Pharyngitis 155. Preparticipation Sports Physical Exam 171. Pharmacotherapy 217

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1 Abdominal Pain Asthma Chest Pain Cough Depression Diabetes Hyperlipidemia Hypertension Joint Pain Low Back Pain Migraine Headache New Onset Headache Pharyngitis 155 Preparticipation Sports Physical Exam 171 Somatization Disorder Tobacco Dependence Upper Respiratory Infection Urinary Tract Infection Pharmacotherapy 217 University of South Alabama, Department of Family Medicine June 30,

2 Abdominal Pain 789.0X GENERAL CONSIDERATIONS Scope of This Article This article discusses atraumatic abdominal pain in adults and older children. Definition of Abdominal Pain Complaint of pain in the area between the ribcage and pelvis. Overview Abdominal pain is frequent symptom encountered by a large portion of the otherwise healthy population (in some studies more than 50%). Most commonly it is a benign complaint reflecting a disease process that can be treated symptomatically. However, it may be the presenting symptom to an acute life-threatening illness that requires rapid assessment and immediate triage to an acute care facility. Red Flags: Red flags are historical or physical findings that suggest a higher severity of illness, requiring further investigation. Red Flag Possible Etiology Possible Consequence Fever Infection Dehydration, sepsis Diarrhea Infection Dehydration Persistent constipation Intestinal obstruction Dehydration Hematochezia Lower or upper GI bleed Hemodynamic instability Persistent Vomiting Multiple etiologies Dehydration, metabolic acidosis Hematemesis Upper GI bleed Hemodynamic instability Severe Pain Perforation, peritonitis Sepsis, hemodynamic instability Pregnancy Ectopic pregnancy, placental Increased fetal and maternal Jaundice abruption Liver failure, biliary obstruction morbidity, mortality Hepatic encephalopathy University of South Alabama, Department of Family Medicine June 30,

3 History The history should include: Duration and frequency of pain Severity and nature of pain. Location and radiation of pain. Aggravating/alleviating factors, such as food, antacids, exertion, defecation. Associated symptoms, including fever, chills, weight loss or gain, nausea, vomiting, diarrhea, constipation, hematochezia, melena, jaundice, change in the color of urine or stool, change in the diameter of stool. Family history of bowel disorders. Alcohol intake. Medication use, including over the counter medications such as aspirin and NSAIDs. Menstrual history. Pain Duration Acute: Pain of less than a few days duration, that has worsened progressively until the time of presentation. Chronic: Pain that has remained unchanged for months or years. Pain that does not clearly fit either category might be called subacute, and requires consideration of the differential diagnoses for both acute and chronic pain. Pain Type Pain Type Character Localization Cause Examples Dull and aching, Distention or Intestinal but can be Poorly localized spasm of a obstruction, colicky hollow organ cholecystitis Visceral Pain Parietal Pain Sharp Well localized Parietal peritoneal irritation Acute appendicitis University of South Alabama, Department of Family Medicine June 30,

4 Pain Location Causes of Abdominal Pain by Location Location Right Upper Quadrant Left Upper Quadrant Right Lower Quadrant Left Lower Quadrant Epigastric Periumbilical Diffuse Causes Hepatitis Cholecystitis Cholangitis Pancreatitis Budd-Chiari Syndrome Pneumonia Splenic Abscess Splenic Infarct Gastritis Gastric Ulcer Pancreatitis Appendicitis Salpingitis Ectopic Pregnancy Inguinal Hernia Nephrolithiasis Inflammatory Bowel Disease Diverticulitis Salpingitis Ectopic Pregnancy Inguinal Hernia Nephrolithiasis Inflammatory Bowel Disease Peptic Ulcer Disease GERD Gastritis Pancreatitis MI Pericarditis Aortic Aneurysm Early Appendicitis Gastroenteritis Bowel Obstruction Aortic Aneurysm Ventral Hernia Gastroenteritis Mesenteric Ischemia Metabolic Irritable Bowel Syndrome Bowel Obstruction Peritonitis University of South Alabama, Department of Family Medicine June 30,

5 Pain Severity The severity of the pain generally is related to the severity of the disorder, especially if acute in onset. As an example, the pain of biliary obstruction, renal colic, or mesenteric infarction is of high intensity, while the pain of gastroenteritis is less marked. Age, mental status, and general health may affect the patient s clinical presentation. A patient taking corticosteroids may have significant masking of pain, and the elderly often present with less intense pain. Associated Symptoms Symptoms that occur in relation to abdominal pain may give important information. Nausea and vomiting occur with a number of disorders. Weight loss may occur in association with malignancy. A change in bowel habits suggests a colonic lesion. Women should be asked whether they are sexually active, the number of sexual partners, whether any sexual partners are new, and whether any sexual partners are experiencing symptoms suggestive of a sexually transmitted infection. Physical Examination General Exam General appearance. Patients with peritonitis try to remain immobile. Vital signs, including measurement of orthostatic changes in blood pressure and heart rate. Obstruction or peritonitis can cause large amounts of third spacing of fluid and intravascular volume depletion or overt shock. Jaundice. Abdominal Exam Auscultation. Hypoactive sounds may be noted in advanced peritonitis or ileus. Highpitched bowel sounds are a feature of early bowel obstruction. Gentle percussion is useful to identify acute peritonitis. Percussion is also used to identify ascites, liver span, and bladder and splenic enlargement. Tympany signifies distended bowel, while dullness may signify a mass. Palpation must be performed gently and while the patient is distracted. Muscular rigidity or guarding is an important and early sign of peritoneal inflammation. Palpation also may detect enlarged organs, masses, or hernias. Rectal and Pelvic Exam A rectal is generally required in all patients with acute abdominal pain. Fecal impaction might be the explanation for signs and symptoms of obstruction in the elderly. Stool for occult blood should also be obtained. A pelvic exam is generally required in all women with acute lower abdominal pain, and is critical for determining whether abdominal pain is due to pelvic inflammatory disease, an adnexal mass or cyst, uterine pathology, or an ectopic pregnancy. University of South Alabama, Department of Family Medicine June 30,

6 ACUTE ABDOMINAL PAIN Surgical Abdomen (AKA Acute Abdomen ) The first priority in patients with acute abdominal pain is to determine who has a rapidly worsening prognosis in the absence of surgical intervention. Only after the clinician is satisfied that the abdominal presentation is not an acute surgical emergency can consideration of other diagnostic possibilities begin. Patients should not eat or drink while a diagnosis of a surgical abdomen remains under consideration. The two syndromes that cause most surgical abdomens are obstruction and peritonitis. The latter encompasses most severe abdominal pathology since intraperitoneal hemorrhage or viscus perforation typically present with common features of peritonitis. Obstruction Obstruction generally presents as pain together with anorexia, bloating, nausea, and vomiting. Physical examination may reveal distension and high-pitched or absent bowel sounds. Abdominal percussion reveals tympany from proximally dilated loops of bowel. An abdominal mass, if present, may suggest an etiology for the obstruction. Peritonitis Patients with peritonitis of any cause tend to appear ill and lie still to minimize their discomfort. Rebound tenderness, abdominal wall rigidity, and percussion tenderness are classically thought to reflect peritonitis. Other subtle signs of peritonitis include diminished bowel sounds and pain worsened when an examiner lightly bumps the stretcher. Initial Diagnostic Testing Complete blood count with differential Electrolytes, BUN, creatinine, and glucose Aminotransferases, alkaline phosphatase, and bilirubin Lipase Urinalysis Pregnancy test in women of childbearing potential While these laboratory tests are important, they are not sufficient to rule in or rule out a diagnosis of surgical abdomen, as a surgical abdomen is a clinical diagnosis. Subsequent Diagnostic Testing Patients clearly in need of urgent laparotomy may proceed directly to the operating room for diagnosis and management. In particular, patients with a painful pulsatile abdominal mass, with or without bruit, should be suspected to have a ruptured aortic aneurysm. University of South Alabama, Department of Family Medicine June 30,

7 However, many patients will not have a firm diagnosis after initial assessment, and in these cases, careful observation of the patient s course will be the most important factor in their management. In addition, the following additional investigations can also be considered: Blood and urine cultures, in the presence of fever or unstable vital signs. CT Scan. When available, CT scanning is the test of choice for detecting partial or complete bowel obstruction, hernias, diverticulitis, renal stones, and aortic aneurysms. It can also be useful in investigating appendicitis, peritonitis, ischemia due to strangulation/adhesions, and pancreatitis. CT scan may play a decision-making role when evaluating demented or obtunded patients. Plain Abdominal Films. Where CT scanning is immediately available, abdominal plain films are not necessary, as they do not provide additional information. However, in the absence of CT scanning, flat and upright or lateral decubitus radiographs are a crucial step in decision making for the suspected surgical abdomen, as proximally dilated loops of bowel are the hallmark of intestinal obstruction, and free intraperitoneal air can confirm a suspicion of hollow organ perforation. Ultrasound. Ultrasound is the preferred test in pregnancy, and evaluating biliary and pelvic pathology. If more readily available, it may also be useful for many of the conditions listed above under CT Scan. Right Upper Quadrant Pain Usually caused by involvement of the liver or biliary tree. Initial assessment The presence of fever and jaundice in a patient with right upper quadrant pain leads to a clinical diagnosis of ascending cholangitis. Acute cholecystitis can also present as a systemically unwell patient with low-grade fever. Patients with an acute rise in aminotransferases and right upper quadrant pain most likely have choledocholithiasis, particularly if there is also an acute rise in bilirubin. Initial Diagnostic Testing Complete blood count with differential. Electrolytes, BUN, creatinine, and glucose. Aminotransferases, alkaline phosphatase, and bilirubin. Lipase. Abdominal ultrasound. (Plain films of the abdomen are unlikely to yield much information.) Subsequent Diagnostic Testing (if available) Endoscopic ultrasound. Endoscopic retrograde cholangiopancreatography (ERCP). Magnetic resonance cholangiopancreatography (MRCP). University of South Alabama, Department of Family Medicine June 30,

8 Epigastric Pain Epigastric pain that is relatively sudden in onset is suggestive of pancreatitis, particularly when it radiates to the back and is associated with nausea, vomiting, and anorexia. Epigastric pain that is less acute and is associated with bloating, abdominal fullness, heartburn, or nausea can be classified as dyspepsia. Most of these patients can safely undergo a therapeutic trial or watchful waiting. However red flags that suggest a need for further investigation include: Age over 50. Weight loss. Persistent vomiting. Dysphagia. Anemia. Hematemesis, melena, or heme positive stool. Palpable abdominal mass. Family history of upper gastrointestinal carcinoma. Previous gastric surgery. Refractory/recurrent symptoms. It is also important to consider nonabdominal etiologies of upper abdominal pain: Cardiac pain. Pleural or pulmonary pathology. Initial Diagnostic Testing Many patients can be managed with a therapeutic trial of antisecretory therapy without further investigation. However, those with red flags or suspicion of pancreatitis should have the following: Complete blood count with differential. Electrolytes, BUN, creatinine, and glucose. Aminotransferases, alkaline phosphatase, and bilirubin. Lipase. Elevated lipase in the presence of epigastric pain is very suggestive of pancreatitis. Amylase is a less specific alternative, if lipase is not available. Subsequent Diagnostic Testing Esophagogastroduodenoscopy (EGD), especially for those with red flags and dyspepsia. Testing for Helicobacter pylori may be considered, especially in refractory/recurrent cases. Abdominal ultrasound if pancreatitis is being considered, since biliary disease is a common etiology for pancreatitis. CT Scan is more sensitive for the diagnosis of pancreatitis than ultrasound; consider if doubts remain after an ultrasound has been obtained. University of South Alabama, Department of Family Medicine June 30,

9 Lower Abdominal Pain Pain in the lower abdomen can be associated with pathology in the following: Distal intestinal tract. Upper abdominal structures with pain radiating into the lower abdomen. The pelvis. The history should include risk factors for infectious and ischemic causes, medication use (e.g., NSAIDs, laxatives), and family history of inflammatory bowel disease (IBD). Patients should be asked about urinary symptoms such as frequency, urgency, and dysuria. Left and/or right lower quadrant pain, when occurring together with diarrhea, is suggestive of colitis and/or ileitis. Diverticulitis presents more frequently as left lower quadrant pain, often with leukocytosis. In older patients, abdominal pain and a change in bowel habits can be the first sign of colon cancer. It is also important to consider nonabdominal etiologies of upper abdominal pain: Retroperitoneal pathology. Cystitis can cause suprapubic pain. Renal colic results in pain that may radiate to the lower abdomen. Lower abdominal pain (pelvic pain) in women is frequently caused by disorders of the internal female reproductive organs. (Discussed below.) Initial Diagnostic Testing Complete blood count with differential. Urinalysis (and culture if results dictate). Subsequent Diagnostic Testing Stool studies in patients with severe or persistent lower abdominal pain associated with diarrhea, and immunosuppressed patients, should include culture for enteric pathogens, microscopy for ova and parasites, and measurement of Clostridium difficile toxin. However, many patients with less severe presentations will often have self-limited illness, and can be managed expectantly. Colonoscopy in patients with illness exceeding two weeks with negative cultures, systemically unwell patients, immunosuppressed patients, and when ileal pathology is suspected. (Note that patients over age 50 are also candidates for screening colonoscopy, and their presenting symptoms provide an opportunity to discuss this.) CT scan, especially in cases suggestive of diverticulitis. University of South Alabama, Department of Family Medicine June 30,

10 Lower Abdominal Pain in Women Additional history in women should include: Regularity and timing of menstrual periods. Possibility of pregnancy. Presence of vaginal discharge or bleeding. Recent history of dyspareunia or dysmenorrhea. In addition to the causes of lower abdominal pain discussed above, other common etiologies of acute lower abdominal pain in women include: Pelvic inflammatory disease (PID). Adnexal cysts or masses with bleeding. Ovarian torsion. Ectopic pregnancy. Uterine pain due to infection (endometritis) or torsion of leiomyomas. A pelvic examination is part of the physical examination whenever pelvic pathology is in the differential diagnosis. Purulent cervical discharge, cervical tenderness, uterine enlargement, or adnexal masses may be detected. PID should be considered when acute left, right, or bilateral abdominal pain is accompanied by fever and an elevated white blood count with left shift. Initial Diagnostic Testing In addition to tests discussed above, women with lower abdominal pain should have the following: Pregnancy test in women of childbearing potential, even when pregnancy is felt unlikely. Wet prep of any abnormal vaginal discharge. Tests for Chlamydia and gonococcus in women with risk factors for sexually transmitted infections, mucopurulent cervical discharge, or suspected PID. Subsequent Diagnostic Testing Pelvic ultrasound, especially if pregnancy test is positive, or pelvic exam is suggestive of PID or adnexal masses. Generalized Abdominal Pain (not meeting the criteria of surgical abdomen ) Generalized abdominal pain with vomiting and/or diarrhea, alone or in association with systemic symptoms, often represents an acute self-limited illness, such as viral or bacterial enteritis or colitis, or toxin-mediated food poisoning. Multisystem symptoms, such as upper respiratory tract involvement or myalgias, may suggest a viral etiology. University of South Alabama, Department of Family Medicine June 30,

11 A condition that may require urgent surgical management, yet present without clear peritoneal findings, is acute mesenteric ischemia/mesenteric infarction. If clinically reasonable, the diagnosis of ischemic bowel disease should be entertained, particularly if the patient has the classic finding of pain out of proportion to physical findings, or risk factors such as congestive heart failure, recent myocardial infarction, hypotension, hypovolemia, sepsis, or cardiac surgery. Young patients should have mesenteric ischemia considered if they have a known personal or family history of hypercoagulable state or venous thrombosis. Diffuse abdominal pain can also be a nonspecific symptom of underlying metabolic, toxic, neurogenic, or other extra-abdominal disease. The presence of systemic illness, fatigue, weakness, nausea, flu-like symptoms, or signs and symptoms of endocrinopathies that are associated with abdominal pain should signal a search for metabolic abnormalities, such as diabetic ketoacidosis or Addison s disease. One should inquire about drug use/withdrawal, toxin/poison exposures, or possible black widow spider bite. Pain localized to one unilateral dermatome is highly suggestive of herpes zoster. Cardiac Thoracic Neurologic Metabolic Hematologic Toxins Infection Miscellaneous Extra-Abdominal Causes of Acute Abdominal Pain Myocardial ischemia Myocarditis Endocarditis CHF Pleurodynia PTE Pneumothorax Empyema Esophagitis Esophageal spasm Esophageal rupture Radiculitis Herpes zoster Uremia Diabetes mellitus Hyperlipidemia Hyperparathyroidism Acute adrenal insufficiency Sickle cell anemia Hemolytic anemia Henoch-Schönlein purpura Acute leukemia Hypersensitivity reactions Lead poisoning Osteomyelitis Typhoid fever Narcotic withdrawal Heat stroke Psychiatric disorders University of South Alabama, Department of Family Medicine June 30,

12 Initial Diagnostic Testing In patients with symptoms suggestive of an acute infectious gastroenteritis or toxin-mediated food poisoning, the most useful diagnostic tool will often be watchful waiting for spontaneous recovery. Patients for whom a metabolic etiology of abdominal pain is suspected should have the following: Complete blood count with differential. Electrolytes, with calculation of an anion gap. BUN, creatinine, blood glucose. Calcium. Subsequent Diagnostic Testing An imaging procedure (angiography, CT/MRI angiography) will generally be required for patients with suspected ischemic bowel disease. CHRONIC ABDOMINAL PAIN Chronic abdominal pain is a common complaint, and the vast majority of patients will have a functional disorder, often irritable bowel syndrome. The initial workup is therefore focused on differentiating benign functional illness from organic pathology. Helpful historical clues include the overall time course of the problem, whether pain is constant or intermittent, abnormalities in bowel habits, and aggravating/alleviating factors. Since many multisystem illnesses could contribute to a nonspecific abdominal complaint, a full physical exam should be performed. Specifically, the physical examination should clarify any focus of abdominal tenderness that may merit and focus further investigation. The following features suggest an organic illness: Unstable vital signs. Weight loss. Fever. Dehydration. Electrolyte abnormalities. Symptoms or signs of gastrointestinal blood loss, anemia, or malnutrition. University of South Alabama, Department of Family Medicine June 30,

13 Initial diagnostic testing The following tests should be considered in most patients with chronic abdominal pain: Complete blood count with differential. Electrolytes, BUN, creatinine, and glucose. Calcium. Aminotransferases, alkaline phosphatase, and bilirubin. Lipase. Ferritin. C-reactive protein and erythrocyte sedimentation rate are sensitive but nonspecific markers that may suggest the presence of occult organic disease; in selected cases, they may have some utility in ruling out organic causes of chronic abdominal pain. Subsequent Diagnostic Testing At the conclusion of the initial workup, young patients with no evidence of organic disease can be treated symptomatically. The use of further invasive testing should be directed at ruling in or out specific diseases and not as a general screen. A diagnosis of new-onset functional illness should only be made with great caution in patients over 50 years of age. These patients, by virtue of their increased risk of malignancy, will likely require investigation with endoscopy, CT, and/or ultrasound. University of South Alabama, Department of Family Medicine June 30,

14 FLOW CHARTS Initial Approach to Abdominal Pain History Physical exam Initial lab tests Radiographs Patient hemodynamically stable YES Rigid (surgical) abdomen? NO Non-rigid abdomen algorithm YES NO Suspect AAA CBC, lytes CT if available or abd films & CXR Surgery consult Nonspecific Obstruction Perforation Limited resuscitation/ urgent CT/surgery Resuscitation/ surgery Consider unusual causes of rigid abdomen Investigate Treat University of South Alabama, Department of Family Medicine June 30,

15 Non-Rigid Abdomen Signs & Symptoms Chronic See chronic abdominal pain discussion above YES See pain location table above Acute Localized? NO Suspect AAA NO Early obstruction Early appendicitis Mesenteric ischemia IBD Enteritis Pancreatitis Metabolic diseases Narcotic withdrawal YES Not Confirmed CT scan Consider GI and/or surgery consult Confirmed Limited resuscitation/ surgery University of South Alabama, Department of Family Medicine June 30,

16 References: Penner, Robert M., Sumit R. Majumdar; Diagnostic Approach To Abdominal Pain In Adults; UpToDate.com; August Tintinalli, Judith E., Gabor D. Kelen, J. Stephan Stapczynski, O. John Ma, David M. Cline; Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 6th Edition; 2004; American College of Emergency Physicians Ables, Adrienne, I. Simon, Emily Melton; Update On Helicobacter Pylori Treatment; American Family Physician; Volume 75, Number 3; February 1, Ramakrishnan, Kalyanakrishnan, Robert Salinas; Peptic Ulcer Disease; American Family Physician, Volume 76; Number 7, October 1, 2007 University of South Alabama, Department of Family Medicine June 30,

17 Definition: Asthma 493.XX Asthma is defined as a chronic inflammatory pulmonary disorder that is characterized by reversible obstruction of the airways. Environmental factors, (e.g. allergens, irritants, cold air, and viruses) play a role in provoking the airway inflammation, which in turn results in wheezing, breathlessness, chest tightness, and coughing due to airway hyper-responsiveness which characterizes the asthma patient. These symptoms are often reversible either spontaneously or with treatment. General Approach to the patient: There are four main components in the management of asthma patients: 1. Assessment and monitoring 2. Pharmacologic therapy 3. Control of factors contributing to asthma severity 4. Patient education Overview: More than 22 million people suffer from asthma in the US; 6 million of them are children. Asthma accounts for nearly 500,000 hospitalizations 13.6 million visits to office based physicians, 1.8 million emergency department visits, and 3780 deaths in the United States each year. Despite an increased understanding of pathophysiology and treatment options, the disease remains undertreated. Asthma guidelines have been established to address the disparity between scientific knowledge and actual management. The Encounter Chief Complaint: Patients often seek medical attention complaining of episodes of wheezing, shortness of breath, or coughing. In the case of exercise induced asthma patients present with similar symptoms brought about mainly by physical exercise. History of Present Illness: Symptoms of asthma are often worsened by allergens or irritants and in a lot of cases by upper respiratory tract infections. Symptoms are often worse at night. Some patients will give a history of multiple doctor visits or emergency room visits for similar symptoms prior to being diagnosed with asthma. Emotions and stress may also act as a trigger for exacerbation of symptoms. Asthma patients often have a history of other allergies (e.g. allergic rhinitis or atopic dermatitis). A family history of asthma may also be elicited. University of South Alabama, Department of Family Medicine June 30,

18 Physical: It is important to keep in mind that asthma patients may have no pertinent findings on examination due to the episodic nature of the illness. However, symptomatic patients may have one or more of the following findings: Wheezing during normal respiration or induced by forced expiration. In acute exacerbations, evidence of respiratory distress in the form of tachypnea, hypoxia and use of accessory muscles may be seen. Hyper-expansion of the lungs. Manifestations of other allergic illnesses as described above. Lab Testing: Pulmonary function testing: Establish the presence of airflow obstruction: FEV 1 <80% Establish reversibility: FEV 1 increases 12% or more after using a short-acting inhaled beta 2 agonist (e.g. albuterol) Special Considerations: Children younger than 5 years of age suffering from asthma are often mislabeled as having recurrent upper respiratory tract infections or reactive airway disease. In this population, the diagnostic criteria discussed above apply as well, however, spirometry is not possible. Hence, a diagnosis is not needed to begin to treat recurrent episodes of wheezing. Classification of Asthma severity: The following classification is used to describe asthma severity in individual patients and aids the physician in choosing the appropriate medication for every patient. Step 4 Severe Persistent Step 3 Moderate Persistent Step 2 Mild Persistent Step 1 Intermittent Days With Symptoms Nights With Symptoms PEF or FEV1 Interference with Normal Activity Continual Frequent 60% Extreme Limitation Daily 5/month >60%- <80% Some Limitation 3-6/week 3-4/month 80% Minor Limitation 2/week 2/month 80% None University of South Alabama, Department of Family Medicine June 30,

19 NOTES: Patients should be assigned to the most severe step in which any feature occurs. Clinical features for individual patients may overlap across steps. An individual s classification may change over time. Patients at any level of severity of persistent asthma can have mild, moderate, or severe exacerbations of asthma. Some patients with intermittent asthma experience severe and life-threatening exacerbations separated by long periods of normal lung function and no symptoms. Management: Goals of Asthma Therapy: 1. Prevent chronic asthma symptoms and exacerbations. 2. Maintain normal activity levels 3. Have normal or near-normal lung functions 4. Minimizing side effects of therapy Patient Education: The following key points should be addressed following the diagnosis of asthma: Patients can live a normal life if the asthma is managed correctly. Asthma is better controlled if the patient works together with the physician. Lack of symptoms does not equal absence of inflammation of the airways, hence, longterm anti-inflammatory medications, if indicated, are important in asthma control. Many exacerbating factors exist in the home, school, or work environment which may lead to asthma attacks. Long-term care and monitoring is essential for the proper management of asthma. Pharmacotherapy: Medications used to control asthma consist of: Long-term control medications: These medications are used daily in the treatment of persistent asthma and include anti-inflammatory agents, long-acting bronchodilators, and leukotriene modifiers. Corticosteroids: Most potent and effective anti-inflammatory medication currently available. The Inhaled form is used as the first line of therapy in the treatment of persistent asthma. Systemic corticosteroids are often used during asthma exacerbations for prompt alleviation of symptoms. Cromolyn sodium and nedocromil: Mild-to moderate anti-inflammatory medications. May be used as initial choice for long-term-control therapy for children. Long-acting beta2-agonists: Long-acting bronchodilator used concomitantly with antiinflammatory medications for long-term control of symptoms. Methylxanthines: Theophylline is a mild-to-moderate bronchodilator used principally as an adjuvant to inhaled corticosteroids in severe cases. Leukotriene modifiers: Leukotriene modifiers may be considered an alternative or used as an adjunct therapy to low doses of inhaled corticosteroids. University of South Alabama, Department of Family Medicine June 30,

20 L O N G - T E R M C O N T R O L M E D I C AT I O N S Name/Products Indications Potential Adverse Effects Inhaled Corticosteroids: Beclomethasone dipropionate Budesonide Flunisolide Fluticasone propionate Triamcinolone acetonide Systemic Corticosteroids: Methylprednisolone Prednisolone Prednisone Cromolyn Sodium and Nedocromil Long-Acting Beta2-Agonists Methylxanthines Theophylline - Long-term prevention of symptoms; suppression, control, and reversal of inflammation. - Reduce need for oral corticosteroid. -For short-term (3 10 days) burst : to gain prompt control of inadequately controlled asthma. - For long-term prevention of symptoms in severe persistent asthma: suppression, control, and reversal of inflammation. - Long-term prevention of symptoms; may modify inflammation. - Preventive treatment prior to exposure to exercise or known allergen. - Long-term prevention of symptoms, especially nocturnal symptoms, added to antiinflammatory therapy - Prevention of exercise-induced bronchospasm. - Not to be used to treat acute symptoms or exacerbations. - Long-term control and prevention of symptoms, especially nocturnal symptoms. - Cough, dysphonia, oral thrush. - In high doses, systemic effects may occur, although studies are not conclusive, and clinical significance of these effects has not been established. -Short-term use: reversible, abnormalities in glucose metabolism, increased appetite, fluid retention, weight gain, mood alteration, hypertension, peptic ulcer, and rarely aseptic necrosis of femur. - Long-term use: adrenal axis suppression, growth suppression, dermal thinning, hypertension, diabetes, Cushing s syndrome, cataracts, muscle weakness, and in rare instances impaired immune function. - Consideration should be given to coexisting conditions that could be worsened by systemic corticosteroids, such as herpes virus infections, Varicella and tuberculosis. -15 to 20 percent of patients complain of an unpleasant taste from nedocromil. -Tachycardia, skeletal muscle tremor, hypokalemia, prolongation of QT c interval in overdose. - Dose-related acute toxicities include tachycardia, nausea and vomiting, tachyarrhythmias (SVT), CNS stimulation, headache, seizures, hematemesis, hyperglycemia, and hypokalemia. - Adverse effects at usual therapeutic doses include insomnia, aggravation of peptic ulcer or reflux, increase in hyperactivity in some children, difficulty in urination in elderly males with prostatism. Leukotriene Modifiers Zafirlukast tablets Zileuton tablets - Long-term control and prevention of symptoms in mild persistent asthma for patients >12 years of age. -Elevation of liver enzymes has been reported. University of South Alabama, Department of Family Medicine June 30,

21 Quick relief medications: These medications are used to provide prompt treatment of acute airflow obstruction and may be the sole medication used in intermittent asthma. Short-acting beta2-agonists: It is the treatment of choice for the relief of acute symptoms and prevention of Exercise Induced Asthma. Anticholinergics: Ipratropium bromide may provide some additive benefit to inhaled beta2-agonists in severe exacerbations. Systemic corticosteroids: Used in moderate-to-severe exacerbations to speed recovery and prevent recurrence of exacerbations. Q U I C K - R E L I E F M E D I C AT I O N S Name/Products Indications Potential Adverse Effects -Tachycardia, skeletal muscle Short-Acting -Relief of acute symptoms; tremor, hypokalemia, Inhaled Beta2-Agonists quick-relief medication. increased lactic acid, Albuterol -Preventive treatment prior to headache, hyperglycemia. - Bitolterol exercise for exercise-induced Inhaled route, in general, Pirbuterol bronchospasm. causes few systemic adverse Terbutaline effects. Anticholinergics Ipratropium bromide Systemic Corticosteroids: Methylprednisolone Prednisolone Prednisone -Relief of acute bronchospasm. -For moderate-to-severe exacerbations to prevent progression of exacerbation, reverse inflammation, speed recovery, and reduce rate of relapse. -Drying of mouth and respiratory secretions, and increased wheezing in some individuals. -Short-term use: reversible abnormalities in glucose metabolism, increased appetite, fluid retention, weight gain, mood alteration, HTN, peptic ulcer, and rarely aseptic necrosis of femur. University of South Alabama, Department of Family Medicine June 30,

