RED FLAGS and TREATMENT Flashcards
Acute Cough Red Flags
Sign of choking?
• Rapid breathing, SOB, Wheezing? • Chest pain? • Blue lips, tongue, face? • Acute confusion? • Mucus or Dry? If mucus, pink in color or blood?
• Inhaled smoke/ flame / fumes/chemical irritants
• Cough because of DVT, PE, trauma, recent
surgery Dr.
• Fever >72hr / >40.5C
• Vomiting • Earache/Barking cough (usually child)
• > 3 weeks • Asthma, COPD, HF, GERD
• ACEi? > 3 weeks Notes: <6 yr: non-pharm only
Acute cough treatment
Antitussive for Dry cough: Dextromethorphan, or codeine
Expectorant: Guaifenesin, Honey
Allergic Rhinitis Redflags
Age <2 yr
• Facial pain?
• Unilateral symptoms (one-sided) • Fever? • Loss of smell/taste? • Sudden onset of sorethroat?
• Allergen cannot be identified. • > 2weeks • OM, Sinusitis, Asthma
Closed ended Questions:
• Symptoms interfere with sleep or daily activities?
No – mild Yes – moderate
• Cannot sleep/function -Severe >2 weeks (1+1) of allergen avoidance and OTC product
Allergic Rhinitis Treatment
Antihistamines (SGA > FGA ) Mild AR
FGA (>2 yr)(Chlorpheniramine, diphenhydramine)
SGA Mild AR
cetirizine (>=6 yrs), desloratadine (>=12 yrs), fexofenadine (>= 2 yrs), loratadine (>=2 yrs)
Intranasal corticosteroide Moderate – Severe AR
(Fluticason (>=2 yr), Triamcinolone (>= 4yr)) Decongestant (>=6 yr)
(Oral - Pseudoephedrine and intranasal – Oxymetazoline, Xylometazoline, Phenylephrine)
Canker/Aphthous sores (inside mouth) Red Flags
Red Flags:
• Can’t eat – severe pain
• > 5 ulcers • >1 cm (peanut size) • >14 days • > 6 times/yr. recurrence
• Bleeding
• Red/white patches – painful and swollen • Fever, joint pain, pharyngitis
• Present on roof of mouth / gums
• Lesions on hands, feet, genitalia, eye > 2 weeks
• Fever, Diarrhea develops • Increase in lesion size
Close ended Questions:
• Recently stopped smoking.
• H/O childhood ulcers. • F/H/O canker sores
Canker/Aphthous sores (inside mouth) Treatment
Anesthetics (>=12 yrs) (benzocaine, lidocaine, Benzylamide solution)
• No D/I
• S/E: Application site burning, edema, erythema, pruritus, rash, stinging, tenderness,
urticaria. • Solution – Rinse. Do not swallow.
• Apply QID before eating so less pain while eating • Max 7 days
Protectant
(Carboxymethylcellulose) • No known drug interaction
• S/E: Sticky or pasty sensation in the mouth.
• Coat after eating the involved area of the mouth with a thin film. Hold in position until it becomes sticky. Do not rub it in.
Seborrheic Red flags
Red Flags:
• Greasy, yellow scales over red and inflamed patches involving the folds between the nose and upper lip, behind the ear, eyelashes and eyebrows, groin (anywhere apart from scalp and scalp margin)
• Moderate to severe (even in scalp)
• Silvery, scaly plaques that bleed easily on scalp and present in elbows, knees, pelvis (Psoriasis)
• Drug induced (Lithium, Haloperidol, Methyldopa, etc.)
• Scales ↓50% within 7- 10 days
• Thickness and plaque / surface area - ↓50% within 6-8 weeks • Condition worsens
• Redness ↓50% within 8-12 weeks
• Itch ↓ to tolerable level within 1-2 weeks
Notes:
Treat only mild scalp seborrhea. High/Low temp makes it worse, but sun exposure makes it better.
Closed ended Questions:
• Dry, white scales scattered diffusely on scalp (Dandruff-treat)
• Exposure to any extreme temperatures or dry weather? • Use of hair pdts?
Seborrheic Treatment
Antifungals: Ketoconazole (cream-Rx shampoo-OTC) Onset 2-3 weeks, Max effect – 4 weeks
• S/E: scalp and skin irritation, itching, stinging, greasy or dry hair or scalp.
• If on corticosteroid, maintain and gradually withdraw over 2-3 weeks to allow ketoconazole effect and to prevent corticosteroid flare-up
Selenium sulfide (Selsun) May bleach hair
• Excessive use may cause hair loss or oily hair
• Avoid hair color use within 2 days of using selenium
• Avoid jewelry contact as it may be damaged
Zinc pyrithione
May discolor hair.
• Safe to use after perm solution • 2nd line
Corn/Callus/Bunion/Ingrown toenail Red Flags
Red Flags:
• Pain 1st MTP joint
• Great toe deviation / deformity.
• Nail appears thickened / discolored.
• Changes in skin color / texture of lesion
• Bump on the outside of foot
• Skin edge surrounding toenail is swollen, painful, bleeding/oozing (Ingrown toenail)
• >65 yr , Malnourished
• PVD, DM, immunocompromised
Closed ended Questions:
• Assess footwear • Pain, burning, hyperkeratosis (to confirm corn/callus)
• Lesion with black dots or seed in the Centre (plantar wart) • Rule out athlete’s foot symptoms
• Bunion / Ingrown toenail – Symptomatic/Ice packs and refer always
• Corn / Callus – No improvement >2 weeks Lesion becomes red/inflamed
Corn – usually on toes
Callus – soles of feet/heel
Corn/Callus/Bunion/Ingrown toenail Treatment
Analgesics For Bunions & Ingrown toenail Acetaminophen
• Avoid excessive alcohol
• Increases INR if on warfarin, check INR if acetaminophen ≥2g/day for ≥ 3 days and adjust warfarin accordingly.
