- diaphragm
                                                                                        YEPSA: Objectives (page 101 of 190)



  - method:           barrier protection (blocks entrance to uterus)
                      - can be left in place for 24 hours
                      - requires fitting by health professional (no, not each time, just to size it… kinda like shoes)
  - efficacy:         80% in general, 94% with perfect use
                      - efficacy increases with concomitant use of spermicide
                      - with multiple acts of intercourse, spermicide should be replaced

- cervical cap
   - method:          barrier protection (blocks entrance to uterus)
                      - can be left in place for 48 hours
                      - requires fitting by health professional
  - efficacy:         higher failure rate than diaphragm
                      - consequence of manner in which it fits over the cervix
                      - most effective in nulliparous women (no previous children)
  - clinical:         unlike diaphragm, there is no need to replace spermicide with multiple acts of intercourse


hormonal contraception
- oral contraceptive pill (OCP)
   - method:          daily combinations of estrogen / progesterone

  - efficacy:         95% in general, 99.9% with perfect use

  - evaluation
     - history:       evaluation of possible contraindications
                      - PMH:            medications, DVT, pulmonary embolism, stroke, CAD, migraines
                      - sexual Hx:      menstrual history
                      - social Hx:      tobacco use, medication coverage (ability to afford)
                      - family Hx:      thromboembolic disease, osteoporosis

                      TABLE: Contraindications to OCP Use
                       absolute contraindications                        relative contraindications
                       • h/o PE                                          • uterine fibroids
                       • h/o CVA                                         • lactation
                       • h/o breast or endometrial CA                    • diabetes
                       • h/o melanoma                                    • sickle cell anemia
                       • h/o hepatic tumor                               • HTN
                       • abnormal liver function                         • age 35+ and smoking
                                                                         • age 40+ and vascular risk


    - examination:    blood pressure is the only necessary part of the physical exam

    - sensitivity:    evaluate for sensitivity to certain hormones
                      - estrogen:        heavy menses, severe cramps, breast tenderness, nausea, fibrocystic disease
                      - progesterone: PMS symptoms, pregnancy with excessive fatigue, weight gain, or HTN
                      - androgen:        oily skin, acne, hirsutism, irregular menses

  - management:       select contraceptives with low activity to hormones for which patient is sensitive

                      BOX: Considerations for Choosing an Oral Contraceptive
                       • prior success of the patient
                       • evidence of androgen, estrogen, or progesterone sensitivities
                       • dosing (lowest dose for age > 35, consider lowest dose if < 35)
                                                                                           YEPSA: Objectives (page 102 of 190)




                       • no efficacy difference between monophasic or multiphasic



- Depo-Provera
  - method:          injectable progesterone formulation (active for 3 months)
  - advantages:      decreased menses, cramps
                     decreased risk of pelvic inflammatory disease (PID)
                     ideal for patients on antiepileptics (progesterone not affected by liver changes)
                     option for women over 35 who smoke
  - limitations:     menstrual irregularities
                     weight gain
                     decreased bone density
                     may take up to 18 months for return of ovulation
  - clinical:        not ideal for long term use due to bone density problems (osteoporosis)

- Ortho Evra
  - method:          transdermal patch
                     - combined method (norelgestromin / ethinyl estradiol)
                     - apply weekly (three weeks on, one week off)
  - advantages:      easier to remember than a pill
  - limitations:     greater variability in estrogen levels relative to OCP
                     - higher variability between subjects
                     - higher overall steady state levels (theoretical higher clot risk)
                     - lower peak levels
                     less effective in obese patients (>198 lb)
                     skin irritation
                     patch detachments

- NuvaRing
  - method:          transvaginal ring
                     - combined method (etonogestrel / ethinyl estradiol)
                     - worn for 3 of 4 weeks; self insertion and removal
  - advantages:      similar efficacy as low dose OCPs
                     easy insertion
                     constant dose delivery, bypassing GI and hepatic systems
  - limitations:     can slip out (just rinse and replace)


intrauterine devices
- copper IUD (ParaGard)
   - method:         insertion of device into uterus by health care professional
   - efficacy:       98% in general, 98.5% with perfect use; good for up to 10 years
   - adverse:        heavier bleeding

- Mirena IUD
  - method:          levonorgestrel intrauterine device (IUD)
                     - packed with sterile inserter, inserted by health professional
                     - duration of 3-5 years (may be effective up to 10)
  - advantages:      decreased menses
  - limitations:     PID, uterine perforation


emergency contraception
- Plan B emergency contraception (EC)
                                                                                      YEPSA: Objectives (page 103 of 190)



  - method:            levonorgestrel 0.75 mg x 2 (12 hours apart)
  - mechanism:         may delay ovulation or decrease probability of implantation
                       does not interfere with post implantation pregnancy
  - adverse:           nausea / vomiting
  - clinical:          more effective when used earlier after sexual contact




Pediatrics
                                                                                     DIAGNOSIS & TREATMENT


- well child history
  - concerns:          address any parental concerns regarding child

  - growth:            growth discussion includes:
                       - height, weight
                       - head circumference

  - diet:              diet discussion includes:
                       - type of diet
                       - tolerance / spitting up
                       - amount of milk
                       - amount of juice and other snacks

  - outputs:           bowel and bladder habits discussion includes
                       - bowel movement frequency, consistency, color
                       - number of wet diapers

  - sleep:             sleep discussion includes:
                       - sleep habits, naps
                       - amount of crying

  - immunizations:     immunization discussion includes:
                       - reactions to previous immunizations
                       - currently scheduled immunizations

  - development:       developmental history discussion includes:
                       - current progress in developmental milestones
                       - parental concerns regarding development

  - guidance:          anticipatory guidance includes:
                       - age-appropriate guidance
                       - items identified through history and physical exam

  BOX: Well Child History
   The well child history can be remembered by use of the following memory device: “Children generally don’t
     often stop imitating dad’s goofiness.”

   Forgive me, for this is the best I could come up with on short notice.
                                                                                            YEPSA: Objectives (page 104 of 190)




1.     Be able to perform routine pediatric health supervision, including:
                • perinatal history
                • growth and development
                • principles of immunizations
                • diet
                • anticipatory guidance
                • unique aspects of the pediatric physical examination

                 (based partially on objectives written by Jen Kaschnewski and Patrick McDonough)


- perinatal history
   - prenatal care
      - PMH:                 major medical problems, current medication use
      - pregnancy Hx:        ability to conceive, problems during previous pregnancies
      - social Hx:           parental figures, siblings, AODA history
      - family Hx:           medical / genetic problems in family members, past difficulties with children
      - plans:               breastfeeding vs. bottlefeeding, safety, general concerns

     - pregnancy history
        - complications: bleeding, eclampsia, maternal illness, GDM
        - nutrition:     adequate weight gain, use of supplements, medications
        - AODA:          substance use and abuse

     - birth and delivery
        - location:       date, time, location of birth
        - vial signs:     age (GA and dating method), weight, length, head circumference
        - delivery:       type of delivery, complications / trauma, resuscitation requirements, APGAR scores

     - postnatal period
        - hospitalization:   NICU stay, return to home
        - screening:         results of genetic screening tests
        - immunization:      administration of immunizations
        - concerns:          initial concerns in postnatal period


- growth and development
   - function:      monitor for abnormalities in pediatric development

     - method:               discussion of length / height and weight at each visit
                             assessment of developmental milestones at each visit

     - interpretation:       for growth:
                             - length:   1.3x by 5 months, 2x by 4 years, 3x by 13 years
                             - weight:   2x by 6 mo., 3x by 12 mo., 4x by 24 mo.

                             for development, see attached document (Developmental Milestones)

     - screening:            screening methods include:
                             - Denver II Developmental Screening Test
                                                                                            YEPSA: Objectives (page 105 of 190)



                              (gross motor, fine motor-adaptive, language, and personal-social skills)

                         - Clinical Adaptive Test (CAD)
                              (problem-solving and visual motor ability)

                         - Clinical Linguistic and Auditory Milestone Scale (CLAMS)
                              (language development from birth to 36 mo.)


- immunizations
   - function:           protection from specific common infectious diseases
                         - prevention of disease in the individual  (e.g. HBV)
                         - prevention of disease in a population    (e.g. rubella)
                         - eradicate disease from the earth         (e.g. smallpox, polio)

  - complications:       vaccination reaction
                         - small risk associated with vaccination
                         - benefit outweighs risk due to morbidity, mortality of diseases

  - clinical:            improving vaccination rates
                         - immunize early and often
                         - get it out of the clinic
                         - state school / day care passport laws
                         - public education / advocacy
                         - combined vaccines (decrease visits, number of shots)

  TABLE: Summary of Pediatric Immunizations
   vaccine    illness             category                          series                     contraindications 1
   Hep B      hepatitis B         protein                           3 dose series              -----
                                                                    begin at birth
      DTaP            diphtheria            toxoid                  5 dose series              previous encephalopathy
                      tetanus               immunogen               begin at 2 months
                      pertussis
      PCV             pneumococcus          polysaccharide          4 dose series              Abx hypersensitivity 2
                                                                    begin at 2 months
      IPV             polio                 inactivated virus       4 dose series              -----
                                                                    begin at 2 months
      Hib             H. flu, type b        polysaccharide          3-4 dose series            -----
                                                                    begin at 2 months
      MMR             measles               live, attenuated        2 shot series              egg allergy
                      mumps                                         begin at 1 year            immunodeficiency
                      rubella                                                                  pregnancy
      varicella       varicella             conjugate               2 dose series              safe in egg allergy
                                                                    begin at 1 year
  1
      caution with all if anaphylactic reaction to previous dose
  2
      streptomycin, neomycin, polymyxin B


- diet
   - breastfeeding:      breastfeeding >> formula
                         - continue until at least 1 year of age, discontinue by 2 years
                         - formula should be iron-fortified
  - milk:                whole cow milk can be introduced after 12 months
  - solids:              solids (iron-fortified cereal) introduced after 4-6 months
                         - introduce fruits, vegetables, and meat thereafter, one at a time, with at least 1-2 day intervals
                                                                                       YEPSA: Objectives (page 106 of 190)



                     - avoid allergenic / toxic foods (honey, nuts, strawberries, seafood) in infants
  - juice:           not an essential part of diet, should be limited to < 4 oz / day
  - fluoride:        supplementation recommended if household water < 6 ppm fluoride

                     BOX: Advantages of Breastfeeding
                      Breastfeeding has numerous advantages over formula feeding, including:

                         • nutritional:       nutritional components are of human origin and well-tolerated
                                              caloric content (20 kcal / oz) ideal for quantity ingested
                                              contains vitamin D, fluoride, and iron
                                              contains growth factors (EFG, lactoferrin, cortisol)

                         • hypoallergenic:    protein (80% whey, 20% casein) is of human origin

                         • immunogenic:       contains bacteriophagic elements (macrophages, IgA)
                                              - leads to decreased rates of diabetes, IBD, lymphoma
                                              - in the short term, leads to decreased AOM, URI, UTI, and diarrhea

                         • probiotic:         lower pH promotes lactobacillus (who are our friends)

                         • social / maternal: promotes bonding between mother and infant
                                              reduces stress and postpartum bleeding, and prolongs amenorrhea
                                              leads to earlier return to prepregnancy weight

                         • financial:         $750-$1,200 /year savings


                      While breastfeeding is highly recommended, many mothers will choose to formula-feed,
                       whether it is related to anxiety, maternal fatigue, or simply personal choice. A mother
                       should not be made to feel guilty about switching to formula.




- anticipatory guidance
   - function:       anticipate problems that may occur with growing child

  - method:          discussion of risks as related to pediatric development

  TABLE: Age-Based Anticipatory Guidance
   age             developmental risk                                   safety recommendations
   newborn         completely dependent                                 • crib safety
                                                                        • car seat use
                                                                        • smoke detectors in home
                                                                        • water heater set to 120°F
                                                                        • SIDS prevention (“Back to “Sleep”)

   4 months            beginning to reach, roll, take solids            • constant bathtub supervision
                                                                        • ingestion / aspiration prevention
                                                                        • caretaker choking, first aid training
                                                                        • toy safety

   6 months            crawling, pulling to stand                       • poison control number
                                                                        • syrup of ipecac
                                                                                         YEPSA: Objectives (page 107 of 190)



                                                                          • walker dangers

   12 months             walking, climbing, stairs                        • water safety, bathtub supervision
                                                                          • poison prevention
                                                                          • continued carseat use

   toddler               increased ability to move around                 • matches
                                                                          • electrical hazards
                                                                          • knives / kitchen hazards
                                                                          • need for supervised play

   preschool             initiative, imitating adults                     • traffic safety
                                                                          • matches / fire hazards
                                                                          • need for supervised play

   school                autonomy                                         • water safety
                                                                          • bicycle safety
                                                                          • fire and burn prevention
                                                                          • strangers

   preteen / teen        rebellion                                        • drugs, alcohol
                                                                          • cigarettes
                                                                          • sports safety
                                                                          • safer sex
                                                                          • driving




- physical examination
   - physical exam of the newborn
      - general:       comfortable appearance, pink color, flexion of all four extremities
      - skin:          birthmarks, rashes
      - head:          normal head circumference, anterior fontanelle present
      - face:          normal face, absence of stigmata of recognizable syndromes
      - eyes:          irises round, of the same color, red reflex present
      - nose:          nares symmetrical
      - ears:          pinnae normal, of the same shape
      - mouth:         palate intact, no teeth or masses
      - chest:         respirations symmetrical, effortless
      - heart:         absence of an audible murmur, heart rate normal, regular in rhythm
      - abdomen:       round, convex abdomen, absence of palpable masses
      - genitalia:     varies with gender (really?)
                       - male:        penile meatus in the proper place, both testes palpable, of the same size
                       - female:      labia majora, minor present, vaginal opening present
      - extremities:   10 fingers, 10 toes, arms of the same size, legs of the same size, full abduction of the hips
      - back:          straight spine, absence of dimples in the midline
      - CNS:           flexor tone is greater than extensor tone, both hands fisted, strong infant cry, reflexes

                       BOX: Hip Dysplasia
                        Ortolani and Barlow maneuvers are used to check for developmental dysplasia of the hip.

                           • Barlow:        adduction of flexed hips, bringing femoral head A → P (bring together)
                           • Ortolani:      abduction of flexed hips, bringing femoral head P → A (spread out)
                                                                                            YEPSA: Objectives (page 108 of 190)




     - common newborn vital signs
        - heart rate:     120-160 /min
        - respirations:   30-60 /min
        - blood pressure: 60-70 mmHg systolic
        - temperature:    97.7-99.3°F (pediatric fever is > 100.4°F)
        - glucose (PRN): > 40 mg/dL

     - APGAR score
       - function:         evaluation of the well-being of newborn infants at the time of delivery
       - method:           repeated twice, at 1 and at 5 minutes
       - clinical:         most normal infants will not score a perfect 10 (lose a point for color)

       TABLE: APGAR Score
                                          0                                1                               2
        Appearance                      blue                  body pink, extremities blue                 pink
        Pulse                          absent                         < 100 bpm                        > 100 bpm
        Grimace                        absent                          grimace                 grimace and cough / sneeze
        Activity                        limp                  some flexion in extremities            active motion
        Respiration                    absent                       slow, irregular                   good, crying



2.     Be able to evaluate, diagnose, and manage common pediatric infections, including:
                • URI
                • otitis media
                • pharyngitis
                • sinusitis
                • pneumonia
                • urinary tract infection (UTI)
                • cellulitis

                   (based partially on objectives written by Dimitri Kamenshikov and Alex Wu)

- upper respiratory infection (URI) / common cold
   - disorder:       infection of the upper respiratory tract

     - etiology:           Rhinovirus (most common), coronavirus, RSV, parainfluenza, adenovirus, influenza

     - epidemiology:       3-8 colds / year is common in children

     - pathogenesis:       upper respiratory tract infection with airborne, droplet, or contact transmission
                           - incubation period of 2-5 days
                           - symptoms secondary to production of inflammatory mediators
                           - course from 3-7 days
     - diagnosis
        - general:         clinical
        - history:         1-2 week history of:
                           - low grade fever
                           - mild irritability
                           - congestion and nasal discharge (clear → cloudy)
                           - cough (dry → productive)
                                                                                       YEPSA: Objectives (page 109 of 190)



    - physical:       not seriously ill, with signs including:
                      - erythematous pharynx with mildly enlarged tonsils
                      - otitis media (viral or secondary bacterial)
                      - clear chest with occasional wheezes
                      - occasional viral exanthem
                      - mucopurulent nasal discharge in some cases
    - laboratory:     rapid diagnosis of RSV, parainfluenza, influenza, adenovirus for certain populations
                      - severely ill
                      - immunocompromised

  - differential:     differential diagnosis includes:
                      - allergic rhinitis
                      - sinusitis
                      - pertussis

  - management:       supportive care (fluids and rest)
                      - OTC medications are of no benefit in pediatric populations
                      - antibiotics only with secondary bacterial AOM or sinusitis
                      handwashing
                      saline drops


- acute otitis media (AOM)
   - disorder:        middle ear infection

  - etiology:         most common organisms are S. pneumoniae, H. influenzae, M. catarrhalis

  - epidemiology:     most common diagnosis in children (300,000 provider visits / year)

  - pathogenesis:     children more prone due to anatomy of eustachian tubes

  - diagnosis
     - general:       clinical diagnosis by examination of eardrums showing evidence of inflammation / effusion
     - history:       preceding / concurrent URI, fever, irritability, ear pain
     - physical:      pneumatic otoscope examination showing:
                      - erythema
                      - tympanic membrane thickening
                      - engorgement of blood vessels
                      - loss of normal light reflex, bony landmarks
                      - decreased mobility of the tympanic membrane
    - laboratory:     tympanocentesis only in immunocompromised, recurrent infection

  - differential:     differential diagnosis includes:
                      - otitis media with effusion (OME)
                      - otitis externa
                      - mastoiditis
                      - furuncle
                      - foreign body
                      - referred pain

  - management:       antibiotic therapy in children with evidence of AOM
                      - amoxicillin:     first line therapy, effective against S. pneumoniae and H. influenzae
                      - Augmentin:       useful in cases of difficult to treat ear infections
                      - cephalosporins: effective against H. influenzae and M. catarrhalis
                                                                                       YEPSA: Objectives (page 110 of 190)



- streptococcal pharyngitis
   - disorder:       pharyngitis secondary to S. pyogenes

  - etiology:        common causes of pharyngitis
                     - viral        (most common overall)
                     - S. pyogenes  (most common bacterial)

  - epidemiology:    uncommon in children younger than 2

  - diagnosis
     - general:      clinical evaluation with use of rapid strep, cultures
     - history:      sudden onset sore throat, fever, headache, generally no rhinorrhea or congestion
     - physical:     tonsillar exudate, palatal petechiae, strawberry tongue, rash, urticaria
     - laboratory:   rapid strep, culture, serology (ASO Ab, DNAse B)

                     TABLE: Calculation of Strep Score
                      criterion                                score
                      tonsillar exudate                        +1
                      tender, anterior cervical adenopathy     +1
                      cough absent                             +1
                      fever present                            +1

                     TABLE: Interpretation of Strep Score
                      score       GABHS probability
                      score = 0   1% in clinic       3% in ED
                      score = 1   4% in clinic       8% in ED
                      score = 2   9% in clinic       18% in ED
                      score = 3   21% in clinic      38% in ED
                      score = 4   43% in clinic      63% in ED

  - differential:    infectious causes may include:
                     - other causes of pharyngitis
                     - peritonsillar abscess
                     - retropharyngeal abscess
                     - epiglottitis

                     noninfectious causes may include:
                     - allergy
                     - trauma
                     - burns, smoke, toxins
                     - psychosomatic
                     - referred pain

  - management:      antibiotic therapy to prevent sequelae (clinical improvement differs by perhaps 12 hours)
                     - penicillin:      first line therapy
                     - amoxicillin:     effective substitute due to improved palatability
                     - macrolides:      useful in β-lactam allergic patients

- sinusitis
   - disorder:       sinus infection

  - etiology:        can be infectious (bacterial, fungal, viral), allergic, or autoimmune
                     - 30% of cases worldwide secondary to S. pneumoniae
                     - second-most common cause is H. influenzae
                                                                                    YEPSA: Objectives (page 111 of 190)



  - pathogenesis:   inflammation of the paranasal sinuses, spread by airborne, droplet, or contact transmission
                    predisposing factors include:
                    - impaired mucociliary function
                    - obstruction of sinus ostia
                    - immune defects
                    - increased risk of microbial invasion

  - diagnosis
     - general:     clinical diagnosis based on long-standing URI symptoms
     - history:     cough, low grade fever, facial pain, headache, thick discharge, bad breath
                    symptoms persisting beyond 10-14 days
    - physical:     sinus pain
    - laboratory:   CT maxi; many false positives

  - differential:   differential diagnosis includes:
                    - allergies
                    - pertussis (non-immunized patients)

  - management:     symptomatic relief and observation
                    amoxicillin: first line antibiotic


- pneumonia
   - disorder:      pulmonary infection

  - etiology:       most are viral, some are bacterial

                    TABLE: Etiology of Pediatric Pneumonia
                      age              etiology
                      0 to 1 mo.       GBS (S. agalactiae)
                                       Gram negative enterics
                                       CMV
                                       L. monocytogenes
                      1 to 3 mo.       C. trachomatis
                                       viral (RSV, parainfluenza)
                                       S. pneumoniae
                                       B. pertussis
                                       S. aureus
                      3 mo. to 5 y.    viral (RSV, parainfluenza, influenza, adeno, rhino)
                                       S. pneumoniae
                                       H. influenzae
                                       M. pneumoniae
                                       M. tuberculosis
                      5 y. to 15 y.    M. pneumoniae
                                       C. pneumoniae
                                       S. pneumoniae
                                       M. tuberculosis
                    1
                      Data from McIntosh K, N Engl J Med 346(6): 429-37

  - pathogenesis:   pulmonary parenchymal infection secondary to:
                    - defects in host defenses protecting the lung
                    - inhalation of a large inoculum
                    - hematogenous infection
  - diagnosis
     - general:     combined clinical and radiologic findings, with empiric treatment
                                                                                    YEPSA: Objectives (page 112 of 190)




                      TABLE: Bacterial vs. Viral Presentation
                       bacterial pneumonia                            viral presentation
                       • abrupt onset cough, fever                    • prodromal rhinorrhea, cough, fever
                       • chest pain                                   • pharyngitis
                       • chills                                       • tachypnea, tachycardia
                       • hypoxia                                      • mild hepatosplenomegaly
                       • toxic appearing


    - laboratory:     laboratory tests to consider include
                      - CBC with differential
                      - blood culture
                      - chest radiograph (bacterial more commonly lobar; viral more commonly diffuse)
                      - sputum (children > 12) for Gram stain, culture, acid fast smear and culture
                      - direct viral examination of nasopharyngeal specimens
                      - M. pneumoniae IgM and IgG
                      - pulse oximetry