22 Stepwise Approach for Management of Asthma: University of South Alabama, Department of Family Medicine June 30,

23 University of South Alabama, Department of Family Medicine June 30,

24 University of South Alabama, Department of Family Medicine June 30,

25 Step Down Therapy: This involves gradual reduction of long-term control medications after a long period of control of persistent asthma. Inhaled steroids may be reduced by about 25% every 3 months until the lowest dose required to treat is reached. If the patient is on chronic systemic steroid therapy, continuous attempts should be made to reduce the dosage. Step Up Therapy: This involves increasing therapy in response to indicators of poor asthma control. A short course of systemic steroids may be necessary to rapidly alleviate the symptoms and regain control of the asthma. It is necessary to explore possible causes of the deterioration of the patient s condition (e.g. non-compliance with medications, infections, or exposure to triggering factors). University of South Alabama, Department of Family Medicine June 30,

26 Strength of Recommendation Label Key clinical recommendations B A A C Inhaled corticosteroids are more effective than cromolyn, nedocromil, theophylline, and leukotriene modifiers for the long-term control of asthma. Inhaled corticosteroids are recommended as first-line treatment in children with acute asthma. The combination of a beta2 agonist and an inhaled corticosteroid is superior to the addition of a leukotriene modifier. Adding an antibiotic to usual care is not recommended in patients with asthma. Managing Exercise Induced Asthma: With this entity, patients will present with a history of wheezing, shortness of breath, chest tightness, or cough spells in response to activity. Generally it begins at the start of exercise, peaks 5 to 10 minutes later and usually resolves in another 20 to 30 minutes. Diagnosis may be confirmed by measuring a 15% decrease in peak flow readings or FEV 1 after vigorous exercise. Pharmacotherapy: Two to four puffs of short-acting beta 2 -agonist 5 to 60 minutes before exercise (effects last 2-3 hours). Use of long-acting beta 2 -agonist (effects last hours) Cromolyn or nedocromil can also be used before exercise (effects last 1-2 hours) Montelukast may be used for this purpose if taken daily. A 6-10 minute warm-up period before exercise may be beneficial to the patient. Increase in long-term control medication, if appropriate. Follow-up: Follow up for proper management and monitoring of asthma is as follows: Every 2-6 weeks while gaining control of symptoms. Every 1-6 months to monitor maintenance of sufficient control. Every 3 months to assess for step down in therapy. University of South Alabama, Department of Family Medicine June 30,

27 During the follow up visit a history of their asthma symptoms should be obtained to ascertain proper asthma control. The following is an example of such a questionnaire: 1) In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home? 2) During the past 4 weeks, how often have you had shortness of breath? 3) During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning? 4) During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)? 5) How would you rate your asthma control during the past 4 weeks? A thorough physical exam should be performed with a special attention to the lung examination. A verification of the asthma severity should be made and medications altered accordingly. Steps for Correct use of an Inhaler: 1. Remove the cap and hold inhaler upright. 2. Shake the inhaler. 3. Tilt your head back slightly and breathe out slowly. 4. Position the inhaler into mouth as directed. 5. Press down on the inhaler to release medication as you start to breathe in slowly. 6. Breathe in slowly (3 to 5 seconds). 7. Hold your breath for 10 seconds to allow the medicine to reach deeply into your lungs. 8. Repeat puff as directed. Waiting 1 minute between puffs may permit second puff to penetrate your lungs better. 9. Spacers/holding chambers are useful for all patients. They are particularly recommended for young children and older adults and for use with inhaled corticosteroids. Avoid common inhaler mistakes. Follow these inhaler tips: Breathe out before pressing your inhaler. Inhale slowly. Breathe in through your mouth, not your nose. Press down on your inhaler at the start of inhalation (or within the first second of inhalation). Keep inhaling as you press down on inhaler. Press your inhaler only once while you are inhaling (one breath for each puff). Make sure you breathe in evenly and deeply. University of South Alabama, Department of Family Medicine June 30,

28 Management of Asthma Exacerbation at Home: Assess Severity Measure PEF: Value <40% personal best or predicted suggests severe exacerbation. Note signs and symptoms: Degrees of cough, breathlessness, wheeze, and chest tightness correlate imperfectly with severity of exacerbation. Accessory muscle use and suprasternal retractions suggest severe exacerbation. Initial Treatment Inhaled short-acting beta2-agonist: up to three treatments of 2-4 puffs by MDI at 20-minute intervals or single nebulizer treatment. Good Response Mild Exacerbation -PEF >70% predicted of personal best -No wheezing or shortness of breath -Response to beta2-agonist sustained for 4 hours May continue beta2- agonist every 3-4 hr for hours. For patients on inhaled corticosteroids, double dose for 7-10 days. Incomplete Response Moderate Exacerbation -PEF 40-70% predicted of personal best -Persistent wheezing and shortness of breath Add oral corticosteroid. Continue beta2-agonist. Poor Response Severe Exacerbation PEF <40% predicted of personal best Marked wheezing and shortness of breath Add oral corticosteroid. Repeat beta2-agonist immediately. If distress is severe and nonresponsive, call your doctor and proceed to emergency department; consider calling 911. Contact clinician for follow-up instructions. Contact clinician urgently (this day) for instructions. Proceed to emergency department. University of South Alabama, Department of Family Medicine June 30,

29 Supplemental Material: Resources for Patients: References: National Institutes of Health (NIH) guidelines University of South Alabama, Department of Family Medicine June 30,

30 Chest Pain 780.5x Definition: A complaint based diagnosis which refers to any of a number of conditions associated with discomfort between the clavicles and the xyphoid process that cause a patient to seek evaluation. General Approach to the patient: Goals: 1. Identify specific or life-threatening causes of chest pain 2. Obtain adequate information to develop a working diagnosis in an efficient manner 3. Arrange for definitive care of identified specific causes of chest pain at time of presentation or with appropriate follow-up 4. Allay fears of patient and family regarding symptom if cause is benign 5. Provide symptomatic relief of patient complaints 6. Avoid ordering unnecessary tests on low risk patients University of South Alabama, Department of Family Medicine June 30,

31 Rules of Thumb: Age Complaint frequency Commonly diagnosed diseases (in descending order of prevalence) Life threatening diseases to consider Key worrisome features (history) Key elements of exam Key diagnostic study Common Treatment Functional limitations >65 Common Common Common Common Common Chest wall pain Asthma Functional GE reflux Asthma Acute chest (sickle cell) Cardiac conditions History of heart disease, History of recent cancer treatment Respiratory rate, Palpation of chest wall Cardiopulmonary exam None, consider CXR NSAIDS, asthma meds Usually none, especially if asthma controlled Chest wall pain Functional Asthma GE reflux Acute chest (sickle cell) Cardiac conditions Pulmonary embolism Cocaine and other substances History of heart disease, History of recent cancer treatment Respiratory rate, Pulse, Palpation of chest wall Cardiopulmonary exam None, consider CXR Disease dependent Based on diagnosis Chest wall pain GE reflux Panic disorder Peptic ulcer disease Atypical chest pain Unstable angina Pulmonary embolism Pneumonia Acute chest (sickle cell) Cocaine and other substances Male sex, History of CAD, diaphoresis, radiation of pain Respiratory rate, Pulse, Palpation of chest wall Cardiopulmonary exam Based on clinical suspicion, consider ECG and if severe cardiac markers Disease dependent Based on diagnosis Chest wall pain GE reflux Atypical chest pain Typical angina Unstable angina Pulmonary embolism Aortic aneurysm Male sex, History of CAD, diaphoresis, severity and radiation of pain Respiratory rate, Pulse, Palpation of chest wall Cardiopulmonary exam ECG, consider cardiac markers, others based on clinical suspicion Disease dependent Based on diagnosis Atypical chest pain Typical angina GE reflux Chest wall pain Unstable angina Pulmonary embolism Valvular disease Aortic aneurysm History of CAD, diaphoresis, severity and radiation of pain Respiratory rate, Pulse, Palpation of chest wall Cardiopulmonary exam ECG, consider cardiac markers, others based on clinical suspicion Disease dependent Based on diagnosis University of South Alabama, Department of Family Medicine June 30,

32 Overview: Chest pain is a common reason for patients and parents of patients to seek care. In a large part because of public attention regarding ischemic heart disease, 50% of adolescents presenting with chest pain were worried about heart disease, despite the fact that heart disease rarely causes chest pain in this age group (less than 5%) 1. Even in adults, the most common etiology is chest wall pain although a cardiac etiology is much more likely than in children and adolescents (ranging from 16% in an office setting to 50% in an emergency department setting). 2,3 The role of the physician is to evaluate and quickly assess the likelihood of the complaint being one of several life threatening conditions. The reality is that often these conditions can be eliminated on the basis of history in the office setting, and then the clinician s main task is one of reassurance. Because of patient and family concern, it is important to quickly reach a decision about whether the symptom warrants intensive evaluation or can be evaluated in a more leisurely fashion (or even be treated symptomatically until it resolves with no further evaluation). Complaints related to an acute onset of symptoms (under 48 hours) are associated with more severe illness but this is not always the case. These complaints always tend to be of more concern to the patient than do more persistent symptoms (some people will have had symptoms for as long as 6 months or more before seeking evaluation). There is no single reassuring finding that can eliminate life-threatening diagnoses from consideration. The most common of these in adults, though, have had evidence based decision rules developed which allow clinicians to comfortably triage patients into appropriate settings for diagnostic tests and definitive treatment. The clinician can take advantage of these decision support tools either by accessing them electronically or using traditional resources and completing calculations by hand or approximating risk and using the support tools to develop rules-of-thumb. Chief Complaint: Typically the complaint is Chest Pain Vitals: Age, gender, and a review of vital signs with attention to the presence or absence of fever, pulse, respiratory rate, basal metabolic index (BMI) and pulse oximeter if applicable should be noted. In addition, in patients over 20, cardiovascular risk factors (tobacco use, diabetes, hypertension, hyperlipidemia, obesity, known CAD, strong family history) should be identified through chart review prior to entering the room as well. General approach to history: The history for chest pain is primarily to establish risk of the symptom being caused by a life threatening condition. This is done by characterizing and documenting the nature of the pain experienced by the patient, the time course of the pain, aggravating and alleviating symptoms, and noting pertinent past medical history. Because pain histories tend to be subjective and patients tend to ruminate over time, it is useful to re-evaluate or even seek out other people to retake the history if it is confusing or does not easily fit into an identifiable pattern. University of South Alabama, Department of Family Medicine June 30,

33 Location Where does your chest hurt? (Can ask patient to indicate with hand the place of most severe pain) Timing When did the pain begin? What were you doing when you first noticed it? What activities are you engaged in when you notice the pain? Are there activities that reliably bring on the pain? Quality What kind of pain is it? (Sharp, dull, aching, stabbing, burning, pressure, etc) Severity How bad is the pain on a scale of 1-10? Aggravating/Relieving factors Does anything make it better? (Stopping, sitting, lying down, shallow breathing, certain positions, certain medications) Does anything make it worse? (Exertion, cough, movement, etc) Associated symptoms Are any other symptoms associated with the chest pain? (Diaphoresis, nausea, vomiting, radiation to arm, radiation to jaw, radiation to other sites, acid brash) Age Specific Concerns in the history: Infants, School Aged Children, Adolescents: Key Question Content Acute onset, decreased breath sounds Genetic predisposition to heart disease (Marfan s, etc) Trauma Hyperventilation, school stressors Breast growth Night cough Cough, fever Acid brash History of sickle cell disease History of cancer treatment (recent or ongoing) History of sympathomimetic ingestion (pseudoephedrine, cocaine, etc) History of pain on exertion, with syncope, with dizziness, or with palpitations History of congenital heart disease Further investigation if positive Consider pneumothorax Disease dependant Consider fracture Consider functional, explore stressors Consider puberty Consider asthma Consider bronchitis, pneumonia Consider reflux Consider acute chest Consider PTE Consider as cause Consider cardiac cause Consider as cause University of South Alabama, Department of Family Medicine June 30,

34 Adults: Questions For Adults From 25 to 65 (Older adults (>65): The questions below are pertinent but the incidence of native cardiac disease is so high that any complaint of chest pain should lead to concern about a cardiac etiology) Key Question Content Further Investigation If Positive Trauma Consider fracture Positional, worsening with movements Consider musculoskelatal Hyperventilation, panic symptoms Consider functional, explore stressors Cough, fever Consider bronchitis, pneumonia Acid brash Consider reflux History of recent or ongoing cancer treatment, Consider PTE immobilization, injury to lower extremity History of sympathomimetic ingestion (cocaine, pseudoephedrine, etc) Upon confirmation that chest pain is potentially cardiac in nature based on characterization of pain Consider as cause Risk factor assessment: Tobacco use (amount and years) Hypertension (years and level of control) Family history of premature CAD (age and relation) Hypercholesterolemia (years and control) Diabetes mellitus (years and control) Known heart disease Documented angina Known CAD Prior myocardial infarction Known congestive heart failure Physical: The physical exam is targeted primarily at confirming clinical suspicion from history and risk factor assessment Vitals - Heart rate, respirations, temperature, weight/height (age below 16), blood pressure General Does the patient appear comfortable or in obvious pain? How is the patient sitting? HEENT n/c Neck probably normal but observe for JVD, auscultate for bruit Chest wall Palpate for reproduction of pain, note if positive Heart Note rate and rhythm, palpate for PMI, auscultate for gallop, rub Lungs Auscultate for rales, wheezes Abdomen (adults) Probably low yield but consider percussion and palpatation for organomegaly or aneurysm, auscultation for bruits Extremities palpate for edema Neuro n/c Musculoskeletal See chest wall Diagnostic studies (see Figures 1&2) University of South Alabama, Department of Family Medicine June 30,

35 General Guidelines Patients under 25: The overwhelming majority of these patients with chest pain do not have a cardiac etiology. (SOR - A) 1, 4 There are no evidence based decision rules at this time to assist with diagnosis o Initial evaluation should include sufficient data to rapidly determine need for evaluation in hospital setting. This would include heart rate, respirations, pulse oximetry for suspected pulmonary or cardiac pain, and a brief assessment of nature and severity of pain (SOR - C). Patients who make an appointment for this complaint over the phone should be offered a prompt appointment (SOR - C). Patients with a recent history of cancer, ongoing cancer treatment, or sickle cell disease and this complaint should receive expeditious evaluation (SOR - C). o Musculoskelatal pain can be diagnosed on the basis of history and physical exam alone without additional studies. A chest x-ray should be obtained for persistent pain or excessive parental concern. (SOR - C). o Functional pain can be diagnosed on the basis of history and physical alone. A chest x-ray should be obtained for persistent pain or excessive parental concern. (SOR - C). Unexplained pain that has worrisome features or is associated with excessive parental concern should be referred for subspecialty evaluation before assigning to functional category (SOR - C). Upon determining that the pain is functional in nature, further work-up should be limited (SOR - C). o Pain of a pulmonary etiology should be assessed on the basis of history and physical with a chest x-ray and pulse oximetry being obtained almost as a matter of course (SOR - C). For those patients at risk for a deep venous thrombosis and pulmonary thromboembolism, a d-dimer or equivalent study should be obtained. A negative study effectively rules out thromboembolic disease. A positive study should lead to further imaging using high resolution CT scanning or nuclear imaging in an emergency department setting (SOR - B). Presumed infectious causes should be evaluated with a chest x-ray if the patient reports significant discomfort, or is febrile, tachypneic, tachycardic, or the diagnosis is unclear in any way. A complete blood count with differential should be obtained on patients with fevers, in particular if the diagnosis is in doubt. In addition, a blood culture should be obtained if broad spectrum antibiotics are being initiated (SOR - B). Possible masses or pneumothorax should be evaluated with chest x-ray (SOR - B). o Pain felt to be of GI origin may be treated empirically, with relief of symptoms serving to confirm the diagnosis (SOR - C). Persistent pain or treatment failure should be referred for subspecialty evaluation (SOR - C). o Initial evaluation of cardiac pain should include a measurement of oxygen saturation. If based on history and physical a congenital problem or rhythm disturbance is suspected then a chest x-ray should be performed. Rhythm disturbances should additionally be investigated with an EKG. Suspected structural problems should be investigated with an echocardiogram (SOR - C). If the pain is predictably exertional, or associated with syncope, or with lightheadedness then the patient should be referred to a cardiologist for additional evaluation (SOR - C). University of South Alabama, Department of Family Medicine June 30,

36 o Over the counter stimulants can cause pain and palpitations. These include cough and cold remedies, nicotine, and caffeine. If suspected to be the cause, a trial of abstinence should result in resolution of symptoms (SOR - C). Cocaine or methamphetamine related chest pain may be difficult to diagnose due to the patients being less than forthcoming (SOR - B). If suspected, obtain a urine drug screen (SOR - C). If the pain is ongoing, further evaluation should occur in the hospital setting (SOR - B). If the pain is remote, screening and treatment for addiction is warranted (SOR - B). Patients over 25: The majority of these patients with chest pain do not have a cardiac etiology, although more so than in the younger age group. (SOR A) 5,6 At any given age, women are less likely to have heart disease than men, although that advantage is reduced following hysterectomy and menopause (SOR - C). Patients above age 65 are more likely to have cardiac disease, a dissecting aneurysm, and herpes zoster as a cause of chest pain (SOR - C). 7 o Initial evaluation should include sufficient data to rapidly determine need for evaluation in hospital setting. This would include heart rate, respirations, pulse oximetry for suspected pulmonary or cardiac pain, and a brief assessment of nature and severity of pain (SOR - C). Patients who make an appointment for this complaint over the phone should be offered a prompt appointment (SOR - C). Patients with a recent history of cancer, ongoing cancer treatment, or known coronary artery disease and this complaint should receive expeditious evaluation (SOR - C). o Musculoskeletal pain can be diagnosed on the basis of history and physical exam alone without additional studies. A chest x-ray should be obtained for persistent pain or excessive concern. (SOR - C). Patients with multiple risk factors should have very close follow-up and possibly an EKG at the time of the visit. If the pain is persistent or clinical suspicion is heightened for any other reason, then an evaluation with a gaited stress test or by a cardiology subspecialist is warranted (SOR - C). A therapeutic trial of NSAIDS can be offered if not contra-indicated (SOR - C). Herpes zoster can present as pain before the rash occurs. o Pain felt to be of GI origin may be treated empirically, with relief of symptoms serving to confirm the diagnosis (SOR - C). Persistent pain or treatment failure should be referred for subspecialty evaluation, as should those people at risk for esophageal cancer (history of long-term alcohol use, cigarette smoking, family history of esophageal cancer (SOR - C). o Evaluation of chest pain in the adult patient is based on certainty of diagnosis, identification of risk factors and application of decision rules. For example, if the pain is characteristic of angina (substernal pain, exertional in nature, and relieved by nitroglycerin) and the patient is a male over 50 the chance of the pain being ischemic cardiac pain is very high and should be expeditiously evaluated. In contrast, a 25 year old woman with exertional pain likely does not have ischemic coronary disease. One such diagnostic decision cascade would be the following (SOR - C): Obtain EKG High risk: New bundle branch block, transient elevation with pain, or sustained V-tach University of South Alabama, Department of Family Medicine June 30,

37 Intermediate risk: ST T wave inversions > 0.2 mv or pathologic Q waves Low risk: Normal or unchanged, especially during pain Characterize the pain based on known characteristics of angina (quality, aggravating and alleviating factors) High risk: Substernal, on exertion, relieved with NTG Intermediate risk: 2 of three Low risk: 1 of three Identify presence of high risk pre-existing disease Recent MI Recent CABG Recent PCI or stent placement Quickly assess whether patient has known heart disease or diabetes from chart review or patient history. Presence of either puts them at increased risk. Assess and transfer if ischemia suspected If the EKG and/or the pain history are high risk and there is a good chance that the patient has disease based on risk factors, then the patient is given an aspirin and sent to a hospital for further evaluation in a monitored setting. High risk for unstable angina includes age over 65, characteristic pain for 20 minutes, ST-T wave changes, or pulmonary edema If the clinical suspicion remains low, continue evaluation in office Quickly assess other risk factors from chart review or additional history (Age, Male sex, Presence of diagnosed hypertension, DM or hyperlipidemia, Presence of tobacco use, Family history of early CAD) Higher risk: Male over 50, Woman over 60 Higher risk: Longstanding hypertension, hyperlipidemia, tobacco use Higher risk: Family history of disease in a first degree relative at the patients age or younger Obtain clarifying labs Lipid profile CBC Blood glucose (consider full chemistry) Consider thyroid studies based on clinical suspicion Assess left ventricular function For any concomitant signs of LV dysfunction (particularly dyspnea on exertion), obtain echogardiogram as part of work-up Consider possibility of aortic aneurysm In patients with Marfan body habitus or with history of long time tobacco use and other risk factors such as age and hypertension, aortic aneurysm should be considered as a cause of chest pain. If there is reasonable clinical suspicion, an x-ray and/or CT of the chest should be obtained. A normal mediastinum rules out the diagnosis University of South Alabama, Department of Family Medicine June 30,

38 Make a clinical assessment of the likelihood of the coronary artery disease. One such model is seen below (SOR B): Another more comprehensive model can be found at (SOR B) If the pretest probability is less than 30%, then further testing should be pursued only with the understanding that the risk of a false positive test is high and that a negative test does not rule out disease. If the pretest probability is greater than 30% but less than 60% then further non-invasive testing is indicated. If the pre-test probability is greater than 60% then non-invasive testing should not be pursued and cardiac catheterization would be the next step. The diagnostic testing decision is as follows: Intermediate probability of CAD, EKG with less than 1 mm ST depression and/or RBBB, able to exercise - Dynamic exercise testing Intermediate probability of CAD or remote history of CAD, EKG with greater than 1 mm ST depression, pre-excitation (WPW), paced rhythm, LBBB, able to exercise - Dynamic exercise testing with additional imaging Intermediate probability of CAD, EKG with or without less than 1 mm ST depression, unable to exercise - Adenosine or dipyridamole myocardial perfusion study It is unclear where the multi-slice CT scanner will fit into the diagnostic algorithm for these patients at this time If after the clinical assessment or after non-invasive testing there is a high probability of left main or 3 vessel disease, uncertain diagnosis after non-invasive testing, or suspected non-atherosclerotic etiology Referral for possible cardiac catheterization If after the clinical assessment or after non-invasive testing there is a low probability of left main or 3 vessel disease Work on risk factor modification University of South Alabama, Department of Family Medicine June 30,

39 o Pain of a pulmonary etiology should be assessed on the basis of history and physical with a chest x-ray and pulse oximetry being obtained almost as a matter of course (SOR - C). If clinically the diagnosis of DVT is entertained, elements of the history, physical exam suggest PTE then a clinical decision should be made as to whether or not a PTE is likely. Use of a validated decision rule such as the one below can assist with this decision (SOR - B). For those patients at risk for a deep venous thrombosis and pulmonary thromboembolism, a d-dimer or equivalent study should be obtained. A negative study effectively rules out thromboembolic disease. A positive study should lead to further imaging using high resolution CT scanning or nuclear imaging in an emergency department setting (SOR - B). If the D- University of South Alabama, Department of Family Medicine June 30,

40 dimer is positive but the clinical suspicion is relatively low and the imaging study is negative then a venous doppler should be obtained and if negative repeated in a week. If the suspicion is high, then pulmonary artery catheterization would be indicated. Presumed infectious causes should be evaluated with a chest x-ray if the patient reports significant discomfort, is febrile, tachypneic, tachycardic, or the diagnosis is unclear in any way. A complete blood count with differential should be obtained on patients with fevers, in particular if the diagnosis is in doubt. In addition, a blood culture should be obtained if broad spectrum antibiotics are being initiated (SOR - B). If a chest x-ray is inconvenient to obtain, a validated clinical rule can be used to determined the urgency with which an x-ray is needed (SOR - B). Complaints suggestive of masses or pneumothorax should be evaluated with chest x-ray (SOR - B). o Symptoms consistent with panic disorder should be evaluated with the following two questions: University of South Alabama, Department of Family Medicine June 30,

41 In the past six months, did you ever have a spell or an attack when all of a sudden you felt frightened, anxious, or very uneasy? In the past six months, did you ever have a spell or an attack when for no reason your heart suddenly began to race, you felt faint, or you couldn t catch your breath? A yes on either question is considered a positive screen but the screen is neither sensitive nor specific enough in a population with a high prevalence of coronary artery disease to predict a lack of cardiac disease. Thus, in patients at significant risk, a cardiac etiology should be pursued prior to attributing the pain to panic disorder. o Over the counter stimulants can cause pain and palpitations. These include cough and cold remedies, nicotine, and caffeine. If suspected to be the cause, a trial of abstinence should result in resolution of symptoms (SOR - C). Cocaine or methamphetamine related chest pain may be difficult to diagnose due to the patients being less than forthcoming (SOR - B). If suspected, obtain a urine drug screen (SOR - C). If the pain is ongoing, further evaluation should occur in the hospital setting (SOR - B). If the pain is remote, screening and treatment for addiction is warranted (SOR - B). o Functional pain is typically a diagnosis of exclusion in adults. Particularly in patients with risk factors for another disease, diagnostic testing should be pursued. At a minimum a chest x-ray should be obtained for persistent pain or concern and a cardiac work-up should be pursued in patients who are at risk (SOR - C). Unusual diagnoses such as recurrent PTE should be entertained over time. Unexplained pain that has worrisome features or is associated with concern should be referred for subspecialty evaluation before assigning to functional category (SOR - C). Once comfortable that the pain is functional in nature, further work-up should be limited (SOR - C). Office Based Management: Musculoskeletal Pain: Non pharmacologic Patients with acute chest wall pain require only conservative management (SOR - C). Patients should be instructed to resume their normal activities as tolerated. Any aggravating factors should be eliminated to the extent possible. Bed rest is not indicated. (SOR - A) Pharmacologic (SOR - C) NSAIDS (see Appendix) relieve chest wall pain through their analgesic properties and also reduce inflammation. Instruct patients to take NSAID regularly until pain resolves. Acetaminophen is an alternative medications in patients for whom NSAID s are contraindicated. A short course of narcotic pain relievers can be used if the pain is severe until NSAID s can take effect but should not be used for recurrent pain. Herpes zoster (SOR B) 7 - The treatment of herpes zoster has three major objectives: (1) treatment of the acute viral infection, (2) treatment of the acute pain associated with herpes zoster and (3) prevention of postherpetic neuralgia. Antiviral agents, oral University of South Alabama, Department of Family Medicine June 30,

42 corticosteroids and adjunctive individualized pain-management modalities are used to achieve these objectives. Antivirals - Antiviral agents have been shown to decrease the duration of herpes zoster rash and the severity of pain associated with the rash. However, these benefits have only been demonstrated in patients who received antiviral agents within 72 hours after the onset of rash. Antiviral agents may be beneficial as long as new lesions are actively being formed, but they are unlikely to be helpful after lesions have crusted. The rule has been proposed to identify who would most benefit from antivirals, that is those who have had the symptoms for under 50 hours, and are over 50 or have more than 50 lesions. (SOR-C) Acylovir (Zovirax) therapy appears to produce a moderate reduction in the development of postherpetic neuralgia in these patients. Other antiviral agents, specifically valacyclovir (Valtrex) and famciclovir (Famvir), appear to be at least as effective as acyclovir. Dosages are available from commonly available references Corticosteroids - Orally administered corticosteroids are commonly used in the treatment of herpes zoster, even though clinical trials have shown variable results. Prednisone used in conjunction with acyclovir has been shown to reduce the pain in patients more than 50 years of age and is useful for reducing symptoms for zoster involving the facial nerve. The dose in adults is generally 30 mg orally twice daily on days 1 through 7; then 15 mg twice daily on days 8 through 14; then 7.5 mg twice daily on days 15 through 21 Analgesics - The pain associated with herpes zoster ranges from mild to excruciating. Patients with mild to moderate pain may respond to over-the-counter analgesics. Patients with more severe pain may require the addition of a narcotic medication. When analgesics are used, with or without a narcotic, a regular dosing schedule results in better pain control, and less anxiety, than "as-needed" dosing. Panic disorder See Depression chapter Pneumonia - See Pneumonia chapter Gastroesophageal reflux disease: 8 Non-pharmacologic: Patients should be instructed to avoid large meals and should not lie down immediately after eating (up to 3 hours). They should also be counseled that acidic foods, alcohol, caffeinated beverages, chocolate, onions, and garlic may exacerbate symptoms and should be withdrawn initially; they can be added back as symptoms permit. Reducing dietary fat should improve symptoms as should weight loss. Medications known to cause reflux should be withdrawn if possible. These include calcium channel agonists, alpha-adrenergic agents, theophylline, nitrates and certain sedatives. The head of the bed should be elevated 4 8 inches. Tight clothing should be avoided as should tobacco use. Pharmacologic: After making diagnosis, it is reasonable to start with either an H2 blocker or a proton pump inhibitor. The choice is based on previous effective and University of South Alabama, Department of Family Medicine June 30,