• Antiepileptics increase acetaminophen metabolism leading to increased toxic metabolite
NSAIDs (Ibuprofen, Naproxen)
• Increase risk of bleeding – Anticoagulants, ASA, SSRI increase risk of bleeding
• Caution in HTN, CVD, renal dysfunction and Asthma.
• Increase lithium and MTX levels
Keratolytic For Corn/Callus
Salicylic acid 12–17.6% liquid 12–40% pads and plasters
• Soak in water, debridement with pumice
stone. Apply Vaseline on normal skin.
• S/E: Burning or irritation.
• Trim pad or plaster to fit the size and shape of the clean and dry area of the lesion.
• Wash hands thoroughly after application.
• Highly flammable
Plantar Warts Red Flags
Red Flags: • Pain at 1st MTP joint • Great toe deviation / deformity. • Nail appears thickened / discolored. • Bump on the outside of foot • Skin edge surrounding toenail is swollen, painful, bleeding/oozing (Ingrown toenail) • Change in color, appearance, or pain • PVD, DM, immunocompromised • Doubt about Diagnosis Closed ended Questions: • Black dot at center, pain when squeezed, skin ridges curved around lesion (to confirm diagnosis) • Warts not gone > 12 weeks • skin has been damaged/painful/inflamed
Plantar Warts Treatment
Salicylic acid (Compound W) 12–17.6% liquid 12–40% pads and plasters
• Soak in water, debridement with pumice stone. Apply Vaseline on normal skin.
• S/E: Burning or irritation.
• Trim pad or plaster to fit the size and shape of the clean and dry area of the lesion.
• Wash hands thoroughly after application.
• Highly flammable
• Contagious Cryotherapy (Compound W Nitro freeze – Nitrous Oxide)
• Do not use it on conditions that are not warts, it may cause serious burns (frostbite) and permanent scarring on the skin.
• Do not inhale nitrous oxide -symptoms can include feeling dizzy or confused and headache.
Athlete’ s Foot Red flags
• Weeping/severely inflamed / eczematous
• Oozing with purulent material
• Painful • Malnourished, elderly
• Toenails thickened or discolored • <16 y/o
• Comorbidities of DM, PVD, cancer, immunocompromised
• No improvement in 2 weeks.
• Symptoms not resolved completely in 6 weeks
Closed ended Questions:
• Blister, burning, redness, maceration, odor +/- (to confirm diagnosis)
• Ask occupation / sport activities
Athlete’ s Foot Treatment
Tolnaftate powder (Tinactin)
• For recurrent infection only.
• Powder sprayed directly on feet – not on shoes opical
(Clotrimazole (Canesten), Miconazole (Micatin spray / cream),Terbinafine - Rx)
• S/E: Local skin irritation or hypersensitivity (burning, erythema, pruritus, rash, stinging
• No known D/I as systemic absorption is minimal
• Oral antifungals only if treatment resistant to topicals
Bacterial Conjunctivitis Redflags
• Painful eyes • Visual disturbance
• Light sensitivity • Blunt Trauma
• Chemical exposure
• Heat exposure (e.g. welder’s arc)
• Foreign body inside eye
• wears contact lenses • eyes protruding Dr.
• clear discharge but eyes not itchy
• child • Discharge very severe
• No improvement / worsening in 2 days.
Closed ended questions:
• Watery (allergic/viral) or purulent discharge?
Bacterial Conjunctivitis Treatment
Ocular antibiotic
Gramicidin/polymyxin B (Polysporin eye drops) (>6 yrs)
• Continue treatment for 2 days after symptoms have resolved.
• Limit use to 4–5 days
• Contagious
• Do not use ear drops in eye
• Patients are sometimes given an antibiotic prescription to fill 3 days after being assessed, if needed
Allergic Conjunctivitis Redflags
• Painful eyes • Visual disturbance
• Light sensitivity • Blunt Trauma
• Heat exposure (e.g. welder’s arc)
• Foreign body inside eye • Chemical exposure
• wears contact lenses • eyes protruding Dr.
• clear discharge but eyes not itchy
Closed ended Questions
• Watery & itchy (allergic)
• Watery & non itchy (viral) or purulent discharge?
• Any environmental allergy?
• No improvement / worsening in 3 days
Allergic Conjunctivitis Treatment
Ocular
Decongestants (Tetrahydrozoline, Naphazoline, Oxymetazoline)
• S/E: stinging, burning
• Caution in closed angle Glaucoma
• Reduces redness and edema
• Do not use >10 days due to risk of rebound hyperemia
Mast cell stabilizer
(Sodium cromoglycate)
• S/E: cu stinging
• Takes 2–3 days to see symptom improvement
Ocular Lubricants
• Help wash out allergens and reduce eyelid swelling and reduce redness.
