Practice Management Book

http://www.fpnotebook.com/

Family Practice Notebook Updates 2015

Aka: Family Practice Notebook Updates 2015, FPN Updates 2015
  1. See Also
    1. Family Practice Notebook Updates
    2. Family Practice Notebook Updates 2014
    3. Family Practice Notebook Updates 2013
  2. Updates: December 2015
    1. Website Updates are now available as an RSS Feed (Website: New functionality)
      1. Thanks to Dr. John Faughnan for the idea of making FPN Updates an RSS feed
        1. RSS Feed: http://www.fpnotebook.com/updates.xml
        2. Json Feed: http://www.fpnotebook.com/updates.json
    2. Insomnia Management (psych, sleep)
      1. Cognitive Behavioral Therapy for Insomnia is more effective than sedatives with longterm effects
      2. CBT-I training was among the best CME experiences I have had in 20 years post-medical school
      3. Updated Insomnia, Organic Insomnia, various CBT-I techniques, Relaxation Techniques
    3. Solitary Lung Nodules (lung)
      1. With growing use of CT Scans ("doughnut of truth"), more incidental Lung Nodules are found
        1. "Sir, you have no Pulmonary Embolism, but you have a 6 mm Lung Nodule that needs follow-up"
      2. Lung Nodule follow-up imaging and evaluation is based on risk factors, Nodule size and Nodule appearance
      3. Lung Cancer Screening CT Chest for ages 55-77 with 30 py and last smoked within 15 years (USPTF, medicare)
    4. Sickle Cell Disease (hemeonc, Hemoglobin)
      1. Prevent pneumococcus with Pneumococcal Vaccine as well as Penicillin until age 5 years
      2. Transcranial doppler Ultrasound for ages 2-16 years old for CVA risk
      3. Screen for Proteinuria and ischemic retinopathy after age 10 years old
      4. Treat Sickle Cell Crisis pain promptly and aggressively
      5. Consider Hydroxyurea for all SCA children over age 9 months old and adults with severe disease
    5. Polycythemia Vera (hemeonc, marrow)
      1. Nearly 40% of patients present with thrombosis at the time of diagnosis
      2. Aquagenic Pruritus (prolonged itching after warm water exposure) is present in 62% of patients
      3. Erythromelalgia (distal extremity congestion, redness, burning with normal pulses) is present in 29% of cases
      4. JAK2 - V617F gene mutation is associated with 96% of primary polycthemia vera cases
      5. Low risk cases are treated with Aspirin and phlebotomy, while high risk cases are treated with Hydroxyurea and interferon
      6. JAK2 Inhibitors are considered in severe, refractory or high risk cases
    6. Cervical Cancer Screening in average risk women
      1. New guidelines from ACP for average risk women
      2. For age <21, do not do Cervical Cancer Screening
      3. For age 21-30, Pap Smear every 3 years and do not perform HPV testing
      4. For age 30-65 years, Pap Smear (with at least one HPV test) every 3 years OR pap and hpv test every 5 years
      5. For age >65 years, stop screening after 3 negative Pap Smears, or 2 negative Pap+HPV with one in last 5 years
    7. Emergency Psychiatric Evaluation of children (psych, peds)
      1. Maintaining child safety is primary
      2. Parental Consent is not required for emergency pediatric psychiatric evaluation and management
      3. Avoid intramuscular Olanzapine with Benzodiazepines in children due to risk of Hypotension and Bradycardia
    8. Urine Drug Screen (psych, cd)
      1. Urine toxicology utility has been markedly reduced by the growing use of synthetics (Synthetic Cannabinoids, Psychoactive Bath Salts)
