The Osler Institute Excellence in Continuing Medical Education “The Best of Series” Family Medicine Syllabus DAY 1 Anemia RX and DX Antibiotic Choices Alternative Medicine Evidence Based Medicine Doctor Patient Interaction Hypertension Pain Management Diabetes Mellitus Maintenance of Certification Test Taking Skills Acid Base and Electrolytes Renal Failure Anticoagulation Gyn Infections I and II Abnormal Vaginal Bleeding Menstrual Disorders and Menopause DAY 4 Reid Blackwelder Reid Blackwelder Reid Blackwelder Reid Blackwelder Reid Blackwelder Reid Blackwelder Reid Blackwelder Reid Blackwelder Reid Blackwelder Reid Blackwelder Reid Blackwelder Reid Blackwelder Reid Blackwelder Evelyn Figueroa Evelyn Figueroa Evelyn Figueroa DAY 2 Geriatric Nutrition Vitamins and Minerals Abuse and Neglect Urinary Incontince Delirium Dementia Mgt of Geriatric Behavioral Problems Geriatric Pharmacology Geriatric Screening and Prevention Parathyroid Thyroid Growth and Growth Disorders Adrenal and Gonadal Disorders Common Eye Problems Brian Krause Brian Krause Brian Krause Brian Krause Brian Krause Brian Krause Brian Krause Eron Manusov Eron Manusov Eron Manusov Eron Manusov Eron Manusov Eron Manusov Eron Manusov Eron Manusov DAY 5 Larry Johnson Larry Johnson Larry Johnson Larry Johnson Larry Johnson Larry Johnson Larry Johnson Larry Johnson Larry Johnson William Bryant William Bryant William Bryant William Bryant David Stager Jr DAY 3 Fibromyalgia Preventative Medicine Congestive Heart Failure Obstructive Sleep Apnea Skin Disorders Rheumatic Syndromes Hyperlipidemia Ped Exanthems Adolescent Gynecology I and I Infertility & ART Contraception Osteoporosis Urinary Tract Statistics and Epidemiology HIV Testing and Counseling Primary Care Management of HIV Psychiatry I (Medical Psychiatry) Psychiatry II (Psychopharmacology I) Psychiatry III (Psychopharmacology II) Psychiatry IV (Psychopharmacology III) Psychiatry V (Psychiatric disorders) Psychiatry VI (Substance Abuse) Psychiatry VII (Ethics) Pediatric Orthopedics Hand and Wrist Injuries Questions and Answers Shoulder Pain Foot and Ankle Electrocardiograms Cardiac Arrhythmias White Cell Disorders Signs, Symptoms and Evaluation, and Cystic Fibrosis Asthma and RSV Bronchiolitis COPD Restrictive Lung Disease Sexual Assault Breast Disease I and II Pelvic Pain Evaluation I and II Other OB Topics I and II Neurology I Neurology II John Saito John Saito John Saito John Saito Robert Kauffman Robert Kauffman Robert Kauffman Robert Kauffman Ajay Gupta Ajay Gupta DAY 6 William Geiger William Geiger William Geiger William Geiger William Geiger William Geiger William Geiger William Geiger Melvin Thornton Melvin Thornton Melvin Thornton Beth Fox Beth Fox Abass Hyderi Abass Hyderi Abass Hyderi Peripheral Vascular Disease Acute Coronary Syndrome Trauma Assessment Lower Back Problems Sports Medicine Mouth and Esophagus GERD and Dyspepsia and Peptic Ulcers GI Cancers Small Bowel Disorders Colitis and Colonic Diseases Liver Disease and Cirrhosis Pancreatitis and Pancreatic Cancer Acute Abdomen Palliative and End of Life Care Cancer Detection Eric Coris Eric Coris Eric Coris Eric Coris Eric Coris Leslie Smith Leslie Smith Leslie Smith Leslie Smith Leslie Smith Leslie Smith Leslie Smith Leslie Smith Lenny Salzberg Lenny Salzberg Questions or comments on this or any other Osler products please contact us at (800)356-7537 or [email protected] The Osler Institute Excellence in Continuing Medical Education “The Best of Series” Family Medicine Syllabus Reid B. Blackwelder , MD Professor & Director of Med Student Education ETSU Quillen College of Medicine Robert P. Kauffman , MD Professor of Obstetrics and Gynecology Texas Tech University HSC School of Medicine William P. Bryant , MD Assistant Professor Children's Hospital at Scott and White Brian D. Krause , MD Psychiatrist Private Practice Eric E. Coris , MD Professor USF College of Medicine Eron G. Manusov , MD Director, Family Medicine Residency Southern Regional AHEC Evelyn Figueroa , MD Associate Program Director University of IL Hosp & Health Sciences System Beth A. Fox , MD Associate Professor ETSU Quillen College of Medicine William J. Geiger , MD, FAAFP Professor Medical College Of Wisconsin Ajay Gupta , MD Associate Professor of Neurology Cleveland Clinic Foundation Abbas Hyderi , MD, MPH