Family Medicine
Recertification & FMCLA Exam Review

Educational Objective:

Recognize effective therapies for smoking cessation.

Key Point:

Smoking cessation programs are most effective when combined with counseling and medication, which includes either nicotine replacement or bupropion.

Explanation:

All patients who smoke should be advised to avoid secondhand smoke and should be assessed for their willingness to quit during every visit. Once they are ready to quit, patients should be connected to a smoking cessation program. Adults should be prescribed either nicotine replacement therapy or sustained-release bupropion, or a tricyclic antidepressant (as a second line drug) but adolescents should receive only bupropion. In pregnant women, a smoking cessation program is the first-line treatment; nicotine replacement should be considered if a smoking cessation program by itself is not effective.

Fast-acting benzodiazepines are not considered appropriate for treatment of nicotine addiction and are not used for smoking cessation. Tricyclic antidepressants have not been shown to be effective for smoking cessation. Electronic cigarettes have not been shown to be effective in smoking cessation.

References:

Cahill K, Stevens S, Lancaster T. Pharmacological treatments for smoking cessation. JAMA. 2014;311(2):193-194.

Michigan Quality Improvement Consortium. Tobacco Control. 2011.

Rose JE, Behm FM. Adapting smoking cessation treatment according to initial response to precessation nicotine patch. Am J Psychiatry. 2013;170(8):860-867.

Wong S, Ordean A, Kahan M; Maternal Fetal Medicine Committee; Family Physicians Advisory Committee; Medico-Legal Committee; Society of Obstetricians and Gynaecologists of Canada. Substance use in pregnancy. J Obstet Gynaecol Can. 2011;33(4):367-384.

According to the American College of Emergency Physicians, absolute contraindications for ketamine administration include known hypersensitivity, conditions in which an increase in blood pressure would be hazardous, infants <3 months of age, and known or suspected schizophrenia, even if currently stable or controlled with medications. Ketamine is suspected to minimally raise intracranial pressure but is not of clinical significance; therefore, head injury or suspected intracranial hypertension is not an absolute contraindication. Ketamine may be helpful in the treatment of seizures, so a seizure disorder is not an absolute contraindication. Ketamine may increase pulmonary hypersecretion, but asthma is not an absolute contraindication to the use of ketamine for pediatric procedural sedation.

References:

Burbulys D, et al. Procedural sedation and analgesia. In: Marx JA, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed., 2010.

Green SM, Roback MG, Kennedy RM, Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update. Ann Emerg Med. 2011;57(5):449-461.

Renal magnesium losses in alcoholics are usually the result of tubular dysfunction, an effect that can be reversed with cessation of alcohol. Alcohol does not cause a significant osmotic diuresis and there is no evidence that it directly changes GFR.

Hypomagnesemia usually has an obvious cause from history. However, if it isn’t clear, one can distinguish between gastrointestinal losses and renal losses

FEMg is equal to [(Urine Mg x Plasma Cr)/ (0.7 x Plasma Mg x Urine Cr)] x 100

Plasma Mg is multiplied by 0.7 as only about 70% of circulating magnesium is free (not bound to albumin) and can be filtered.

Normally, if a patient is hypomagnesemic, they will lower their urinary magnesium to < 30 mg total, or a fractional excretion of Mg < 2%. Values higher then this indicate magnesium wasting by the kidney.

Educational Objective:

Discuss laboratory confirmation of anaphylaxis.

Key Point:

The best test to order to determine whether this patient is having an anaphylactic reaction is a serum total/mature tryptase level.

Explanation:

Adult anaphylactic reactions almost always (&gt;90%) involve the skin or mucous membranes as some combination of urticaria, erythema, pruritus, or angioedema.

Dyspnea is only present in 59%, syncope or lightheadedness in 33%, and diarrhea or abdominal cramps in 29% (Memphis study).

Children, however, may be different. An Australian study found that cutaneous features were present in 82.5%, whereas 95% had respiratory symptoms. The reasons why a lack of dermal findings would be more common in children than in adults are not well understood.

Total/mature tryptase levels can be obtained in situations where it is unclear whether a patient is having an anaphylactic reaction or some other condition such as septic shock, carcinoid syndrome, or cardiogenic shock.&nbsp;

Tryptase levels are elevated in the setting of anaphylaxis. Mature tryptase levels should be obtained along with a total tryptase level. If the ratio of total to mature tryptase levels is below 10, anaphylaxis is suggested. If only a total tryptase level can be obtained, then it is best to obtain an initial level during the event of concern and then to obtain a repeat level after the acute symptoms have resolved.

References:

Schwartz LB.&nbsp;Laboratory tests to support the clinical diagnosis of anaphylaxis.&nbsp;Revised December 12, 2014. Accessed February 5, 2016.

Barksdale AN, et al. Allergy, hypersensitivity, and anaphylaxis (Chapter 109). In: Walss R, et al.&nbsp;Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed.,2018.1418-1429.e.2.

Webb LM, Lieberman P. Anaphylaxis: a review of 601 cases. Ann Allergy Asthma Immunol. 2006 Jul. 97(1):39-43.

Educational Objective:

Discuss the vascular anatomy of the umbilical cord.

Key Point:

The umbilical cord contains 1 umbilical vein and 2 umbilical arteries.

Explanation

The vein would be cannulated for emergency vascular access.

The umbilical cord usually falls off around 2 weeks after birth. Separation delayed by longer than 1 month can be associated with immune deficiencies and infection.

Approximately 30% of infants with a single umbilical artery have congenital abnormalities such as trisomy 18.&nbsp;

Reference:

Carlo WA. The umbilicus. In: Kliegman RM, et al.&nbsp;Nelson Textbook of Pediatrics. 20th ed., 2016: 890-891.