      2. Urine toxicology misses many standard substances
        1. Does not detect the most frequently used Benzodiazepines (Alprazolam, Clonazepam, Lorazepam)
        2. Variable detection of MDMA (Ecstasy)
        3. Does not detect semi-synthetic and synthetic Opioids
    9. Pediatric Cervical Spine Injury (peds, ortho, spine)
      1. Spine evaluation in preverbal children under age 2 years old is very challenging
      2. Cases in which c-spine may be cleared in age <2-5 years without imaging (all criteria must be present):
        1. No serious injury (especially multisystem Trauma, intubation)
        2. No signs of significant brain injury or coma (GCS <14 or GCS-eye:1)
        3. No motor or sensory neurologic findings
        4. No neck symptoms (no pain or Torticollis and freely moves neck)
    10. Occult Bacteremia in Children age under 36 months (id, peds)
      1. Urinalysis may be only test needed in well appearing, non-toxic febrile child aged 3-12 months
      2. Full septic evaluation is needed age <28 days or Fever Without Focus Red Flags
      3. Multiple decision rules assist evaluation of Fever Without Focus in non-toxic children ages 29-90 days
      4. Occult Bacteremia is uncommon in a well appearing, immunized, previously healthy child ages 3-36 months
    11. Allergic Rhinitis (ent, allergy)
      1. Impermeable covers for pillows and mattresses are unlikely to benefit
        1. Other bedroom related Allergen Controls may help (but limited evidence)
      2. Intranasal Steroids are first-line management and more effective than Antihistamines
        1. Although onset of effect within hours of use, maximal effect is reached only after 2-4 weeks
        2. Despite stratifying Intranasal Steroids by potency, no evidence for one agent's efficacy over another
      3. Immunotherapy is now available in sublingual form
        1. Unfortunately, only for some grasses and short ragweed, and at >$250 per month
      4. Corrected Intranasal Corticosteroid pregnancy category (Budesonide is Category B, not Beclomethasone)
        1. Thanks to Benjamin Ho for the correction
    12. Acute Abdominal Pain (gi, surgery)
      1. Reviewed approach to history, exam and labs in Acute Abdominal Pain
      2. Caution in elderly and immunocompromised (underwhelming presentations of acute abdominal catastrophe)
        1. Normal White Blood Cell Count and lack of fever do not exclude serious conditions
      3. Treat acute pain (typically with Opioids) appropriately while performing evaluation
      4. Consider Lactic Acid as a marker of Mesenteric Ischemia
      5. Abdominal Bedside Ultrasound can focus testing (Nephrolithiasis, Cholecystitis, AAA, Pelvic Pain)
      6. Aside from pregnancy and pediatrics, Abdominal CT is the workhorse of undifferentiated Abdominal Pain
      7. Plain film xray has low utility (although will demonstrate free air)
      8. Re-evaluate in 6-12 hours persistent Abdominal Pain with non-diagnostic evaluation and unclear cause
    13. Newborn Respiratory Distress (nicu, lung)
      1. General update
      2. Noninvasive Positive Pressure Ventilation (e.g. N-CPAP) is preferred over Endotracheal Intubation (non-RDS)
      3. Avoid hyperoxygenation (increased mortality with FIO2 100%)
        1. Supplemental Oxygen FIO2 21-50% to keep Oxygen Saturation >90%
    14. Central Line Placement pearl (er, procedure)
      1. For introducer, use Angiocatheter 18g - long as an alternative to steel needle
      2. May be easier to maintain catheter within vessel lumen while threading guide wire
    15. Ischemic Stroke (neuro, cv)
      1. Of those given Thrombolytics for CVA, 15% are stroke mimics and have at least a 1% risk of serious bleeding
    16. Pulmonary Embolism (lung, cv)
      1. Troponin Increase in PE raises mortality risk from 1.4% to 16.4%
      2. Non-massive PE patients may be candidates for outpatient management (negative Hestia Score, PESI<66-86)
    17. Direct Thrombin Inhibitors and Factor Xa Inhibitors (hemeonc, coags)
      1. Monoclonal Antibody reversal agents are on their way for Dabigatran (Pradaxa): Idarucizumab (Praxbind)
      2. Rivaroxaban (Xarelto) reversal agents are expected in the next year as well
    18. Nephrolithiasis (urology)
      1. Medical expulsive therapy (e.g. Flomax) does not appear to benefit, except possibly in >5mm distal ureteral stones
    19. HEART Score (cv, cad)
      1. May be the preferred acute Chest Pain risk stratification scoring system
    20. Metformin (endo, pharm)
      1. Pearls on decreased GI side effects with Metformin (start 500 mg and titrate slowly, with meals, use XR)
    21. Medication Use in the Elderly, Beers List, STOPP (geri, pharm)
      1. Limit PPIs to <8 weeks
      2. Avoid Nonbenzodiazepine Hypnotic Agents
      3. Nitrofurantoin may be used if CrCl > 30-40 ml/min (previously >60 ml/min)
    22. Chronic Narcotic Guideline in non-Cancer Pain (rheum, pain, pharm)
      1. Taper dose when functional status or pain severity does not improve 30% over baseline, or with last dose increase
    23. More expensive medications with weak indications (pharm)
      1. Durlaza (XR Aspirin) for coronary disease prevention
      2. Spiriva Respimat for Asthma
    24. Erythromelalgia (derm)
      1. Recently had a case of an elderly man with bilateral distal extremity duskiness with intact distal pulses
