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USMLE Step 3 (Subject) / Ambulatory Medicine (Lesson)

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• Glaucoma A form of optic neuropathy that is caused by ↑ intraocular pressure (defined as > 20 mmHg) and results in loss of vision if left untreated. Open-Angle Glaucoma:- Etiology: Drainage canals are blocked; the angle between the iris and cornea is open. Most common.- Symptoms: Chronic; gradual loss of peripheral vision- Diagnosis: High intraocular pressures and an abnormal cup-to-disk ratio (> 50%)- Treatment:→ Non-selective topical β-blockers (e.g., timolol, levobunolol) → Topical adrenergic agonists (e.g. epinephrine – only in open-angle glaucoma due to mydriatic effect)- Topical cholinergic agonists (e.g., pilocarpine, carbachol)- Topical carbonic anhydrase inhibitors (e.g., dorzolamide, brinzolamide) Closed-Angle Glaucoma:- Etiology: The angle between the iris and the cornea is closed, imparing drainage- Risk factors: African American ethnicity, a family history, female gender, age > 40-50- Symptoms: Acute; presents with eye pain, headache, nausea, conjunctival injection, halos around lights, and fixed, dilated pupils- Diagnosis: High intraocular pressures (≥ 30 mmHg; normal 8-21 mmHg)- Treatment: Contact an ophthalmologist immediately!→ Pupillary constriction: Topical pilocarpine→ ↓ intraocular pressure: Timolol, acetazolamide. Laser iridotomy.→ Systemic: Acetazolamide, mannitol
• Herpes zoster opthalmicus Infection of the V1 branch of CN V (the ophthalmic division of the trigeminal nerve). Particularly common in immunocompromised states such as HIV infection. Sx/Exam: - Fever- Headache- Malaise- Periorbital burning/itching, conjunctivitis, keratitis, ↑ intraocular pressure, optic neuropathy- Cranial nerve palsies- Vesicles are purulent and progress to crusting. Tx: - IV acyclovir/valacyclovir/famciclovir within 72 hours after the appearance of the rash ↓ the incidence of complications.- Refer immediately to an ophthalmologist.
• Influenza An acute respiratory illness caused by influenza A or B. Occurs primarily during the winter. Symptoms/Exam:- Generally presents following an incubation period of 1-2 days with acute-onset upper and lower respiratory tract symptoms, myalgias, fevers, and weakness. Diagnosis:- Rapid antigen tests have a sensitivity of only 40-60%. - Diagnosis may be established through PCR testing or viral culture. Treatment:- The antiviral drugs zanamivir and oseltamivir can be used prophylactically or to treat existing infection in at-risk individuals; most effective when given within 48 hours of exposure or at symptom onset.- Most influenza strains have become resistant to amantadine and rimantadine. Complications:- Pneumonia is the 1° complication of influenza. - Risk factors: Diabetes mellitus, cardiopulmonary disease, patients > 50 years of age, nursing residents- 2° bacterial pneumonia, often from Streptococcus pneumoniae, is an important complication and is responsible for one-quarter of influenza-related deaths.- Other complications: Myositis, rhabdomyolysis, CNS involvement, myocarditis, pericarditis
• Allergic rhinitis Affects up to 20% of the adult population. Patients may also have asthma and atopic dermatitis. Symptoms/Exam:- Presents with congestion, rhinnorhea, sneezing, eye irritation, and postnasal drip.- Identify exposure to environmental allergens such as pollens, animal dander, dust mites, and mold spores. May be seasonal.- Exam reveals edematous, pale mucosa; cobblestoning in the pharynx; scleral injection, and blue, boggy turbinates. Diagnosis:- Diagnosed by clinical exam.- Skin prick testing to a standard panel of antigens can be performed, or blood testing can be conducted to look for specific IgE antibodies via radioallergosorbent testing (RAST). Treatment:- Allergen avoidance: Use dust mite-proof covers on bedding and remove carpeting. Keep the home dry and avoid pets.- Drugs: → Antihistamines (diphenhydramine, fexofenadine): Block the effects of histamine released by mast cells. Selective antihistamines such as fexofenadine may cause less drowsiness than nonselective agents such as dephenhydramine.→ Intranasal corticosteroids: Anti-inflammatory properties yield excellent symptom control.→ Sympathomimetics (pseudoephedrine): α-adrenergic agonist effects result in vasoconstriction.→ Intranasal anticholinergics (ipratropium): ↓ mucous membrane secretions.→ Immunotherapy ("allergy shots"): Slow to take effect, but useful for difficult-to-control symptoms.
