"Polymyalgia Rheumatica and Giant Cell Arteritis" (My Synopsis)

Polymyalgia Rheumatica and Giant Cell Arteritis
BRIAN UNWIN, COL, MC, USA, CYNTHIA M. WILLIAMS, CAPT (R), MC, USN, and WILLIAM GILLILAND, COL, MC, USA, Uniformed Services University of the Health Sciences, Bethesda, Maryland 
Am Fam Physician. 2006 Nov 1;74(9):1547-1554.

     Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are two diseases that are often seen together. CGA is it most common vasculitis in adults, and PMR is the most most common inflammatory disease in adults. It is important to know the GCA is an inflammation in medium to large arteries. PMR causes muscle and joint pain in the proximal muscles (hip, neck and shoulders). Occasionally there is also pitting edema, distal joint pain, and systemic symptoms. The core criteria for PMR includes; age over 50 years old, aching proximal muscles, symptoms lasting two weeks, morning stiffness of the girdle muscles for 45 minutes, and elevated ESR or CRP. A normal ESR can be estimated by using this formula (age/2 for men; for women is age/2 plus 5). The ESR in PMR is usually above 40 mm/hr. An ESR above 100mm/hr would occur in a patient with PMR and GCA.  Other lab work to order in PMR is a CBC, CK, thyroid, BMP, RF, UA, and SPEP. A chest x ray can help rule out cancer causing paraneoplastic syndrome. Treatment consists of corticosteroids with a slow taper. The treatment will last an average of 1.8 years. Older women with higher ESR may be at more risk for relapse or GCA. Patients with recurrent relapses or who cant tolerate a slow taper should be referred to a specialist. A that point, a rheumatologist may consider using a DMARD. Patients on long term steroids may need bisphosphonates, alendronate, vitamin D and calcium, or another type of prophylaxis to maintain bone density. 
     CGA can affect any medium or large artery, including the extracranial carotids, the temporal artery, or the thoracic aorta. The disease presents as a new onset temporal headache, fatigue, anorexia, or weight loss.  There may also be scalp tenderness. Jaw claudication or vision problems (diplopia, blurry vision) are signs of ischemia. Patients over 50 years old with signs and symptoms should be treated immediately to avoid progression to blindness. An elevated ESR (>50mm/hr) or CRP is another sign to have urgent treatment.  Diagnosis is made by temporal artery biopsy. The exact spot of the vasculitis should be identified on the patient's skin because taking a biopsy of an unaffected part (skip lesions) will lead to negative results. The sample should be at least 1 cm. A negative biopsy in a patient with strong clinical indication for disease may prompt a contralateral biopsy. Ultrasound may aid in performing the biopsy. After the initial treatment is started, a referral to a rheumatologist is warranted. Methotrexate is another treatment option. Treatment last for about three months. The patient will have to be monitored for a thoracic aneurysm every two years by x ray. Patients on long term steroids will need osteoporosis prophylaxis. 

"Pityriasis Rosea" (My Synopsis)

Pityriasis Rosea, by DANIEL L. STULBERG, M.D., Utah Valley Regional Medical Center, Provo, Utah JEFF WOLFREY, M.D., Good Samaritan Regional Medical Center, Phoenix, Arizona
Am Fam Physician. 2004 Jan 1;69(1):87-91.

     Pityriasis rosea is an acute rash of uncertain origin. Community outbreaks occur in clusters. Recurrence is rare, which suggests immunity. It appears to be viral, but no connection or proof has been found. It occurs mostly in children and young adults in either gender.  The first symptom is that of a generalized viral URI. Then comes the herald patch on the trunk. It is a large, round, red, raised, scaly, collarette lesion. It can easily be mistaken for eczema. Over the next few days to weeks, similar smaller (0.5-1cm) lesions start to appear over the trunk.  These lesions typically follow a "christmas tree" pattern on the back because they follow the langer lines of the skin. It looks like a V shaped pattern if present on the chest or a horizontal pattern on the abdomen. The extremities are spared. Pruritis is variable, but it is intense in a quarter of the patients. Topical treatment for the itching is effective, but oral antihistamines or steroids are an option. One study had shown that treatment with two weeks of erythromycin will resolve the rash. UV light has also helped with the rash and itching. The disease will usually resolve on its' own within 5-8 weeks. A rash lasting greater than three months may be a misdiagnosis. The differential includes tinea corporis, pityriasis lichenoides, viral exanthem, lichen planus, medication reaction, or syphilis (rash on palms and soles). 

"An Approach to Interpreting Spirometry" (My Synopsis)

An Approach to Interpreting Spirometry
TIMOTHY J. BARREIRO, D.O., and IRENE PERILLO, M.D., University of Rochester School of Medicine and Dentistry, Rochester, New York
Am Fam Physician. 2004 Mar 1;69(5):1107-1115.

     Spirometry is an important test to do in the office setting because a history and physical exam are poor tools to diagnosis obstructive ventilatory patterns. Spirometry measures how fast the lungs can change volume during forced exhalation. A flow volume loop is created which will show characteristic patterns depending on the disease process.  The FVC is the amount of air that the patient can forcefully exhale. The FEV1 is the portion of the air that is exhaled in one second. The ratio that is measured is the FEV1/FVC. The ratio in a normal patient is over 80%, and the results are normalized based on the height, weight, race, and gender of the patient. Spirometry can be done on patients who are current or former smokers over the age of 44 years. A baseline test may be considered in patients who are taking medications with pulmonary toxicity.  The test is also used to track treatment response. Contraindications include recent surgery of the abdomen, thoracic, or eye, recent myocardial infarction, unstable angina, pneumothorax, hemoptysis, or an acute disorder than would hinder performing the test. The spirometry should be performed three times to determine the validity of the results. The difference between the three results should not exceed 0.2L.
    In patients with obstruction, the FVC may be normal or low, the FEV1 will be low, and the FEV1/FVC ratio will be less than 0.7. In this case, a bronchodilator challenge test can be ordered.  A bronchodilator is given and the spirometry is repeated. A positive test will show a rise in 12% in FEV1, and 200 ml increase in FVC or FEV1, or a 15-25% increase in FEV25-75%. This test is positive in reversible airway disease. If the test is negative and the bronchodilation does not change the spirometry results, then the patient has an obstructive ventilatory impairment. 
     In patients with a restrictive impairment, the FVC and FEV1 will be low, but the ratio of FEV1/FVC will be normal (above 0.7).  These patients need to be referred for static lung volumes (DLCO, DLCO/VA, ERV) to determine severity (DLCO can also be done in obstruction to determine asthma vs COPD; it goes up in asthma). A maximum voluntary ventilation maneuver (MMVM) can be done to determine if the restriction is due to poor patient effort, neuromuscular disease, or airway lesion. 
     In either case, severity must be determined after the spirometry is interpreted. 

"Pediculosis and Scabies: A Treatment Update" (My Synopsis)

Pediculosis and Scabies: A Treatment Update
KAREN GUNNING, PharmD, University of Utah College of Pharmacy, Salt Lake City, Utah KARLY PIPPITT, MD, University of Utah School of Medicine, Salt Lake City, Utah BERNADETTE KIRALY, MD, University of Utah School of Medicine, Salt Lake City, Utah MORGAN SAYLER, PharmD, University of Iowa College of Pharmacy, Iowa City, Iowa
Am Fam Physician. 2012 Sep 15;86(6):535-541.

     Pediculosis is an infestation of lice on the head, body, or pubic region. The typical presentation is pruritus after 2-6 weeks of infestation. Since it is a delayed hypersensitivity reaction, subsequent infections will cause itching in 1-2 days. Constant scratching will lead to excoriations, lichenification, hyperpigmentation, and cellulitis. Diagnosis is made when a live louse is found. Finding a nit (a louse egg) is not diagnostic.  A good place to check for head lice is behind the ears and on the back of the neck. When a diagnosis is made, all members of the household should be examined and treated. Washing clothing, bedsheets, and towels (fomites) in hot water (122° F) will eradicate the parasites. Pubic lice can will be found in pubic hair and the seams of clothing. Patients who present with pubic lice should be checked for other STI's as well. 
     First line treatment is with permethrin. It is left in  the patients' damp hair for 10 minutes once a week. Two treatments should be effective. Resistant communities (such as England) can be treated with malathion. Oral ivermectin is a second line medication when there is resistance to either topical treatment. Nonpharmacologic treatments include wet combing with a lice comb and a leave-in conditioner. Another option to consider is to apply Cetaphil Gentle Skin Cleanser to the scalp, comb out after two minutes, dry with a hair dryer, and shampoo the hair after 8 hours. 
     Scabies presents with a generalized itchy rash, which is worse at night.  It may present as excoriations, eczemations, pyoderma, papules, nodules, or vesicles. The face and neck are spared (except in infants).  A burrow type lesion (short, gray, wavy lines) may be found on the hands, feet and in the finger webs.  Diagnosis can be made by finding a mite, egg or fecal matter on a skin scraping of the lesion. Treatment consists of permethrin cream on the entire body (neck down) for 8-14 hours. A second treatment can be done a week later. The pruritus may continue for up to two more weeks.  Oral ivermectin is second line therapy (due to cost).  Cloth washing should be at 140°F and with a hot clothes dryer.
     Norwegian scabies (or crusted scabies) presents as a generalized scaling, nail abnormalities, and thick, crusted lesions on the feet and hands. Pruritis is not present or minimal. An outbreak may have thousands of mites on the body, whereas in traditional scabies, there may only be a dozen. It is tougher to treat as well. Treatment includes daily permethrin cream and frequent oral ivermectin.

"Common Eye Emergencies" (My Synopsis)

Common Eye Emergencies
CHRISTOPHER D. GELSTON, MD, University of Colorado School of Medicine, Aurora, Colorado
Am Fam Physician. 2013 Oct 15;88(8):515-519.

