1 Didactic Day 1
- Develop a PICO question appropriate to the family medicine setting
- Use point of care resources to locate information
- Appraise point of care information and apply to a specific patient case
Resource: Center for Information Mastery
Assignment (due Didactic Day 5): Information Mastery Presentation
Mobile MediCard: Information Mastery
Jill McHale (Part 1): Fatigue
Jill McHale is a 43 year old woman who reports that she has been feeling very tired over the last few months. She lives with her husband Brian, her 15 year old daughter Theresa, and her 10 year old son Patrick. She does not work outside her home.
Over the years, she has gone to the emergency room on three separate occasions for fractures of her left clavicle, superficial trauma to her face, and a minor concussion.
She is withdrawn but pleasant in your office. She is 66 inches tall and weighs 120 pounds. (She weighed 135 pounds in your office six months ago). Her vital signs are normal, as is the rest of her physical exam. Health Maintenance including cervical cancer screening is all up to date.
Questions to Consider
- What additional history is needed?
- What is the differential diagnosis?
- What tests would you order (if any)?
- How would you manage this case?
- Develop a differential diagnosis of fatigue and depression.
- Screen for common causes of fatigue.
- List initial treatments for depression.
MAJOR DEPRESSIVE DISORDER DIAGNOSTIC CRITERIA – “SIGE CAPS”
To diagnose a major depressive episode, at least 5 of the following 9 symptoms must have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms must be either (a) depressed mood or (b) loss of interest or pleasure.
- Sleep – increased or decreased (if decreased, often early morning awakening)
- Interest – decreased
- Energy – decreased or fatigued
- Concentration/difficulty making decisions
- Appetite and/or weight increase or decrease
- Psychomotor activity – increased or decreased
- Suicidal ideation
- Depressed mood most of the day, almost every day
Required Reading: Common Questions About the Pharmacologic Management of Depression in Adults
Required Reading: No Magic Pill: A Prescription for Enhanced Shared Decision-Making for Depression Treatment
Required Reading: Fatigue: An Overview
- Describe an approach to the patient with acute pain
- Describe an approach to the patient with chronic pain
- Name indications for imaging in back pain
- Identify non-opioid treatment options for nonmalignant pain
- Develop a differential diagnosis for back pain
Low Back Problems in Adults
Reprinted with the permission of Ron Adler, MD
- Low back problems are extremely prevalent and costly.
- PCPs are ideally suited to being back problems experts.
- The most important diagnostic instruments are the history and the physical exam.
- A tiny percentage of primary care patients have serious conditions that can be suspected from the history.
- Routine spinal imaging tests are NOT indicated. Imaging tests are indicated in the setting of red flags (refer to below) or severe problems persisting beyond 1 month.
- Most back problems improve spontaneously; therefore, conservative management is almost always indicated.
- The most important therapeutic instrument is patient education.
- Most patients will have recurrent back problems.
- A small but substantial percentage of patients will have chronic problems.
- Early and gradual return to usual activities is superior to bedrest.
Initial Approach to the Patient
- Is there a serious systemic disease causing the pain?
- Is there neurologic compromise that might require surgical evaluation?
- Is there social or psychological distress that may amplify or prolong pain?
“Red Flags (consider imaging)”
- Failure to improve (>1 month)
- Prior history of cancer
- Unexplained weight loss
- History of osteoporosis
- Corticosteroid use
- Leg pain on walking
- Relieved by sitting or standing
- Onset <40 years old, gradual onset
- Pain duration >3 months
- Morning stiffness
- Improved by exercise
- Progressive pain
- Urinary or fecal retention or incontinence
- Neurological deficit
- Fever and/or constitutional symptoms
Cauda Equina Syndrome
- Nerve root compression causing urinary retention, bilateral weakness, saddle anesthesia.