  - differential:     bacterial vs. viral

  - management:       admission for:
                      - infants < 2-3 months
                      - children with underlying immunodeficiency, metabolic disease, cardiopulmonary disease
                      - respiratory distress, hypoxia, sepsis, dehydration, poor compliance

                      antibiotics based on etiology
                      - S. pneumoniae: amoxicillin
                      - atypical:        erythromycin
                      - S. aureus:       cephalosporin
                      - MRSA:            vancomycin
                      - HSV:             acyclovir
                      - CMV:             ganciclovir


- urinary tract infection (UTI)
   - disorder:         infection of the bladder or kidney

  - etiology:         causes vary by origin
                      - community-associated: E. coli, Enterococcus, S. aureus, S. saprophyticus
                      - iatrogenic / nosocomial: Pseudomonas, coagulase-negative staph

  - epidemiology:     common in children

  - risk factors:     risk factors include:
                      - female gender
                      - uncircumcised male infants
                      - vesicoureteral reflux (VUR)

  - pathogenesis:     sources include:
                      - colonization of the periurethral area
                      - hematogenous source (generally 1st 8-12 weeks of life)

  - diagnosis
     - general:       urinalysis with suspicious symptoms
     - history:       “frequency, urgency, pain on urination”
                                                                                         YEPSA: Objectives (page 113 of 190)



                        - young children: fever, crying on urination, frequency, hematuria, GI symptoms, poor growth
                        - older children: fever, chills, malaise, hematuria, flank pain, new onset enuresis
       - physical:      CVA tenderness, uncircumcised
                        generally to rule out other causes (masses, trauma)
       - laboratory:    rapid screening (dipstick for nitrite, esterase)
                        urine cultures (100,000 cfu/mL in clean-voided method)

     - differential:    asymptomatic bacteruria

     - management:      diagnostic studies
                        - renal ultrasound:                    check for hydronephrosis
                        - voiding cystourethrogram (VCUG): check for reflux
                        - DMSA scan:                           check for anatomical scarring
                        - radionucleotide scan:                consideration of obstruction
                        antibiotic therapy (cephalosporin, TMP/SMX, amoxicillin, nitrofurantoin)


- cellulitis
   - disorder:          inflammation of connective tissue underlying the skin

     - etiology:        S. pyogenes (majority), S. aureus, many others

     - risk factors:    risk factors include:
                        - immunodeficiency
                        - trauma

     - pathogenesis:    acute inflammation of connective tissue underlying the skin
                        - direct invasion
                        - hematogenous dissemination

     - diagnosis
        - general:      clinical
        - history:      differs slightly with etiology
                        - S. pyogenes:     trauma; prodromal illness (fever, pharyngitis, chills, abdominal pain )
                        - S. aureus:       recent local trauma
       - physical:      rapidly-advancing rash with poorly demarcated borders

     - differential:    other etiologies of rash

     - management:      bed rest, elevation
                        antibiotics
                        - S. pyogenes (GAS): amoxicillin
                        - S. aureus:         cephalosporins, vancomycin


3.     Be able to evaluate, diagnose, and manage fever in young children.

- fever of unknown origin (FUO)
   - disorder:      elevation of temperature > 100.4°F

     - etiology:        concern for infectious diseases, such as viral (58% of cases), bacterial (8% of cases)

     - pathogenesis:    elevation of body temperature
                        - secondary to effects on hypothalamic thermoregulatory center
                        - results from cytokines produced in response to infection or inflammation
                                                                                         YEPSA: Objectives (page 114 of 190)



     - diagnosis
        - general:     evaluation to rule out serious bacterial infections (SBIs)
        - history:     duration and height of fever, method of measurement, use of antipyretics
                       behavior, appetite, activity level
       - physical:     vital signs (fever, hypothermia, tachypnea, irregular respirations, apnea, hypotension)
                       skin exam (cyanosis, poor perfusion, rashes)
                       other signs (meningeal signs [Kernig, Brudzinski signs], pneumonia, murmur, MSK infection)
       - laboratory:   sepsis evaluation of all infants < 1 month
                       - CBC, blood culture, urinalysis, urine culture, chest x-ray
                       - lumbar puncture and CSF examination / culture
                       varied recommendations beyond 1 month of age
                       - low risk children: careful observation (esp. those above 3 months)
                       - high risk children: full sepsis evaluation

     - differential:   common causes of acute fever include:
                       - viral illness
                       - bacterial infections (meningitis, UTI)

                       TABLE: Bacterial Infections
                        age               etiology
                        0 to 3 mo.        E. coli, Klebsiella
                                          Enterococcus
                                          S. agalactiae
                                          L. monocytogenes
                        3 mo. to 5 years  S. pneumoniae
                                          N. meningitidis
                                          H. influenzae type b
                                          S. pyogenes (GAS)
                        age > 5 years     N. meningitidis
                                          S. pneumoniae
                        any age           M. tuberculosis

                       other considerations, particularly in prolonged fever, include:
                       - infection
                       - collagen vascular disease
                       - malignancy

     - management:     hospitalization for infants < 1 month, high risk children 1-3 months
                       careful consideration of antibiotic use
                       - obtain appropriate cultures first
                       - do not use in older children with unremarkable lab results
                       careful consideration of antipyretic therapy
                       - antipyretics for discomfort, wait until after medical evaluation if possible
                       - acetaminophen, ibuprofen common
                       - no aspirin in children (Reye syndrome, which causes fatty liver, encephalopathy)

     - clinical:       normal diurnal variation of body temperature (higher in afternoon vs. morning)
                       oral and rectal measurements underestimate core body temperature
                       - rectal:     = core body temperature (CBT)
                       - oral:       = CBT – 0.5°C
                       - axillary:   = CBT – 1.0°C


4.     Be able to evaluate, diagnose, and manage acute dehydration.
                                                                                          YEPSA: Objectives (page 115 of 190)



                (based partially on objectives written by Andrew Kastenmeier)

- pediatric dehydration
   - disorder:       insufficiency of fluids

  - etiology:           most commonly related to acute gastrointestinal illness

  - pathogenesis:       three basic causes
                        - low intake:          poor appetite
                        - high output:         vomiting, diarrhea, burns
                        - high metabolism:     sepsis

  - diagnosis
     - general:         largely clinical diagnosis based on history, symptoms, and physical exam findings
     - examination:     physical exam findings include:
                        - HEENT: dry or cracked mucous membranes, absent tears
                        - CV:         orthostatic or low blood pressure, increased heart rate, “thready” pulses
                        - GU:         low to absent urine output
                        - skin:       increased capillary refill, delayed retraction, tenting

                        TABLE: Symptoms and Signs in Dehydration
                               mild dehydration            moderate dehydration                 severe dehydration
                              (5% of body weight)        (10% loss of body weight)           (15% loss of body weight)
                         • dry mucus membranes         • fainting                          • rapid weak pulse
                         • extreme thirst              • tachycardia                       • cold hands and feet
                         • dry, warm skin              • rapid and deep breath             • rapid breathing
                         • low UOP                     • severe cramps                     • cyanosis
                         • flushed face                • bloated stomach                   • confusion
                         • headache                    • low blood pressure                • lethargy
                         • weakness, dizziness         • heart failure
                         • arm or leg cramps           • sunken fontanel
                         • crying with few or no tears • sunken eyes
                         • sleepy or irritable         • crying with few or no tears
                                                       • lack of skin elasticity

    - laboratory:       may be drawn in cases severe enough to require IV rehydration
                        - CBC            (hemoconcentration, elevated WBC count)
                        - electrolytes   ([Na+] variable, bicarbonate may suggest acid-base disorder)
                        - BUN / Cr       (ratio > 20:1 suggests dehydration)
                        - urinalysis     (specific gravity > 1.020, uOsm > 500 suggest dehydration)

  - management
    - general:          principles of rehydration
                        - estimate degree of dehydration using history and physical exam
                        - determine appropriate form of rehydration (ORT or IV)
                        - calculate maintence fluid and deficit fluid
                        - replace fluid at the appropriate rate, with continual monitoring of child

    - oral:             oral rehydration therapy (ORT) in mild to moderate cases
                        - calculate desired volume of replacement fluid (mild: 60 mL/kg; moderate: 80 mL/kg)
                        - administer 25% / hour for 4 hours and reevaluate

    - IV:               IV rehydration in severe cases, or mild/moderate cases where ORT not tolerated
                        - isotonic DH:        replace volume in 24 hours, with 50% in 8 hours, 50% in next 16 hours
                        - hypertonic DH:      replace volume in 48 hours, with 50% each day
                        - hypotonic DH:       replace with 3% saline at a rate to increase [Na+] by 1-2 mEq/hr
                                                                                          YEPSA: Objectives (page 116 of 190)




     TABLE: Summary of Pediatric Caloric, Fluid, and Electrolyte Requirements
     category        shorthand        rule
     caloric
     • daily         100:50:20        100 kcal/kg for 1st 10 kg, 50 kcal/kg for 2nd 10 kg, 20 kcal/kg thereafter
     • hourly        4:2:1            4 kcal/kg for 1st 10 kg, 2 kcal/kg for 2nd 10 kg, 1 kcal/kg thereafter

     fluids              1:1              1 mL fluid for each 1 kcal expended

     electrolytes        2.5              2.5 mEq Na+, 2.5 mEq K+ for each 100 kcal expended




5.     Be able to evaluate, diagnose, and manage child abuse and neglect.

- non-accidental trauma (NAT)
   - disorder:       child abuse vs. child neglect
                     - abuse:     injuries intentionally perpetrated by caretaker resulting in morbidity or mortality
                     - neglect:   failure to provide child with appropriate food, clothing, medical care, schooling

     - etiology:        generally seen with high risk parents, children, and social situations

     - epidemiology
        - prevalence:   1-1.5% of children abused each year
        - mortality:    1,200 deaths / year

     - risk factors
        - parent:       abused as child, not nurtured
                        low self esteem

       - child:         unwanted / unplanned, stepchild
                        difficult (deformed, retarded, colic, behavioral problems)
                        poor bonding (⅓ of all abused children are ex-premies)

       - situation:     social isolation (functionally single parent)
                        stress (divorce, marriage, poverty, drugs, new child)

     - diagnosis
        - general:      high index of clinical suspicion combined with suggestive history / findings

       - history:       inconsistencies in the history, lack of history
                        unexplained delays in seeking care

       - physical:      any trauma under age 3
                        recurrent injury
                        pathognomonic injuries
                        - round “cigarette burn” scars
                        - marks suggesting rope or strap burns
                        - suspicious scars / bruises at various stages of healing
                        - burns in pattern suggesting immersion (e.g. “stocking” burns)
                        retinal hemorrhage in otherwise normal child (suggesting “shaken baby” syndrome)

       - imaging:       multiple fractures at varying stages of healing
                                                                                           YEPSA: Objectives (page 117 of 190)



                         hairline, tendon-avulsion fractures
                         meningeal tears in absence of injury
                         unexplained subdural hematoma

     - management:       admit the child and report to police or social services
                         utilize “I” statements
                         - “I’m concerned this may not be accidental”
                         - “I’m required by law to look into this”
                         use “non-accidental injury” vs. “abuse”


     BOX: Acute Stress in Children
      Children may react to acute stress situations, such as abuse, in
       varying ways. This may include:

        • withdrawal or sadness
        • development of new and excessive anxieties or fears
        • acting out with anger and expression




Primary Care
                                                                                        DIAGNOSIS & TREATMENT


1.     Assess individual health risks and make appropriate health promotion recommendations for patients of any
       age.


pediatrics and adolescent medicine

     TABLE: USPSTF Recommendations for Screening in Children and Adolescents
                       screening tests                comments                                                   efficacy
      newborn          • PKU, TSH                     repeat TSH, PKU at 2 weeks if tested                          A
                       • Hgb electrophoresis          before 24h of life

      6-12 months             • Hgb or Hct                      screen only high risk                                B

      3-5 years               • blood [lead]                    screen only high risk                                B

      all kids                • ht, wt, head circ.              optimal frequency for questions has not              B
                              • developmental screen            been defined

                              • BP, auscultate heart            frequency ill-defined; accurate BP hard              B
                              • femoral pulse (newborn)         in kids < 3 years

                              • Mantoux PPD Tb test             screen only high risk, start at 12-15                B
                                                                months
                                                                                    YEPSA: Objectives (page 118 of 190)



 adolescents            •   Gonorrhea culture           screen high risk groups                               B
                        •   fAb for Chlamydia
                        •   ELISA for HIV
                        •   VRDL/RPR for syphilis

 adolescent females     • pap smear                     screen if sexually active                             A



TABLE: USPSTF Recommendations for Healthy Advice Giving
                     objective                        counseling                                        evidence 1
  newborns           prevent SIDS                     infant back to sleep                              A      C
                     improve nutrition                diet, breastfeed                                  A      C
  children           prevent household injuries       smoke detectors                                   B      B
                                                      flame-resistant sleepwear                         A      B
                                                      hot water heater 120-130°F                        A      B
                                                      childproof med containers                         A      B
                                                      bike helmets                                      A      B
                                                      firearm storage                                   B      C
                     prevent dental disease           F supplement (if inadequate H2O)                  A      C
                                                      regular dental visits                             B      C
                                                      regular brushing, flossing                        B      C
                     prevent tobacco effects          effects of passive smoke                          A      A
  kids / adolescents prevent MVA effects              safety seats, seatbelts                           A      B
                     healthy diet, exercise           limit dietary fat                                 A      C
                                                      emphasize fiber                                   B      C
                                                      regular exercise                                  A      C
  adolescents        prevent tobacco use              tobacco counseling                                A      C
                     prevent EtOH use                 EtOH counseling                                   B      C
                     prevent drug use                 drug counseling                                   B      C
                     prevent STIs                     abstinence                                        A      C
                                                      if not, condoms                                   A      C
                                                      also, female condoms                              B      C
                     prevent unintended pregnancy     abstinence, contraceptives                        A      B
                     prevent youth violence           teach problem-solving skills                      C      C
                                                      reduce EtOH use                                   B      C
1
   column 1: does health improve if behavior changes?
   column 2: does counseling help to change behavior?


BOX: ISCI Recommendations on Child Preventive Services (Level II or Better)
 The following are ISCI recommendations for child preventive services that must be delivered based on Level II
   or better evidence:

   • cervical cancer screening
   • bicycle safety
   • motor vehicle safety
   • poisoning safety
   • burn prevention
   • choking prevention
   • fall prevention
   • firearm safety
   • water safety
                                                                                                  YEPSA: Objectives (page 119 of 190)




        • blood lead testing
        • sleep positioning and SIDS
        • neonatal screening
        • obesity screening
        • tobacco use screening and brief intervention




adult medicine

  TABLE: USPSTF Well Adult Care Recommendations on Risk Factor Identification
                          when to begin          interval           tools                                               evidence
   sexual history         first visit            periodically       sexual history                                        B/C
     (if sexually active)
   STI/HIV risk           first visit            ongoing, PRN       sexual, drug,                                         B/C
                                                                    occupational history
   pregnancy,             before onset of sexual Q1-2 years         education for risk                                     B
     contraception        activity, or age 18                       reduction
   drugs, alcohol,        first visit            ongoing            MAST, CAGE,                                            B
     tobacco                                                        Stages of Change
   CHD risk 1             first visit            update at periodic genogram / FHx                                        A/B
                                                 health exam 3
   cancer risk 2          first visit            update at periodic genogram / FHx                                         B
                                                 health exam 3
   depression risk        first visit            ongoing, PRN       depression scales                                      B
  1
    family history of cardiac disease, diabetes mellitus, hypercholesterolemia
  2
    family history of colorectal, lung, breast, ovary, prostate, or skin cancer
  3
    every 1-3 years, depending on age


  TABLE: Well Adult Care Recommendations on Screening
                       when to begin      interval                              tools                                   evidence
   MEN AND WOMEN
      height, weight         first visit              periodic                  compare with national norms,                A
                                                                                consider waist-hip ratio
      blood pressure         first visit              Q 1-2 y, optimum has      chart record, flow sheet                    A
                                                      not been determined
      cholesterol            men: 35y                 At least q 5 y; benefit   cardiac risk includes FHx of heart          A
                             women: 45y               may continue into later   disease or high cholesterol level; if
                             FHx, cardiac risk: 20y   years                     high BP, smoking, or DM, should
                                                                                check HDL
      colon CA testing       average risk: 50y        depends on test           all agree that screening should be          B
                             increased risk: 40y                                done, but how and how often varies
      • FOBT                 as above                 annual                    high false positive; lowest cost and        B
                                                                                risk
      • DRE                  as above, varies         annual                    some do not recommend, including             I
                                                                                USPSTF
      • sigmoidoscopy        as above                 Q 3-5 y                   some recommend use together w/              B
                                                                                FOBT, evidence for combined
                                                                                unclear; USPSTF recommends either
                                                                                FS or FOBT
      • colonoscopy          as above                 unclear, 3-10 y           highest cost, highest risk, most             I
                                                                                accurate
      skin exam (for CA)     unknown                  unknown                   clinicians should remain alert for           I
                                                                                lesions with malignant features in
                                                                                context of PE
                                                                                                        YEPSA: Objectives (page 120 of 190)



    urinalysis               not recommended              not recommended            routine not recommended; may be              D1
                                                                                     used in monitoring high-risk pts (ie.
                                                                                     DM, HTN)
    plasma glucose           40 y, earlier if high risk   1-3 y                      fasting preferred; high-risk groups          I2
                                                                                     include positive FHx, certain ethnic
                                                                                     groups, other cardiac risk
    thyroid screening        65 y                         Q 3-5 y                    TSH                                          I3
    anemia testing           not recommended              not recommended            CBC or Hgb                                    I
    vision testing           65 y                         periodic (varies)          Snellen, tumbling E, some advocate          A/B
                                                                                     glaucoma screen
    hearing testing          65 y                         periodic                   history: formal testing if positive          A
    STIs, HIV testing        high risk                    periodic                   RPR or VDRL, consider HIV in high-           A
                                                                                     risk people, known contacts, sex
                                                                                     workers, multiple partners, men with
                                                                                     men
    WOMEN ONLY
    Papanicolaou smear       18 y or onset of sexual      At least q 3 y             No need for routine smear after              A
                             activity; consider           (USPSTF, AAFP,             hysterectomy for benign reasons
                             stopping at 65 if low        ACPM, CTF);
                             risk                         Annual (ACS, ACOG)
    breast CA screening      see below                    see below                  mammography essential component              A
    mammograms               50 y                         Q 1-2 y until age 70;      mammograms after 70 y; insufficient       A (50 y)
                             40 y routine (ACOG,          some insurers (ie.         evidence but may consider if life         B (40 y)
                             AMA, ACS) and high-          Medicare) only pay q 2     expectancy is long
                             risk women (most             y
                             include USPSTF)
    clinical breast exam     18 y, ACOG, ACS              with mammogram or          should not be used alone or in lieu of       B/I
                             40 y, as above               annually                   mammogram
                             50 y, as above
    self-breast exam         teach with first pap         monthly by ACS             efficacy questioned and not                 D/I
                                                                                     recommended by many groups; use to
                                                                                     remind about mammograms
    chlamydia testing        when sexually active         routine with pap           increased risk with multiple sexual       A/B/C
                                                          (annual) or other pelvic   partners, HX of STIs, or inconsistent
                                                          exam until age 25; also    condom use; cervical swab, self-
                                                          women > 25 y who are       administered vaginal swab, and urine
                                                          at increased risk          tests being studied
    MEN ONLY
    prostate CA (PSA, DRE)   40-50 y                      unknown                    most authorities do not recommend            D
                                                                                     screening
    Chlamydia testing        first sexual activity        periodic                   urethral swab, urine test being studied       I
1
  USPSTF, AAFP, ACP
2
  USPSTF: indeterminant; ADA: recommends; CTF: does not recommend
3
  not recommended by USPSTF, ACP, CTF; only recommended by ACOG
4
  A (first sexual activity until 25 y); B (> 25 y, high-risk); C (> 25, low-risk)


BOX: ICSI Adult Care Recommendations (Level I Evidence)
    The following are ICSI recommendations for adult care that must be delivered based on Level I evidence:

      • aspirin chemoprophylaxis
      • tobacco use screening and brief intervention
      • colorectal cancer screening
      • hypertension screening
      • influenza immunization
      • Pneumovax (PPV 23) immunization
      • problem drinking screening and brief counseling
      • vision screening
      • cervical cancer screening
      • total cholesterol and HDL-C screening
      • breast cancer screening
                                                                                           YEPSA: Objectives (page 121 of 190)




        • Chlamydia screening
        • Ca2+ chemoprophylaxis counseling




2.     Be able to evaluate, diagnose, and manage chest pain.

                (based partially on objectives written by Doug Newton)

chest pain
- chest pain history
   - HPI:                 history of present illness should include:
                          - location, quality, and severity of pain
                          - onset, time course, and context of the pain
                          - associated symptoms (e.g. SOB, diaphoresis, N/V, palpitations, dizziness, feeling of doom)
                          - modifying factors
                          - treatments, medications used

     - PMH:               past medical history should include:
                          - previous coronary, pulmonary, GI disease
                          - cardiac risk factors (hypertension, hyperlipidemia, diabetes mellitus, smoking)
                          - embolism risk factors (venous stasis, hypercoagulable state, endothelial damage)
                          - medications and allergies

     - FH:                family history should include:
                          - history of coronary disease
                          - history of diabetes, obesity, hypertension, hyperlipidemia

     - SH:                social history should include:
                          - history of smoking
                          - history of alcohol use


     TABLE: High vs. Low Risk of Ischemic Disease
      high risk symptoms                                         low risk symptoms
      • radiation of pain to L arm or neck                       • sharp pain
      • diaphoresis                                              • reproducible with direct palpation
      • presence of pain < 1 hour                                • presence of pain > 48 hours


     BOX: Risk Factors for Coronary Artery Disease
      There are six primary risk factors that affect the incidence of CAD. They include:

        • age:                    male > 45 years old, female > 55 years old
        • family history:         CAD in male relative < 55 years old, CAD in female relative < 65 years old
        • hypertension:           systolic BP > 140, diastolic BP > 90
        • diabetes mellitus:      history of diabetes (3-5x increased risk of major CV event)
        • tobacco use:            history of smoking (effects last 1-2 years after cessation of smoking
        • dyslipidemia
           - total cholesterol:   > 300 mg/dL
           - triglycerides:       > 150 mg/dL
           - HDL-C:               < 40 mg/dL
                                                                                       YEPSA: Objectives (page 122 of 190)




          - LDL-C:              based on risk factors
                                - no major risk factors:                         > 160 mg/dL
                                - 10-20% coronary risk1, no known CVD/PVD:       > 130 mg/dL
                                - 20% or more1, no known CVD/PVD:                > 100 mg/dL
                                - diabetes mellitus:                             > 100 mg/dL
                                - known CVD/PVD:                                 > 70 mg/dL

  1
      risk of major coronary event as defined by ATP III guidelines

  BOX: Risk Factors for Thromboembolic Events
      The major risk factors for thromboembolic events can be categorized by Virchow’s triad.