• Keep in fridge – soothing effect
Viral Conjunctivitis
• Always refer
Contagious
• Children should be kept out of school until there is no ocular discharge (approximately 1 week)
Dry Eye Red Flags
• Painful eyes • Visual disturbance • Light sensitivity • Blunt Trauma • Chemical exposure • Heat exposure (e.g. welder’s arc) • Foreign body inside eye • wears contact lenses • eyes protruding Dr. • clear discharge but eyes not itchy • if medication-induced or undiagnosed condition (blepharitis) • No improvement / worsening in 5 days Closed ended Questions: • Burning, fatigue, foreign body sensation
Dry eye treatment
Ocular Lubricants
(CMC, Polyvinyl alcohol,propylene glycol)
Keep in fridge – soothing effect
Constipation Red flags
- <2 y/o • Fever • Vomiting • Eating disorder
- Severe or persistent belly pain
- Unexplained Weight loss
- Blood or mucus in stools
- Severe pain when defecating
- Alternating with diarrhea
- Moderate to extreme thirst
- Rectal or abdominal mass
- Fatigue or overall weakness
- Nocturnal symptoms
- Recent abdominal surgery
- F/H/O colon cancer in > 50 yr patient
- No bowel movement in 7 days or does not resolve in 14 day despite medication use
- Bloating and cramping not relieved after defecating
Constipation Treatments
Bulk-forming:
Psyllium (>6 yr) (Metamucil)
• Onset: 5-15 min • S/E: Flatulence, bloating
• Separate 2 hrs. from other meds
• Drink with 250 ml water.
• Psyllium powder and capsules are gluten-free.
Enemas (>2 yr) • Onset: 15-30 mins
(mineral oil, phosphate, tap water)
• Risk of mechanical trauma to rectal wall
Osmotic agents
Glycerin suppository
• S/E: Rectal irritation
Lactulose (>=1 yr) • Onset: 24 48 hrs
.• S/E: Flatulence, abdominal cramps
• Separate 2 hrs. from other meds
Magnesium citrate
• May reduce bioavailability of digoxin and tetracycline
• Use only if not responsive to other agents
PEG (>2 yrs) • Onset: 48-96 hrs
• S/E: diarrhea, flatulence, nausea, retching, abdominal bloating, cramping, anal irritation
• Separate 2 hrs. from other meds
Sodium phosphate • Onset: 0.5 – 3 hrs
• S/E: Hypocalcemia, hypokalemia and hypernatremia
• ACEi, ARBS, diuretics AND NSAIDS may enhance nephrotoxic effect of NaPO4
Stimulants
Bisacodyl tabs & suppositories
(Dulcolax) (>= 6yrs)
• Onset: PO: 6–12 h PR: 0.5–1 h
• Milk, antacid, PPI decrease acidity of the stomach which may damage the special (enteric) coating of bisacodyl leading to decreased effect
Senna (>2 yr) • Onset: 6-12 hrs.
• S/E: Abdominal pain, diarrhea, hypokalemia, dehydration, allergic reactions
• Discolor urine to pink
Stool softner
Docusate • Onset: 12-72 hrs
• S/E: Usually well tolerated. Mild, transient nausea or GI cramps may occur
Diaper Dermatitis Red Flags
Red Flags:
• Acute onset with oozing pus, blisters, or ulceration
• Frequent recurrence, with no rash-free period in between
• Rash outside the diaper area
• Moderate or severe presentation
• Fever, nausea or vomiting
• Complicated by secondary infection or UTI comorbidity
• Behavioral change like crying nonstop, overall weakness
• Signs if abuse or neglect
• Immunocompromised
• Rashes don’t get better after 7 days of treatment or worsen
• Symptoms do not completely resolve within 14 days despite medication use
Closed ended Questions:
• Fungal – Beefy/tomato red plaques, satellite pustules, Inguinal folds involvement, thrush in oral cavity
• Inflammatory – redness, swelling, warmth, pain
Diaper Dermatitis Treatment
Barrier
Zinc oxide 10-40 %
• Onset: skin protection is immediate
• Duration: skin protection lasts about 3 h.
• Should be always applied as barrier with each diaper change.
Antiinflammatory
Hydrocortisone 0.5% (>2 yr)
• Onset: for pruritus relief is immediate; inflammation relief takes about 2 days
• Caution (Dr.) if <2 y/o due to increased absorption
• Should not be used for more than 2 wk.
Antifungals (clotrimazole, ketoconazole, miconazole)
• Onset: clinical improvement and relief of pruritus within 1 wk.
• Duration: continue for minimum of 4 wk.
• S/E: Blistering, irritation, mild burning, transient pruritus, stinging
Diarrhea Red Flags
Red Flags:
• Blood / Mucus in stools
• Severe diarrhea (>6 unformed stool for >48h)
• Worsening, persistent, or chronic diarrhea
• Extensive stomach pain or cramping
• Vomiting >4h
• Fever >38.5C
• < 2 y/o
• Frail elderly
• Pregnant
• DM, kidney failure, HF, immunocompromised
• Dehydration - weakness, dry mouth, decreased urination, child – reduced no. of diapers, few/no tears when crying
• Recent antibiotic use
• Weight loss
Symptoms of diarrhea persist >48 hrs even with antidiarrheal
• Dehydration symptoms despite being on ORS
• Blood in stools
• Fever develops
Diarhhea Treatment
Attapulgite Discontinued -2021
Loperamide (>12yr. - OTC) (Imodium)
• S/E: Abdominal cramps or discomfort, drowsiness, dizziness, dry mouth, skin rash
• Increased level by ritonavir or quinidine
• Use with caution in children <12 y of age.