43 ineffective therapy and cost to patient. (see appendix for choices and dosages) If the H2 blocker was used initially but is only partially effective, it may be necessary to switch to a PPI. Once symptoms resolve, reduce dose to the lowest required to maintain patient symptom free. Antacids may be added for additional symptom relief, especially early on or when symptoms flair. Chest pain with cardiac risk factors - Those patients who following diagnostic testing are found to be of low immediate risk of having significant coronary artery disease should reduce their risk factors if possible. The sex, age, and family history cannot obviously be change. On the other hand patients can quit the use of tobacco products, reduce their blood pressure, monitor and control their lipids and blood pressure, increase their physical activity and reduce their weight. The stages of change model identifies the likelihood of a patient making a significant lifestyle change. Physicians are most likely to make a difference when the patient is in the contemplation stage (by eliciting commitment) and in the preparation stage (by offering assistance) Precontemplation is the stage at which there is no intention to change behavior in the foreseeable future. Many individuals in this stage are unaware or underaware of their problems. Contemplation is the stage in which people are aware that a problem exists and are seriously thinking about overcoming it but have not yet made a commitment to take action. Preparation is a stage that combines intention and behavioral criteria. Individuals in this stage are intending to take action in the next month and have unsuccessfully taken action in the past year. Action is the stage in which individuals modify their behavior, experiences, or environment in order to overcome their problems. Action involves the most overt behavioral changes and requires considerable commitment of time and energy. Maintenance is the stage in which people work to prevent relapse and consolidate the gains attained during action. For addictive behaviors this stage extends from six months to an indeterminate period past the initial action. Risk Factor Target (no CAD) Target (CAD or diabetes) Smoking Abstinence Abstinence Hypertension 140/85 130/80 Hyperlipidemia (LDL) 130 (2 Risk factors) 100 (consider 70) Diabetes (A1c) n/a 7.0 Urgent referral to emergency department for evaluation under controlled conditions and possible admission (SOR - B): Suspected PTE based on history and risk factors Pain associated with hypoxia, regardless of etiology Suspected acute cardiac event Pneumothorax Referral to specialist (SOR - C): Suspected congenital heart disease Pain associated with syncope, exertion, or lightheadedness in child or adolescent University of South Alabama, Department of Family Medicine June 30,

44 Suspected cardiac ischemic pain in an adult Gastroesophageal reflux associated with dysphagia, early satiety, iron deficiency anemia, odynophagia, vomiting, weight loss or if not improved in reasonable time with conservative measures. Consider referral if at risk for Barrett s esophagus (i.e. white male age >45 with long history of symptoms, history of long-term alcohol use, cigarette smoking, family history of esophageal cancer. Consider referral if etiology needs to be made clear and cardiology work-up non revealing) Pain associated with cocaine use Mass in chest Follow-up (SOR - C): Patients who are at risk for potentially life threatening disease should follow through on recommended consultations and follow-up when problem has been evaluated. For patients with musculoskeletal pain, schedule follow-up for two to four weeks but if the pain resolves and the patient is not at risk for ischemic heart disease they may elect to cancel the appointment. For patients with pain from herpes zoster, they should follow-up for infection or non-resolution in 2 4 weeks Patients with gastroesophageal reflux disease should be re-evaluated for reduction of symptoms within 4 weeks and resolution within 8 weeks Patients felt to be symptomatic from stimulant use, a visit following a week of abstinence is usually sufficient. At that visit, counseling regarding excessive stimulant use should be provided. For patients with multiple cardiac risk factors, aggressive risk factor modification should begin when patient is amenable to change. The follow-up visit soon after a negative stress test will often present itself as an opportunity for the physician to facilitate change. This follow-up should occur within a week of the negative stress test. Suggested for further reading: Chapter 23 Chest Pain in Current Diagnosis & Treatment in Family Medicine. Jeannette E. South-Paul, Samuel C. Matheny, Evelyn L. Lewis eds Accessible by subscription at Pnaju A, Hemmerlarn B, Guyatt G, Simel D. Is this patient having a myocardial infarction? JAMA, 1998; 280: Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr., Fihn SD, Fraker TD Jr., Gardin JM, O Rourke RA, Pasternak RC,Williams SV. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for the Management of Patients with Chronic Stable Angina) Available at University of South Alabama, Department of Family Medicine June 30,

45 Resources for patients: Chest pain, acute accessed on Familydoctor.org at Chest pain, chronic accessed on Familydoctor.org at Heartburn: Hints on dealing with the discomfort accessed on Familydoctor.org at Smoking: Steps to Help You Break the Habit accessed on Familydoctor.org at References: 1. Pantell R, Goodman B. Adolescent chest pain: a prospective study. Pediatrics 1983 Jun;71(6): Klinkman MS, Stevens D, Gorenflo DW. Episodes of care for chest pain: a preliminary report from MIRNET. J Fam Pract 1994;38: Cayley W. Diagnosing the Cause of Chest Pain Am Fam Physician 2005;72: Evangelista, JA, Parsons, M, Renneburg, AK. Chest pain in children: diagnosis through history and physical examination. J Pediatr Health Care 2000; 14:3. 5. Marsan R, Shaver K, Sease K, et al. Evaluation of a clinical decision rule for young adult patients with chest pain. Academic Emergency Medicine 2005; 12: Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr., Fihn SD, Fraker TD Jr., Gardin JM, O Rourke RA, Pasternak RC,Williams SV. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for the Management of Patients with Chronic Stable Angina) Stankus S, Dlugopolski M, Packer D. Management of herpes zoster (shingles) and postherpetic neuralgia Am Fam Physician 2000;61: , DeVault K and Castell D. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterology 2005; 100: University of South Alabama, Department of Family Medicine June 30,

46 Appendix University of South Alabama, Department of Family Medicine June 30,

47 University of South Alabama, Department of Family Medicine June 30,

48 University of South Alabama, Department of Family Medicine June 30,

49 Cough Definition: Cough A rapid expulsion of air from the lungs typically in order to clear the lung airways of fluids, mucus, or material; also called tussis. General Approach to the patient: Goals: 1. Identify specific or life-threatening causes of cough. 2. Arrange for definitive care of identified specific causes of cough at time of presentation or with appropriate follow-up. 3. Provide symptomatic relief of patient complaints. Age 0-2 years 2-14 years years >65 years Complaint Very Common Common Common Common frequency Commonly diagnosed diseases (in descending order of prevalence) URI GERD Croup Asthma URI Postnasal drip Asthma Croup GERD URI Postnasal drip Asthma GERD Medication side URI Postnasal drip Asthma GERD Medication side Life threatening diseases to consider Key worrisome features (history) Key elements of exam Key diagnostic study Pneumonia Congenital malformations Foreign body aspiration Fever Cyanosis Respiratory Distress ENT Lung Based on history and physical Pneumonia Foreign Body Aspiration Malignancy Fever Shortness of Breath ENT Lung Based on history and physical effect Pneumonia Malignancy Fever Shortness of breath ENT Lung Based on history and physical effect Pneumonia Malignancy Fever, shortness of breath, orthopnea, PND ENT Lung Cardiac Based on history and physical Common Treatment Functional limitations Disease dependent Based on diagnosis Disease dependent Based on diagnosis Disease dependent Based on diagnosis Disease dependent Based on diagnosis University of South Alabama, Department of Family Medicine June 30,

50 Overview: Cough is a very common complaint experienced by all age groups. Cough is a normal mechanism of the body that clears secretions from the bronchial tree and trachea. Cough is an involuntary reflex mediated through the vagal afferents. There is some degree of voluntary control over this reflex. Voluntary control is manifested as cough inhibition (holding back a cough) or voluntary cough. Involuntary cough is triggered by vagus nerve stimulation in the back of the throat and bronchial tree. A large number of common diseases including asthma, GERD, bronchitis, and post-nasal drip can cause cough through airway irritation. In addition, there are life-threatening ailments like pneumonia and lung cancer that may present with cough as a chief complaint. A thorough history and physical exam is important in determining the cause of cough. Chief Complaint: Typically the complaint is Cough Vitals: Age, respiratory rate, pulse, temperature and weight should be noted prior to going into the room through chart review and review of vital signs. Fever and/or tachypnea may suggest pneumonia or other systemic illness. General approach to history: The history for cough is primarily to identify underlying causes of cough. Questions are directed at determining the nature of the cough (productive vs. nonproductive), time course and modifying factors. Timing How long have you been coughing? Is it getting better, staying the same, or getting worse? When do you cough the most (night, day, etc)? Nighttime cough suggests asthma or GERD. Quality Are you coughing anything up? If so, what color is it? Green or yellow sputum was once thought to be suggestive of bacterial infection, although this remains controversial. Severity How much are you coughing? Are you coughing so much that you vomit? Aggravating/Relieving factors Does anything make it better or worse? (Eating, lying down, going outside, pollen exposure, etc) Associated symptoms Are any other symptoms associated with the cough? (Chest pain, dyspnea, acid brash, wheezing) Symptom Review Targeted at common causes of cough for patient s age. See tables and flowcharts. University of South Alabama, Department of Family Medicine June 30,

51 Physical: The physical exam is targeted primarily at identifying underlying causes of cough and ruling out serious pathology (i.e. pneumonia, severe COPD exacerbation) General Watch out for respiratory distress (labored breathing, accessory muscle use) HEENT Look for pharyngeal erythema (present with many causes of cough), Nasal drainage (upper airway cough syndrome) Neck n/c Heart Listen for murmurs and arrhythmias particularly in older patients. Lungs Listen for wheezes (asthma), crackles (pneumonia) and rhonchi (bronchitis) Abdomen Assess for epigastric tenderness (GERD), although, most patients with GERD will not have epigastric tenderness. Extremities n/c Neuro n/c Musculoskeletal n/c Disease Specific Indicators: Infants ages 0 2 years: Disease URI GERD Asthma Croup (age 0-6 years) Pneumonia Children Ages 2-14 years: Disease URI Asthma GERD Pneumonia Bronchitis UACS (Upper Airway Cough Syndrome) Suggestive findings on history and physical Daycare attendance. Sick contacts. Duration of cough <2 weeks. Nasal congestion. Spitting up after feeding. Poor weight gain. Duration of cough >2 weeks. Nighttime cough. Wheezing. Cough worsened by environmental exposure or change. Asthma, Allergies or Eczema in siblings or parents. Coughing for >1 week with most URI s. Barking cough, inspiratory stridor, abrupt onset. Low grade fever. Productive cough, tachypnea, fever, ill appearance, crackles on physical exam. SpO2 <95% Suggestive findings on history and physical Daycare attendance. Sick contacts. Duration of cough <2 weeks. Nasal congestion. Sore throat. Nighttime cough. Wheezing. Cough and/or dyspnea on exertion. Family or personal history of asthma, allergies or eczema. Coughing for >1 week with most URI s. Bad taste in mouth, worsening symptoms after eating acid or spicy foods, abdominal or chest pain after eating acid or spicy foods. Duration >2 weeks or recurrent. Productive cough, fever, shortness of breath, crackles on physical exam. SpO2 <95%. Productive cough, no fever, no shortness of breath. Duration >2 weeks. Runny nose, watery eyes, post-nasal drip. Sore throat that is worse in morning and better throughout the day. (This sore throat comes from post nasal drainage irritating the back of the throat) University of South Alabama, Department of Family Medicine June 30,

52 Adults >15 years: Disease URI Asthma GERD Pneumonia Bronchitis UACS (Upper Airway Cough Syndrome) ACEI Smoking Lung Cancer Suggestive findings on history and physical Sick contacts. Duration of cough <2 weeks. Sore throat. Nasal congestion Nighttime cough. Wheezing. Cough and/or dyspnea on exertion. Family or personal history of asthma, allergies or eczema. Coughing for >1 week with most URI s. Beta blocker use may worsen asthma. Bad taste in mouth, worsening symptoms after eating acid or spicy foods, abdominal or chest pain after eating acid or spicy foods. Duration >2 weeks or recurrent. Productive cough, fever, shortness of breath, crackles on physical exam. SpO2 <95%. See Diehr Rule Table below. Productive cough, no fever, no shortness of breath. Duration >2 weeks. Runny nose, watery eyes, post-nasal drip. Sore throat that is worse in morning and better throughout the day. (This sore throat comes from post nasal drainage irritating the back of the throat) Pt taking ACEI. Duration of cough >2 weeks. May or may not correspond to starting or increasing ACEI. Patient continues to smoke (regardless of amount). Weight loss, fatigue, hemoptysis, current or former smoker University of South Alabama, Department of Family Medicine June 30,

53 Diagnostic studies: General guidelines Types of diagnostic studies will depend upon clinical suspicion of underlying cause. In some cases a therapeutic trial may be used as a diagnostic study (i.e. trial of proton pump inhibitors for cough secondary to GERD). University of South Alabama, Department of Family Medicine June 30,

54 Suspected cause Study to order When to order Asthma Spirometry In patients >6 years old to make diagnosis and follow disease. Asthma Chest X-ray Initial presentation or dramatic change in asthma pattern GERD Barium swallow Infants GERD H.Pylori Adults who do not respond to standard therapy GERD Endoscopy (GI referral) Patients who fail standard therapy Pneumonia Chest X-ray All patients in whom pneumonia is suspected UACS Allergy testing Patients who fail standard therapy Croup Soft-tissue film of neck All children in whom croup is suspected. Lung Cancer Chest X-ray All patients in whom lung cancer is suspected. Office Based Management: URI See URI handout Non pharmacologic Continue normal activity as tolerated. Hot showers (breathing warm, moist air) and humidifiers may help clear the nasal passages. Hot soups and liquids such as tea may also help clear nasal passages by a vapor action. Pharmacologic Cough suppressants. Combination products are available to target specific constellations of symptoms and can be chosen on the basis of patient complaints. Antihistamines are useful for runny nose and post-nasal drip. Decongestants are useful for nasal congestion and sinus pressure. Cough suppressants and decongestants are not recommended for patients less than 2 years of age. Most systemic cough suppressants suppress cough by action on the central nervous system. Cough drops, numbing lozenges and OTC throat sprays are all useful for symptom relief. Follow-up Patients should be told that most URI s resolve within 7 days, but cough can persist for several weeks after an upper respiratory infection. Patients should return for respiratory difficulty, persistent high fever, or in 2 weeks if not better. Asthma See asthma chapter University of South Alabama, Department of Family Medicine June 30,

55 GERD: Nonpharmacologic Infants - Reduce amount given at each feed and increase frequency of feeding (i.e. If currently taking 4 oz every 4 hrs, give 2 oz every 2 hrs). This will maintain adequate calories, but limit gastric distention and pressure. Also keeping child upright after feeding can minimize symptoms. Children and adults - Limit intake of foods that provoke symptoms. Avoid lying down for at least 30 minutes after eating. Pharmacologic - A trial of H2 blockers or Proton Pump Inhibitors is often diagnostic and therapeutic. In adults these are often started empirically and a response to the treatment is considered diagnostic of GERD. Follow-up - Cough secondary to GERD may persist for several weeks after initiating therapy. Patients should follow up in 1 month if cough has not resolved or sooner for problems. Upper Airway Cough Syndrome (UACS): Non-pharmacologic - Avoid allergens. Formal allergy testing may be useful in identifying allergic triggers. Pets (especially house cats and dogs) are common offenders as is thick carpeting that tends to retain dust and other allergens. Removal of these offenders may dramatically improve symptoms. Pharmacologic - Antihistamines have traditionally been the mainstay of therapy. They are effective, inexpensive and available OTC as well as by prescription. Inhaled nasal steroids are very effective in treating post-nasal drip and UACS. They are not effective acutely, but if used regularly will prevent most allergic mediated postnasal drip. Anticholinergics may be tried if patients do not tolerate antihistamines and inhaled nasal steroids. Leukotriene modifiers are approved for allergic rhinitis and may be considered although their role remains unclear. Follow-up - UACS may persist for 1-2 weeks after treating post-nasal drip and allergic rhinitis. Patients should return in 1 month if not better, sooner for problems. Croup: Non-pharmacologic Cool humidified air may help with symptoms but no studies prove this. Pharmacologic Nebulized racemic epinephrine may help relieve symptoms temporarily. Systemic steroids have been shown to prevent hospitalization and hasten recovery. Otherwise, pharmacologic therapy is targeted toward symptoms. University of South Alabama, Department of Family Medicine June 30,

56 Follow-up - Patients should follow up in 1 week if not better and sooner for increasing work of breathing. Croup is generally a self-limited illness, but occasionally children do require intubation due to subglottic stenosis from croup. Parents should also be informed that symptoms are likely to be worse at night than during the day. Pneumonia: Non pharmacologic Relative rest can help with symptoms of dyspnea. Sitting up for at least 20 minutes per day may help with clearing pulmonary secretions. Frequent voluntary coughing may aid in clearing secretions. Chest physical therapy may also be useful to loosen pulmonary secretions. Pharmacologic Systemic antibiotics for days. If patient is hypoxic or appears ill, hospitalization and IV antibiotics are recommended. Supplemental O2 is given to keep O2 Sats >90%. After patient is afebrile for 24 hrs, antibiotics may be changed to PO. Patients may be discharged home when they are no longer oxygen requiring and are able to tolerate PO antibiotics. See for pneumonia severity index to aid in decision whether to admit to hospital or treat as an outpatient. Follow-up Patients should follow up in 1 week if not better and sooner for worsening shortness of breath or if still running fever for more than 72 hrs after starting antibiotics. ACE Inhibitor induced cough: ACE inhibitors are commonly used for treating HTN and nephropathy in diabetes. Cough is a common side effect of these drugs thought to be mediated by elevations in the levels of bradykinin. ACE inhibitors block the enzyme responsible for degrading bradykinin. Bradykinin is thought to stimulate the cough centers directly. The cough may start anytime after initiating ACE inhibitors but often begins about 1 month after starting the drug. Discontinuing the drug will result in resolution of the cough within 2 weeks if this is the cause of the cough. ACE inhibitors should be stopped in all patients with unexplained cough. Angiotensin receptor blockers have a similar effect on blood pressure but do not result in bradykinin elevations and may be used instead of ACE inhibitors in most patients. Smoker s cough: Non pharmacologic - Smoking is a common cause of chronic cough. All patients who continue to smoke should be advised to stop smoking, both for their health and as a diagnostic tool. Pharmacologic There are numerous pharmacologic aids to smoking cessation including nicotine replacement and selected antidepressants. Patients should be offered pharmacologic intervention if they are unable to stop smoking on their own. Follow-up - In most smokers who present with a cough, the cough is secondary to smoking and will resolve when smoking ceases or is reduced significantly. If the cough does not resolve within 1 month of smoking cessation, other causes should be investigated. University of South Alabama, Department of Family Medicine June 30,

57 Lung Cancer: Nonpharmacologic Stop smoking. Potentially, lung or partial lung resections depending on extent and type of cancer. Pharmacologic Depends on type of cancer. Numerous regimens are used by oncologists. These patients will be co-managed with an oncologist. When to refer to a specialist for further evaluation: Asthma Severe persistent asthma or asthma that does not respond to conventional therapy. GERD Symptoms that do not respond to PPI and H. Pylori eradication (if infection is present) Lung Cancer All patients with lung cancer should be seen by an oncologist. Supplemental materials: Free on-line resource covering diagnosis and management of cough on FP Notebook Suggested for further reading: Chest Journal: Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines, Resources for patients: Chronic Cough Handout from Familydoctor.org - References: 1. Irwin, R. Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines. Chest 129: 1S-129S University of South Alabama, Department of Family Medicine June 30,

58 Major Depression (Adult >16 y.o. ) ICD Definition: Major Depression Diagnostic and Statistical Manual of Mental Disorders, 4 th Edition (DSM-IV) criteria discussed below. DSM-IV Criteria for Major Depressive Episode A. Five or more of the following symptoms have been present and documented during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. B. Note: Do not include symptoms that are clearly due to a general medical condition, or mood-congruent delusions or hallucinations. 1.depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). 2.markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others) 3.significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day 4.insomnia or hypersomnia nearly every day 5.psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) 6.fatigue or loss of energy nearly every day 7.feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) 8.diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) 9.recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide C. The symptoms do not meet criteria for a mixed episode. D. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). F. psychotic symptoms, or psychomotor retardation. University of South Alabama, Department of Family Medicine June 30,

59 The symptoms are not better accounted for by bereavement ( i.e., after the loss of a loved one), the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, Dysthymic Disorder Chronic (>2 years) and frequent low mood, often experienced as emptiness or sadness, often accompanied with lethargy and self-criticism, and requiring a least 2 other symptoms of depression. Atypical Depression Depressive symptoms not meeting criteria for another mood disorder. General approach to the patient: Goals: 1. Identify patients a risk of developing major depression. 2. Identify patients who have signs and symptoms consistent with major depression. 3. Identify patients with risk of suicide. 4. Initiate appropriate therapy. 5. Continue surveillance for improvement or worsening. Overview: Approximately 5 to 10 percent of primary care patients meet DSM-IV criteria for major depression. Up to 50 percent of depressed patients are not recognized. The lifetime risk of major depression in the community is 7 to 12 percent in men and 20 to 25 percent in women. "Normal depression" occurs in the course of any active, eventful life. The most important single marker of pathologic depression is that it interferes with the person's ordinary expectable function. This expectable function can apply to self care, the maintenance of important relationships, the performance of work-related tasks, and economic self-support. It is difficult to make a case for a major depression, regardless of symptom severity, without observable interference with function. The three subgroups of depressive disorder according to (DSM-IV) are major depression, dysthymia, and atypical depression or depression not otherwise specified (NOS). A number of medical conditions may present with depression, including stroke, diabetes, dementia, cancer, hypothyroidism, chronic fatigue syndrome, fibromyalgia, systemic lupus erythematosus, coronary heart disease, anxiety and panic disorders and some medications. Patients with medical illnesses such as diabetes and heart disease have higher prevalences of major depression, with estimates between 10 and 20 percent. Several depression screening instruments are available; most instruments have relatively good sensitivity (80 percent to 90 percent) but only fair specificity (70 percent to 85 percent). Treatment may include antidepressants or specific psychotherapeutic approaches (eg, cognitive behavioral therapy or brief psychosocial counseling), alone or in combination. In most patients major depression is a relapsing, remitting illness. After a first episode there is a greater than 40 University of South Alabama, Department of Family Medicine June 30,

60 percent rate of recurrence over a two-year period; after two episodes, the risk of recurrence within five years is approximately 75 percent. Contributory or predisposing factors Older age Physical illness, particularly if debilitating, painful, or life-threatening. Multiple sclerosis, HIV/AIDS, and cancer carry an especially high risk. Physical illness is the main precipitant of depression in later life Some medically prescribed drugs including alpha-methyldopa, beta-blockers (research has shown no significant correlation), L-dopa, and interferon Drug and alcohol misuse Stress, especially recent adverse events, notably divorce or marital adversity. Vulnerability to adverse events is increased by social isolation and by increasing age Poverty and unemployment Patients with other psychiatric diagnoses (e.g. personality disorders) also have a higher risk of major depressive disorder Patients encountered in the primary care setting with the following characteristics are at risk for depression: Personal or family history of depression Multiple medical problems Unexplained physical complaints Chronic pain Overutilization of medical services Clinical presentation: Symptoms Depressed mood may have to be elicited by specific questioning. A patient may complain initially of physical problems (e.g. persistent lethargy) Anhedonia (loss of interest and pleasure in usual activities) is usually present to some degree Weight loss, or weight gain, is commonly associated with depression Disturbed sleep pattern with early morning waking is common; some patients can present with hypersomnia Suicidality is the primary concern, and should be queried by direct questioning, such as 'Have you ever thought that life is not worth living?' or 'Have you ever thought of harming yourself?' There is no evidence that such questions can put the idea of suicide into a patient's mind for the first time. Feelings of guilt and/or unworthiness are common; these can be of delusional intensity in that patients may feel that others are avoiding them, or that they have committed some crime, or have delusions of poverty Physical symptoms, often without clear medical basis, may be a presenting feature. Preoccupation with bodily function is common, especially with bowel function; these feelings may be of delusional intensity (e.g. 'my bowels are stopped up'). But genuine constipation is also common in depression, especially in older patients University of South Alabama, Department of Family Medicine June 30,

61 Signs Weight loss is common. Malnutrition is a particular risk in the elderly Activity disturbance may be a feature of severe depression. Psychomotor retardation is common, with both slowed speech and movement. The voice may be toneless, the face expressionless. Or agitation, reflected both in thinking and in bodily movement, may be predominant. Both patterns can occur at different times in the same patient Differential diagnosis There are several medical conditions, such as hypothyroidism, which produce depressionlike symptoms that resolve when the underlying medical condition is treated. Cardio vascular CHF Cardio myopathy M.I. Medication Anti- Hypertensives Reglan H2 blockers Illicit drugs Chemotheraputic Antiparkinson Antiepileptics Psychotropics NSAIDS OCP S Metabolic/ Nutritional Cushings Addison s Pheo- Chromo cytoma Thyroid Disease Parathyroid Dz DM Hypo glycemia Electrolyte imbalance Carcinoid Ovarian failure Testicular failure Renal failure Heavy metal poisoning Infections Hepatitis HIV/ AIDS Mono nucleosis Syphilis TB Lyme disease Encephalitis Influenza Hematology/ Oncology Pernicious anemia malignancies Neurology CVA Huntington s Chorea Multiple sclerosis Parkinson s disease Alzheimer s disease Narcolepsy Wilson s disease Misc. COPD Hepatic failure University of South Alabama, Department of Family Medicine June 30,

62 University of South Alabama, Department of Family Medicine June 30,

63 Chief Complaint: Some patients present to their primary care physician with a chief complaint of depressed mood. Others may not readily offer such a history, often because they do not recognize that they are depressed, and sometimes because they are reluctant to acknowledge a psychological basis for their symptoms. History of present illness: Determine history of present illness including: - Onset may be gradual over months or years or may be abrupt. - Severity of symptoms and degree of functional impairment. - People diagnosed with major depression have a heterogeneous course from selflimiting to life-threatening. Predictors of poor outcome include severity at initial assessment, lack of reduction of social difficulties at follow-up and low educational level. Categorize severity of symptoms and degree of functional impairment as follows: o Mild: few, if any, symptoms in excess of those required to make the diagnosis and only minor impairment in occupational and/or social functioning o Moderate: symptoms or functional impairment between mild and severe o Severe: several symptoms in excess of those necessary to make the diagnosis and marked interference with occupational and/or social functioning University of South Alabama, Department of Family Medicine June 30,

64 - Number and severity of previous episodes, treatment responses and suicide attempts. - Ask about concurrent psychiatric conditions. Obtaining a past psychiatric history is important in terms of understanding prognosis and risk factors. For example, knowledge of past episodes of major depression, past co-occurring mental/behavioral health conditions, and past self-harm attempts is important for establishing risk and need to involve other mental health professionals. - Psychosocial stressors (significant loss, conflict, financial difficulties, life change, abuse). Pertinent medical history that may complicate treatment includes: prostatism, cardiac conduction abnormalities, and impaired hepatic function. A past medical history and brief review of systems is generally sufficient to rule out medical disorders causing major depression. Unlike younger persons with depression, elderly persons with depression usually have a medical comorbidity. Major depression is more common in medically ill patients who are older than 70 years and hospitalized or institutionalized. Severe or chronic diseases associated with high rates of depression include stroke (30 to 60%), coronary heart disease (8 to 44%), cancer (1 to 40%), Parkinson's disease (40%), Alzheimer's disease (20 to 40%), and dementia (17 to 31%). Physical: Perform a routine physical examination to rule out physical causes of depression and pay particular attention to: Evidence of self-neglect, including weight loss Signs of self-harm, such as scars on wrists or arms Drug injection sites Injuries (e.g. bruises resulting from falls) that might be the result of alcohol or drug misuse Restlessness, agitation, and psychomotor retardation Self-administered or professionally administered depression screening tools are useful adjuncts to the clinical interview. Examples are: Patient Health Questionnaire (PHQ-9), the Deck Depression Inventory, the Hamilton Rating Scale for Depression, Geriatric Depression Scale for the elderly and the Quality Improvement for Depression scale. Two-Item Screening Tool: 1. During the past month, have you felt down, depressed or hopeless? 2. During the past month, have you felt little interest or pleasure in doing things? Five-Item Geriatric Depression Scale: Are you basically satisfied with your life? Do you often get bored? Do you often feel helpless? Do you prefer to stay at home rather than going out and doing new things? Do you feel pretty worthless the way you are now? University of South Alabama, Department of Family Medicine June 30,

65 BATHE Mnemonic can assist in identifying signs and symptoms of depression. Background: What is going on in your life? Affect: How do you feel about it? Trouble: What troubles you most about the situation? Handle: What helps you handle the situation? Empathy: This is a tough situation to be in. Anybody would feel as you do. Your reaction makes sense to me. SIG E CAPS Mnemonic may be helpful for remembering the symptoms of major depression. Sleep disorder (increased or decreased) Interest deficit (anhedonia) Guilt (worthlessness, hoplessness regret) Energy deficit Concentration deficit Appetite disorder (increased or decreased) Psychomotor retardation or agitation Suicidality Suicidal risk assessment: The evaluation of a patient who may be suicidal includes an assessment of ideation, plan, and intent. Components of an evaluation for suicide risk include the following: Presence of suicidal or homicidal ideation, intent, or plan Access to means for suicide and the lethality of those means Presence of psychotic symptoms, command hallucinations, or severe anxiety Presence of alcohol or substance use History and seriousness of previous attempts Family history of or recent exposure to suicide Immediate psychiatric services, usually including hospitalization, are necessary in patients felt to be at imminent risk for self-harm. Substance abuse assessment: Current alcohol or other drug problems can be assessed by the CAGE or CAGE(AID) screen. CAGE(AID) questions are modified with text in parentheses. CAGE or CAGE(AID) questions should be preceded by two questions: 1. Do you drink alcohol? 2. Have you experimented with drugs? University of South Alabama, Department of Family Medicine June 30,