        • venous stasis:        varicose veins, poor activity, post-surgical
        • hypercoagulability:   severe trauma / burn, cancer, late pregnancy, smoking, obesity, OCP use
        • endothelial damage:   hypertension




- chest pain physical exam
   - general:          vital signs, general patient appearance
                       - hypotension:          concerning for MI, PE, pneumothorax
                       - tachycardia:          concerning for MI, PE, hypoxia
                       - uneven arm BPs:       suggests aortic rupture

  - pulmonary:          inspection, percussion, palpation, auscultation
                        - dullness:            concerning for PE, pneumonia
                        - crackles:            concerning for heart failure
                        - deviated trachea:    concerning for pneumothorax
                        - pain on palpation: suggestive of costochondritis (but may still be incidental)

  - cardiovascular:     heart sounds, peripheral pulses
                        - rub:                  concerning for pericarditis
                        - aortic insufficiency: concerning for dissection
                        - loud P2 sound:        concerning for PE

  BOX: Physical Exam Red Flags for Acute Coronary Syndromes
      Several physical exam findings are extremely concerning for acute coronary syndromes (ACS). These include:

        • new mitral regurgitation
        • hypotension
        • rales
        • S3
        • jugular venous distension (JVD)



  TABLE: Characteristics of Non-Ischemic Causes of Chest Pain
   disorder                              differentiating signs, symptoms
   reflux esophagitis                    • no ECG changes
                                         • heartburn
                                         • worse in recumbent position, while straining
                                                                                         YEPSA: Objectives (page 123 of 190)



                                             • most common cause of chest pain

 pulmonary embolism                          • tachypnea, hypoxemia, hypocarbia
                                             • no pulmonary congestion on CXR
                                             • clinical presentation may resemble hyperventilation
                                             • both PaO2 and PaCO2 are decreased
                                             • pain often not marked
                                             • D-dimer assay positive

 hyperventilation                            • dyspnea
   (primary or secondary)                    • frequently young
                                             • tingling and numbness of the limbs, dizziness
                                             • PaCO2 decreased, PaO2 increased or normal

 spontaneous pneumothorax                    • dyspnea
                                             • auscultation, CXR

 aortic dissection                           • severe pain with changing localization
                                             • possible obstruction of an origin of a coronary artery
                                             • possible asymmetric pulses
                                             • possible broadening of the mediastinum on CXR
                                             • new aortic valve regurgitation

 pericarditis                                • change of posture and breathing influence pain
                                             • friction sound may be heard
                                             • ST-elevation but no reciprocal ST-depression

 pleuritis                                   • stabbing pain when breathing

 costochondritis                             • palpation tenderness
                                             • movements of chest influence pain
                                             • might be insignificant incidental finding

 HSV (shingles)                              • no ECG changes
                                             • rash, localized paresthesia before rash

 ectopic beats                               • transient
                                             • localization to apex

 peptic ulcer, cholecystitis, pancreatitis   • clinical examination

 depression                                  • continuous feeling of heaviness in the chest
                                             • no correlation to exercise
                                             • normal ECG

 alcoholism                                  • young male patient in ED, inebriated



BOX: Life-Threatening Causes of Chest Pain
 The six life-threatening causes of chest pain that must be ruled out, particularly in an acute setting, include:

   • unstable angina (MI)
   • myocardial infarction (MI)
                                                                                       YEPSA: Objectives (page 124 of 190)




      • aortic dissection
      • pneumothorax
      • pulmonary embolism
      • esophageal rupture




- acute myocardial infarction
            (for a more complete discussion of AMI, see Medicine, Objective 3)

  - disorder:         necrosis secondary to insufficient O2 supply to an area of the heart

  - etiology:         vast majority secondary to coronary atherosclerosis

  - presentation:     typical presentation includes:
                      - crushing substernal chest pain (longer than 20 min, not relieved by nitroglycerin or rest)
                      - radiation (arms, jaw, neck, shoulder, abdomen)
                      - non-pleuritic pain

  - diagnosis
     - general:       diagnosis based on 2 of 3 criteria
                      - typical symptoms
                      - ECG findings
                      - cardiac enzymes

    - examination:    physical findings may include:
                      - skin:       sympathetic response
                      - lungs:      rales (indicative of CHF)
                      - heart:      systolic murmurs, S3 (systolic dysfunction), S4 (LV noncompliance), arrhythmia

    - laboratory:     cardiac enzymes
                      - CK:       general indicator of muscle damage
                      - CK-MB: more specific to myocardium
                      - TnI:      highly specific cardiac marker, begins elevation within 6 hours of damage
                      - TnT:      high levels associated with high mortality

    - ECG:            temporal progression in an untreated Q-wave MI:
                      - peaked T waves           (hyperacute)
                      - ST elevation             (acute; represents myocardial injury)
                      - T wave inversion         (hours to days)
                      - Q wave development       (weeks to months; represents scar tissue)

  - management
    - immediate:      immediate measures include:
                      - bed rest
                      - ASA
                      - O2 (2-4 L/min)
                      - nitrates
                      - morphine (or other pain control)

    - thrombolytic:   choice of thrombolytic therapy guided by ECG, time of presentation
                      - heparin drip within 12 hours of onset
                      - add tPA for STEMI
                                                                                     YEPSA: Objectives (page 125 of 190)




    - interventional: percutaneous transluminal coronary angioplasty (PTCA)

    - prophylactic:   adjuvant therapies that reduce mortality include:
                      - β blockers to all patients with evolving MI if no contraindications
                      - ACE-I / ARB initiation within several hours unless hypotensive or h/o ACE-I angioedema

                      long term secondary prevention
                      - smoking cessation
                      - patient education
                      - statin treatment to < 100 mg/dL

    - other:          other measures in the acute setting include:
                      - stool softener
                      - NPO until stable
                      - anxiolytics


  TABLE: Evaluation of Suspected Coronary Artery Disease
   pretest probability              diagnostic evaluation
   low pretest probability          • explain why pain is unlikely to be cardiac in origin
                                    • consider resting ECG if it will help reassure patient

   intermediate pretest probability      • unstable angina: ED triage protocols, immediate hospitalization for ACS
                                         • stable angina: nonemergent stress testing

   high pretest probability              • unstable angina: ED triage protocols, immediate hospitalization for ACS
                                         • stable angina: nonemergent stress testing


  BOX: Evaluation of Suspected Coronary Artery Disease: General Considerations
   General considerations in the evaluation of suspected CAD include:

     • teach patients and families the symptoms of ACS and instruct to call 911 if such symptoms occur
     • to reduce requests for unnecessary testing:
        - elicit patient concerns
        - perform a detailed history and physical examination
        - obtain an ECG
        - address concerns with a careful review of clinical findings




- pulmonary embolism
   - disorder:     blockage of a pulmonary artery or branch from an embolic material

  - etiology:         types of emboli include:
                      - thromboembolism (90% from DVT of the legs)
                      - non-thrombotic embolism (air, marrow, fat, amniotic fluid, foreign body)

  - epidemiology
     - incidence:     1% of general population at autopsy
                      - 30% of patients with severe burns, trauma, fractures
                      - 65% with hospitalized patients using special techniques
                                                                                 YEPSA: Objectives (page 126 of 190)



  - mortality:    50,000 deaths per year

- pathogenesis:   movement and lodging of preformed clot in the pulmonary vasculature
                  obstruction of pulmonary air flow
                  - respiratory compromise:       high V/Q segment causing hypoxemia, increased dead space
                  - hemodynamic compromise: increased resistance to flow




                  FIGURE: Big-Ass Saddle Clot


- risk factors
   - general:     Virchow’s triad
                  - blood stasis
                  - hypercoagulability
                  - endothelial damage

  - specific:     specific risk factors include:
                  - h/o clot or clotting disorder
                  - heart disease (CHF, atrial arrhythmia, mural thrombosis)
                  - cancer
                  - trauma / major LE surgery
                  - pregnancy
                  - exogenous estrogens
                  - immobility
                  - obesity
                  - age
                  - clotting disease

- presentation:   massive pulmonary embolism
                  - sudden cardiac death
                  - electromechanical dissociation (ECG rhythm with no palpable pulse)
                  - surviving patients mimic MI (chest pain, dyspnea, shock, ↑ temperature, ↑ LDH)

                  small emboli
                  - normal circulation: transient chest pain, cough, pulmonary hemorrhage without infarction
                  - poor circulation:   infarct, with dyspnea, tachypnea, fever, chest pain, cough, hemoptysis

- diagnosis
   - history:     symptoms concerning for PE include:
                  - chest pain / chest wall tenderness
                  - back / shoulder / upper abdominal pain
                  - syncope
                                                                                    YEPSA: Objectives (page 127 of 190)



                   - hemoptysis
                   - dyspnea
                   - painful respiration
                   - new onset wheezing
                   - new cardiac arrhythmia
                   - feeling of impending doom

                   BOX: Pulmonary Embolism Triad
                    The classic triad of signs and symptoms in pulmonary embolism includes:

                      • hemoptysis
                      • dyspnea
                      • chest pain

                    However, this triad is neither sensitive nor specific, and only occurs in 20% of patients.


  - examination:   signs concerning for PE include:
                   - tachycardia
                   - tachypnea
                   - possible pleural friction rub

  - laboratory:    laboratory tests include:
                   - D-dimer
                   - venous ultrasound
                   - V/Q scan
                   - pulmonary angiography (gold standard)

- differential:    differential diagnosis of chest pain includes:
                   - acute MI
                   - pulmonary embolism
                   - pneumothorax
                   - esophageal rupture
                   - aortic dissection

- management:      general management includes
                   - heparin anticoagulation
                   - fibrinolytic agent (if hemodynamically compromised)

- complications:   pulmonary infarction
                   - relatively uncommon, occurring in 1 of 10 pulmonary emboli
                   - usually occurs in setting of underlying CHF with no collateral circulation

- prognosis:       severity of disease depends on:
                   - extent of pulmonary flow obstruction
                   - size of the occluded vessels
                   - number of emboli
                   - overall cardiovascular status
                   - release of vasoactive factors (e.g. thromboxane A2) from the site of thrombus


TABLE: Management of Suspected Pulmonary Embolism
 pretest probability             diagnostic evaluation
 low pretest probability         V/Q scan or D-dimer, with additional testing 1 required if:
                                 • nondiagnostic V/Q
                                                                                              YEPSA: Objectives (page 128 of 190)



                                                • D-dimer > 0.5 µg/dL

         intermediate pretest probability       V/Q scan
                                                • normal V/Q: rules out diagnosis
                                                • nondiagnostic V/Q: follow with D-dimer or serial ultrasound to r/o

         high pretest probability               admit to the hospital and begin anticoagulation pending results
                                                • V/Q scanning
                                                • ultrasound if result indeterminate
                                                • angiography if ultrasound negative or equivocal 2
     1
         serial venous ultrasound is reasonable
     2
         noninvasive testing insufficiently sensitive to rule out embolization in a patient with a high pretest probability



3.        Be able to evaluate, diagnose, and manage cough.

                   (based partially on objectives written by Annie Hahn Nguyen)

cough

- history
   - HPI:                   HPI should include:
                            - severity, duration, onset
                            - other symptoms, modifying factors
                            - sputum, hemoptysis, pattern of cough

     - PMH:                 PMH should include:
                            - h/o pulmonary diseases
                            - h/o cardiac problems
                            - immunocompromised states (including medications, genetic conditions)

                            current medications, especially:
                            - ACE inhibitors
                            - β blockers

     - social Hx:           smoking history

     - family Hx:           lung problems, cancers

     - ROS:                 systemic symptoms (weight loss, fevers, night sweats)


- physical exam (comprehensive pulmonary exam)
   - general:       introduce self to patient, inspect for:
                    - respiratory distress       increased RR, nasal flaring, intercostal recessions
                    - classic presentations:     includes “pink puffer” vs. “blue bloater”
                    - cushingoid appearance (→ probable severe asthmatic on oral steroids)
                    - weight loss                (→ possible chronic disease, lung CA)
                    - paraphernalia:             O2, medications, sputum pot, etc.

     - vital signs:         measure basic vital signs:
                            - temperature :            note presence of fever
                            - pulse:                   note presence of pulsus paradoxus
                            - respiratory rate:        perform while taking patient’s pulse to diminish anxiety effect
                                                                                       YEPSA: Objectives (page 129 of 190)




- HEENT
  - eyes:           inspect eyes for:
                    - conjunctival palor
                    - Horner’s syndrome         (→ possible Pancoast’s syndrome from apical lung CA)

  - mouth:          inspect mouth and tongue (all sides) for:
                    - mass lesions            (→ possible smoking-related mouth cancer)
                    - central cyanosis        (→ ≥ 5 g/dL unsaturated Hb in the blood)

  - neck:           inspect neck for jugular venous pressure

                    inspect trachea for:
                    - midline location          (deviation → possible throat cancer)
                    - tracheal tug              (movement → lung pathology
                    - cricosternal distance     (< 3 fingers suggests lung hyperinflation)

                    inspect neck for cervical lymphadenopathy
                    - upper lymph nodes:        submental, submandibular, posterior auricular nodes
                    - lower lymph nodes:        cervical lymph node chain
                    - Virchow’s node            (L supraclavicular fossa node → stomach CA)

- chest
   - inspection:    inspect for the following general items:
                    - presence of surgical scars, chest drains, radiotherapy tattoos
                    - intercostal recessions
                    - symmetric movement

                    inspect for the following chest deformities:
                    - barrel chest              (→ chronic lung hyperinflation, such as asthma and COPD)
                    - pectus carinatum          (sternal protrusion → chronic childhood asthma, rickets, Marfan’s)
                    - Harrison’s sulcus:        groove deformity of lower ribs, associated with sternal protrusion
                    - kyphosis:                 ↑ forward convexity causing difficulties with lung ventilation
                    - scoliosis:                ↑ lateral convexity causing difficulties with lung ventilation

                    note breathing patterns:
                    - Cheyne-Stokes             (alternating apnea, hyperventilation → brainstem lesion)
                    - Kussmall respirations     (deep, labored → severe acidosis)

  - palpation:      assess chest expansion
                    - place palms of hands symmetrically on either side of chest wall, thumbs pointing to midline
                    - thumbs should separate symmetrically by ≥ 5 cm upon deep inspiration

                    assess tactile vocal fremitus with the word “ninety nine” (insensitive, can be omitted)
                    - normal fremitus:          (→ vesicular breathing)
                    - increased fremitus:       (→ bronchial breathing)
                    - decreased fremitus:       (→ consolidation)

  - percussion:     note the following findings on percussion:
                    - resonance:               (→ normal)
                    - dullness:                (→ consolidation, collapsed lung, abscess, neoplasm)
                    - “stony” dullness:        (→ pleural effusion)
                    - hyperresonance:          (→ lung hyperinflation, pneumothorax, emphysematous bulla)

  - auscultation:   note the following findings of diminished breath sounds:
                    - localized decrease:      (→ pneumothorax, effusion, tumor, collapse, pleural thickening)
                                                                                      YEPSA: Objectives (page 130 of 190)



                      - generalized decrease:      (→ emphysema, asthma, muscular chest, obesity, fibrosis)
                      - bronchial breathing:       (→ consolidation, abscess, neoplasm, fibrosis, effusion)

                      note the following added sounds:
                      - wheeze, polyphonic:     (→ asthma, COPD)
                      - wheeze, monophonic: (→ bronchial CA)
                      - crepitation, coarse:    (→ pulmonary edema, fibrosis)
                      - crepitation, fine:      (→ COPD, bronchiectasis)
                      - pleural rub:            (→ pneumonia, pulmonary embolus)

                      BOX: Lung Sounds
                       Differentiating lung sounds can be difficult. As a general rule:

                          • wheezes:            “musical” sound indicative of airway narrowing
                          • crepitations:       “popping” sound indicative of opening during expansion
                          • pleural rub:        “grating” sound indicative of pleural membrane friction



    - sputum:         examine sputum, if available

  - extremities:      inspect nails and hands for evidence of:
                      - nicotine staining
                      - clubbing
                      - peripheral cyanosis
                      - intrinsic muscle atrophy (→ possible Pancoast’s syndrome from apical lung CA)

                      check for tremor, of which respiratory disease includes two types
                      - fine finger tremor       (→ use of β-agonist bronchodilators)
                      - asterixis:               (→ CO2 retention, supported by bounding pulse, papilledema, HA)


- laboratory / imaging
   - laboratory:     laboratory tests to consider include:
                     - WBC with differential
                     - ESR / CRP

  - imaging:          imaging tests to consider include:
                      - CXR
                      - sinus CT
                      - thoracic CT

  - special tests:    special tests to consider include:
                      - peak flow meter
                      - spirometry
                      - bronchoscopy / bronchioalveolar lavage (BAL)
                      - laryngoscopy
                      - biopsy

- differential diagnosis
   - psychosocial:     anxiety, environmental irritants (noxious fumes, cold air, smoke)
   - secondary:        secondary causes may include:
                       - GI:         (GERD, gastric outlet obstruction, incompetent GE junction), postnasal drip
                       - cardiac:    (CHF, pulmonary edema, mitral stenosis, pericarditis)
                       - acquired: “smoker’s cough” (COPD: chronic bronchitis / emphysema)
                                                                                                YEPSA: Objectives (page 131 of 190)



     - vascular:           pulmonary embolism
     - infectious:         infection (viral, bacterial, fungal, TB), post-infectious
     - inflammatory:       asthma, interstitial lung disease
     - neoplastic:         lung CA, lympohma
     - congenital:         cystic fibrosis
     - anatomic:           mediastinal masses (esophageal tumor, aortic aneurysm, enlarged LA), foreign body
     - allergic:           angioedema
     - traumatic:          laryngitis
     - endocrine:          substernal thyroid
     - drugs:              ACE inhibitors, β-blockers

                           TABLE: Common Clinical Features of Selected Etiologies of Cough
                            disorder                       clinical features
                            anaerobic infection / abscess  • foul-smelling sputum

                            asthma                                • cough
                                                                  • SOB, wheezing
                                                                  • atopy, eczema
                                                                  • family history

                            bronchiectasis / abscess              • large volume sputum throughout the day

                            cancer                                • systemic symptoms (fatigue, weight loss, night sweats)
                                                                  • chronic cough in smokers

                            COPD                                  • h/o smoking
                                                                  • long-standing sputum production (esp. in a.m.)

                            GERD                                  • associated with heartburn / regurgitation

                            infection                             • yellow / green sputum

                            sinusitis                             • persistent postnasal drip
                                                                  • acute onset / postviral
                                                                  • sputum



- management:              regarding the management of chronic cough:
                           - most common causes of chronic cough are GERD and allergic rhinitis
                           - look for red flags of malignancy
                           - smoking cessation for smokers
                           - cough ≤ 3 weeks is acute, cough ≥ 6-8 weeks is chronic


4.     Be able to evaluate, diagnose, and manage diabetes.

                   (based partially on objectives written by Ben Walker)

- diabetes mellitus
   - disorder:             metabolic disease characterized by hyperglycemia

     - etiology:           related to defects in insulin secretion, insulin action, or both

     - epidemiology
                                                                                     YEPSA: Objectives (page 132 of 190)



  - prevalence:     20 million (most common endocrine disorder in the U.S.)
  - incidence:      1 million / year
  - mortality:      6th leading cause of death in U.S.

- pathogenesis:     alterations in CHO, fat, and protein metabolism

- classification:   based on pathologic mechanism
                    - type 1:    autoimmune β cell destruction and absolute insulin deficiency (5% of DM)
                    - type 2:    acquired insulin resistance and impaired insulin secretion (90% of DM)
                    - type 4:    gestational diabetes mellitus (GDM)

- presentation:     varies with subtype
                    - type 1:     polyuria, polydypsia, polyphagia with h/o viral illness
                    - type 2:     asymptomatic obese patient with numerous risk facotrs

                    TABLE: Diabetes Mellitus Clinical Presentation (Type 1 vs. Type 2)
                                           type I                             type II
                     other names           “insulin-dependent”                “non-insulin-dependent”
                                           “juvenile onset”                   “adult onset”
                     age of onset          < 35 years old                     > 35 years old
                     type of onset         abrupt (days to weeks)             gradual (weeks to months)
                     precipitating factors altered immune response            obesity
                                           environmental stressors            genetic predisposition
                                                                              age
                     insulin response
                     • pancreatic insulin  negligible / absent                present
                     • response to glucose negligible / absent                decreased
                     • response to meals   negligible / absent                normal 1
                     • insulin resistance  negligible / absent                present
                     symptoms              polydipsia                         frequently none or mild
                                           polyphagia
                                           polyuria

                                             usually lean at onset                associated with obesity
                    stress response          ketoacidosis                         hyperglycemia without ketosis 2
                    treatment                insulin for all patients             diet / exercise usually effective
                                                                                  insulin in 20-30%
                    1
                      normal in absolute terms, but insufficient for glycemic control
                    2
                      insulin levels are usually sufficient to prevent lipolysis

- diagnosis
   - normoglycemia: requires both:
                    - fasting glucose:        < 100 mg/dL
                    - 2 hours post-challenge: < 140 mg/dL

  - prediabetes:    diagnosed by either:
                    - fasting glucose:        100-126 mg/dL             (Dx: impaired fasting glucose)
                    - 2 hours post-challenge: 140-200 mg/dL             (Dx: impaired glucose tolerance)

  - diabetes:       diagnosed by any one of:
                    - fasting glucose:        ≥ 126 mg/dL (on multiple occasions)
                    - 2 hours post-challenge: ≥ 200 mg/dL (on multiple occasions)
                    - random plasma glucose: ≥ 200 mg/dL, with classic symptoms (polydipsia, -uria, -phagia)

- management:       varies with subtype
                                                                                      YEPSA: Objectives (page 133 of 190)



                      - type 1:    focus on insulin replacement
                      - type 2:    focus on lifestyle changes, risk factor reduction, hypoglycemic agents

  - complications:    complications of uncontrolled diabetes include:
                      - diabetic retinopathy
                      - diabetic nephropathy
                      - diabetic neuropathy


diabetes subtypes and related disorders
- type 1 diabetes mellitus
   - disorder:        autoimmune pancreatic β cell destruction, leading to absolute insulin deficiency

  - epidemiology
     - prevalence:    5% of patients with diabetes mellitus
     - ethnicity:     more common in Caucasians (particularly in the Northern Hemisphere)
                      less common in African Americans, native Americans, Southern Hemisphere
    - gender:         males = females

  - genetics:         susceptibility in HLA-DR3, -DR4, or -DQ8 (virtually all DM1 patients have these haplotypes)

  - pathogenesis:     autoimmune destruction of pancreatic β cells (T-cell mediated pathology)

                      environmental trigger thought to initiate immune process in genetically-susceptible people
                      - postulated factors include viruses, toxins, proteins
                      - more recently, hygiene theory (lack of exposure to certain infectious agents) proposed

                      associated with development of autoantibodies
                      - islet cell antibodies (ICA)
                      - GAD antibodies
                      - insulin autoantibodies

                      clinical onset is abrupt, but pathologic course occurs over months to years

                      80-90% of β cells must be destroyed before hyperglycemia occurs




                      FIGURE: Stages in Development of DM1

  - presentation:     characterized by classic symptoms
                      - polyuria        (osmotic diuresis secondary to glycosuria)
                      - polydipsia      (thirst secondary to polyuria)
                                                                                      YEPSA: Objectives (page 134 of 190)