• Discontinue if symptoms persist longer than 48 h
• Not used in C. Diff, IBD
Bismuth subsalicylate (>12yr. - OTC) Liquid and tabs
• S/E: Black tongue and stools, tinnitus
• Avoid if taking anticoagulants, MTX, probenecid, salicylates
• Avoid in salicylate allergy
• D/C if develop ringing of ear
Psyllium (>6 yr.) (Metamucil)
• S/E: Cramping, flatulence
• Space by 2hrs with other meds
ORS C/I:
• Protracted vomiting despite small frequent feedings.
• Worsening diarrhea and an inability to keep up with losses
• Stupor or coma
• Intestinal ileus
• Breastfeeding should be continued during episodes of diarrhea and ORS should be offered.
GERD Red Flags
Severe belly pain
• Weight loss
• Black tarry stools or blood in stools / vomit
• Difficulty/painful swallowing
• Chest pain radiating to the back and jaw
• Choking
• Dizziness, fatigue, pale appearance, cold extremities
• Vomiting
• Abdominal mass
• >50 y/o
Symptoms persist >14 days despite medication use
Closed ended Questions:
• Mild/ Mod/ severe
• NSAIDs us
GERD Treatment
Antacid (Alginic acid (Gaviscon), CaCo3, Mg salts)
• Decrease absorption of fluoroquinolones, tetracyclines, iron and digoxin, INH
• S/E: Constipation with Ca and Al, Diarrhea with Mg
H2RA
(famotidine (>12yrs), Ranitidine (>16 yrs), Nizatidine)
• S/E: Headache, Dizziness, Nausea
• All level decreased by antacid so separate by 0.5-1 hour
PPI (OTC: esomeprazole 20mg)
• Take 30 min before food
• S/E: Headache, nausea, diarrhea, rash.
• CYP2C19 inhibitors so may increase levels carbamazepine, triazolam, warfarin but conflicting data with clopidogrel.
• May decrease absorption ampicillin, iron, digoxin
Fever Red flags
Red Flags: 911 • <3 months • Stiff neck, seizure, localized pain, redness, swelling • New wheeze/cough • Recent / ongoing chemo • Child very ill, fussy, irritable crying incessantly Dr. • <6 months • Persistent wheeze/cough • New onset rash/fever • Confused/delirious • Recent surgery/dental procedure • Recent travel • intake of raw food • Recent new medication •Persists > 24 hours with medication or for more than 3 days • > 40.5C at anytime
Fever Treatment
Acetaminophen
• Avoid excessive alcohol
• Increases INR if on warfarin, check INR if acetaminophen ≥2g/day for ≥ 3 days and adjust warfarin accordingly.
• Antiepileptics increase acetaminophen metabolism leading to increased toxic metabolite
NSAIDs (ASA, Ibuprofen, Naproxen)
• S/E: GI intolerance and bleeding, allergic reactions, tinnitus, visual disturbances, nephropathy.
• Increase risk of bleeding – Anticoagulants, ASA, SSRI increase risk of bleeding
• Caution in HTN, CV, renal dysfunction, Asthma.
• Increase lithium and MTX levels
Headache (Tension & Migraine) Redflags
• 1st or worst headache ever
• Sudden
• Changes in balance, consciousness, mental status, vision
• Fever
• One-sided weakness
• More severe/more frequent headaches
• >50 y/o
• Precipitated by sneezing or coughing
Use Tylenol, NSAIDs ≥15 days a month or triptans, opioids > 10days
• Symptoms are bothersome despite being on pain relievers
• Headaches interfere with QOL
• Progressive, more frequent
• Pain killer overuse / druginduced
Closed ended Questions:
• Differentiate between Tension type (two-sided) and migraine (one-sided, N&V, sensitivity to light/sound or both, +/- aura)
Headache (Tension & Migraine) Treatment
Acetaminophen • Avoid excessive alcohol
• Increases INR if on warfarin, check INR if acetaminophen ≥2g/day for ≥ 3 days and adjust warfarin accordingly.
• Antiepileptics increase acetaminophen metabolism leading to increased toxic metabolite
• Do not use more than 15 days
NSAIDs (ASA, Ibuprofen, Naproxen)
• S/E: GI intolerance and bleeding, allergic reactions, tinnitus, visual disturbances, nephropathy.
• Increase risk of bleeding – Anticoagulants, ASA, SSRI increase risk of bleeding
• Caution in HTN, CV, renal dysfunction, Asthma.
• Increase lithium and MTX levels
• Do not use more than 15 days
Hemorrhoids Redflags
Red Flags:
• 1st time
• Last for more than 7 days
• Bleeding when passing stool / black tarry stool
• seepage or leakage of stool or mucus between bowel movement
• Protrude and didn’t go back
•No symptoms relief within 7 days of medication use
• Symptoms worsen (severe pain, bleeding, protrusion)
• <12y/o
• Fever, pus, severe pain
Closed ended Questions:
Painful (external)
No pain (internal)
Hemorrhoids Treatment
Local anesthetic
(dibucaine, Pramoxine (Anusol Plus))
• Relieves pain
• S/E: burning and itching
• Do not use >7 days
Antiinflammatory: Hydrocortisone acetate
• Relieves itching and inflammation
• Limit use to 7 days but if with improvement can be up to 14 days
Astringent: Zinc sulfate (Anusol), Hamamelis
• No drug interaction
Vasoconstrictor: (Phenylephrine (Preparation H. Pe))
• Controls bleeding.