      2. Differential diagnosis includes PAD, PCV, Raynauds, Frostbite, Calcium Channel Blockers, SLE, RA
    25. Panniculitis (derm, rheum)
      1. Subcutaneous, often tender indurated or nodular lesions typically on the lower legs
      2. Erythema Nodosum and many other conditions categorized by their histology
    26. SGLT2 Inhibitor (endo, dm)
      1. Add possible Fractures (primarily Invokana) to other potential adverse effects (e.g. UTI)
      2. Is it worth the high cost and adverse effects for a 0.5 to 1% Hemoglobin A1C drop
    27. Herbal Toxicity and lethal plants (pharm, alternative)
      1. Examples: Nightshade, hemlock, mistletoe, oleander, daphne, jasmine, yew, red sage
    28. Zoster Sine Herpete (id, virus)
      1. Thanks to Dr. Joseph Abraham for pointing out that Zoster can occur without rash (added to Herpes Zoster)
    29. Nail Abnormality (derm)
      1. Re-reviewed Nail Abnormalities (nail color changes, Onychomadesis, Green Nail Syndrome...)
    30. Leukocytosis (hemeonc, lab)
      1. Updated Leukocytosis, Neutrophilia, Lymphocytosis...
    31. Knee Pain (ortho, knee)
      1. Knee Osteoarthritis Management
      2. Patellofemoral Syndrome
    32. Decubitus Ulcer (surgery, derm, wound)
      1. Updated including specific dressing recommendations
    33. Obsessive Compulsive Disorder (psych, anxiety)
      1. Updated
    34. Pediatric Limp (ortho, peds)
      1. Extensive updates
    35. Renal Cell Carcinoma (hemeonc, renal)
      1. Added
    36. Eustachian Tube Dysfunction (ent, ear)
      1. Such a common diagnosis, and I realized I did not have an entry
    37. Congestive Heart Failure (cv)
      1. CHF pathophysiology in Systolic Dysfunction, Diastolic Dysfunction and Myocardial Infarction
      2. BNP interpretation in Obesity (BNP is half of non-obese patients, even in CHF)
      3. AHA Heart Failure Stages
    38. Alcohol Withdrawal (psych, cd)
      1. Brief update on Librium as preferred Benzodiazepine in Alcohol Withdrawal
      2. GabapentinMechanism and dosing reviewed (as an alternative or as Benzodiazepine-sparing agent)
    39. Images Problem (Website: Bug)
      1. Google images discontinued a prior image search api that fpnotebook was using
      2. Image search is currently being re-worked building up an image database
      3. Expected resolution by March 2015
    40. Printing Problem (Website: Bug)
      1. The site is now printable (previously print-outs were unreadable with link URLs embedded in the text)
  3. Updates: November 2015
    1. Prostate Cancer Screening
      1. Updated with yet more data on why not to order PSA
    2. Joint Injection (intraarticular Corticosteroid)
      1. Updated efficacy
    3. Pediatric Reflux
      1. General updates including pediatric dosing of Proton Pump Inhibitors and H2 Blockers
    4. Dysuria
      1. Extensive updates on evaluation
    5. Supraventricular Tachycardia
      1. Extensive updates
    6. Cognitive Behavioral Therapy
      1. Added new entry
    7. Assorted emergency updates
      1. ACEP guidelines in support of Procedural Sedation without Fasting
      2. Vasopressor precautions
      3. Oral foreign body
      4. Nasal Foreign Body
      5. Bleeding after Tonsillectomy
    8. Pediatric Throat Injury
      1. Added approach to penetrating oral Trauma in Children
    9. Bell's Palsy
      1. General updates, especially regarding expected course and risk of recurrence
    10. Liver Disease
      1. Extensive updates on Acute Hepatitis (including in pregnancy, Viral Hepatitis)
      2. Extensive updates on Cirrhosis (including Cirrhotic Ascites, SBP, Hepatic Encephalopathy)
    11. Intrathecal Pump
      1. Added pump indications, Mechanism, complications and their management and precautions
    12. Carotid Dissection in Blunt Neck Trauma
      1. Updated regarding children's increased risk
    13. Alcohol Withdrawal
      1. Updated protocols
    14. Hyponatremia
      1. Updated common causes, SIADH, Hyponatremia Management
    15. Post-Cardiac Arrest Care (ROSC)
      1. Early Coronary Angiography (PCI) in which Acute Coronary Syndrome is considered most likely
    16. Sternoclavicular Dislocation
      1. Updated on posterior dislocation
    17. Kinesiology Tape
      1. No evidence of efficacy but probably not harmful
    18. Dementia Management
      1. Prevagen is without significant evidence
    19. Peripheral Neuropathy
      1. Management reviewed with efficacy
    20. Prescription Drug Abuse
      1. Prescription Drug Monitoring Program reviewed
    21. Cardiac Risk Management
      1. Aspirin indications have narrowed for primary prevention to 10% Framingham risk 50-70 yo
    22. Chronic Sinusitis
      1. Updated
    23. Jardiance (SGLT Inhibitor)
      1. Modestly effective, but very expensive Oral Hypoglycemic with marginal cardiovascular benefit
    24. Insulin
      1. NPH Insulin and Regular Insulin are 10% of cost of newer Insulin analogues and with similar outcomes
    25. Clozapine
      1. Clozapine REMS Program added, with ANC requirement
    26. Tramadol
      1. As with Codeine, Children who are ultrarapid CYP2D6 metabolizers run the risk of respiratory depression
      2. Avoid Tramadol use in children
  4. Updates: October 2015
    1. Autonomic Dysreflexia
