Dr neil jaddou m. D board certified and professor of family medicine



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# Indications for CABG are GNEMONIC(UnLimiTeD):

U : Unable to perform PCI(diffuse disease)

L : Left main coronary artery

T : Triple-vessel disease

D : Depressed ventricular function.

# Drug that increases the elasticity of RBC : Pentoxyphilline

# Heparin induced thrombocytopenia treatment : Direct thrombin inhibitors(Hirudin, lepirudin, bivalirudin)

1. A 52-year-old white male is being considered for pharmacologic treatment of hyperlipidemia because of an LDL cholesterol level of 180 mg/dL. Before beginning medication for his hyperlipidemia, he should be screened for:  (check one)

A. Hyperthyroidism

B. Hypothyroidism

C. Addison’s disease

D. Cushing’s disease

E. Pernicious anemia

Answer:


1.B

Somerset Family Medicine Clinical Module

Bread & Butter of Family Medicine:

Walking Into The Exam Room & The Board



ANTIBIOTICS

If you over prescribe can cause c. dificil colitis (psudomembreneous colitis), MRSA,candida, (can give diflucon 150mg)



Sore Throat: Majority of ST are caused by virus, ST can potentially be strep if you have the following:

  • ST, HA, fever, stomach pain, dysphagia, “swallowing glass or razer blade” body pain, no cough

  • May have nausea and vomiting, Phyryngeal exudate (white spot on tonsils)

  • Beefy red throat, Petachie on posterior palate

  • Anterior submandibular LN. (post. LN highly suggestive of Mono (infectious mono. Especially if patient is very fatigue) Some patient may have both. Do not give Amoxil in mono they may get a rash. To test for mono, do blood test called monospot. To test for Strep, do rapid strep. Sometime some doctors order strep culture.

URI: Majority are cold virus

  • Duration, can last 5-10d sometime longer.

  • Clear runny nose, post nasal drip, sneezing, bodyache, tired, fever, ST, HA

  • Cough, mainly dry. If sputum of the cough is yellow or green does not always mean bacterial. Do not prescribe Abx, some are allergic rhinitis. Above you can prescribe non-sedating antihistamine such as Claritin and herbal medicine such as vitamin C, fluids, rest etc

Acute Sinusitis; Sever sinus tenderness, headache, teeth pain, frontal sinus pain, sometimes worse with position. You may prescribe abx.

OM: if ear drum is red give abx. In Europe they do not prescribe abx for om. They give supportive RX of Ibuprofen and possible eardrops such Aurlgan ear drop for pain.

Otitis externa: if turgate is painful, ear canal swollen and eardrum is normal can give cortisporing ear drops. If sever can also give oral abx.

Acute Bronchitis: Majority is virus. However in smokers/asthmatics or COPD can potentially turn into pneumonia. So treat with Abx for above patients, possible inhaler (or nebulizer) could be steroid inhalers or po steroids as well depending on breathing status, may give cough syrup with codine (do not drive), or may send to ER. Others can treat with cough syrup alone.

Pneumonia: to be safe send to ER. However some can be treated with Rocephin shot plus z-pack or levaquin. Do not treat anyone with pneumonia as an outpatient who is SOB (low pulse ox) or pediatrics or elderly.

Laryngitis: Caused by virus use honey and tea, Tylenol or Ibuprofen if needed.( hoarsness case, ddx)

Tuberculosis: Hemoptysis, (ddx), Malaria:

H. Pylori: Causing gastritis and PUD, Nobel prize, RX with triple therapy of PPI/Abx/Abx , bismuth (black stool/tongue)

Traverlers diarrhea: Cipro/Bismuth Watery diarrhea, Giardia/Cholera

Hemmorrhagic colitis/Food poisoning: Bloody diarrhea: E. coli: O157:H7,

Gastro-enteritis: BRATY diet, if not better get fecal leukocytes, c.dificil antibody, stool culture ova/parasite

Pinworms: fecal/oral, Dx with Scothch tape “tape test” in am, anal itching/wt loss , Rx: treat ALL family mebendazole

Scabies:Trails burrowing mites are linear/s-shaped tracks accompanied by rows of pimple-like insect bites. Elemite cream

Clinical Vignettes

1. A 27-year-old male presents with what he thinks is a sinus infection. He has a 2-day history of right maxillary pain associated with nasal congestion and clear rhinorrhea.  The only significant findings on examination are a low-grade fever and subjective tenderness with palpation over the right maxillary sinus. Which one of the following treatments is most supported by current evidence?  (check one)

A. Antihistamines

B. Oral decongestants

C. Topical vasoconstrictor sprays

D. Oral analgesics

E. Nasal lavage

2. A 30-year-old white male complains of several weeks of nasal stuffiness, purulent nasal discharge, and facial pain.  He does not respond to a 3-day course of trimethoprim/sulfamethoxazole (Bactrim, Septra).  Follow-up treatment with 2 weeks of amoxicillin/clavulanate (Augmentin) is similarly ineffective. Of the following diagnostic options, which one is most appropriate at this time?  (check one)

A. Pulmonary function testing

B. Coronal CT of the sinuses

C. Culture and sensitivity testing of the discharge

D. Erythrocyte sedimentation rate

3. A 32-year-old African-American female presents with a 3-day history of fever, cough, and shortness of breath.  She has been healthy otherwise, except for a sinus infection 2 months ago treated with amoxicillin.  She does not appear toxic. A chest radiograph reveals an infiltrate in the right lower lobe, consistent with pneumonia. Which one of the following would be the best choice for antibiotic treatment?  (check one)

A. High-dose amoxicillin

B. Azithromycin (Zithromax)

C. Doxycycline

D. Levofloxacin (Levaquin)

E. Cefuroxime axetil (Ceftin)

4. A 7-year-old male presents with a 3-day history of sore throat, hoarseness, fever to 100 degrees (38 degrees C), and cough. Examination reveals injection of his tonsils, no exudates, and no abnormal breath sounds. Which one of the following would be most appropriate?  (check one)