• Onset of action ranges from a few seconds to 1 min. Duration of action is 2–3 h
Protectants: Glycerin, White Petrolatum
• No drug interaction and significant adverse effect
Nausea & Vomiting Red Flags
Persisted for more than 3 days without known cause • Vomiting of > 6hrs • Significant weight loss • Dehydration symptoms (dry mouth, decreased urination, dizzy, weak) • Fever • Abdominal pain • Blood or coffee-grounds in vomitus • Altered level of consciousness • History of recent head trauma • Blood in stool • Difficulty swallowing • Age >55 y • Require pregnancy test? • vomiting lasting longer than 6 hours
Nausea & Vomiting
Anticholinergic
Scopolamine patch
• Motion sickness - 1 patch Q72hrs
• Usually used for long travel
• S/E: Sedation, constipation, dry mouth, blurred vision, rash, allergic contact dermatitis.
• Wash hands after use.
• Additive CNS side effects like sedation with sedatives, CNS depressants including alcohol
Antihistamines
(Promethazine, Dimenhydrinate, diphenhydramine IR & LA formulations)
• S/E: Sedation, constipation, dry mouth, blurred vision, rash.
• Additive CNS side effects like sedation with sedatives, CNS depressants including alcohol.
• Increased constipation, dry mouth with anticholinergics
Ginger
(Gravol)
• S/E: Abdominal discomfort, diarrhea, heartburn, pepperlike irritant effect in the mouth and throat.
Pinworms Red Flags
- Always should be diagnosed by Dr.
- <12 y/o or >50 y/o, pregnant, hepatic/renal impairment
- history of colorectal cancer, IBD
- belly pain, rectal or anal pain
- severe diarrhea, bloody stools in large amount or dark in color
- self-inflicted skin lesions, bleeding skin
- fever
- extreme poor appetite
- Itching has not resolved within 7 days of the 2nd course of treatment or any sign of bacterial superinfection
- S/E of the medication N&V, diarrhea, stomach cramps persist for > 3 days.
- S/E of Dizziness, drowsiness > 24 hours
Pinworms Treatment
Anthelmintics: Pyrantel pamoate (Combatrin)
• 2 doses 2 weeks apart.
• S/E: Anorexia, nausea, vomiting, abdominal cramps, diarrhea, headache, dizziness, drowsiness.
• Close contact/ family should be treated prophylactically.
• Avoid in the 1st trimester of pregnancy.
• Caution in hepatic impairment.
• No restrictions for school
Vaginal Symptoms VC Red Flags
• Fishy odor • Grey/off-white colored discharge • Frothy / creamy discharge • Fever, pelvic pain • 1st time • >= 4 episodes / year • Last episode < 2months • Sexually active & at risk of STI (multiple partners, unprotected) • Pregnant • <12 y/o • Diabetes, immunocompromised • Red flags • Symptoms still present 1 week after starting therapy • Increased irritation or symptoms Closed ended Questions: • Itching inside/ outside/ both • Use Douches? • H/O antibiotics
Vaginal Symptoms VC Treatment
Antifungals 1. Clotrimazole (Canesten) 2.Miconazole (Monistat) Available as – [internal cream, external cream, combo – internal \+ external, ovules, suppositories] [1 day, 3 days, 7 days pack] • Continue using while in periods. • Preferred to apply / insert at bedtime • Reduces effectiveness of condoms but still use. • Select based on internal/external itchiness. • Partner treatment not needed • May decrease effectiveness of vaginal progesterone so, avoid • Use lower strength (more days) during pregnancy Fluconazole oral tab (Diflucan, Canesoral) • S/E: Headache, nausea, abdominal pain, diarrhea, dyspepsia, dizziness. • Do not use in girls <12 y. • D/I: Increase QTc prolongation effect of dronedarone, FQ, macrolides, methadone and TCA, decrease metabolism of atorvastatin, increase risk of bleeding with warfarin even as a single dose
Smoking Cessation Red Flags
• Recent MI (within 2 weeks), history of stroke • Uncontrolled HTN or CVD • Pregnant, breastfeeding • <18 y/o • On medications like Clozapine, Olanzapine, Fluvoxamine, opioid analgesics, warfarin • Comorbid substance abuse disorders, history of depression or schizophrenia Mood changes from smoking cessation therapy • Chest pain (persisting), SOB while on NRT Closed ended Questions: • Number of cigarettes per day • Number of quit attempts • What products were used during prior quit attempt(s) • If any products worked • Smoking pattern (throughout the day/certain times)
Smoking Cessation Treatment
Nicotine
Replacement Therapy
1. NRT gum 2. NRT lozenge 3. NRT inhaler 4. NRT mouth
spray 5. NRT patch
• Avoid acidic food and beverage 15 minutes before and after use due to reduced absorption
• Stop smoking when NRT starts
• For patch, Patients who experience insomnia from the 24-hour patch may benefit from removing the patch at night and using an immediate-release product first thing in the morning, then applying a new patch.
• For Gums, Caution patients not to chew like regular gum (increased side effects).
Varenicline (Champix)
• Reduces urge
• Set Quit date.
• Take with food.
• Report any mood changes
Bupropion • CYP2d6 substrates like atomoxetine, SSRI, risperidone may have decreased clearance.
• Codeine and tamoxifen may have reduced effectiveness.
• Avoid MAOIs due to increased hypertension
Lice (Head or pubic) Red Flags
Red Flags:
• Recurrent
• Extensive and severe lesion
• Signs of skin infection characterized by redness and pus
• Redness with mild, greasy scales on scalp
• Silvery, scaly plaques that bleed easily on scalp and present in elbows, knees, pelvis
• Dry, white scales scattered diffusely on scalp
• Red flags
• Live lice 24 hrs. after 2nd treatment
• Itching persists >4 weeks after 2nd treatment.
Closed ended Questions:
• Live lice seen?