                     - polyphagia      (inability to maintain tissue secondary to protein degradation, lipolysis)

                     other symptoms may include:
                     - blurry vision
                     - fatigue
                     - numbness / tingling in extremities
                     - recurrent infection
                     - poor wound healing

  - management:      insulin replacement

  - complications:   diabetic ketoacidosis (DKA)
                         (for management of DKA, see Medicine, Objective 6)


- type 2 diabetes mellitus
   - disorder:        hyperglycemia characterized by a variable combination of:
                      - insulin resistance
                      - impaired insulin secretion

  - epidemiology:    90-95% of all cases of diabetes mellitus
     - prevalence:   overall prevalence of 8%
     - ethnicity:    Native Americans > African Americans > Hispanic Americans > Caucasian Americans
     - age:          increasing prevalence with age (15% at age ≥ 65, 25% at age ≥ 85)
     - onset:        average age of diagnosis at 50 years
     - trends:       steadily increasing since the 1940s
                     significant increase in type 2 proportion of childhood diabetes

  - genetics:        strong multifactorial familial inheritance
                     - 50% risk with 2 affected parents
                     - concordance rate nearly 90% in identical twins
                     no specific genetic abnormalities have yet been identified

  - pathogenesis:    variable combination of insulin resistance and impaired insulin secretion
                     - insulin resistance: deficient peripheral response to compensatorily high insulin levels
                     - ↓ insulin secretion: reduced secretion due to islet cell burnout

  - presentation
     - age:          > 30 years old
     - history:      obesity, family history
     - status:       may report recent weight gain
     - symptoms:     none or mild; may already have onset of some complications
     - laboratory:   ketosis common

  - risk factors:    risk factors for DM2 include:
                     - family history of DM2
                     - overweight (BMI > 25)
                     - presence of prediabetes (IFG or IGT)
                     - age > 45 years old
                     - habitual physical inactivity
                     - history of gestational diabetes (GDM) or previous delivery of ≥ 9 lb infant
                     - hypertension (>140/>90)
                     - dyslipidemia (TG > 250 and/or HDL < 40)
                     - polycystic ovarian syndrome
                     - history of cardiovascular disease
                                                                                       YEPSA: Objectives (page 135 of 190)



  - management:      lifestyle intervention (more effective even than pharmacologic intervention)

                     BOX: Summary of Recommendations for Diabetes
                      • Hb A1c:             < 7.0%
                      • blood pressure:     < 130/80 mmHg
                      • lipids
                         - LDL-C:           < 100 mg/dL
                         - HDL-C:           > 40 mg/dL in men, > 50 mg/dL in women
                         - TG:              < 150 mg/dL
                         - total:           < 200 mg/dL
                      • aspirin:            75-162 mg/day in patients age > 40
                      • smoking:            stop smoking in all patients




- metabolic syndrome (insulin resistance)
  - disorder:       insulin resistance

  - etiology:        central obesity

  - epidemiology:    common syndrome
                     - affects 24% of adults over 30 years old
                     - affects 40% of adults over 60 years old
                     more prevalent in obese patients and minorities

  - pathogenesis:    adipose tissue acts as an endocrine organ, and when enlarged, can result in:
                     - ↑ inflammatory mediators
                     - ↑ lipid release, ↓ lipid clearance
                     - ↑ circulating triglycerides, ↓ HDL-C

  - presentation:    consequences of insulin resistance include:
                     - dyslipidemia
                     - sodium retention
                     - fibrinolytic dysfunction (via tPA1, IL-6, MMP, others)
                     - endothelial dysfunction (decreased nitric oxide production, platelet activation, etc.)
                     - sympathetic nervous system activation

  - diagnosis:       based on criteria from the National Cholesterol Education Program

                     BOX: Criteria for Metabolic Syndrome
                      National Cholesterol Education Program criteria requires
                       at least 3 of the following:

                         • waist circumference: men:   > 40 inches
                                                women: > 35 inches

                         • triglycerides:          > 150 mg/dL

                         • HDL cholesterol:        men:   < 40 mg/dL
                                                   women: < 50 mg/dL

                         • blood pressure:         > 130/85 mmHg
                                                                                          YEPSA: Objectives (page 136 of 190)




                            • fasting glucose:       > 110 mg/dL


                          This can be remembered from the mnemonic:
                            “W. tries hard but fails”



  - complications:       can lead to atherosclerosis, cardiovascular disease, and kidney disease

  - management:          weight loss, increased exercise has been shown to be effective in reducing this disease


diabetes evaluation
- initial evaluation of new presentations
   - history
      - symptoms:        polydipsia, polyphagia, polyuria, obesity
      - general health: diet habits, weight history, and physical activity, risk factors for atherosclerosis
      - infections:      skin, foot, dental, and GU
      - complications: ocular, cardiovascular, renal, neurologic, sexual function
      - gestation:       delivery of infant weighing > 9 lbs, toxemia, stillbirth, history of gestational DM
      - family history: diabetes, obesity, blood pressure, lipids
      - social history: alcohol and drug abuse
      - medications:     current medications, including OTCs and alternative therapies

  - physical exam
     - vital signs:      height, weight, BMI, BP
     - optic fundi:      signs of cataract, diabetic retinopathy
     - oral exam:        signs of ulceration
     - cardiovascular:   pulses, cardiac health
     - foot exam:        ulcerations, fungal infections, wound healing
     - neurological:     sensory exam of the extremities

  - labs
     - serum:            plasma glucose, HbA1c, fasting lipid panel, serum Cr, LFTs
     - urine:            ketones, glucose, microalbuminuria


- ongoing evaluation at subsequent visits
   - general
      - weight:         each visit
      - blood pressure: each visit
      - HbA1C:          every 6 months if stable, every 3 months if on insulin or poorly controlled
      - lipids:         annual (less frequently if normal)
      - proteinuria:    annual (if indicated)
      - dil. eye exam: annual
      - foot exam:      annual or more common; more often in patients with high risk foot conditions

  - special considerations
     - smoking:        assist with cessation as much as possible
     - aspirin:        consider for secondary prevention of CVD, or primary prevention in high risk patients:
     - ACE-I:          consider for patients > 55 years with at least one CVD risk factor
                                                                                    YEPSA: Objectives (page 137 of 190)



diabetes management
- lifestyle changes
   - method:        dietary control and increased exercise
   - function:      associated with improved control of sugars, lipids, hypertension, and CAD
   - goals:         exercise recommendations include:
                    - 30 minutes of moderate activity
                    - should be done most days of the week
                    dietary recommendations include:
                    - reduced caloric intake
                    - fat < 30% of calories
                    - saturated fat < 10% of calories
                    - increased fiber intake
   - clinical:      evaluate for vascular, neurologic, or ocular damage that would preclude some exercise
   - web resources: Medline Plus Medical Encyclopedia: Diabetes Diet
                          (http://www.nlm.nih.gov/medlineplus/ency/article/002440.htm)
                    ADA: Diabetes Mellitus and Exercise
                          (http://care.diabetesjournals.org/cgi/content/full/25/suppl_1/s64)

                     BOX: Lifestyle Changes in Diabetes
                       One of the most important components in the management of diabetes is encouragement
                        and support in attaining major lifestyle changes.

                         • diet:        balanced, high in whole grains, fruit, vegetables, and low in fat and CHO
                         • exercise:    30 minutes / day of moderate physical activity, most days of the week
                         • weight loss: attain and maintain normal weight




- glycemic control
   - method:         factors in glycemic management include:
                     - lifestyle changes
                     - oral hypoglycemic agents (type 2)
                     - insulin (type 1, advanced type 2)
  - function:        reduce diabetic complications
  - goals:           as per indicators of glycemic control

                     TABLE: Indicators of Glycemic Control
                                                     HbA1c                 fasting glucose       post prandial glc.
                      AACE recommendations            < 6.5                      < 110               2h < 140
                      ADA recommendations             < 7.0                     90-130              peak < 180


medications
- insulin
   - agents:         vary based on pharmacology
                     - short-acting:         lispro, aspart, regular
                     - intermediate/long: NPH, lente, glargine
  - function:        glycemic control (DM1)
                     - long-acting:    basal insulin replacement
                     - short-acting:   injections given with meals
  - mechanism:       stimulation of insulin receptors
  - pharmacology:    subcutaneous / IV administration
  - adverse:         possible adverse effects include:
                     - hypoglycemia
                                                                                        YEPSA: Objectives (page 138 of 190)



                        - local reactions
                        - weight gain
  - clinical:           chronic DM1 is associated with diminished awareness of hypoglycemia (must be cautious)
                        regular insulin is now primarily a recombinant form (as opposed to swine insulin in the past)
                        glargine is useful as a basal insulin as it has no peak
                        regular insulin is currently the only insulin that can be given IV

  TABLE: Insulin Pharmacology
   type                    indications                        pharmacology                  cost
   very rapid 1            • pre-meal bolus                   • onset:    15 min            $80 per 10 mL vial
   • aspart (Novalog)      • basal insulin                    • peak:     30-90 min           (100 units / mL)
   • lispro (Humalog)                                         • duration: 3-5 hr

      rapid / regular            • pre-meal bolus             • onset:    30-60 min         $35 per 10 mL vial
      • Humulin R                • basal insulin              • peak:     2-3 hr              (100 units / mL)
      • Novalog R                                             • duration: 4-6 hr

      intermediate               • basal insulin (2/day)      • onset:    2-4 hr            $35 per 10 mL vial
      • NPH                                                   • peak:     4-12 hr             (100 units / mL)
      • lente                                                 • duration: 14-20 hr

      long-acting 2              • basal insulin              • onset:    6-10 hr           $35 per 10 mL vial
      • glargine (Lantus)                                     • peak:     minimal             (100 units / mL)
      • detemir (Levimir)                                     • duration: 20-30 hr
      • ultralente (Humulin U)
  1
      permits more flexibility, but costs more money
  2
      used in combination with rapid-acting to maximize benefits of one injection



- sulfonylureas
   - agents:           first generation:       chlorpropamide, tolbutamide
                       second generation:      glipizide, glyburide
  - function:          glycemic control (DM2)
  - mechanism:         increased insulin secretion
                       - activates sulfonylurea receptor (SUR), a component of β cell KATP channels
                       - results in channel inhibition, increased Ca2+ influx, and insulin secretion
  - pharmacology:      metabolized in liver, excreted in urine
  - adverse:           side effects include
                       - hypoglycemia (most common, especially with long-acting agents)
                       - weight gain
                       - nausea
                       - skin reactions
  - contraindications: possible contraindications include:
                       - ketoacidosis
                       - post-MI patients (possible poorer outcomes)
  - interactions:      fluconazole, SMX, rifampin
  - clinical:          well-established therapy that works well in combination with other hypoglycemic agents


- biguanides
   - agents:            metformin
   - function:          glycemic control (DM2)
   - mechanism:         increased insulin action and lowering of blood glucose, with no effect on secretion
                                                                                       YEPSA: Objectives (page 139 of 190)



                     potential mechanisms include:
                     - reduced intestinal glucose absorption, hepatic glucose production
                     - increased insulin-mediated glucose utilization in muscle and liver
                     - anti-lipolytic effect
- indications:       first-line therapy in obese patients that cannot control glucose with diet, exercise alone
                     advantages over sulfonylureas include:
                     - less hypoglycemia
                     - no weight gain
                     - lipid-lowering effect
- contraindications: should not be used in:
                     - renal insufficiency (creatinine > 1.5 mg/kg)
                     - liver disease
                     - alcohol abuse
                     - congestive heart failure (requiring medical therapy)
                     - serious acute illness (infection, decreased tissue perfusion, etc.)
                     - acute / chronic metabolic acidosis or status post-lactic acidosis
                     - age > 80 years
                     should be temporarily withheld in:
                     - patients undergoing contrast studies
                     - acute illnesses
                     - surgery
- pharmacology:      rapid absorption, not metabolized, rapidly cleared renally
- adverse:           adverse effects include:
                     - GI disturbance (metallic taste, nausea, diarrhea)
                     - lactic acidosis (rare)
- interactions:      cimetidine (lowers renal clearance of metformin)
- clinical:          synergistic effects with sulfonylureas
                     related drug (phenformin) withdrawn in 1977 due to potentially lethal lactic acidosis
                     should discontinue for 48 h after IV iodine contrast due to risk of acute renal failure


TABLE: Adverse Effects and Costs of Oral Hypoglycemics
 agents                   mechanism                   adverse                                clinical
 sulfonylureas            ↑ insulin release           hypoglycemia                           well-established therapy
 • glipizide                                          weight gain                            in combination with
 • glyburide                                          nausea                                 other agents, or in place
 • glimepiride                                        skin reactions                         of metformin
                                                      abnormal LFTs

 meglitinides                  ↑ insulin release              hypoglycemia                   generally similar to
 • repaglinide                                                (less than sulfonylureas)      sulfonylureas
 • nateglinide                                                weight gain

 biguanides                    ↓ gluconeogenesis              metallic taste                 first line therapy unless
 • metformin                   ↑ insulin sensitivity          nausea, GI discomfort          contraindicated, and
                                                              lactic acidosis                does not cause wt. gain

 thiazolidinediones            ↓ gluconeogenesis              weight gain                    useful in combinations
 • pioglitazone                ↑ insulin sensitivity          edema
 • rosiglitazone                                              URI
                                                              myalgia
                                                              hepatotoxicity

 α-glucosidase inhibitors      ↓ glucose absorption           GI discomfort                  poorly tolerated due to
 • acarbose                                                   bloating, flatulence           side effects
                                                                                           YEPSA: Objectives (page 140 of 190)



      • miglitol                                                  diarrhea




5.     Be able to evaluate, diagnose, and manage hypertension.

- hypertension
   - disorder:           blood pressure elevation above standardized value

     - etiology:         may be primary or secondary
                         - primary HTN:       hypertension of unknown origin                   (90-95% of HTN)
                         - secondary HTN:     hypertension secondary to a known cause          (5-10% of HTN)

     - epidemiology:     gradually increasing incidence of CAD and stroke as BP rises above 110/75

     - classification:   JNC-VII criteria for diagnosis of HTN, with BP evaluated at ≥ 2 visits
                         - normal:              < 120 / 80
                         - pre-hypertension: (120-139) / (80-89)
                         - stage 1 HTN:         (140-149) / (90-99)
                         - stage 2 HTN:         ≥ 160 / ≥ 100

     - risk factors:     risk factors include age, gender, race, weight, diet, alcohol use, and genetics

                         BOX: Epidemiological Risk Factors for Hypertension
                          • age:             elderly
                          • gender:          male
                          • race:            African American
                          • weight:          obese
                          • diet:            large Na+ intake, small K+ intake
                          • alcohol:         excessive alcohol intake
                          • genetics:        family history


     - presentation:     may be asymptomatic
                         nonspecific symptoms may include:
                         - headache
                         - dizziness
                         - confusion
                         - tinnitus
                         specific clinical features associated with certain etiologies of secondary hypertension

                         TABLE: Common Clinical Features of Selected Etiologies of Hypertension
                          disorder                       clinical features
                          coarctation of the aorta       • presentation in young children (not exclusively)
                                                         • HTN in upper extremities
                                                         • diminished / delayed femoral pulses
                                                         • low / unobtainable arterial BP in lower extremities

                         Cushing’s syndrome                    • cushingoid facies
                                                               • central obesity
                                                               • proximal muscle weakness
                                                               • ecchymoses

                         hyperparathyroidism                   • otherwise unexplained hypercalcemia
                                                                                    YEPSA: Objectives (page 141 of 190)



                                                          • polyuria / polydypsia (from Ca2+ excretion)
                                                          • kidney stones
                                                          • osteoporosis

                   hypothyroidism                         • elevated TSH
                                                          • coarse and thinning hair, dry skin, brittle nails
                                                          • cold intolerance
                                                          • fatigue
                                                          • memory or concentration difficulties, depression
                                                          • constipation

                   oral contraceptives                    • h/o OCP use

                   pheochromocytoma                       • paroxysmal elevatiosn in blood pressure
                                                          • headache
                                                          • palpitations / sweating

                   primary aldosteronism                  • otherwise unexplained hypokalemia
                                                          • elevated aldosterone to renin ratio
                                                          • benign adrenal tumor

                   primary renal disease                  • elevated Cr
                                                          • abnormal urinalysis

                   sleep apnea syndrome                   • headache
                                                          • daytime somnolence & fatigue
                                                          • morning confusion with difficulty in concentration
                                                          • personality changes
                                                          • depression
                                                          • persistent systemic hypertension
                                                          • cardiac arrhythmia (potentially life-threatening)


- diagnosis:       based on JNC criteria (above)

- evaluation
   - goals:        initial evaluation of patients has three objectives
                   - assess lifestyle and identify other cardiovascular risk factors or concomitant disorders
                   - reveal identifiable and often curable causes of secondary hypertension
                   - assess presence or absence of CVD and target organ damage

  - examination:   initial physical examination includes:
                   - general:         measurement of BP with verification in the contralateral arm
                                      calculation of BMI, measurement of waist circumference
                   - CNS:             neurological assessment
                   - HEENT:           optic fundi ophthalmoscopy
                                      palpation of the thyroid gland
                   - CV:              thorough cardiac auscultation
                                      auscultation for carotid, abdominal, and femoral bruits
                                      palpation of distal pulses
                   - respiratory:     thorough pulmonary auscultation
                   - abdominal:       thorough abdominal exam (enlarged kidneys, masses, aortic pulsation)
                   - extremities:     inspection / palpation of edema

  - laboratory:    initial laboratory testing includes:
                                                                                     YEPSA: Objectives (page 142 of 190)



                     - hematology:     H&H
                     - chemistry:      serum potassium, calcium, BUN / Cr, blood glucose
                     - metabolic:      lipid profile
                     - urine:          urinalysis

  - special tests:   initial testing should include electrocardiogram (ECG)

- screening:         USPSTF guidelines based on age:
                     - over 18:     screen all patients during all office visits
                     - under 18:    no recommendations for or against screening


- management
  - lifestyle:       lifestyle changes include:
                     - weight reduction:        reduce weight, ideally to normal BMI, in a controlled fashion
                     - dietary adjustments:     DASH diet (high fruits and vegetables, low total and saturated fat)
                                                Na+ reduction (below 2.4 g Na / 6 g NaCl daily)
                     - physical activity:       30 minutes / day of aerobic activity, 4+ days per week
                     - alcohol moderation:      ≤ 2 drinks / day for men, ≤ 1 drink / day for women
                     - smoking cessation:       stop smoking to decrease overall CV risk

  - pharmacology: stepwise addition of antihypertensive agents

                     TABLE: Summary of Antihypertensive Medications
                      class                     mechanism                     adverse 1              compelling
                                                                                                    indications 2
                     thiazides                   diuretic               • urinary frequency     • overall first line
                     • hydrochlorothiazide                              • hyponatremia          • CHF
                                                                        • hypokalemia           • DM
                                                                                                • recurrent stroke
                                                                                                • hypercalciuria

                     β-blockers                  vasodilation           • decreased pulse       • s/p MI
                     • atenolol                                         • fatigue               • angina pectoris
                     • metoprolol                                       • asthma exac.          • DM
                                                                                                • CHF

                     ACE inhibitors              ↓ angiotensin effect   • cough                 • CKD
                     • captopril                                        • hypokalemia           • DM
                     • enalapril                                        • angioedema            • CHF
                                                                                                • recurrent stroke

                     ARBs                        ↓ angiotensin effect   • hypokalemia           • CKD
                     • losartan                                         • angioedema            • DM



                     Ca2+ channel blockers       vasodilation           • peripheral edema      • angina pectoris
                     • amlodipine (DHP)                                                         • DM
                     • verapamil (non-DHP)



                     α-agonists                  vasodilation           • nasal congestion      • BPH
                     • prazosin
                                                                                          YEPSA: Objectives (page 143 of 190)




                        1
                            all have concerns for hypotension (headache, dizziness, orthostasis)
                        2
                            compelling indications, for which agents have been shown to have more beneficial effects




                        FIGURE: Classification and Management of Blood Pressure for Adults

     - complications:   hypertensive complications affect multiple systems
                        - PAD:          atherosclerosis, dissecting aorta, AAA, aneurysmal rupture
                        - heart:        concentric LVH, cardiomyopathy, arrhythmia, MI
                        - kidney:       nephrosclerosis, ischemia, infarction, CKD
                        - brain:        CVA, TIA, aneurysmal rupture, multiple lacunar infarcts
                        - retina:       arterial thickening, AV nicking, hemorrhage, hard exudates, papilledema


6.     Be able to evaluate, diagnose, and manage tobacco use.

- tobacco use and abuse
   - disorder:       use of tobacco products

     - epidemiology
        - mortality:    430,000 deaths / year (2nd leading cause of death)
        - prevalence:   45.3 million (20.8% of US citizens) smoke in the US
        - gender:           men (23.9%) > women (18.0%)

     - complications:   tobacco is linked to:
                        - coronary artery disease (RR 2-4)
                        - CVA (RR 2)
                        - COPD (10x increase in mortality)
                        - reproductive difficulties (infertility, preterm delivery, stillbirth, LBW, SIDS)
                        - cancer of the lung, oropharynx, exophagus, pancreas, cervix, and stomach
                                                                                          YEPSA: Objectives (page 144 of 190)



  - management:        make smoking a vital sign, and assess at every visit
                       provide brief motivation for patients currently wanting to quit
                       for patients ready to quit:
                       - set a quit date, within 1 month of office visit
                       - agree on 10-20 activities to do as alternatives to smoking
                       - contract (write quit date, activities on prescription pad, sign, and have patient sign)
                       - give copy to patient, maintain copy on chart
                       offer pharmacotherapy to all adults as an aid to successful quitting
                       counsel to reinforce relapse prevention for any tobacco user who recently quit


motivational interviewing
- motivational interviewing
  - function:          encouragement of behavioral changes through a client-centered approach

  - method
    - ask:             ask about the negative behavior
                       - ask / determine the type, quantity, and history
                       - determine stage or readiness to change

    - advise:          advise all patients to quit

    - assess:          assess commitment and barriers
                       - assess for self-efficacy
                       - examine pros and cons
                       - offer information
                       - assess for relevant goals
                       - explore for more commitment

    - assist:          assist patients committed to change
                       - reinforce commitment to change
                       - help develop or refine a plan

    - arrange:         arrange follow-up with the patient


- basic tenets of motivational interviewing
   - empathy:          express empathy
                       - use open-ended questions
                       - embody reflective listening
                       - legitimize patient’s feelings and experiences
                       - acknowledge and explore patient’s ambivalence
                       - understand the struggle to change
                       - support the patient’s right to choose or reject change

  - discrepancy:       develop discrepancy between goals and actions
                       - explore the patient’s values and health priorities
                       - highlight the discrepancy between the problem behavior and the patient’s priorities
                       - allow the patient to present reasons for change

  - accept:            roll with resistance
                       - do not oppose patient’s resistance, but accept it using reflective listening
                       - acknowledge that change is difficult

  - support:           support self-efficacy
                       - enhance the patient’s confidence in his or her capability to change
                                                                                          YEPSA: Objectives (page 145 of 190)



                      - help the patient build on past successes
                      - offer a range of alternative approaches and choices for taking the next step


stages of readiness to change
- pre-contemplation
   - definition:      not considering change
   - goal:            move to contemplation; consider change
   - barriers:        barriers include:
                      - lack of knowledge of risks or consequences
                      - lack of self- efficacy
                      - contentment

- contemplation
   - definition:      ambivalent about change
   - goal:            move to determination; promote commitment to change
   - barriers:        barriers include:
                      - lack of knowledge of risks / consequences
                      - lack of self efficacy
                      - contentment
                      - indecisiveness

- determination / preparation
   - definition:      firmly committed to change within one month
   - goals:           design a plan for change and move to action
   - barriers:        barriers include:
                      - loss of commitment
                      - knowledge of options for change
                      - making decisions about plans for change

- action
   - definition:      engaged in change
   - goals:           optimize plans, maintain changes
   - barriers:        barriers include:
                      - failure and disillusionment
                      - overconfidence

- maintenance
  - definition:       continuing change which is well-learned, but with risk of relapse
  - goals:            stable, new lifestyle, with attainment of original goals
  - barriers:         risk of relapse through:
                      - major stress
                      - major loss
                      - failure to identify or satisfy the initial reasons for change

- relapse
   - definition:      resumption of undesired behavior
   - goals:           goals include:
                      - identify relapse
                      - reframe as opportunity to learn
                      - restage
  - clinical:         remember that relapse is a normal, expected stage of behavior change

- termination
   - definition:      firmly entrenched in new lifestyle, with very low risk of relapse
   - goals:           maintain termination
                                                                                          YEPSA: Objectives (page 146 of 190)



  - clinical:          only 15% of nicotine or alcohol-dependent patients reach termination


strategies for increasing patient compliance
- open-ended questions
   - concept:         open-ended questions are those that:
                      - call for descriptive answers
                      - encourage patients to say what is important to them
                      - elicit contextual information
   - importance:      the importance of open-ended questions is that they are better able to:
                      - uncover patient priorities and values
                      - avoid socially-desirable responses
   - examples:        comparison of closed and open questions
                      - closed:      “Would you like to quit smoking?”
                      - open:        “How do you feel about your smoking?”