      1. Added
    2. Excited Delirium
      1. Added
    3. Ring Removal
      1. Added
    4. PSVT
      1. Valsalva is more effective if modified to include postural change
    5. Pneumonia in the Nursing Home
      1. Updated Pneumonia in the Nursing Home, Infections in Older Adults, Infection in the Nursing Home Resident
      2. Added SOAR Pneumonia Score
    6. Common Benign Skin Growths
      1. Updated various benign skin lesions
    7. Genetics
      1. Updated Genetics and Pharmacogenetics
    8. Syncope
      1. When is testing indicated
    9. Emergency Department Migraine Headache Care
      1. Efficacy of Magnesium
    10. Penicillin Allergy
      1. Approach, cross-reactivity
    11. Hyperkalemia
      1. Hyperkalemia from Trimethoprim-sulfamethoxazole with ACE/ARB in older than 60 years old
      2. Hyperkalemia Management with Dextrose and Insulin (Indications for more Dextrose)
    12. Rapid Sequence Intubation
      1. Atropine in RSI (not needed)
    13. Bronchiolitis
      1. Bronchiolitis discharge indications
    14. Catheter Associated Urinary Tract Infections
      1. Updates including Purple Urine Bag Syndrome (PUBS)
    15. Lumbar Disc Disease (and Lumbar Radiculopathy)
      1. Systemic Corticosteroids may be effective
    16. Pediatric Cervical Spine Injury
      1. Who needs imaging
    17. Acute Pulmonary Edema Management
      1. Nitrates appear safe in severe Aortic Stenosis (although small study)
    18. Mechanical Ventilation
      1. General updates
    19. Infantile Colic
      1. General updates
    20. Implantable cardiac devices
      1. Updated cardiac Pacemaker, Automatic Internal Cardiac Defibrillator, Left Ventricular Assist Device (LVAD)
    21. Intentional Drug Overdose
      1. Updated Calcium Channel Blocker Overdose
      2. Updated Beta Blocker Overdose
      3. Added information on BupropionOverdose
      4. Added Intravenous Lipid Emulsion
    22. Intravenous Fluids
      1. Updated isotonic saline
    23. Scabies
      1. General updates
    24. Conjunctivitis
      1. General updates on precautions
    25. Anticoagulation
      1. Updates on follow-up visit precautions
    26. Testosterone Replacement
      1. Cardiovascular risks and is Testosterone indicated
    27. Surgical Antibiotic Prophylaxis
      1. Antibiotics for dental procedures not needed after most joint replacements
    28. Serotype B Meningococcal Vaccine
      1. Updates including indications
    29. Substance Misuse
      1. Updates with surprising abuse of seemingly benign medications
    30. Gliptins
      1. Severe Joint Pain risk added
    31. Female Sexual Dysfunction
      1. Added Addyi (Flibanserin), but wonder about its high cost for low efficacy and Hypotension
  5. Updates: September 2015
    1. Osteoporosis
      1. Updated Osteoporosis, Osteoporosis Secondary Causes and Medication Causes of Osteoporosis
      2. Updated Osteoporosis Evaluation and Osteoporosis Management
    2. Childhood behavioral problems
      1. Sleep Problems in Children
      2. Thumb-Sucking
    3. Female Sexual Dysfunction
      1. General updates
    4. Foodborne Illness
      1. General updates
    5. Important primary care journal articles of 2014
      1. Updates based on American Family Physician review
    6. Sports Physical
      1. General updates
    7. Tibial Nerve Block
      1. Updated technique
    8. Angioedema
      1. Updated management
    9. Anaphylaxis
      1. Updated including the "Dirty Epinephrine Drip"
    10. Salter Harris Fracture
      1. Updated
    11. Electronic Prescription
      1. Updated precautions
    12. Miscellaneous medication updates
      1. Updated various dosing precautions
    13. Chest Tube
      1. Updated cell salvage device (autologous transfusion)
    14. Atrial Fibrillation Rate Control
      1. Diltiazem may be more rapid acting and effective with less Hypotension risk than Metoprolol
    15. Fluoroquinolones
      1. Updated adverse effects (esp. Tendinopathy)
    16. Obesity and Emergency Stabilization
      1. Added a new entry for pitfalls and pearls in the stabilization of the obese patient
    17. Myasthenia Gravis
      1. Updated contraindicated medications
    18. Perirectal Abscess
      1. Miscellaneous updates including perianal abscess Incision and Drainage pearls
    19. Emergency Department Patient Satisfaction
      1. Added patient expectations regarding empathic providers
    20. Pulmonary Embolism
      1. General updates in diagnosis and management
    21. Undifferentiated Shock
      1. Updated crystalloid, isotonic crystalloid and an overall approach to fluid management
    22. Sacubitril and Valsartan (Entresto)
      1. Indicated in Systolic Dysfunction
      2. Sacubitril (neprilysin inhibitor) increases vasodilation and Sodium excretion
      3. Risk of Hypotension (NNH 21) and Angioedema (NNH 200)
    23. Influenza Vaccine
      1. Updates on 2015 Influenza Vaccine and Live Attenuated Influenza Vaccine (Flumist)
    24. NSAIDS
      1. More warnings about cardiovascular risk
    25. Pharmacogenetics
      1. General updates
    26. Psychosis
      1. New long-acting Antipsychotic injectables
    27. Antibiotic Stewardship
      1. Added
    28. Proton Pump Inhibitors
      1. Cardiovascular risk added
    29. Auralgan or Aurodex
      1. No longer allowed in U.S. per FDA
