25 Self Study (Alcoholism, Antibiotics, Autism, Health Systems, Immunizations, Patient Centered Communication, Simulation Experience and Sexuality, Transgender Care
Learning Objectives
- Screen for Alcoholism
- Use motivational interviewing with patients with alcohol misuse
required video: Alcoholism
Video: Alcoholism
Poul LaPlante MD 3/14/17
Underdiagnosis
- In primary care and hospitalized patients ETOH problem only diagnosed in about 40% of those suffering from it 1
Reasons for Underdiagnosis
- Lack of organized approach to diagnosis and treatment
- Denial prominent in alcohol problems, especially minimizing use
- Potential for conflict in confrontation with patients
- Feeling that this is not a medical problem 2
Diagnostic Tools (over 200)
- CAGE (1964): 4 questions; simple; best for severe disease
- MAAST and others: 10-30 questions; sensitive; time consuming
- AUDIT: current gold standard; 10 questions; Sensitive; somewhat time consuming
Drinkers When Quitting Complain Most
- Do you drink? If no, why not (US 60% adults drink alcohol)
- When was your last drink? (default 1-2 days )
- Ever cut down or quit? Normal drinkers don’t have to cut down or quit except in pregnancy or weight loss. Very high sensitivity for alcohol use disorder
- Has anyone complained about your drinking? Highest sensitivity
- Largest amount consumed in 1 sitting? Past year? + is ≥ 7 drinks for men, 5 for women
Associated Points of History
- Legal: 2 DUI arrests has extremely high sensitivity for presence of an alcohol use disorder
- Family History: 60% of alcoholics in detox have 1st degree relative with the disease
- Blackouts, injuries, morning drinking, drinking alone, unable to stop, previous treatment or AA, drink every day, drinking when unplanned or will affect responsibility, other drug use, tobacco use
Communicating Diagnosis
- Refer to “problems with alcohol” or “alcohol use disorder” rather than alcoholism
- Remain factual and neutral
- State why you are concerned (factual evidence)
- Talk about denial
- Outline natural history of alcohol misuse
Helping Patient Accept Diagnosis
- Get patients definition of alcohol problem
- Offer alternatives for definition
- “If drinking causes problems and you keep drinking, you have a drinking problem”
- “Inconsistent Inability to control Intake”
Treatment
- Evaluate for need of withdrawal management
- Suggest abstinence, if patient insists on moderating drinking
- Alcohol challenge test
- Suggest “Open” AA meeting; frame it in terms of learning more
- Deal with objections which may arise such as: God, bad with groups, will power, shy, afraid they will see people they know
Other Resources
- Smart recovery: good program, not many meetings
- Rational Recovery: on line only
- LICSW, psychiatrists, and others who have experience with addictions
Follow Up
- Inquire as to drinking status each visit; If someone is not receptive to talking about it today, they may be more open in the future.
- Avoid Benzodiazepines. If patient is unable to stay sober and is depressed, consider SSRI
- Adjunctive medications such as naltrexone, acamprosate, disulfiram of limited utility
References
- Moore, Richard. “Under-diagnosis” Journal of Medical Education (1987) 46-52
- Clark, William. “Primary Care Physician and the Patient with Alcoholism” American Journal of Medicine (1981) 275-286
Antibiotics Self-Study Learning Objectives
- Identify appropriate antibiotics for the treatment of infections common in the ambulatory setting.