- summarizations
   - concept:          summarizes the most important aspects of what the patient said
   - importance:       the importance of summarizing statements is that they:
                       - convey that you have listened and that you care
                       - allow a check for accuracy
                       - may aid in transitioning to another topic
  - examples:          summarizing statements include:
                       - “What you’ve said is important.”
                       - “I value what you say.”
                       - “Here are the salient points.”
                       - “Did I hear you correctly?”

- reflective statements
   - concept:           mirror what the patient just said with slightly different words
                        - do not add any meaning, interpretation, or label
                        - do not question, agree, or disagree

                        reflective listening                              not reflective listening
                        • “I hear you.”                                   • directing         • disagreeing
                        • “I’m accepting, not judging you.”               • warning           • labeling
                        • “This is important.”                            • advising          • interpreting
                        • “Please tell me more.”                          • persuading        • reassuring
                                                                          • moralizing        • questioning
                                                                          • agreeing          • withdrawing


  - importance:        the importance of reflective statements is that they are:
                       - convey understanding, interest, and empathy
                       - cover up expressions of physician emotions that might otherwise
  - examples:          drug abuse
                       - statement:      “My girlfriend gets really angry when I get stoned and pass out.”
                       - reflection:     “She gets mad when you do that.”
                       alcoholism
                       - statement:      “I’m not a pleasant drunk; I’ve really beaten people up badly.”
                       - reflection:     “You’ve hurt people when you’ve gotten drunk.”

- educating about risks and consequences
   - concept:          in educating about risks and consequences:
                       - remember that patients often have key information already
                       - avoid lectures
                                                                                       YEPSA: Objectives (page 147 of 190)



                      - start with open-ended question about what patients already know
                      - emphasize risks and consequences that are relevant to the patient
                      - if appropriate, offer one or two new pieces of information
                      - assess for relevance of new information
  - importance:       fundamental to patient understanding of the need to change
  - clinical:         for patients with large needs for knowledge:
                      - ask if they would like to hear more now or later
                      - schedule another visit if patient would be more receptive
                      - provide written information appropriate for age, gender, culture, and literacy
                      - link patients with other resources

- affirmations
   - concept:         the purposes of affirmations are to:
                      - support the patient
                      - convey respect and understanding
                      - encourage more progress
                      - help clients / patients reveal less positive aspects of themselves
  - importance:       reassurance in continuing to change behaviors
  - examples:         “I can understand how it would be difficult to give up drinking now.”
                      “You’ve accomplished a lot in a short time.”

- eliciting self-motivational statements
   - concept:            motivation is difficult
                         - physicians often have insufficient information to know how to motivate the individual
                         - this issue can be avoided by having the patient self-motivate
   - importance:         fundamental to motivation and perception of the ability to change
   - examples:           problem recognition
                         - “How has [behavior] made problems for you?”
                         - “How do you think you’ve been hurt by [behavior]?”
                         concern
                         - “What worries do you have about your [behavior]?”
                         - “What are you afraid might happen if your [behavior] continues like it is?”
                         intention to change
                         - “What might be some advantages of changing your [behavior]?”
                         - “What might be better for you if you changed your [behavior]?”
                         - “On a scale of 0-10, how important is change? …Why didn’t you say [2-3 less]?”
                         optimism
                         - “What difficult goals have you attained in the past? …How can this be applied?”
                         - “What might work for you if you decided to change your [behavior]?”
                         - “On a scale of 0-10, how confident are you? …Why didn’t you say [2-3 less]?”

- developing discrepancy
   - concept:         ask patient whether behavior helps or hinders attaining their goals
   - importance:      forces the patient to understand where current behaviors are potentially harmful
   - examples:        “Running a marathon may be difficult while smoking 5 packs a day…”
                      “You probably won’t finish medical school if you continue to smoke all that crack…”

- heightening discomfort
   - concept:         draw patients out about:
                      - the pain of engaging in behavior that interferes with their goals
                      - the pain of being “stuck” with indecision about changing
   - importance:
   - examples:        “…and hasn’t it been so difficult to have your kids see that, day after day?”
                      “…and wouldn’t you be so proud if you would be able to buy your girlfriend that ring with all
                      the money you’re saving?”
                                                                                       YEPSA: Objectives (page 148 of 190)




Psychiatry
                                                                                    DIAGNOSIS & TREATMENT


1.     Be able to evaluate, diagnose, and manage depression / suicide risk.

- major depression
  - disorder:           period of 2 or more weeks of depressed mood that interferes with daily living
  - etiology:           multifactorial
                        - genetic
                        - socioeconomic and environmental factors
                        - neurological factors (monoamines, hormones, neural atrophy)

     - epidemiology
        - prevalence:   lifetime prevalence of 5-20%
        - morbidity:    leading cause of disability worldwide, leading cause of lost worktime for women in US
        - gender:       more common in women

     - presentation:    highly variable presentations, including:
                        - sadness
                        - fatigue
                        - “lack of pep”
                        - GI disturbance
                        - altered sleep patterns
                        - decreased libido

     - risk factors:    risk factors include:
                        - family history of mood disorder
                        - prior episodes of depression
                        - prior suicide attempts or psych hospitalizations
                        - age 20-40
                        - AODA history
                        - social history

     - comorbidities:   comorbidities and/or primary causes may include:
                        - bipolar disorder
                        - anxiety
                        - anemia
                        - hypothyroidism
                        - chronic illness
                        - alcohol and substance abuse

                        TABLE: Prevalence of Depression as a Comorbidity
                         primary disorder         depression %
                         myocardial infarction        40-65 %
                         coronary artery disease      18-20 %
                         Parkinson’s disease           40 %
                         multiple sclerosis            40 %
                         cerebrovascular accident     10-27 %
                                                                                     YEPSA: Objectives (page 149 of 190)



                   cancer                              25%
                   diabetes                            25%
                   chronic pain syndromes          not available
                   Alzheimer’s disease             not available
                   diabetes                        not available


- diagnosis
   - general:      clinical, criteria-based
   - history:      important questions to ask include:
                   - diagnostic criteria questions
                   - risk factors
                   - comorbidities

                   DSM-IV Criteria: Major Depressive Episode
                    A: 5 or more of the following in the same 2 week period
                       at least one of the symptoms is (1) depressed mood or (2) loss of interest
                       represents a change from previous function
                       1.) sadness:            depressed mood, dysphoria, irritability, or feeling tense
                       2.) interest:           loss of interest in things once considered pleasurable
                       3.) guilt:              feelings of shame, guilt, worthlessness, hopelessness
                       4.) energy:             fatigue or loss of energy
                       5.) concentration: inability to focus
                       6.) appetite:           significant loss/gain in appetite/weight
                       7.) psychomotor:        psychomotor agitation or retardation
                       8.) sleep:              insomnia or hypersomnia
                       9.) suicide:            suicidal ideation or thoughts of death
                    B: criteria for Mixed Episode not met
                    C: clinically significant distress or impairment
                    D: not due to a substance or general medical condition
                    E: not better explained by bereavement (i.e. < 2 months after loss)

                   memory device: SIGECAPSS

- screening:       two question screen (sensitivity 97%, specificity 67%): “During the past month…”
                   - “…have you often been bothered by little interest or pleasure in doing things?”
                   - “…have you often been bothered by feeling down, depressed, or hopeless?”

- management:      modalities with proven efficacy include:
                   - pharmacotherapy
                   - psychotherapy
                   - exercise therapy
                   - electroconvulsive therapy (cures 90% of recalcitrant depression)

                   modalities with less evidence include:
                   - transcranial magnetic stimulation
                   - light therapy (except in seasonal depression, though more evidence emerging)

- complications:   common complications / effects of depression may include:
                   - suicide (10-15% of all patients hospitalized with depression)
                   - poor performance at school or work
                   - marital discord
                   - drug and alcohol abuse
                                                                                            YEPSA: Objectives (page 150 of 190)



  TABLE: Pharmacotherapy in the Treatment of Depression
                              mechanism 1                          adverse                         comments
  SSRIs                       inhibit neuronal reuptake            • restlessness, agitation       first line treatment in
  • fluoxetine (Prozac)       of 5-HT                              • headache                      depression and anxiety
  • sertraline (Zoloft)                                            • GI upset (N, D)               due to relatively low
  • paroxetine (Paxil)                                             • insomnia                      side effects, low
  • escitalopram (Lexapro)                                         • ↓ libido                      overdose risk
  • citalopram (Celexa)                                            • weight gain (5-10%)

   tricyclics                        inhibit neuronal reuptake     • anticholinergic 2             second-line treatment in
   • amitryptiline (Elavil)          of NE and 5-HT                • confusion / delirium          depression and anxiety
   • desipramine (Norpramin)                                       • sedation
   • imipramine (Tofranil)                                         • weight gain (20%)
   • nortriptyline (Pamelor)

   DA reuptake inhibitors            inhibit reuptake of DA        • dry mouth                     alternative therapy in
   • buproprion (Wellbutrin)                                       • headache                      the treatment of
                                                                   • agitation                     depression, particularly
                                                                   • nausea                        useful to help quit
                                                                   • seizures                      smoking

   SNRIs                             inhibit reuptake of NE        • nausea                        alternative therapy in
   • venlafaxine (Effexor)                                         • dizziness                     the treatment of
   • duloxetine (Cymbalta)                                         • insomnia                      depression, tend to be
                                                                   • sedation                      more “activating”
                                                                   • constipation

   atypical / mixed                  inhibit reuptake of varied    • dizziness                     notable for unusual side
   • mirtazapine (Remeron)           neurotransmitters             • dry mouth                     effects
   • trazodone (Desyrel)                                           • HA, blurred vision
                                                                   • sedation
                                                                   • constipation
                                                                   • ↑ appetite (mirtazapine)
                                                                   • priapism (trazodone)

   MAO inhibitors                    irreversibly inhibit          • headache                      effective, but last line
   • phenelzine (Nardil)             monoamine oxidase, an         • drowsiness                    therapy secondary to
   • tranylcypromine (Parnate)       enzyme responsible for        • dry mouth                     substantial side effects
   • selegiline (Emsam)              degrading monamines           • weight gain                   and overdose risk
                                                                   • postural hypotension
                                                                   • sexual disturbance
                                                                   • hypertensive crisis
  1
      all reuptake inhibitors have some non-specificity for other neurotransmitters
  2
      dry mouth, blurry vision, constipation, retention, tachycardia



- suicidality
   - disorder:           self-inflicted non-accidental death

  - epidemiology
     - incidence:        30,000 suicides / year
     - prevalence:       cause of death in 1% of US population
                         - 8th most frequent cause of death in adults
                                                                                         YEPSA: Objectives (page 151 of 190)



                           - 2nd most frequent cause of death in adolescents

     - risk factors
        - gender:          male gender for completed suicides, female gender for attempted suicides
        - race:            Caucasian
        - age:             elderly
        - religion:        Protestant
        - season:          spring, fall
        - economy:         economic hardships
        - career:          professionals (esp. physicians)
        - class:           upper, lower class
        - relationship:    single, widowed, divorced
        - access:          presence of firearms in home
        - stressors:       recent loss by death, divorce, or separation
        - comorbidity:     disorders including:
                           - substance abuse and other psychiatric illness
                           - chronic medical conditions

     - assessment:         to assess current suicidality:
                           - “Are you having any thoughts that life isn’t worth living?”
                           - “Do you wish that you were dead?”
                           - “Have you thought about taking your life?”
                           - “Have you developed a plan for committing suicide? If so, what is your plan?”
                           - “Do you have access to a way to carry out your plan?”
                           - “What keeps you from harming yourself?”
                           - “Do you feel that you can be safe right now?”

                           suicide history questions include:
                           - “Have you ever had thoughts about killing yourself?”
                           - “Have you ever attempted suicide? If so, would you tell me about the attempt?”

     - management:         every suicidal patient must be asked to contract for safety

     - clinical:           asking about suicide does not lead to increased attempts



2.     Be able to evaluate, diagnose, and manage chemical dependence.

                   (based partially on objectives written by Charles Hamilton)

- definitions
   - substance abuse: substance use leading to detrimental effects on functioning
   - dependence:      substance use characterized by tolerance to use or withdrawal with continued use
   - tolerance:       requirement for increasing dose to achieve same effects (or less effects from same dose)


- substance use disorders
   - disorder:       dependence on or abuse of substances
   - etiology:       multifactorial
                     - genetic factors
                     - psychosocial factors
                     - neuroadaptation

                           TABLE: The Moral and Disease Model of Substance Abuse
                                                   moral model                disease model
                                                                                    YEPSA: Objectives (page 152 of 190)



                    alcohol and drugs are…       evil                         psychoactive substances
                    substance use is…            evil                         risky
                    substance users are…         evil                         at risk
                    substance abuse is…          evil                         preventable
                    addicts are…                 EEEEEEVIL!                   treatable

- epidemiology
   - prevalence:    9.4% of Americans over age 12 have alcohol or drug abuse or dependence
   - gender:        males > females (2:1)
   - education:     non-college graduates > college graduates
   - income:        highest with annual income < $20,000

- classification:   at-risk drinking varies with gender

                    TABLE: At Risk Drinking
                             per week              per occasion
                     men     > 14 drinks           > 4 drinks
                     women   > 7 (11) drinks       > 3 drinks
                     elders  > 7 drinks            > 1 drink

- screening:        CAGE (1 question is positive, sensitivity 43-94% and specificity 78-96%)
                    - cut down:     “Ever felt the need to cut down?”
                    - annoyed:      “Ever felt annoyed by others criticizing your drinking?”
                    - guilty:       “Ever felt guilty about your drinking?”
                    - eye-opener:   “Ever had a drink first thing in the morning, or to help with a hangover?”

                    Two Item Conjoint Screen / TICS (1 question is positive, sensitivity / specificity 80%)
                    - “In the past year, have you ever felt you ought to cut down on your drinking or drug use?”
                    - “In the past year, have you ever drank or used drugs more than you meant to?”

- diagnosis
   - general:       criteria-based definitions, but often uncovered through screening
   - principles:    important points to consider include:
                    - establish quantity and freqency
                    - question about other drugs, past history of use
                    - question about substance use in friends
                    - normalize prior to asking questions
                    - consider non-verbal cues as a positive screen

                    DSM-IV Criteria: Substance Abuse
                     A. substance use leading to clinically significant impairment
                        manifested by 1 or more of the following in the last 12 months:
                        1) recurrent failure to fulfill role obligations
                        2) recurrent physically hazardous use
                        3) recurrent substance-related legal problems
                        4) recurrent social or interpersonal problems
                     B. symptoms have not met the criteria for Substance Dependence


                    DSM-IV Criteria: Substance Dependence
                     A. substance use leading to clinically significant impairment
                        manifested by 3 or more of the following in the last 12 months:
                        1) tolerance, as defined by:
                                                                                              YEPSA: Objectives (page 153 of 190)




                                a) need for increased amounts to achieve the desired effect
                                b) diminished effect with continued use of the same amount
                         2)     withdrawal, as defined by:
                                a) characteristic withdrawal syndrome for the given substance
                                b) same or similar substance is taken to relieve withdrawal symptoms
                         3)     substance often taken in larger amounts or for longer periods than intended
                         4)     persistent desire or unsuccessful efforts to cut down or control use
                         5)     excessive time spent in activities necessary to obtain, use, or recover
                         6)     social, occupational, or recreational activities are given up or reduced
                         7)     use is continued despite recognition of there being a problem

                     specify:
                     • with physiological dependence:              evidence of tolerance and/or withdrawal
                     • without physiological dependence:           no evidence of tolerance or withdrawal

                     course specifiers:
                     • early full remission
                     • early partial remission
                     • sustained full remission
                     • sustained partial remission
                     • on agonist therapy
                     • in a controlled environment



- treatment
   - principles:    principles of treatment include:
                    - detoxification (first goal)
                    - insistence on abstinence
                    - avoidance of other substances associated with dependence or abuse (“habit trading”)
                    - involvement of the family
                    - unscheduled tox screens
                    - self help groups
                    - sanctioned treatment
                    - contingency contracting (e.g. pt agrees that employers notified if they use)
                    - change of peer group

  - pharmacology: pharmacologic aids include:
                  - aversive agents (disulfram)
                  - anti-craving agents (naltrexone, acamprosate)
                  - replacement agents (methodone)


TABLE: Characteristic Withdrawal Syndromes
                        onset        peak             resolution     symptoms
 alcohol withdrawal   12-18 hours 24-48 hours           4 days       tremor, insomnia, irritability, seizure


 delirium tremens         24 hours      48-72 hours     7 days       anxiety, agitation, delirium, diaphoresis, disorientation


 heroin                   8 hours       24-48 hours       ---        • early:   anxiety, myalgia, rhinorrhea, lacrimation
                                                                     • mid:     sweats, fever, chills, muscle spasm, insomnia
                                                                     • late:    vomiting, diarrhea, HTN, tachycardia
 methadone              24-48 hours     48-96 hours       ---


 cocaine                      ---        2-4 days         ---        fatigue, depression, hunger
                                                                     nightmares, sweating, muscle cramps
                                                                                              YEPSA: Objectives (page 154 of 190)



      nicotine               12-24 hours    2-3 days      3 weeks    dysphoria, insomnia, irritability, restlessness
                                                                     decreased pulse, increased weight




3.     Be able to evaluate, diagnose, and manage anxiety / panic attacks.

anxiety and panic disorders
- generalized anxiety disorder (GAD)
   - disorder:        generalized pathologic excessive anxiety and worrying

     - etiology
        - genetic:      higher concordance rates among related
        - neural:       involvement of specific neurotransmitter systems and regions of the brain
                        - neurotransmitters: NE, GABA, serotonin
                        - neuroanatomy:       frontal lobe, limbic system

     - epidemiology
        - onset:        generally early 20s (though people of any age may develop the disorder)
        - prevalence:   4-7% in the general population
        - gender:       higher in women
        - ethnicity:    higher in African Americans

     - complications:   may lead to other psychiatric illnesses
                        - major depression
                        - alcohol abuse
                        - panic disorder (found in 25%)

     - diagnosis:       criteria-based

                        DSM-IV Criteria: Generalized Anxiety Disorder (GAD)
                         A: excessive anxiety and worry occurring more days than not for at least 6 months
                         B: person finds it difficult to control the worry
                         C: at least 3 of the following (1 in children):
                            1.) restlessness or feeling keyed up or on edge
                            2.) being easily fatigued
                            3.) difficulty concentrating or mind going blank
                            4.) irritability
                            5.) muscle tension
                            6.) sleep disturbance
                         D: not better explained by an axis I disorder:
                            1.) panic disorder:           concern with not having a panic attack
                            2.) social phobia:            concern with public embarrassment
                            3.) OCD:                      concern with contamination
                            4.) separation anxiety: concern with being away from home or close relatives
                            5.) anorexia nervosa:         concern with gaining weight
                            6.) hypochondriasis:          concern with having a serious illness
                            7.) PTSD:                     anxiety and worry associated with PTSD


     - differential:    same as panic disorder and agoraphobia
                        particularly important to rule out drug-induced conditions
                        - caffeine intoxication
                        - stimulant abuse
                        - alcohol withdrawal
                                                                                     YEPSA: Objectives (page 155 of 190)



                      - sedative-hypnotic withdrawal

  - management:       SSRIs, buspirone are first line

  - course:           chronic, with symptoms that fluctuate over time


- panic disorder
   - disorder:        pathologic anxiety in discreet situations

  - etiology
     - genetic:        higher concordance rates among related
     - behavioral:     conditioned and learned responses are likely involved
     - psychoanalytic: repression may be involved

  - pathogenesis:     numerous areas have been implicated, but none conclusively
                      - catecholamine elevation in the CNS
                      - locus coeruleus abnormality
                      - CO2 hypersensitivity (false suffocation alarm theory)
                      - lactate metabolism abnormality
                      - GABA neurotransmitter abnormality

  - complications:    associated with several other psychiatric illnesses
                      - suicide:            higher in panic patients (even in those who are not depressed)
                      - major depression: occurs in 50% of patients with panic disorder or agoraphobia
                      - alcohol abuse:      occurs in 20% of patients, may begin as an attempt to self-medicate

  - diagnosis
     - agoraphobia: anxiety about being in places or situations where escape would be difficult or embarrassing
     - panic attacks: discrete period of intense fear or discomfort, with characteristic symptoms
     - panic disorder: recurrent, unexpected panic attacks leading to persistent anxiety

                      DSM-IV Criteria: Panic Attack (non-codable: must be associated with separate disorder)
                       A: discrete period of intense fear or discomfort, with ≥ 4 of the following 13:
                          1.) palpitations, pounding heart, or accelerated heart rate
                          2.) sweating
                          3.) trembling or shaking
                          4.) sensations of shortness of breath or smothering
                          5.) feeling of choking
                          6.) chest pain or discomfort
                          7.) nausea or abdominal distress
                          8.) feeling dizzy, unsteady, lightheaded, or faint
                          9.) derealization (feelings of unreality) or depersonalization (detachment)
                          10.) fear of losing control or going crazy
                          11.) fear of dying
                          12.) paresthesias (numbness or tingling sensations)
                          13.) chills or hot flushes