     The eye injuries discussed in this article are retinal detachment, globe injuries, and chemical injuries. Retinal detachment is when the retina separates from the epithelium of the back of the eye. Usually the posterior vitreous detaches, which causes the retina to stretch and tear. The vitreous humor gets into the tear and under the retina, causing the separation. Symptoms include unilateral scotomas and increased floaters. If the retina is only torn, the vision may appear a bit cloudy or even normal. If the retina is detached, it may present as a rapidly expanding area of vision loss. When the macula is involved, the vision deficit becomes more prominent. Diagnosis comes from a proper fundic exam and an ocular ultrasound. Treatment consists of a ophthalmologist referral. Surgery will ultimately be needed. These patients have a higher risk of detachment in the opposite eye so they should be evaluated regularly.
     A mechanical globe injury occurs when a laceration or rupture occurs in the cornea, usually from a foreign body. It presents as eye pain, tearing, redness, or decreased vision after trauma. Diagnosis comes from a complete eye exam with a penlight or slit lamp. Fluorescein dye may help visualization of the laceration. If the foreign body is visible, it should not be removed. Lacerations smaller than 1 cm can be treated with topical antibiotics. If a globe injury has occurred, it is important not to increase pressure on the eye. Antiemetics can be given to reduced the risk of valsalva pressure. Systemic prophylactic antibiotics (levofloxacin or moxifloxacin) can be given to protect against posttraumatic endophthalmitis. A tetanus shot and immediate ophthalmologic referral is needed. 
     Chemical burns occur when an noxious fluid gets in the eye. It can damage the epithelium and cause conjunctival and scleral ischemia. Alkaline fluids are worse than acidic solutions. Symptoms include pain, redness, decreased vision and increased sensitivity to light.  Examination will show swelling, cloudiness, conjunctival injection or conjunctival ischemia (a white eye). The extent of the burn can be quantified by the amount of limbal ischemia. No ischemia is a grade I burn. A grade II burn will have ischemia in less than a third of the limbus. Grade III will have stromal haze than obscures the iris detail and up to half of the limbus will be ischemic. A grade IV burn will have ischemia in more than half of the limbus. Treatment includes copious flushing of the eye with at least 2L of fluid. The pH can be checked after 5 minutes to determine when it is in a safe range 7-7.5. 

"Pituitary Adenomas: An Overview" (My Synopsis)

Pituitary Adenomas: An Overview
MARCY G. LAKE, DO, U.S. Naval Hospital, Sigonella, Italy LINDA S. KROOK, MD, Naval Hospital, Bremerton, Washington SAMYA V. CRUZ, MD, U.S. Naval Hospital, Rota, Spain
Am Fam Physician. 2013 Sep 1;88(5):319-327.

     Pituitary adenomas are very common and as many of 20% of the population may have one. The vast majority of these are incidentalomas with no clinical significance. Those larger than 10mm are called macroadenomas and those smaller are called microadenomas. The most common type of pituitary adenoma is a prolactinoma, followed by nonfunctioning, growth hormone secreting tumor, ACTH, FSH, LH and TSH. They arise from monoclonal tissue in the anterior pituitary (lactotroph, gonadotroph, corticotroph, thyrotroph, or somatotroph).
     PItuitary adenomas present either with hormone hypersecretion, hormone deficiency, mass effect complications (neurologic dysfunction), or incidentally. The most common hormone presentations are hyperprolactinemia, acromegaly, and cushing disease. If a hormonal origin is considered to be the cause, an endocrine panel (serum prolactin, IGF-1, LH/FSH, TSH, T4, and an appropriate cortisol test) should be ordered. An elevated serum prolactin above 250 mcg/L is most likely a prolactinoma. If it is above 500 mcg/L it would be a macroprolactinoma. Sometimes a non-prolactinoma will cause elevated prolactin when the tumor compresses the pituitary stalk, known as the "stalk effect".
     Neurologic symptoms from mass effect include headaches (stretching the neural sheath), visual changes (optic chiasm superiorly, cranial nerves III, IV, VI laterally), CSF rhinorrhea, seizures, and pituitary apoplexy. An MRI can be done with and without gadolinium, or a thinly cut, coronal plane CT can be used instead.
     Incidentally found adenomas occur by using imaging for unrelated reasons. A complete endocrine panel should be done in this case even if the patient is asymptomatic. If the tumor is functioning, it should be treated accordingly (prolactinomas are treated with a dopamine agonist and a GH or ACTH secreting tumor should be referred to neurosurgery and endocrinology). If it is a nonfunctioning macroadenoma, visual field testing should be done. Patients with visual symptoms (or with asymptomatic impingement on imaging) will need referral to an ophthalmologist. Patients with microadenomas or macroadenomas and normal vision will get a repeat MRI and endocrine panel in one year. If there is no change after one year, then testing can be repeated in 2-3 years. If the tumor becomes larger than 1 cm, then visual field testing should be repeated. Any changes in the endocrine panel need to be investigated.
     The three treatment goals for pituitary adenoma are lowering hormone secretion, shrinking the tumor, and fixing any hormone deficiencies. The dopamine agonists used in prolactinomas are bromocriptine and cabergoline. Side effect include nausea, vomiting and fatigue. When these medications are used in high doses to treat parkinsonism, there is an increased risk of heart valve problems (this has not been seen in levels used to treat prolactinomas). ACTH and GH secreting tumors are usually treated with transsphenoidal resection. Other options include octreotide and lanreotide, which inhibit GH secretion. Pegvisomant is a IGF-1 antagonist which is another option.  Treatments to shrink the tumor include radiation, radiosurgery, and resection.

"Outpatient Management of Alcohol Withdrawal Syndrome" (My Synopsis)

Outpatient Management of Alcohol Withdrawal Syndrome
HERBERT L. MUNCIE JR., MD, Louisiana State University School of Medicine, New Orleans, Louisiana YASMIN YASINIAN, MD, New Orleans, Louisiana LINDA OGE', MD, Louisiana State University School of Medicine, New Orleans, Louisiana
Am Fam Physician. 2013 Nov 1;88(9):589-595.

     Alcohol dependence is present in up to 9% of all family medicine patients. In women, alcohol dependence is defined as those who average more than one drink a day, seven drinks a week, or more than four drinks on one occasion. In men, dependence is defined as more than two drinks a day, 14 drinks a week, or five drinks on a single occasion. Alcohol withdrawal syndrome occurs from a sudden abstinence after a long period of drinking (two weeks or more). Treatment of AWS requires identification of the condition, assessing the complication risk, and symptom recognition. Screening for alcohol abuse can be done using the CAGE questionnaire (or the AUDIT or MAST test). The four CAGE questions are:
1. Have you ever felt the need to CUT DOWN on your drinking?
2. Do you feel that people ANNOY you about how much you drink?
3. Have you ever felt GUILTY about your drinking?
4. Do you ever need an EYE opener (a drink in the morning to feel better)?
     Alcohol use disorder can be diagnosed if the patient is positive for at least two of the following:
-drinking more than expected
-persistent desire or inability to quit
-spending a lot of time getting alcohol or drinking alcohol
-having a craving, desire or urge to drink
-having problems fulfilling work, home or school obligations
-continued use despite persistent problems due to drinking
-drinking during times that are hazardous
-altering activities because of drinking
-continuing to drink even though you know it is having a harmful effect
-gaining tolerance (drinking more to attain effect)
-having withdrawal symptoms
     Withdrawal symptoms will start with 6-24 hours after last drink. AWS is diagnosed if at least two of the following symptoms occur; sweating, tachycardia, hand tremor, insomnia, nausea/vomiting, hallucinations (visual, auditory, or tactile), anxiety, psychomotor agitation, or tonic-clonic seizures. If AWS is not treated, it could lead to delirium tremens (disorientation, impaired attention, hallucinations, hyperthermia, tachycardia, tachypnea, diaphoresis, and altered consciousness). There are three stages to AWS. Stage one is mild and will present with anxiety, tremors, headaches, palpitations and GI issues. Stage two moderate and presents with sweating, systolic hypertension, tachypnea, confusion, and hyperthermia. Stage three is severe and is includes delirium tremens. AWS severity is assessed with the CIWA-Ar scale seen here (http://www.aafp.org/afp/2013/1101/afp20131101p589-f1.gif). A score of 8 or less is considered mild withdrawal. Moderate withdrawal has a score of 9-14. A score of 15-20 is moderate. Above 20 is severe. Medication is not needed in patients with a score of less than 10.
     A patient with mild or moderate AWS can be treated as an outpatient if the patient can take oral medications, is committed to the treatment, is willing to follow up frequently, and has proper support at home to assist in medication compliance. Family support is critical in the outpatient setting. Patients with severe withdrawal, serious psychiatric problems, laboratory abnormalities, or poor support at home should be treated as an inpatient.
     Patients are given thiamine and folic acid to combat and deficiencies from heavy drinking. Thiamine can lower the risk of Wernicke encephalopathy. The medications used for reducing psychomotor agitation, seizures and convulsions in AWS are benzodiazepines and anticonvulsants. Long acting benzodiazepines are more effective than intermediate or short acting benzodiazepines. Shorter acting benzodiazepines are more addictive and have a higher potential for abuse. A "loading dose" is not needed. The benzodiazepine can be given as a fixed dose or a symptom-triggered dose (triggered with a CIWAS-Ar score above 9). Symptom-triggered doses end up giving the patient less medication over a shorter period of time. There is no difference in results between either schedule. Anticonvulsants, such as carbamazepine and valproic acid, is also effective in AWS treatment. Gabapentin has shown to be equally effective.
Most patients are evaluated on a daily basis until symptoms decrease and the medication dosage is decreased. Medication can be lowered when a CIWAS-Ar is less than 10. Symptoms should be gone within a week. Patients can then be referred to an long term outpatient treatment center. If they miss an appointment or resume drinking, then they should be referred to a specialist
   

My Synopsis of "Myocardial Infarction: Management of the Subacute Period"

Myocardial Infarction: Management of the Subacute Period
MICHAEL G. MERCADO, MD, Naval Hospital Camp Pendleton Family Medicine Residency Program, Camp Pendleton, California DUSTIN K. SMITH, DO, U.S, Naval Hospital Guam, Agana Heights, Guam MICHAEL L. MCCONNON, MD, Naval Hospital Pensacola Family Medicine Residency Program, Pensacola, Florida
Am Fam Physician. 2013 Nov 1;88(9):581-588.