66 CAGE Questions: Have you ever: C felt you ought to cut down on you drinking (or drug use)? A had people annoy you by criticizing you drinking (or drug use)? G felt bad or guilty about your drinking (or drug use) E had a drink (or drug use) as an eye opener first thing in the morning to steady your nerves or get rid of a hangover or to get the day started? Each affirmative response earns one point. One point indicates a possible problem. Two points indicate a probable problem. Treatments: Goals: To protect the patient from the frequent and hazardous complications of depressive illness - especially self-harm, self-neglect, malnutrition, substance misuse To relieve the depressive illness To relieve any disorders in addition to, or resulting from the, e.g. malnutrition, substance misuse To restore the patient to former levels of social and occupational functioning To prevent recurrence of the depression To prevent cardiovascular risks associated with depression Depression is often most successfully treated with a combination of therapies, for example, medication combined with some form of psychotherapy. There are four main treatment choices: Psychotherapy: Some forms of psychotherapy may be more or as effective as medication in major depression. There is also good evidence that psychotherapy enhances the effect of medication in depression. Psychotherapy can be a useful alternative for patients who will not take or cannot tolerate medication, or who have a history of overdose. The forms of psychotherapy best proven in depression are: Cognitive behavior therapy (CBT), which is directed towards altering negative belief systems and dysfunctional thinking and behavior Brief psychotherapy, especially interpersonal therapy (IPT), which focuses on relationships and how they affect functioning and self-esteem Psychodynamic psychotherapy: longer-term treatment, with many US adherents; less convincing evidence-based studies of its effectiveness to date Counseling. A very broad category, from practical advice given by professionals to trained volunteers. Generally, this takes a problem-solving approach, with a focus on the present Several self-help groups exist for people with depression. They are typically free of charge and are facilitated by lay persons; they offer support and encouragement from other persons with depression. Can be a useful adjunct to pharmacotherapy University of South Alabama, Department of Family Medicine June 30,

67 Non pharmacologic: Can take 8-10 weeks to show improvement. Pharmocologic: (See Below Chart) Selective serotonin-reuptake inhibitors (SSRIs) are considered first-line therapy for depression because of established efficacy, a favorable adverse effect profile, and their relative safety in overdose. No single SSRI has an efficacy advantage over another. Dropout rates in patients taking SSRIs are generally two thirds to one half those of patients taking tricyclic antidepressants. The potential for a fatal overdose is significantly lower with SSRIs than with tricyclic antidepressants. SSRIs cost more than most other antidepressant agents, but this disadvantage is offset by a decreased need for inpatient and outpatient care. SSRIs have been proved to be as effective as tricyclic antidepressants in controlled clinical trials, with about 70 to 75 percent of patients responding to treatment. Slight improvements in a patient's symptoms may be detected within several days of starting treatment, but two to three months of therapy are necessary to achieve the full benefit of treatment. Dual mechanism antidepressants (venlafaxine, bupropion, and duloxetine) are also considered first-line therapy for depression, with efficacy comparable to SSRIs Mirtazapine may be especially useful in depression with comorbid anxiety, but should be reserved for nonresponders of first-line therapy because of the potentially bothersome adverse effects of weight gain and sedation Tricyclic antidepressants (TCAs) have established efficacy comparable to SSRIs, but are considered second-line therapy because of their associated adverse effects and potential lethality in overdose. Secondary amine TCAs (i.e. desipramine) generally have equal efficacy and fewer adverse effects than the parent tertiary amines (i.e. amitriptyline, imipramine) Monoamine oxidase inhibitors (MAOIs) are reserved for patients who do not respond to first or second-line therapies because of the numerous and potentially severe interactions with other medications. They may be particularly useful in patients with depression with atypical features Trazodone is structurally related to nefazadone. Due to its sedating effects, its use is primarily reserved for patients with insomnia or anxiety. Nefazodone is not widely used due to risk of hepatic damage and failure St John's Wort is a herbal extract that is widely used over-the-counter in the treatment of depression, and is efficacious in the treatment of mild-to-moderate depression Transdermal selegilene is approved for the treatment of adults with major depressive orders; however, its place in therapy is yet to be established S-adenosyl-methionine (SAM) is involved in the methylation of neurotransmitters, monoamines, and phospholipids. SAM synthesis is impaired in depressed patients, so that supplementation results in increased levels of serotonin, dopamine, and phosphatides and clinical improvement in depressive symptoms. Currently SAM is not widely used in the practice setting University of South Alabama, Department of Family Medicine June 30,

68 A patient s response to antidepressant treatment should be evaluated between 4 and 6 weeks. If there is less than a 25% reduction in symptoms when evaluated, switch to a different medication. If there is a partial response and there are no side effects, increase the dose. First episode treatment duration 6 to 12 months Second episode treatment duration 3 years Second episode with complicating factors lifetime treatment duration Third episode lifetime treatment duration Complicating factors are those situations where there are higher rates of recurrence after stopping antidepressants and include: - Pre-existing dysthymia - Recurrence - Inability to achieve remission of symptoms in response to previously attempted lowering dose or discontinuation. Referral to a behavioral health or substance abuse provider if there are personality disorders and/or substance abuse issues present. Physical treatments: Electroconvulsive therapy (ECT) remains a valuable treatment, especially in the urgent treatment of a patient who is acutely suicidal or severely malnourished Electroconvulsive therapy (ECT) is a first-line option in patients with depression and psychotic features who have not responded to antipsychotic and antidepressant medications, and patients with severe nonpsychotic depression who have not responded to adequate trials of two antidepressants. ECT is used most often in patients older than age 60. Patients with delusions, psychomotor retardation, early morning awakening, and a family history of depression are most likely to benefit from ECT. ECT may reverse the memory loss and confusion associated with pseudodementia. Contraindications include recent myocardial infarction, brain tumor, cerebral aneurysm, and uncontrolled heart failure. ECT is an effective short-term therapy but has higher relapse rates over six to 12 months; patients with a history of medication resistance have higher relapse rates following ECT. Transcranial magnetic nerve stimulation (TMS) is not yet clinically available, but is being evaluated as an alternative to ECT Phototherapy may be effective for seasonal depression (seasonal affective disorder) Vagus nerve stimulation electrically stimulates the left vagus nerve at the cervical level. The device is surgically implanted, and received FDA approval in July 2005 for the treatment of treatment-resistant depression for individuals who have failed four other treatment trials. Its efficacy remains to be fully evaluated University of South Alabama, Department of Family Medicine June 30,

69 Consider consult Suicide and homicidal risk Severe mental confusion, raising the question of dementia Severe delusions or hallucinations that do not have a clear depressive content, suggesting schizophrenia or similar psychosis (or severe depression) Alcohol or drug abuse Bipolar disorder or question of bipolar disorder Depression that has not responded to typical measures Depression associated with any psychotic symptoms University of South Alabama, Department of Family Medicine June 30,

70 Pharmacologic: University of South Alabama, Department of Family Medicine June 30,

71 University of South Alabama, Department of Family Medicine June 30,

72 Diabetes Diabetes mellitus type 2: 250.xx Definition: Symptoms of diabetes and a casual (regardless of relationship to meals) plasma glucose of 200mg/dl. Symptoms are polyuria, poldipsia, and unexplained weight loss. OR Fasting plasma glucose of 126 mg/dl. This would be obtain following abstinence from caloric intake for 8 hours. OR 2-h plasma glucose 200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water. This chapter does not include patients with Type 1 diabetes, diabetes from genetic disorders or chemically induced diabetes (such as from certain medications used to treat AIDS) although many of the principles are the same. It also does not include gestational diabetes. (N.B. Impaired fasting plasma glucose (IPG - FPG 100 mg/dl to 125 mg/dl) and impaired glucose tolerance 2-h plasma glucose (IGT mg/dl to 199 mg/dl) are considered risk factors for future diabetes and cardiovascular disease. Patients with this finding should be monitored closely for development of frank diabetes and should have counseling regarding optimizing weight and exercise regimen) Overview: Diabetes mellitus is a disease characterized by hyperglycemia. Type 2 diabetes mellitus is the most common form of this disease and is both due to an under secretion of insulin as well as inadequate activity of the endogenous circulating insulin. It affects over 15 million people in the United States and accounts for over 15% of all healthcare costs. The mortality rate in patients with the disease is higher by a factor of 10. Patients with diabetes are much more likely to suffer from blindness, renal failure, and have a lower extremity amputation. 1 The recommendations in this chapter are from the Standards of Medical Care in Diabetes This report provides an evidence-based approach to the prevention and management of diabetes mellitus, as well as prevention and management of complications. The American Diabetes Association has worked on an ongoing basis to monitor evidence from English language, peer reviewed articles published between 1988 and The professional practice committee of the American Diabetes Association updates the recommendations and publishes them annually in this report. University of South Alabama, Department of Family Medicine June 30,

73 Goals of the care process: 1. Identify patients at risk of developing diabetes and implement risk factor modification strategies to prevent diabetes from manifesting. 2. Identify patients who have developed clinical diabetes prior to development of end-organ damage. a. Detect and treat secondary causes. b. Offer counseling to assist with correction through diet and exercise. c. Offer counseling to reduce or eliminate concomitant lifestyle risk factors such as tobacco abuse or obesity. 3. Initiate treatment using medication known to be effective in combinations known to be effective for all components of the metabolic syndrome including achieving glycemic control, blood pressure control, and lipid reduction. 4. Monitor for reduction in and maintenance of blood sugar, blood pressure, and lipids at physiologic levels that are associated with elimination of end-organ damage. 5. Continue surveillance for concomitant conditions which magnify untoward effects of diabetes. Screening Rules of Thumb: Age < and above Frequency of impaired Glucose tolerance Risk factors Rare in people with BMI < 85 th percentile without 2 risk factors Family history of type 2 diabetes in first or second-degree relative Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander) Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, or PCOS) Maternal history of diabetes or GDM Rare in people with BMI < 25 without risk factors Previous plus: Previous impaired glucose tolerance Uncommon in people with BMI > 25, more common with risk factors All of Previous plus: Inactivity High risk ethnic group Delivery of baby > 9 lbs History of gestational diabetes Hypertension HDL < 35 Triglyceride > 250 History of vascular disease Common in people with BMI > 25 All of Previous Recommendation for screening Obesity with 2 risk factors Indicated for BMI > 25 with 1 risk factor Indicated for BMI > 25 with 1 risk factor Indicated Regardless of risk factors University of South Alabama, Department of Family Medicine June 30,

74 Prevention/Delay in high risk patients, particularly those with IPG or IGT Make patients aware of benefits of weight loss and physical activity Patients with Impaired Fasting Glucose or Impaired Glucose Tolerance should be strongly encouraged to lose weight and exercise Follow-up visits should be scheduled with attention to risk factor reduction Glucose screening should occur every 2 years if impairment detected until diabetes diagnosed, otherwise should occur periodically Other risk factors should be attended to Medication not recommended If tests are normal, repeat testing should be carried out at least at 3 year intervals (SOR - E) Approach to the Patient: Chief Complaint: Typically the condition is detected via lab result following complaint of symptoms or when end organ damage has occurred. The symptom based complaint (polydipsia, polyuria, or weight loss) leads to testing, following which the disease is diagnosed and management is initiated. The visit should be an initial or follow-up for diabetes and management. Outcomes should improve as more screening of asymptomatic individuals either in the community or in the office setting occurs. Because of the complex nature of the disease, care should be taken to avoid casual initiation of therapy. Vitals: Initial and subsequent visits: Age, gender, weight/height (BMI), pulse, previous blood pressures, current blood pressure (with confirmation in opposite arm if warranted) should be noted and compared to age related norms prior to going into the room through chart review and review of vital signs. History of Present Illness (new evaluation): Patient should be queried regarding disease. Patient should then be queried regarding major risk factors for cardiovascular disease; should be reassessed periodically. (SOR - C) University of South Alabama, Department of Family Medicine June 30,

75 Specific areas to be addressed: AREA OF CONCERN CONTENT DATA COLLECTION Symptoms of diabetes and Presence of polyuria, polydipsia, Symptoms control weight loss Complications Lifestyle modification Comorbid illness which affect treatment Pertinent family, social history Previous control Current and previous treatments Complications of control Infectious complications End organ damage Possibility of reducing dietary caloric intake Possibility of increasing exercise Screening for depression Medication review for medicines associated with hyperglycemia Risk of pregnancy Family history Social history Use of substances which might affect diabetes Use of tobacco A1C, blood sugar log Document current meds, previous meds, meal history, beliefs and attitudes regarding disease and treatment Frequency and severity of ketoacidosis and hyperglycemia Prior or current infections, particularly skin, foot, dental, and genitourinary infections Symptoms and treatment of chronic eye; kidney; nerve; genitourinary (including sexual), bladder, and gastrointestinal function; heart; peripheral vascular; foot; and cerebrovascular complications associated with diabetes Current eating patterns, nutritional status, weight history, growth history if adolescent Exercise history and current activity Age appropriate depression screen Contraception and reproductive and sexual history Family history of endocrine disorders, diabetes Lifestyle, cultural, psychosocial, educational, and economic factors that might influence the management of diabetes Alcohol, and/or controlled substance use Ask, advise, assess, assist, arrange Psycho-Social assessment and care Attitudes about the illness, Expectations of medical management, outcomes, quality of life and resources Screen for Psycho-Social problems, depression, anxiety, eating disorder, cognitive impairment University of South Alabama, Department of Family Medicine June 30,

76 History of Present Illness (Follow-up visit): Allow patient to verbalize concerns. Inquire about self management goals and progress towards achievement. Inquire about side effects of medications. Inquire about status of lifestyle modification. Consider review of Risk Factors and/or target organ questions approximately every 12 to 24 months, more frequently if poor control If previously under control but no longer or resistant (SOR - C): Possible cause Drug induced Key Question Content Drug use: Prescription Herbal OTC Illicit/recreational Foods Environmental exposure Further investigation if positive Inquire in non-judgemental way Encourage patient to bring in all medications Correlate use with blood pressure measurements Alcohol use Frequency of alcohol use Stages of change model Lack of adherence Some people have trouble taking medications. Do you? Establish office systems to facilitate adherence Educate patient about treatment Collaborate with other health professionals Individualize regimen Promote social support Minimize economic barriers University of South Alabama, Department of Family Medicine June 30,

77 Target organ surveillance (SOR - B): Complication Key risk factor Recommendations Heart Hypertension, blood pressure control Target <130 systolic,< 80 diastolic Dyslipidemia Target HDL 40 in men and 50 in women Triglycerides < 150 Target without CAD LDL < 100 Target with CAD LDL < 70 Antiplatelet Target ASA ( mg/day) Smoking cessation CHD screening and treatment Measure blood pressure at each visit If SBP between 130 and 139 and DBP 80-89, and not at target after 3 months of diet, add ACEI or ARB If 140 systolic, and DBP 90 treat with drug class demonstrated to reduce CVD events in patients with diabetes (ACE inhibitors, ARBs, B-blockers, diuretics, Thiazide diuretic if GFR 50 ml/min and loop diuretic if GFR 50 ml/min and calcium channel blockers) with ACEI being initial choice If renal insufficiency and macroalbuminuria develops, ARB delays progression Elderly should have blood pressure reduced slowly Initiate lifestyle modification focusing on weight loss and increased activity, reduction of saturated fat, trans fat, cholesterol intake Begin statin if they have Coronary vascular disease (CVD), or over the age of 40 If under age 40, begin statin if lifestyle modifications in-effective and LDL >100 or in those with multiple CVD risk factors May consider adding fibrate to improve HDL and triglycerides but combination with statins not tested Statin contraindicated in pregnancy Indications Known CAD Increased CAD risk (age >40, family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria). Not indicated in under 21 Indicated with clopidrogel or other agent if disease severe or progressive If allergic, bleeding, on coumadin, or otherwise not a candidate; consider other agents All patients advised abstinence Cessation counseling and other forms of treatment should be offered to all smokers In asymptomatic patients, evaluate risk factors to stratify patients by 10-year risk, and treat risk factors accordingly. (B) In patients with known CVD, ACE inhibitor, aspirin, and statin therapy (if not contraindicated) should be used to reduce the risk of cardiovascular events. (A) Add B-blocker if prior MI to reduce mortality. In patients >40 years of age with another cardiovascular risk factor, ACE inhibitor, aspirin, and statin therapy (if not contraindicated) should be used to reduce the risk of cardiovascular events. (B) Use caution with hypoglycemics if patient has CHF, Metformin and TZD are contraindicated in patients with treated CHF (C) University of South Alabama, Department of Family Medicine June 30,

78 Complication Key risk factor Recommendations Kidney Eye Neuropathy Autonomic neuropathy Foot care Foot Care con t. Prevention of disease Detection of disease Treatment to prevent progression Prevention of disease Detection of disease Treatment to prevent progression Prevention of disease Detection of disease Treatment to prevent progression Prevention of disease Detection of disease Treatment to prevent progression Prevention of disease Detection of disease Treatment to prevent progression Optimize blood sugar control Optimize blood pressure control Screening for microalbuminuria and measure serum creatinine atleast annually ACEI and ARB used if any evidence of albuminuria (micro or macro) unless contraindicated ARB has been shown to delay progression of nephropathy in patients with type 1 DM with hypertension and microalbuminuria One can substitute for intolerance If disease develops, avoid excess protein Refer to nephrologist when GFR falls below 60, blood pressure or hyperkalemia difficult to control Optimize blood sugar control Optimize blood pressure control Aspirin therapy for cardioprotection does not increase the risk of retinal hemorrhage Should have dilated eye exam upon diagnosis and annually, exam is required more frequently if retinopathy is progressing. Should have eye exam prior to pregnancy Laser therapy is effective and patients with disease detected should be referred for treatment Optimize blood sugar control Educate patients regarding self care Annually screen using monofilament and 128 Hz tuning fork Referral to specialized center indicated for patients with insensate feet Manage autonomic neuropathy symptomatically (tricyclic drugs, gabapentim, duloxitine) Optimize blood sugar control Surveillance for resting tachycardia, exercise intolerance, orthostatic hypotension, constipation, gastroparesis, erectile dysfunction, pseudomotor dysfunction, impaired neurovascular function, brittle diabetes, and hypoglycemic autonomic failure Evaluation of bladder dysfunction should be performed for individuals with diabetes who have recurrent urinary tract infections, pyelonephritis, incontinence, or a palpable bladder Optimize blood sugar control Treat symptoms Optimize blood sugar control Perform comprehensive annual foot exam. Educate patients about general foot care Use monofilament, tuning fork, palpation, visual exam Screen for peripheral artery disease with claudication history and pedal pulse palpitation Consider ABIs for any symptoms or if high risk Refer patients with prior lower extremity complications to specialized center Refer for claudication or positive ABI for definitive repair University of South Alabama, Department of Family Medicine June 30,

79 Complication Key risk factor Recommendations Preconception/ Pregnancy care Geriatric care Diabetes care in the hospital Prevention of complications and poor outcomes Prevention of complications and poor outcomes Prevention of complications and poor outcomes HGB A1c should be normal < 7% prior to conception Pregnancies should be planned. Educate about the need for good glucose control Medications should be reviewed prior to conception Tight glycemic control should be considered in relatively healthy patients whose life expectancy is > 10 years Screening for diabetic complications should be individualized in older adults, but particular attention should be paid to complications that would lead to functional impairment. (E) Polypharmacy, depression, cognitive impairment all may dictate less aggressive care Evidence is strongest for blood pressure control, less strong for blood sugar and lipid control All patients with diabetes admitted to the hospital should have their diabetes clearly identified in the medical record. (E) All patients with diabetes should have an order for blood glucose monitoring, with results available to all members of the health care team. (E) Physical: The physical exam is targeted at identification of risk factors or target organ damage, and progress in modification or elimination of risk factors. Complete exam should be performed initially and elements repeated periodically as indicated General General body habitus. Sexual maturation stage (if pubertal), HEENT Fundi - Visualize looking for vascular disease Oral Visualize for potential dental problems, gum disease Thyroid Palpate for nodule if thyroid disease suspected Neck Auscultate for bruits Heart Auscultate for valvular disease and evidence of failure Lungs Auscultate for evidence of failure Abdomen - Palpate abdomen looking for hepatosplenomegaly Extremities Palpate femoral, pedal pulses periodically, check for pedal edema Neuro Complete exam of extremities including 10 g monofilament and 128 Hz tuning fork vibration test Musculoskeletal Hand/finger exam, particularly if using glucometer requiring finger sampling Skin Injection site problems and acanthosis nigricans University of South Alabama, Department of Family Medicine June 30,

80 Lab Testing (SOR - B): Lab test Reason Initial Follow-up Hemoglobin A1c Assess blood sugar Point of care if possible, biannual if at Yes control goal, quarterly if not Urinalysis End-organ damage Yes Annual if normal Electro-cardiogram End-organ damage Yes For symptoms and periodic Potassium Monitoring for medication Yes Every 6 to 12 months and when effect, particularly ACEI (Chem 8) medication change dictates and ARB Thyroid stimulating hormone Common symptom complex Creatinine Estimate GFR Yes Lipid profile HDL-C LDL-C Triglyceride Urinary albumin excretion Cardiovascular risk factor Detect early nephropathy, monitor disease No Yes Yes For symptoms Every 6 to 12 months and when medication change dictates If at target (LDL < 100 mg/dl, HDL> 50 mg/dl, Triglycerides < 150) repeat every 2 years Annual Office Based Management: Therapeutic goals should be individualized with the following being the ideal: Achieve glycemic control as measured by o Hemoglobin A1c < 7.0 (key target) o Preprandial capillary plasma glucose mg/dl o Peak postprandial CPG (if measured) < 180 mg/dl Achieve blood pressure control o Blood pressure consistently below 130/80 Achieve lipid control as measured by o LDL < 100 mg/dl o Triglycerides < 150 mg/dl o HDL >50 mg/dl Take into account the special requirements of children, pregnant women, and elderly when setting targets Tighter control (Hgb A1c < 6)may be attempted to reduce complications but it may be at a cost of increased hypoglycemia University of South Alabama, Department of Family Medicine June 30,

81 Non-pharmacological (SOR - B) Disease Self Reason Management Follow-up Management Self monitoring of blood glucose (SMBG) Confirm self reported blood glucose with hemoglobin A1c Negotiate and set glycemic goal Encourage patient to become educated through Diabetic Self Management Education classes Has been shown to assist with tight control Identifies average level of blood glucose over past 3 months (see appendix) HgbA1c at 7% or below has been shown to reduce microvascular and neuropathic complications and possibly macrovascular disease Educated patient more likely to be compliant Reach agreement with patient on frequency and timing based on hypoglycemic medication and therapeutic goals 3 or more times daily for patients using multiple insulin injections or insulin pump Perform initially and then twice a year if 7% or under or quarterly in patients whose therapy was changed, or if A1C over 7%. Using point of care testing allows for timely decision on therapy change when needed. Goal of 7% is optimal for most patients but highly motivated patients can attempt to achieve euglycemia (< 6%) and the very young or very old may require less stringent goals Arrange for classes, encourage compliance Monitor at each visit Lifestyle Modification Weight loss to achieve BMI kg/m2 Monitor types and sources of calories, select foods low in calories and only 45 65% of intake should be carbohydrate Reason Management Follow up Moderate weight loss of 7% body weight improves glyemic control, and prevents development of disease in those at risk Improves blood sugar control, faclitates weight loss Exercise increase, 150 min per week of moderate intensity aerobic physical activity (50 to 70% of max heart rate), calorie reduction, referral to dietician for Medical Nutritional Therapy. Individualized eating plan Have patient bring values to office at frequent intervals. Encourage enhanced non-pharmacologic care or change medication regimen if not at target University of South Alabama, Department of Family Medicine June 30,

82 Reducing protein if renal insufficiency a concern Reduce saturated fat, minimize trans fats Encourage use of reduced calorie sweeteners Increase aerobic activity Limit alcohol Eliminate tobacco Immunize against influenza and pneumonia Encourage use of reduced calorie sweeteners Reduces rate of progression Reduces rate of progression of heart disease Substitutes for empty calories Weight loss, glycemic control Reduction to 1 oz ( 1 drinks/day) in men or 0.5 oz ( 0.5 drink/day) in women shown to reduce BP Additional risk factor reduction Illness leads to more severe illness and death in diabetic patients Substitutes for empty calories Limit to 10% total calories (0.8 g/kg/day) Limit to < 7% total calories Diet beverages should be substituted for sugar based drinks Regular moderateintensity physical activity; at least 30 min of continuous/intermittent (preferably 60 min) 5 d/wk, but preferably daily Inquire regarding intake on diagnosis. Periodically inquire. Employ stages of change model Inquire regarding use on diagnosis. Periodically inquire. Employ stages of change model Administer pneumovax once and again at 65, administer influenza annually Diet beverages should be substituted for sugar based drinks If patient not at target, negotiate a combination of enhanced compliance, enhanced self monitoring to identify problem, and medication change Offer repeat as needed Monitor weight at each visit, inquire about diet and exercise, encourage referral and compliance with recommendations Encourage at every visit Encourage at every visit Encourage at every visit Encourage at every visit University of South Alabama, Department of Family Medicine June 30,

83 Pharmacologic Treatment: Hypoglycemic agents: Indication: Failure of lifestyle modifications to achieve goal (SOR - A) Class Of Medication Mechanism Of Action Cautions Oral sulfonylurea Thiazolidinediones Biguanides Glinides Glucagon-like peptide 1 agonist Amylin agonist Alpha-glucosidase inhibitors Stimulates pancrease to make more insulin Sensitize the body to insulin and/or control hepatic glucose production Sensitize the body to insulin and/or control hepatic glucose production Stimulates pancrease to make more insulin, short acting Stimulates pancrease to make more insulin, administered sub-q Slows gastric emptying, inhibits glucagon production, administered sub-q Slow the absorption of starches Caution in renal insufficiency Contraindicated with abnormal LFTs and CHF Contraindicated for creatinine > 1.4 in women or 1.5 in men or CHF (lactic acidosis) High frequency of nausea (and weight loss) High incidence of nausea, must be used with insulin Contraindicated in inflammatory bowel disease or cirrhosis Commercial combinations Any class of drug (including insulin) can be used in combination with any other class but the following are available commercially: Sulfonylurea + Biguainide As above As above Thiazolidinedione + Biguanide As above As above Strategy for instituting hypoglycemic agents 1-3 Give interventions adequate time before reassessing; if not at goal, reassessment should incorporate evaluation of compliance and frank discussion of medication use. Once goal has been achieved, continually reassess regarding medication reduction and compliance. Lifestyle modifications and metformin IF A1c not at goal reassess and THEN Combination with sulfonylurea OR glitazone OR Insulin IF A1c not at goal reassess and THEN Combination of two hypoglycemic or add or intensify insulin IF A1c not at goal reassess and THEN add or intensify insulin Ultimately combination may include insulin, metformin with or without a glitazone Other meds can be used as adjunct or when patient is intolerant of above meds. University of South Alabama, Department of Family Medicine June 30,

84 Insulin therapy: 3 Indication: Failure of lifestyle modifications and oral agents to achieve goal Insulin Category Type Onset/Peak/Duration Immediate Acting Insulin lispro solution 15 min/1 hour/ 2-5 hours Insulin aspart solution 15 min/1.5 hour/ 3-5 hours Rapid-Acting Regular 45 min/3 hour/ 8-12 hours Prompt insulin zinc solution 75 min/6 hour/ hours Intermediate-Acting Isophane insulin suspension NPH 120 min/8 hour/ 24 hours Lente 120 min/11 hour/ 24 hours Long-Acting Ultralente 360 min/20 hours/ 30 hours Lantus 60 min/5 hours/24 hours Strategy for instituting insulin agents: Give interventions adequate time before reassessing; if not at goal, reassessment should incorporate evaluation of compliance and frank discussion of medication use. Insulin is routinely subcutaneous though occasionally insulin pumps are used. Newer delivery systems via inhalation will be available soon. Once goal has been achieved, continually reassess regarding medication reduction and compliance. Begin with combination of hypoglycemics AND Insulin o Single dose of intermediate or long acting in the evening (10 units or 0.2 units/kg) o Check fasting daily and increase dose every 3 days until at target o Reduce by 10% if hypoglycemic IF A1c not at goal at 2-3 months reassess and THEN o If fasting at target check during day, add fast acting IF A1c not at goal reassess and THEN o Check 2 hour post-prandial Glycemic goals for adults with diabetes A1C: <7.0% Preprandial capillary plasma glucose: Peak postprandial capillary plasma glucose : mg/dl ( mmol/l) <180 mg/dl (<10.0 mmol/l) Hypoglycemia: Recommendations Glucose (15 20 g) is the preferred treatment for the conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used. If SMBG 15 min after treatment shows continued hypoglycemia, the treatment should be repeated. Once SMBG glucose returns to normal, the individual should consume a meal or snack to prevent recurrence of hypoglycemia. (E) University of South Alabama, Department of Family Medicine June 30,