                      DSM-IV Criteria: Panic Disorder without Agoraphobia
                       A: both of:
                          1.) recurrent, unexpected panic attacks
                          2.) at least one followed by 1 month or more of 1 or more of the following:
                              i.) persistent concern about additional attacks
                                                                                   YEPSA: Objectives (page 156 of 190)




                            i.) worry about the implications of the attack (losing control, “going crazy”)
                            i.) significant change in behavior related to the attacks
                    B: absence of agoraphobia
                    C: not due to a substance or general medical condition
                    D: not better explained by:
                       1.) social phobia:         on exposure to feared social situations
                       2.) specific phobia:       on exposure to a specific phobic situation
                       3.) OCD:                   on exposure to an object of obsession
                       4.) PTSD:                  on exposure to stimuli associated with a severe stressor
                       5.) separation anxiety: in response to being away from home or close relatives


                   DSM-IV Criteria: Agoraphobia (non-codable: must be associated with a separate disorder)
                    A: anxiety about places or situations where escape would be difficult or embarrassing
                       1.) involves clusters of symptoms such as being home alone, being in a crowd, etc.
                       2.) consider diagnosis of specific phobia if limited to one or a few specific situations
                       3.) consider diagnosis of social phobia if avoidance is limited to social situations
                    B: situations are avoided or else endured with marked distress
                    C: not better explained by:
                       1.) social phobia:          on exposure to feared social situations
                       2.) specific phobia:        on exposure to a specific phobic situation
                       3.) OCD:                    on exposure to an object of obsession
                       4.) PTSD:                   on exposure to stimuli associated with a severe stressor
                       5.) separation anxiety: in response to being away from home or close relatives


- differential
   - medical:      medical illnesses
                   - angina
                   - cardiac arrhythmia
                   - congestive heart failure
                   - hypoglycemia
                   - hypoxia
                   - pulmonary embolism
                   - severe pain
                   - thyrotoxicosis
                   - pheochromocytoma
                   - Ménière’s disease

  - psychiatric:   other psychiatric illness
                   - schizophrenia
                   - mood disorders
                   - personality disorders
                   - adjustment disorder with anxious mood

  - pharmacology: drugs of abuse / prescribed medications
                  - caffeine
                  - aminophylline, related compounds
                  - sympathomimetic agents (decongestants, diet pills)
                  - monosodium glutamate
                  - psychostimulants and hallucinogens
                  - alcohol withdrawal
                  - withdrawal from benzodiazepines, other sedative-hypnotics
                  - thyroid hormones
                  - antipsychotic medication
                                                                                       YEPSA: Objectives (page 157 of 190)




  - management:       SSRIs for long-term control of anxiety
                      benzodiazepines for panic attacks

  - prognosis
     - course:        fluctuates in intensity and severity
     - outcome:       total remission is uncommon, but 50-70% will show some improvement over time


- post-traumatic stress disorder (PTSD)
   - disorder:        pathologic response to trauma characterized by three major elements:
                      - re-experience
                      - avoidance and emotional numbing
                      - autonomic arousal

  - history:          first specified as PTSD in 1980 in DSM-III
                      - originally associated with soldiers (“shell shock,” “war neurosis”)
                      - increasingly realized to occur with many other traumatic events

  - etiology:         stressor outside the range of normal human experience

  - epidemiology
     - onset:         can occur at any age, with onset ranging from hours to years after the event
     - incidence:     varies with type of trauma
     - gender:        women > men
                      - women:      1.2%, generally associated with physical assault or rape
                      - men:        0.5%, generally associated with combat

  - risk factors:     risk factors include:
                      - severity, type, and proximity of trauma
                      - gender (female > male for most traumas)
                      - previous trauma
                      - family, genetics (demonstrated with offspring of PTSD survivors of holocaust)
                      - history of emotional disturbance
                      - level of social support after the trauma

                      TABLE: Likelihood of Event Resulting in PTSD
                       event                                  risk
                       assault or violence                    28.8 %
                       • military combat                      28.9 %
                       • rape / sexual assault                28.9 %
                       • held captive, tortured, kidnapped    54.5 %
                       • shot, stabbed                        24.4 %

                       other injury or shocking event             11.7 %
                       • serious car accident                     6.5 %
                       • other serious accident                   21.6 %
                       • natural disaster                         4.1 %
                       • life-threatening illness                 31.2 %

                       learning of trauma to someone close        2.7 %

                       learning of unexpected death               14.2 %

                       any trauma                                 13.6 %
                                                                                    YEPSA: Objectives (page 158 of 190)




- pathophysiology: decreased REM latency
                   dysregulation of the HPA axis
                   - ↑ norepinephrine levels (hypersensitivity)
                   - ↓ corticosteroid levels (hyporesponsiveness)
                   dysfunction of the serotonergic pathways
                   dysfunction of the noradrenergic pathways
                   reduced hippocampal size (corticosteroid pathology)
                   hypersensitivity of the amygdala startle response
                   - fear-potentiated startle
                   - increased by yohimbine, decreased by prazosin
                   - alcohol, benzodiazepines: help acutely, increase chronically with regards to PTSD

- complications:   associated comorbidities may include:
                   - frank major depression
                   - other anxiety disorders
                   - alcohol and drug abuse
                   - anger and irritability
                   - poor impulse control
                   - use of PTSD as an excuse for misbehavior

- diagnosis:       see DSM-IV Criteria, “Posttraumatic Stress Disorder (PTSD)”

- differential:    differential diagnosis includes:
                   - major depression
                   - adjustment disorder
                   - panic disorder
                   - GAD
                   - acute stress disorder
                   - OCD
                   - depersonalization disorder
                   - factitious disorder
                   - malingering
                   - physical injury (e.g. brain injury)

- management:      management includes:
                   - behavioral therapy (extinction) to retrain the brain that nothing bad happens
                   - pharmacologic therapies (SSRI, prazosin) to diminish CRH, NE effects
                   - learning new coping strategies

- prognosis:       good outcomes associated with:
                   - rapid onset of symptoms
                   - good premorbid functioning
                   - strong social support
                   - absence of psychiatric or medical comorbidity

- clinical:        only psychiatric disorder to be attributed to a specific event


DSM-IV Criteria: Posttraumatic Stress Disorder (PTSD)
 A: exposure to a traumatic event in which both:
    1.) person experienced, witnessed, or was confronted with actual or threatened trauma
    2.) response involved intense fear, helplessness, or horror (children: can be disorganization or agitation)
                                                                                       YEPSA: Objectives (page 159 of 190)




   B: event is reexperienced with 1 or more of:
      1.) recurrent, intrusive, distressing recollections (children: can be repetitive play in related themes)
      2.) recurrent distressing dreams about the event (children: can include unrecognized content)
      3.) acting / feeling as if the traumatic event were reoccurring, such as illusions, hallucinations, flashbacks
      4.) intense psychological distress upon exposure to cues related to the event
      5.) intense physiological reactivity upon exposure to cues related to the event

   C: avoidance, indicated by 3 or more of:
      1.) efforts to avoid associated thoughts, feelings, or conversations
      2.) efforts to avoid activities, places, or people that arouse recollections
      3.) inability to recall an important aspect
      4.) markedly diminished interest or participation in significant activities
      5.) feelings of detachment or estrangement from others
      6.) restricted range of affect, such as being unable to have loving feelings
      7.) sense of foreshortened future, such as having diminished expectations

   D: increased arousal, indicated by 2 or more of:
      1.) difficulty falling or staying asleep
      1.) irritability or outbursts of anger
      3.) difficulty concentrating
      4.) hypervigilance
      5.) exaggerated startle response

   E: duration of disturbance is more than 1 month

   F: significantly interferes with functioning, social activities, or relationships

   specifiers:
   • acute:         duration of symptoms is less than 3 months
   • chronic:       duration of symptoms is greater than 3 months
   • delayed onset: onset of symptoms is at least 6 months after the stressor




medications for use in anxiety and panic disorders
- SSRIs
   - agents:         fluoxetine, paroxetine
   - function:       first line treatment of anxiety, non-sedating
   - mechanism:      5-HT (serotonin) reuptake inhibition
   - pharmacology:   slow onset of action (2-6 weeks after beginning treatment)
   - adverse:        non-neurologic serotonin receptor stimulation
                     - general:         weight gain (5-10%)
                     - neurologic:      headache, restlessness, agitation, insomnia
                     - GI:              nausea, vomiting
                     - GU:              sexual dysfunction (delayed orgasm, anorgasmia)
   - complications:  severe complications may include:
                     - SSRI withdrawal syndrome: flu-like (headache, dizziness, myalgia, irritability, sleep effects)
                     - serotonin syndrome: mental status changes, increased muscle tone, autonomic instability
   - clinical:       safe, effective, low risk in overdose, and rarely abused, but may initially increase anxiety

- buspirone (BuSpar)
   - function:       anti-anxiety medication
                                                                                              YEPSA: Objectives (page 160 of 190)



     - mechanism:           5-HT1A partial agonist (unique mechanism)
     - pharmacology:        slow onset of therapeutic action (2-4 weeks)
     - adverse:             no interaction with alcohol, tolerance does not develop

- benzodiazepines
   - agents:                alprazolam, diazepam, oxazepam, lorazepam, clonazepam

     - function:            common drug used in treatment of anxiety
                            - rapid relief of symptoms (as opposed to weeks for antidepressants)
                            - can alleviate restlessness or nervousness sometimes associated with starting antidepressants

     - indications:         indications include:
                            - anxiety:        used when more rapid onset is desired (SSRIs still first line)
                            - insomnia:       safe, effective in some patients; substantial risk in elderly (sedation)
                            - sedation:       prior to surgical procedures
                            - seizures:       adjunct for treatment of epilepsy and seizure states
                                              - clonazepam: documented efficacy against absence seizures
                                              - diazepam: IV administration for status epilepticus
                            - anesthesia:     component of balanced anesthesia (given IV)
                            - withdrawal:     control of alcohol or other sedative-hypnotic withdrawal states
                                              - used to prevent potentially life-threatening withdrawal symptoms
                                              - benzodiazepines preferred due to wide margin of safety
                            - relaxant:       specific neuromuscular disorders

     - mechanism:           GABA potentiation in the CNS
                            - barbiturates: prolong GABA, as opposed to intensifying it
                            - convulsants:  can also bind this complex

     - adverse:             adverse effects include:
                            - oversedation:              particularly in elderly, hepatic, and renal patents
                            - respiratory suppression:   when combined with alcohol
                            - psychomotor slowing:       memory impairment, accidents, injury
                            - physical dependence:       withdrawal can be life-threatening
                            - addiction:                 rare; mostly in patients at risk for substance abuse
                            - anger or hostility:        anxiolytic effects in persons who harbored feelings of hostility
                            - teratogenicity:            not yet fully established

     - interactions:        CNS depressants (combination of alcohol with benzodiazepines can be fatal)




Surgery
                                                                                           DIAGNOSIS & TREATMENT


1.     Perform / demonstrate appropriate sterile technique, wound evaluation, and closure.

                   (based partially on objectives written by Julie Gerig)

- sterile technique
   - function:              minimization of possible sources of infection
   - principles:            general principles include:
                                                                                        YEPSA: Objectives (page 161 of 190)



                       - prepare and maintain select surfaces as sterile
                       - minimize potential sources of contamination by segregating sterile and non-sterile areas
  - technique:         scrubbing in
                       - surgical hand scrub
                       - gowning
                       - gloving
  - web resource:      detailed discussion can be found at:
                            http://www.surgeryencyclopedia.com/A-Ce/Aseptic-Technique.html


surgical wound classification
- clean wounds
   - description:    clean wounds are characterized by:
                     - incisions made through disinfected skin
                     - no entry into respiratory, GI, or GU tracts
   - epidemiology:   infection rate < 2%

- clean-contaminated wounds
   - description:    clean-contaminated wounds are characterized by:
                     - incisions made through disinfected skin with entry into respiratory, GI, or GU tracts
                     - tract has been prepared mechanically or antibacterially, with no active infection present
   - epidemiology:   infection rate < 3%

- contaminated wound
   - description:    contaminate wounds include:
                     - all traumatic wounds
                     - any surgical incision that enters respiratory, GI, or GU tract resulting in major spillage
   - epidemiology:   infection rate < 5%

- infected wound
   - description:      incision in an already infected area
   - epidemiology:     infection rate > 50%


  TABLE: Factors that Influence Wound Healing
   promote wound healing            hinder wound healing
   • vitamin A                      • malnutrition
   • good nutrition                 • diabetes
   • hyperbaric oxygen              • steroids
      (theoretical)                 • NSAIDs
                                    • chemotherapy
                                    • smoking
                                    • decreased temperature
                                    • inadequate PO2
                                    • infection
                                    • necrosis
                                    • movement
                                    • foreign bodies
                                    • radiation



traumatic wound classification

  TABLE: Wound Classification
                                                                                           YEPSA: Objectives (page 162 of 190)



                                            tetanus prone                           non-tetanus prone
      age                                   more than 6 hours                       less than 6 hours
      configuration                         stellate, avulsion                      linear
      depth                                 > 1 cm deep                             ≤ 1 cm deep
      mechanism                             projectile, crush, burn, frostbite      sharp surface (glass, knife)
      contaminants                          dirty wound                             “clean” wound
      viability                             devitalized tissue                      viable tissue


     TABLE: Guidelines for Tetanus Prophylaxis Based on Immunization History
       history of tetanus immunization tetanus prone                       non-tetanus prone
       unknown, or <3 doses            Td prophylaxis and hTIg 1           Td prophylaxis and tetanus hTIg 1
       ≥ 3 doses                       Td only if >5 years since last dose Td only if >10 years since last dose
     1
       human tetanus immunoglobulin


wound closure
- primary intention
   - method:               close apposition of wound edges using suture, staples, tape, or other means
   - physiology:           scab forms and tissue heals from the bottom up, resulting in fibrous union

- delayed primary intention (third intention)
   - method:          wound left open until wound bed judged sufficiently clean, then closed with close apposition
   - physiology:      tissue replacement results in scar tissue

- secondary intention
   - process:         wound left open to heal on its own (utilized with dirty, contaminated, or necrotic wounds)
   - physiology:      tissue scars from the bottom up, leaving wound contraction
                      - larger tissue defect
                      - greater inflammatory response
                      - larger amounts of granulation tissue
                      - greater myofibroblast and collagen cross-linking

- skin graft
   - process:              split portion of skin containing epidermis and part of dermis used to close wound
   - physiology:           tissue scars at edges


2.     Be able to evaluate and examine a breast mass, and provide treatment options.

                   (based partially on objectives written by Vannessa Curtis)

- breast cancer
   - disorder:             cancer of the breast

     - etiology:           risk factors include:
                           - age
                           - family history (including male relative with breast cancer)
                           - known mutation
                           - early menarche
                           - nulliparity
                           - OCP use (slight)
                           - hormone replacement therapy

     - epidemiology:       most common cancer in United States (incidence of 200,000 / year)
                                                                                   YEPSA: Objectives (page 163 of 190)




- presentation:    breast mass, found on:
                   - self breast examination
                   - clinical screening

- diagnosis
   - history:      important questions include:
                   - menstrual and pregnancy history
                   - hormone use
                   - nipple discharge
                   - presence of warmth / tenderness
                   - constitutional symptoms (weight loss, nausea, fatigue)
                   - bone pain
                   - risk factors for breast cancer

  - examination:   important findings to note include:
                   - asymmetry
                   - dimpling, retractions
                   - excoriations, erythema, edema
                   - axillary / supraclavicular lymphadenopathy
                   - nipple discharge

                   TABLE: AJCC Clinical Staging of Breast Cancer
                    stage    description
                    stage 0  carcinoma in situ

                   stage I       small, localized
                                 • tumor < 2 cm in diameter with no nodal involvement, no metastases

                   stage II      small with nodes; large without nodes
                                 • tumor > 5 cm in diameter, no nodal involvement or metastases
                                 • tumor < 5 cm in diameter, involved but moveable ax. nodes, no metastases

                   stage III     large with nodes
                                 • cancers of any size with possible skin involvement; pectoral / chest fixation
                                 • nodal involvement inc. fixed axillary nodes or internal mammary nodes
                                 • no metastases

                   stage IV      distant metastases


  - imaging:       methods of imaging include:
                   - diagnostic mammography
                   - ultrasound
                   - magnetic resonance imaging (MRI)

                   TABLE: Diagnostic Imaging in Breast Cancer
                    modality                indications
                    diagnostic mammogram    indicated for:
                                            • change in previous screening mammogram
                                            • irregular density
                                            • spiculated lesions
                                            • microcalcifications

                   ultrasound                   seemingly benign mass in a young woman without risk factors 1
                                                                                      YEPSA: Objectives (page 164 of 190)




                      MRI                          difficult-to-visualize breast
                  1
                      well-circumscribed, mobile

  - procedures:   suspicious lesions may be further evaluated by:
                  - fine needle aspiration (FNA)
                  - open biopsy

                  TABLE: Diagnostic Procedures in Breast Cancer
                   modality                indications
                   fine needle aspiration  indicated for palpable mass, with no further workup needed if:
                                           • aspirate is non-bloody
                                           • mass disappears completely after aspiration

                      biopsy (open or core)        indicated for masses that are:
                                                   • solid
                                                   • suspicious on mammography
                                                   • associated with niple discharge or ulceration



  - follow-up:    staging workup for cancer includes:
                  - bilateral mammogram
                  - chest x-ray
                  - liver function tests (LFTs)
                  - Ca2+, ALP

- differential:   differential diagnosis of a breast mass includes:
                  - DCIS
                  - invasive ductal carcinoma, invasive lobular carcinoma, inflammatory carcinoma
                  - Paget’s disease of the breast
                  - cystosarcoma phyllodes
                  - fibrocystic disease of the breast
                  - fibroadenoma
                  - intraductal papilloma
                  - ductal ectasia
                  - abscess
                  - adenitis

- management:     modalities of therapy include:
                  - surgical removal (lumpectomy, total mastectomy, modified radical mastectomy)
                  - radiation therapy
                  - chemotherapy

                  TABLE: Breast Cancer Interventions
                   cancer                  interventions
                   LCIS 1                  interventions include:
                                           • careful f/u
                                           • bilateral prophylactic mastectomy (high risk patients)

                      DCIS 2                   interventions include:
                                               • total mastectomy
                                               • lumpectomy with radiation and f/u
                                                                                     YEPSA: Objectives (page 165 of 190)



                   stage I or stage II        interventions include: 3
                                              • modified radical mastectomy
                                              • lumpectomy with axillary dissection and radiation

                   stage III or stage IV      surgical resection and chemoradiation

                   phylloides and sarcomas    wide local excision

                   inflammatory carcinoma     chemotherapy followed by radiation, mastectomy, or both

               1
                 LCIS = lobular carcinoma in situ (increased risk of cancer)
               2
                 DCIS = ductal cell carcinoma in situ (precancerous condition)
               3
                 survival is equal between interventions, adjuvant chemotherapy is optional

               breast reconstruction options include:
               - TRAM (transverse rectus abdominus muscle) flap
               - saline implant
               - latissimus dorsi flap

- prognosis:   5 year survival varies with stage

               TABLE: Breast Cancer 5 Year Survival
                stage                 survival
                stage 0:               100%

                   stage I:                   100%

                   stage II:
                   • stage IIA                92%
                   • stage IIB                81%

                   stage III:
                   • stage IIIA               67%
                   • stage IIIB               54%

                   stage IV:                  20%


               BOX: Poor Prognostic Factors in Breast Cancer
                   Poor prognostic factors in breast cancer include the following:

                     • involved axillary lymph nodes
                     • large primary tumor size
                     • absence of tumor hormone receptor (ER, PR) proteins
                     • growth factor (HER2) overexpression
                     • undifferentiated histologic grade



- screening:   screening modalities include self breast exam and mammography
               - self breast exam:        no evidence for efficacy
               - clinical breast exam:    weak evidence for efficacy
               - mammograpy:              effective at age ≥ 50, questionable at age 40-49
               - MRI:                     not used due to high false positive rate
                                                                                            YEPSA: Objectives (page 166 of 190)




3.     Be able to perform the initial evaluation and treatment of a trauma patient.

                  (based partially on objectives written by Molly Kaiser)

- evaluation and management of a trauma patient
   - primary assessment
      - function:     stabilization and rapid assessment of hemodynamically compromised patients
      - method:       ABCDE
                      - airway
                      - breathing
                      - circulation
                      - disability
                      - exposure

     - secondary assessment
        - function:     close examination of critical components not involved in the initial assessment
        - method:       head-to-toe physical exam with special attention to:
                        - neurologic exam
                        - cardiovascular exam
                        - abdominal exam
                        - musculoskeletal exam
                        - radiology (AP chest, AP/lat C-spine, AP pelvis, AP/Lat of any injured extremities)

     - tertiary assessment
        - function:      reassessment for missed injuries or injuries associated with those already discovered
        - method:        reexamination of patient after stability
        - clinical:      abdominal exam in a trauma patient is notoriously unreliable


     TABLE: Immediate Management of the Trauma Patient
      component  management
      airway     • protect neck with rigid cervical collar
                 • assess for airway obstruction
                    - suction secretions from the mouth and throat
                    - open mouth with chin lift, jaw thrust maneuvers
                 • establish airway
                    - endotracheal intubation (oral or nasal)
                    - consider cricothyroidotomy, tracheostomy

      breathing        • maintain oxygenation
                         - administer 100% O2
                         - place on continuous pulse oximetry monitoring
                       • maintain ventilation
                         - assess quality, symmetry of breath sounds
                         - assess for work of breathing
                         - decompress a tension pneumothorax (does not require CXR for diagnosis)

      circulation      • control hemorrhage
                       • obtain IV access with two large-bore catheters
                          - obtain blood for type and cross
                          - replace fluids (2-3 L crystalloid, then blood products if needed)
                          - adequate UOP to gauge resuscitation: 0.5 mL / kg / hr
                       • attach cardiac monitor leads
                       • assess for signs of peripheral perfusion (pulses, capillary refill)
                                                                                   YEPSA: Objectives (page 167 of 190)




   disability      • assess level of consciousness (LOC)
                      - Glasgow Coma Scale
                      - AVPU (alert, responds to verbal commands, responds to pain, unresponsive)
                   • pupillary size and response to light
                   • brief neurological examination

   exposure        • undress patient to assess for other injuries
                   • monitor temperature (T<34°C associated with decreased survival)




- Glasgow coma scale
  - function:       measure of impaired consciousness
  - method:         clinical evaluation of three elements, with scoring range from 3-15
                    - eye opening:               1-4 points possible
                    - verbal response:           1-5 points possible
                    - motor response:            1-6 points possible
  - interpretation: score ranging from 3-15, correlated with prognosis following traumatic brain injury (TBI)
                    - mild impairment:           14-15 points
                    - moderate impairment: 9-13 points
                    - severe impairment:         3-8 points
  - clinical:       does not provide valid prognostic information for:
                    - children < 4
                    - patients with “metabolic” causes of coma (intoxication, shock, postictal state)
                    - some orbit and spine injuries