     Acute management of an MI usually starts with aspirin/clopidogrel, anticoagulation, fibrinolysis, echo and angiography. Depending on the LVEF and the results of the angiogram, a bypass, PCI stenting, or medical management will be recommended. Discharge medication will be prescribed depending on the situation. 
     All patients will be given aspirin indefinitely. The dose should be lowered at discharge. Patients who have an allergy to aspirin can take clopidogrel. Dual antiplatelet therapy (aspirin and clopidogrel or other P2Y12 inhibitor) is recommended for up to a year in patients with bear metal stents and at least a year in patients with drug-eluting stents. Post MI patients can be given dual therapy of 2 different P2Y12 inhibitors (clopidogrel and ticagrelor) for up to a year. A PPI can be added in patients with GI bleeding. 
     Beta blockers may be started gradually and indefinitely on patients with a LVEF less than 40%. Mortality benefit had not been documented for the first month post MI. It can be started within 24 hours after an event. It may not benefit patients who had a remote history of MI. Patients with preserved systolic function can take it for at least three years. 
     All post MI patients with a history of hypertension, diabetes, heart failure, chronic kidney injury or LVEF less than 40% should be on an ACEI. It should be continued indefinitely. ARBs can be used on those patients who cannot tolerate ACEIs. The two medications should not be used together. Aldosterone blockers (eplerenone) can reduce mortality in post MI patients with a low LVEF, diabetes or signs of heart failure. The creatinine clearance should be above 30 and the potassium should be less than 5. 
     Statins should be started and continued indefinitely on these patients before they are discharged. Patients already on a statin may benefit from a higher dose (up to 80 mg/day). The dose can be titrated to get an LDL less than 70-100. 
    Discharge planning is an important tool which is not always done properly. It includes medication review, patient education, referral to cardiac rehab, activity and lifestyle recommendations, and a follow up plan. Sexual activity can resume in a week. Driving can start in three weeks. Air travel should be halted for two weeks. Physical activity can be resumes as tolerated

My Synopsis of "The Newborn Foot"

The Newborn Foot
ALVIN I. GORE, M.D., D.P.M., San Diego, California JEANNE P. SPENCER, M.D., conemaugh Memorial Medical Center, Johnstown, Pennsylvania
Am Fam Physician. 2004 Feb 15;69(4):865-872.

     The foot can be separated into 3 anatomic regions. The hindfoot is the heel part of the foot and includes the talus and calcaneus. The forefoot is the front "fingers" part of the foot and consists of the metatarsals and phalanges. The midfoot is the.... middle part of the foot and contains everything else (navicular, cuboid, and cuneiforms). 
     Metatarsus adductus is the deformity where the metatarsals pitch in medially. The lateral aspect of the feet have a convexed appearance. The first and second digits have a splayed appearance and the medial midfoot develops a deep cleft in the skin. This article discusses performing the "V" test by placing the infant's foot between the clinician's index and middle finger to better observe any deformity. Treatment is conservative. Patients can perform stretching exercises, which consists of stabilizing the hindfoot while distally distracting the forefoot and correcting the position. In severe refractory cases, serial casting and bracing may be needed, but it is rare. 
     Clubfoot has four components to the deformity;
1. Inversion and adduction of the forefoot
2. Inversion of the heel and hindfoot (the heels may actually face each other)
3. Tight achilles causing flexed ankle "equinus" (foot stuck in plantarflexion)
4. Internal rotation if the leg
On x ray, the talus and calcaneus will appear "stacked". Basically the foot is flexed "down and in". There are two types of clubfoot. It can be extrinsic (supple) or intrinsic (rigid). Extrinsic is a severe position or soft tissue deformity and is treated with serial casting. Intrinsic deformity will need a surgical correction. 
     Calcaneovalgus is a deformity of the tibiotalar joint where the foot is in extreme dorsiflexion. The dorsum of the foot may be in contact with the anterior part of the distal leg. It may be associated with an overstretched achilles tendon, tight anterior leg muscles, or an externally rotated calcaneus. The deformity has an "up and out" appearance. It will oftentimes resolve on it's own. Stretching exercises can aid in resolution. It is performed by gently putting the foot in plantar flexion and inversion. Splinting or casting may be needed in severe cases.
     Congenital vertical valgus is a deformity also known as "rocker bottom foot". The hindfoot is pointed down, in an "equinus" position, and the forefoot is dorsiflexed. This causes the midtarsal bones to become dislocated. Patients with this deformity may have other congential deformities as well, so a thorough exam should be performed.  Stretching can be done, but surgery is usually needed. 
     Polydactyly is the "sixth" toe or "sixth" finger. They are primarily genetic. Treatment is usually surgery (or ligation banding if it is purely soft tissue). Syndactyly are webbed toes/ fingers. It is a genetic deformity. Treatment is not necessary and is only done for cosmetic purposes. Overlapping toes are often familial and bilateral. It is corrected with gently stretching and paper tape splinting. Surgery may be needed if treatment is delayed.  

Google Analytics Certified!!

Ok so no article today but I did finish my google analytics course, so that has to be worth something....

"Lower Extremity Abnormalities in Children" (My Synopsis)

Lower Extremity Abnormalities in Children
P MELA SASS, M.D., and GHINWA HASSAN, M.D., State University of New York–Downstate Medical Center, Brooklyn, New York 
Am Fam Physician. 2003 Aug 1;68(3):461-468.

     Lower extremity abnormalities in children are usually normal variations that resolve on their own. The two types of variations are rotational and angular problems. When a parent brings their child in, it is important to figure out what their exact concerns are. It may be a gait issue, a cosmetic problem, or it may just be pressure from a concerned relative to get it "checked out". A complete medical and family history are needed because these issues can have a developmental or genetic component. The physical exam includes plotting the patient on a growth chart, a neurologic exam, ROM of extremities, and assessment of joint laxity. A trendelenburg test will assess contralateral hip abductor strength. The lateral foot should be observed for flat feet.
     Rotational problems of the lower extremities can be seen if certain angles are greater than two standard deviations from the average. The foot progression angle measures to what degree a person's feet deviate from a straight line while walking. Hip rotation can be measured by having the patient lie prone with the knees bent. Internal hip rotation will present with the patients' legs angled away from each other, whereas external hip rotation will present with the legs crossing eachother. The thigh-foot angle compares the axis of the thigh to the angle of the foot when the knee is bent at 90 degrees. Measuring the distance between medial malleolus or medial femoral condyles (while the legs are together), can determine the amount of genu varum (bow legs) or genu valgum (knock-knees), respectively. Most patients appear genu varum from birth to two years old and then appear genu valgum at 3-7 years old. It is part of normal development. If the deformity is unilateral, greated than two standard deviations, or getting worse, then x rays are warranted.
     There are three causes of intoeing (I remember calling it "pigeon toes" during Chinese jump rope). The first cause is metatarsus adductus. The forefoot is adducted and the lateral forefoot is convexed. The most common cause is intrauterine packing. Flexibility can be assessed by abducting the forefoot. It will usually resolve by the time the child turns one year old. The parent can stretch the child's midfoot, but referral to an orthopedist for serial casting will be needed if the intoeing does not resolve by eight months. The second cause is internal tibial torsion. The most common causes are intrauterine position, sleeping prone, and "sitting on the feet". the knees are facing forward but the tibial torsion causes the feet to be angled inwards. It will resolve by the time the child turns eight years old. If the deformity is significant, then corrective surgery may be needed. The third cause is femoral anteversion. It also has "pigeon toes", but this time there is femoral torsion instead of tibial torsion. Here, the feet and patellar are angled inward. The deformity peaks at 4-6 years, and then slowly resolves. The deformity is benign but surgery can be considered if it is severe.
      Out-toeing is less common than intoeing. The first cause is femoral retroversion  which is the opposite of femoral anteversion. The femur is twisted outwards. It is associated with stress fractures and slipped capital femoral epiphysis. Referral to an orthopedist is recommended if it does not improve within one year. External tibial torsion is the opposite of internal tibial torsion. The tibia rotates laterally to cause the out toeing. It is seen when the child is 4-7 years old. Surgery can be considered in severe cases when the patient is over 10 years old.
     Flat feet is seen when ligament laxity causes the foot to sag during weight bearing. If the arch appears when the child is standing on his or her toes, then the it is not a true flat foot, and treatment is not necessary. If the foot is stiff and painful, then an orthopedic referral is needed.

"Pertussis: A Reemerging Infection" (My Synopsis)

Pertussis: A Reemerging Infection
JONATHAN M. KLINE, PharmD, BCPS; WILLIAM D. LEWIS, MD; ELEANOR A. SMITH, MD; LLOYD R. TRACY, MD; and SARAH K. MOERSCHEL, MD, West Virginia University School of Medicine, Eastern Division, Harpers Ferry, West Virginia 
Am Fam Physician. 2013 Oct 15;88(8):507-514.