• Scalp /pubic +/- eyelashes
Head:
• Bedmates and infected family members to be treated prophylactically.
• Children can go to school next day after the first treatment.
Pubic:
• Close and sexual contacts (past 1 month) to be treated prophylactically and tested for STI.
Lice (Head or pubic) Treatment
Permethrin 1% (Nix cream rinse, Kwellada) • C/I: Chrysanthemum allergy • Wash hair with conditioner free shampoo. Dry with towel. Apply cream. Leave for 10 min. Rinse • Repeat after 1 week • S/E: itchiness, redness • Can take AH if itching continues • For Head & Pubic Pyrethrin (R & C Shampoo) • C/I: Chrysanthemum & Ragweed allergy • Apply to ‘dry hair’. Massage & leave for 10 min. Add water & work up lather. Rinse • Repeat after 1 week • For Head & Pubic Dimethicone (Nyda spray) • Not < 2y • Spray over ‘dry hair’ . Massage till completely wet. Leave for 30 min. Comb with lice comb. Leave for 8 hours. Wash. • Repeat after 1 week • For head only. Isopropyl myristate (Resultz) • Apply to dry hair & scalp. Leave for 10 min & wash. • For head only. Lacrilube nonmedicated eye ointment • For public lice on eyelash. • Apply BID for 10 days after manual removal
Scabies Redflags
Always to be diagnosed by Dr.
Red Flags:
• Immunocompromised (HIV or lymphoma)
• Severe itching at night
• Lesions are malodorous
• Papules on genitals or breasts
• Red, hot, hard, painful skin area with fever and vague body discomfort (malaise)
• Red plaques with silvery scale which may bleed when removed
• no improvement or new burrows and papules develop within 2 weeks of starting treatment
• itching persists 4 weeks after initiating
treatment
• signs of bacterial infection (pustules) do not improve or worsen within 3 days of treatment after initiating treatment
• signs of bacterial infection (pustules) do not improve or worsen within 3 days of treatment
Scabies Treatment
Crotamiton • No drug interaction • Mainly for anti-itch. • Less effective than permethrin • Massage. Leave for 48 hrs hrs. Take shower. Neck -> sole Head-> sole (< 2yrs) Permethrin 5% (Kwellada-P, Nix dermal cream) • Massage. Leave for 8-14 hrs. Take shower. Neck -> sole Head-> sole (< 2yrs) • Repeat after 1 week. • C/I: chrysanthemum allergy • Treat sexual partner in last month. • Children may go to school 1 day after 2nd treatment. Sulfur Limited data to support use
skin damage from the sun Red Flags
Covers large area of the body (>10% in adults or >5% in children • <5 y/o or 60 y/o (bec they have thin skin) • Affected area involves face, ear, eyelid, inner surface of arm, hands, feet • Concomitant trauma (electrical trauma) • More than minimal blistering • Immunocompromised, diabetes, chronic alcohol abuse • Fever, pus/oozing, swollen or tender lumps in the groin • Pain not relieved by 48 hrs. • Burn not improved in 48 hrs. • Significant risk or sign of scarring • Signs and symptoms of infection develop
skin damage from the sun Treatment
Acetaminophen • Avoid excessive alcohol • Increases INR if on warfarin, check INR if acetaminophen ≥2g/day for ≥ 3 days and adjust warfarin accordingly. • Antiepileptics increase acetaminophen metabolism leading to increased toxic metabolite. NSAIDs (Ibuprofen, naproxen) • S/E: GI intolerance and bleeding, allergic reactions, tinnitus, visual disturbances, nephropathy. • Increase risk of bleeding – Anticoagulants, ASA, SSRI increase risk of bleeding • Caution in HTN, CV, renal dysfunction, Asthma. • Increase lithium and MTX levels Antihistamines (diphenhydramin e, cetirizine, hydroxyzine) Alcohol, benzodiazepines, barbiturates increase CNS side effects (sedation, dizziness, impairment of cognition & performance) TCAs, scopolamine increase anticholinergic side effects (dry mouth, dry eyes, constipation, urinary retention) Avoid combination with CYP2d6 inhibitors (bupropion, paroxetine, amiodarone, celecoxib) leads to increase FGA level
Dysmenorrhea Red flags
• Onset of pain 2 years after first menstruation • Symptoms outside first 3 days of menses • Change in pain severity and pattern • Change in degree of flow, odor, color or flow pattern of menstrual fluid • Severe pain • Red flags • NSAID trial for 3 cycles Closed ended questions: • Pain Scale • Need for contraception? (Offer COC if patient desires – serves 2 purposes) Closed ended questions: • Pain Scale • Need for contraception? (Offer COC if patient desires – serves 2 purposes)
Dysmenorrhea Treatment
NSAID (Ibuprofen, Naproxen) • S/E: GI intolerance and bleeding, allergic reactions, tinnitus, visual disturbances, nephropathy. • Increase risk of bleeding – Anticoagulants, ASA, SSRI increase risk of bleeding • Caution in HTN, CV, renal dysfunction, Asthma. • Increase lithium and MTX levels
Low Back Pain Red Flags
Red Flags: • Major/minor trauma • Age <20 / > 50 • H/O cancer • Fever, weight loss, chills • Pain worse in supine position • Bladder/ fecal dysfunction • > 3 months • Morning stiffness >30 min • Pain radiating to thigh and leg & tingling/numbness • > 3 months • symptoms not relieved after adequate trial of at least 2 analgesics • worsening symptoms
Low Back Pain Treatment
NSAIDS
(Ibuprofen, Naproxen)
• Preferred if no C/I
• S/E: GI intolerance and bleeding, allergic reactions, tinnitus, visual disturbances, nephropathy.