Common Infections in the Ambulatory Setting – Best Antibiotic Choices
| ENT/Respiratory Infections Otitis Media 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) Acute Sinusitis Common Bugs: S. Pneumo, H. Flu 1st Line: Amox (consider double dose), Levofloxacin if resistant Pharyngitis 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) Pneumonia 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 Traveller’s Diarrhea 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 UTI (Uncomplicated) 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) |
STI’s 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 Acne Common Bug: P. Acnes 1st Line: Doxy (Beware of photosensitivity rxn) Cellulitis/Impetigo/Abscess 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 Penicillin +++ Group A Strep, oral anaerobes, T. pallidum ++ Strep pneumoniae, — S. aureus, Gonorrhea Amoxicillin +++ Group A Strep, Listeria, oral anaerobes ++ Strep Pneumo, Enterococcus + H. Flu, Moraxella, E. coli — S. aureus, Gonorrhea Dicloxacillin +++ 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. Erythromycin +++ “Atypicals” (Mycoplasma, Chlamydia, Legionella), Group A Strep, Pertussis ++ Strep pneumo, C. trachomatis, P. acnes + 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 Doxycycline +++ C. trachomatis, Lyme, P.Acnes, MRSA, RMSF, “Atypicals” (Mycoplasma, Chlamydia, Legionella) ++ Strep pneumo, H. Flu, Moraxella |
Metronidazole (Flagyl) 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 Cipro/Oflox/Norflox +++Gram Negs, Pseudomonas ++ Gonorrhea, Enterococcus + Strep — Anaerobes, “Atypicals” (Mycoplasma, Chlamydia pneumoniae, Legionella) Levofloxacin (Levaquin), Gatifloxacin (Tequin) +++ Gram Negs, Pseudomonas, “Atypicals” (Mycoplasma, Chlamydia pneumoniae, Legionella), Strep pneumo (including resistant strep) ++ Enterococcus — Anaerobes, Staph |
Mobile Medicard: Antibiotics in the Outpatient Setting
Autism self-study
Learning Objectives
- Describe how to approach a patient with autism
- Identify reasons autism is more prevalent than in the past
Health Systems self-study
Learning Objectives
- define the quadruple aim
- Describe factors that contribute to the high cost of US healthcare
Required Reading: The Developing Vision of Primary CareOverkillFrom Triple to Quadruple Aim
Optional Reading: The 10 Building Blocks of High Functioning Primary Care
100 Million Healthier Lives Concept Paper
Immunizations self-study
Case
Ashley O’Brien is a 12-month-old baby coming to you for a well-child check. She was born at a birthing center with the help of a midwife. Her mother, Peggy O’Brien, had a healthy pregnancy and a normal vaginal delivery at term without any complications.
Her parents have many concerns about the 12 month vaccines.
Weight: 75th percentile
Length: 50th percentile
Head Circumference: 65th percentile
Questions to Consider
- What history is needed?
- How can you discuss immunizations with this parent while preserving your doctor-patient relationship?
- What role does evidence-based medicine have in your discussion?
- How will you manage this case?
Learning Objectives
By the end of the session, the active participant will be able to:
- Develop strategies for discussing immunizations with parents.
- Use cultural humility and non-judgmental discussion approaches.
- Practice shared decision making.
Mobile Medicard: Immunization Handouts
Simulation Experience and Sexuality self-study
Students will spend one half day at the Brighton Avenue Simulation Lab, interviewing patients with common symptoms and presentations to family medicine. Students will interview 5 simulated patients over the course of a 4 hour period of time. Each simulation experience will take 30 minutes: 20 minutes for the actual interview and 10 minutes for documentation or reflection. Immediately prior to the interview, students will receive a one-page handout which will describe the goals for the interview, the chief complaint, pertinent history, and handouts pertinent to the case, as needed. The purpose of this simulation experience is for feedback and not evaluation.
Teen Sexuality
One of the simulation cases involves a teen age girl and her mother, who are seeing the student for the teen’s camp or sports physical, depending on the time of year. A major goal of this interview is to discuss sexuality issues with the patient, using the following framework.
Sexuality RISK Assessment
Introduce through generalizing statements that cover the following points:
1) many of your teen patients have questions and concerns about sexuality issues,
2) sexuality impacts health and
3) you like to protect time to discuss this with all of your teen patients.