- Neuro-surgical emergency
- Caused by massive midline disc herniation
- Prevalence among all with LBP: 0.0004
Required Reading: Integrative Pain Management
Required Reading: Chronic Low Back Pain
Required Reading: Acute Low Back Pain
Required Reading: Chronic Nonmalignant Pain
Mobile Medicard: Pain
Optional Reading: Acute Migraine Treatment
Optional Reading: Approach to Acute Headache
Complementary/Alternative Medicine RESOURCES
- Describe common complementary and alternative medicine approaches to pain and other symptoms.
- Identify which complementary and alternative medicine interventions are supported by evidence.
Traditional Chinese Medicine (TCM) is one of the most elaborate and highly developed systems of healing in the world (easily rivaling biomedicine). According to Daoist philosophy, the universe is divided into two opposing and complementary forces: yin and yang, which are expressed in various antagonist relationships (e.g., cold vs. heat, dry vs. damp). A state of perfect health exists when yin and yang in all their forms are perfectly balanced in every part of the body. Illness results when internal and external factors disrupt this balance and create a “pattern of disharmony”, which manifests as pain and other symptoms.
Acupuncture is one of several TCM interventions designed to influence the balance of yin and yang (others include Chinese herbal medicine, meditative exercises such as tai chi and qigong, dietary interventions, and manual therapies such as tui na). One manifestation of this balance can be found in the movement of Qi (pronounced chee), or TCM’s vital force. Qi flows in a series of corporeal “channels” called meridians. Fourteen major meridians form an invisible network connecting the body surface with the internal organs. By taking a detailed history and performing a physical exam, TCM practitioners identify obstructions or other irregularities (i.e., patterns of disharmony) in the optimal flow of Qi through the meridians, which manifest as illness. Acupuncturists insert and manipulate needles at various locations in one or more meridian (acupoints) to correct these irregularities and restore balance to the system. A related technique, acupressure, is based on the same principle but without the insertion of needles.
It is important to note that TCM and allopathic diagnoses bear little resemblance. Two different patients given the same allopathic diagnosis (e.g., tension headache), will have two different TCM diagnoses, which would be described using entirely incompatible terminology (e.g., stagnation of liver-qi or dampness-heat lodging in spleen). In Chinese-style acupuncture, which is commonly practiced in the US, needles are inserted beneath the skin and mechanically manipulated (by a twisting or pulling action) in order to elicit a dull, radiating sensation (called de qi). Needles may also be stimulated with heat or (in recent times) electric current. A typical acupuncture session involves the placement of multiple needles, sometimes a considerable distances from symptomatic part (on account of the meridian principle), which are left in place for a number of minutes. As with many allopathic interventions (e.g., physical therapy), a series of treatments (a minimum of four) are usually required before a patient can determine whether or not acupuncture is helpful. While most patients see acupuncturists for the treatment of chronic and recurrent pain, all illnesses could theoretically respond to a combination of TCM interventions.
Acupuncture is one of the fastest growing practitioner-based integrative therapies in the country, and it has become a highly professionalized clinical discipline. After 3½ years of classroom instruction and clinical training at fully accredited institutions, students graduate with one of several master’s degrees and must pass a series of board exams before practicing. Like physicians, the state board of medicine licenses acupuncturists. Unlike physicians, acupuncturists are largely reimbursement directly from their patients, as insurance coverage remains spotty.
A consensus on acupuncture’s efficacy (compared to sham acupuncture) for even a single condition has yet to emerge (and may never emerge). It is, nevertheless, still possible to draw a number of practical conclusions regarding acupuncture effectiveness from an ever-expanding research base. For many common, chronically painful conditions (e.g., neck and low back pain, osteoarthritis, headache syndromes, fibromyalgia), it can be stated with some confidence that acupuncture: (1) is more effective than no treatment, (2) is comparable to a variety of other treatments (e.g., massage, chiropractic, supervised exercise, cognitive behavioral therapy, many pharmaceuticals), (3) produces small effect sizes on average, and (4) is responsive to expectancy enhancement (see Session 13). One of the principle advantages of acupuncture is its record of safety in the US. As mentioned above, state government has taken on the responsibility of ensuring the competency of acupuncturists, and the FDA regulates single-use, disposable acupuncture needles as medical devices. The most common adverse effects are bleeding and pain at the insertion site. More serious harms, such pneumothorax or infection, are extremely rare.