    30. Prevention of Ischemic Stroke
      1. Updated antiplatelet agents
    31. Head Lice
      1. Updated management
    32. Skin and Soft Tissue Infection
      1. Updated Cellulitis, Skin Infection and Necrotizing Fasciitis
    33. Immunizations
      1. General update
    34. Serum Potassium Disorders
      1. Updated Hypokalemia and Hyperkalemia
  6. Updates: August 2015
    1. Eyelid Swelling
      1. Added a new differential for Eyelid Edema and updated several related eye conditions (e.g. stye)
    2. Antidepressants
      1. Updated
    3. Rosacea
      1. General updates on management
    4. Common Pediatric Skin Rashes
      1. Updated Roseola, Pityriasis Rosea, Scarlet Fever, Impetigo, Erythema Infectiosum
      2. Also updated Molluscum Contagiosum, Tinea Infections and Atopic Dermatitis
    5. Reversible Causes of Cardiopulmonary Arrest
      1. Updated with empiric interventions
    6. Cervical Spine Injury
      1. Updated evaluation
    7. Vertebral Compression Fracture
      1. Updated management
    8. Aortic Dissection
      1. Updated evaluation and management
    9. Spontaneous Vaginal Delivery
      1. General updates
    10. Pediatric Abdominal Pain
      1. General updates, especially regarding imaging
    11. Procedural Sedation
      1. General Updates and Added ASA Physical Status Score
    12. Sepsis
      1. Added decision pathway
    13. Post-Cardiac Arrest Care (ROSC)
      1. Updated general stabilization points
    14. Subarachnoid Hemorrhage
      1. Excluded with negative Head CT AND LP with no Xanthochromia and <2000 Red Blood Cells
    15. Pyoderma Gangrenosum
      1. Added a review of Pyoderma Gangrenosum and Pathergy
      2. Expanded on Skin Ulcer differential diagnosis
    16. Bridging protocol
      1. Recommended for only patients at high risk of thrombosis (as of 2015, BRIDGE Trial)
      2. Bridging does not appear to reduce thrombosis risk
      3. Bridging is associated with major bleeding complication in 2% of patients
    17. Expedited Partner Treatment
      1. Updated
    18. COPD Management
      1. Yet another combination agent: Stiolto Respimat (Tiotropium/olodaterol)
    19. Nephrolithiasis
      1. Another study demonstrates Tamsulosin and Nifedipine are ineffective in medical expulsive therapy
    20. Insulin
      1. Another Humalog preparation
    21. Drug-induced Photosensitivity
      1. Updated prevention and symptomatic management
    22. Metabolic Syndrome
      1. Updated efficacy on prevention of Diabetes Mellitus progression
    23. Opioid Abuse
      1. Updated Suboxone
    24. Phosphate Binders
      1. Added new entry on available preparations
    25. FDA Pregnancy Category
      1. Prescription bottle labeling changes
    26. PCSK9 Inhibitor
      1. Yet another very, very expensive Monoclonal Antibody - this time for LDL Cholesterol lowering
  7. Updates: July 2015
    1. Psychosis
      1. Extensive updates to history, exam, differential diagnosis
    2. Preventive Health Care of Men Who Have Sex With Men
      1. New addition on preventive care
    3. Polyarticular Arthritis
      1. Extensive updates on Joint Pain and Polyarticular Arthritis
    4. Hepatitis C
      1. Extensive updates
    5. Type II Diabetes Mellitus
      1. Updated Oral Hypoglycemics
    6. Pericarditis
      1. General updates
    7. Human Trafficking
      1. Added Human Trafficking (e.g. Forced Labor, Sexual Slavery, Organ Trafficking)
    8. Growth Evaluation
      1. Updated Short Stature, Tall Stature and added Growth Hormone Deficiency
    9. Enclosed Vehicle Excessive Heat
      1. Added Enclosed Vehicle Excessive Heat
      2. Never leave children unattended in a vehicle (28-43 U.S. deaths per year due to Heat Stroke)
    10. Hyperlipidemia Management
      1. Non-Statin lipid lowering agents have little to no evidence of reducing cardiovascular events
    11. Atypical Antipsychotics
      1. Exercise caution when using Atypical Antipsychotics (e.g. Abilify) outside their standard indications
      2. Although used in severe refractory Major Depression, they should not be used as first-line agents
    12. Child Abuse
      1. Updates
    13. Cervical Spine Injury
      1. CT Cervical Spine (high grade with <3 mm slices) may be sufficient in clearing c-spine in obtunded patients
    14. Euglycemic ketoacidosis
      1. Flozins (e.g. Invokana) increase risk, especially with renal Impairment
    15. Nonmelanoma Skin Cancer
      1. Niacinamide 500 mg twice daily may help prevent recurrence
    16. Probiotics
      1. Update on indications and use
    17. Intrauterine Device
      1. Liletta, another Levonorgestrel IUD, is released
    18. Parkinson's Disease
      1. Another Carbidopa/Levodopa agent (Rytary)
    19. Fentanyl Patch
      1. Release of Fentanyl intermediate patches as 4 times the cost
    20. Tetanus
      1. Added new topic
    21. Pacemaker
      1. Expounded on Twiddler's Syndrome
    22. Infective Endocarditis
      1. Extensive updates
  8. Updates: June 2015
    1. Neck Masses in Adults
      1. Added Causes of Neck Mass in Adults and their evaluation
    2. Gastroesophageal Reflux Disease
      1. Assorted updates on GERD, Barrett Esophagus, Proton Pump Inhibitors
      2. Added GerdQ Questionnaire
    3. Low Back Pain
      1. Updated evidence based management options