• Increase risk of bleeding – Anticoagulants, ASA, SSRI increase risk of bleeding
• Caution in HTN, CV, renal dysfunction, Asthma.
• Increase lithium and MTX levels
Acetaminophen • Avoid excessive alcohol
• Increases INR if on warfarin, check INR if acetaminophen ≥2g/day for ≥ 3 days and adjust warfarin accordingly.
• Antiepileptics increase
Acetaminophen metabolism leading to increased toxic metabolite.
Opioids
• Not very effective
• Can be given for short time if C/I to NSAIDs
Swimmer’s Ear Red Flags
• Fever • Hearing loss • Ear surgery in last 6 weeks • Ear tubes • Severe pain • Watersports as hobby • Ear pain, itching, fullness with or without hearing loss, with discharge • Always to be diagnosed by Dr. • Red flags • Symptoms not improved in 48-72 hrs. • Symptoms worsen or not completely resolved in 1 week • superinfection develops
Swimmer’s Ear Treatment
Gramicidin/polymyxin B (Polysporin ear drops) • No significant drug interaction. • Limit use to 4-5 days only • Under Dr’s Supervision • Eye drops can be used in ear. Antipyrine/benzocaine (Auralgan) • Avoid if ruptured eardrum • Oral analgesics preferred • May mask symptoms of worsening swimmer’s ear
Bad Breath (Halitosis) Red Flags
• Painful, red, swollen areas around the gums or tongue or pus-filled area within the mouth (candidiasis, bacterial infection or gingivitis)
• Recent dental extraction / surgery
• Medical conditions like respiratory disease, sinusitis, tonsillitis, rhinitis
• Patient concerned but friends/family do not share concern
Q for assessment
• Use alcoholic mouthwash?
• Wear dentures?
• CASED?
• Symptoms don’t improve in 1 week
• Tongue hurts or bleeds following cleaning
• Tongue causes excessive gagging
Bad Breath (Halitosis) Treatment
Chlorhexidine gluconate (Rx) • Tooth staining may occur Cetylpyridinium / Zinc / essential oil containing mouthwashes • Avoid alcoholic mouth washes • Trial for 1 week • Tooth staining may occur
Chickenpox Red Flags
- Blisters on face, chest and/or back that are itchy
- Fever
- Vaccine status (VZV)
- Medication use: allopurinol, antiepileptic
- Infants, adults & immunocompromised
- Fever with cough (measles)
- Always to be diagnosed by Dr.
- Red flags
- Fever persists more than 48 hours
- Pain persists despite being on analgesic
Chickenpox Treatment
Acetaminophen • Avoid excessive alcohol
• Increases INR if on warfarin, check INR if acetaminophen ≥2g/day for ≥ 3 days and adjust warfarin accordingly.
• Antiepileptics increase acetaminophen
metabolism leading to increased toxic metabolite.
• Avoid ASA due to Rye syndrome
Calamine lotion • If <6 months old, consult doctor before use.
• Keep in fridge for soothing effects.
Cold Sores Red Flags
• > 14 days • >6 times/ year • Excessively red, swollen, pus • Area beyond lips or perioral area • Lesions inside the mouth • Fever, swollen glands • Immunocompromised Qs • Exposure to sunlight (e.g beach, ski hills) • Prior burning, tingling before lesion appeared • Vesicles break with sticky fluid (not pus) and then crust • Single / multiple lesions & is painful • Fever develops • Lesions spread • LA cause erythema/edema • Not resolved >2 weeks
Cold Sores Treatment
Anesthetics (>2yr) Benzocaine (Orajel), camphor, menthol, phenol(Blistex), Pramoxine (Polysporin)
• Apply to affected area for 1–5 h then remove.
• May offer temporary relief of pain and itching.
Topical Antiviral
Docosanol 10% (Abreva) (>12 yr)
• Apply to affected area at the first sign of pain, itching, burning, redness or tingling every 3 h for 5– 10 days
• S/E: Mild and infrequent stinging sensation.
Burns Redflags
• Deep partial-thickness (waxy, white-red, painful when pressured) / Fullthickness (waxy, whitegrey- black charred, painless) • < 5 yr / >60 yr. • Face, ear, eyelid, inner surface of arm, hands, feet, perineum (groin/rectum) • Large surface area • Chemical, Electrical, Inhalation burns Dr. • DM, chronic alcohol abuse, immunocompromised Qs • Appearance? • Painful/Painless? • Red flags • Not healed completed after 7 days • Symptoms worsen • Pain not responding to analgesics *Recommend Tetanus vaccine to patient *Use sunscreen for up to 1 year
Burns Treatment
Analgesics
Acetaminophen
• Avoid excessive alcohol
• Increases INR if on warfarin, check INR if acetaminophen ≥2g/day for ≥ 3 days and adjust warfarin accordingly.
• Antiepileptics increase acetaminophen metabolism leading to increased toxic metabolite.
NSAIDS
Ibuprofen
• Increase risk of bleeding – Anticoagulants, ASA, SSRI increase risk of bleeding
• Caution in HTN, CVD,renal dysfunction and Asthma.
• Increase lithium and MTX
Antihistamines Oral Diphenhydramine
• For itch control
• Do not use topical preparation.