Five components of sexuality:
R: Relationship
I: Identity
S: Sex (Health and Reproduction)
K: (K) Coercion/Sexualization
S: Sensuality
Relationship: An introductory exploration into sexuality. This includes who one is attracted to on an emotional and physical level.
- How do you feel about relationships in general/about your own sexuality?
- Have you ever been in a relationship with a boyfriend or girlfriend? How has that been for you?
- What about more casual relationships – “Friends with benefits,””hook-ups”, etc..? How has that been?
Identity: A sense of who one is sexually, including a sense of maleness or femaleness. This includes gender identity, gender role, biological sex.
- Some people are getting involved in sexual relationships. Have you had a sexual experience with a guy or girl or both?
- Have you ever had sex with men? Women? Both?
- Do you think you might be lesbian, gay, bisexual, or transgendered? Tell me about your experience with this.
- Do you think you need to have sex to find out if you’re lesbian, gay, or bisexual? If the answer is “yes” to the above question, then how do you feel about this? Do you have any questions, or would you like someone to talk with about this? (provide resources)
Sexual Health and Reproduction: Attitudes and behaviors related to producing children, care and maintenance of sex and reproductive organs, and health consequences of sexual behaviors. This includes facts and information, feelings and attitudes, anatomy and physiology, reproductive systems, and intercourse and other sexual acts.
- Have you had sex? Number of partners? Using contraception?
- Degree and types of sexual experience (vaginal, oral, anal sex)
- Have you/partner ever been pregnant or had an abortion?
- Have you ever been checked for a sexually transmitted infection (STI)? Knowledge about STIs and prevention?
- for females: Ask about menarche, last menstrual period (LMP), and menstrual cycles. Also inquire about breast self examination (BSE) practices.
- for males: Ask about testicular self-examination (TSE) practices.
Coercion/Sexualization: The use of sexuality to manipulate or control others. Media plays a role here. This includes flirting, seduction, harassment, withholding, pressuring or being pressured to have sex. It also includes feeling pressured (or pressuring others) to participate in sexual acts, incest, date rape and sexual violence.
- Comfort with sexual activity, enjoyment/pleasure obtained? History of sexual/physical abuse?
- Have you had an experience in the past where someone did something to you that you did not feel comfortable with or that made you feel disrespected?
- If someone abused you, who would you talk to about this? How do you think you would react to this?
- Have you ever had sex unwillingly?
- Have you ever tried sex for money, drugs, clothes, or a place to stay?
Sensuality: Awareness, acceptance of, and comfort with one’s own body; Physiological and psychological enjoyment of one’s own body and the body of others. This includes body image, skin hunger, fantasy, human response cycle.
- Has anyone ever been concerned about your weight or eating habits? Have you ever been concerned?
- Comfort with sexual activity, enjoyment/pleasure obtained?
- Questions or concerns about sexual pleasure, orgasm, sexual desire?
Maine Confidentiality Laws
Sexual Intercourse:
- Age of consent for sexual intercourse = 14
- If teen is 14 or 15, and partner is 5 or more years older = no legal consent
- Adolescents have the legal right to confidential mental health, substance abuse, and family planning services
Adult involvement for Abortion: Minors can consent to abortion if:
- Consent of parent or adult family member AND consent of patient
- Options counseling
- Judicial consent AND consent of patient
Resources
- Schools: Gay Straight Alliance,
- Youth Resource –website for bisexual, lesbian, gay and questioning youth – www.youthresource.org
- Counseling services: school, community
- Advocates for Youth – www.advocatesforyouth.org
- Sexual Assault Response Services of Southern Maine – www.sarsonline.org
- Planned Parenthood of Northern New England – www.ppnne.org
- Family Crisis Services – Young Adult Abuse Prevention Program (YAAPP) – www.familycrisis.org
Transgender self-study
Required Reading: Affirmative Care for Transgender and Gender Non-Conforming People
Required Reading: Caring for Transgender and Gender-Diverse Persons: What Clinicians Should Know