     Pertussis is an upper respiratory infection also known as whooping cough. It has a 7-10 day incubation period. The presentation in the incubation period varies widely. There are three stages of pertussis after the incubation period. The first stage is the catarrhal stage. It lasts for up to two weeks. The presentation includes malaise, rhinorrhea, sneezing, lacrimation, and cough. The patient may be afebrile and highly contagious. The second stage is the paroxysmal stage. It can last from 1-6 weeks. This is the stage where the patient presents with the classic paroxysmal cough, in which the patient can have a severe coughing spell in between "whoops" of inspiration. This occurs because the patient has difficulty expelling the thick secretions from the lungs. The paroxysms can lead to emesis, cyanosis, proptosis, salvation, distended neck veins, and lacrimation. The last stage is the convalescence stage. In this stage, the coughing abates and the patient becomes susceptible to other URIs. This stage lasts up to three weeks. Atypical presentation of pertussis is common and may only present as a chronic cough. Any patient with a chronic cough of greater than three weeks may have atypical pertussis.
     Infants who have not received the full series of vaccinations may only have partial immunity. Patients who become infected with pertussis under the age of six months should be admitted to the hospital. Complications in this group are apnea, pneumonia,  seizures, and death. Adults may present with weight loss, urinary incontinence, syncope, rib fractures (from coughing), subconjunctival hemorrhage, abdominal hernias, and vertebral artery dissection.
     Laboratory testing on pertussis is done by culture or PCR. Cultures can be taken from nasopharyngeal aspirate or a posterior nasopharyngeal swab. PCR has a higher sensitivity. Serological testing is done on patients who present after symptoms for many weeks.
     Treatment includes macrolides or TMP/SMX. It should be started within three weeks of onset of symptoms, or within six weeks in patients younger than 1 year. Treatment prevents the spread of the disease and does not help in remission. Antibiotic prophylaxis can be given to all close contacts for three weeks. Prophylaxis can be withheld in those who will not have contact with infants younger than 6 months. The prophylaxis of choice is azithromycin.
     Vaccination is the current form of prevention. There are two versions of the vaccine: DTaP and Tdap. The difference is that the DTaP has a higher concentration of the diphtheria toxoid. Tdap is used in patients older than six years old because the DTaP has an increased risk of reaction at the injection site. The vaccination schedule for DTaP is given at 2, 4, 6, and 15-18 months. It it given one more time at age 4-6 years.  Patients between 11-18 years old and 19-64 years old get a Tdap booster. A Tdap booster is also given at 7-10 years to patients who did not get the full 5 dose childhood schedule, if pregnant (at 27-36 weeks), and if 65 or older and in contact with children less than 1 year old.

"Treatment of Obstructive Sleep Apnea in Primary Care" (My Synopsis)

Treatment of Obstructive Sleep Apnea in Primary Care
LYLE D. VICTOR, M.D., M.B.A., Oakwood Hospital and Medical Center, Dearborn, Michigan
Am Fam Physician. 2004 Feb 1;69(3):561-569.

     A good friend of mine called me and said that his wife thinks that he has sleep apnea. "Is that bad?", he said. I gave him a brief overview, and then decided that it would be a good topic to review today. SO AWAY WE GO!
     OSA is a partial or complete airway obstruction which causes breathing to stop during sleep. It is seen in overweight patients who snore. They will often be sleepy during the day. Disease severity can be measured with an "apnea-hypopnea index". If the number of apneic or hypopneic episodes equal 20 or more per hour, then treatment is recommended. 
     First line therapy is sleep hygiene. Patients should allot enough time to dedicate to sleep. Deprivation of sleep can cause snoring. Things that affect nasal outflow (rhinitis, polyps, septal deviation) and mouth breathing are risk factors for OSA. Patients with OSA should avoid alcohol and sedatives because they can increase snoring by relaxing the tongue and parapharyngeal muscles. Most patients with OSA are overweight or obese. Weight loss of 20-30 lbs. will lead to significant improvement. Patients may also get relief if they sleep at an elevated position. 
     If sleep hygiene is not fully effective, then the patient will need CPAP. This is a mask that the patient wears when they go to bed. It pushes air into the nostrils to keep the pharyngeal airway open. Patients usually require 6-12 cm of pressure to reduce the number of episodes each night. The pressure may be reduced slightly after a month of use or if the patient has some weight loss. Many patients have a hard time tolerating the mask while sleeping. One way to address this is to uses bilevel pressure ventilation, which lowers the pressure upon exhalation. This will reduce the work of breathing.  Other strategies to help with patient compliance is to make sure the mask fits right, using nasal pillows, using a full face mask, adding a humidifier, or giving the patient a nasal steriod spray. Complications of CPAP include air leakage, claustrophobia, skin irritation, and conjunctivitis. 
     Surgery is another option if the patient cannot tolerate CPAP. Uvulopalatoplasty removes part of the soft palate and uvula. Jaw surgery attempts to advance the maxillomandibular bone. Another technique moves "the anterior tip of the mandible forward along with its lingual attachments". Another approach, which uses maxillary and mandibular osteotomies, is more invasive. Tracheostomy is a last resort treatment, used in respiratory failure or in severe apnea. 
     Oxygen is partially effective by treating desaturation, but it does not reverse the obstruction. 

"Dermatologic Conditions in Skin of Color: Part II. Disorders Occurring Predominantly in Skin of Color" (My Synopsis)

Dermatologic Conditions in Skin of Color: Part II. Disorders Occurring Predominantly in Skin of Color
ROOPAL V. KUNDU, MD, and STAVONNIE PATTERSON, MD, Northwestern University Feinberg School of Medicine, Chicago, Illinois
Am Fam Physician. 2013 Jun 15;87(12):859-865.

    This article focuses on 5 issues; dermatosis papulosa nigra, pseudofolliculitis barbae, acne keloidalis nuchae, keloids, and general hair disorders. 
     Dermatosis papulosa nigra looks like multiple, small (1-5mm) dark-brown papules on the head and neck (think Morgan Freeman). It is benign. Treatment is not needed unless the patient wants them removed for cosmetic reasons. 
     Pseudofolliculitis barbae are the razor bumps that occurs when the hair curls back on itself and penetrates the skin. The best way to treat this is to either stop shaving, destroy the follicles, or permanently remove the hair. Proper shaving techniques includes shaving in the direction of the hair growth, using clippers or single blade razors, not making the skin taut during shaving, and avoiding plucking. Leaving it "scruffy" will also work. Properly preparing the skin (brushing the hair, applying warm compresses, gently massaging the area) can also reduce the inflammation. Applying topical steroids, benzoyl peroxide, retinoids, and topical antibiotics may also help.
     Acne keloidalis nuchae is a chronic inflammation of the follicles on the back of the head. It looks similar to a keloid and is associated with hair loss. The etiology is not known. Treatment consists of topical and intralesional steroids, antibiotics, retinoids, as well as imiquimod, laser therapy, and surgery. 
     Keloids are benign growths of hypertrophic scar tissue over areas of previous trauma, such as  acnes, piercings, tattoos, surgery, or infections (think of that big branded Omega sign on the shoulders of many professional athletes). Prevention is the best intervention (like not getting tattooed, pierced, or "branded")  Avoiding excessive movement of a lesion or incision and keeping it clean may also help. Medications include intralesional steroids, fluorouracil, bleomycin, excision, radiation and cryotherapy. Steroid injections are the first line treatment and can be used every 1-2 months. 
     Hair of dark skinned ethnicities is more curly and brittle. These people wash their hair less to avoid breakage. It should be washed at least every 1-2 weeks to get rid of the buildup of hair products. Conditioning can soften the hair and reduce fragility. Hair grease and emollients can help, but it can increase the incidence of acne, irritation, and seborrheic dermatitis. Chemically straightening this hair more than once every two months can cause it to break. Using heat to straighten it can cause damage. Heat should not be used more than once every 1-2 weeks. Traction alopecia occurs when tight braids and weaves pull out the hair that it is anchored to. It is more prominent in the frontal and temporal area. Centrifugal cicatricial alopecia is hair loss at the crown of the head. Etiology is unknown. It is a scarring alopecia thought to be from excessive relaxers, traction and heat. 
     

"Recommendations for Preconception Counseling and Care" (My Synopsis)

Recommendations for Preconception Counseling and Care
NARGES FARAHI, MD, and ADAM ZOLOTOR, MD, DrPH, University of North Carolina School of Medicine, Chapel Hill, North Carolina
Am Fam Physician. 2013 Oct 15;88(8):499-506.

     Although half of all pregnancies are unintentional, preconception care can greatly benefit the fetus. All patients of reproductive age should be counseled on contraception, as well as health risks that may affect pregnancy. Patients considering becoming pregnant should consider environmental exposures, genetic history, medications, psychiatric illness, psychosocial factors, and substance abuse. Workplaces which may exposure expecting mothers to toxins include clinical and laboratory health care, dry cleaning, manufacturing, printing, and agriculture. Mercury exposure from certain fish should also be considered. Patients with a personal or family history of genetic or congential disorders should be referred for genetic counseling and carrier testing. Teratogenic medications should be stopped. Patients should be screened for depression, anxiety, substance abuse and intimate partner violence. All women should be screened for HIV, measles immunity, and rubella immunity. All high risk women should be screened for chlamydia, gonorrhea, syphilis and TB.
     All women considering having children should start taking 400 mcg of folic acid and continue until 12 weeks gestation. Patients with epilepsy, diabetes, obesity, or at high risk of neural tube defects,  can take 4-5 mg daily. 
     Patients who are overweight or obese are at increased risk of macrosomia, shoulder dystocia, IUGR, spontaneous abortion, stillbirth, and preeclampsia. Overweight patients who have oligomenorrhea or amenorrhea may regain fertility with weight loss. Patients who opt for bariatric surgery should wait 12-18 months after the procedure before getting pregnant. Post bariatric patients will also need a pre-pregnancy CBC and multivitamins to combat nutritional deficiencies. Patients who are underweight should be counseled about the risks of preterm or low birth weight births. Low birth weight is associated with osteoporosis, amenorrhea, infertility, arrhythmias and nutritional deficiencies. 
     Medications for common medical conditions may need to be altered. Patients with acne cannot take isotretinoin because it is severely teratogenic. Patients with asthma should not use oral corticosteroids because it lowers birth weight and increases the risk of preeclampsia. ACEIs and ARBs are associated with fetal anomalies and death. Diabetic patients should discontinue oral antidiabetic medications and switch to insulin. Elevated glucose can lead to congenital malformations. Patients with hyperthyroidism should use propylthiouracil instead of methimazole in the first trimester. For patients with seizure disorder, monotherapy at the lowest possible dose should be used do to the teratogenic effects of most of the antiepileptic medications. Patients who need blood thinners should not use warfarin because of its harmful side effects. Statins and atenolol should be avoided. 