Frostbite Redflags
• Deep frostbite – area is
deep purple/ dark hemorrhagic blisters, weeping blisters, waxy and numb
• Fever, pus
Qs
• Ask color and type of blisters
• Blue/white with no blisters (frostnip)
• Intact blisters with white-
• Red flags
• Numbness, tingling continues after 24 hrs – 911
• Pain does not improve after analgesics - 911
Frostbite Treatment
NSAIDS
Ibuprofen
• Avoid excessive alcohol
• Increase risk of bleeding –
Anticoagulants, ASA, SSRI increase risk of bleeding
• Caution in HTN, CVD, renal dysfunction and Asthma.
*Recommend Tetanus vaccine to all patients
Sports Injuries Red flags
• Severe pain • Cracking/grating sound (fracture) • Joint deformity • Inability to bear weight on injured limb • Eye (Blurry/pain/discharge) • Head (Confusion, headache, drowsiness) • Ear (Hearing loss/pain) • Nosebleed > 20 mins • > 14 days Qs • Pain scale • Red flags • No improvement in 2 weeks • Worsens in 2-3 days
Sports Injuries Treatment
NSAIDS
Ibuprofen
• Avoid excessive alcohol
• Increase risk of bleeding – Anticoagulants, ASA, SSRI increase risk of bleeding
• Caution in HTN, CVD, renal dysfunction and Asthma.
Minor cuts and wounds Red Flags
• Tetanus vaccine required (<3 primary doses, > 10 yrs ago, unknown status) • Animal/human bite • Deep puncture (exposed fat tissue/bone) • Deep partial/full thickness burns • Severe pain • > 2 cm wound • Gaping • Pierced foreign material • Bleeding > 10 mins • Discolored, abnormal smell • DM, PVD, increase age, smoking, obesity, immunocompromised, malnutrition Qs • Pain scale • Red flags • Pain increased • Not healed > 3 weeks • Sign of infection after 48 hr
Minor cuts and wounds Treatment
NSAIDS
Ibuprofen
• Avoid excessive alcohol
• Increase risk of bleeding –
Anticoagulants, ASA, SSRI increase risk of bleeding
• Caution in HTN, CVD, renal dysfunction and Asthma.
Antibiotic
Topical Polysporin
• Do not use > 7 days
• S/E: itching and burning
• Not recommended in deep, animal bites and serious burns
*Recommend Tetanus vaccine to all patients
* Do not use any antiseptic
* Use sunscreen upto 6 months
Insomnia Redflags
• Symptoms due to shift work
• Urge to move legs/ unpleasant sensations in leg
• Patient snore/snort/gasp/breathing pauses
• Irrepressible need to sleep during day
• Sleepwalk/Sleep terrors/nightmares
• Red flags
• Medication ineffective for 3 consecutive nights
• Need therapy for > 7 days
Closed ended Questions:
• Transient (< 3 days), > 3days- 3 weeks (Short term), chronic (>3 week)
• Sleep latency, total sleep
time, awakening during sleep
• Enquire if following good sleep hygien
Insomnia Treatment
Antihistamine Diphenhydramine (Nytol, Sleep aid) • Avoid alcohol intake • Avoid driving • S/E: dry mouth, constipation, dizziness, urinary retention • Not recommended - > 65 yrs, Glaucoma, cognitive , MAOi in last 2 weeks Melatonin • 1st line in jet lag • Avoid driving • Avoid alcohol • S/E: Headache, fatigue, dizziness
Heat related disorders Red Flags
Red Flags: 911 • Loss of consciousness • Confusion/altered mental status • Seizures • SOB • Frequent vomiting • Little/no urine output • Skin – hot/dry/ no sweat • Red flags • No recovery in 20-30 min after monitoring the symptoms - 911 Close ended Questions: • N&V (not persistent), headache, muscle cramps, dizziness, tiredness – Monitor
Heat related disorders Treatment
Only self-care measures and monitoring
• Antipyretic does not help
Hair Care Red Flags
• Gradual Hair ‘loss’
• Oval patches on scalp
• terrors/nightmares
• shedding does not resolve in 4–6 months after removal of trigger or beginning of therapy
• No improvement after 1 year of treatment
Closed ended Questions:
• Hair Thinning? (Treat)
• Family History
• Exposure to chemo, radiation, heavy metals, meds (colchicine, cyclosporin) – Educate
• Pregnancy, childbirth, crash dieting within 2 months – educate
• Use of hair pdts/dryer/straightener/ hairstyles like pony tail
Hair Care Treatment
Minoxidil
(Rogaine) 2% solution – males 5% foam- males & females
• Do not apply directly to hair.
• Leave for 4 hrs. and wash off.
• Increase in hair fall for 1st 2 months that will reduce gradually.
• S/E: Itchiness, dryness, greasy appearance (more with solution)
• Max effect: after 1 year
Infant Colic Red flags
- Fever / lethargy
- Weight loss, dehydration
- Diarrhea
- Regurgitation/vomiting
- High-pitched crying
- Parental mood disorders like anxiety, depression
- Maternal drug ingestion (illicit/pharmacologic)
- > 5months of age , < 2weeks age
- F/H/O Migraine/Atopy
- History of fall or trauma, infant refusal to move or use limbs, and suspicious bruising
- > = 3 hours crying constantly
- > 3 days after medication use
Infant Colic Treatment
Simethicone (Oval)
• No clinically meaningful adverse effects.
• May be added to breast milk or formula sucrose (Dandelion Kisses)
• “Sweet-taste” mediated activation of endogenous opioid system proposed.
• Do not substitute with honey because of risk of botulism in infants.
• store in refrigerator for up to 48 h.