A. Recommend symptomatic treatment

B. Perform a rapid antigen test for streptococcal pharyngitis

C. Treat empirically for streptococcal pharyngitis

D. Perform a throat culture for streptococcal pharyngitis

E. Perform an office test for mononucleosis


5. An 18-year-old male presents with a sore throat, adenopathy, and fatigue. He has no evidence of airway compromise. A heterophil antibody test is positive for infectious mononucleosis.
Appropriate management includes which one of the following?   (check one)

A. A corticosteroid

B. An antihistamine

C. An antiviral agent

D. Strict bed rest

E. Avoidance of contact sports1.


6. The treatment of choice for a 4-month-old infant with suspected pertussis is:  (check one)

A. Supportive care (respiratory, fluids) only

B. Ceftriaxone (Rocephin)

C. Ampicillin

D. Gentamicin (Garamycin)

E. Erythromycin


Answers:


1. C 2.B 3.D 4.A 5.E 6.B

Antibiotic

Adult Dose

Pediatric Dose

Comments

Amoxicillin (Amoxil) (a form of PCN)1st line, Inhibit Cell wall

Augmentin (amoxil + Clav. acid)

500mg TID x 7-10 d

Also comes in 250mg



125mg/5ml TID x 7-10 d

250mg/5ml TID x 7 -10d

30-50mg/kg/day


Not if allergic to PCN.

Cephalexin (Keflex)

1st line, inhibit cell wall

1st gen. cephalosporin



500mg TID x 7-10 d

Also comes in 250mg



Best for skin infection

125mg/5ml TID x 7-10 d

250mg/5ml TID x 7-10 d

30-50mg/kg/day


If allergic to PCN may be allergic to Keflex (5%). give if rash, aphylactic Dont GIVE

Erythromycin, Macrolide 1st line

Interfere with protein synthesis



500mg TID x 7-10 d

125mg/5ml TID x 7 days

250mg/5ml TID x 7 days

30-50mg/kg/day


Give if allergic to PCN. SE: GI

Azithromycin (Zithromax) (macrolide)

2nd line: Z-pack

Z-pack 2 today and one day 2-5

10mg/kg QD x 1 day +

5mg/kg QD x4 days

100mg/5ml, 200mg/5ml


Every patient wants z-pack. Atypical pneumonia caused by Mycoplasma, Treat Chlymedia

Ciprofloxacin (Cipro)2nd line

Quinolones/Inhibit DNA

500mg BID x 3-5 d

For UTI in elderly 7d



For age >18

Levaquine forpneumonia

Risk tendinitis/tendon rupture,. Treat divertics

Ceftriaxone (Rocephin)2nd line, IM 3rd gen. cephlo, cell wall







Used of sever infection and pneumonia, used to treat GC

Trimethoprim/Sulfamethoxazole (Bactrim-DS)2nd line, Sulfonamid

Bactrim DS 3-5d UTI 7 day in elderly

In children bactrim liquid

MRSA treatment

Not for pregnant women or allergic to sulfa drugs.



Metronidazole (Flagyl)

500mg TID x 5-7 d




Treat c-diff., bacteria vaginosis, and trichemonas, Not for pregnant women. Can Not Drink ETOH. Diverticulitis

Doxycycline (Vibramycin, tetracycline)

2nd line



100mg PO BID

>12 years

Acne. MRSA, if allergic to Sulfa. bronchitis Not for pregnant women. Treat Chlymedia

Nitrofurantoin (Macrobid)

100mg BID x 7 days




UTI treatment for pregnant women.

Acyclovir and Valtrex, antivirals

Look up dosing

Valtrex very expensive

Treat Shingles and genital herps

Bacroban cream or ointment







Minor skin infection, Impitigo

Sulfasulamide (Bleph-10) opth sln

Tobramyocing op slon. Erythr oint







Eye infections

BOARD PEARLS :

# Amoxicillin used for treatment of lyme disease.

# Erythromycin +Theophylline leads to Theophylline toxicity.Treatment for theophylline toxicity is beta blockers.

# Azithromycin is the drug of choice for atypical pneumonia, rheumatic fever and prophylaxis of MAC.

# Ciprofloxacin is the drug of choice for Anthrax,Typhoid fever in OPD,Prophylaxis of meningococcal meningitis.

# Ciprofloxacin causes Seizures and Phototoxicity.

# Acyclovir +Valcyclovir is used for treatment of H.Simplex.

# MRSA outpatient we use Bactrim-DS , if inpatient we use Vancomycin.

# linezolid(Zyvox,vivox) is also used to treat MRSA if they are allergic to clindamycin, it is very expensive so not used often.

# patient with Anaphylaxis treatment order CPR(if patient is not responsive)àepinephrine injectionàIV fluidsàantihistamines and steroids given.

# Augmentin is a penicillin resistant penicillin.

# Alendronate(anti osteoporosis) helps to prevent hip fracture.

# Pentoxyfylline is used for treatment of venous ulcers if patient is unable to tolerate compression therapy.

# Indomethacin not prescribed for older patients due to its propensity to produce more CNS adverse effects than other NSAIDS.

# Sulfonamides side effects : GNEMONIC (ABC RASH)

A : aplastic anemia

B :bilirubin displace(kernicterus in meningitis)

C : crystalluria

R : rash(most common side effect)

A : acetylation



S : SLE

H : hemolysis(G6PD deficiency).


# Primigravida with pregnancy with vomiting and nausea treatment is Doxylamine and Vitamin B6
# Metronidazole is also used to treat Pseudomembranous colitis and Amoebiasis. It is contraindicated for pregnant woman.
# Doxycycline is the only tetracycline that is safe in kidney disease patients.


Somerset Family Medicine Clinical Module

Bread & Butter of Family Medicine:

ASTHMA

Asthma is a chronic pulmonary disease characterized by inflammation, hypersecretion and bronchospasm of airways.