85 Glucagon should be prescribed for all individuals at significant risk of severe hypoglycemia, and caregivers or family members of these individuals should be instructed in its administration. Glucagon administration is not limited to health care professionals. (E) Individuals with hypoglycemia unawareness or one or more episodes of severe hypoglycemia should be advised to raise their glycemic targets to strictly avoid further hypoglycemia for at least several weeks in order to partially reverse hypoglycemia unawareness and reduce risk of future episodes. (B) Antihypertensive agents: 4 Indication: Failure of lifestyle modifications to achieve goal See Hypertension Chapter For Implementation Strategy Indication Medication Notes Initial therapy If not at target, add ACEI or ARB Thiazide-type diuretic, if GFR 50ml/min and loop diuretic if GFR 50ml/min Add BB, Aspirin, statin Aim for <130 mmhg for systolic DCCB do not delay progression of kidney disease MI, CAD or high risk for CAD Kidney disease ACEI and/or ARB Goal: Below 130/80 Lipid lowering agents: 5 Indication: Failure of lifestyle modifications to achieve goal See hyperlipidemia chapter for in-depth discussion of meds and implementation strategy Indication Medication Notes LDL not at target HDL not at target Triglycerides not at target Statin Bile acid sequestrants Nicotinic acid Fibric acid Nicotinic acid Fibric acid Statin Bile acid sequestrants Fibric acid Nicotinic acid Statin Bile acid sequestrants Expensive and effective. Statin should be started, in addition to life style therapy regardless of baseline lipid levels for patients with CVD and for patients over the age of 40 and has 1 or more risk factor Less expensive and less effective Inexpensive and much less effective Expensive and much, much less effective Inexpensive and somewhat effective Expensive and less effective Expensive and much less effective Not indicated Expensive and effective Inexpensive and somewhat effective Expensive and much less effective Not indicated University of South Alabama, Department of Family Medicine June 30,

86 Strategy for instituting anti-hyperlipidemic agents: Give interventions adequate time before reassessing, if not at goal, reassessment should incorporate evaluation of compliance, frank discussion of medication use. When goal achieve, continually reassess regarding medication reduction and compliance Lifestyle modifications and blood sugar control IF profile not at goal reassess and THEN Initiate statin therapy IF profile not at goal reassess and THEN Consider combination of two classes of medications o Patient should be apprised of risk of myopathy and rhabdomyolisis Additional agents: 2 Prevention of MI Indication Medication Notes Smoking cessation assistance Weight loss ASA, clopidigrel for failure or allergy Nicotine delivery via various methods, bupropion Orlistat Aggranox third choice Remember stages of change Side effects include oily spotting on underwear, flatulence, urgent bowel movements, fatty or oily stools, increased number of bowel movements Situations requiring urgent attention (SOR - B): Pregnant patient Suspected or diagnosed diabetic ketoacidosis as diagnosed by hyperglycemia and ketonuria or ketonemia. Suspected or diagnosed hyperosmolar state as diagnosed by profound hyperglycemia, and symptoms of polyuria, polydipsia, mental confusion, etc, and/or lab evidence of excess serum osmolarity Evidence of rapidly progressing end organ damage such as acute coronary syndrome, retinal hemorrhage, renal failure, or transient ischemic attack Return visit (SOR-C) Monitor and comply with age appropriate health maintenance protocols. Attention to acute complaints with particular attention to worrisome symptoms that are consistent with end-organ damage University of South Alabama, Department of Family Medicine June 30,

87 Post-visit Assessment Concern Periodicity Normal Blood Sugar Impaired Glucose Tolerance Diabetes diagnosed, A1c < 7 Diabetes diagnosed, A1c 7 8, blood pressure or lipids not at goal Diabetes diagnosed, A1c < 8, Diabetes diagnosed, A1c >8, lipids and blood pressure controlled Diabetes diagnosed, A1c >8, or lipids and blood pressure not controlled Blood pressure, lipids, and glucose controlled with medications Interval development of disease Progression Progression Progression, long term sequelae Progression, long term sequelae Assess efficacy, monitor for compliance Assess efficacy, monitor for compliance Monitor for side effects, progression Recheck every 3 years. Encourage lifestyle modifications. Encourage participation in community screening opportunities. Recheck every 1year. Encourage lifestyle modifications. Reduce or eliminate modifiable risk factors. Weight loss of 5-10% of body weight, Exercise 150 min per week. Encourage participation in community screening opportunities. Follow-up q 3-6 months, monitor lifestyle changes and A1c until no longer at risk of progression or until decision is made to begin medication. Reduce or eliminate modifiable risk factors. Facilitate lifestyle modifications. Suggest self-monitoring. Particular attention to surveillance Follow-up q 3months, monitor lifestyle changes and A1c until no longer at risk of progression. If no progress in 3 months consider medication. Facilitate lifestyle modifications. Reduce or eliminate modifiable risk factors. Attention to self-monitoring. Particular attention to surveillance Follow-up q 3months, monitor lifestyle changes, A1c until no longer at risk of progression. If no progress on glucose in 3 months consider medication. Facilitate lifestyle modifications. Work on blood pressure and lipid reduction at each visit. Attention to selfmonitoring. Particular attention to surveillance Follow-up q 2-4 months, monitor lifestyle changes and A1c (q 3 m) until reduced. If no rapid progress consider medication. Facilitate lifestyle modifications. Reduce or eliminate modifiable risk factors. Particular attention to surveillance Follow-up q 2-4 months, monitor lifestyle changes A1c (q 3 m), blood pressure, lipids until reduced. If no rapid progress consider medication. Particular attention to surveillance and drug SE. Facilitate lifestyle modifications. Reduce or eliminate modifiable risk factors. Office visit every 3 4 months, labs every 6 12 months, control other risk factors and comorbidities as needed. Particular attention to surveillance and drug SE. Facilitate lifestyle modifications. Reduce or eliminate modifiable risk factors. University of South Alabama, Department of Family Medicine June 30,

88 Supplemental Materials: On-line resource outlining a series on encounters with patients with chronic illnesses American diabetes association resources for health professionals Suggested for further reading: The Standards of medical care in diabetes 2008accessed at Management of Hyperglycemia in Type 2 Diabetes: A consensus algorithm for the initiation and adjustment of therapy Diabetes Care (2006) 29: accessed at 6e0a875089f3a6&keytype2=tf_ipsecsha on 5/14/2007 Dickerson L, Gibson M. Management of Hypertension in Older Persons. Am Fam Physician 2005;71: Accessed at U.S. Preventive Services Task Force. High Blood Pressure Screening. Release date July 2003 accessed at Onusko E. Diagnosing secondary hypertension Am Fam Physician 2003;67: accessed at Resources for patients: Diabetes patient handout Diabetes and Diet Exercise Prescription on the Net References: 1. Florence J, Yeager B. Treatment of Type 2 Diabetes American Family Physician (10) American Diabetes Association. Standards of Medical Care in Diabetes Diabetes Care , (S 1): S4 S43 3. Schoof M, Ehlers K. Short-acting insulin analogues vs. human insulin for diabetes. American Family Physician 72 (5): 805 University of South Alabama, Department of Family Medicine June 30,

89 4. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report [Published erratum in JAMA 2003;290: 197]. JAMA 2003;289: accessed at on 2/06/06 5. Safeer R, Lacivita C. Choosing drug therapy for patients with hyperlipidemia. Am Fam Physician Jun 1;61(11): Appendix: University of South Alabama, Department of Family Medicine June 30,

90 Appendix 2 University of South Alabama, Department of Family Medicine June 30,

91 University of South Alabama, Department of Family Medicine June 30,

92 Hyperlipidemia mixed (Adult >20) Definition Adult: Total cholesterol, LDL, HDL, triglycerides not at risk factor specific goal on a validated lab This chapter does not cover all necessary information for children or patients with diabetic dyslipidemia, (see diabetes chapter), very high LDL cholesterol, or markedly elevated triglycerides. This chapter does include information regarding patients with concomitant hypertension. General Approach to the patient Goals of the care process 1. Identify patients who are at significant risk to develop complication from hyperlipidemia and implement risk factor modification strategies to meet lipid goals. 2. Identify patients who are at risk of a major cardiac event (20%) and implement intensive lipid lowering therapy a. Detect and treat secondary causes b. Offer counseling to assist with correction through diet and exercise c. Offer counseling to reduce or eliminate concomitant risk factors such as tobacco abuse or obesity d. Initiate treatment using medication known to be effective. 3. Identify patients who are at a reduced risk of a major cardiac event (10% - 20%) and implement lipid lowering activities a. Detect and treat secondary causes b. Offer counseling to assist with correction through diet and exercise c. Offer counseling to reduce or eliminate concomitant risk factors such as tobacco abuse or obesity d. Initiate treatment using medication known to be effective in combinations known to be effective should lifestyle modifications not be effective 4. Identify patients who are at a low risk of a major cardiac event (<10%) and implement lipid lowering activities and medication when necessary a. Detect and treat secondary causes b. Offer counseling to assist with correction through diet and exercise c. Offer counseling to reduce or eliminate concomitant risk factors such as tobacco abuse or obesity d. After adequate trial of lifestyle and risk factor modification, initiate treatment using medication known to be effective in combinations known to be effective. University of South Alabama, Department of Family Medicine June 30,

93 Rules of Thumb Age Frequency of hyperlipidemia Frequency of ischemic cardiac disease Risk factors Recommendation for screening LDL goal (men) (men) (men) > (women) (women) (women) Common Common Common Common Rare Cigarette smoking Hypertension Low HDL Fm Hx in first degree relative Every 5 years if > 1 RF Fasting lipid profile (total cholesterol, LDL, HDL, triglyceride) CHD and CHD risk equiv <100 Multiple (2+) risk factors <130 Zero to one risk factor <160 Rare but can progress rapidly Cigarette smoking Hypertension Low HDL Fm Hx in first degree relative Every 5 years Fasting lipid profile (total cholesterol, LDL, HDL, triglyceride) CHD and CHD risk equiv <100 Multiple (2+) risk factors <130 Zero to one risk factor <160 Common Cigarette smoking Hypertension Low HDL Fm Hx in first degree relative Every 5 years Fasting lipid profile (total cholesterol, LDL, HDL, triglyceride) CHD and CHD risk equival <100 Addition al risk factors <130 Zero risk factor <160 Common Current level likely consistent with previous levels, risk factors same as to younger patients Screening interval uncertain if not already elevated, No screen if life expectancy < 10 years CHD and CHD risk equival <100 Addition al risk factors <130 Zero risk factor <160 CHD risk equivalents: Other clinical forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and symptomatic carotid artery disease); Diabetes Multiple risk factors that confer a 10-year risk for CHD >20%. CHD and CHD risk equivalents give a >20% risk of a CHD event within 10 years. University of South Alabama, Department of Family Medicine June 30,

94 Overview Coronary heart disease (CHD) is the single leading cause of death in the United States, accounting for more than one in five deaths each year, or approximately 900,000 fatalities. It is the leading cause of death in women at this time as well. An estimated $403 billion is spent annually to care for patients with CHD. 1, 2 Consistent evidence from long-term, prospective studies indicates that high levels of total cholesterol and LDL and low levels of HDL are important risk factors for coronary heart disease, the leading cause of morbidity and mortality in the United States. The risk for coronary heart disease increases with increasing levels of total cholesterol and LDL, and declining levels of HDL, in a continuous and graded fashion with no clear threshold of risk. According to National Center for Health Statistics data from 1988 to 1994, 17.5 percent of men and 20 percent of women 20 to 74 years of age had high levels of total cholesterol (240 mg per dl [6.20 mmol per L] or higher). 3 The following recommendations are from the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III). 2 This report provides an evidence-based approach to the prevention and management of the most common variants of hyperlipidemia, with emphasis on primary and secondary prevention of coronary artery disease. It makes extensive use of population based evidence such as the Framingham projections to assist the clinician with identification of persons in need of more intensive treatment. Evidence from peer reviewed articles published between 1995 and 2000 was selected and graded by the ATP III working group and was used to formulate a set of recommendations which formed the basis for the guideline. These were updated to reflect the results from large randomized controlled trials completed in the early 2000s in The working group focused on Patient-oriented outcomes, primarily reduction in myocardial events. The reduction in morbidity as well as mortality from this disease is reflected in the following recommendations. Because the therapy is considered relatively innocuous, little attention was paid to other patient factors, such as well being, for these recommendations. These recommendations may not be appropriate for patients who suffer from unrelated diseases that may limit lifespan to less than 10 years or patients who find medication use onerous. In addition, patients who must make choices regarding medications because of cost should be made aware that the medications used to treat this condition are expensive and should be strongly encouraged to manage the condition with lifestyle modifications initially and perhaps offered extra time to do so. The Encounter Chief Complaint: Typically the condition is detected through screening of asymptomatic individuals either in the community or in the office setting. The complaint is typically regarding the evaluation or followup of hyperlipidemia although it may be that the initiation of treatment occurs with an incidental finding the patient has multiple risk factors or the level is markedly elevated. A complaint of University of South Alabama, Department of Family Medicine June 30,

95 chest pain that is assessed as non-cardiac will often generate a serum lipid profile that may indicate the patient is at an elevated risk of cardiac disease. Vitals Initial and subsequent visits: Age, gender, weight/height (BMI), blood pressure, (previous and current) should be noted prior to going into the room through chart review and review of vital signs. History of Present Illness (new evaluation): Patient should be encouraged to identify what concerns exist. Patient should then be queried regarding major risk factors for cardiovascular disease. Should be reassessed periodically. (SOR - B) Presence of CAD Key Question Content Further investigation if positive Known or suspected CAD (Risk 100%) Other ASCVD (Risk 100%) Anginal type chest pain, previous MI, coronary stent placement, CABG History of peripheral artery disease, abdominal aortic aneurysm, angina, claudication Evaluate chest pain, obtain records, communicate with cardiologist, aggressive RF reduction Obtain records, communicate with cardiologist, investigate based on suspicion, aggressive RF reduction Diabetes (Risk > 20%) Current status of blood sugar (if known) Assess blood sugar, if diabetes need stricter control (See diabetes mellitus chapter), aggressive RF reduction Major Risk Factor Key Question Content Further investigation if Tobacco use Hypertension, blood pressure control Target 140 systolic, 90 diastolic Current use of tobacco Past use of tobacco Use of antihypertensives, results of previous screenings positive Counsel regarding cessation, assess stage of change Measure blood pressure at each visit If above140 and not at target after 3 months of diet and exercise add drug in class demonstrated to reduce CVD events University of South Alabama, Department of Family Medicine June 30,

96 Low HDL cholesterol (< 40 mg/dl) Family history of premature CHD Results of previous screenings CHD in male first degree relative <55 years; CHD in female first degree relative <65 years Age men >45 years; women >55 years Diet, exercise, consider addition of fibrate if unsuccessful Aggressive modifiable RF reductions as indicated by additional risk factors Aggressive modifiable RF reductions as indicated by additional risk factors Risk analysis based on major risk factor inventory 0-1 risk factor, 10 year risk < 10% > 2 risk factors, risk analysis based on Framingham risk scores found in ATP III or at o Risk assigned as <10%, 10% - 20%, or > 20% Life habit risk factors Obesity Current weight (from vitals) Calculate BMI Physical inactivity Athrogenic diet Emerging risk factors lipoprotein (a), homocysteine, prothrombotic and proinflammatory factors, impaired fasting glucose, and evidence of subclinical atherosclerotic disease. Assess for metabolic syndrome Current physical activity Past physical activity Current diet Past diet Familial history, body habitus, unusual symptoms Truncal obesity, weight gain, elevated blood pressure Counsel regarding activity, assess stage of change Counsel regarding diet, assess stage of change Investigate as indicated by history, clinical suspicion, refer to specialist if concerned following initial investigation, consider use of aspirin and aggressive statin use Abdominal Obesity* Waist Circumference Men >102 cm (>40 in) Women >88 cm (>35 in) Triglycerides ³150 mg/dl HDL cholesterol Men <40 mg/dl Women <50 mg/dl Blood pressure >130/85 Fasting glucose >110 mg/dl University of South Alabama, Department of Family Medicine June 30,

97 Red Flags Secondary hyperlipidemia considered when suggested by age, history, physical, severity, or lab findings (SOR - C) Secondary cause Key signs or symptoms Further investigation if positive Diabetes Polyuria, polydipsia, obesity, weight changes Fasting or random blood sugar Hypothyroidism Weight gain, cold T4, TSH intolerance Obstructive liver disease Right upper quadrant pain, jaundice Liver associated enzymes, coagulation studies Chronic renal failure History of hypertension or Serum BUN and creatinine Drug induced diabetes, oliguria History of progestin, anabolic steroid or corticosteroid use LDL cholesterol goals and strategies (SOR - A) Risk category LDL goal LDL level to institute therapeutic lifestyle change 10 year risk > 20% <100 > 100 (consider 10 year risk between 10% and 20% < 130 (consider < 100) > 70) > 130 (consider > 100) Abstinance and repeat studies LDL level to consider drug Therapy > 100 concurrent with lifestyle changes > 130 concurrent with lifestyle changes but can initiate between 100 and 129 by choice 10 year risk < 10% < 160 > 160 > 190 ( optional after lifestyle changes ineffective) University of South Alabama, Department of Family Medicine June 30,

98 History of Present Illness (Follow-up visit): Allow patient to verbalize concerns. Inquire about changes in status, focusing on possible development of cardiac disease. Inquire about side effects of medications. Inquire about status of lifestyle modification. Consider review of Risk Factors approximately every 12 to 24 months, more frequently if poor control. If previously under control but no longer or resistant (SOR - C) Possible cause Key Question Content Further investigation if positive Drug induced Drug use Progestin Anabolic steroid Corticosteroid use Inquire in non-judgemental way Encourage patient to bring in all medications Correlate use with lipid measurements Lack of adherence Some people have trouble taking medications. Do you? Establish office systems to facilitate adherence Educate patient about treatment Collaborate with other health professionals Individualize regimen Promote social support Minimize economic barriers Physical The physical exam is targeted at identification of risk factors or target organ damage, and progress in modification or elimination of risk factors. General Look for evidence of tobacco use, general body habitus looking for truncal obesity, acanthosis nigricans. HEENT Fundi N/A Neck Ausculate for carotid bruits initially and periodically Thyroid Palpate for nodule if thyroid disease suspected Heart Auscultate for valvular disease and evidence of failure Lungs Auscultate for evidence of failure Abdomen Listen for abdominal bruits initially and periodically and (adults over 40) palpate abdomen looking for large pulsating mass in abdomen if abdominal aortic aneurysm is suspected. Extremities Palpate femoral, pedal pulses periodically, check for capillary refill initially and periodically Neuro N/A Musculoskeletal N/A Skin Observe for xanthomas University of South Alabama, Department of Family Medicine June 30,

99 Lab Testing (SOR - C) Lab test Reason Initial Follow-up Lipid profile HDL-C LDL-C Triglyceride Monitor effect of therapy, progression of disease Yes Every 6 weeks until at goal if at medium or high risk, then every 6 months. Electrocardiogram Cardiac disease No For symptoms of Dynamic cardiac testing Glucose BUN, creatinine Liver associated enzymes Additional risk factor, identify metabolic syndrome Additional risk factor, monitor for side effect No Yes No possible angina For symptoms of possible angina When moving from sedentary to more active lifestyle Follow USPSTF guidelines Chem 8 may be useful if on meds that affect kidneys or if suspicion of occult disease Monitor effect of meds Optional Upon initiation of statins or nicotinic acid, or medication change Office Based Management Non pharmacologic (SOR - B) Lifestyle Reason Management Follow-up Modification Weight loss to achieve BMI kg/m2 Loss of as little as 10 lbs reduces or prevents Exercise increase, calorie reduction Encourage at every visit Reduce saturated fats, dietary cholesterol, Increase fiber intake Increase aerobic activity Eliminate tobacco hyperlipidemia Improves lipid control, facilitates weight loss Weight loss, BP reduction Additional risk factor reduction Therapeutic lifestyle changes (TLC) eating plan 30 minutes on most days Inquire regarding use on diagnosis. Periodically inquire. Employ stages of change model Encourage at every visit Encourage at every visit Per stages of change model University of South Alabama, Department of Family Medicine June 30,

100 Pharmacologic treatment General Principles 4 Therapeutic lifestyle changes (TLC) remain an essential modality in clinical management. TLC has the potential to reduce cardiovascular risk through several mechanisms beyond LDL lowering. TLC Features: TLC diet: Saturated fat <7% of calories, cholesterol <200 mg/day. Consider increased viscous (soluble) fiber (10-20 g/day) and plant stanols/sterols (2gm/day) as therapeutic options to enhance LDL lowering. Weight management Increased physical activity In high-risk persons, the recommended LDL-C goal is 100 mg/dl. o An LDL-C goal of < 70 mg/dl is a therapeutic option especially for patients at very high risk. o If LDL-C is >100 mg/dl, an LDL-lowering drug is indicated simultaneously with lifestyle changes. o If baseline LDL-C is < 100 mg/dl, institution of an LDL-lowering drug to achieve an LDL-C level 70 mg/dl is optional on the basis of available clinical trial evidence. o If a high-risk person has high triglycerides or low HDL-C, consideration can be given to combining a fibrate or nicotinic acid with an LDL-lowering drug. When triglycerides are > 200 mg/dl, non-hdl-c is a secondary target of therapy, with a goal 30 mg/dl higher than the identified LDL-C goal. For moderately high-risk persons (2 risk factors and 10-year risk 10% to 20%), the recommended LDL-C goal is < 130 mg/dl; an LDL-C goal < 100 mg/dl is optional. o When LDL-C level is between 100 to 129 mg/dl, at baseline or on lifestyle therapy, initiation of an LDL-lowering drug to achieve an LDL-C level 100 mg/dl is optional. Any person at high risk or moderately high risk who has lifestyle-related risk factors (eg, obesity, physical inactivity, elevated triglyceride, low HDL-C, or metabolic syndrome) is a candidate for TLC to modify these risk factors regardless of LDL-C level. When LDL-lowering drug therapy is employed in high-risk or moderately high-risk persons, intensity of therapy should be sufficient to achieve at least a 30% to 40% reduction in LDL-C levels. For people in lower-risk categories, the recommended LDL-C goal is 160 mg/dl. o When LDL-C level is > 190 mg/dl, at baseline or on lifestyle therapy, initiation of an LDL-lowering drug to achieve an LDL-C level 160 mg/dl is an option. o When LDL-C level is between 160 to 189 mg/dl, at baseline or on lifestyle therapy, initiation of an LDL-lowering drug to achieve an LDL-C level <160 mg/dl is an option. University of South Alabama, Department of Family Medicine June 30,

101 Lipid lowering agents 5 Indication: Failure of lifestyle modifications to achieve goal Indication Medication Notes LDL not at target Statin Expensive and effective Bile acid sequestrants Less expensive and less effective Nicotinic acid Inexpensive and much less effective Fibric acid Expensive and much, much less effective HDL not at target Nicotinic acid Inexpensive and somewhat effective Fibric acid Expensive and less effective Statin Expensive and much less effective Bile acid sequestrants Not indicated Triglycerides not at target Fibric acid Expensive and effective Nicotinic acid Inexpensive and somewhat effective Statin Expensive and much less effective Bile acid sequestrants Not indicated Strategy for instituting anti-hyperlipidemic agents Give interventions adequate time before reassessing, if not at goal, reassessment should incorporate evaluation of compliance, frank discussion of medication use. When goal achieved, continually reassess regarding medication reduction and compliance and encourage maintenance of lifestyle modifications Lifestyle therapies o Emphasize reduction of saturated fat and cholesterol o Encourage physical activity o Dietary counseling IF profile not at goal in 6 weeks reassess and THEN Intensify LDL-lowering therapy o Reinforce reduction in saturated fats and cholesterol o Consider adding plant stanols o Increase fiber o Dietary counseling IF profile not at goal in 6 weeks reassess and THEN Consider initiation of statin, bile acid sequestrant, or nicotinic acid therapy o Monitor and offer therapy for metabolic syndrome o Intensify weight and physical activity counseling o Dietary counseling IF profile not at goal in 6 weeks reassess and THEN Consider intensification of statin, bile acid sequestrant, or nicotinic acid therapy University of South Alabama, Department of Family Medicine June 30,

102 IF profile not at goal in 6 weeks reassess and THEN Consider combination of two classes of medications o Patient should be apprised of risk of myopathy and rhabdomyolisis Consider referral to lipid specialist Situations requiring urgent attention (SOR - B) Triglyceride > 1000 mg/dl because of association with acute pancreatitis requires urgent treatment beyond the scope of this discussion LDL > 220 mg/dl because of association with accelerated cardiovascular disease requires urgent treatment Follow-up (SOR - B) Monitor and comply with age appropriate health maintenance protocols. Attention to acute complaints with particular attention to worrisome symptoms that are consistent with endorgan damage (see following table) University of South Alabama, Department of Family Medicine June 30,

103 Post-visit assessment Concern Periodicity Normal lipids (lipids at Progression target) Recheck 5 years. Screen for metabolic syndrome. Encourage lifestyle modifications. Encourage participation in community screening opportunities. Metabolic syndrome Progression Follow-up six months to one year. Encourage lifestyle modifications, weight reduction. Monitor glucose, lipids, consider aspirin. Lipids above target but not at treatment threshold in low risk patient. Lipids above target but not at treatment threshold in medium risk patient. Lipids above target but not at treatment threshold in low risk patient with a single severe risk factor (heavy smoking, uncontrolled hypertension, etc), multiple life habit measures or 10 year risk approaching 10% Lipids above target but not at treatment threshold in medium risk patient with severe risk factor(s) (heavy smoking, uncontrolled hypertension, etc), multiple life habit measures or 10 year risk approaching 20% Lipids above treatment threshold. Controlled lipids Progression Progression Progression, development of cardiac disease Progression, development of cardiac disease Progression, development of cardiac disease Monitor for side effects, progression Follow-up every 6-12 months until reduced or until decision is made to begin therapy. Encourage lifestyle modifications. Follow-up every 6 weeks to 3 months until reduced. Strongly consider medication therapy. Encourage lifestyle modifications. Follow-up every 3-6 months until reduced. Strongly consider medication therapy if unable to reach goal. Encourage lifestyle modifications. Follow-up every 6 weeks until reduced. Strongly consider medication therapy if unable to reach goal. Encourage lifestyle modifications. Follow-up every 6 weeks until reduced. Strongly consider medication therapy after 3 months if unable to reach goal. Encourage lifestyle modifications. Office visit every 3 6 months, lipids annually, additional labs on medication change or periodically, monitor and control other risk factors and comorbidities as needed. Consider low dose aspirin. Encourage lifestyle modifications. University of South Alabama, Department of Family Medicine June 30,

104 Supplemental materials On-line resource outlining a series on encounters with patients with chronic illnesses Suggested for further reading Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Executive Summary accessed at Lockman A, Tribastone A, Knight K, Franko J. Treatment of Cholesterol Abnormalities. Am Fam Physician 2005;71: Accessed at U.S. Preventive Services Task Force. Screening for Lipid Disorders in Adults. Release date July 2001 accessed at Safeer R, Ugalat P. Cholesterol Treatment Guidelines Update Am Fam Physician 2002;65: accessed at Resources for patients Cholesterol patient handout What should I know about cholesterol? - Patient Information Handout - March 15, year risk calculator Live Healthier, Live Longer (NHLBI) Introduction to the TLC diet Be Heart Smart! Eat Foods Lower in Saturated Fat and Cholesterol Exercise Prescription on the Net University of South Alabama, Department of Family Medicine June 30,

105 References 6. American Heart Association. Heart disease and stroke statistics update. Accessed online June 2006, at: 7. National Cholesterol Education Program. Third report of the expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). Accessed online June 2006, at: 8. Berg AO. Screening adults for lipid disorders. Recommendations and rationale. Am J Prev Med 2001;20(3 suppl): Grundy S, Cleeman J, Merz N, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation. 2004;110: Accessed June 2006 at Safeer R, Lacivita C. Choosing drug therapy for patients with hyperlipidemia. Am Fam Physician Jun 1;61(11): Appendix University of South Alabama, Department of Family Medicine June 30,

106 Drugs, trade name, and type Advicor lovastatin/niacin Statin/niacin combo 20/500,20/750,20/1000 SR) Altoprev lovastatin statin (10,20,40,60 SR) Antara fenofibrate micronized fibric acid(43,130) Caduet amlodipine/atorvastatin CCB/Statin (2.5/10,2.5/20,2.5/40,5/10,5/20,5/40,5/80,10/10,10/20,10/40,10/80) cholestyramine cholestyramine binding agent (pwdr) Colestid colestipol binding agent (1 g tabs; 5 g granule packets) Crestor rosuvastatin statin (5,10,20,40) gemfibrozil gemfibrozil binding agent (600) Lescol fluvistatin statin (20,40) Lescol XL fluvistatin statin (80SR) Lipitor atorvastatin statin (10,20,4080) Lipofen fenofibrate fibric acid (50, 100, 150) Lofibra capsules fenofibrate micronized fibric acid(67, 134, 200) Lofibra tablets fenofibrate fibric acid (54, 160) Lopid gemfibrozil fibric acid (600) lovastatin lovastatin statin (10,20,40) Mevacor lovastatin statin (10,20,40) niacin niacin nicotinic acid (50,100,250,500; IM; IV) Niaspan niacin nicotinic acid (500,750,1000 SR) nicotinic acid niacin nicotinic acid (50,100,250,500; IM; IV) Omacor omega-3-acid ethyl esters (1 g) Pravachol pravastatin statin (10,20,40,80) pravastatin pravastatin statin (10,20,40) Pravigard PAC aspirin, buffered/pravastatin (81/20,81/40,81/80,325/20,325/40,325/80) Questran cholestyramine binding agent (pwdr) Slo-Niacin niacin nicotinic acid (250,500,750 SR) Tricor fenofibrate fibric acid (48, 145) Triglide fenofibrate fibric acid (48, 145) Vytorin ezetimibe/simvastatin statin/binding (10/10, 10/20, 10/40, 10/80) WelChol colesevelam binding agent Zetia ezetimibe binding agent Zocor simvastatin statin (5,10,20,40,80) University of South Alabama, Department of Family Medicine June 30,