    4. Electrolytes and acid base
      1. Extensive physiology updates (Sodium and Water Homeostasis, Potassium Homeostasis, acid-base )
    5. Sudden Infant Death Syndrome (SIDS)
      1. General updates
    6. Massive Transfusion protocol
      1. Updated based on PROPR trial outcomes (1:1:1 ratio of platelets, plasma, Red Blood Cells) has best outcomes
    7. Croup
      1. Updated severe croup protocol
    8. Atypical Moles
      1. General updates
    9. Hypertension General Measures
      1. Updates including DASH Diet
    10. Breast Cancer Monitoring
      1. Acute, emergent complications of Breast Cancer and its management
      2. Updates include Tumor Lysis Syndrome, Lymphedema differential diagnosis, Pericardial Effusion and Cardiac Tamponade
    11. Traumatic Cardiopulmonary Arrest
      1. New topic added
    12. Subdural Hematoma
      1. Over age 65 years old, are unlikely to need surgical intervention if <=1 mm midline shift, <= 10 mm width
    13. Eye Trauma
      1. Expanded on Intraocular Foreign Body management
    14. Congestive Heart Failure
      1. Accelerated Diagnostic Protocol added
    15. Skeletal Survey
      1. Added indications, protocol
    16. Variant Angina
      1. Added general approach
    17. Hypertension Management for Specific Comorbid Diseases
      1. Updated management of Hypertension in Coronary Artery Disease
    18. Drug Assistance Programs
      1. Added
    19. Bowel Regimen in Chronic Narcotic Use
      1. Updated bowel regimen
    20. Miscellaneous Updates
      1. Drug Interaction - Amiodarone with sofosbuvir (Protease Inhibitor for Hep C treatment)
      2. Powdered Alcohol
      3. Beta-lactams alone for community acquired Pneumonia
      4. Proair RespiClick
  9. Updates: May 2015
    1. Anxiety Disorder
      1. Generalized Anxiety Disorder and Panic Disorder updated
    2. Advanced Airway in Children
      1. Bag-valve-mask is preferred pre-hospital
    3. Ketamine
      1. Updated with dose related effects
    4. Geriatric emergency care
      1. See Preventing Adverse Events in Hospitalized Elderly
      2. Added disposition algorithm
    5. Contraception
      1. Extensive updates
    6. Pediatric dental update
      1. Tooth Avulsion, Tooth Luxation, Tooth Fracture and Tooth Pain updated
    7. Temporal Arteritis
      1. Assorted Updates
    8. Inflight Emergencies
      1. Updated Flight Medicine
    9. Blast Injury
      1. Added emergency approach to Blast Injury
    10. Acute Coronary Syndrome
      1. Updated Moderate Risk Acute Coronary Syndrome Management (NSTEMI) based on 2014 guidelines
    11. Pulmonary Embolism Diagnosis
      1. Updated the Accelerated Diagnostic Protocol and D-Dimer cutoffs
    12. FAST Exam
      1. Test Sensitivity may be as low as 22% for abdominal free fluid in blunt Trauma
    13. Cerebrovascular Accident Management
      1. Intraarterial procedures may be effective with improved function in severe CVA (NIHSS >16) within 6 hours
    14. Bioterrorism and Chemical Toxins
      1. Extensive updates to Biological Weapon, Chemical Weapon
    15. Coronary Artery Bypass Graft
      1. Perioperative and postoperative medications to reduce readmissions
    16. Iodine
      1. Added dietary recommendations in light of new Iodine in pregnancy recommendations
    17. Obesity
      1. Updated Obesity Medications
    18. Cardiac Risk Factor reduction
      1. Clarified Statin indications
      2. Corrected Folic Acid as disproven
    19. COPD Management
      1. Added Dailresp to drug information
    20. Nephrolithiasis
      1. Updated calcium oxalate Nephrolithiasis prevention
    21. Decubitus Ulcers
      1. Updated management and prevention
    22. Irritable Bowel Syndrome
      1. Updated management
    23. Shift Work Disorder (Night Shift WorkerTiredness)
      1. Added management strategies
  10. Updates: April 2015
    1. Fibromyalgia
      1. General updates
    2. Acute Abdominal Pain
      1. Updates related to acute Abdominal Pain Evaluation with imaging
    3. Tetralogy of Fallot Exacerbation (Tet Spell)
      1. Updated management
    4. Cellulitis
      1. Antibiotics updated
    5. Procedural Sedation
      1. Added support for End-Tidal CO2
    6. Emergency Medical Service
      1. Added Emergency Medical Service and Emergency Medicine Treatment and Labor Act (EMTALA)
    7. Atrial Fibrillation
      1. Added precautions regarding the complex patient in A fib RVR
    8. Email
      1. Added management pearls
    9. Dangerous Behavior
      1. Updated disposition
    10. Serotonin Syndrome
      1. Updated Opioid causes
    11. Gestational Diabetes
      1. Extensive updates
    12. Angioedema
      1. Hereditary Angioedema agents (e.g. Icatibant, Berinert) appear effective in ACE InhibitorAngioedema
    13. Hyperlipidemia in Diabetes Mellitus
      1. Choose either high dose or moderate dose Statins (or no Statin) based on cardiovascular risk
    14. Medications Associated with Weight Gain
      1. Updated the list
    15. Angioedema
      1. Icatibant and Berinert are intended for hereditary Angioedema
      2. However, these agents are used off label for ACE InhibitorAngioedema (and now there is better evidence)
    16. Asymptomatic Bacteriuria
      1. Updated with more caution regarding those who should not be treated