Diagnostic evaluation: history and physical exam are crucial for the diagnosis.

Remember: not all wheezes are asthma, not all asthma wheezes! Peak flow testing can provide additional evidence of airway obstruction and support clinical impression. Airway obstruction exists when peak flow is less than 80% of predicted. When diagnosis is still uncertain, complete pulmonary function testing can be obtained:

  • Allergy testing (skin test, blood test, in vitro-specific IgE antibody test)

  • Chest x-ray to exclude alternatives, hyperinflation seen

  • Arterial blood gas(mild hypoxia & respiratory alkalosis)

  • Bronchial provocation (methacholine challenge) if spirometry is normal or near normal

  • Sinus x-ray or CT scan

  • CBC with eosinophils, total IgE, sputum exam

  • spirometry/PFTs -decrease FEV1/FEV, increase RV,increase TLC(PFTs may be normal or exacerbations)



In 2-23% of adults with asthma, and rarely in children with asthma, aspirin (acetylsalicylic acid) and non-steroidal anti-inflammatory drugs (NSAIDs) cause asthma exacerbations. ASA triad (Samters triad): hypersensitivity to aspirin, chronic rhinosinusitis and nasal polyps, and severe bronchial asthma.

Lung volume measurements in diagnosis of asthma(PFTs):

Test

Normal

Mild

Moderate

Severe

FEV1(% of FEC)

>75

60 - 75

40 - 60

<40

RV(% of predicted)

80-120

120 - 150

150 - 175

>200





Here are the key messages from the EPR-3 (Expert Panel Report) Asthma Guidelines.

  1. Inhaled corticosteroids are the most effective anti-inflammatory medication for long term management of persistent asthma. 
    2) Write asthma action plan for every patient
    3) Initial assessment of asthma severity
    4) Review of the level of asthma control (impairment and risk) at all follow up visits

  2. 5) Periodic, follow up visits (at least every 6 months)
    6) Assessment of exposure and sensitivity to allergens and irritants and

  3. recommendation to reduce relevant exposures. 
    7) Asthma education by a qualified health professional.
    9) Education regarding the danger of over-use of short-acting beta-agonists.



Classification of Asthma Severity


Components of Severity

Intermittent

Persistent Mild

Persistent Moderate or Severe

Symptoms

Less or 2 days per week

More 2 days per week, but not daily

daily

Nighttime awakenings

Less or 2 times per month

3 to 4 times per month

More than once per week

Short-acting beta agonist use for symptom control (not prevention of exercise-induced bronchospasm)

Less or 2 days per week

More than 2 days per week, but not more than once per day

Daily

Interference with normal activity

none

Minor limitation

Some or extremely limitation

Lung function

Normal FEV1 between exacerbation; FEV1 more than 80%of predicted; FEV1/FVC normal

FEV1 more or equal 80 % of predicted;

FEV1/FVC normal



FEV1 more than 60 but less 80 % (M) or less than 60% (S);

FEV1/FVC reduced 5%





Classification of Asthma Control

Stepwise Approach for Asthma Management

Step

Preferred treatment

Alternative treatment

1 (intermittent asthma)

Inhaled short-acting Beta2 agonist, as needed Albuterol (Proair) Salbutamol (Ventolin)




2 (persistent asthma: mild, moderate and severe)

Low-dose inhaled corticosteroids Beclomethasone (Q-var)

Cromolyn, leukotriene receptor antagonist Singulair, nedocromil, theophylline

3

Low-dose inhaled corticosteroids plus long-acting inhaled Beta2 agonist

Salmeterol (Serevent) or Medium-dose inhaled corticosteroids

Low-dose inhaled corticosteroid plus on the of the following – Singulair, theophylline or Zileuton (Zyflo)

4

Medium-dose inhaled corticosteroids plus long-acting inhaled beta2 agonist

Adv-air (Fluticasone plus salmeterol)

Medium-dose inhaled corticosteroid plus one of the following – Singulair theophylline or Zileuton

Consult with asthma specialist if step 4 is required, consider consultation at step 3. Step 5 and 6 are not pictured as it is for asthma specialist.

Each step: Patient education, environmental control, management of comorbidities.

Step 2-4: consider subcutaneous allergen immunotherapy for patients who have allergic asthma.

Quick-relief medication for all patients: Inhaled short-acting beta2 agonist as needed: up to 3 treatments at 20-minute intervals. Short course of oral corticosteroids may be needed.

Use of inhaled short-acting beta2 agonist 2 or more days a week for symptom relief (not for exercise-induced asthma) indicated inadequate control and the need to step up treatment.



If step-up needed, first check adherence, environmental control, comorbid conditions.

Step down is possible if asthma is well controlled at least three months.

DRUG

MOA

S/E

BETA 2 Agonists

albuterol/salbutamol

Terbutaline :short acting.Relaxes bronchial smooth muscle.D.O.C for pregancy with acute asthma attack.

Salmeterol and formeterol : long acting agent for prophylaxis.

formeterol(fast acting, used in acute attack & prophylaxis.



Tremors

Tachycardia

Tolerance


Corticosteriods

Inhaled corticosteroids are 1st line treatment for long-term control of asthma

Beclomethasone, prednisone: inhibit the synthesis of virtually all cytokines.

loss of potassium

obesity


puffiness of face(moon face)

cough


sore throat

muscarinic antagonists

Ipratropium and Tiotropium: competitively blocks muscarinic receptors, pretending bronchoconstriction.

D.O.C in labour with acute attack of asthma.



drowsiness, blurred vision, dry mouth, heat intolerance, flushing, decreased sweating, difficulty urinating, abdominal cramping, constipation, rapid heart beat, confusion, memory problems, and glaucoma

methylxanthines

Theophylline:causes bronchodilation by inhibiting phosphodiesterase,thereby decreasing cAMP hydrolysis and increasing cAMP levels.