In 1895, D.D. Palmer, a magnetic healer from Davenport, believed that he restored hearing to a janitor in his building by manipulating his cervical spine. This experience led him to develop a theory that vertebral subluxations (joint misalignments) interfered with the flow of a vital force, which he called innate intelligence, that travelled through peripheral nerves to nourish all tissues in the body. By manually “adjusting” the spine, these subluxations could be reduced and proper flow restored. It follows from this theory that this restoration could potentially impact all diseases. While relatively few chiropractors (the so-called “straights”) still subscribe to these early vitalistic views and restrict their practices to the original forms of spinal adjustments, most (the “mixers”) take an entirely biomechanical view of their work and employ a variety of other manual and non-manual (e.g., dietary supplements and lifestyle counseling) interventions to treat their patients.
Despite a long, acrimonious history of tension between chiropractors and physicians, nowadays it is not uncommon to find chiropractors well integrated into mainstream medical services. Three explanations best account this turn of events: (1) the existence of a robust research effort investigating chiropractic’s effectiveness, mostly for low back pain, (2) a recognition among allopaths of their own disappointing results for these same patients, and (3) modern chiropractic’s highly professionalized culture. Chiropractic training involves a four-year, fully accredited program, which confers a doctoral degree. Some chiropractors go on to do two or three-year postgraduate residency programs in specialized areas. They sit for boards and are licensed in all 50 states (by their own board). Unlike acupuncture, insurance coverage for chiropractic is common, but reimbursements may be limited.
Modern chiropractors by and large restrict their scope of practice to treating neuromuscular conditions anatomically related to the spine. While the majority of patients have low back pain, chiropractors also commonly see patients with neck pain, shoulder pain, upper/lower extremity pain and headache. A detailed history combined with anatomic and functional examinations is usually sufficient to diagnosis clinically relevant spinal misalignments or other pathology. Radiographs may occasionally be ordered. The primary method of manual adjustment involves the localized application of rapid (high-frequency), short (low-amplitude) manual thrusts, delivered in a controlled fashion, to increase the range and quality of joint motion. Other manual techniques, such as joint mobilization (passively moving a joint through its range of motion), as well as specialized devices (e.g., electrical stimulation) are also commonly employed. The scope of practice varies considerably from to state to state, but most chiropractors spend a fair amount of time educating their patients regarding diet, exercise and ergonomics. Some will also manage certain non-musculoskeletal conditions (e.g., migraine, irritable bowel syndrome). Repeat visits are standard in order to assess the effectiveness of treatment or to sustain benefits over the long-term.
Patient satisfaction with their chiropractic care is generally high. However, as with all manual therapies, controlled trials are hampered by the challenges involved in developing adequate sham controls. While attention controls (e.g., education and prescriptions for back exercises) are commonly employed (and better than nothing), the risk of performance bias is high since neither patients nor practitioners are blinded. The rare trials with adequate sham-controls may reduce, but cannot entirely eliminate, this bias. Like acupuncture, chiropractic is clearly better than no treatment for a range of painful conditions linked to the spine. For non-specific low back pain, its effectiveness appears to be comparable to most other treatments, including allopathic interventions like physical therapy and medications. Common adverse effects include temporary increase in local discomfort, radiating pain and fatigue. Serious adverse effects (e.g., worsening disc herniation or cauda equina syndrome) are extremely rare. A controversial association between cervical manipulation and vertebrobasilar artery (VBA) strokes has been published. Although some studies have shown a temporal association between visits to a health care professional (including chiropractors) and VBA strokes, cause and effect has not been established.