107 University of South Alabama, Department of Family Medicine June 30,

108 Essential Hypertension (Adult >16) Definition: Adult Hypertension > 140/90 on at least two separate readings Stage /90-99 Stage 2 >160 /100 Normal blood pressure <120/80 Prehypertension /80-89 This chapter does not pertain to patients with diabetes mellitus or known coronary artery disease. This chapter does include patients with concomitant hyperlipidemia (272.4) (N.B. Pediatric hypertension is a growing problem (associated with obesity and genetic factors) and should be identified and managed appropriately. In that population hypertension is identified as blood pressure > 95 th percentile on 3 separate occasions) General Approach to the patient: Goals of the care process 1. Identify patients at risk of developing hypertension and implement risk factor modification strategies to prevent hypertension from manifesting 2. Identify patients who have developed clinical hypertension prior to development of end-organ damage a. Detect and treat secondary causes b. Offer counseling to assist with correction through diet and exercise c. Offer counseling to reduce or eliminate concomitant risk factors such as tobacco abuse or obesity 3. Initiate treatment using medication known to be effective in combinations known to be effective 4. Monitor for reduction in and maintenance of blood pressure at physiologic levels that are associated with elimination of end-organ damage 5. Continue surveillance for concomitant conditions which magnify untoward effects of hypertension Rules of Thumb: Age >70 Frequency of pre-hypertension Common Common Common Common Uncommon Frequency of Common Uncommon Common Very common Approaches 90% hypertension Most common cause of refractory hypertension Noncooperation, Alcohol, Oral contraceptives (in women) Non-cooperation, Alcohol, Oral contraceptives (in women) Noncooperation, Alcohol, Oral contraceptives (in women) Noncooperation, Thyroid disease Non-cooperation, Thyroid disease, Atherosclerotic renal artery stenosis University of South Alabama, Department of Family Medicine June 30,

109 Red Flags: Secondary Hypertension (considered when suggested by 1) age, history, physical, severity, or lab findings 2) Poor response to drug therapy 3) An increase after initial period of good control 4) Sudden onset (SOR - C) Secondary Cause Pheochromocytoma Key Signs or Symptoms Labile hypertension and/or Paroxysmal hypertension associated with headache, palpitatons, pallor, perspiration Further Investigation if Positive 24 hour urine for metanephrines and normetanephrines Renovascular hypertension Coarctation of aorta Cushings syndrome/ other mineralocorticoid excess Elevated serum creatinine with use of ACEI or ARB, Known atherosclerosis, flash pulmonary edema, abdominal bruit Diminished lower extremity pulses and/or delayed or absent femoral pulses Truncal obesity, glucose intolerance, purple striae Suspected fibromuscular dysplasia: (Women between 15 and 50) digital subtraction angiography Suspected atherosclerosis Renal function normal High risk: angiogram Moderate risk: CT, MR, or US Low risk: No study Renal insufficiency US Doppler or MRA CT angiogram Sleep apnea History of snoring, daytime somnolence, neck over 17 inches Sleep study Hyperparathyroidism Hypercalcemia, nonspecific pains, fatigue, kidney stones Hyperthyroidism Palpitations, weight loss, sweats T4, TSH Hypothyroidism Weight gain, cold intolerance T4, TSH Serum K+, 24 hour urine for aldosterone or other mineralocorticoids Intact PTH, ionized calcium Overview: Hypertension (high blood pressure) is a disorder characterized by an elevated blood pressure over that of the normal population that if left untreated is associated with damage to kidneys, heart, and blood vessels of the extremities and eyes. It is a disease of rising prevalence with 50 million Americans potentially in need of treatment. It is the most common diagnosis given to patients over 65 following an office visit. Unfortunately estimates are that 30% of the population is unaware that they suffer from hypertension, 40% of those who have a diagnosis of hypertension are not being treated and of those that are being treated 66% are not controlled. Hypertension as a finding increases with patient age, patient weight, and a patient diet that is high in sodium and low in fresh fruits and vegetables. The lifetime risk, in fact, approaches 90% by age Reduction of systolic blood pressure by 5 mm Hg over the entire population will result in a 14% overall reduction in mortality from stroke, a 9% reduction in death from CAD, and a 7% decrease in all-cause mortality. 2 In addition in clinical trials, antihypertensive therapy has been associated with reductions in stroke incidence (averaging percent); myocardial infarction (averaging percent); and heart failure (averaging >50 percent). 3 University of South Alabama, Department of Family Medicine June 30,

110 The following recommendations are from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7). (5) This report provides an evidence-based approach to the prevention and management of hypertension. Evidence from English language, peer reviewed articles published between 1997 and 2003 was selected and graded by the JNC7 working group and was used to formulate a set of recommendations which formed the basis for the guideline. They focused on Patient-oriented outcomes that included not only mortality but also other outcomes that affect patients lives and well-being, such as sexual function, ability to maintain family and social roles, ability to work, and ability to carry out daily living activities. As these outcomes are strongly affected by nonfatal stroke, HF, CHD, and renal disease, this morbidity as well as mortality from these diseases is reflected in the following recommendations. The Encounter Chief Complaint: Typically the condition is detected through screening of asymptomatic individuals either in the community or in the office setting. The complaint is typically regarding the evaluation or followup of hypertension although it may be that the initiation of treatment occurs with an incidental finding if it is Stage 2 or greater. A complaint of headache, epistaxis, (not harbingers of hypertension) will often generate a blood pressure reading that may indicate pre-hypertension or hypertension. Vitals: Initial and subsequent visits: Age, gender, weight/height (BMI), pulse, previous blood pressures, current blood pressure (with confirmation in opposite arm if warranted) should be noted prior to going into the room through chart review and review of vital signs. History of Present Illness (new evaluation): Patient should be encouraged to identify what concerns exist. Patient should then be queried regarding major risk factors for cardiovascular disease. Patient should be reassessed periodically. (SOR - B) Tobacco use Risk Factor Key Question Content Further Investigation if Positive Current use of tobacco Past use of tobacco Counsel regarding cessation, assess stage of change Oral contraceptive use Obesity Physical inactivity Dyslipidemia Diabetes mellitus Reduced kidney function Family history of premature cardiovascular disease or death Use of oral contraception Current weight (from vitals) Current physical activity Past physical activity Current lipid status (if known) Current status of blood sugar (if known) Current kidney function (if known) First degree relatives and age of CV disease or death Actual risk 41/10,000 use years, either need to discontinue or continue combined with antihypertensive therapy if no other contraception method appropriate Calculate BMI Counsel regarding activity, assess stage of change Assess lipids, counsel regarding activity and diet, assess stage of change Assess blood sugar, if diabetes need stricter control (See diabetes mellitus chapter) Assess kidney function (serum and urine), if reduced function for age need stricter control If strong family history consider stricter control University of South Alabama, Department of Family Medicine June 30,

111 All patients with newly identified hypertension should have an investigation via history, physical exam, and laboratory to identify possible target organ damage Questions that assess potential target organ damage (SOR - B): Target Organ Key Question Content Further Investigation if Positive Heart Dyspnea, chest pain (especially on exertion), Stress test, ECHO Carotid arteries Episodic unilateral weakness Carotid dopplers Other peripheral arteries Claudication Peripheral artery dopplers Kidneys Length of time from disease onset, Serum creatinine, urine for control of blood pressure microalbuminuria Eyes Vision changes Dilated eye exam History of Present Illness (Follow-up visit): Allow patient to verbalize concerns. Inquire about changes in status. Inquire about side effects of medications. Inquire about status of lifestyle modification. Consider review of Risk Factors and/or target organ questions approximately every 12 to 24 months, more frequently if poor control If previously under control but no longer or resistant (SOR - C): Possible Cause Key Question Content Further Investigation if Positive Drug use -Inquire in non-judgemental way Prescription -Encourage patient to bring in all Herbal medications Drug induced OTC -Correlate use with blood pressure Illicit/recreational measurements Foods Environmental exposure Alcohol use Frequency of alcohol use -Stages of change model NSAID use Frequency of NSAID use -Substitute acetaminophen Lack of adherence Some people have trouble taking medications. Do you? -Establish office systems to facilitate adherence -Educate patient about treatment -Collaborate with other health professionals -Individualize regimen -Promote social support -Minimize economic barriers Physical: The physical exam is targeted at identification of risk factors or target organ damage, and progress in modification or elimination of risk factors. General Look for evidence of tobacco use, general body habitus looking for striae, moon facies. Observe for neurologic asymmetry suggestive of cerebrovascular damage, determine whether cuff size was correct. HEENT Fundi - Visualize looking for vascular disease initially and periodically Neck Ausculate for carotid bruits initially and periodically Thyroid Palpate for nodule if thyroid disease suspected Heart Auscultate for valvular disease and evidence of failure University of South Alabama, Department of Family Medicine June 30,

112 Lungs Auscultate for evidence of failure Abdomen Listen for abdominal bruitsinitially and periodically and (adults over 40) palpate abdomen looking for large pulsating mass in abdomen if abdominal aortic aneurysm is suspected. Extremities Palpate femoral, pedal pulses periodically, check for pedal edema initially and periodically Neuro N/A Musculoskeletal N/A Lab Testing (SOR - B): Lab Test Reason Initial Follow-up Urinalysis End-organ damage Yes Annual if normal Electrocardiogram End-organ damage Yes For symptoms and periodic Potassium Secondary cause, monitoring for Yes Every 6 to 12 months and when effect of medication (Chem 8) medication change dictates Calcium Secondary cause Yes For symptoms Creatinine Estimate GFR Yes Every 6 to 12 months and when medication change dictates Glucose Additional risk factor Yes (Chem 8) Follow USPSTF guidelines Hematocrit Secondary cause Yes For symptoms and periodic Lipid profile HDL-C LDL-C Triglyceride Urinary albumin excretion Office Based Management: Additional risk factor Yes Follow ATP-III guidelines Additional risk factor, monitor disease progression Optional Unknown Non pharmacologic (also appropriate for pre-hypertensive patients) (SOR - B): Lifestyle Modification Weight loss to achieve BMI kg/m2 Increasing fruits, vegetables, potassium, calcium. Reducing sodium Increase aerobic activity Limit alcohol Eliminate tobacco Reason Management Follow-up Loss of as little as 10 lbs reduces or prevents hypertension Improves blood pressure, facilitates weight loss Reduction to 2.4 g per day correlated with reduction in BP Weight loss, BP reduction Reduction to 1 oz (2 drinks/day) in men or 0.5 oz (1 drink/day) in women shown to reduce BP Additional risk factor reduction Exercise increase, calorie reduction DASH eating plan DASH eating plan 30 minutes on most days Inquire regarding intake on diagnosis. Periodically inquire. Employ stages of change model Inquire regarding use on diagnosis. Periodically inquire. Employ stages of change model Encourage at every visit Encourage at every visit Encourage at every visit Encourage at every visit Per stages of change model Per stages of change model University of South Alabama, Department of Family Medicine June 30,

113 Pharmacologic treatment (Figure): General Principles: Systolic blood pressure target 130 for patients with diabetes or kidney disease, 140 otherwise. Diastolic will follow systolic. The lower without symptoms, the better Lifestyle modifications much more important for long-term, especially in patients on medication For stage 1, a thiazide-type diuretic is a safe, inexpensive first choice For stage 2, dual drug therapy often needed. Many combinations include a thiazide diuretic and are good first choices Pay attention to compelling indications Pay attention to additional risk factors and focus on reduction or elimination In the face of resistance, think non-adherence Self-monitoring can be helpful. This entails monitoring in home, office, or other settings such as drug stores where blood pressure cuffs are maintained. Initiation of therapy, choosing a medication: Initiation of therapy (SOR - A) Compelling Indication First Line Other Considerations None Heart failure Post myocardial infarction CAD or high risk for CAD Thiazide-type diuretic Thiazide-type diuretic, ACEI, ARB, BB, aldosterone agonists BB, ACEI, aldosterone agonists Thiazide-type diuretic, ACEI, BB ACEI, ARB, CCB also indicated. BB may not offer equal protection from CVA CCB not indicated Diabetes Thiazide-type diuretic, ACEI, ARB, CCB Chronic kidney disease ACEI, ARB Goal 130/80 Recurrent stroke prevention Older patient Thiazide-type diuretic, ACEI Thiazide-type diuretic, CCB If angina not controlled can add long-acting dihydropyridine or nondihydropyridine CCB Follow more stringent diabetic guidelines Use caution during ongoing ischemia. BB may not offer equal protection from CVA Maintaining systolic < 160 lowers stroke risk by 33%. BB may not offer equal protection from CVA Situations requiring urgent attention (SOR - B): Pregnant patient Hypertensive crisis as defined by BP > 180/120 and evidence of impending or progressive organ dysfunction. BP must be immediately reduced to prevent or limit organ damage. Examples of diseases needing urgent attention include hypertensive encephalopathy, intracerebral hemorrhage, acute MI, acute LVF with pulmonary edema, unstable angina, dissecting aortic aneurysm, or ecclampsia Hypertensive urgency as defined by severe elevation in blood pressure (above stage II) but lack of end-organ damage. Symptoms might include severe headache, shortness of breath, epistaxis, or severe anxiety University of South Alabama, Department of Family Medicine June 30,

114 Follow-up (SOR - B): Monitor and comply with age appropriate health maintenance protocols. Attention to acute complaints with particular attention to worrisome symptoms that are consistent with end-organ damage Post-visit assessment Concern Periodicity Recheck 2 years. Encourage Normal Blood Pressure Progression lifestyle modifications. Encourage participation in community screening opportunities. Pre-hypertension Progression Follow-up six months to one year. Encourage lifestyle modifications. Encourage participation in community screening opportunities. Stage 1 hypertension, pre-treatment Progression Follow-up bi-monthly until controlled or until decision is made to begin medication. Encourage lifestyle modifications. Consider suggesting self-monitoring Follow-up monthly until target Stage 1, initiation of treatment achieved, obtain labs for Assess efficacy, monitor for monitoring. Encourage lifestyle compliance modifications. Consider suggesting self-monitoring Initiation of treatment, stage 2 hypertension Controlled blood pressure Assess efficacy Monitor for side effects, progression Follow-up monthly or more frequently until target achieved, obtain labs for monitoring. Encourage lifestyle modifications. Consider suggesting self-monitoring Office visit every 3 6 months, Potassium, creatinine every 6 12 months, control other risk factors and co-morbidities as needed. Low dose aspirin when control achieved. Encourage lifestyle modifications. Consider suggesting self-monitoring Supplemental materials: On-line resource outlining a series on encounters with patients with chronic illnesses Reference card from The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure University of South Alabama, Department of Family Medicine June 30,

115 Suggested for further reading: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure accessed at on 3/06/08 Dickerson L, Gibson M. Management of Hypertension in Older Persons. Am Fam Physician 2005;71: Accessed at U.S. Preventive Services Task Force. High Blood Pressure Screening. Release date July 2003 accessed at Onusko E. Diagnosing secondary hypertension Am Fam Physician 2003;67: accessed at Moser, Marvin, Setaro, John F.Resistant or Difficult-to-Control Hypertension N Engl J Med : accessed at (subscription) Resources for patients: Hypertension patient handout DASH Diet Exercise Prescription on the Net References: National Heart, Lung, and Blood Institute. Morbidity and Mortality: 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases. Accessed November and unpublished data computed by Wolz M and Thom T, National Heart, Lung, and Blood Institute. June Vasan RS, Larson MG, Leip EP, Evans JC, O Donnell CJ, Kannel WB, et al. Impact of high normal blood pressure on the risk of cardiovascular disease. N Engl J Med 2001;345: Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report [Published erratum in JAMA 2003;290: 197]. JAMA 2003;289: accessed at on 2/06/06 Wiysonge CS, Bradley H, Mayosi BM, Maroney R, Mbewu A, Opie LH, Volmink J.. Betablockers for hypertension. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD DOI: / CD pub2 accessed at University of South Alabama, Department of Family Medicine June 30,

116 Modified from JNC VII (5) University of South Alabama, Department of Family Medicine June 30,

117 Appendix Antihypertensive drugs (taken from JNC7) University of South Alabama, Department of Family Medicine June 30,

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120 Joint Pain 719.4x Definition: Joint Pain pain derived from the articulating surfaces of bones and is divided into 3 categories. Monoarticular joint pain Pain in 1 joint Oligoarticular joint pain Pain in 2 4 joints Polyarticular joint pain Pain in more than 4 joints General Approach to the patient: Goals: 1. Identify specific or life-threatening causes of joint pain. 2. Arrange for definitive care of identified specific causes of joint pain at time of presentation or with appropriate follow-up. 3. Provide symptomatic relief of patient complaints. 4. Avoid ordering unnecessary tests on low risk patients. Rules of Thumb: Age >70 Complaint frequency Commonly diagnosed diseases (in descending order of prevalence) Life threatening diseases to consider Key worrisome features (history) Key elements of exam Key diagnostic study Common Treatment Functional limitations Occasional Common Common Common Common Trauma Infection Avascular necrosis Hemarthrosis Cancer Infection Overuse Trauma Cancer Infection Overuse Trauma Crystals Arthritis Cancer Infection Trauma Overuse Arthritis Crystals Cancer Infection Osteoarthritis Trauma Crystals Cancer Infection Fever Fever Fever Fever Fever Vitals Lymph Joint exam X-rays of affected and surrounding joints Disease dependent Based on diagnosis Vitals Lymph Joint exam Vitals Lymph Joint exam Vitals Lymph Joint exam Vitals Lymph Joint exam X-ray X-ray X-ray X-ray NSAID Alter activities Typically limited by pain NSAID Typically limited by pain NSAID Typically limited by pain Disease dependent Based on diagnosis University of South Alabama, Department of Family Medicine June 30,

121 Overview: Almost 100% of people experience joint pain at some point in life. Many cases of joint pain are treated without seeing a physician using OTC analgesics, ice packs, heating pads and other home remedies. The differential diagnosis of joint pain is quite broad (see tables) and often presents a diagnostic dilemma. Due to the high prevalence of benign, self-limited conditions and the varied presentations and overlap of different types of inflammatory arthritis, there is no single widely accepted approach for evaluating the patient with joint pain. There are numerous guidelines and rules for interpreting diagnostic tests, but most diagnostic data is based on expert opinion. There is better evidence for diagnosis and treatment of some of the more common diseases such as rheumatoid arthritis that are based on randomized controlled trials. Tests that are available for diagnosing inflammatory arthritis are neither sensitive nor specific and may lead to confusion if ordered indiscriminately. Synovial fluid tests (microscopy, cell counts and culture) can be diagnostic in some cases and are almost always helpful when a joint effusion is present. Chief Complaint: Typically the complaint is Joint pain with or without reference to a specific joint Vitals: Age, gender, temperature, and weight loss or gain should be noted prior to going into the room through chart review and review of vital signs. General approach to history: The history for joint pain is targeted at identifying the cause of joint pain and determining if infection is a potential cause of the joint pain. Timing When did your joint pain begin? What were you doing when you first noticed it? Is your pain worse in the morning or at night? Location Does it hurt in the joint or the skin or muscles around the joint? (Patients sometimes mistake muscular pain or bursitis for joint pain) Have you had pain in any other joints? Quality What kind of pain is it? (Sharp, dull, aching, stabbing, burning, etc) Severity How bad is the pain on a scale of 1-10? Aggravating/Relieving factors Does anything make it better or worse? (Sitting, lying down, lifting, bending over, etc) Is the pain or stiffness worse after you rest for more than 30 minutes? Associated symptoms Are any other symptoms associated with the joint pain? (Recent heavy lifting, trauma, morning stiffness, fevers) Symptom Review Consider asking about fever, weight loss, lymphadenopathy, fatigue University of South Alabama, Department of Family Medicine June 30,

122 Age specific concerns: Toddlers and young children: Children will often present with a limp or simply quit using the affected joint rather than complaining directly about the pain. Pediatric limp has a broad differential diagnosis. Septic arthritis and osteomyelitis should always be entertained in the differential, particularly if there is a joint effusion and/or fever present. Nursemaid s elbow is a common cause of elbow pain and disuse in young children. This is due to subluxation of the radial head (often occurs after child is lifted by the arm) Adolescents: By far most common causes of joint pain in this age group are trauma and overuse injuries. Fever, joint effusions and lymphadenopathy may suggest joint infections. Ankle sprains are a particularly common cause of joint pain in this age group. Systemic symptoms, involvement of multiple joints, and duration of pain >8 weeks may suggest rheumatologic causes. Adults: Although trauma and overuse are still very common causes of joint pain in this age group, adults are more likely than other age groups to present with rheumatologic diseases that respond to specific interventions. Rheumatologic disorders should be strongly suspected in patients who have joint pain for more than 8 weeks. Older adults: Osteoarthritis is the most common cause of joint pain in the elderly. Occasionally, rheumatologic disorders present in the elderly. Osteoporosis and pathologic fractures are also considerations in this age group. Physical: The physical exam is targeted primarily at identifying joint effusions, palpating for bony tenderness and examining range of motion in the affected joints. General Does the patient appear ill? Are they sitting in an awkward position due to pain? Musculoskeletal Inspect joint for swelling, redness and effusion. Palpate joint for bony tenderness, effusion and warmth. Test active and passive range of motion. True intra-articular processes will limit both types of motion whereas periarticular pathology (bursitis, etc) will limit active range of motion more than passive range of motion due to placing more strain on tendons. This examination can be useful in deciding whether to get an X-ray of the affected joint. If there is suspicion of fracture (bony tenderness or trauma), plain films are indicated. If there is a joint effusion, a therapeutic and diagnostic arthrocentesis is important to rule out infection. Elbow Consider lateral epicondylitis (tennis elbow) patient will have tenderness over lateral epicondyle and pain over lateral epicondyle on resisted extension of wrist.. No pain on passive movement of elbow. Hip Consider trochanteric bursitis (tender to palpation over greater trochanter). No pain on passive movement of hip. Listed below in the tables are some findings that may be present on physical exam to provide clues in the setting of polyarticular joint pain. University of South Alabama, Department of Family Medicine June 30,

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125 Laboratory Findings: University of South Alabama, Department of Family Medicine June 30,

126 Diagnostic Studies: Acute joint pain and no signs of infection Consider X-rays. Acute joint pain and ANY suspicion of septic arthritis Urgent arthrocentesis mandatory. Consider X-rays Chronic joint pain without systemic signs/symptoms X-ray affected joints. Chronic joint pain with systemic signs/symptoms (fever, fatigue, etc) CBC, ESR as an initial screen for inflammatory disorders. Consider ANA and rheumatologic work-up if ESR is elevated. X-ray affected joints. Although there are many more tests that can be ordered in the evaluation of joint pain (as listed in tables above), most of the diseases they detect are rare. It is a waste of health care resources to order an extensive laboratory work-up on all patients presenting with joint pain. Exhaustive work-up should be reserved for those patients with persistent symptoms or symptoms strongly suggestive of rheumatologic disease as listed above. Office Based Management: Sprains/strains Generally diagnosed on basis of history of trauma or overuse and absence of fracture on X-ray. Non-pharmacologic: Rest Relative rest until pain is improving Ice Apply cold compresses for 20 minutes at a time several times a day Compression Ace Bandages may help with swelling Elevation Keeping affected joint elevated may help with swelling Pharmacologic: NSAIDs Help with pain and inflammation. Have patient take medication on a regular basis for several days to one week and then on an as needed basis. Osteoarthritis Generally diagnosed by history and degenerative changes on X-ray. Non pharmacologic: Rest will improve symptoms to some degree. Modify behaviors that exacerbate symptoms (running, repetitive joint movements, etc). Pharmacologic: Tylenol is first-line. NSAIDs may be used but are potentially dangerous if used long term (GI Bleeds). Narcotics may ultimately be needed in older patients if other therapies fail. Corticosteroid injections may be of benefit, but should not be given more than 4 times per year due to systemic effects of corticosteroids and the potential for worsening osteoarthritis if they are overused. University of South Alabama, Department of Family Medicine June 30,

127 Lateral epicondylitis - Generally diagnosed by history of overuse and physical exam. Non pharmacologic: Rest is the definitive treatment. Special brace that puts pressure over extensor carpii insertion onto lateral epicondyle may be of benefit. Pharmacologic: NSAIDs on a regular basis for 1 week then as needed may help. Local corticosteroid injections have been shown to be helpful. Trochanteric Bursitis - Generally diagnosed by history of overuse and physical exam. Non pharmacologic: Rest. Pharmacologic: NSAIDs on a regular basis for 1 week then as needed may help. Local corticosteroid injections have been shown to be helpful. Rheumatologic Disorders: Nonpharmacologic: Rest. Avoid activities that aggravate symptoms. Pharmacologic: Disease dependent. Patients are generally referred to rheumatologist for initiation of disease modifying therapies. Follow-up: Patients should follow up in 1-2 weeks if not improving, sooner for development of any signs of septic arthritis (fever, joint effusion, etc). Suggested for further reading: Sloane, P. Essentials of Family Medicine 4 th edition. Chapters 20, 22, and 42. References: Richie, A.M. et al. Diagnostic Approach to PolyArticular Joint Pain. American Family Physician Sept 15, 2003; Vol 68. No. 6 p Chokkalinhan, S. Diagnosing Acute Monoarthritis in Adults: A Practical Approach for the Family Physician. American Family Physician July 1, 2003; Vol 68 No. 1 p University of South Alabama, Department of Family Medicine June 30,

128 Low Back Pain Definition: Acute low back pain: Back pain of <1 month duration, typically under 7 days upon presentation. Subacute low back pain: Back pain of 1-2 months duration. Chronic low back pain: Back pain of >2 months duration. Goals: 1. Identify specific or life-threatening causes of low back pain. 2. Arrange for definitive care of identified specific causes of low back pain at time of presentation or at follow-up. 3. Provide symptomatic relief of patient complaints. 4. Avoid ordering unnecessary tests on low risk patients. Rules of thumb: Age >70 Complaint frequency Commonly diagnosed diseases Life threatening diseases to consider Key worrisome historical features Key elements of exam Key diagnostic studies Common treatment Functional limitations Trauma Infection Functional Cancer Infection Night pain Based on clinical suspicion Based on clinical suspicion Disease dependent Based on diagnosis Rare Rare Common Common Uncommon Functional Trauma Scoliosis Cancer Infection Night pain Spinal curvature Typically none indicated unless red flags present NSAID Alter activities Typically limited by pain Functional Disc disease Cancer Infection Bowel or bladder incontinence Reflexes Straight leg raise Typically none indicated unless red flags present NSAID Typically limited by pain Functional Fracture Cancer Infection History of cancer History of back surgery Reflexes Straight leg raise Typically none indicated unless red flags present NSAID Typically limited by pain Osteoarthritis Cancer Fracture Functional Cancer Infection History of cancer History of back surgery Reflexes Straight leg raise Plain films, CBC, ESR, based on clinical suspicion Disease dependent Based on diagnosis University of South Alabama, Department of Family Medicine June 30,

129 Overview: Over 90% of people will experience an episode of acute low back pain during life. The overwhelming majority (over 90%) of these episodes of low back pain will be due to nonspecific, functional causes, such as muscle strains and other ill-defined causes. The vast majority of patients will improve regardless of treatment and resume all normal activities within 3 months. In most cases low back pain will be managed conservatively, and can be expected to resolve without specific interventions. Functional low back pain is most common in the middle years of life. It is important to keep in mind when seeing people complaining of low back pain that a small percentage will have severe underlying pathology. It is important to recognize these causes in a timely fashion, especially if they will be responsive to specific interventions. If lifethreatening causes such as cancer, osteomyelitis, or abdominal aortic aneurysm are suspected, then urgent work-up should be initiated. To identify that subset of patients at risk for serious underlying pathology and order appropriate diagnostic studies, red flags have been identified through retrospective studies and meta-analyses of studies on low back pain that are associated with serious causes of low back pain. The most efficient strategy is to screen patients who present with a complaint of back pain using history, physical exam, and a knowledge of disease epidemiology, performing diagnostic studies only on those patients who have an intermediate risk of non-functional pain or a significant risk of life threatening illness. Patients fitting the profile of functional low back pain typically have a benign and self-limiting course, and thus it is important to avoid exposing them to unnecessary tests and procedures. The evidence for diagnosis and management of low back pain is primarily based on consensus and expert opinion, as there are no results from large, high quality, randomized, double blind trials available. Such studies are very difficult to undertake for low back pain, given that the overwhelming majority of patients improve rapidly regardless of treatment. As a result, the available studies for low back pain examine red flags, the identification of ominous signs and symptoms, and their association with pathology. Chief complaint: Typically the complaint is low back pain. Vitals: Age, gender, fever, and weight loss or gain should be noted prior to going into the room, through review of the chart and vital signs. University of South Alabama, Department of Family Medicine June 30,