"Dermatologic Conditions in Skin of Color: Part I. " (My Synopsis)

Dermatologic Conditions in Skin of Color: Part I. Special Considerations for Common Skin Disorders 
ROOPAL V. KUNDU, MD, and STAVONNIE PATTERSON, MD, Northwestern University Feinberg School of Medicine, Chicago, Illinois
Am Fam Physician. 2013 Jun 15;87(12):850-856.

     Ethnic skin has more pigmentation and acts differently than lighter skin. Basal cell carcinoma is the second most common skin cancer in african americans (its #1 in caucasian, asian, and hispanic skin). It is because of the greater protection dark skin gets from the increased melanin. Basal cell looks like a solitary pearly papule with a rolled border and telangiectasias. In patients with darker skin, the lesion will be pigmented. It may thus be difficult to recognize. It can be found on areas that are exposed to the sun, such as the head and neck. There is an elevated risk of basal cell carcinoma in areas of previous trauma, such as in scars, radiated areas, or in those who are immunocompromised. Diagnosis can be done with a shave biopsy. Treatment includes topical fluorouracil, curettage, or excision. It generally has a good prognosis.
     The most common skin cancer in african americans (and indians) is squamous cell carcinoma. It is #2 in hispanics, japanese, and chinese. Lesions most commonly occur in non-sun exposed areas (legs, scalp, groin), but UV light does have some role in the disease. Risk factors in darker colored skin is chronic scarring and inflammation. The lesions appearance varies, but it typically has erythematous patches, plaques, and nodules. Shave biopsy is done on these lesions. Treatment includes topical fluorouracil or imiquimod.
     Melanoma has the highest mortality rate of all the skin cancers, but the rate has dropped. Time of diagnosis and staging is directly related to the mortality rate. Patients with darker skin are often not diagnosed as early as patients with lighter skin, and thus are diagnosed at a more advanced stage, with worse outcomes. Melanoma follows the ACBDE mnemonic;
Asymmetry
Border irregularity
Color variation
Diameter (>6mm)
Evolution
It presents as a singular, pigmented, rapidly changing area. It is commonly found on the back, lower legs, and non-skin exposed areas. The most common subtype in patients of darker skin is acral lentiginous melanoma, which is melanoma affecting the palms, soles or nail beds. In hispanics and whites, the most common subtype is superficial spreading melanoma. Lesions are typically excised with 2 mm margins. Management is largely based on biopsy results.
     Acne must be treated carefully to avoid scarring or hyperpigmentation from the treatment. Skin and hair products could exacerbate acne, so it is important to discuss the use with the patient. Treatment of acne starts with benzoyl peroxide, topical antibiotics, and retinoids. Oral antibiotics can be given to patients with moderate to severe acne. If the acne is resistant, nodular, or cystic, then isotretinoin can be considered. Combination therapy is also effective.
     Postinflammatory hyperpigmentation is a common side effect when treating acne. Treatment for acne should be started at a low dose to avoid inflammation and irritation. Treatment that makes it worse should be avoided (it depends on the patient). When is appears, it looks like tan or brown spots. Treatment consists of managing the underlying condition. Sunscreen use should be encouraged. Hydroquinone cream alone or in combination with a topical steriod or retinoid may be helpful.  It will usually improve within 6-12 months.

"Treatment Options for Insomnia" (My Synopsis)

Treatment Options for Insomnia
KALYANAKRISHNAN RAMAKRISHNAN, MD, and DEWEY C. SCHEID, MD, MPH, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
Am Fam Physician. 2007 Aug 15;76(4):517-526.
http://www.aafp.org/afp/2007/0815/p517.pdf

     Insomnia is defined as poor sleep that affects daytime performance. It affects over 33% of adults in some shape or form. Risk factors include being female, increasing age, unemployment, medical comorbidities, low socioeconomic status, and psychiatric illness. Criteria for insomnia includes having at least one of the following:
problems initiating or maintaining sleep, poor sleep quality, or waking up too early;
AND one of these daytime problems:
impairment in attention, concentration, or memory; daytime sleepiness, fatigue, malaise, mood disturbances, tension headaches, or errors/accidents during the day.
     Acute insomnia occurs for less than 30 days. Causes of acute insomnia include stress (environmental or situational) or death/illness of a loved one. Chronic insomnia lasts for more than 30 days. Causes include medical disorders (CHF, COPD, HIV, ESRD, GERD, cancer, chronic pain), medications (mostly those that are anticholinergic or have anticholinergic side effects, including CNS stimulants, MAOIs, steroids, antidepressants), psychiatric disorders, sleep-wake schedule disorders, substance abuse and primary sleep disorders.
     When evaluating a patient with insomnia, the clinician should first rule out any coexisting medical or psychiatric conditions. A sleep history should be taken, with attention given to Sleep habits, substance abuse, daytime functioning, and nighttime limb movements. Additional information should be ascertained from their partner or caregiver. Patients will also get a mini-mental status exam, a neurologic exam, and a medication review with their physical exam.  Patients will need to keep a sleep diary for at least two weeks. A polysomnography can be done if the patient has sleep apnea or a limb movement disorder. An actigraphy is used to monitor a patient's' activity and movement during sleep.
     Treatments starts with nonpharmacologic therapy. Examples include CBT, exercise, relaxation therapy (tensing and flexing certain muscle groups), stimulus control therapy (no bright lights, no noise, no coffee, etc), and temporal control measures (waking up at the same time and no naps during the day). When these techniques are ineffective, a low dose of hypnotics can be given for a few weeks. They have abuse and tolerant potential, so caution should be exercised. OTC antihistamines are not very effective and are not recommended. There are many herbal supplements on the market, but they have no benefit, other than melatonin and valerian root. Melatonin can stabilize the circadian rhythm. Valerian root causes sedation because it is a GABA inhibitor.
     Barbiturates are a GABA-a agonist. and are effective for short term insomnia. Opiates may be helpful in certain patients, like those who cannot sleep because of pain. Of the antidepressants available, trazodone is the one most often prescribed for insomnia. Benzodiazepines have less risk of abuse and overdose than barbiturates. Shorter acting benzos (estazolam, triazolam, and temazepam) are preferred because of their rapid action. These medications should not be used beyond four weeks due to the risk of dependence, withdrawal and rebound insomnia.
     Nonbenzodiazepine hypnotics (zolpidem, zaleplon, eszopiclone) are similarly effective as benzos with less adverse drug risk, abuse, and dependence. They do not affect the sleep stages like the benzos do. Zaleplon causes less memory and psychomotor impairment than benzos and zolpidem. It does cause changes in color perception.  Eszopiclone is approved for use longer than 35 days. Non-benzos are more expensive, but do not show better efficacy than traditional benzos.
     Ramelteon is a melatonin receptor agonist. it has low likelihood of abuse and dependence. Side effects are rare. It is the only non scheduled medication approved for insomnia.
   

My Synopsis of "Evaluating the Febrile Patient with a Rash"

Evaluating the Febrile Patient with a Rash
HARRY D. MCKINNON, JR., MAJ, MC, USA, and THOMAS HOWARD, COL, MC, USA, Dewitt Army Community Hospital, Fort Belvoir, Virginia
Am Fam Physician. 2000 Aug 15;62(4):804-816.
http://www.aafp.org/afp/2000/0815/p804.html