Along with medicinal herbs, massage is presumably the oldest from of treatment in the world. Like spinal manipulation, massage therapy maintains the ancient tradition of “hands-on” healing, though its origins predate chiropractic by many thousands of years. Virtually every culture throughout history has incorporated some type of massage into its system of healing. Shiatsu and tui na, for example, are techniques used in Traditional Chinese Medicine. Swedish massage, which integrates five basic stroke patterns (gliding, kneading, tapping, friction and vibration) focuses on muscles and is the most widely practiced form in US. Other more specialized massage techniques include myofascial release, reflexology (foot massage), trigger point therapy, and structural integration (e.g., Rolfing), which focuses more on connective tissue than muscles. Massage is sometimes combined with aromatherapy, in which the therapeutic effects of the essential oils from various herbs may contribute to its clinical benefit.
Most patients seek massage for the treatment of acute or chronic pain. Massage therapists are trained to manipulate soft tissues with the intension of reducing localized pain and improving function. The precise mechanisms by which this occurs is unknown, but probably involves some combination of local and systemic effects, including the promotion of a relaxation response; the release of intrinsic opioids (e.g., endorphins) in the central nervous system; the stimulation of inhibitory, large diameter afferent nerves; and enhancement of local blood and lymphatic circulation. Like all manual therapies for pain, the potential for a significant placebo response is ever present. Other potential indications for massage therapy include stress, anxiety, and promotion of growth in preterm infants.
Most of the evidence in support of massage therapy for pain comes from trials comparing it to no massage or an active/attention control. Most of the evidence is for short-term benefit only. Since it is not possible to devise a suitable control to adequately address the risk of performance bias (patients and therapist cannot be blinded), it is unknown to what extent the benefits of massage therapy differ from placebo. Fortunately, massage has the advantage of being quite safe, with limited risk of minor adverse effects (e.g., temporary increase in pain). Contraindications include direct application of over sites of acute inflammation or infection, severe osteoporosis, non-consolidated fractures, burns, deep venous thrombosis or active cancer.
Most states regulate massage therapy, but training and accreditation standards vary considerably. In states with regulatory oversight, a minimum of 500 hours of training from an accredited program is required. It’s important to note that massage therapy, like other hands-on modalities, involve talents that go beyond mere training and certification. This tends to create a high degree of variability in quality of care, even among the most well-trained therapists.
Tai Chi (or Tai Chi Chuan) is a venerable martial art form used more commonly for promoting health than for combat or self-defense. It falls under the general category of mind-body movement therapies, which also includes qi gong (also from Traditional Chinese Medicine) and yoga (Indian Ayurvedic Medicine). Numerous styles of tai chi have evolved over the centuries, but all involve a combination of slow, rhythmic circular motions, focused breathing, and mindful contemplation intended to restore the balance of Qi (see Acupuncture above). The most popular form in the West is the Yang Style, which ranges from 24 (simplified) to 108 (classical) postures or movements. Regardless of style, Tai Chi performed in the standing position with both knees slightly flexed.
Besides promoting a placebo response, tai chi may theoretically benefit health is several ways. With sufficient duration and complexity (i.e., pacing of alternating postures), tai chi practice provides a moderately intense level exercise. When practiced regularly, it may consequently enhance cardiopulmonary fitness, increase muscle strength and endurance, and improve postural stability. These effects have to lead to clinical trials investigating the benefits of tai chi for cardiovascular disease prevention, chronic obstructive pulmonary disease, multiple sclerosis-related fatigue, knee pain and function in osteoarthritis and rheumatoid arthritis, and fall risk in community-dwelling elderly, Parkinson’s disease and post-stroke rehabilitation. Since sham-controlled trials are not really feasible, the evidence for tai chi’s effectiveness comes largely from trials comparing it to no treatment or active/attention controls. Research is also compromised by the wide heterogeneity in tai chi practices across studies. Notwithstanding these limitations, evidence suggests that tai chi may modestly decrease the risk of falls and improve lower extremity pain in selected elderly patients. Despite a potential for injuries from falls during practice, studies have shown that tai chi is quite safe, particularly when led by an experienced instructor.