  TABLE: Glasgow Coma Scale
    feature                                           score
    eyes
      • open spontaneously                               4
      • open to speech                                   3
      • open to pain                                     2
      • no response                                      1
    verbal response 1
      • oriented (coos, babbles)                         5
      • confused (irritable cries)                       4
      • inappropriate words (cries to pain)              3
      • incomprehensible sounds (moans to pain)          2
      • no response                                      1
    motor response 1
      • obeys (normal spontaneous movements)             6
      • localizes (withdraws to touch)                   5
      • withdraws (withdraws to pain)                    4
      • abnormal flexion                                 3
      • abnormal extension                               2
      • no response                                      1
    TOTAL SCORE                                        3-15
  1
    parentheses indicate findings in preverbal children

  TABLE: Glasgow Coma Scale: Interpretation
   total score interpretation
   GCS 3-8     severe impairment / injury
                                                                                               YEPSA: Objectives (page 168 of 190)



      GCS 9-13           moderate impairment / injury
      GCS 14-15          mild to absent impairment / injury



4.     Perform a comprehensive musculoskeletal evaluation and examination (ankle, knee, and low back pain).

                 (based partially on objectives written by Bill Wong)

- generic musculoskeletal / joint exam
   - function:        identify injury or source of pain in joints
                      - deformities, tenderness, or ecchymosis
                      - associated nerve, neurovascular, or tendon injuries
                      - inability to perform spontaneous movements

     - method:              standardized joint exam includes the following 6 components:
                            - inspection
                            - palpation
                            - ROM (active, passive)
                            - strength
                            - laxity
                            - special tests

     - interpretation:      strength grading is as follows:
                            - 0:     paralysis
                            - 1:     visible contraction
                            - 2:     full ROM with gravity eliminated
                            - 3:     full ROM against gravity
                            - 4:     full ROM with decreased strength
                            - 5:     full ROM with normal strength

     BOX: Musculoskeletal Red Flags
      The following exam features indicate a need for further evaluation

         • hemarthrosis                  (internal derangement)
         • poor treatment response       (internal derangement)
         • bony swelling                 (tumor)
         • fever                         (osteomyelitis, septic arthritis
         • rash / joint swelling         (collagen vascular disorders, gonococcal arthritis)




knee
- knee exam
   - inspection:            effusion, swelling, echymosis, resting position, surgical scars, muscle tone

     - palpation:           should include the following:
                            - patella / peripatella
                            - quadriceps tendon
                            - patellar tendon
                            - medial collateral ligament (MCL)
                            - medial joint line
                            - tibial tubercle
                            - femoral condyles
                                                                                       YEPSA: Objectives (page 169 of 190)



                      - pes anserine
                      - lateral joint line
                      - lateral collateral ligament (LCL)

  - ROM:              flexion / extension (active if possible, passive otherwise)

  - strength:         flexion / extension

  - laxity:           laxity tests include:
                      - valgus pressure       (MCL: lateral displacement, knee at 30° flexion)
                      - varus pressure        (LCL: medial displacement, knee at 30° flexion)
                      - anterior drawer       (ACL)
                      - Lachman test          (ACL: anterior displacement, knee at 30° flexion)
                      - posterior drawer      (PCL)
                      - internal rotation     (overall stability)
                      - external rotation     (overall stability)

  - special tests:    special tests include:
                      - McMurray test        (menisci: leg from flexion to extension with valgus, varus pressures)
                      - Nobles test          (iliotibial band: pressure at lateral femoral condyle during extension)
                      - Patellar grind       (patellofemoral syndrome: lateral displacement, quadricep tightening)

  - web resources:    web resources include:
                      • http://www.fpnotebook.com/ORT55.htm
                      • http://medicine.ucsd.edu/clinicalmed/Joints.html
                      • https://inside.fammed.wisc.edu/education/musculo/index.html

- Ottawa rules: knee
  - function:        indications for radiographic imaging of the knee
  - guidelines:      image with any of the following:
                     - age > 55
                     - tenderness at the head of the fibula
                     - isolated patellar tenderness
                     - inability to flex to 90°
                     - inability to bear weight (4 steps) both immediately and in the ED


- anterior cruciate ligament (ACL) tear
   - anatomy:          connects posterolateral femur to anteromedial tibia
   - etiology:         commonly associated with contact or other high risk sports
                       - skiing
                       - basketball
                       - football
                       - volleyball
   - epidemiology:     second most common knee injury
   - mechanism:        knee hyperextension
                       - sudden foot plant with cut to opposite side
                       - valgus stress causes tibial anterior displacement
                       - ACL ruptures as tibia displaces anteriorly
   - diagnosis
      - history:       characterized by:
                       - painful “popping” sensation at the time of injury
                       - hemarthrosis within 1-2 hours of injury
                       - buckling sensation of knee
      - examination: positive Lachman test
      - radiology:     indicated for avulsion fracture suspicion, preoperative management, or pediatric patients
                                                                                         YEPSA: Objectives (page 170 of 190)



  - web resource:     http://www.fpnotebook.com/ORT256.htm

- posterior cruciate ligament (PCL) tear
   - anatomy:          connects posterior intercondylar tibia to medial condyle of the femur
   - mechanism:        direct trauma to proximal tibia
                       - hyperflexion
                       - fall on flexed knee
   - diagnosis
      - history:       suggestive history
      - examination: positive posterior drawer sign
      - radiology:     to evaluate for tibial avulsion fracture
   - web resource:     http://www.fpnotebook.com/ORT256.htm

- collateral ligament tear of the knee
   - anatomy:          medial, lateral ligaments (MCL, LCL) that stabilize knee against valgus, varus movement
   - mechanism:        medial collateral ligament (common)
                       - valgus load without rotation
                       - force against lateral knee (in slight flexion)
                       - common injury in contact sports
                       lateral collateral ligament (uncommon)
                       - pure varus load without rotation
                       - force against medial knee
                       - rarely occurs without concurrent PCL or ACL injury
   - diagnosis
      - history:       suggestive history
      - examination: positive valgus, varus laxity; localized pain, bruising or swelling
      - radiology:     knee x-ray in all suspected tears
   - web resource:     http://www.fpnotebook.com/ORT255.htm

- menisci tear
  - anatomy:          medial, lateral semilunar cartilage discs that disperse friction at, cushion knee joint
  - epidemiology:     most common knee injury
  - mechanism:        twisting injury (fixed tibila rotation with knee flexion or extension)
  - diagnosis
     - history:       characterized by:
                      - twisting injury to the knee while weight-bearing
                      - initial tearing, painful sensation
    - examination:    point tenderness, intermittent locking or buckling, joint effusion, positive McMurray’s
    - radiology:      knee x-ray
  - web resource:     http://www.fpnotebook.com/ORT257.htm

- patellar tendonosis (Jumper’s knee)
   - anatomy:         patellar tendon inflammation
   - epidemiology:    males > females (6:1), most common ages 25-40
   - mechanism:       chronic, repetitive stress on patellar tendon, particularly with athletes in jumping sports
                      - high jump
                      - basketball
                      - football
                      - gymnastics
   - diagnosis
      - history:      chronic repetitive knee extension
      - examination: large knee effusion, defect between tibial tubercle and inferior patella, poor active extension
   - web resource:    http://www.fpnotebook.com/ORT262.htm

- chondromalacia patella (patellofemoral syndrome)
   - anatomy:       degeneration of the patellar cartilage
                                                                                        YEPSA: Objectives (page 171 of 190)



  - epidemiology:     most common running injury
  - mechanism:        mechanisms include:
                      - overuse syndrome in athletes, particularly runners
                      - patellar degeneration
                      - anatomic variation
  - diagnosis
     - history:       characterized by:
                      - anterior knee pain, peripatellar knee pain
                      - stifness, progressive aching
                      - provocation by stairs, running, squatting, prolonged sitting
    - examination:    tender peripatellar area, positive patellar apprehension test, no knee effusion
    - radiology:      indicated only in age > 50 (arthritic conditions), children (neoplasm)
  - web resource:     http://www.fpnotebook.com/ORT258.htm


ankle / foot
- ankle / foot exam
   - inspection:      asymmetry, swelling, ecchymosis

  - palpation:        palpation includes:
                      - lateral ligaments (ATF, CF, PTF)
                      - anterior ankle joint
                      - lateral, medial malleolus
                      - proximal 5th metatarsal head
                      - navicular bone
                      - Achilles tendon
                      - plantar fascial insertion site (medial calcaneal tuberosity)
                      - MTP joints

  - ROM:              active if possible, passive otherwise
                      - plantarflexion, dorsiflection
                      - inversion, eversion

  - strength:         strength testing includes:
                      - plantarflexion, dorsiflexion
                      - inversion, eversion

  - laxity:           drawer test        (anterior talofibular ligament: leg in L hand, heel in R hand, displace)

  - special:          squeeze test       (Achilles: patient on knee on exam table, squeeze calf for plantarflexion)

  - web resources:    web resources include:
                      • http://courses.washington.edu/colleges/vids/foot.shtml
                      • http://www.fammed.wisc.edu/medstudent/pds/three/mskvideos.html

- Ottawa rules: ankle
  - function:         indications for radiographic imaging of the ankle
  - guidelines:       image with pain in the malleolus or midfoot pain and any 1 of:
                      - bony tenderness at posterior edge or tip of either malleoli
                      - bony tenderness over the navicular
                      - bony tenderness at the base of the 5th metatarsal
                      - inability to bear weight (4 steps) both immediately and in the ED


- lateral ankle sprain
   - anatomy:          commonly damaged ligaments (in order) include:
                                                                                          YEPSA: Objectives (page 172 of 190)



                      - anterior talofibular ligament          (ATF)
                      - calcaneofibular ligament               (CF)
                      - posterior talofibular ligament         (PTF)
  - epidemiology:     80-85% of ankle sprains, highest rates in:
                      - basketball
                      - ice skating
                      - soccer
  - mechanism:        ankle inversion with plantarflexion
  - diagnosis
     - history:       “pop” on injury, ankle swelling, decreased function
     - examination:   generally used only for follow-up, and may include:
                      - ankle anterior drawer test (ATF)
                      - ankle talar tilt / inversion stress test (CF)
                      - crossed leg test (high ankle sprain)
    - radiology:      indications for initial imaging according to Ottawa ankle rules
                      indications for follow-up imaging include:
                      - symptomatic beyond 6 weeks
                      - persistent crepitus
                      - locking / catching sensation
  - web resource:     http://www.fpnotebook.com/ORT19.htm

- medial ankle sprain
  - anatomy:         deltoid ligament
  - epidemiology:    rare due to thickness, stability of ligament
  - mechanism:       major trauma
  - diagnosis:       history of trauma with medial ligamentous instability of the ankle


spine
- spinal exam
   - inspection:      alignment (scoliosis, kyphosis, lordosis), leg length

  - palpation:        palpation includes:
                      - spinous processes
                      - sacroiliac joints
                      - paraspinal musculature

  - ROM:              active ROM of neck
                      - flexion / extension
                      - rotation
                      - lateral bending

                      active thoracolumbar ROM
                      - flexion / extension
                      - rotation
                      - lateral bending

  - laxity:           ---

  - special:          special tests include:
                      - Spurling maneuver      (c. radiculopathy: press pt. head forward, ipsilaterally to affected side)
                      - straight leg raise     (l. radiculopathy: raise straight leg of supine patient past 45°)
                      - Patrick’s test         (hip / SI joint pathology: press down on crossed leg while pt. supine)
                      - femoral stretch:       (upper l. radiculopathy: extend hip while patient prone)
                                                                                        YEPSA: Objectives (page 173 of 190)



- musculoskeletal strain
  - disorder:        pain secondary to muscles, ligaments, tendons, or bones

  - etiology:        common causes include:
                     - repetitive motion injury
                     - trauma
                     - postural strain
                     - overuse
                     - prolonged immobilization

  - presentation:    acute onset, frequently related to specific event

  - symptoms:        common symptoms include:
                     - pain (burning, twitching, activity-related)
                     - fatigue
                     - sleep disturbances

- radiculopathy
   - disorder:       pain and weakness secondary to nerve root dysfunction

  - etiology:        common causes include:
                     - herniated nucleus palposus
                     - foraminal stenosis
                     - tumor
                     - synovial cyst
                     - congenital malformations
                     - spondylolisthesis
                     - infection (abscess)

  - epidemiology
     - incidence:    lumbosacral radiculopathy in 3-5% of the population
     - gender:       men = women
     - age:          men in 40s, women in 50s - 60s

  - presentation:    acute onset, frequently with no inciting event

  - symptoms
     - pain:         hallmark symptom of lumbar radiculopathy
                     - described as “shooting,” “burning,” “sharp,” and radiating throughout dermatome
                     - exacerbated by sitting, coughing, sneezing, relieved by standing
    - paresthesia:   unusual sensations, often similar to electricity
    - numbness:      loss of sensation
    - weakness:      poor muscle strength throughout the dermatome

  - differential:    factors suggesting specific diagnoses include:
                     - cancer:         localized bone pain in the elderly
                     - herniation:     worsened by sitting, improved by standing and flexion
                     - rheumatic:      morning stiffness relieved by exercise
                                       (ask about urethritis, conjunctivitis, rash, bowel habits, tick bites)

  TABLE: Dermatomes and Myotomes in Radiculopathy
   segment sensation                     motor                                               reflexes
      C5   deltoid, lateral shoulder     deltoid, biceps                                     biceps
      C6   radial arm / thumb            biceps, brachioradialis                             biceps
      C7   2nd to 4th finger             triceps, wrist extensors                            triceps
                                                                                        YEPSA: Objectives (page 174 of 190)



      L3         medial thigh / knee               quadriceps                                knee jerk
      L4         medial leg                        anterior tibial muscles                   knee jerk
      L5         dorsum of foot / great toe        toe extensors, inversion, eversion        ---
      S1         lateral foot / little toe         plantarflexion, toe flexion               ankle jerk


- cauda equina syndrome
   - disorder:      compressive lesion of the cauda equina
                    - at L1 to L2, spinal cord tapers into the conus medullaris
                    - below this, nerve roots float freely within the dural sac

  - etiology:           causes may include:
                        - tumor
                        - disc herniation
                        - spinal fracture
                        - abscess
                        - hematoma

  - presentation:       variable, difficult to recognize
                        - lumbar back pain
                        - bladder problems (incontinence, urinary retention)
                        - bowel problems (including sphincter dysfunction)
                        - sexual dysfunction
                        - saddle / perineal anesthesia (most sensitive sign)
                        - progressive pain, weakness in one or both legs
                        - diminished LE reflexes

  - symptoms
     - sensory:         spontaneous pain, with no sensory dissociation
     - motor:           LMN symptoms (atrophy, fasiculation, hyporeflexia)
     - autonomic:       urge incontinence, impotence (late onset, less frequent)

  - diagnosis:          MRI

  - management
    - surgical:         emergent surgical decompression
                        - should be done within 48 hours, as early as possible
                        - does not repair already present nerve damage
    - medical:          corticosteroids, anti-inflammatory agents (NSAIDs), analgesics, bed rest

  - prognosis:          can be disabling if not recognized early enough
                        - good prognosis associated with decompressive surgery within 48 hours of presentation
                        - presenting signs and symptoms not correlated with outcome

  BOX: Back Pain Red Flags
   The red flags for imaging can be remembered by the acronym “TITO,” as in famous Latin jazz
     musician Tito Puente. He had lumbar radiculopathy. Not really, but it’s easier to remember then.

      • trauma:         major trauma, minor trauma in older patients, steroid use, osteoporosis, age >70
      • infection:      fever, chills, weight loss, risk factors (IVDA, UTI), immunosuppressed
      • tumor:          age > 50 or < 20, history of CA, unexplained weight loss
      • other:          progressive neurological deficit, prolonged > 4-6 weeks, cauda equina syndrome
                                                                                      YEPSA: Objectives (page 175 of 190)




5.   Be able to evaluate, diagnose, and manage acute and chronic vascular disease.

             (based partially on objectives by Karen Carlson)

- abdominal aortic aneurysm (AAA)
   - disorder:        localized dilation of the abdominal aorta exceeding normal diameter by ≥ 50%
   - etiology:        degenerative process of the aortic wall, with risk factors that include:
                      - hypertension
                      - smoking
                      - hyperlipidemia
                      - obesity
                      - emphysema
                      - genetic factors
                      - male gender
   - presentation:    asymptomatic unless ruptured, may be found incidentally on imaging
   - diagnosis
      - history:      sudden onset, non-fluctuating pain in the abdomen, back, or flank
      - examination: pulsatile abdominal mass
                      signs of rupture include:
                      - tenderness, hypotension , tachycardia
                      - pallor, cool temperature, diminished pulses
      - imaging:      multiple modalities of imaging may be indicated
                      - ultrasound:      size of aneurysm, presence of clot
                      - CT/MRI:          anatomy, localization of aneurysm
                      - arteriogram:     involvement of other vessels
   - management
      - symptomatic: operative repair
      - asymptomatic: varies with size
                      - size < 4 cm:     antihypertensives
                      - size 4-5 cm:     consider surgery
                      - size > 5cm:      surgery (incidence of rupture > 25% over 5 years)

- thoracic aortic aneurysm
   - disorder:        localized dilation of the thoracic aorta
   - etiology:        risk factors include:
                      - atherosclerosis
                      - Marfan syndrome
                      - trauma
                      - syphilis
   - presentation:    asymptomatic unless ruptured, may be found incidentally on imaging
   - diagnosis
      - history:      may indicate effect on surrounding structures
                      - chest pain, pressure                (rupture)
                      - cough, hemoptysis                   (tracheal compression)
                      - chest pain, dyspnea, syncope        (aortic valve insufficiency)
      - examination: signs of rupture include:
                      - hypotension
                      - tachycardia
                      signs of aortic annulus involvement include:
                      - cardiac tamponade
                      - Beck’s triad (hypotension, distant heart sounds, distended neck veins)
      - imaging:      multiple modalities of imaging may be indicated
                      - CXR:             wide thoracic aorta
                      - ECG:             cardiac ischemia (if aneurysm affects coronary vasculature)
                                                                                           YEPSA: Objectives (page 176 of 190)



                    - CT / ECHO:      evaluate involvement of aortic valve, potential tamponade
                    - aortography:    operation planning
  - management:     operative repair when:
    - symptomatic: operative repair
    - asymptomatic: varies with size
                    - size < 4 cm:    antihypertensives
                    - size 4-5 cm:    consider surgery
                    - size > 5cm:     surgery

- aortic dissection
   - disorder:         tear in the wall of the aorta causing separation of layers
   - etiology:         risk factors include:
                       - hypertension
                       - chest trauma
                       - Turner syndrome
                       - Marfan syndrome
                       - bicuspid aortic valve
  - epidemiology:      80% mortality rate of ruptured dissections
  - presentation:      acute onset abdominal pain
  - diagnosis
     - history:        symptoms include:
                       - rapid onset tearing pain in the abdomen, chest, or back
                       - nausea, vomiting
                       - lightheadedness
    - examination:     signs on examination include:
                       - hypotension
                       - new aortic murmur                (suggests retrograde dissection to aortic root)
                       - diminished peripheral pulses (suggests dissection to visceral arteries)
                       - oliguria                         (suggests dissection to renal arteries)
                       - neurological signs               (suggests dissection to spinal arteries)
    - imaging:         may be diagnosed with CXR, CT, TE US, MRI, or aortogram
                       - chest x-ray:      wide mediastinum
                       - CT:               dissection / clot in aortic lumen
  - management:        general principles of management include stabilization and surgery
                       - fluid resuscitation
                       - antihypertensive therapy
                       - operative repair

- carotid artery disease
   - disorder:        atherosclerotic disease of the carotid arteries
   - etiology:        risk factors similar to those of coronary heart disease, including:
                      - family history of atherosclerosis
                      - age
                      - smoking
                      - dyspilidemia
                      - diabetes mellitus
                      - high fat, high cholesterol diet
                      - lack of exercise
   - presentation:    TIA or carotid bruit on physical examination
   - diagnosis
      - history:      symptoms of a TIA include:
                      - blurred or loss of vision in one or both eyes
                      - extremity weakness
                      - slurred speech
                      - loss of coordination
                      - dizziness, confusion
                                                                                        YEPSA: Objectives (page 177 of 190)



                       - swallowing difficulties
    - examination:     signs of carotid artery disease may include:
                       - carotid bruit
                       - neurologic deficits
                       - retinal plaques (Hollenhorst plaques)
    - imaging:         either carotid duplex US or MRI to assess degree of stenosis
  - management:        varies with degree of stenosis
                       - symptomatic, >70% stenosis:        urgent carotid endarterectomy
                       - asymptomatic, stenosis > 60%: elective carotid endarterectomy
                       - stenosis < 50%:                    medical management

- mesenteric vascular disease
  - disorder:        disease of the vasculature of the abdominal viscera
  - etiology:        related to atherosclerosis
  - presentation:    abdominal pain with eating
  - diagnosis
     - history:      symptoms include
                     - crampy abdominal pain with eating
                     - anorexia
                     - N/V/D/C
     - examination: signs include:
                     - pain out of proportion to exam
                     - abdominal distension
                     - GUIAC positive
                     - atrial fibrillation
                     - abdominal bruits
                     - signs of peripheral / coronary vascular disease
     - laboratory:   acute disease is associated with:
                     - ↑ WBC count
                     - metabolic acidosis
                     - ↑ Hct
     - imaging:      varies with acute vs. chronic
                     - acute:         “thumbprinting” of bowel wall on x-ray
                     - chronic:       angiography
  - management
     - acute:        urgent examination and resection of infarcted bowel
     - chronic:      based on results of angiography


- peripheral vascular disease
   - disorder:       disease of blood vessels in the extremities
   - etiology:       related to atherosclerosis
   - presentation:   extremity pain
   - diagnosis
      - history:     symptoms vary with time course
                     - acute:      sudden LE pain, paresthesia
                     - chronic:    claudication, non-healing ulcers
      - examination: signs vary with time course
                     - acute:      pulselessness, pallor, poikilothermia, pain, paresthesia
                     - chronic:    local hair loss, pallor / rubor depending on position, thick nails, thin skin
                                   atrophy, extremity coolness, diminished pulses, ulcerations
      - imaging:     modalities include:
                     - Doppler flow measurement (most common)
                     - arteriography (gold standard)
   - management
      - acute:       heparin, thrombolysis, embolectomy
                                                                                             YEPSA: Objectives (page 178 of 190)



       - chronic:           address risk factors, angioplasty, revascularization, amputation if infected

     TABLE: Claudication: Neurogenic vs. Vasogenic
                            neurogenic claudication                       vasogenic claudication
      etiology              ischemia of lumbar roots                      peripheral vascular disease
      precipitating factors • prolonged standing                          • prolonged standing
                            • downhill ambulation                         • uphill ambulation
                                                                          • bicycling
      alleviating factors        • flexion                                • standing at rest
                                 • change in position
                                 • uphill ambulation
      complications              weakness                                 no weakness