Associate Professor University of IL Hospital & Health Sciences System Larry E. Johnson , MD, PhD Assoc. Professor of Geriatrics & Family Med. University of Arkansas John Saito , MD President & CEO Pulmonary & Sleep Disorder Consultants Lenard Salzberg , MD Associate Director Family Medicine Residency Southern Regional AHEC Leslie C. Smith , MD, MS, MA Professor University of IL David Stager, Jr , MD Assistant Clinical Professor of Ophthalmology Children's Medical Center Melvin H. Thornton II , MD Associate Professor of OB/GYN REI Columbia University Review of Anemias Reid B. Blackwelder, M.D. ([email protected]) Professor Family Medicine East Tennessee State University Goals Review the terminology used to discuss anemias Address clues in the history and exam that can direct the evaluation Describe one approach to using lab tests to suggest a diagnosis Review some aspects of treatment of common anemias Definitions Normal values vary according to age and gender (and lab) On the boards, you will always be given the normals in parentheses Definitions Anemia refers to a reduction in the number or volume of RBCs to less than a normal level. May occur due to: Acute/chronic blood loss Decreased production Breakdown of blood (hemolysis) Definitions & Interpretation Specific lab values must be interpreted in context of patient and illness Are Hgb levels of 14.0 in a male smoker, or of 12.5 in a severely volume contracted woman, "normal”? Clinical context and condition of patient determine urgency of Dx and Rx But the boards will not try to trick you! 1 Indices MCV (mean corpuscular volume) Useful index for distinguishing anemias If homogenous RBC population Normal MCV 82-97 fL Macrocytosis > 97 fL Microcytosis < 82 fL Peripheral Smear Spherocytes/Ovalocytes Sickle cells Schistocytes Traumatic hemolysis Prosthetic valve DIC TTP Hemolytic-uremic syndrome Indices RDW (red blood cell distribution width) If elevated, indicates variability of RBC (anisocytosis) Unreliable value in diagnosis Peripheral Smear "Teardrop" cells Bone marrow disease (fibrosis, tumor) Oval macrocytes and hypersegmented polys: Megaloblastic anemia Immature (blast) cells Leukemia History Associated with Anemia “Evaluation of Anemia” Evaluation of a Patient with Anemia Patient, not Disease-centered Presence of Inherited Anemia Spherocytosis, ovalocytosis Hemoglobinopathy Presence of Chronic Illness Chronic infection Diabetes Hypothyroid, renal, hypoadrenal Collagen vascular diseases Malignancy 2 Social Hx Associated with Anemia Nutritional Strict vegan (B12) Few fruits/veggies (folate) Alcohol use (folate, marrow suppression, liver disease) Symptoms attributable to anemia alone History Associated with Anemia Surgery Partial or total gastrectomy Medications can cause Bone marrow depression Hemolysis (G-6-PD deficiency) Review of Systems Pregnancy & Menses Symptoms suggesting undiagnosed medical problem Physical findings Pallor of oral mucosa/conjunctiva Usually not present until Hgb level less than 7-8 g/dl No correlation between level and signs/symptoms Often not present if anemia develops slowly Physical findings – Volume Status Orthostasis Baseline tachycardia Widened pulse pressure Flow murmurs Flat neck veins Decreased urine output Decreased turgor Palmar crease pallor suggests hgb <7 g/dl Fun fact to amaze students with your wisdom Physical findings - Skin Jaundice (hemolysis) Petechiae/ecchymoses (bleeding disorders) Lymphadenopathy (malignancy/infection) Glossitis, macroglossia (pernicious anemia) Angular cheilitis (Fe deficiency) 3 Physical findings - Neurologic Paresthesias Dementia Ataxia Decreased proprioception/vibration sense (pernicious anemia) Laboratory Tests Approach varies greatly depending upon reference, anecdotal experience, circumstances, etc Regardless of approach, have a rationale Recognize the difference between patient in office vs in hospital (usually acutely ill) Try not to "shotgun" (though we all do it!) Absolute Reticulocyte Count Abs Retic Count = Retic Count x RBC Abs retic count < 100,000 suggests defect in RBC production Abs retic count > 100,000 suggests acute bleeding or hemolysis Physical findings Heme positive stool (GI loss) Splenomegaly Hemolysis Sequestration Malignancy One Approach CBC Peripheral smear Check retic count Various Pearls Serum Fe Negative