Unlike the great majority of clinical interventions, tai chi is most often done in group settings, which could theoretically contribute to its value. A typical class consists of progressive training in a particular form (most likely Yang Style). Each subsequent class adds more to the repertoire. Instructors are there to demonstrate proper technique, observe and correct participant postures, create an atmosphere of comradery, and encourage individual practice between sessions. Tai chi instructors are not licensed by states. Various tai chi organizations offer training and certification programs with differing criteria and levels of instructor certification.
Required Reading: Evidence for CAM Therapies
Optional Reading: Acupuncture
- Identify appropriate antibiotics for the treatment of infections common in the ambulatory setting.
Common Infections in the Ambulatory Setting – Best Antibiotic Choices
Consider no Rx and f/u prn (if >6 mo)
Common Bugs: S. Pneumo, H. Flu
1st Line: Amox (80/mg/kg/day, three divided doses)
Common Bugs: S. Pneumo, H. Flu
1st Line: Amox (consider double dose), Levofloxacin if resistant
Common Bugs: Group A strep
1st Line: PCN 500 bid x 10 days
Erythromycin x 10 D if PCN allergy Amox in kids (liquid amox tastes better than liquid PCN)
Common Bugs: S. Pneumo, Atypicals, H. Flu
1st Line: macrolide, doxycycline
Consider Levofloxacin if refractory,
Pt. is elderly, pt. has co-morbidities
|GI Tract Infections
Common Bugs: E. Coli, Salmonella, Shigella, Campylobacter, Parasite
1st Line (Bacterial): Cipro 500 BID x 3 days, initiate if Sx’s >24 hours, fever, bloody diarrhea;
Single-dose azithromycin for kids
1st Line (Giardia, Entamoeba):MetronidazolePseudomembranous Colitis
Common Bugs: C. Difficile
1st Line: Flagyl or PO VancoGU Tract Infections
Common Bugs: E. Coli, other Gram negs, S. Saphrophyticus
1st Line: Macrobid 100 BID x 5D, Bactrim DS BID x 3D
Cipro 250 BIDx 3D (second line)
Chlamydia: 1 gm Azithro po x 1
Gonorrhea: Ceftriaxone 250 IM x 1
& Azithro 1 gram PO x 1
Partner(s) must be treatedVaginitis
Candida: OTC antifungals or Fluconazole 150mg PO x T
Bacterial Vaginosis: Flagyl (po/pv) Trichomonas: Flagyl (treat partner)Skin Infections
Common Bug: P. Acnes
1st Line: Doxy (Beware of photosensitivity rxn)
Diclox/Keflex (QID), 2nd line: Clinda
Drain Abscess, Can use Bactroban for impetigo; MRSA: Bactrim, Doxy
Oral Antibiotics – Guidelines for Coverage of Common Bacteria
(Drug names below link to Lexicomp entry, accessible from any computer logged into Tufts library)
|Penicillins SE: GI upset, allergic reaction (rash, anaphylaxis), yeast infection, ↓ seizure threshold, C. diff colitis
+++ Group A Strep, oral anaerobes, T. pallidum
++ Strep pneumoniae,
— S. aureus, Gonorrhea
+++ Group A Strep, Listeria, oral anaerobes
++ Strep Pneumo, Enterococcus
+ H. Flu, Moraxella, E. coli
— S. aureus, Gonorrhea
+++ S. aureus, ++ Strep, + Oral anaerobes
— Gram Negs, MRSA
Amoxicillin/Clavulanic Acid (Augmentin)
+++ Group A Strep, oral anaerobes, H. flu, E. coli, Pasteurella multocida, S. aureus
++ Strep pneumo, Enterococcus
— resistant PneumococcusCephalosporins SE: GI upset, allergic reaction (5% cross-allergenicity with PCN), yeast infection C. diff colitis
1st Generation: Cephalexin (Keflex)
+++ Group A Strep, Strep pneumo
++ S. aureus, + H. flu, Moraxella, E. coli
2nd Generation: Cefuroxime, others
+++ H. flu, E. coli, Moraxella
++ Strep pneumo, other Gram (-), GC
|Macrolides SE: GI upset, allergic rxn (rare), yeast infxn, C. diff colitis.↑QT interval when combined w/ azoles (anti-fungals). Drug interxns: can increase levels of other drugs by inhibiting p450.