130 General approach to history: The history for low back pain is targeted primarily to identify red flags. If no red flags are present, the history allows the provider to characterize and document the nature of the pain experienced by the patient. This information may be useful if the pain does not spontaneously resolve. Timing When did your back pain begin? What were you doing when you first noticed it? Location Where does your back hurt? (Ask patient to point with one finger to place of most severe pain.) Quality What kind of pain is it? (Sharp, dull, aching, stabbing, burning, etc.) Severity How bad is the pain on a scale of 1-10? Aggravating/Relieving factors Does anything make it better or worse? (Sitting, lying down, lifting, bending over, etc.) Associated symptoms Are any other symptoms associated with the pain? (Recent heavy lifting, trauma.) Symptom Review Consider asking about fever, weight loss, dysuria, hematuria, leg weakness or numbness, bowel or bladder incontinence, groin numbness. Age specific concerns: Infants and school aged children: It is uncommon for children to complain of low back pain of such severity as to occasion a physician s office visit. When children do present with back pain to the office, the history is key in determining whether the complaint is related to a functional problem or a somatic disorder. The younger the patient is, the more likely it is a somatic cause. Conversely, as children approach middle school age, functional low back pain is likely. The pain is commonly a function of book carrying methods or improper footwear. Adolescents: Patients in this age group are more likely to present to the office with a complaint of back pain than younger patients. Suspicion of functional back pain becomes more common with book bags greater than 25% of body weight, improper footwear, overuse or awkward athletic maneuvers, or prolonged sitting or standing. Resolution depends on identification of the underlying cause and correction of the functional problem. Scoliosis is likely to present as back pain in this age group. Questions for parents of children or for adolescents: Key Question Content Further Investigation if Positive Trauma Night pain New onset of severe pain in child who has never had similar complaint Associated with school (both sexes) Associated with school (female) Consider fracture Consider cancer, infection, rheumatologic Consider cancer, infection, rheumatologic Investigate book bag weight Investigate footwear University of South Alabama, Department of Family Medicine June 30,

131 Adults: Functional low back pain is by far the most common cause of low back pain in this age group. Risk stratification is based on red flags. Questions for adult: Age Key Question Content Further Investigation if Positive Any Trauma Consider fracture Radiation in dermatome distribution Disc herniation, varicella zoster Previous surgery, history of alcoholism or injection drug use Discitis Fever, persistent pain Discitis, rheumatologic Bowel or bladder dysfunction, saddle anesthesia Cauda equine syndrome Inconsistent response, overreaction Malingering, non organic pain Physical activity, overuse None needed, alter activities to protect back Night/rest pain Cancer, ankylosing spondylitis, infection Any female over age 14 Flank pain, fever, dysuria Pyelonephritis, PID > 50 History of cancer Metastatic disease > 60 History of uncontrolled hypertension, smoker Abdominal aortic aneurysm Physical: The physical exam is targeted primarily at identifying red flags and assessing range of motion. General Posture (Is pain causing patient to sit or move in an awkward fashion?) HEENT N/C Neck N/C Heart N/C Lungs N/C Abdomen (adults over 60) Listen for abdominal bruits and palpate abdomen looking for large pulsating mass in abdomen if abdominal aortic aneurysm is suspected. Palpate for suprapubic and CVA tenderness if UTI/pyelonephritis is suspected. Pelvic Check for cervical/urethral discharge and adnexal masses if sexually transmitted disease (PID) is a possibility. Extremities See neuro exam. Neuro Strength in hip, leg and foot. Assess DTR s in knee and ankle. Perform sensory exam if patient reports numbness. Unilateral numbness or weakness suggests acute disk herniation. Musculoskeletal Palpate spinous processes of lumbar spine (curvature, alignment, tenderness). Palpate paraspinal muscles to assess for tenderness or muscle spasm. Assess range of motion (flexion, extension, rotation, side-to-side bending). Perform straight leg raise test to assess pain when sciatic nerve is stretched. University of South Alabama, Department of Family Medicine June 30,

132 Straight-leg-raise test: Purpose Of Test Maneuver Positive Finding Negative Finding Interpretation of Positive Result Diagnostic studies: Detect sciatic nerve root entrapment Lie patient flat on table. Slowly raise heel while keeping leg straight. Stop when patient reports pain, resistance is felt, or 70 degree angle between bed and leg is reached. Note angle of elevation where patient reports pain. Shooting pain from back to below the knee on the side of leg being raised. No pain, back pain during maneuver, upper leg pain, pain in other leg. Indicates nerve root entrapment. Suggests acute disk herniation. General guidelines No diagnostic studies are indicated in the absence of red flags. Plain films are indicated in all ages for pain following trauma, pain greater than 4 weeks duration, persistent or severe neurologic deficit, or fever. Cervical swabs and perhaps pelvic ultrasound are indicated if sexually transmitted disease (PID) a possibility. Dip urinalysis is indicated for females with any urinary symptoms or if pyelonephritis is otherwise clinically suspected. OFFICE BASED MANAGEMENT Functional Low Back Pain: Nonpharmacologic There is general agreement among physicians that patients with acute nonspecific lower back pain require only conservative management. Patients should be instructed to resume their normal activities as tolerated. Any aggravating factors should be eliminated to the extent possible. Bed rest is not indicated, and has actually been shown to delay recovery in patients with low back pain. Back pain education booklets provide lots of information to patients, and teach exercises, postures, and lifting techniques that may be useful in preventing back pain. Both physical therapy and chiropractic spinal manipulation have been shown to offer small short-term benefits, but significantly increase the cost of medical care, and do not decrease the recurrence of back pain or change long-term outcomes. Pharmacologic NSAIDs relieve low back pain through their analgesic properties and also reduce inflammation. Instruct patients to take the NSAID regularly until back pain resolves. Acetaminophen is an alternative medication in patients for whom NSAIDs are contraindicated. Skeletal muscle relaxants may be useful in low back pain where muscle spasm is identified. They are prescribed to be taken regularly until back pain resolves, but no longer than 4 weeks. Avoid narcotic pain relievers unless pain is severe and not improved with NSAIDs and muscle relaxants. University of South Alabama, Department of Family Medicine June 30,

133 Acute disc herniation: Nonpharmacologic Bed rest for 2-3 days is recommended to avoid aggravating the injury, thereby increasing inflammation and ultimately worsening nerve root impingement. Patients should then gradually resume normal activities as tolerated. Low back exercises and educational booklets may be of some benefit. Most patients with radicular findings (even decreased reflexes and strength) will significantly improve over time with conservative management. Surgical intervention has not been conclusively shown to be of long-term benefit, though more rapid initial recovery may occur. Pharmacologic Same as for functional low back pain with one exception. If patient is unable to take NSAIDs, consider a high dose oral corticosteroid for 5-7 days to reduce inflammation, although there are no controlled prospective studies to support corticosteroid use in low back pain. Pyelonephritis See UTI chapter. Referral to specialist for further evaluation and treatment: Possible scoliosis noted on physical exam with or without confirmatory plain films. Urgent referral to specialist for further evaluation and treatment: Possible primary or metastatic cancer as identified on imaging studies. Possible infectious etiology as identified through blood work or on imaging studies. Progressive neurologic deficits involving bowel, bladder, or saddle anesthesia. Possible abdominal aortic aneurysm greater than 4 cm as identified on imaging studies. Follow-up: Patients should follow up if back pain has not resolved in 4 weeks, or sooner for fever, dramatic increase in pain level, or new onset of numbness or weakness. Non-resolution of symptoms should prompt investigation for structural causes, rheumatological causes, as well as reevaluation for the possibility of infection and cancer. If all symptoms resolve with therapy, the patient need follow up only for regularly scheduled health maintenance visits. University of South Alabama, Department of Family Medicine June 30,

134 Flow chart: University of South Alabama, Department of Family Medicine June 30,

135 Suggested further reading: Chapter 23: Low Back Pain in Current Diagnosis and Treatment in Family Medicine; Jeannette E. South-Paul, Samuel C. Matheny, and Evelyn L. Lewis, editors; accessible by subscription at Patel, A.T. and A.A. Ogle; Diagnosis and Management of Acute Low Back Pain; Am Fam Physician; 2000 Mar 15;61(6): , ; accessible online at Humphreys, S.C., J.C. Eck, and S.D. Hodges; Neuroimaging in Low Back Pain; Am Fam Physician 2002;65: ; accessible online at Resources for patients: Back Pain Low; accessed on Medline Plus at Low Back Pain: Tips on Pain Relief and Prevention; accessed on Familydoctor.org at Relieving Low-Back Pain With Exercise; by Brian Shiple, DO; The Physician and Sportsmedicine; Vol 25, No. 8, August 97; accessed at References: Frymoyer, J.D.; Back Pain and Sciatica; N Engl J Med 1988;318: Carey, T.S., J. Garrett, A. Jackman, C. McLaughlin, J. Fryer, D.R. Smucker DR; The Outcomes and Costs of Care for Acute Low Back Pain Among Patients Seen by Primary Care Practitioners, Chiropractors, and Orthopedic Surgeons: The North Carolina Back Pain Project; N Engl J Med 1995;333: Malmivaara, A., U. Hakkinen, T. Aro, et al; The Treatment of Acute Low Back Pain: Bed Rest, Exercises, or Ordinary Activity?; N Engl J Med 1995;332: Cherkin, D.C., R.A. Deyo, M. Battle, J. Street, and W. Barlow; A Comparison of Physical Therapy, Chiropractic Manipulation, and Provision of an Educational Booklet for the Treatment of Patients with Low Back Pain; N Engl J Med 1998:339: Weber, H; Lumbar Disc Herniation: A Controlled, Prospective Study With Ten Years of Observation; Spine 1983;8: Wheeler, A.H.; Pathophysiology of Chronic Low Back Pain; University of South Alabama, Department of Family Medicine June 30,

136 Definition: Migraine Headaches 346.XX Migraines are a common form of headaches that are genetically based and occur in 18% of women and 6% of men. They affect either one side or both sides of the head and are widely associated with various gastrointestinal, autonomic and Neurologic symptoms. Goals: 1. Establishing a diagnosis 2. Encourage use of a headache diary to establish frequency of headaches, severity of attacks, and uncover triggers. 3. Establish an individualized treatment regiment based on headache frequency and severity as well as impact on the patient s daily routine. 4. Provide education to the patient aimed at reducing migraine frequency through trigger avoidance and life style modifications. Red Flags: The following symptoms and signs warrant investigations (mainly brain imaging) directed towards exclusion of secondary headaches: A new or different headache Red Flags for a Secondary Headache Disorder "Thunderclap" headache (peak intensity within seconds to minutes) Worst headache ever Focal neurologic signs or symptoms, such as papilledema, motor weakness, memory loss, papillary abnormalities, or sensory loss Change in existing headaches New onset headache after age 50 Headache associated with systemic symptoms (fever, weight loss, jaw claudication) Overview: Migraine headache patients are frequently encountered in a primary care physician s office. The direct and indirect costs of migraine have been estimated at approximately $17 billion per year. Migraines may present with or without auras (an aura being a wide variety of gastrointestinal, autonomic, or neurologic symptoms). Migraines without auras are the most frequent type, occurring in approximately 80% of migraine patients. They are described as a deep and dull headache if mild or moderate but throbbing in severe ones. They are typically University of South Alabama, Department of Family Medicine June 30,

137 worsened by rapid head movements, sneezing, or straining and are associated in typical cases with some degree of photophobia and phonophobia. Typical migraines usually last 4 hours or more if left untreated. They are described to be unilateral in 60-70% of cases and bifrontal or global in up to 30% of cases. They are frequently first encountered in the 2 nd and 3 rd decade of life, but may also be encountered in children as well. Multiple factors are thought to be involved in the etiology of migraines. Some of the factors put forward include a genetic role, a vascular role, as well as a possible role of Serotonin. The Encounter Chief Complaint: The patient may present to the office for an acute migraine attack wanting quick relief of his headache or present with a history of chronic migraine headaches expressing a desire to decrease the frequency and severity of the attacks. Even though, the patient presenting with an acute attack needs quick relief of his medication, a detailed history of his migraines must be elicited with the goal of therapy to decrease his attack rate and severity. History of Present Illness: Acute Migraine Attack: Classical Migraines: Classical migraine patients present with unilateral dull to throbbing headaches that are positional and are exacerbated by loud noises or bright light. Patients tend to seek dark quiet rooms during an acute attack. There attacks usually start in the morning and very rarely does it wake them up from sleep. They are preceded by an aura that is temporary and typically lasts less than an hour. Auras: Neurological symptoms: Visual disturbances (most common) Numbness and/or tingling in the face or fingers. (2 nd most common) Autonomic symptoms: Nasal congestion or rhinorrhea Tearing Color and temperature change Changes in pupil size Some patients may report migraine triggers. These triggers commonly include stress, menstruation, lack of sleep, hunger, head trauma, some medication like oral contraceptives and certain foods and beverages. Atypical migraines may present with only some of the above symptoms making it difficult at times to differentiate it from other forms of headaches. University of South Alabama, Department of Family Medicine June 30,

138 Key Questions to ask the Patient: How frequent are your headaches? How can you characterize your headaches? Which part of your head is affected during the headache? How long do your headaches last, if left untreated? When do these headaches occur during the day? Have you noticed any triggers to your migraines? When you are having a headache, what makes it worse? What do you do to relieve your headaches? Do you have any other symptoms during the headaches? Can you tell if you are about to have a headache? If yes, what symptoms do you have before the headache starts? Does anyone in your family have similar headaches? Migraine Variants: Hemiplegic Migraines: These migraines are associated with motor and sensory deficits which may last longer that the headaches itself and at times lasting for a few weeks. Basilar type Migraines These are associated with dysarthria, vertigo, diplopia, tinnitus, decreased hearing, ataxia, or altered consciousness. Migrainous vertigo This may cause episodes of vertigo that frequently is misdiagnosed. IHS Criteria for Migraine with Typical Aura: A At least 2 attacks fulfilling criteria B B C Aura consisting of at least one of the following, but no motor weakness: Fully reversible visual symptoms including positive features (e.g., flickering lights, spots, or lines) and/or negative features (i.e., loss of vision) Fully reversible sensory symptoms including positive features (i.e., pins and needles) and/or negative features (i.e., numbness) Fully reversible dysphasic speech disturbance At least two of the following: Homonymous visual symptoms and/or unilateral sensory symptoms At least one aura symptom develops gradually 5 minutes or more and/or different aura symptoms occur in succession over 5 or more minutes D Headache fulfilling criteria for migraine without aura beginning during the aura or follows the aura within 60 minutes University of South Alabama, Department of Family Medicine June 30,

139 IHS Criteria for Migraine without Aura Headache Descriptions (Any 2) Associated Symptoms (Any 1) Unilateral Pulsatile quality Moderate to severe pain intensity Aggravation by or causing avoidance of routine physical activity Nausea and/or vomiting Photophobia and phonophobia Must have 5 attacks fulfilling the above criteria and no signs of a secondary headache disorder. The headaches last 4 72 hours Physical Examination: The physical examination in a migraine patient is usually normal; however, a comprehensive neurologic exam is necessary to rule out focal neurological deficits, which are seen in secondary headaches. Lab Testing: Patients with classical migraines do not require any lab testing. Differential Diagnosis: Tension Type Headaches (TTH): This is the most common type of primary headaches. Unlike migraine headaches they are not as severe and are not described as throbbing. Rapid head movements do not aggravate them. They are very rarely associated with nausea, vomiting, photophobia or phonophobia. Patients with TTH may present with episodic attacks (<15 days/month) or chronic tension type headaches (>15 days/month). Cluster Headaches: Cluster headaches are less frequently encountered in an office than migraine headaches. They are thought to be worse in intensity than any other primary headache. Cluster headaches start more commonly in the 3 rd and 4 th decade of life. They are associated with symptoms of sympathetic hypofunction and parasympathetic hyperfunction. University of South Alabama, Department of Family Medicine June 30,

140 Characteristics of Primary Headache Disorders: Migraine Tension-Type* Cluster Location Unilateral Bilateral Strictly unilateral Intensity Moderate/severe Mild/moderate Severe Duration 4 to 72 hours 30 min to 7 days 15 to 90 min Quality Throbbing Pressing/tightening Severe Associated symptoms Yes No Yes -- autonomic Gender Female > male Female > male Male > female Management of Migraine Headaches: Therapy of migraines is divided into treatment of acute attacks as well as preventive therapy targeted to patients with frequent disabling headaches. Acute Treatment: Non-Pharmacologic Therapies: The following therapies may be used in conjunction with pharmacologic therapy: Relaxation Training Thermal biofeedback with relaxation training EMB biofeedback Cognitive-behavioral therapy Pharmacologic Therapy: Concepts of Pharmacologic Therapy: 1) Use NSAIDs in the treatment of mild-to-moderate migraine headaches. 2) Use migraine-specific agents in patients with moderate-to-severe migraines or in patients with mild-to-moderate migraines who fail to respond to NSAIDs. 3) Use of non-oral routes to administer medications in patients with significant nausea or vomiting. (Anti-emetics may play an important role in alleviating these symptoms) 4) Medication-overuse headaches (rebound headache) are caused by frequent use of acute medications. Patients requiring frequent rescue medications should use preventive therapy. Migraine-Specific Medications: Triptans (Sumatriptan, Naratriptan, Rizatriptan, Zolmitriptan): Effective and relatively safe in the treatment of Migraine headaches and may be used as the first line therapy in patients with moderate-to-severe headaches. Triptans may be administered via an intranasal or subcutaneous route in patients with significant nausea or vomiting. Ergot Alkaloids and derivatives: Ergotamine PO/PR and caffeine combinations may be considered in the treatment of selected patients with moderate-to-severe migraine. Dihydroergotamine may be administered through an intravenous, intramuscular, subcutaneous, or intranasal route and are reasonable treatment choices in the therapy of moderate-to severe migraines. University of South Alabama, Department of Family Medicine June 30,

141 Nonspecific Medications: NSAIDs, and other nonopiate analgesics: NSAIDs and combination medications are a reasonable first-line therapy for mild-to-moderate migraine headaches. Acetaminophen alone, however, is not recommended for migraines. Butalbital-containing analgesics: These are effective in the treatment of migraines, however, should be limited and patients should be carefully monitored due to overuse, medication-overuse headaches, and withdrawal concerns. Opiate Analgesics: These are also effective in the treatment of migraine headaches, but, however, carry the risk of overuse and dependence. Non-oral routes play an effective role in the rescue therapy for acute migraine headache resistant to other medications provided the sedation side effect will not put the patient at risk. Preventive Therapy: Goals of Preventive Therapy: 1) Reduce attack frequency, severity, and duration 2) Improve responsiveness to treatment of acute attacks 3) Improve function and reduce disability Indications of Preventive Therapy (one or more of the following): 1) Recurring migraines that significantly interfere with daily routine despite acute treatment. 2) Frequent headaches. 3) Contraindications to or failure or overuse of acute therapy. 4) Adverse effects with acute therapies. 5) Presence of uncommon migraine conditions (migraine variants) mentioned previously. 6) Patient preference Follow-up Frequent follow up may be necessary initially to assess adequacy of response to therapy. Patients are encouraged to use their headache diary to assist the physician in adjusting the dose and type of medication most appropriate for his/her symptoms. However, when initiating preventive therapy it may take 2-3 months to achieve full therapeutic effect of the medication. University of South Alabama, Department of Family Medicine June 30,

142 Acute Therapies Acute Therapies Quality of evidence Scientific effect Adverse effects Triptans (serotonin 1B/1D receptor agonists) Sumatriptan nasal spray A +++ Occasional Oral triptans Naratriptan A ++ Rizatriptan A +++ Sumatriptan A +++ Zolmitriptan A +++ Sumatriptan SC A +++ Frequent Ergot alkaloids and derivatives DHE IV B ++ Frequent DHE SC/IM B +++/++ Occasional DHE IV plus antiemetics B +++ Frequent DHE nasal spray A ++ Occasional Ergotamine B + Frequent Antiemetics Chlorpromazine IM/IV C/B ++ Mild to moderate Metoclopramide IM B + Infrequent to occasional PR/IV B Prochlorperazine PR/IM B +++ Occasional IV B +++ NSAIDs and nonopiate analgesics Acetaminophen B 0 Infrequent Ketorolac IM B + Infrequent Oral NSAIDS Occasional Aspirin A ++ Diclofenac K B ++ Flurbiprofen B + Ibuprofen A ++ Naproxen B + Naproxen sodium A ++ Combination analgesics Acetaminophen, aspirin, caffeine A +++ Infrequent Barbiturate hypnotics Butalbital, ASA, caffeine C? Occasional Butalbital, ASA, caffeine, codeine B ++ Opiate analgesics Butorphanol nasal spray A +++ Frequent Opiates oral combinations A ++ Occasional Acetaminophen, codeine combinations Opiates parenteral B ++ Frequent Butorphanol IM Meperidine IM/IV Methadone IM Other medications Corticosteroids C + Infrequent IV plus antiemetics Dexamethasone Hydrocortisone Isometheptene compound B + Infrequent Lidocaine IN B ++ Frequent University of South Alabama, Department of Family Medicine June 30,

143 Preventive Therapies Quality of evidence Scientific effect Preventive Therapies Adverse effects Antiepileptics Carbamazepine B ++ Occasional to frequent Divalproex sodium/sodium valproate A +++ Occasional to frequent Gabapentin B ++ Occasional to frequent Topiramate C? Occasional to frequent Antidepressants Tricyclic antidepressants Amitriptyline A +++ Frequent Nortriptyline C? Frequent Protriptyline C? Frequent Doxepin, imipramine C? Frequent Selective serotonin reuptake inhibitors Fluoxetine B + Occasional Fluvoxamine, paroxetine, sertraline C? Occasional Monoamine oxidase inhibitors Phenelzine C? Frequent Other antidepressants Bupropion, mirtazepine, trazodone, venlafaxine C? Occasional Beta-blockers Atenolol B ++ Infrequent to occasional Metoprolol B ++ Infrequent to occasional Nadolol B + Infrequent to occasional Propranolol A ++ Infrequent to occasional Timolol A +++ Infrequent to occasional Calcium channel blockers Diltiazem C? Infrequent to occasional Nimodipine B + Infrequent to occasional Verapamil B + Infrequent to occasional NSAIDs Aspirin B + Infrequent Fenoprofen Flurbiprofen Mefenamic acid Ibuprofen C? Infrequent Ketoprofen B + Infrequent Naproxen/naproxen sodium B + Infrequent Serotonin antagonists Cyproheptadine C? Frequent Methysergide A +++ Frequent Other Feverfew B ++ Infrequent Magnesium B + Infrequent Vitamin B2 B +++ Infrequent Adapted from the AAN Evidence-based guidelines for Migraine Headache University of South Alabama, Department of Family Medicine June 30,

144 Migraine Algorithm Initial Visit Detailed History Diagnostic Screening & Differential Diagnosis Assess illness severity: Attack frequency and duration Pain severity Impact Non-Headache symptoms Patient history and preferences Intermittent mild-to-moderate migraine Intermittent moderate-to-severe migraine Aspirin/NSAID (large dose) Aspirin/acetaminophen + antiemetic Behavioral Therapies Rescue Oral/Nasal/SC Triptans or DHE Oral Triptan If Initial Treatment Unsuccessful Alternative oral/nasal/sc Triptan If Unsuccessful Frequent Headaches 4 attacks / month Consider prophylaxis & acute treatment for breakthrough migraines If Unsuccessful Consider Referral University of South Alabama, Department of Family Medicine June 30,

145 Supplemental Material Resources for Patients: References: American Academy of Neurology Evidence-based guidelines for migraine headache International Headache Society headache classification University of South Alabama, Department of Family Medicine June 30,

146 New Onset Headache 784.0, 346.XX, Definition: Headache, or cephalalgia, is defined as diffuse pain in various parts of the head General Approach to the patient Overview: Headache is among the most common pain problems encountered in family practice. One epidemiologic study 1 found that 95 percent of young women and 91 percent of young men experienced headache during a 12-month period; 18 percent of these women and 15 percent of these men consulted a physician because of their headache. Missed workdays and medical benefits associated with headache cost American industry approximately $50 billion annually. Chief Complaint: Patients will present complaining of headaches of different descriptions depending on the etiology. Most patients with primary headaches will present after trying OTC remedies. History of Present Illness: A systematic case history should include the following: Age at onset Presence or absence of aura and prodrome Frequency, intensity and duration of attack Time and mode of onset Quality site and radiation of pain Precipitating and relieving factors Associated symptoms and abnormalities Effect of activity on pain Number of headache days per month Family history of migraine Relationship with food/alcohol Response to any previous treatment Any recent change in vision Association with recent trauma Any recent changes in sleep, exercise, weight, or diet State of general health Change in work or lifestyle (disability) Change in method of birth control (women) Possible association with environmental factors Effects of menstrual cycle and exogenous hormones (women) University of South Alabama, Department of Family Medicine June 30,

147 Diagnostic instruments: The brief headache screen, adopted by the American Academy of Neurology, appears to be well suited to identify migraine in the primary care setting. This screen includes the following questions: Use the frequency of severe and mild headache and medication use to categorize patients as migraine (i.e.: episodic, severe), daily headache and/or medication overuse. Q1. How often do you get severe headaches (i.e. without treatment it s difficult to function)? This question alone identifies migraine. Any patient with severe headaches which are episodic should be assumed to have migraine. Q2. How often do you get other (milder) headaches? Daily headaches should always be evaluated for "worrisome" features. Patients with daily headaches (at times severe and migrainous) may have "transformed migraine," often due to medication overuse. Q3. How often do you take headache relievers or pain pills? Use of symptomatic medications more than 3 days/week represents medication overuse. The label, "drug rebound headache," should not be applied without a complete evaluation that has considered secondary and "worrisome" headaches. When drug rebound headache is recognized, symptomatic medications must be withdrawn for the patient to improve. Q4. Has there been any recent change in your headaches? The best screening question for "worrisome" headaches. A patient with a stable pattern of headache for 6 months has the same likelihood of an underlying tumor as a patient without headache. Q5. How often do you miss work (or leisure activities) because of headache? Good question for headache-related disability. Q6. Are you satisfied with your current headache medicine? Rapidly assesses acute therapy. Q7. Are you on a preventive medicine for headache? If not, would you like to be?determines the patient's preference for prophylaxis. MIGRANES IN A MINUTE MIGRAINE IN A MINUTE Adapted from Morris Maizels, MD, Kaiser Permanente University of South Alabama, Department of Family Medicine June 30,

148 Danger signs: Headaches may be the presenting symptom of a space-occupying mass or vascular lesion, infection, metabolic disturbance, or a systemic problem. Sudden onset of headache Symptom New headache in patients under the age of five or over the age of 50 may suggest underlying pathology. The "first" or "worst" headache of my life A worsening pattern Focal neurologic symptoms other than typical visual or sensory aura Fever associated with headache Change in mental status The rapid onset of headache with strenuous exercise Head pain that spreads into the lower neck and between the shoulders New headache type in a patient with cancer New headache type in a patient with Lyme New headache type in a patient with HIV suggests Headache during pregnancy or postpartum Possible Diagnosis Subarachnoid hemorrhage Cluster headache may sometimes be confused Intracranial hemorrhage, CNS infection, or a space occupying lesion Intracranial hemorrhage or central nervous system (CNS) infection A mass lesion, subdural hematoma, or medication overuse headache A mass lesion, arteriovenous malformation, or collagen vascular disease Intracranial, systemic, or local infection Intracranial hemorrhage, CNS infection, or a space occupying lesion Carotid artery dissection or intracranial hemorrhage Irritation due to either infection or subarachnoid blood Metastasis. Meningoencephalitis Opportunistic infection or tumor Preeclampsia, cortical vein or venous sinus thrombosis, carotid dissection, and pituitary apoplexy Other features suggesting a specific headache source Chronic nasal stuffiness or chronic respiratory infection suggests a diagnosis of sinusitis. Impaired vision suggests the presence of glaucoma. Visual field defects suggest the presence of a lesion of the optic pathway. The presence of nausea, vomiting, worsening of headache may be caused by a tumor. Sudden, severe, unilateral vision loss suggests the presence of optic neuritis. Headache, fatigue, generalized aches and pain, and night sweats in subjects age 55 years or older suggest the presence of temporal arteritis. Intermittent headaches with high blood pressure are suggestive of pheochromocytoma. Physical: The majority of patients with headache complaints have a completely normal physical and neurologic examination. If a complete and careful history does not point to a primary etiology, further examination is warranted in the following areas: Obtain blood pressure and pulse Listen for bruit at neck Palpate the head, neck, and shoulder regions Check temporal and neck arteries Examine the spine and neck muscles A comprehensive neurologic examination University of South Alabama, Department of Family Medicine June 30,

149 Danger Signs on Exam: Neck stiffness Papilledema Focal neurologic signs Sign Possible Diagnosis Meningitis Intracranial mass lesion, pseudotumor cerebri, encephalitis, or meningitis Intracranial mass lesion, arteriovenous malformation, or collagen vascular disease. Indications for imaging studies Patients with any of the danger signs noted above need urgent brain imaging: Recent significant change in the pattern, frequency or severity of headaches Progressive worsening of headache despite appropriate therapy Focal neurologic signs or symptoms Onset of headache with exertion, cough, or sexual activity Orbital bruit Onset of headache after age 40 years NOTE: Neuroimaging is usually not warranted for patients with migraine and a normal neurologic examination. The data are insufficient to recommend CT or MRI when neuroimaging is necessary. A head CT scan (with and without contrast) is likely to be sufficient in most patients. An MRI along with MRA are indicated when posterior fossa or vascular lesions are suspected. As many as 90 percent of all benign headaches fall under a few categories, including: migraine, tension-type, and cluster headache. While a population-based study found that the one-year prevalence of episodic tension-type headache was 38 percent, most of these people do not present to physicians for care. Characteristics of Primary Headache Disorders: Migraine Tension-Type* Cluster Location Unilateral Bilateral Strictly unilateral Intensity Moderate/severe Mild/moderate Severe Duration 4 to 72 hours 30 min to 7 days 15 to 90 min Quality Throbbing Pressing/tightening Severe Associated symptoms Yes No Yes -- autonomic Gender Female > male Female > male Male > female MIGRAINE HEADACHES See Chapter on Migraines University of South Alabama, Department of Family Medicine June 30,