acute phase reactant Decreases with any stress (fever, etc) TIBC Only elevated in Fe deficiency Also a negative acute phase reactant % Saturation Decreases in both Fe def and ACD 4 Various Pearls - Ferritin Proportional to body's iron stores Generally both increase with age Less than 16-35 ng/dl suggests depleted stores If older than 65, less than 45 ng/dl Even though it is a positive acute phase reactant, must have Fe to elevate. Can have ferritin of 50-60 ng/mL and still have Fe-deficiency Bone marrow iron stores: "gold standard" Potential Evaluation Pathway Microcytic Anemia (MCV < 82fL) Suspect Anemia Check CBC, peripheral smear, Retic count Evaluation of Microcytic Anemia MCV, Abs Retic Count Microcytic Anemia MCV < 82fL Ferritin Level Low Normal or High Check serum Fe Low Normal or High Fe Deficiency Anemia AOCD Check serum lead High Normal Hgb Electrophoresis Lead Toxicity Check Ferritin level Low value (generally<30 ng/mL) suggests/confirms iron def Normal or high value - check serum iron Serum Fe Low Fe - anemia of chronic disease (ACD) Normal or increased - check serum lead level Lead Level High - lead toxicity • Anemia is late sequellae, by the way Normal - do Hgb electrophoresis Thalassemia Thalassemia, Other Fe-Deficiency vs. Anemia of Chronic Disease s Fe-Def Serum Fe (40-150 mcg/dl) Low TIBC(Transferrin)(200-400µg/dl) High % Sat (Fe/TIBC) (16-60%) Low Ferritin: m: 16-200 ng/ml f: 4-160 ng/ml Low ACD Low Nl or Low Low Causes of Iron-Deficiency Anemia Increased need Pregnancy Normal growth Nl or High 5 Causes of Iron-Deficiency Anemia Causes of Iron-Deficiency Anemia Decreased Intake or Absorption Increased blood loss Childhood Gastric surgery Achlorhydria Celiac sprue Fe-Deficiency Anemia 10-25% young women 1% men Up to 10% elderly 10-20% pts w/Fe def anemia have CA Up to 50% pts have GERD/PUD GERD, PUD, gastritis Inflammatory Bowel Disease Malignancy Menstruation Treatment Retic count up by 2 weeks Anemia corrected by 6 weeks 4-6 months to correct depleted Fe stores Fe-Def vs AOCD? To distinguish Fe-def vs. AOCD in an elderly ill patient Consider empiric trial of Fe replacement. Be sure to follow retic and Hgb If no change in 2-3 weeks, stop Fe Potential Evaluation Pathway Normocytic Anemia (MCV 82-97 fL) 6 MCV 82-97 fL Evaluation of Normocytic Anemia Corrected Abs Retic Count Changes of Marrow failure Yes No Bone Marrow Bx ACD Check Corrected Absolute Reticulocyte Count High Low or Normal LDH, Haptoglobin Normal Response to Blood loss Abnormal If Low or Normal… Any changes suggesting marrow failure? Coombs Positive Negative Hemolytic Dz Splenomegaly No Yes Hypersplenism, Drug, Infection, Hemoglobinopathy Evaluation of Normocytic Anemia Any changes suggesting marrow failure? Yes Do bone marrow biopsy • Myelodysplasia • Infiltrative disease • Aplastic anemia Evaluation of Normocytic Anemia Corrected Absolute Reticulocyte Count… High: Check LDH, haptoglobin Normal - can be expected response to blood loss Abnormal - check Coombs No Dx is AOCD Evaluation of Normocytic Anemia Corrected Absolute Reticulocyte Count…High: Any splenomegaly? Yes - Check RBC morphology and Coombs Negative Coombs - hypersplenism, drug effect, infection, hemoglobinopathy Positive Coombs - hemolytic disease No Hemolytic disease Causes of Normocytic Anemia Decreased RBC production Bone marrow failure Aplastic anemia RBC destruction/loss Acute blood loss (may be occult) Hypersplenism Hemolytic anemia 7 Hemolytic anemia Anemia of Chronic Disease - Rx Intrinsic RBC anomalies If AOCD, iron replacement doesn't help and may be detrimental Consider erythropoietin therapy Spherocytosis G6PD defects Hemoglobinopathies Check epo levels, iron studies Provide Fe as well May or may not be appropriate Rx now Extrinsic factors Mechanical Infectious (DIC) Autoimmune antibodies Goal Hgb level 10-12 Higher increases morbidity and mortality MCV >97fL Evaluate smear for megalocytes Present Examples of Evaluation Pathways Macrocytic Anemia (>97 fL) Absent Megaloblastic Anemia Non-Megaloblastic Anemia Check B12, Folate Abs Corr Retic Count Low Normal High Low or Normal Deficiency Drug, Idiopathic Liver/Thyroid Dz Schilling’s Bone Marrow Bx Hemolytic Dz Acute Blood Loss Hypersplenism No Yes Aplastic Anemia Evaluation of Macrocytic Anemia Look for macrocytes, hypersegmented polys If Present - Megaloblastic anemia Check B12, Folate levels One or both low - deficiency (replace) If levels normal - consider due to drug or idiopathic • Referral for eval, bone marrow Evaluation of Macrocytic Anemia Look for macrocytes, hypersegmented polys If Absent - Non-megaloblastic anemia Review Abs Corrected Retic Count 8 Evaluation of Macrocytic Anemia If Absolute corrected Retic Count is: Low or Normal Eval for liver disease, hypothyroidism If absent, aplastic anemia High Hemolytic disease Acute blood loss Hypersplenism Evaluation of Macrocytic Anemia The most common cause of macrocytosis? Alcohol Transfusion Avoid transfusion "triggers" Plan for autologous blood if possible Administer unit-by-unit based on reassessment Transfuse to relieve symptoms related to blood loss when other replacement has failed Evaluation of Macrocytic Anemia Many drugs can cause macrocytosis without megaloblasts Phenytoin OCs Methotrexate Barbiturates TMP-SMX Zidovudine Treatment of Macrocytic Anemia Must be tailored to cause Discontinue offending drugs/agents Replacement Folic acid: 1 mg/d Vit B12 • 1000 microgram/d IM for 5 days, then weekly until Hct normal, then monthly for life (medical myth) • Studies suggest po replacement as effective Closing Clinical Pearls Remember to put the numbers into the clinical context Labs done on ill patients in the hospital are different than in an outpatient evaluation Try not to shotgun Or at least admit we are doing it! 9 This page was intentionally left blank. A Clinical Approach to Antibiotic Use Reid Blackwelder, MD Professor, Family Medicine James H. Quillen College of Medicine Goals Review how to choose an antibiotic Discuss the factors involved in this dance Review antibiotic classes (not all) Consider specific indications Review adverse reactions Suggest some selections based on particular infections Choosing an Antibiotic Identify the organism! Or at least consider the most likely ones This can seem unimportant Clinical “Pathways” or “Protocols” make decisions for you Gram stains seem less commonly used It requires a good history, exam and clinical thinking Clinical Decision Making If you are uncertain about exactly what antibiotic to prescribe… Challenge yourself to think or write down the most likely organism… And the clinical context This is a dying art! The History and Exam Still the most likely ways to help prioritize likely causes, and what the boards use most! 1 The History – Likely Cause of Pneumonia for… Shaking chill and rust-colored sputum Pneumococcal A farmer who delivered a sick calf, with myalgias, fever Q fever 2 weeks of illness with onset of sore throat, cough The Physical Exam – Likely cause of Pneumonia if… A vesicular lesion on the tympanic membrane in a patient with an atypical presentation Mycoplasma The black necrotic lesion of ecthyma gangrenosum Pseudomonas Mycoplasma The Lab (Gram stain) – Likely cause of Pneumonia if… Gram positive lancet-shaped diplococci Strep Pneumoniae Large gram positive bacilli Klebsiella Small pleomorphic gram negative coccobacilli Haemophilus influenzae Boards and Practice Obviously, these skills are critical in your daily practice Patients usually present with less than the “classic” history or physical findings Board questions are much more likely to present a “typical” picture Pharmacokinetics The antibiotic must be able to reach the site of infection at adequate concentration Not all antibiotics can reach the prostate Skin infections Meningitis And do so not to fool you 2 As a class, Penicillins are: Bactericidal Inhibits cell wall mucopeptide synthesis Penicillin G Drug of choice for Syphillis Neisseria meningitidis Pasteurella multocida Actinomyces Active against most anaerobes Not useful against Penicillin G Drug of choice for streptococcus Resistance becoming an issue Broad penetration into tissues Main ADR is allergy Aminopenicillins Ampicillin, Amoxicillin Activity Less active against streptococci Improved gram-neg activity Active against H. flu Gram negative organisms H. Influenzae Penicillinase resistant Penicillins Oxacillin, nafcillin, methicillin Drug of choice for S. aureus As a class, Cephalosporins are: Bactericidal Inhibit cell wall mucopeptide synthesis Not MRSA Less active against strep, anaerobes 3
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