Is a zero order kinetics.

cant be given as inhalation.


cardiotoxicity

neurotoxicity

theophylline+ciprofloxacin/erythromycin : inhibit metabolism of theophylline and leads to toxicity.


cromolyn

prevents the release of vasoactive mediators from mast cells.useful for exercise-induced bronchospasm. effective only for prophylaxis of asthma ; not effective during an acute attack. toxicity is rare.

Coughing

nausea


throat irritation

chest tightness



anti leukotrines

zileuton: A 5-lipoxygenase pathway inhibitor. blocks conversion of arachidonic acid to leukotrienes.

Monterlukast , Zafirleukast: blocks leukotriene receptors.

headache;

stomach pain, heartburn, upset stomach, nausea, diarrhea;

tooth pain;

tired feeling;

fever, stuffy nose, sore throat, cough, hoarseness; or

mild rash.



Mast cell stabilizers

Nedocromil,

sodium cromoglycate ,

ketotifen

used only for prophylaxis and not used for treatment.



headache ,cough,throat irritation and abdominal pain.

stop antigen - antibody reaction

Omalizumab(Xolair): antibody against anti IgE antibody (monoclonal antibody against IgE)

Used for prophylaxis.



tightness in your chest, trouble breathing,

hives or skin rash,

feeling anxious or light-headed, fainting,

warmth or tingling under your skin,

swelling of your face, lips, tongue, or throat.



ASTHMA MANAGEMENT WITH DRUGS

Board pearls:

# beta 2 agonists + steroids : decrease pottasium in asthma patients.

# meds for asthma exacerbation (mnemonic): ASTHMA

A - albuterol

s - steroids(Beclomethasone and predisone)

T - Theophylline

H - humidified o2

M - monterleukast , magnesium

A - anticholinergics( Ipratropium and Tiotropium)

# Corticosteroids inhaled in rush & can lead to thrush

# asthma should be suspected in children with multiple episodes of CROUP & URIs associated with dyspnea.

Clinical Vignettes

1. A 22-year-old competitive cross-country skier presents with a complaint of not being able to perform as well as she expects.  She has been training hard, but says she seems to get short of breath more quickly than she should.  She also coughs frequently while exercising. A review of systems is otherwise negative.  Her family history is negative for cardiac or pulmonary diseases.  Her physical examination is completely normal, and pulmonary function tests obtained before and after bronchodilator use are normal. After you discuss your findings with the patient, she acknowledges that her expectations may be too high, but can think of no other cause for her problem. Which one of the following would be the next reasonable step?  (check one)

A. An echocardiogram to look for cardiomyopathy or valvular dysfunction

B. Counseling regarding competition stress and athlete burnout syndrome

C. A sports medicine consultation to evaluate her training regimen

D. A trial of inhaled albuterol (Proventil) for exercise-induced bronchospasm

2. A 24-year-old female with a past history of asthma presents to the emergency department with an asthma exacerbation.  Treatment with an inhaled bronchodilator and ipratropium (Atrovent) does not lead to significant improvement, and she is admitted to the hospital for ongoing management.  On examination she is afebrile, her respiratory rate is 24/min, her pulse rate is 92 beats/min, and oxygen saturation is 92% on room air.  She has diffuse bilateral inspiratory and expiratory wheezes with mild intercostal retractions. Which one of the following should be considered in the acute management of this patient?  (check one)

A. Chest physical therapy

B. Inhaled fluticasone/salmeterol (Advair)

C. Oral azithromycin (Zithromax)

D. Oral prednisone

E. Oral theophylline

3. A 6-year-old male is brought in for evaluation by his mother, who is concerned that he may have asthma. She reports that he coughs about 3 days out of the week and has a nighttime cough approximately 1 night per week. There is a family history of eczema and allergic rhinitis. Which one of the following would be the preferred initial treatment for this patient?   (check one)

A. A leukotriene receptor antagonist such as montelukast (Singulair)

B. A low-dose inhaled corticosteroid such as budesonide (Pulmicort Turbuhaler)

C. A long-acting beta-agonist such as salmeterol (Serevent)

D. A mast-cell stabilizer such as cromolyn sodium (Intal)

4. When prescribing an inhaled corticosteroid for control of asthma, the risk of oral candidiasis can be decreased by:  (check one)

A. using a valved holding chamber

B. limiting use of the inhaled corticosteroid to once daily

C. adding nasal fluticasone propionate (Flonase)

D. adding montelukast (Singulair)

E. adding salmeterol (Serevent)

Answers:


1.D 2.D 3.B 4.A

Somerset Family Medicine Clinical Module

Bread & Butter of Family Medicine:

THYROID DISEASE
Epidemiology:

- Hypothyroidism: 4-6% of the population, Primary congenital hypothyroidism – 1/3,000 infants

-Hyperthyroidism:2-3% of the population

-Age – onset is 40s-50s for both hypo- and hyperthyroidism

-Sex – MIndications for Testing: Symptoms of hyper- or hypothyroidism, Family history of autoimmune thyroiditis, Goiter on physical exam
Testing of Thyroid Function

TFTs include, TSH, T4,T3



TSH measurement: The single best test for assessing thyroid function.

High TSH levels lead to 1° hypothyroidism; low TSH levels lead to thyrotoxicosis.



Radioactive iodine uptake (RAIU) and scan: Determines the level of iodine

uptake by the thyroid. Useful in differentiating thyrotoxic states, but

has a limited role in determining malignancy.

Diagnosis

TSH

T4

T3

Causes

1° hyperthyroidism

Low

High

High

Graves’ disease, toxic multinodular goiter, toxic adenoma, amiodarone,

molar pregnancy, postpartum

thyrotoxicosis, postviral thyroiditis.


1° hypothyroidism

High

Low

Low

Hashimoto’s thyroiditis, hypothyroid

phase of thyroiditis, iatrogenic

factors (radioactive iodine thyroid

ablation, excision with inadequate

supplementation, external radiation,

lithium, or amiodarone), iodine

defi ciency, infi ltrative disease.