     When trying to diagnosis a rash, a proper description of the lesion is important. Macules are round and flat. Papules are less than 0.5 cm and raised. Nodules are deep in the dermis and palpable. Plaques are large elevations of the skin. A pustule is a purulent fluid filled area of skin. A vesicle is a small pustule.
    Eruptions can be categorized into central, peripheral, and petechial. Centrally distributed eruptions are more common. They usually start in the head and neck, and then progress peripherally. Examples include rubeola, rubella, roseola, and erythema infectiosum. Rubeola is also known as measles. The rash starts at the hairline and spreads downward. It does not affect the palms and soles. It also causes blue spots on the oral mucosa, called koplik spots. Rubella looks the same as rubeola except that it only lasts 2-3 days (as opposed to 4-6 days in measles). It is also less severe. An infection of HHV-6 is also known as roseola, or exanthem subitum. It occurs after fever but spares the face. It fades within 3 days. Parvovirus causes fifth's disease, also known as slapped cheek disease or erythema infectiosum. The red facial rash occurs after the fever resolves. It then spreads to produce a lacy reticular rash the lasts up to 8 weeks. Parvovirus can cause fetal hydrops and fetal death in pregnant women.
     Lyme disease presents with a very common target shaped lesion called erythema migrans. It has a characteristic central clearing. There may also be central necrosis, induration, or vesiculation. Patients in this situation may present with a recent history of hiking, camping, or being in a tick infested area. It is more common on the extremities. Penicillin or cephalosporin treatment may cause a drug reaction that will look like a viral exanthem.
     Peripheral eruptions present as erythema multiforme, which is a maculopapular rash more common in men. It is often found on the palms, soles, knees and elbows. It initially looks like a dull-red macular lesion that grows into a papule with a central vesicle or bullae. The mouth and lips are often involved. There are two classifications of erythema multiforme. In the minor form, the bullae and systemic symptoms are absent, and the mucous membranes are not involved. The major form is usually due to a drug reaction. It presents with bullae, mucosal involvement, fever, difficult micturition, and conjunctivitis. Secondary syphilis presents with a localized diffuse rash on the head, neck, palms, and soles. It usually occurs 6 months after infection. Patients may also present with condyloma lata.
     Petechial eruptions can be a sign of a serious infection, such a meningococcemia. It occurs more commonly in infants, alcoholics, asplenic patients, and those with complement deficiencies. Along with a polymorphous, maculopapular, petechial rash, the patient will have spiking fevers, tachypnea, tachycardia, and mild hypertension. Chronic meningococcemia will have arthritis and arthralgia.
     Rocky mountain spotted fever is another cause of a rash in a febrile patient. It usually presents on the fourth day of infection as pink macules on the wrists, forearms, ankles, palms, and soles. It will spread to include the arms, legs, abdomen and face. The rash eventually becomes red and petechial. Scarlet fever has a "finely punctate erythema" on the trunk and face, which then spreads to the extremities. Patients will also present with a strawberry tongue.
     Toxic shock syndrome and scalded skin syndrome will present with as a diffuse scarlatiniform rash. Nikolsky's sign will be positive. Kawasaki's disease presents with a rash that is scarlatiniform on the trunk and erythematous on the palm and soles. The lips may look dry and cracked. The oropharynx will be injected. There may also be a strawberry tongue. Herpes zoster is a painful pustular lesion that will affect a unilateral dermatome. Chicken pox looks like "a dewdrop on a rosepetal" which starts on the head and spreads down and to the extremities. The pustules will present in all stages of healing.
     Nodular eruptions present as erythema nodosum. It affects the legs, knees and arms.There are many causes which include infection, medication, SLE, sarcoidosis, ulcerative colitis, behcet's syndrome, and pregnancy.

My Synopsis of "Fever in Returning Travelers: A Case-Based Approach"

Fever in Returning Travelers: A Case-Based Approach
HENRY M. FEDER, JR., MD, and KENIA MANSILLA-RIVERA, MD, University of Connecticut School of Medicine, Farmington, Connecticut
Am Fam Physician. 2013 Oct 15;88(8):524-530.
http://www.aafp.org/afp/2013/1015/p524.pdf

     The rate of coming back from traveling to a developing world with a fever is about 3-19%. The most common diseases are dengue fever and malaria. They are usually seen in travelers going to the Caribbean, Central America, South America, South Central America, Southeast Asia, and Sub-Saharan Africa. Enteric fever may be seen in travelers coming out of South Central Asia. Sub-Saharan Africa also has a high rate of rickettsiae, schistosomiasis, and filariasis.
     When evaluating a fever in a patient who has recently returned from travel, it is important to ask about when and where they traveled, if they took any travel prophylaxis, if they were exposed to any insects or sick people, if they had sex with any of the locals, if they drank the water or ate the food, if they got sick during the travel, and if they were exposed to any illnesses since being back to the U.S. Depending on the infection, the fever may take anywhere from a day to a month to appear.
     Malaria has five different subtypes. P. knowlesi is the newest species. The life cycle of the Plasmodium starts with the human being infected from the mosquito bite. The "sporozoites" then go to the liver. They turn into "merozoites" and cause RBC rupture and fever spikes. P.malariae causes "quartan" fevers (every fourth day). The other species cause "tertian" fevers (every third day). P. falciparum can cause fulminant disease by binding to the vasculature and blocking blood flow. Symptoms of malaria include fever, headache, jaundice, muscle and joint pain, abdominal pain, nausea, and vomiting. If hemolysis, dark urine and hematuria occur, it is called blackwater fever. Prophylaxis includes using DEET mosquito repellent and oral mefloquine. The treatment of choice is chloroquine, unless the patient traveled to a chloroquine resistant area, in which the treatment is tetracycline plus mefloquine.
     Salmonella typhi and S. paratyphi are the causes of typhoid fever. It is transmitted through contaminated water and food. The clinical presentation is similar to malaria. The symptoms include fever, malaise, anorexia, vomiting, and abdominal pain. Children may present with diarrhea, whereas adults may present with constipation. Patients may also present with  maculopapular, pink colored, rose spots on the trunk. Lab tests include ESR, CRP, and liver function tests. Blood, urine or stool cultures can be used to diagnose S. typhi infection. Vaccination is the best prophylaxis. Treatment includes oral ciprofloxacin, cefixime or azithromycin. Resistance to fluoroquinolones, amoxicillin, and TMP/SMX are common.
     Dengue fever occurs through a mosquito bite. The symptoms include spiking fevers, leukopenia, retro-orbital headaches, nausea, maculopapular rash, vomiting, muscle pain, and joint pain. There is also a disease called dengue hemorrhagic fever, which presents with a triad of hemorrhage, thrombocytopenia, and plasma leakage. Patients may also present with hypotensive shock. Patients may also be asymptomatic. One diagnostic test is called the tourniquet test. A blood pressure cuff is inflated at a pressure between the systolic and diastolic pressure. If it creates the appearance of petechiae in numbers more than 20/inch on the skin, then the test is positive (it shows an increase in capillary fragility and thrombocytopenia). Dengue IgM antibody titers can be tested for as well. Prophylaxis includes using DEET and treatment consists of hydration and bed rest.

My Synopsis of "Treatment-Resistant Depression"

Treatment-Resistant Depression
ALISON LITTLE, MD, MPH, Oregon Health & Science University, Portland, Oregon
Am Fam Physician. 2009 Jul 15;80(2):167-172.
http://www.aafp.org/afp/2009/0715/p167.pdf

     Depression is seen in up to 15% of the population, but only 60% get treatment. Of those treated, between 1/3 and 2/3's of the patients do not respond to initial treatment. Depression is considered treatment-resistant when failure occurs with at least two different drug classes (given for at least 8 weeks). Serum levels can be drawn to determine if the patient was properly taking and receiving an adequate dose. At this point, the clinician should go back and confirm the diagnosis. Comorbid disease treatment should be optimized as well. A psychotherapy consult may be warranted, even though effectiveness data is limited. Combination therapy may provide added benefit.
     Different medication classes have different side effects. TCA's can cause cardiovascular, anticholinergic, sedation and weight gain issues. MAOIs can lead to malignant hypertension when mixed with certain foods. Venlafaxine can cause nausea and vomiting. Paroxetine can cause sexual side effects. Mirtazapine can cause weight gain. Sertraline can cause diarrhea.
     The STAR*D trial was designed to treat resistant depression, where different combinations of medications were used in a stepwise manner to achieve remission. Patients who needed more steps were more likely to experience relapse. Only about half of the patients achieved sustained remission. ECT can be used when medication is contraindicated. It's major side effect is transient cognitive impairment. Vagal nerve stimulation has not shown benefit over placebo.

My Synopsis of: "Antibiotic Use in Acute Upper Respiratory Tract Infections"

My Synopsis of:
Antibiotic Use in Acute Upper Respiratory Tract Infections
ROGER ZOOROB, MD, MPH; MOHAMAD A. SIDANI, MD, MS; RICHARD D. FREMONT, MD; and COURTNEY KIHLBERG, MD, MSPH, Meharry Medical College, Nashville, Tennessee
Am Fam Physician. 2012 Nov 1;86(9):817-822.
http://www.aafp.org/afp/2012/1101/p817.pdf

     Most URIs are viral and do not need antibiotic treatment. The End.
     Overuse of antibiotics causes.....you know the rest.


     You're still here? ok well, I guess i'll give you the long version. The common cold is almost exclusively viral. Symptoms are sore throat, runny nose (regardless of color), cough, sneezing, and nasal congestion.
     Influenza is viral. The best treatment is vaccination prophylaxis. Patients who are older than 65, younger than 2, pregnant, or have severe or chronic illness should be treated with antivirals (neuraminidase inhibitors).
     Rhinosinusitis is inflammation of the nasal mucosa. If the infection is bacterial, there will be purulent nasal discharge, maxillary tooth pain, maxillary sinus pain, and symptoms which have worsened after an initial period of improvement. The clinician should wait for the symptoms to be present for 10 days before considering the infection to be bacterial. The primary bugs in rhinosinusitis are S. pneumoniae, H. influenzae, and M. catarrhalis. First line medication is amoxicillin, or TMP/SMX if the patient allergic to penicillin. A short course of therapy is as effective as a 10 day course.
     Otitis media is an infection of the middle ear. The most common bugs are H. influenzae, S. pneumoniae, and M. catarrhalis. Infants (less than 8 weeks old) may be infected by GBS, gram-negative enterococcus, or C. trachomatis. This group should get a full sepsis workup. Patients less than two years old with bilateral OM should be started on antibiotics (amoxicillin) immediately. Ceftriaxone is a good second line medication. If there is no improvement after 3 days, the patient should be assessed and given amoxicillin/clavulanate.  
     Most pharyngitis infections are viral. If it is viral, it is most likely group A beta-hemolytic strep. The modified centor criteria can help guide treatment. The parameters are:
no cough (1)
age 3-14  (1) or above 45 years old (-1)
anterior cervical lymph node inflammation (1)
fever (1)
tonsillar redness or fever (1)
In a person with a score of 1, testing should be done. If the score is 2-3, then rapid antigen testing should be performed. A person with a score of 4 or higher should get antibiotics (amoxicillin, azithromycin, or first generation cephalosporins).
     Laryngitis is inflammation of the vocal cords or larynx. Symptoms include cough, fever, runny nose, muffled voice, and headache. It is almost always viral and self limited.
     Epiglottitis affects the epiglottis and can cause death if it closes off the throat. The most common bug is S. aureus and MRSA (H. influenzae B is no longer a significant problem because of vaccination). Antibiotic treatment includes ceftriaxone, cefotaxime, or ampicillin/sulbactam.
     Bronchitis is inflammation of the trachea and large airways. The most common bugs are B. pertussis, C. pneumonia, and M. pneumonia. The infections are self limiting and do not require antibiotics unless pneumonia develops, or the patient is immunocompromised.

