Family Medicine
Certification Exam Review

Lumbar disk herniations are most common in people aged 30-50 years, and the pain is more commonly located in the midline with worsening of the pain during coughing or sitting.

Reference:
Lin M. Musculoskeletal back pain. In: Marx J, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed, 2009.

Educational Objective:

Discuss the early warning signs (red  flags) in a pregnant patient that have been shown to signify an elevated risk for a severe course of COVID-19.

Key Point:

According to the Society for Maternal-Fetal Medicine, the early warning signs of a possible adverse COVID-19 course in a pregnant patient have been found to include:

1. Increasing dyspnea and/or work of breathing;

2. Inability to maintain room air oxygen saturation above 95%;

3. Persistent or more frequent fevers;

4. Worsening of myalgias.

Explanation: 

These 4 early warning signs are easily missed in pregnant patients because they are not signals of higher risk for severe disease in non-pregnant patients. However, in the context of the hypercoagulability of pregnancy, worsening myalgias and fevers are early warning signs of an impending cytokine storm. Pregnant patients with signs of respiratory compromise are also at higher risk of clinical deterioration than non-pregnant patients. 

These warning signs of a possibly poor clinical course do NOT imply an immediate need for ICU admission; however, their presence should lead to admission at least to a general ward with close monitoring for sudden clinical  deterioration.

References:

Society for Maternal-Fetal Medicine Management Considerations for Pregnant Patients With COVID-19 Developed with guidance from Torre Halscott, MD, MS and Jason Vaught, MD 4.30.20 Society for Maternal-Fetal Medicine Management Considerations for Pregnant Patients With COVID-19. (Published April 30, 2020) (Accessed July 28, 2020). 

Ellington S, Strid P, Tong VT, et al. Characteristics of Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status — United States, January 22–June 7, 2020. MMWR Morb Mortal Wkly Rep 2020;69:769–775. DOI: http://dx.doi.org/10.15585/mmwr.mm6925a1 (Published June 26, 2020) (Accessed July 28, 2020).

Centers of Disease Control and Prevention: Coronavirus Disease (Covid-19) - Considerations for Inpatient Obstetric Healthcare Settings    (Updated May 20, 2020) (Accessed July 28, 2020).

In most immunocompetent patients, Staphylococcus is the most common organism causing osteomyelitis, with methicillin-resistant staphylococcus (MRSA) representing a significant and rapidly growing percentage of these infections. However, in people with sickle cell disease, in whom osteomyelitis may arise in bony sites of avascular necrosis (secondary to bone infarctions), Salmonella species and Enterobacter (possibly from microinfarct areas of the bowel) are possible pathogens since they seem to have a particular predilection for avascular bony areas. In this subset of patients, empiric antibiotics should, therefore, cover both staphylococcus (including MRSA) AND gram-negative organisms. Of the above choices, only the combination of vancomycin plus meropenem achieves this therapeutic goal. Other regimens can achieve the same goal, for example, all third-generation cephalosporins will cover Salmonella.

Reference:

Wheeless, Clifford R. “Osteomyelitis/Infection in the Sickle Cell Patient.” Wheeless' Textbook of Orthopaedics, Wheeless Online, 22 Aug. 2012

Sanford Guide to Antimicrobial Therapy 2009 DK Gilbert et al.

Educational Objective:

List agents appropriate as initial monotherapy for hypertension

Key Point:

Thiazide diuretics, calcium channel blockers, ACE inhibitors, and ARBs are all appropriate choices for hypertension monotherapy. Beta blockers have been associated with adverse cardiovascular effects in elderly patients, and should not be used without a specific indication.

Explanation:

According to JNC8 Guidelines, in the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). Beta blockers are not recommended for the treatment of isolated hypertension. These same first line agents are recommended in older adults with the caution that the incidence of pedal edema with these agents is higher in the elderly. These recommendations have replaced those of the original ALLHAT trial.

References:

James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; 311:507

James, Paul A., et al. "2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8)." Jama 311.5 (2014): 507-520.

Laubscher, Tessa, Loren Regier, and Shannon Stone. "Hypertension in the elderly New blood pressure targets and prescribing tips." Canadian Family Physician 60.5 (2014): 453-456.

Educational Objective:

Treat generalized anxiety disorder with pharmacotherapy.

Key Point:

Selective serotonin reuptake inhibitors (SSRI) or serotonin–norepinephrine reuptake inhibitors (SNRI) are drugs of choice for the treatment of generalized anxiety disorder.

Explanation:

Both selective serotonin reuptake inhibitors and serotonin–norepinephrine reuptake inhibitors have proven efficacy against generalized anxiety disorder, and they are first-choice medications for this patient. The choice between these medications should be guided by other considerations, including their tendency to produce withdrawal syndrome , their adverse-event profiles, the potential for drug interactions, risk of suicide, and the likelihood of toxicity in overdose, as well as the patient’s prior experience. Benzodiazepines are anxiolytic but are generally recommended for short term use only. Pregablin is sometimes used as a second or third line therapy in generalized anxiety disorder. It has approval for that use in Europe but is not approved by the US FDA for that indication.

References:

National Collaborating Centre for Mental Health, National Collaborating Centre for Primary Care. Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults. Management in primary, secondary and community care. London: National Institute for Health and Clinical Excellence; 2011.

Zun LS and Nordstrom K. Anxiety Disorders, Rosen’s Emergency Medicine. 2018; 102: 1353-1357