Total T4 measurement: Not an adequate screening test. Ninety-nine percent, of circulating T4 is bound to thyroxine-binding globulin (TBG). Total T4 levels can be altered by changes in levels of binding proteins.

T3 resin uptake (T3RU): Used with total T4 or T3 to correct for changes,in TBG levels (e.g., the free thyroxine index = total T4 × T3RU).

Free T4 measurement: The preferred screening test for thyroid hormone levels; more useful for nstable thyroid states.
Hyperthyroidism

Refers to causes of thyrotoxicosis (↑ levels of T3/T4 due to any cause) in which, the thyroid overproduces thyroid hormone, including Graves’ disease, toxic, multinodular goiter (also called Plummer’s disease), and toxic adenomas.


HISTORY/PE

Presents with weight loss, heat intolerance, nervousness, palpitations, ↑bowel frequency, insomnia, and menstrual abnormalities.

Exam reveals warm, moist skin, goiter, sinus tachycardia or atrial fibrillation, fine tremor, lid lag, and hyperactive refl exes. Exophthalmos, pretibial myxedema, and thyroid bruits are seen only in Graves’ disease

DIAGNOSIS

The initial test of choice is serum TSH level, followed by T4 levels and, rarely,

T3 (unless TSH is low and free T4 is not elevated).

TREATMENT


  • 1°therapy is radioactive 131I thyroid ablation; antithyroid drugs (methimazole or propylthiouracil) may also be used if radioactive iodine is not indicated. Thyroidectomy is rarely indicated.

  • Give propranolol for adrenergic symptoms while awaiting the resolution of hyperthyroidism.

  • Administer levothyroxine to prevent hypothyroidism in patients who have undergone ablation or surgery.

Hypothyroidism

Hashimoto’s thyroiditis is the most common cause of hypothyroidism. Anti-TPO antibodies are _. The second most common cause is iatrogenic. Myxedema coma refers to severe hypothyroidism with ↓ mental

status, hypothermia, and other parasympathetic symptoms. Mortality is 30–60%.

HISTORY/PE

Presents with weakness, fatigue, cold intolerance, constipation, weight gain, depression, menstrual irregularities, and hoarseness. Exam may reveal dry, cold, puffy skin accompanied by edema, bradycardia, and delayed relaxation of DTRs.

TREATMENT


  • Uncomplicated hypothyroidism (e.g., Hashimoto’s disease): Administer levothyroxine.

  • Myxedema coma: Treat with IV levothyroxine and IV hydrocortisone (if adrenal insufficiency has not been excluded).



Thyroiditis:

Inflammation of the thyroid gland. Common subtypes include subacute granulomatous, radiation-induced, autoimmune (lymphocytic, chronic, or Hashimoto), postpartum, and drug-induced (e.g., amiodarone)



HISTORY/PE

The subacute form presents with a tender thyroid accompanied by malaise and URI symptoms. Other forms are associated with painless goiter.



DIAGNOSIS

Thyroid dysfunction (typically thyrotoxicosis followed by hypothyroidism), with ↓ uptake on RAIU during the thyrotoxic phase.



TREATMENT

  • β-blockers for hyperthyroidism; levothyroxine for hypothyroidism.

  • Subacute thyroiditis is usually self-limited; treat with NSAIDs or with oral

corticosteroids for severe cases.
Thyroid Neoplasms :

Thyroid nodules are very common and show an ↑ incidence with age. Most are benign.

HISTORY/PE

-Usually asymptomatic on initial presentation.

-Hyperfunctioning nodules present with hyperthyroidism and local symptoms, (dysphagia, dyspnea, cough, choking sensation) and are associated with a _ family history (especially medullary thyroid cancer).

- ↑ risk of malignancy is associated with a history of neck irradiation, “cold” nodules on radionuclide scan, male sex, age < 20 or > 70, firm and fixed solitary nodules, a _ family history (especially medullary thyroid cancer), and rapidly growing nodules with hoarseness.

-Medullary thyroid carcinoma is associated with multiple endocrine neoplasia (MEN) type 2 and familial medullary thyroid cancer.

DIAGNOSIS

- The best method of assessing a nodule for malignancy is fi ne-needle aspiration (FNA), which has high sensitivity and moderate specificity.

- TFTs (TSH to exclude hyperfunction).



- Ultrasound determines if the nodule is solid or cystic; a radioactive scan determines whether it is hot or cold (cancers are usually cold and solid). Hot nodules are never cancerous and should not be biopsied.


  • Type

  • character

Prognosis

  • Papillary

  • Represents 75–80% of thyroid

  • cancers. The female-to-male ratio is

  • 3:1. Slow growing; found in thyroid

  • hormone–producing cells.

  • Ninety percent of patients survive 10

years or more after diagnosis; the

  • prognosis is worse in elderly patients

  • or those with large tumors.

  • Follicular

  • Accounts for 17% of thyroid

  • cancers; found in thyroid hormone–

  • producing cells

  • Ninety percent of patients survive 10

  • years or longer after diagnosis; the

  • prognosis is worse in elderly patients

  • or those with large tumors

  • Medullary

  • Responsible for 6–8% of thyroid

  • cancers; found in calcitoninproducing

  • C cells; the prognosis

  • is related to degree of vascular

  • invasion.

  • Eighty percent of patients survive at

  • least 10 years after surgery.

  • Anaplastic

  • Accounts for 2% of thyroid

  • cancers; rapidly enlarges and

  • metastasizes.

  • Ten percent of patients survive for

  • > 3 years.