My Synopsis of "Diagnosis and Treatment of Acute Pyelonephritis in Women"

My Synopsis of:
Diagnosis and Treatment of Acute Pyelonephritis in Women
RICHARD COLGAN, MD, and MOZELLA WILLIAMS, MD, University of Maryland School of Medicine, Baltimore, Maryland JAMES R. JOHNSON, MD, University of Minnesota, Minneapolis, Minnesota
Am Fam Physician. 2011 Sep 1;84(5):519-526.
http://www.aafp.org/afp/2011/0901/p519.pdf

     Pyelonephritis occurs when a bacterial infection from the bladder spreads up the ureter to the kidney and renal pelvis. It is most prevalent in females between 15-29 years old.  The most common bacteria is E. coli, followed by K. pneumoniae, S. saprophyticus, P. aeruginosa, GBS, and enterococci.  Risk factors include having sex at least three times a week per month,  previous UTIs, new sexual partners, spermicide use, and a family history of UTIs. Complicated pyelonephritis occurs in patients with an abnormal genitourinary tract.  Imaging (CT with contrast) is not necessary unless the symptoms are not resolving and an abnormal tract is suspected. Kidney function and metformin use will need to be addressed when contrast is used. These patients may present with a polymicrobial infection and a higher likelihood of antibiotic resistance.
     Clinical findings of pyelonephritis include urinary frequency, urinary urgency, dysuria, abdominal pain, fever, chills, malaise, nausea, vomiting, anorexia, and flank pain. Urinalysis will show leukocyte esterase, pyuria, hematuria, and WBC casts. A urine culture will grow at least "10 to the fifth degree" CFUs. A peripheral blood smear will show leukocytes. A blood culture is only used if the patient is sick enough to be admitted.
     Uncomplicated pyelonephritis can be managed as an outpatient. Patients who may need hospitalizations are those with comorbid conditions, hemodynamic instability, male, pregnancy, toxic appearance, severe flank or abdominal pain, or anorexia. Treatment in outpatient cases can be done with fluoroquinolones as long as the community resistance of E. coli is less than 10%.  Patients can get there first dose intravenously and then step down to an oral preparation. IV route is also better if the patient is having nausea and vomiting.  If E. coli resistance is above 10%, then a dose of ceftriaxone or gentamicin is given first. TMP/SMX is only effective in patients with known sensitivity. In certain cases it is given empirically with ceftriaxone or gentamicin.
    Complicated pyelonephritis usually gets admitted. They are started on a fluoroquinolone, an aminoglycoside, a broad spectrum cephalosporin, or a carbapenem.  They can also eventually step down to an oral medication. Pregnant women are given a second or third generation cephalosporin.
     Patients should improve in two to three days. If not, then a different treatment or alternative diagnosis should be considered.
   

"Treatment of Alzheimer Disease" (My Synopsis)

A synopsis of;
Treatment of Alzheimer Disease
BRADFORD T. WINSLOW, MD, Swedish Family Medicine Residency, Littleton, Colorado MARY K. ONYSKO, PharmD, University of Wyoming School of Pharmacy, Laramie, Wyoming CHRISTIAN M. STOB, DO, Denver Health Medical Center, Denver, Colorado KATHLEEN A. HAZLEWOOD, PharmD, University of Wyoming School of Pharmacy, Laramie, Wyoming
Am Fam Physician. 2011 Jun 15;83(12):1403-1412.
http://www.aafp.org/afp/2011/0615/p1403.pdf

     Alzheimer's disease is a progressive disease that affects memory and cognition. About 50% of people over 85 have it. It is more common in women. It occurs through the accumulation of amyloid plaques and neurofibrillary tangles. It leads to loss of neurotransmitters, inflammation, ischemia, cholesterol metabolism, and mitochondrial metabolism. Although thoroughly studied, there does not appear to be evidence that diet, environment, disease, or socioeconomic factors are associated with alzheimer's disease. The author appears to be hopeful,according to the abstract.
     There are a few different types of medications used in the treatment of alzheimer's disease. Donepezil, rivastigmine, and galantamine are acetylcholinesterase inhibitors which stop the enzyme that destroys the acetylcholine. It is a first line agent for any stage of alzheimer's disease.  It has shown improvement in behavior and ADLs, but the effect is small. If the medication does not help in 8 weeks, it can be discontinued.
     Memantine is an N-methyl-D-aspartate receptor antagonist, which is thought to lower amino acid neurotoxicity by preventing glutamatergic activity. It can be used to treat moderate to severe alzheimer's disease. The effect on cognition is statistically significant but not clinically significant. Its benefits in moderate alzheimer's disease are inconsistent, but its better than nothing.  Combining memantine and acetylcholinesterase inhibitors does not appear to show much benefit.
     Selegiline is a MAO-b inhibitor that appeared to have improvement in cognition, but the benefit is no different than placebo after six weeks.  Antipsychotics, such as olanzapine and risperidone, have been used to treat agitation in the past, but are not recommended because they cause worsening of functional ability. Estrogen and vitamin E have also not shown benefit. Testosterone has shown mild improvement to quality of life, but it is not clinically meaningful and does cause an increase of cardiovascular side effects.
     Once a patient is diagnosed with alzheimer's disease, a baseline functional assessment should be performed. The patient and family need to be educated on the disease process. If the condition is severe, the patient is started on an acetylcholinesterase inhibitor (with or without the memantine). If the disease is moderate, then the patient will be treated with the acetylcholinesterase alone. During the first 2-4 weeks of treatment, any side effects should be addressed. The medication can be switched to another acetylcholinesterase if the patient cannot tolerate it. Memantine can be added if the disease becomes severe. The medication can be stopped if the patient continues to deteriorate, if the patient is noncompliant to the medication, if the patient develops a serious comorbid disease, or if the patient/ caregiver decide to discontinue it.
   

"Pharmacologic Management of Adult Depression" (My Synopsis)

My Synopsis or AFP's
Pharmacologic Management of Adult Depression
STEPHEN M. ADAMS, MD; KARL E. MILLER, MD; and ROBERT G. ZYLSTRA, EdD, LCSW University of Tennessee College of Medicine, Chattanooga, Tennesse
Am Fam Physician. 2008 Mar 15;77(6):785-792.
http://www.aafp.org/afp/2008/0315/p785.pdf

     The incidence of depression is over 10% in all patients presenting in the outpatient setting. Only about 50% of depressed patients will respond to treatment of a single antidepressant. Only about 1/3 of these patients will have remission after 12 weeks. In patients who respond to treatment, it may take at least 8 weeks for a response to occur.
     TCAs are antidepressants medication that block norepinephrine and serotonin reuptake. Examples include amitriptyline, imipramine, and nortriptyline. side effects include weight gain, sedation, constipation, dry mouth, orthostatic hypotension and reflex tachycardia. TCAs are metabolized by the P450 system. An overdose from TCAs can be fatal but may only just cause respiratory depression, arrhythmias, hallucination and hypertension.
     SSRIs, including citalopram, escitalopram, fluoxetine, paroxetine, and sertraline, inhibit serotonin reuptake presynaptically. SNRIs, including duloxetine and venlafaxine, inhibit serotonin and norepinephrine reuptake presynaptically. Side effects from these drugs include agitation, insomnia, GI problems, and sexual disfunction. They are also metabolized by the P450 system. Medications that are metabolized by the P450 system slow the metabolism or other medications using the P450 system, thus SSRIs and TCA don't play well together.
     Bupropion inhibits presynaptic reuptake of norepinephrine and dopamine. Mirtazapine blocks 5HT2A and 5HT2C serotonin receptors. These two can interact with TCAs and SSRIs. MAOIs are not often used due to their poor side effect profile when mixed with certain foods.
     Different antidepressants do different things (duh). Amitriptyline is more effective but has more side effects. Fluoxetine is less effective than other meds. Mirtazapine has a faster onset of action, but can affect sleep and increase weight gain. Bupropion increases weight loss and does not cause sexual side effects. Of the SSRIs paroxetine causes the most weight gain, fluoxetine causes the least.
     Whichever treatment is used, the patient needs to give the medication 1-2 months to let it take effect before changing it or adding something else. If the medication does work, its need to be continued for 6 months to a year to prevent relapse. SSRIs and SNRIs need to be tapered slowly to avoid "discontinuation syndrome".
    Patients who received psychotherapy, CBT or regular contact from their doctor ( in the form of office visits or phone calls) have a higher rate of compliance. Adding benzodiazepines to antidepressants help compliance.  Patients who receive a combination of psychotherapy and medication get more benefit than only one.
   