    17. Acute Pain Control
      1. Updated with precautions regarding stepped Oral Analgesics and Opioid extended use
    18. HPV Vaccine (Gardasil)
      1. Gardasil-9 is the new and improved version with more antigens (and more local reactions)
    19. Hemodialysis and Anemia
      1. Ferric pyrophosphate (Triferic) is released in 2015 for maintenance iron replacement during Hemodialysis
    20. Premature Rupture of Membranes
      1. Added the AmniSure ROM Test (PAMG-1 Protein Marker Test)
    21. Medication updates (miscellaneous)
      1. Levothyroxine (less restrictions)
      2. Chantix (more warnings)
      3. Toujeo (Lantus patent extender)
    22. Toxic Shock Syndrome
      1. Added new topic
    23. Unintended Pregnancy
      1. Added as new topic
    24. Cerebrovascular Accident
      1. Extensive updates
    25. Abdominal Aortic Aneurysm
      1. Updated with new guidelines
    26. Major Update to Neurology
      1. Extensive updates to Neurology anatomy, physiology and pathophysiology
      2. Started NeuroExplorer web application to explore Neurologic Anatomy and pathways
    27. Major Update of Resources/Books and Links
      1. Cardiology Books, Cardiology Links and EKG Resources
      2. Dentistry Books and Dentistry Links
      3. Dermatology Links and Dermatology Books
      4. Endocrinology Books, Endocrinology Links, Diabetes Mellitus Resources and Obesity Resources
      5. Otolaryngology Links and Otolaryngology Books
      6. Emergency Medicine Resources and Emergency Medicine Links
      7. Ophthalmology Books and Ophthalmology Links
      8. Geriatric Links and Geriatric Books
      9. Gastroenterology Links and Gastroenterology Books
      10. Gynecology Links and Gynecology Books
      11. Hematology and Oncology Books and Hematology and Oncology Links
      12. HIV and AIDS Links and HIV and AIDS Books
      13. Infectious Disease Books and Infectious Disease Links
      14. Laboratory and Pathology Links and Laboratory and Pathology Books
      15. General Medical Links and General Medical Books
      16. Pulmonology Resources, Pulmonology Links and Asthma Resources
      17. Neurology Resources and Neurology Links, Headache Resources, Dementia Resources and Epilepsy Resources
      18. Neonatology Links and Neonatology Books
      19. Obstetrics Patient Education, Obstetrics Books and Obstetrics Links
      20. Orthopedic Links, Orthopedic Books and Orthopedic Patient Education
      21. Pediatric Links and Pediatric Books
      22. Pharmacology Links and Pharmacology Books
      23. Preventive Medicine Links
      24. Mental Health Links, Mental Health Books and Chemical Dependency Resources
      25. Radiology Resources, Radiology Links and Ultrasound Resources
      26. Nephrology Links
      27. Rheumatology Links and Rheumatology Books
      28. Sports Medicine Links and Sports Medicine Books
      29. Surgery Links
      30. Urology Links
  11. Updates: March 2015
    1. Hemoptysis
      1. Extensive updates on the evaluation
    2. Lung Cancer
      1. Extensive updates
    3. Peptic Ulcer Disease
      1. Updates on Peptic Ulcer Disease, Dyspepsia, and Helicobacter Pylori
    4. Pediatric Head Trauma Algorithm
      1. Decision rules related to isolated non-frontal scalp hematoma
    5. Chronic Shoulder Dislocations
      1. Chronic Shoulder Dislocations present for >3-4 weeks are a risk for axillary artery rupture
      2. Relocation should be by orthopedics (typically in the OR)
    6. Knee Dislocation
      1. Obese patients are at risk even with low velocity injuries
    7. Acute Pancreatitis
      1. Lactated Ringers is preferred over Normal Saline
    8. Hyponatremia and Hypernatremia
      1. Extensive updates
    9. Antiemetics
      1. Updates to agents, dosing and selection
    10. Smoke Inhalation
      1. Cyanide Poisoning is common in Smoke Inhalation and cyanokit is a safe empiric therapy in severe cases
    11. Infertility
      1. Extensive updates
    12. Emergency Decision Cycle
      1. Added the Emergency Decision Cycle, as well as the OODA Loop and AAADA Model
    13. Trauma
      1. Updated Pelvic Fracture management and Hemorrhage Management
    14. High Flow Nasal Cannula
      1. Updated
    15. Neck Vascular Injury in Blunt Force Trauma
      1. Added criteria for CT Neck Angiogram
    16. Hand Injuries
      1. General update
    17. Low Risk Chest Pain
      1. Cardiac Risk Factors do not help to exclude acute coronary event
      2. Then, why do we use Chest Pain Decision Rules that include Cardiac Risk Factors
    18. Undifferentiated Shock
      1. Extensive update
    19. Kawasaki Disease
      1. General Update
    20. Infectious Mononucleosis
      1. General Update
    21. Pediatric Vaccination
      1. Vaccine Safety and refusal updated
    22. Inhaled Insulin
      1. Is Afrezza another Exubera?
    23. Analgesics in Pregnancy
      1. Updated
    24. Intranasal Corticosteroids
      1. Flonase and Nasocort are OTC
    25. Dermatologic conditions
      1. Rosacea and Psoriasis treatments updated
    26. Binge Eating
      1. Updated with additional medication management
    27. Hospital Transitions
      1. Updated with readmission prevention
    28. TMJ Dysfunction
      1. General updates
    29. Wellen's Syndrome
      1. T Wave inversion or biphasic in v2-3 is an ominous sign