BOARD PEARLS:
# sodium iodine ,pottasium iodide and lugol’s iodide are fast acting antithyroid drugs A/K/A thyroid constipating drugs.These are the drug of choice for thyroid storm.
# Euthyroid sick syndrome: TSH-normal , T3 very low, caused due to MOF,sepsis,shutdown metabolism to conserve energy,supress conversion of free T4 to T3. it is normal and there is no treatment.
# TBG levels are tested to find out if thyroid hormones levels are endogenously produced or endogenously produced.
# THYROID STROM : TREAT urgently with IV propranalol,propylthiouracil and corticosteroids.high dose potassium iodide SSKI is also used.
# Bone loss is seen with hyperthyroidism.
# Hypothyroid and PKU could present as delayed walking in children, mental retardation and global developmental delay.

BOARD PEARLS FOR THYROID NEOPLASMS :
# PAPILLARY CARCINOMA : it is the slow growing and spreads via lymphatics. MNEMONIC 5P’s

P : papillae (branching)

P : palpable lymph nodes

P : pupil nuclei (orphan annie nuclei)

P : psammoma bodies with in lesions

P : positive prognosis.


# FOLLICULAR CARCINOMA : Spreads hematogenously with distant metastasis to lung and bone.

Hurtle cells are seen in both papillary and follicular carcinomas but mostly seen in follicular carcinoma.


# MEDULLARY CARCINOMAS : Arise from parafollicular cells of the thyroid.

medullary carcinoma is the only cancer with an elevated CALCITONIN level .

medullary carcinoma : DNA testing is the most effective screening test.
# ANAPLASTIC CARCINOMA : Highly malignant with rapid and painful enlargement.

spreads by direct extension.

# Cold nodules on RAI scan should be biopsy.
# Hyperfunctioning thyroid nodules are not malignant

Clinical Vignettes
1. An asymptomatic 55-year-old male visits a health fair, where he has a panel of blood tests done.  He brings the results to you because he is concerned about the TSH level of 12.0 µU/mL (N 0.45-4.5).  His free T4 level is normal. Which one of the following is most likely to be associated with this finding?  (check one)

A. Atrial fibrillation

B. Reduced bone density

C. Systolic heart failure

D. Elevated LDL cholesterol

E. Type 2 diabetes mellitus


2. A 67-year-old female presents with progressive weakness, dry skin, lethargy, slow speech, and eyelid edema.  Of the following medications currently taken by this patient, which one is most likely to be causing her symptoms?  (check one)

A. Donepezil (Aricept)

B. Lithium

C. Lisinopril (Prinivil, Zestril)

D. Alendronate (Fosamax)

E. Glyburide (DiaBeta, Micronase)

3. A 54-year-old female takes levothyroxine (Synthroid), 0.125 mg/day, for central hypothyroidism secondary to a pituitary adenoma.  The nurse practitioner in your office orders a TSH level, which is found to be 0.1 mIU/mL (N 0.5-5.0).  Which one of the following would you recommend?  (check one)

A. Decrease the dosage of levothyroxine

B. Increase the dosage of levothyroxine

C. Order a free T4 level

D. Order a TRH stimulation test

E. Repeat the TSH level in 3 months


4. In a patient with a solitary thyroid nodule, which one of the following is associated with a higher incidence of malignancy?  (check one)

A. Hoarseness

B. Hyperthyroidism

C. Female gender

D. A nodule size of 2 cm

E. A freely movable nodule

5. A small child with failure to thrive is found to have a bone age that is markedly delayed relative to height age and chronologic age. The most likely etiology is:  (check one)

A. Cystic fibrosis

B. Hypothyroidism

C. Down syndrome

D. Fetal alcohol syndrome

E. Gonadal dysgenesis


6. Chronic excess thyroid hormone replacement over a number of years in postmenopausal women can lead to:  (check one)

A. Diffuse nontoxic goiter

B. Osteoarthritis

C. Osteoporosis

D. Hyperparathyroidism

7. A woman presents in the postpartum period with palpitations, irritability, and heat intolerance. Radioactive iodine uptake is low. Which one of the following statements is correct?  (check one)

A. She has Graves disease.

B. She will likely have an elevated thyroid-stimulating hormone level and a high triiodothyronine-to-thyroxine ratio.

C. She should be treated with a thiourea.

D. She should be treated with propranolol.

Answers:

1. D 2.B 3.D 4.A 5.B 6.C 7.D



Somerset Family Medicine Clinical Module

Bread & Butter of Family Medicine:

GOUT


  • What is it?

    • Group of disorders related to hyperuricemia

    • Crystal-induced arthropathy caused by monosodium urate crystal deposition in tissue resulting in acute and chronic arthritis, soft tissue masses/nodules called tophi (classically on earlobe, but can be on fingers, toes, prepatellar bursa, olecranon), urate nephropathy, and uric acid nephrolithiasis

Gout is caused by monosodium urate monohydrate crystals; pseudogout is caused by calcium pyrophosphate (CPP) crystals and is more accurately termed calcium pyrophosphate disease (CPPD).

Epidemiology

    • Common - Prevalence: 6 per 1,000 men; 1 per 1,000 women

  • Risk factors

    • Hyperuricemia (Odds ratio: 32 times more likely than those with normal serum uric acid)

    • Male gender

    • EtOH ingestion (beer and liquor > wine)

    • Metabolic syndrome, and separately, obesity, HTN, diabetes, dyslipidemia, and renal insufficiency

    • Diet rich in purines (e.g., meats, liver, kidney, shellfish, anchovies, sardines) or high-fructose corn syrup (e.g., soda beverages); dehydration

Medications that can cause hyperuricemia via underexcretion (e.g., thiazide diuretics,

    • niacin) and overproduction (e.g., chemo causing high turnover of cells)

    • Family hx especially with genetic conditions like Lesch-Nyhan Syndrome (deficiency in hypoxanthine-guanine-phosphoribosyltransferase resulting in overproduction of uric acid)

  • Diagnosis

      • Affected joint is inflamed (red, hot, swollen, and exquisitely tender)

      • Up to 75% are monoarticular

      • First metarsotarsophalangeal joint involved in ~50% of initial attacks (called Podagra)

      • Untreated attacks last up to 3 weeks with absence of inflammation between attacks (unless chronic or tophaceous phase has occurred)

      • Can have renal colic 2/2 uric acid renal stones

    • Best initial test?