"Behavior Disorders of Dementia: Recognition and Treatment" (My Synopsis)

My synopsis of "Behavior Disorders of Dementia: Recognition and Treatment"
ABI V. RAYNER, M.D., M.P.H., JAMES G. O’BRIEN, M.D., and BEN SCHOENBACHLER, M.D., University of Louisville School of Medicine, Louisville, Kentucky
Am Fam Physician. 2006 Feb 15;73(4):647-652.
http://www.aafp.org/afp/2006/0215/p647.pdf


     Dementia can lead to cognitive and psychotic features. Cognitive features include agitation, wandering, and aggression. Hallucinations, delusions, and delusional misidentifications are examples of psychotic features. The psychotic features are more of a burden to the caregiver than the cognitive ones. The first step in management is to find and remove any precipitating factors (drugs, alcohol, caffeine, hunger, or thirst). The caregiver should have a good understanding about the disease and the manifestations. It is important to create a safe environment for the patient, by removing weapons, as well as furniture that may promote tripping or falls. There are several behavioral techniques that should be used when dealing with dementia patients. Trying to reason with dementia patients is not as effective as trying to distract them. Closed-ended questions are less confusing than opened-ending questions. Rather than responding to the content of what the patient is saying, it may be better to respond to the emotional content (validation therapy). Recounting pleasurable memories and experiences is known as reminiscence therapy.  Setting a daily schedule for these patients, like having meals at the same time each day, will provide beneficial consistency for these patients.
     With all medications for the elderly, it is better to start with one medication at a time, and with the lowest dose possible. First line agents for psychotic symptoms is atypical antipsychotics (clozapine, olanzapine, quetiapine and risperidone). They are better tolerated and cause less extrapyramidal side effects (especially quetiapine) than typical antipsychotics. Patients on atypicals may have exacerbations of tremor, rigidity, dystonia, and dyskinesia. These medications can be sedating, so they are better given at night.
     The typical antipsychotic used to manged delirium and acute agitation is haloperidol (olanzapine is the atypical antipsychotic that works well with acute agitation). The most common side effect is prolonged rigidity.
     Anticonvulsants/ mood stabilizers (depakote and carbamazepine) are second line agents for dementia. The narrow therapeutic window of carbamazepine somewhat limits its use. Sedation is common with these medications.
     The acetylcholinesterase inhibitors are donepezil, galantamine, and rivastigmine. These medications may delay cognitive loss in dementia. They are not effective for psychosis and thus are used as adjunctive therapy.
     The two anxiolytics are buspirone and lorazepam. Although these are commonly used in dementia, they are not first line therapy and there is little research to support its usage. They are specifically used in patients with acute agitation. Patients with lewy body syndrome may worsen when these medications are used.

My Synopsis of AFP's "Recognition and Evaluation of Nontraumatic Subarachnoid Hemorrhage and Ruptured Cerebral Aneurysm"

Recognition and Evaluation of Nontraumatic Subarachnoid Hemorrhage and Ruptured Cerebral Aneurysm
AARON A. COHEN-GADOL, MD, MSc, and BRADLEY N. BOHNSTEDT, MD, Indiana University School of Medicine, Indianapolis, Indiana
Am Fam Physician. 2013 Oct 1;88(7):451-456.
http://www.aafp.org/afp/2013/1001/p451.pdf

     Nontraumatic subarachnoid hemorrhage is due to a ruptured aneurysm in the brain. If the clinician suspects an SAH, then the patient should be sent to the ER.  Most of the time the symptoms are generic and nonspecific. These kinds of patients are likely to be misdiagnosed. Common obvious symptoms include a thunderclap headache or the "worst headache on my life".  Patients may state that the headache feels "different" than ones previously experienced. Other less common symptoms include back pain, meningismus, dysphagia, lightheadedness, dizziness, nausea, weakness, or focal neurologic deficits. Patients with autosomal dominant polycystic kidney disease have an increased risk of SAH. Questions that you can ask to qualify the patient include asking about headache severity, headache onset, previous history of aneurysm or SAH, significant family history, smoking history, alcohol and illicit drug history, and history of hypertension.
     All patients with a suspected SAH should reflexively get a noncontrast CT head. The most common reason for misdiagnosis is not getting a CT. It is 85% sensitive if done within 5 days, but 50% sensitive if done after a week. It may also be hard to identify on CT if the patient has a hemoglobin below 10 g/dL. Negative CT results will trigger an LP. A positive LP will show xanthochromia (blood breakdown causing a yellow discoloration). If the LP or CT was positive, then the patient will be sent for a CT angiogram. If it is negative then it will be repeated in a week. If it is positive then the neurosurgeon can decide on the course of action.
     MRI and fluid-attenuated inversion recovery (FLAIR) are other image studies that can be considered, especially of the patient cannot tolerate contrast.
   

"The Psychiatric Review of Symptoms: A Screening Tool for Family Physicians" My Synopsis of an Article from AFP

The Psychiatric Review of Symptoms: A Screening Tool for Family Physicians
DANIEL J. CARLAT, M.D., Anna Jacques Hospital, Newburyport, Massachusetts
Am Fam Physician. 1998 Nov 1;58(7):1617-1624.
http://www.aafp.org/afp/1998/1101/p1617.html

     This article describes a really nice way to go over a psychiatric review of systems (PROS) when interviewing the patient. Even though time is limited when the doctor is with the patient, this is an important part of the physical exam that should not be ignored. The mnemonic is  "depressed patients seem anxious, so claim psychiatrists". The mnemonic stands for;
Depression (bipolar disorder, dysthymia)
Personality disorder (borderline personality disorder)
Substance abuse
Anxiety (panic with agoraphobia, OCD)
Somatization and eating disorders
Cognitive disorder (dementia, delirium)
Psychotic disorders (schizophrenia, delusional disorder)
     When interviewing the patient, it is important to try to build a rapport before beginning the psychiatric questions. Patients may feel embarrassed or ashamed. Normalization is an interviewing technique where the clinician lets the patient know that the behavior in question is normal or an understandable reaction to the situation. Symptom assumption is phrasing the question in such a way that the clinician assumes the behavior is occurring (like saying "how much do you drink" instead of "do you drink". Transitional technique is a way to create a smooth flow between questions, rather than jumping around from topic to topic. It expedites the interview process.
     D. For depression, the clinician can simply ask "are you depressed?" If the patient says yes, then the clinican can go into the neurovegetative symptoms of SIGECAPS (sleep, interest, guilt, energy, concentration, appetite, psychomotor, and suicide). Depression is diagnosed by having 4 symptoms plus a depressed mood for for at least 2 weeks. Dysthymia is having two of the following symptoms (sleep, guilt, energy, concentration, appetite) plus two years of depression.  A great question can be "when was the last time you WEREN'T depressed". For suicide, the questions should be asked in levels. The clinician should ask if the patient had ever thought about suicide. If the patient says yes, the questions can progress to questions about if there is a plan in place, if preparations have been made (getting bullets, pills, etc) and if the patient has ever attempted suicide. If the threat is significant, an urgent psychiatric evaluation may be needed.      Bipolar disorder can be screened for by asking "do you ever get so happy/ energetic that you begin to speak too fast or become too hyper". If so, then the mnemonic "DIGFAST"
(Distractibility,
Indiscretion,
Grandiosity,
Flight of ideas,
Activity increase,
Sleep deficit,
Talkativeness) can be used to look for a manic episode. A manic episode is defined as having three of the seven symptoms from the mnemonic with an elevated or irritable mood for one week.
      P. Borderline personality disorder is a fear of being abandoned after being rejected. Red flags include a history of doctor shopping, legal suits against doctors (or other professionals), attempted suicides, multiple brief relationships and marriages, and categorizing people into either "all good" or "all bad". The mnemonic is "I DESPAIRR"
(Identity problem,
Disordered affect,
Empty feeling,
Suicide behavior,
Paranoia or dissociative symptoms,
Abandonment terror,
Impulsivity,
Rage,
Relationship instability).
     S. Substance abuse can be discovered with the classic "CAGE" questions. The questions should be asked in a nonjudgmental way. Open ended questions such as "do you have a drink occasionally?" has shown to be way more sensitive over close ended questions like "how much do you drink?" A quick two question drinking test ("have you ever had a drinking problem?", and "when was your last drink?") is a simple and effective screener. Positive answers will be "yes" and "within the last 24 hours". Other drugs can be asked about in a similar fashion.
     A. Anxiety disorders can be screened for by asking  "are you an anxious or nervous person?"  These patients can also be screened for panic disorder, agoraphobia, and OCD. The clinician can ask about a history of panic attacks, limiting where the patient goes because of anxiety, and excessive compulsions or repetitive actions that interfere with normal activities.
     S. The mnemonic for somatization disorder is "Recipe 4 pain: Convert 2 Stomachs to 1 Sex". It means that somatization disorder is diagnosed by the presence of 4 pain symptoms, 1 conversion symptom, 2 GI symptoms, and 1 sexual symptom.  Eating disorders can be screeened for by asking if the patient has ever felt like they were overweight. If yes, then other behaviors, such as binging, extreme dieting, laxative use, vomiting, can be asked about.
     C. Cognitive disorders, such as dementia, can be determined by conducting formal cognitive testing if the patient has a possible history or impairment. Screening with the MMSE is ineffective in low risk patients. A rapid screen for memory problems can be done by asking the patient about the date and place, repeating 3 words now and later, and asking general questions that people would normally know (first president, who is Abe Lincoln, etc). Patients who struggle may need a more expansive evaluation.
     P. Psychotic symptoms include delusions, hallucinations, and looseness of association. Psychotic patients may also have concomitant depression, substance abuse, and dementia. These symptoms may be subtle and may take a little more investigation to discover. The clinician may ask quaestion such as "do you think that people must have stolen objects that are misplaced?", "does your mind play tricks on you?" or "do you ever think that you hear people in your home, coming for you?" Paranoia is another symptom which can be asked about.
      In any case, a quick screen is not absolute and should lead the clinician to a more detailed examination.