150 TENSION TYPE HEADACHE IHS Criteria for Diagnosis of Tension Type Headaches Headache Description (Any 2) Associated Symptoms (Any 1) Pressing or tightening Mild to moderate intensity Bilateral location No worsening with exertion No nausea or vomiting Photophobia or phonophobia (1 allowed) Must have had >10 previous headache episodes and no evidence of a secondary headache disorder Tension type headache is the most common headache syndrome. Tension type headaches feel like pressure or tightness all around the head and have a tendency to wax and wane in intensity. The revised IHS classification distinguishes three subtypes of tension type headache: Infrequent episodic TTH with headache episodes less than one day a month Frequent episodic TTH with headache episodes 1 to 14 days a month Chronic TTH with headaches 15 or more days a month Treatment: Episodic: Simple analgesics such as acetaminophen, aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs) are the drugs of choice for abortive therapy. Combination drugs containing ergotamine, caffeine, butalbital and codeine should be avoided due to the potential for drug dependency and analgesic overuse (rebound) headaches. Chronic headaches: Prophylactic therapy is indicated for patients with chronic headaches requiring daily analgesics. Tricyclic antidepressants, specifically amytriptyline, has shown benefit. Mirtazapine showed positive results in one randomized controled trial. SSRIs have shown mixed results. Biobehavioral techniques ( mind-body therapies) can be useful for managing chronic tension type headaches, either alone or in combination with antidepressant medications. Psychotherapy, relaxation therapy, and biofeedback all may be useful. Physical therapy also may reduce the frequency of headaches in some cases. University of South Alabama, Department of Family Medicine June 30,

151 Table 2. Recommended Mind-Body Therapies for Headache Therapy Migraine headache Behavioral therapy with prophylactic drug therapy Cognitive behavior therapy Combination of progressive muscle relaxation and biofeedback Electromyographic biofeedback Relaxation training Thermal biofeedback (alone or in combination with relaxation training) Tension headache Cognitive behavior therapy Cognitive behavior therapy in children and adolescents with chronic headache Home-based behavioral therapies Muscular biofeedback Progressive muscle relaxation Relaxation training in children and adolescents with chronic headache Stress management training Evidence rating B A A A A A B A B B B A B A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see University of South Alabama, Department of Family Medicine June 30,

152 CLUSTER HEADACHES IHS Criteria for the General Diagnosis of Cluster Headache Headache Description (All 4) Autonomic Symptoms (Any 2) Rhinorrhea Lacrimation Severe headache Facial sweating Unilateral Miosis Duration of min Eyelid edema Orbital, periorbital, or temporal location Conjunctival injection Ptosis *No evidence of a secondary headache disorder. CLUSTER HEADACHE Cluster headaches are characterized by repetitive headaches that occur for weeks to months at a time, followed by periods of remission. Cluster headache is relatively uncommon; the prevalence is less than 1 percent. Men are affected more commonly than women, with a peak age of onset of 25 to 50 years. The pain of cluster headache begins quickly without any warning and reaches a crescendo within a few minutes. The headache is usually deep, excruciating, continuous, and explosive in quality, although occasionally it may be pulsatile and throbbing. The pain usually begins in or around the eye or temple; less commonly it may start in the face, neck, ear, or hemicranium. The pain is always unilateral; it remains on the same side of the head during a single cluster, but can switch sides during the next cluster in a small percentage of patients. Some patients report superimposed paroxysms of stabbing ice pick-like pain in the periorbital region that lasts for a few seconds and occur once or several times in rapid succession. Cluster headaches are associated with ipsilateral lacrimation and redness of the eye, stuffy nose, rhinorrhea, sweating, pallor, and Horner's syndrome. Nausea and vomiting may occur. Photophobia occurs ipsilateral to the pain. Focal neurologic symptoms are rare other than Horner's syndrome. Over 50 percent of sufferers report that alcohol is a potent precipitant of cluster headaches during a cluster bout; this sensitivity to alcohol ceases when the cluster ends. A typical cluster headache lasts from 15 minutes to three hours. The frequency of attacks depends upon the type of cluster: Episodic cluster headaches are most common, occurring in about 80 to 90 percent of patients suffering from this disorder. They are characterized by one to three attacks of periorbital pain per day over a six to twelve week period, followed by an average pain free interval of six months to one year. The remission may last for years. Chronic cluster headaches are characterized by the absence of sustained periods of remission. Either form of cluster headache can transform into the other. Attacks of pain tend to recur at the same hour each day for the duration of a single cluster; attacks occur between 9 pm and 9 am in up to 80 percent. Most patients experience one cluster per year, but this is not predictable. University of South Alabama, Department of Family Medicine June 30,

153 Management: Abortive therapy Abortive therapy of cluster headaches can be difficult because of the short duration of each episode. Nevertheless, a number of medications have proven effective Oxygen Acute cluster headaches can be aborted by inhalation of 100 percent oxygen in the majority of patients. Oxygen inhalation should be given for 20 minutes in an upright sitting position. Triptans are helpful in aborting an acute cluster attack. Octreotide appears to be effective and well tolerated in the treatment of acute cluster headaches. DHE Intranasal dihydroergotamine has been shown to relieve the pain of an acute cluster attack. Prophylaxis Prophylactic therapy should be started as soon as possible at the onset of a cluster episode. Verapamil was found to be effective for prophylaxis but there is a four to six week delay before the headaches remit. Prednisone is highly effective for prophylaxis, but should not be used chronically due to side effects. Lithium appears to be particularly effective for the chronic form of cluster headaches. Ergotamine, Cyproheptadine, and Indomethacin have also been shown to be effective. Prophylactic medications can be tapered after the expected duration of the cluster has passed. The drugs can be restarted if symptoms recur at the lowest effective dose. Strength of Recommendations Key clinical recommendation The first-line treatments for acute cluster headache are oxygen or sumatriptan, or a combination of the two. Less well-studied alternatives for acute treatment include intranasal dihydroergotamine, intranasal lidocaine, and intranasal capsaicin. Verapamil, in a dosage of 360 to 480 mg daily, can effectively reduce the number of attacks during a cluster headache period. Less well-studied alternatives for prophylaxis include prednisone and antiepileptic drugs; they should only be considered if verapamil is not tolerated or not effective. Label A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, opinion, or case series. Surgical Therapy: Patients with chronic cluster headaches that do not respond to medications may be considered for surgical therapy aimed at the trigeminal nerve. A case series found that 15 of 17 patients who underwent complete or partial section of the trigeminal nerve had complete or nearcomplete relief of symptoms. A B A B University of South Alabama, Department of Family Medicine June 30,

154 Diagnosis and Treatment of Headache Algorithm Diagnosis algorithm Evaluate type of headache Take a detailed history and assess functional impairment Rule out causes for concern Consider secondary headaches Refer to specialist Migraine Treatment Categorize and select treatment based on severity and functional impairment Patient education and lifestyle modifications Tension-type Headache Establish diagnosis Acute treatment Prophylactic treatment Patient education and lifestyle modifications Cluster Headache Establish diagnosis Acute treatment Prophylactic treatment Patient education and lifestyle modifications Resources for Patients: References: International Headache Society headache classification American Academy of Neurology Evidence-based guidelines for migraine headache Evaluation of Acute Headaches in Adults; American Family Physician, February 15, 2001 Tension-Type Headache; American Family Physician, September 1, 2002 Management of Cluster Headache; American Family Physician, February 15, University of South Alabama, Department of Family Medicine June 30,

155 Acute Pharyngitis Streptococcal sore throat (GABHS pharyngitis) 462 Acute pharyngitis Acute laryngopharyngitis Chronic pharyngitis Chronic nasopharyngitis Definition: A complaint of throat discomfort with or without cough or fever. General Approach to the patient: Goals: 7. Identify specific or life-threatening causes of throat pain 8. Obtain adequate information to develop a working diagnosis in an efficient manner 9. Arrange for definitive care of identified specific causes of throat pain at time of presentation or with appropriate follow-up 10. Detect and treat streptococcal pharyngitis in a timely manner 11. Allay fears of patient and family regarding symptom if cause is benign 12. Provide symptomatic relief of patient complaints 13. Avoid exposure to antibiotics when not indicated University of South Alabama, Department of Family Medicine June 30,

156 Rules of Thumb: Age Complaint frequency Commonly diagnosed diseases (in descending order of prevalence) Life threatening diseases to consider Key worrisome features (history) Key elements of exam 0-18 months 18 m- 5 y 5 y-15 y >45 Very uncommon Thrush Ulcerative pharyngitis (herpesvirus Herpangina Hand-footmouth Mouth breathing from URI GABHS Meningitis Epiglottitis Inconsolability Toxic appearance Assess hydration status Uncommon Common Uncommon Very Uncommon Herpangina Group A B hemolytic strep (GABHS) Allergic rhinitis Hand-footmouth Mouth breathing Ulcerative pharyngitis (herpesvirus) Meningitis Epiglottitis Kawasaki Disease C diphtheriae Drooling Toxic appearance Prolongued febrile illness Assess hydration status Abscense of nuccal rigidity GABHS Allergic rhinitis Mouth breathing Infectious mononucleosis Gonococcal pharyngitis Meningitis Abcess Palatal Cellulitis C diphtheriae Cancer Voice changes Dehydration Assess hydration status Visualize pharynx Determine if cough, rhinitis is present Abscense of nuccal rigidity Infectious mononucleosis Allergic rhinitis GABHS Gonococcal pharyngitis Abcess Palatal Cellulitis Meningitis Cancer C diphtheria HIV Voice changes Dehydration Severe sore throat Assess hydration status Visualize pharynx Determine if cough, rhinitis is present Abscense of nuccal rigidity Allergic rhinitis Rhino-sinusitis Viral pharyngitis GABHS Abcess Palatal Cellulitis Cancer Meningitis HIV Autoimmunie disorder Environmental exposure Voice changes Mental status changes High fevers Ulcerstion Brief mental status exam Abscense of nuccal rigidity Visualize pharynx Assess breath for fetid nature Key diagnostic study Common Treatment Functional limitations None Depends on clinical situation Depends on clinical situation Assess prior probability for GABHS. If over 30%, Rapid antigen test If GABHS, PCN If non-gabs, supportive care Out until treated for 24 hrs if GABHS If prior probability for GABHS over 30%, Rapid antigen test If GABHS, PCN If non-gabs, supportive care Out until treated for 24 hrs if GABHS If prior probability for GABHS over 30%, Rapid antigen test If GABHS, PCN If non-gabs, supportive care Out until treated for 24 hrs if GABHS Depends on clinical situation Depends on clinical situation Depends on clinical situation University of South Alabama, Department of Family Medicine June 30,

157 Overview: Chief Complaint: Typically the complaint is Sore throat Vitals: Age, gender, and a review of vital signs with attention to the presence or absence of fever, pulse, respiratory rate, and pulse oximeter if applicable should be noted. General approach to history: The history for pharyngitis is primarily to establish risk of the symptom being caused by a life threatening condition and to determine whether the patient has streptococcal pharyngitis. This is done initially by observing the patient for signs of toxicity, and listening to the quality of the patient s voice. Following this, the time course of the illness and associated symptoms will give important clues as to whether this is infectious due to bacterial causes, infectious due to viral causes, inflammatory, or related to another disease process (such as Gastroesophageal Reflux Disease) Vocal Quality - Location Where does your throat hurt? (Can ask patient to indicate with hand the place of most severe pain) Timing When did the pain begin? Has there been a change over time? What is the relationship of the pain with associated symptoms such as fever? Quality What is the severity of the pain? How would you characterize the pain? (Sharp, dull, aching, stabbing, burning, etc) Severity How bad is the pain? (Consider pain scale) Are you able to swallow liquids? Solids? Aggravating/Relieving factors Does anything make it better? Does anything make it worse? List medications tried for relief. Associated symptoms Are any other symptoms associated with the throat pain? (fevers, rashes, mouth ulcers, cough, coryza, acid brash) Risk Factors (child and adolescent) - Exposure to other children or adults with similar illness (identify diagnosis) Risk Factors (adult) Exposure to tobacco (amount, time of exposure), Exposure to alcohol (amount, time of exposure), Illness contacts University of South Alabama, Department of Family Medicine June 30,

158 Age Specific Concerns: Infants, toddlers: Key Question Content Whitish patches in mouth Sores in mouth Lesions on hands, feet as well as in mouth Cough, coryza Toxic appearance Drooling, toxic appearance Household contact with GABHS Further investigation if positive Consider thrush Consider primary herpes outbreak, herpangina Consider coxsackie virus Consider viral rhinosinusitis Consider life threatening infection such as meningitis, sepsis, pertusis, diphtheria Consider epiglottitis Consider GABHS School Aged Children, Adolescents: Key Question Content Acute onset, lack of cough, coryza, desquamating rash, GABHS in community Acute onset, fever, lack of cough or coryza, GABHS in community Acute onset, lack of cough or coryza, Cough, coryza Sores in mouth Lesions on hands, feet as well as in mouth Toxic appearance Drooling, toxic appearance Household contact with GABHS Prolonged course, adenopathy, GABHS testing negative History of oral-genital contact History acid brash History mouth breathing Ill appearance, neck stiffness History of prolonged illness, desquamating rash, cherry red lips History of non-vaccination Prolonged illness, adenopathy, tests for common infectious illnesses negative Immunocompromised patient Further investigation if positive Consider very strongly GABHS (pre-test probability >80%) Consider strongly GABHS (pre-test probability >50%) Consider GABHS (pre-test probability between 30 and 50%) Consider viral rhinosinusitis (pre-test probability < 30%) Consider primary herpes outbreak, herpangina Consider coxsackie virus Consider life threatening infection Consider epiglottitis Consider GABHS Consider infectious mononucleosis Consider gonnococcal pharyngitis Consider laryngoesophageal reflux Consider as cause Consider meningitis Consider Kawasaki disease Consider as rubeola, diphtheria, other preventable infectious causes Consider connective tissue disease, hematologic disease, HIV Consider thrush University of South Alabama, Department of Family Medicine June 30,

159 Young adults (patients over 15 but younger than 45): Key Question Content Acute onset, fever, lack of cough, coryza, GABHS in community, Household contact with GABHS Cough, coryza with or without fever Toxic appearance Drooling, toxic appearance Prolonged course, adenopathy, GABHS testing negative History of oral-genital contact History acid brash History mouth breathing Ill appearance, neck stiffness History of no or improper vaccination History of dyspnea Prolonged illness, +/- adenopathy, tests for infectious illness negative Immunocompromised patient History of neck tenderness at thyroid Prolonged illness, adenopathy, tests for infectious illness negative, particular if history of exposure to tobacco or alcohol Further investigation if positive Consider GABHS (pre-test probability between 30 and 50%) Consider GABHS Consider viral rhinosinusitis (pre-test probability < 30%) Consider life threatening infection Consider epiglottitis or peritonsillar abcess Consider infectious mononucleosis Consider gonnococcal pharyngitis Consider laryngoesophageal reflux Consider as cause Consider meningitis, sepsis, life-threatening soft tissue infection Consider as rubeola, diphtheria, other preventable infectious causes Consider spontaneous pneumothorax Consider connective tissue disease Consider thrush, HIV Consider thyroiditis Consider hematologic illness Older adults (patients over 45): Key Question Content Acute onset, fever, lack of cough, coryza, GABHS in community, Household contact with GABHS Cough, coryza with or without fever Toxic appearance Drooling, toxic appearance History of oral-genital contact History acid brash History mouth breathing Ill appearance, neck stiffness History of no or improper vaccination Further investigation if positive Consider GABHS (pre-test probability between 30 and 50%) Consider GABHS Consider viral rhinosinusitis (pre-test probability < 30%) Consider life threatening infection Consider epiglottitis or peritonsillar abcess Consider gonnococcal pharyngitis Consider laryngoesophageal reflux Consider as cause Consider meningitis, sepsis, life-threatening soft tissue infection Consider as rubeola, diphtheria, other preventable infectious causes University of South Alabama, Department of Family Medicine June 30,

160 History of dyspnea Tenderness at neck Prolonged illness, +/- adenopathy, tests for infectious illness negative Immunocompromised patient History of neck tenderness at thyroid Prolonged illness, adenopathy, tests for infectious illness negative, particular if history of exposure to tobacco or alcohol Exposure to environmental toxins Consider spontaneous pneumothorax Consider carotidynia, Consider connective tissue disease Consider thrush, HIV Consider thyroiditis Consider hematologic illness Consider environmental cause Physical: The physical exam is targeted primarily at confirming an infectious process, identifying lifethreatening causes, and confirming clinical suspicion Vitals - Heart rate, respirations, temperature, weight/height (age below 16), blood pressure General Does the patient appear toxic? How does the patient react to his or her environment? HEENT Sclera and nasal turbinates for coryza, tympanic membranes for fluid, purulence, oropharynx for purulence, lesions, Koplick spots, Neck Check for adenopathy, document presence or absence of rigidity, Heart Note rate and rhythm, presence or absence of murmurs Lungs Auscultate for rales, wheezes Abdomen n/c Extremities n/c Neuro n/c Musculoskeletal n/c Diagnostic studies: General Guidelines 1-7 Patients under 5: The evidence regarding management of febrile infants below the age of 5 who do not have a readily identifiable source of fever has been well established and will not be reviewed here. The likelihood of a child under the age of 3 having GABHS is very small and the clinician should look for sources other than GABHS as the source of the child s fever (SOR - C). Diagnostic studies are dictated by the suspicions generated by the history, the findings on physical exam, and ultimately the clinician s index of suspicion for GABHS or other treatable bacterial or viral illnesses, or the suspicion of a serious bacterial infection requiring urgent evaluation in an urgent care environment. Patients between 5 and 15: The majority of cases of GABHS occur in this age group, although the majority of people in this age group who have symptoms of pharyngitis do not have GABHS. (SOR A) Identifying and appropriately treating those patients with GABHS infections is felt to be important because treatment of GABHS will reduce symptoms by 24 hours when compared to watchful waiting and is believed to prevent rheumatic fever. (SOR - C). Testing algorithms include decision making based on symptoms, use of rapid streptococcal antigen (Positive predictive value 86%, negative predictive value 88%, time to result 10 minutes or less) and/or throat culture (Sensitivity 90%, specificity 99% under ideal conditions for presence or absence of GABHS, time to result hours).the evidence for optimal use of rapid testing, empiric treatment, or determining the absence of clinically University of South Alabama, Department of Family Medicine June 30,

161 significant GABHS based on history and physical alone has not been determined but a compilation of the literature with a proposed approach is found in Figure 1. (SOR - C). Additional ambulatory testing for patients where GABHS is not suspected or who are GABHS negative might include a complete blood count and/or monospot (infectious mononucleosis, hematologic concerns) or chocolate agar culture (gonnococcal pharyngitis) or empiric therapy (laryngoesphageal reflux). If a life threatening infection is suspected, further testing in a hospital setting might include direct visualization (epiglottis, peritonsilar abscess, palatal cellulitis, diptheria), diagnostic imaging (abscess). Patients over 15: A number of diseases and conditions can cause symptoms of pharyngitis. As with younger children and adolescents, identifying and appropriately treating patients with GABHS infections is felt to be important because treatment of GABHS will reduce symptoms by 24 hours when compared to watchful waiting and is believed to prevent rheumatic fever. (SOR - C).?? Because of the lower prevalence, testing algorithms are proposed which include decision making based on symptoms, use of rapid streptococcal and/or throat culture but they are based only on expert opinion. A proposed approach based on existing evidence is found in Figure 2. (SOR - C). Additional ambulatory testing for patients who are GABHS negative might include a complete blood count and/or monospot (infectious mononucleosis, hematologic concerns), chocolate agar culture (gonnococcal pharyngitis), or thyroid function tests (tender thyroid) or empiric therapy (laryngoesphageal reflux).in patients with persistent symptoms, consider immunologic testing for connective tissue diseases. In patients with persistent symptoms and exposure to tobacco and/or alcohol referral for direct visualization might be warranted, particularly of the symptoms are associated with voice changes, weight loss, or other worrisome signs. If a life threatening infection is suspected, further testing in a hospital setting might include direct visualization (epiglottis, peritonsilar abscess, palatal cellulitis, diptheria), diagnostic imaging (abscess). Office Based Management: APPLICABLE TO ALL AGES GABHS pharyngitis Non-pharmacologic (SOR-C) Increased fluid intake is felt to help with symptoms and will help patient to avoid dehydration. Topical anesthetics such as Chlorasceptic spray help patient to tolerate symptoms until infection resolves and assist with maintaining hydration. Ingestion of fluid that is not at room temperature (either warmer or colder) is often easier for the patient. Clean toothbrushes and other personal items after the infection has been treated. Pharmacologic (SOR B) Treatment with IM penicillin is the gold standard for prevention of non-suppurative and suppurative sequelae. Cure rates with oral regimes dosed anywhere from every 12 to every 6 hours have been found to be equivalent. The failure rate is anywhere from 5 15%. Alternative antibiotics for use with those patients who reprt allergies or have treatment failures are found in the appendix. Antipyretics likely aid in symptom relief and should be offered to patients.. University of South Alabama, Department of Family Medicine June 30,

162 Other viral and presumed viral causes Non-pharmacologic (SOR-C) Increased fluid intake and humified air are felt to help with symptoms as have topical anesthetics such as Chlorasceptic spray. Ingestion of fluid that is not at room temperature (either warmer or colder) is often easier for the patient. Pharmacologic (SOR B) Antibiotics are known not to be effective. Decongestants, cough suppressants, and antihistamines are felt to be harmful in children and to have significant side effects with the potential of some symptom relief in adults. Nasal ipatropium was found to help in adults with nasal congestion. Antipyretics likely aid in symptom relief. Allergic rhinitis see allergic rhinitis chapter INFANTS, TODDLERS, YOUNG CHILDREN Herpes gingivostomatitis Non-pharmacologic (SOR C) - Pain associated with swallowing may limit oral intake of infants and children, placing them at risk for dehydration. Intake should be encouraged through the use of cold beverages, ice cream, and yogurt. Pharmacologic (SOR A) - Oral acyclovir (15 mg/kg/dose 5 times a day PO for 7 days, maximum 1 g/day) started within 72 hr of onset reduces the severity and duration of the illness Thrush: Non pharmacologic The condition may resolve spontaneously without treatment. The aprent can be offered the activity of cleansing the bottle nipples or treatment of the breast of the mother which may be effective Pharmacologic (SOR B) Thrush is traditionally treated with nystatin oral suspension. For neonates, the dose is 100,000 U (1.0 ml) given in each cheek pouch every 6 hours after feedings for at least 7 to 10 days; for pediatric patients, the dose is 1 to 2 million U/day divided every 6 hours until resolution. Fluconazole suspension (3 mg per kg orally once daily for seven days) is possibly more effective based on one small study (SOR B). Gentian Violet is also effective OLDER CHILDREN AND ADOLESCENTS Infectious Mononucleosis Non-pharmacologic (SOR C) Good supportive care is the mainstay of therapy including adequate hydration; nonsteroidal anti-inflammatory drugs or acetaminophen for fever and myalgias; and throat lozenges or sprays, or gargling with a 2 percent lidocaine (Xylocaine) solution to relieve pharyngeal discomfort. Enforced bed rest has been found to slow recovery and patients should be advised to increase activities as tolerated. Patients should avoid contact sports until asymptomatic University of South Alabama, Department of Family Medicine June 30,

163 Pharmacologic (SOR B) Acylclovir has been found to offer no clinical benefit. Corticosteroids may offer some benefit to those patients who suffer from significant edema. Antibiotics should be used for GABHS as well as suspected cellulitis from bacterial causes. ADOLESCENTS AND ADULTS Gonnococcal pharyngitis Non-Pharmacologic (SOR C) Many patients are asymptomatic. Positive cultures should be reported and contact tracing initiated through public health mechanisms. Persons with gonococcal pharyngitis should be counseled regarding safe sex and should be offered testing for HIV and syphilis. Pharmacologic (SOR B) Recommended first-line antibiotic is a single dose of ceftriaxone A single dose of spectinomycin may be used (if available) in patients who cannot tolerate cephalosporins. However, it is considered unreliable in pharyngeal infections, and so patient should have a pharyngeal culture 3-5 days after treatment to confirm eradication All patients should also be treated for chlamydial infection if it has not been ruled out Gastroesophageal reflux disease: Non-pharmacologic: Patients should be instructed to avoid large meals and should not lie down immediately after eating (up to 3 hours). They should also be counseled that acidic foods, alcohol, caffeinated beverages, chocolate, onions, and garlic may exacerbate symptoms and should be withdrawn initially, they can be added back as symptoms permit. Reducing dietary fat should improve symptoms as does weight loss. Medications known to cause reflux should be withdrawn if possible. These include calcium channel agonists, alpha-adrenergic agents, theophylline, nitrates and certain sedatives. The head of the bed should be elevated 4 8 inches. Tight clothing should be avoided as should tobacco use. Pharmacologic: After making diagnosis, it is reasonable to start with either an H2 blocker or a proton pump inhibitor. The choice is based on previous effective and ineffective therapy and cost to patient. (see appendix for choices and dosages) If the H2 blocker was used initially but is only partially effective, it may be necessary to switch to a PPI. Once symptoms resolve, reduce dose to the lowest required to maintain patient symptom free. Antacids may be added for additional symptom relief, especially early on or when symptoms flair. University of South Alabama, Department of Family Medicine June 30,

164 Urgent referral to emergency department for evaluation under controlled conditions and possible admission (SOR - B): Suspected sepsis or other significant invasive soft tissue infection requiring IV antibiotics Suspected Kawasaki Disease Moderate to severe dehydration Pneumothorax Referral to specialist (SOR - C): ENT - The American Academy of Otolaryngology Head and Neck Surgery states that children with three or more infections of the tonsils or adenoids per year, despite adequate medical therapy, are candidates for tonsillectomy The following criteria are also used: seven documented tonsil infections in any 1 year, five documented tonsil infections in each of 2 consecutive years, and three documented tonsil infections in each of 3 consecutive years. Tonsil infections are defined by three of the following criteria: fever ( > 101_F), dysphagia, cervical adenopathy, positive GABHS culture, and tonsillar exudates. Additionally, suspected malignancy should be urgently referred Gastroenterology Suspected laryngoesophageal reflux that does not respond to conservative therapy should be referred, especially if the patient has a history of tobacco or significant alcohol use. Rheumatology Suspected connective tissue cause of symptoms Follow-up (SOR - C): Patients with GABHS pharyngitis should be free from contagion within 24 hours of beginning antibiotics and can increase activity as tolerated. They should be symptom free within 4 days and should return for re-evaluation if they are not. Patients with other viral, bacterial or fungal causes should be instructed to return for signs or symptoms of dehydration. They otherwise should be symptom free within 2 weeks. Patients with infectious mononucleosis should be informed that they will continue to have symptoms for several weeks to months. They should return for signs or symptoms of dehydration. They may return to full activity (including contact sports) when free of symptoms. If hepatosplenomegaly was detected, ultrasound imaging and follow-up imaging may be warranted. Patients with gastroesophageal reflux disease should be re-evaluated for reduction of symptoms within 4 weeks and resolution within 8 weeks University of South Alabama, Department of Family Medicine June 30,

165 Resources for patients: Strept throat - Patient Information Handout accessed at Things to know about infectious mononucleosis. - Patient Information Handout accessed at - October 1, 2004 Heartburn: Hints on dealing with the discomfort accessed on Familydoctor.org at Smoking: Steps to Help You Break the Habit accessed on Familydoctor.org at References: 1. Laine Keahey MD Blake Bulloch MD Rose Jacobson RN Milton Tenenbein MD Amin Kabani Diagnostic accuracy of a rapid antigen test for GABHS performed by nurses in a pediatric ED American Journal of Emergency Medicine - Volume 20 (2) 2. Simasek M and, Blandino D, Treatment of the common cold. Am Fam Physician2007;75:515-20, Chapter 249. Herpes simplex in Nelsons Textbook of Pediatrics Jeannette E. South- Paul, Samuel C. Matheny, Evelyn L. Lewis eds Accessible by subscription at 4. Hayes C and Williamson H management of Group A Beta-Hemolytic Streptococcal Pharyngitis Am Fam Physician 2001;63: , Perkins A. An approach to diagnosing the acute sore throat. Am Fam Physician 1997;55:131-8, Ebell M. Epstein Barr Virus Infectious Mononucleosis Am Fam Physician 2004;70: , C.M. Discolo et al. Management of pediatric pharyngitis Pediatr Clin N Am 50 (2003) Bisno A et al Practice guidelines for the diagnosis and management of GABHS Clin Inf Dis 35 (2) Accessible by subscription at University of South Alabama, Department of Family Medicine June 30,

166 Appendix University of South Alabama, Department of Family Medicine June 30,

167 Approach to pharyngitis symptoms (Ages 5-15) History and physical suggest GABHS is likely Signs and symptoms suggestive of GABHS 1. Lack of cough 2. History of fever 3. Tonsillar exudates 4. Swollen, tender anterior lymph nodes None or one present Symptomatic treatment, consider other causes, rapid antigen test or culture if clinical uncertainty exists Two or three present Rapid antigen test, treat if positive, if negative consider other causes, culture if clinical uncertainty exists or rheumatic fever strain prevalent All four present Rapid antigen test, treat if positive if negative consider culture and empiric treatment while awaiting result. Can offer empiric treatment without testing if disease highly prevalent or rheumatic fever strain prevalent Household contact with GABHS or patient with scarletinaform rash Empiric treatment with antibiotics For persistent symptoms in face of fatigue if CBC shows 50% lymphocytes and heterophile antibody is +, consider Mono (see following page) Supportive care University of South Alabama, Department of Family Medicine June 30,

168 University of South Alabama, Department of Family Medicine June 30,