      • Arthrocentesis of affect joint to evaluate for crystals and rule out septic arthritis

        • Synovial fluid analysis

          • Urate crystals (negatively birefringent)

          • WBC usually 2,000-50,000/mm3 (neutrophil-predominant); for infxn, WBC >50K

          • Should always check gram stain and cx to rule out infxn (which can coexist)

      • In clinical practice, a presumptive dx can be made with classic Podagra + hyperuricemia

if there is fluid in the joint,it needs analysis immediately .

    • Other labs

      • CBC can show neutrophil-predominant leukocytosis; check Cr for renal insufficiency

      • Elevated serum uric acid level (may be normal during 15% of acute attacks due to precipitation in tissue)

      • UA, 24-hr urinary uric acid

      • X-ray may show “punched-out” erosions (for recurrent/chronic gout); urate stones are radiolucent and thus invisible on x-ray

      • Biopsy of soft tissue nodule or synovial membrane (rarely done if other labs not helpful)

  • Other less common complications urate crystals deposit in other organs

    • Nerve or spinal cord impingement by urate deposition

    • Eye involvement including keratitis and anterior uveitis

  • Treatment for Acute Gout – discontinue any meds (e.g., diuretics) that may contribute




Class

MOA

Names

Clinical Info

Caution

NSAIDs,

except aspirin (which can alter uric acid lvl and intensify acute attacks)

Inhibits COX pathway, reducing prostaglandin and thromboxane synthesis

Indomethacin 50mg po TID

Naproxen 750mg po x1, then 250mg q8h or 500mg BID

First-line

Taper to lowest effective dose; give with food if GI upset



Renal insufficiency, PUD, liver disease

Lifestyle modification

Avoid EtOH, diets high in purines and high-fructose corn syrup




First line




Colchicine

Concentrates in PMN cells and inhibits microtubule polymerization, preventing neutrophil activity

Colchicine 1.2mg po x1, then 0.6mg 1hr later

Second line

Effective if given within first 24 hrs of attack



GI side effects (n/v/diarrhea), bone marrow suppression(neutropenia);

If renal impairment with CrCl<30, cannot give til 2 weeks later



Steroids

Anti-inflammatory effects via multiple pathways

IV/po systemic corticosteroids

(e.g., prednisone 40mg po x1-3 days, then tapered over 2 wks)



Intra-articular

Second line

Systemic given with multiple jts; intra-articular with single or few jts



Rule out septic joint, caution with diabetes, HTN, PUD, glaucoma, etc.

Adrenocorti-cotropic hormone (ACTH)

Induces patient’s own adrenal corticosteroid production

ACTH 25 USP units SC for acute small-joint monoarticular gout; 40 USP units IM/IV for larger joints or polyarticular gout

Second line

Hypersensitivity reaction

Combination therapy




NSAIDs + Colchicine
Steroids + Colchicine
NSAIDs + steroids

First line for severe attacks involving multiple large joints

Third line if others not effective




Treatment for Chronic Gout



    • Indications: >2 attacks per year, tophi present, or radiographic evidence of joint damage

    • Goal serum uric acid <6

    • Do NOT start until 2-3 wks after acute attack has resolved, because acute changes in serum uric acid level can intensify and prolong an acute attack

    • If Pt is already on chronic therapy during an acute attack, okay to continue meds.

Class

MOA

Names

Clinical Info

Caution

Xanthine oxidase inhibitors

Inhibits xanthine oxidase, which usually converts hypoxanthine into uric acid (from purine metabolism)

Allopurinol 100mg po daily, adjust q2-4wks until goal serum uric acid lvl
Febuxostat 40mg po daily, titrate to 80mg daily

First-line

Co-prescribe with colchicine 0.5-1mg/d OR low-dose NSAIDs on initiation of treatment to prevent rebound acute attacks



Allopurinol: monitor for renal insufficiency and hypersensitivity rxn (rash, hepatitis, interstitial nephritis)

Lifestyle modification

Avoid EtOH, diets high in purines and high-fructose corn syrup.

Increase fluid intake.






First line




Uricosuric agents

Given only if pt is underexcretor (i.e. 24-hr urinary uric acid <800)



Inhibit tubular reabsorption of uric acid

Probenecid 250mg po BID and titrate qMonthly until goal
Sulfinpyrazone 50mg po BID and titrate qMonthly until goal

Second line

-Only given if normal renal fxn without h/o renal stones

-Also co-prescribe with colchicine or low-dose NSAIDs as above


Increase risk of stone formation and renal failure
Can alkalinize urine with potassium citrate supplementation to decrease urate stone formation (also counsel to increase fluid intake)

Other agents with modest uricosuric effects

Inhibit tubular reabsorption of uric acid

Fenofibrate

Losartan

Amlodipine

Third line




Uricase

Breaks down uric acid to allantoin, which is inactive and readily excreted by the kidneys

Rasburicase IV

Pegloticase IV

(uricase enzyme is obtained by recombinant DNA Therapy as uricase is absent in humans)

Third line

Expensive and rarely used for gout; used mainly in tumor lysis syndrome



Hypersensitivity reactions



BOARD PEARLS :
# Patients with gout should take low protein diet as increase protein results in increase uric acid .
# Gout crystals appear yellow when parallel to the condenser.
# Colchicine is most effective drug used for resistant gout. S/E :-myopathy and GI disorders.
# Colchicine inhibits neutrophil chemotaxis.
# Gout significantly increased the risk of preeclampsia, preterm birth, cesarean delivery, low birth weight, and small-for-gestational age infants.There are currently five drugs that can be used to treat gout during pregnancy: allopurinol (Zyloprim), colchicine (Colcrys), febuxostat (Uloric), pegloticase (Krystexxa), and probenecid.
# Causes of hyperurcemia:

*increase cell turnover(hemolysis,blast crisis,tumor lysis,myelodysplasia,psoriasis)

*cyclosporine

*lead poisoning

*salicylates

*starvation

*dehydration
# Pseudogout: pt. has a history of hemochromatosis and hyperparathyroidism.
# punched out lesions with overhanging cortical bone(RAT BITE erosions) are seen in advanced gout.
# Culture of joint fluid is positive in only 50% or less of gonococcal arthritis.
# The basic test to run on synovial fluid are the 3 Cs(cell count,crystals and cultures) and the gram strain.