6.     Be able to evaluate, diagnose, and manage the acute abdomen.

                    (Based partially on objectives written byJoe Crill. For clinical features of common diseases
                    presenting with abdominal pain, please see Medicine objective 5)

acute abdominal pain
- history of present illness (HPI)
   - location:         epigastric, periumbilical, RUQ, LUQ, RLQ, LLQ; change in location

     - quality:             dull, sharp, burning, cramping

     - severity:            0-10; change in severity

     - timing:              time course of symptoms
                            - abrupt onset:      life-threatening condition
                            - gradual onset:     inflammation / obstruction
                            - abrupt worsening: perforation
                            - colicky pain:      gastroenteritis, partial bowel obstruction, IBS

     - context:             context of symptoms
                            - association with ethanol, particular foods, medications
                            - stress, trauma
                            - travel history
                            - menstrual history
                            - toxic / infectious / drug exposures

     - assoc. sx:           additional symptoms, including:
                            - N/V, diarrhea
                            - headache, fever/chills
                            - belching, bloating, flatus
                            - changes in bowel / bladder habits
                            - mental status changes
                            - weight gain / loss

     - modifying:           alleviating or exacerbating factors

     - treatment:           treatments sought, medications used
                            - fiber
                            - change in diet
                            - laxatives
                                                                              YEPSA: Objectives (page 179 of 190)



                  - other herbal or complimentary therapy
- impact:         effect on activities of daily living

- perception:     patient concerns, perceptions of the injury


TABLE: Differential Diagnosis Based on Pain Characteristics
 characteristics    location           differential
 chronic            upper              • ulcer
                                       • nonulcer dyspepsia
                                       • gastroesophageal reflux (GERD)
                                       • biliary colic
                                       • chronic pancreatitis
                                       • irritable bowel syndrome

                    lower               • irritable bowel syndrome (IBS)
                                        • abdominal tics
                                        • lactose intolerance
                                        • dysmenorrhea
                                        • endometriosis
                                        • chronic pelvic pain
                                        • inguinal hernia
                                        • hip disorder
                                        • inflammatory bowel disease (IBD)
                                        • cancer

 acute visceral     epigastric          • ulcer
                                        • nonulcer dyspepsia
                                        • biliary colic
                                        • gastroesophageal reflux (GERD)
                                        • MI
                                        • pericarditis
                                        • ruptured AAA

                    periumbilical       • early appendicitis
                                        • gastroesophageal reflux (GERD)
                                        • mesenteric ischemia
                                        • small bowel obstruction (SBO)
                                        • ruptured AAA

 acute parietal     RUQ                 • cholecystitis
                                        • cholangitis
                                        • ulcer
                                        • hepatitis
                                        • perihepatitis
                                        • pneumonia
                                        • pulmonary embolism (PE)

                    RLQ                 • appendicitis
                                        • perforated ulcer
                                        • pelvic inflammatory disease (PID)
                                        • ectopic pregnancy
                                        • ovarian cyst
                                        • salpingitis
                                        • yersinia adenitis
                                                                                         YEPSA: Objectives (page 180 of 190)



                                               • inguinal hernia
                                               • epididymitis
                                               • testicular torsion
                                               • inflammatory bowel disease (IBD)
                                               • ureteral stone

                          LLQ                  • abdominal tics
                                               • pelvic inflammatory disease (PID)
                                               • ectopic pregnancy
                                               • ovarian cyst
                                               • salpingitis
                                               • irritable bowel syndrome (IBD)




- past medical history (PMH)
   - medical history: significant medical conditions, including:
                      - PUD, gastritis
                      - malignancy
                      - IBD, IBS
                      - obstruction, diverticulitis, polyps
                      - hepatitis, cirrhosis, pancreatitis
                      - gallbladder disease, kidney stones
                      - UTIs, STDs
                      - LMP, pregnancy history

  - surgical history:    particularly abdominal surgeries

  - medications:         current medications

  - allergies:           drug and non-drug allergies

  - children:            special considerations in children include:
                         - h/o low birth weight (< 1500 kg → increased risk of necrotizing enterocolitis)
                         - breast feeding history, appetite
                         - exposure to other sick children
                         - jaundice
                         - poison or heavy metal ingestion


- family history (FH):
                         malignancy, IBD, IBS, gallbladder disease, kidney disease, colon cancer


- social history (SH):
                         diet, exercise, EtOH / drug use, sexual history, trauma


- physical exam (PE)
   - general:        initial findings may include:
                     - vital signs
                     - patient position                           (still → peritoneal, writhing → colic)

  - inspection:          significant findings may include:
                         - distension
                                                                                         YEPSA: Objectives (page 181 of 190)



                     - striae, spider nevi, caput medusae
                     - masses / bulges
                     - jaundice, cyanosis
                     - scars, lesions
                     - ecchymosis (Grey Turner’s sign)

  - auscultation:    significant findings may include
                     - increased bowel sounds                    (may suggest gastroenteritis)
                     - early obstruction, hunger
                     - decreased bowel sounds                    (may suggest peritonitis, ileus)
                     - hepatic / splenic friction rub            (suggests inflammation)
                     - bruits

  - percussion:      significant findings may include:
                     - hepatomegaly, splenomegaly
                     - abdominal tympany

  - palpation:       significant findings may include:
                     - tenderness, rigidity
                     - guarding, rebound tenderness
                     - bulges, masses, hepatosplenomegaly
                     - abdominal aortic distension / pulsation

  - advanced:        advanced abdominal testing includes:
                     - fluid wave / shifting dullness            (indicates ascites)
                     - Murphy’s sign                             (suggests acute cholecystitis)
                     - McBurney’s point, Psoas sign              (suggests appendicitis)
                     - obturator sign                            (suggests appendicitis, pelvic inflammation)

  - other:           other systems / tests to consider
                     - pelvic exam                               (cervical motion tenderness, masses, tenderness)
                     - hernia exam                               (hernia)
                     - rectal exam                               (masses, FOBT, tenderness)
                     - cardiopulmonary exam                      (atypical MI, angina, PNA, etc.)


- other studies
   - laboratory:     indications for labs include:
                     - metabolic panel:      evaluate metabolic causes of abdominal pain
                     - LFT, amylase:         evaluate upper abdominal pain, pain radiating to back
                     - urinalysis:           pyuria, hematuria
                     - β-HCG:                female who may be sexually active
                     - ABG:                  differentiate metabolic acidosis and necrosis

  - radiology:       indications for radiology include:
                     - plain film:          suspicion of SBO, perforation
                     - ultrasound:          RUQ pain, gynecologic pain
                     - CT abdomen:          no idea of what the hell’s going on



abdominal pain: red flags

  TABLE: Indications for Immediate Evaluation and Differential Diagnosis
  indication           differential
  abrupt onset         • perforation or rupture
                                                                                       YEPSA: Objectives (page 182 of 190)



                              • acute vascular even
                              • volvulus
                              • strangulated hernia
                              • ovarian torsion
                              • pancreatitis

     shock                    • perforation or rupture with bleed
                              • pancreatitis

     distension               • bowel obstruction
                              • ileus
                              • volvulus
                              • toxic megacolon
                              • abdominal aortic aneurism (AAA)
                              • ascites

     peritonitis              • appendicitis
                              • tics
                              • cholecystitis
                              • cholangitis
                              • abscess
                              • pelvic inflammatory disease (PID)
                              • pancreatitis



     BOX: Abdominal Red Flags
      Besides previously mentioned red flags, other signs and symptoms
        suggesting a more ominous cause of abdominal pain include:

        • fever
        • blood in stool, vomitus
        • persistent constipation
        • persistent N/V, diarrhea
        • severe pain
        • jaundice
        • family history of IBD, GI cancer
        • weight loss; growth deceleration in children




7.    Be able to evaluate, diagnose, and manage the following genitourinary complaints:
               • hematuria
               • acute scrotal pain
               • lower urinary tract symptoms
               • urinary incontinence

                   (based partially on objectives written by Rachel Lamb and Andrew Dodd)

hematuria
  - disorder:              presence of blood in the urine
  - differential:          differential diagnosis includes:
                           - trauma
                                                                                      YEPSA: Objectives (page 183 of 190)



                       - kidney stones
                       - urinary tract infection (UTI)
                       - benign prostatic hypertrophy (BPH)
                       - bladder cancer
                       - IgA nephropathy
                       - benign familial hematuria
  - clinical:          frank discoloration of the urine may be secondary to:
                       - macroscopic hematuria: frank blood in the urine
                       - hemoglobinuria:           presence of Hb in the urine
                       - myoglobuinuria:           presence of Mb in the urine

- bladder cancer
   - disorder:         cancer of the urinary bladder
   - etiology:         risk factors include:
                       - smoking
                       - chemical exposure
                       - chemotherapy, radiation therapy
                       - chronic bladder inflammation
                       - age (elderly)
                       - race (Caucasian)
                       - gender (male)
  - presentation:      painless hematuria
  - diagnosis
     - history:        history significant for:
                       - painless hematuria with occasional dysuria
                       - history of smoking
                       - industrial carcinogens
    - laboratory:      urinalysis and culture
    - procedures:      cystoscopy with cytology and biopsy, IVP
  - management:        varies with stage but may include:
                       - trans-urethral resection of the bladder
                       - radical cystectomy ± chemotherapy

- benign prostatic hyperplasia (BPH)
   - disorder:         enlargement of the prostate secondary to stromal and epithelial hyperplasia
   - etiology:         related to balance of androgens and estrogens
   - presentation:     urinary tract obstruction
   - diagnosis
      - history:       common symptoms include:
                       - hesitancy, weak stream
                       - nocturia
                       - urinary retention
                       - frequent UTI
      - examination: digital rectal exam (DRE)
      - laboratory:    common laboratory workup includes:
                       - PSA
                       - BUN, Cr
                       - urinalysis
      - imaging:       ultrasound
   - management
      - pharmacologic: α-antagonists (doxazosin, tamsulosin)
      - hormonal:      antiandrogens (finasteride, dutasteride)
      - surgical:      transurethral resection of the prostate (TURP), open resection
      - dilation:      transurethral balloon dilation

- renal calculi (kidney stones)
                                                                                         YEPSA: Objectives (page 184 of 190)



  - disorder:         nephrolithiasis / urolithiasis secondary to concretions in the urine
  - etiology:         varies with type
                      - calcium oxalate:      excessive Ca2+
                      - struvite:             urea-splitting bacteria (Proteus, Klebsiella, Serratia)
                      - uric acid:            gout, chemotherapy, acid/base metabolism disorders
                      - calcium phosphate: hyperparathyroidism, renal tubular acidosis
                      - cystine:              cystinuria
  - presentation:     severe flank pain
  - diagnosis
     - history:       common symptoms include:
                      - severe flank pain (may refer to testes, penis)
                      - restless patient
    - laboratory:     common laboratory tests include
                      - CBC
                      - BMP (BUN, Cr)
                      - urinalysis and culture
    - imaging:        abdominal x-ray, IVP
  - management
    - temporizing:    conservative therapy for up to 4 weeks
                      - 90% of stones ≤ 4 mm will pass without intervention
                      - 99% of stones ≥ 6 mm will require intervention
    - analgesia:      NSAIDs, narcotics
    - intervention:   types of urologic interventions include:
                      - extracorporeal shock wave lithotripsy (ESWL)
                      - percutaneous nephrolithotomy
                      - open surgery (rare)

- hematuria secondary to kidney disease
   - disorder:        kidney disease presenting with hematuria
   - etiology:        causes include:
                      - renal cell cancer
                      - polycystic kidney disease (PKD)
                      - papillary necrosis
                      - glomerular disease
   - diagnosis
      - history:      varies with etiology, but may include:
                      - hematuria
                      - pain
                      - hypertension
                      - palpable abdominal mass
                      - weight loss
      - laboratory:   labs may include:
                      - LFTs
                      - Ca2+
                      - specific blood tests (anti-nuclear Ab, anti-GBM Ab)
      - imaging:      imaging modalities may include:
                      - x-ray
                      - abdominal CT
      - procedures:   renal biopsy
   - management:      treatment may include:
                      - radical nephrectomy (renal cell CA)
                      - glucocorticoids, cytotoxic drugs (specific glomerulonephropathies)


acute scrotal pain
  - disorder:         pain in the scrotum
                                                                                       YEPSA: Objectives (page 185 of 190)



  - differential:      differential diagnosis includes:
                       - testicular torsion
                       - trauma
                       - incarcerated inguinal hernia
                       - infection (epididymitis)

- testicular torsion
   - disorder:         ischemia secondary to compression from twisting on the spermatic cord
   - etiology:         risk factors include:
                       - bell clapper deformity (nonattachment of testicles by gubernaculum to scrotum)
                       - abrupt temperature change
  - presentation:      acute testicular pain
  - diagnosis
     - history:        common symptoms may include:
                       - acute onset scrotal pain (often following vigorous activity or minor trauma)
                       - previous episodes of transient testicular pain
    - examination:     physical exam may include:
                       - loss of cremasteric reflex
                       - bell clapper deformity
                       - acute swelling
                       - tenderness
    - imaging:         color Doppler US to evaluate testicular perfusion, intrascrotal anatomy
  - management:        surgical detorsion and bilateral orciopexy (correct within 6 hours for best outcome)

- epididymitis
   - disorder:         inflammation of the epididymis
   - etiology:         bacterial infection
                       - sexually active:          C. trachomatis, N. gonorrhoeae
                       - non-sexually active:      UTI pathogens (E. coli, Pseudomonas)
                       chemical epididymitis (urinary reflux)
  - presentation:      gradual onset testicular pain (peak within 24 hours)
  - diagnosis
     - history:        sympoms may include:
                       - scrotal pain and edema
                       - urinary frequency, urgency, or dysuria
                       - urinary retention
                       - nausea, fever, chills
                       - abdominal / flank pain
    - laboratory:      workup includes:
                       - UA with Gram stain and culture
                       - urethral swab Gram stain and culture
  - differential:      rule out testicular torsion
  - management:        treatment may include:
                       - antibiotics
                       - analgesics
                       - supportive care (scrotal elevation and support, ice pack)

- testicular trauma
   - diagnosis:        US to determine integrity of the tunica albuginea
   - treatment:        scrotal exploration (if torn) with:
                       - removal of nonfunctional seminiferous elements
                       - closure of tear


- urinary tract infection (UTI)
   - disorder:         presence of microorganisms in the urine
                                                                                    YEPSA: Objectives (page 186 of 190)



                   - cystitis:       infection of the bladder
                   - pyelonephritis: infection of the kidney(s)
                   - prostatitis:    infection of the prostate

- etiology:        common causes vary with situation
                   - normal host:    E. coli (80% of all UTI), Staphylococcus saprophyticus (sexually active)
                   - nosocomial:     Enterobacter, Klebsiella
                   - nephrolithasis: Proteus, Klebsiella
                   - STIs:           Chlamydia trachomatis, Neisseria gonorrhoeae, HSV2

- epidemiology:    lifetime prevalence of 20% in women
                   accounts for 40% of nosocomial infections

- risk factors:    risk factors include:
                   - female gender
                   - foreign bodies (i.e. catheters)
                   - obstruction (pregnancy, prostatic enlargement, tumor, neurologic disorders, stones)
                   - vesicoureteral reflux
                   - antibiotic treatment
                   - sexual activity

- presentation:    frequency, urgency, dysuria, nocturia

- diagnosis
   - history:      women with classic UTI symptoms and no vaginal complaints need no further testing
   - laboratory:   dipstick urine positive for:
                   - leukocyte esterase
                   - nitrites
                   - white blood cells on microscopy
                   urine culture if pyelonephritis, recurrent, or equivocal U/A
                   - clean void method:         > 100,000 cfu / mL
                   - indwelling catheter:       > 10,000 cfu / mL
                   - straight catheter:         > 1,000 cfu / mL
                   - aseptic method:            any amount
  - procedures:    detailed workup (IVP or renal IS, cystocopy, VCUG) required for:
                   - first UTI in males
                   - first pyelonephritis in prepubescent females
                   - recurrent infections
                   - persistent symptoms after sterilization of urine (r/o carcinoma)

- differential:    symptoms suggestive of other diagnoses include:
                   - urethritis:     pain at onset of urination
                   - vaginitis:      external dysuria, vaginal irritation or discharge
                   - Chlamydia:      long, insidious onset
                   - pyelonephritis: fever, flank pain, nausea / vomiting

- management
  - general:       general measures include:
                   - wipe from front to back
                   - empty bladder before and after intercourse
                   - avoid contraceptive diaphragm

  - antibiotics:   antibiotics for uncomplicated UTI
                   prophylaxis for relapsing / reinfecting UTI
                                                                                            YEPSA: Objectives (page 187 of 190)



- urinary incontinence
   - disorder:       involuntary leakage of urine
   - etiology:       types of urinary incontinence include:
                     - stress incontinence
                     - overflow incontinence
                     - urge incontinence
                     - true incontinence
   - diagnosis
      - history:     important questions to ask include:
                     - amount of leakage
                     - association with activities
                     - voiding symptoms
                     - PMH (meds, trauma, pelvic / urinary tract surgery, OB Hx, malignancy, NM disorders, DM)
      - examination: important examination includes:
                     - perianal sensation
                     - sphincter tone
                     - lower extremity motor function, sensory function, and reflexes
                     - vaginal exam
      - workup:      further evaluation may include:
                     - UA with culture
                     - cytology
                     - measurement of postvoid residual urine volume (PVR)
                     - cystoscopy
                     - urodynamic evaluation
   - management:     varies with etiology


     TABLE: Etiology and Classification of Urinary Incontinence
                disorder                          classification                           treatment
                                                                                           • bladder neck suspension
                          leakage with increase in       low resistance between bladder    • pessaries
         stress
                          intraabdominal pressure               neck and urethra           • estrogen therapy
                                                                                           • α-adrenergic stimulation
                                                         urinary retention from bladder
                       overfilling and uncontrollable                                      • self catheterization 1
         overflow                                         outlet obstruction or detrusor
                                  emptying                                                 • surgical relief
                                                                   hypotonicity
                                                                                           • anticholinergics
                                                              detrussor instability        • α-adrenergic stimulation
         urge           inability to get to bathroom
                                                              (neurologic defects)         • bladder denervation
                                                                                           • augmentation cystoplasty
                                                             sphincter abnormality
                        constant or periodic loss of
         true                                                (exstrophy of bladder,        • surgical intervention
                          urine without warning
                                                             vesicovaginal fistula)
     1
         avoid indwelling catheters due to risk of UTI



8.        Be able to evaluate neck masses.

                    (based primarily on objectives written by Catherine Skagen)

- neck mass: evaluation
   - history:        important elements of the history include:
                     - mass duration / growth
                     - malignancy history
                                                                                     YEPSA: Objectives (page 188 of 190)



                   - prior surgeries
                   - neck irradiation
                   - recent URI or other illness

- examination:     full neck examination includes:
                   - lymphadenopathy
                   - thyroid
                   - ROM
                   - old surgical scars
                   - signs of infection (peritonsillar abscess, URI, pharyngitis, thrush)
                   - signs of URI
                   - palpitations / tachycardia (Graves)
                   - pretibial myxedema


TABLE: Differential Diagnosis and Clinical Features of Neck Masses
classification disorder                         clinical features
thyroid        thyroid mass                     workup:
               • Hashimoto’s                    • exam (distinguish goiter from nodular)
               • iodine deficiency              • order TSH, free T3
               • Grave’s disease                   - high TSH, low T3: Hashimoto, subacute, iodine def.
               • DeQuervain’s (subacute)           - low TSH, high T3: Grave’s, adenoma, TMNG
               • cyst                           • FNA
               • neoplasm                       • radioactive iodine uptake (scintigraphy)
               • multinodular goiter               - “hot” usually benign
                                                   - “cold” commonly benign, but requires more workup
                                                • ultrasound (controversial; will pick up “incidentalomas”)

infectious       peritonsillar abscess             symptoms: sore throat, dysphagia, “hot potato” voice, deviated
                                                      uvula, fever, drooling
                                                   diagnosis: aspiration
                                                   treatment: I&D, Abx, hydration

                 mononucleosis                     symptoms:
                                                   • fever, sore throat, LAD (80%)
                                                   • fatigue
                                                   • hepatosplenomegaly
                                                   • exudative adenotonsillitis
                                                   • post-cervical lymphadenopathy

                                                   diagnosis: CBC, monospot, (+) heterophile Ab

                 CMV                               symptoms: mild URI, no exudative pharyngitis
                                                   diagnosis: (–) heterophile Ab, CMV serology

                 TB                                symptoms: painless nodes, lack of erythema, open sinus tracts
                                                   diagnosis: smear / pathology of node or drainage, culture

                 atypical infection                clinical features:
                                                   • atypical mycobacterium: unilateral LAD, neg. PPD/CXR
                                                   • AIDS: hairy leukoplakia, Kaposi’s, candidiasis, aphthous
                                                   • toxoplasmosis: cold sx, post-triangle LAD, Ab test
                                                   • actinomyces: no LAD, blue, rubbery, central loculation
                                                   • cat scratch disease: regional LAD, mild sx
                                                                              YEPSA: Objectives (page 189 of 190)



inflammatory   retropharyngeal abscess       epidemiology: kids (usually)
                                             symptoms: fever, malaise, dysphagia, non-discrete
                                             diagnosis: lateral x-ray, axial CT

               parapharyngeal abscess        symptoms: fever, rigors, malaise, dysphagia, aphasia, drooling,
                                               torticollis
                                             diagnosis: leukocytosis, annemia, CT

               salivary gland infection      epidemiology: elderly, dehydrated
                                             symptoms: enlarged / tender gland, pain w/ eating, d/c
                                             diagnosis: x-ray for sialolith, CT if abscess suspected

vascular       jugular vein thrombosis       symptoms: diffusely swollen, tender, hx of indwelling catheter
                                             diagnosis: CT w/ contrast or duplex, Doppler US

congenital     thyroglossal duct cyst        epidemiology: < 30 y/o
                                             location: midline, inferior to hyoid
                                             examination: soft, retracts with tongue protrusion

               branchial apparatus anomaly   epidemiology: < 30 y/o
                                             location: between ear canal & clavicle
                                             examination: smooth, fluctuant, nontender, ill-defined margins
                                             diagnosis: needle aspiration → decompression; thin,
                                               mucopurulent fluid

               cystic hygroma                epidemiology: < 2 y/o (90%)
                                             examination: multiloculated, cystic mass
                                             diagnosis: transillumination, CT scan, asp. (clear yellow)
                                             complications: enlarges during URI, compromising airway

               hemangioma                    epidemiology: < 6 mo/o
                                             diagnosis: CT scan
                                             complications: can lead to airway obstruction
                                             prognosis: proliferate during year 1, most regress by 5 y/o

               dermoid cyst                  epidemiology: 20’s
                                             location: midline
                                             examination: smooth, not attached to larynx or hyoid, dougy
                                               consistency

               teratoma                      location: midline or nasopharyngeal
                                             examination: irregular, firm
                                             complications: can lead to airway obstruction

               laryngocele                   examination: soft, compressible, visible with Valsalva

               mucocele (ranula)             location: associated with sublingual gland
                                             examination: soft, compressible
                                             diagnosis: salivary amylase, CT scan
YEPSA: Objectives (page 190 of 190)

								
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