+++ “Atypicals” (Mycoplasma, Chlamydia, Legionella), Group A Strep, Pertussis
++ Strep pneumo, C. trachomatis,
+ S. aureus, H. Flu, Moraxella
Azithromycin, Clarithromycin (Biaxin)
+++ “Atypicals,” Group A Strep, C. trachomatis, Pertussis
++ Strep pneumo, H. flu, Moraxella, S. aureusTrimethoprim/Sulfamethoxizole
SE: Allergic reaction (rash, Steven’s Johnson Syndrome), GI upset, yeast infxn, C. diff colitis, E. multiforme, Anemia with G-6PD deficiency
+++ E. coli, PCP
++ Strep pneumo, H. Flu, Moraxella, MRSA
— Group A Strep, anaerobesTetracyclines SE: GI upset, photosensitivity rash, allergic rxn, C. diff colitis, yeast infection, bone/teeth discoloration: avoid < 8 yo, pregnant
+++ C. trachomatis, Lyme, P.Acnes, MRSA, RMSF, “Atypicals” (Mycoplasma, Chlamydia,
++ Strep pneumo, H. Flu, Moraxella
SE : disulfiram-like rxn (severe GI upset w/ EtOH), GI upset, metallic taste, allergic rxn
+++ Abdominal/Vaginal Anaerobes, C. difficile, Bact. vaginosis, Trich, Giardia, Ameobiasis
— Gram Negs, Gram PositivesClindamycin SE: GI upset, allergic rash, yeast infection,
C. diff colitis
+++ Oral/Vaginal Anaerobes,
S. aureus, Grp A Strep
++ Bacterial vaginosis, Strep pneumo, Trich
— Gram Negs, MRSAFluoroquinolones
SE: GI upset, allergic rxn (1%), HA, yeast infection, C. diff colitis. Damages developing cartilage: avoid in pregnacy, kids
+++Gram Negs, Pseudomonas
++ Gonorrhea, Enterococcus
— Anaerobes, “Atypicals” (Mycoplasma, Chlamydia pneumoniae, Legionella)
Levofloxacin (Levaquin), Gatifloxacin (Tequin)
+++ Gram Negs, Pseudomonas, “Atypicals” (Mycoplasma, Chlamydia pneumoniae, Legionella), Strep pneumo (including resistant strep)
— Anaerobes, Staph
Mobile Medicard: Antibiotics in the Outpatient Setting
- Use the USPSTF as a source for age-based prevention and screening services
- Use decision aids in making health maintenance recommendations
- Describe common cancer screening recommendations
Resources for Evidence-Based Preventive Medicine Guidelines
1) United States Preventive Services Task Force
AHRQ ePSS App: Free app with preventive guidelines by age and characteristics
Or use online at: https://www.uspreventiveservicestaskforce.org/Page/Name/tools-and-resources-for-better-preventive-care
Click for the different level of recommendation for guidelines (grade A, grade B…)
Required reading:Health Maintenance in School Aged Children I
Required reading:Health Maintenance in School Aged Children II
2) Statin Decision Aid and 10 year CV Risk Calculator
3) AAFP Summary of Recommendations for Clinical Preventive Services
4) Evidence-Based Cancer Decision Aid Tools (Mammogram Decision Aid Tool for Women 40-49, Prostate Cancer Screening)
Decision Tool: http://breastscreeningdecisions.com/#/
Article: How to Counsel Men About PSA Screening