Joint aspiration is done because in monoarticular i.e septic arthritis it must be ruled out because it leads to bone erosions with in a day.


# Synovial Fluid Analysis:


DISEASE

WBCs

Crystals/polarization

Non Inflammatory Disease

Osteoarthritis



<2,000

Negative

Inflammatory Disease

Rheumatoid arthritis

(Gout & Pseudogout)

5,000 - 50,000



Acute gout: needle shaped uric acid crystal,-ve birefringent.

Pseudogout: rhomboid shape uric acid crystals,+ve birefringent



Septic arthritis

>50,000

-ve gram stain and culture usually negative for GC and absent crystals.



There are few exceptions to the above:septic arthritis may sometimes present with <50,000WBC/mm3 in the joint aspiration if antibodies are given before the joint aspiration.

Somerset Family Medicine Clinical Module

Bread & Butter of Family Medicine:

ALLERGIC RHINITIS

Allergic rhinitis and asthma often coexist and more than half of the asthma cases can be attributed to seasonal allergies. In some cases allergic rhinitis and asthma may be thought of as manifestation of the same disease.



Treatment:

LIFESTYLE AND AVOIDING ALLERGENS

The best treatment is to avoid the pollens that cause your symptoms. It may be impossible to avoid all pollen. But you can often take steps to reduce your exposure.

Antihistamins: 1st generation (Diphenhydramine), 2nd generation (Loratadine, fexofenadine, cetirizine);



  1. Decongestants: symptomatic relieve, for short period of time. Do not use Afrin (oxymetazoline nasal) for more than 3 days – it causes rebound congestion. Saline nasal spray and irrigation with special device “neti (or nutty) pot”

  2. Corticosteroid Nasal Spray: the most effective treatment and first-line therapy for the long-term management of mild to moderate persistent symptoms (Flonase, Nasonex)

  3. Leukotriene inhibitors: useful in both asthma and allergic rhinitis (Singulair, Accolate)

  4. Oral corticosteroids: only for severe allergy and at the lowest dose for short period of time

  5. Desensitization therapy: injections weekly or biweekly

  6. Ophthalmic symptoms: OTC – Zaditor (ketotifen ophthalmic), Naphcon, Cromolyn ophthalmic. Prescription – Patanol. Avoid Visine!!!

BOARD PEARLS :

Symptoms:

Symptoms that occur shortly after you come into contact with the substance you are allergic to may include:

Itchy nose, mouth, eyes, throat, skin, or any area

Problems with smell

Runny nose

Sneezing

Watery eyes “red eyes”

Symptoms that may develop later include:

Stuffy nose (nasal congestion)

Coughing(non productive)

Clogged ears and decreased sense of smell

Sore throat

Dark circles under the eyes,conjunctivitis

Puffiness under the eyes

Fatigue and irritability

Headache

Exams and Tests:

The health care provider will perform a physical exam and ask about your symptoms. You will be asked whether your symptoms vary by time of day or season, and exposure to pets or other allergens.

Allergy testing may reveal the pollen or other substances that trigger your symptoms. Skin testing is the most common method of allergy testing.

If your doctor determines you cannot have skin testing, special blood tests may help with the diagnosis. These tests, known as IgE RAST tests, can measure the levels of allergy-related substances.



A complete blood count (CBC) test called the eosinophil count may also help diagnose allergies.

Somerset Family Medicine Clinical Module

Bread & Butter of Family Medicine:

MIGRAINE
What is Migraine?

  • Its Neurovascular disease categorized as a primary headache disorder according to International Headache Society (IHS)

  • It is the second most common cause of headache after tension headache

  • The pain of migraine occurs when excited brain cells trigger the trigeminal nerve to release chemicals that irritate and cause swelling of blood vessels on the surface of the brain. These swollen blood vessels send pain signals to the brainstem, an area of the brain that processes pain information. The pain of migraine is a referred pain that is typically felt around the eye or temple area. Pain can also occur in the face, sinus, jaw or neck area. Once the attack is full-blown, many people will be sensitive to anything touching their head. Activities such as combing their hair or shaving may be painful or unpleasant.

  • It is usually episodic headache disorder characterized by combinations of neurologic, gastrointestinal, and autonomic changes.

  • Migraine is recurrent, often life-long, and characterized by attacks.



Epidemiology


  • Migraine is an extraordinarily common disease that affects 36 million men, women and children in the United States.

  • Nearly 1 in 4 U.S. households includes someone with migraine.

  • Amazingly, over 10% of the population - including children - suffers from migraine. That's more than diabetes and asthma combined!

  • About 18% of American women and 6% of men suffer from migraine (F>M).

  • Migraine is most common during the peak productive years, between the ages of 25 and 55.

  • Migraine ranks in the top 20 of the world's most disabling medical illnesses.

Risk Factor

  • Family history. Migraine tends to run in families. If one parent suffers from migraine, there is a 40% chance a child will suffer. If both parents suffer, the chance rises to 90%.

  • Age. Migraines can happen at any age but most often begins at puberty and most affects aged between 35 and 45 years

  • Sex. In childhood, boys are affected more than girls, but after adolescence, when estrogen influence begins in young girls, the risk of migraine and its severity rises in females.

  • Hormonal changes. More severe and more frequent attacks often result from fluctuations in estrogen levels and decrease after menopause.

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