Page 317 - TNFlipTest

Toronto Notes 2019 Common Presenting Problems
Investigations
• ECG,CXR,andothersifindicated(cardiacenzymes,d-dimers,liverfunctiontests,etc.) • refertoEDifsuspectseriousetiology(e.g.aorticdissection,MI)
Management of Common Causes of Chest Pain
• angina/ischemicheartdisease
■ nitroglycerin (NTG): wait 5 min between sprays and if no effect after 3 sprays, send to ED
• myocardialinfarction
■ ASA(160-325mg,chewedstat),clopidogrel(Plavix®),LMWH(enoxaparin),morphine,oxygen,NTG ■ ± reperfusion therapy with fibrinolytics (e.g. tPA, RPA, TNK, or SK) if within 12 h (ideally <30 min)
or percutaneous intervention (cath lab) if <90 min
■ startβ-blocker(e.g.metoprololstartingdose25mgPOq6horbid,titratingtoHRgoalof55-60bpm)
• endocarditis:antibioticchoiceisbasedonwhetherpatienthasanativeorprostheticheartvalveaswell as culture and sensitivity results
• GERD:antacids,H2-blockers,PPIs,patienteducation
• costochondritis: NSAIDs
Treatment of Stable Ischemic Heart Disease
• seeCardiologyandCardiacSurgery,C25
Common Cold (Acute Rhinitis)
• seeInfectiousDiseases,PneumoniaandInfluenza,ID7 Definition
• viralURTIwithinflammation
Epidemiology
• mostcommondiagnosisinfamilymedicine,peaksinwintermonths • incidence:adults=2-4/yr,children=6-10/yr
• organisms
■ mainly rhinoviruses (30-35% of all colds)
■ others: coronavirus, adenovirus, RSV, influenza, parainfluenza, coxsackie virus
• incubation:1-5d
• transmission:person-personcontactviasecretionsonskin/objectsandbyaerosoldroplets
Risk Factors
• psychologicalstress,excessivefatigue,allergicnasopharyngealdisorders,smoking,sickcontacts
Clinical Features
• symptoms
■ local: nasal congestion, clear to mucopurulent secretions, sneezing, sore throat, conjunctivitis, cough ■ general: malaise, headache, myalgias, mild fever
• signs
■ erythematous nasal/oropharyngeal mucosa, enlarged lymph nodes ■ normal chest exam
• complications
■ secondary bacterial infection: otitis media, sinusitis, bronchitis, pneumonia ■ asthma/COPDexacerbation
Differential Diagnosis
• allergicrhinitis,pharyngitis,influenza,laryngitis,croup,sinusitis,bacterialinfections
Management
• patienteducation
■ symptoms peak at 1-3 d and usually subside within 1 wk
■ cough may persist for days to weeks after other symptoms disappear
■ no antibiotics indicated because of viral etiology
■ secondary bacterial infection can present within 3-10 d after onset of cold symptoms
• prevention
■ frequent hand washing, avoidance of hand to mucous membrane contact, use of surface disinfectant ■ yearly influenza vaccination
• symptomaticrelief
■ rest, hydration, gargling warm salt water, steam, nasal irrigation (spray/pot)
■ analgesics and antipyretics: acetaminophen, ASA (not in children because risk of Reye’s syndrome),
ibuprofen
■ cough suppression: dextromethorphan or codeine if necessary (children <6 yr of age should not use
any cough/cold medications) ■ decongestants, antihistamines
Family Medicine FM19
MI in Elderly Women
Elderly women can often present with dizziness, back pain, lightheadedness, or weakness, in the absence of chest pain
MI in Diabetics
May present with dyspnea, syncope, and fatigue in the absence of chest pain
Influenza vs. Colds: A Guide to Symptoms
Features
Onset of illness Fever Exhaustion level Cough
Throat Nose Head Appetite Muscles Chills
Flu Cold
Sudden Slow High fever None Severe Mild Dry severe ±
or hacking
Fine Sore
Dry and clear Runny
Achy Headache-free Decreased Normal
Achy Fine
Yes No
• patientswithreactiveairwaydiseasewillrequireincreaseduseofbronchodilatorsandinhaledsteroids
Echinacea for Preventing and Treating the Common Cold
Cochrane Database Syst Rev 2014;2:CD000530 Purpose: To assess whether Echinacea preparations are effective and safe for the prevention and treatment of the common cold.
Methods: Meta-analysis of RCTs comparing mono- preparations of Echinacea with placebo. Primary efficacy outcome was number of individuals with at least one cold in prevention trials, and duration of colds in treatment trials. Primary safety and acceptability outcome was number of participants dropping out due to adverse events.
Results: 24 double-blind trials with 4,631 participants were included. No prevention study comparisons comparing Echinacea and placebo found a statistically significant difference in terms of number of patients with at least
one cold episode, though a relative risk reduction of 10% to 20% was identified. Of treatment trials reporting on duration of colds, only 1 study of 7 showed a significant effect favouring Echinacea over placebo. No significant differences were found between Echinacea and placebo groups in number of dropouts due to adverse events, though prevention trials showed a trend towards higher dropout numbers due to adverse events in treatment groups.
Conclusions: Echinacea products have not been shown to provide benefits for treating colds, although it is possible there is a weak benefit from some Echinacea products. Individual prophylaxis trials consistently show positive (if non-significant) trends, although potential effects are of questionable clinical relevance.