  12. Updates: February 2015
    1. Colorectal Cancer Screening
      1. Updated Colorectal Cancer Screening and surveillance protocols, as well as Colon Polyp
    2. Laceration Repair
      1. General repair updates, debunking myths (e.g. irrigation solution choice)
      2. Wound Infection
    3. Disability
      1. Updated Disability, Impairment Evaluation, Disability Evaluation, Functional Capacity Evaluation
      2. Updated Social Security Disability Insurance
    4. Kcentra
      1. Added dosing, precautions
    5. Measles
      1. Updated Differential Diagnosis, Labs and a general review
    6. Restraints
      1. Updated Chemical Restraints and Physical Restraints
      2. Finger Tip Injury
    7. Fingertip Injury
      1. Added Fingertip Injury entry with links and Finger Tip Injury Dressing
    8. Hypertension Management
      1. JNC-8 based Hypertension Management goals
      2. Who can keep track of these constantly shifting targets?
    9. Trauma Transfer
      1. Incorporated Trauma Transfer recommendations
    10. Cesarean Section
      1. Updated Cesarean Section and Vaginal Birth after Cesarean (VBAC)
    11. Dental Splint
      1. Added various techniques to Dental Splint in Tooth Avulsion and Tooth Luxation
    12. Tissue Adhesive
      1. Added various tricks for utilization
    13. Seborrheic Dermatitis
      1. Updates on specific management strategies
    14. Non-Invasive Positive Pressure Ventilation
      1. Extensive update on Noninvasive Ventilation
      2. Includes update on Continuous Positive Airways Pressure (CPAP) and Bilevel Positive Airway Pressure (BIPAP)
      3. Acute Respiratory Failure approach to CPAP (Hypoxemia) versus BIPAP (hypercarbia, Ventilatory failure)
    15. Ataxia
      1. Extensive additions related to Ataxia and Pediatric Ataxia
    16. Chest Tubes
      1. Chest Tube placement is frequently too low (with risk of peritoneal placement)
      2. Small Caliber Chest Tubes are very effective even for a large Pneumothorax
    17. Influenza
      1. Renal Dosing for Tamiflu and a new IV antiviral Peramivir
    18. Medication updates
      1. Victoza is exploited for its GI side effects to be remarketed as Saxenda at high dose, higher cost for weight loss
      2. Tramadol also causes Hypoglycemia (another reason not to use it)
      3. TENS units are now OTC
      4. Belsomra, a new drug for Insomnia, has an interesting Mechanism, but is no better than Ambien, and at 30x the cost
      5. Soy works for Hot Flushes with you are in the 40% (esp asian, hispanic) who convert Soy Isoflavone to equol (Estrogenic)
      6. Yet another very expensive Hepatitis C treatment: Ombitasvir, Paritaprevir/r and Dasabuvir (Viekira Pak) with Ribavirin
    19. Miscellaneous updates
      1. Home Blood Pressure Monitoring
      2. Cough Symptomatic Treatment
  13. Updates: January 2015
    1. Tranexamic Acid
      1. Added entry and reviewed uses, dosing
      2. EMS is starting to use in the field for Massive Hemorrhage
    2. Newborn Resuscitation
      1. Moderate updates
    3. Cancer Survivor Care
      1. Updated Cancer Survivor as well as Breast Cancer Survivor and Prostate Cancer Survivor Care
      2. Updated follow-up in Melanoma
      3. Updated follow-up in Non-Hodgkin's Lymphoma, Acute Myeloid Leukemia, Acute Lymphoblastic Leukemia, Hodgkin's Lymphoma
    4. Takotsuba Cardiomyopathy
      1. Added Takotsuba Cardiomyopathy (Stress Cardiomyopathy)
    5. Neonatal Bilirubin
      1. Updated Neonatal Bilirubin, Phototherapy and Exchange Transfusion in Newborns for specific age/risk criteria
      2. Added Bilirubin management calculator to DrBits Calc 2014
        1. http://www.fpnotebook.com/test/fpncalc/
    6. Guillain-Barre Syndrome
      1. Updates on precautions (non-specific presentations)
    7. CVA Thrombolysis
      1. Thrombolytics in Pregnancy
    8. Prochlorperazine (Compazine)
      1. Added data on reducing Compazine adverse effects (Akathisia, Dystonia) with Diphenhydramine
    9. Muscle Weakness in Children
      1. Extensive update on an approach to Muscle Weakness in Children
    10. Eating Disorder
      1. Updated Anorexia Nervosa and Bulimia including new DSM V Criteria
    11. Endocarditis
      1. Updated Bacterial Endocarditis, especially precautions
    12. Antibiotic Associated Diarrhea
      1. IV Antibiotic Associated Diarrhea in the ED
    13. Risk Management
      1. Added additional Malpractice pointers
    14. Cardiac Arrest
      1. ECMO and intubation precautions following Return of Spontaneous Circulation (ROSC)
      2. Vasopressin during Cardiac Arrest
    15. Diabetic Ketoacidosis
      1. Anion Gap normalization is a good marker of when to stop the Insulin Drip
    16. Dental Emergency
      1. Extensive updates on Dental Pain, Tooth Fracture, Tooth Luxation, Tooth Avulsion
      2. Also added Emergency Dental Kit, Dental Infection, Dental Incision and Drainage, Periapical Block
    17. Neonatal Sepsis
      1. Extensive updates to Neonatal Sepsis, Neonatal History
    18. Congenital Heart Disease
      1. Extensive updates to Congenital Heart Disease and Congenital Heart Disease Causes
      2. Added Truncus Arteriosus, Ebstein Anomaly, Endocardial Cushion Defect, Total Anomalous Pulmonary Venous Return

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