• Hearing loss Conductive:- Location of damage: Outer and middle ear.- Diagnosis: → Weber test: Lateralization in the affected ear.→ Rinne test: Bone conduction will be audible longer than air conduction.- Examples:→ Cerumen impaction→ Foreign bodies→ Otitis externa→ Tumor/mass→ Otosclerosis (progressie fixaiton of stapes) Sensorineural:- Location of damage: Inner ear- Diagnosis:→ Weber test: Lateralization to normal ear.→ Rinne test: Air conduction will be audible longer than bone conduction.- Examples:→ Otitis media→ Barotrauma→ Perforation of the tympanic membrane→ Presbyacusis (age related)→ Drug induced (e.g., aspirin, aminoglycosides)
• Epistaxis Bleeding from the nose or nasopharynx. Roughly 90% of cases are anterior nasal septum bleeds at Kiesselbach's plexus. The most common etiology is local trauma 2° to digital manipulation. Other causes include dryness of the nasal mucosa, nasal septal deviation, use of antiplatelet medications, bone abnormalities in the nares, rhinitis, and bleeding diathesis. Symptoms/Exam:- Posterior bleeds: More brisk and less common; blood is swallowed and may not be seen.- Anterior bleeds: Usually less severe; bleeding is visible as it exits the nares. Treatment:- Treat with prolonged and sustained direct pressure and topical nasal vasoconstrictors (phenylephrine or oxymetazoline).- If bleeding does not stop, cauterize with silver nitrate or insert nasal packing (with antibiotics to prevent toxic shock syndrome, covering for S aureus).- If severe, type and screen, obtain IV access, and consult an ENT surgeon.
• Atopic dermatitis (eczema) Pruritic, lichenified eruptions that are classically found in the antecubital fossa but may also appear on the neck, face, wrists and upper trunk. Has a chronic course with remissions.- Characterized by an early age of onset (often in childhood)- Associated with a ⊕ family history and a personal history of atopy.- Patients tend to have ↑ serum IgE and repeated skin infections. Symptoms/Exam:- Presents with severe pruritus, with distribution generally in the face, neck, upper trunk, and bends of the elbows and knees. The skin is dry, leathery, and lichenified.- The condition usually worsens in the winter and in low-humidity environments. Differential: Seborrheic dermatitis, contact dermatitis, impetigo. Diagnosis: Clinical Treatment:- Keep skin moisturized.- Topical steroid creams should be used sparingly and should be tapered once flares resolve.- The first-line steroid-sparing agent is tacrolimus ointment.
• Contact dermatitis Caused by exposure to allergens in the environment; may lead to acute, subacute, or chronic eczematous inflammation. - Irritant contact dermatitis: Non-immune-mediated irritation caused by a substance; usually presents as burning, pruritus, and pain from dry, cracked skin. Has no clearly demarcated borders.- Allergic contact dermatitis: Type IV hypersensitivity; usually occurs as pruritus from vesicles and bullar in a demarcated rash. Symptoms:- Patients complain of itching, burning, and an intensely pruritic rash. Exam:- Acute: Presents with papular erythematous lesions and sometimes with vesicles, weeping erosions where vesicles have ruptured, crusting, and excoriations. The pattern of lesions often reflects the mechanism of exposure (e.g., a line of vesicles or lesions under a watchband).- Chronic: Characterized by hyperkeratosis and lichenification. Diagnosis:- A clinical diagnosis that is made in the setting of a possible exposure.- Patch testing can be used to elicit the reaction with the agent that caused the dermatitis.- Consider the occupation and hobbies of the individual and the exposure area of the body to determine if they suggest a diagnosis. Treatment:- Avoid causative agents.- Cold compresses and oatmeal baths help sooth the area.- Administer topical steroids. A short cause of oral steroids may be needed if a large region of the body is involved.
• Psoriasis An immune-mediated skin disease characterized by pink plaques with silvery scale and sharply defined margins. The condition is often chronic with a probably genetic predisposition. Symptoms/Exam:- Presents will well-demarcated, silvery, scaly plaques on the knees, elbows, gluteal cleft, and scalp. Nails may show pitting and onycholysis. Treatment:- Limited disease: Topical steroids, topical vitamin D analogs, topical retinoids.- Generalized disease (involving > 30% of the body): UVB light exposure; PUVA (psoralen and UVA) if UVB is not effective. Methotrexate, acitretin, and anti-TNF agents may also be used for severe cases.
• Erythema nodosum An inflammatory condition that is characterized by tender red or violet nodules. More common in women than in men. Although often idiopathic, it may also be 2° to sarcoidosis, IBD, and infections (steptococcal infection, coccidioidomycosis, TB). Symptoms/Exam:- Lesions are painful and may be preceded by fever, malaise, and arthralgias. Recent URI or diarrheal illness may suggest a cause.- Exam reveals deep-seated, poorly demarcated, painful red nodules without ulceration on the shins. Differential: Cellulitis, trauma, thrombophlebitis Treatment:- Treat the underlying disease. The condition is usually self-limited, but NSAIDs are helpful for pain.- In more persistent cases, potassium iodide drops and systemic corticosteroids may be of benefit.
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• Rosacea Most commonly affects people with fair skin, those with light hair and eyes, and those who have frequent flushing. Symptoms/Exam:- Presents with erythema and with inflammatory papules that mimic acne and appear on the cheeks, forehead, nose, and chin.- Open and closed comedones (whiteheads and blackheads) are not present.- Recurrent flushing may be elicited by spicy foods, alcohol, or emotional reactions.- Rhinophyma (an enlarged nose with an irregular texture) occurs late in the course of the disease and results from sebaceous gland hyperplasia.- Patients may have ocular symptoms such as blepharitis, conjunctival injection, and lid margin telangiectasias. Differential: The absence of comedones in rosacea and the patient's age help distinguish the condition from acne vulgaris. Treatment:- Initial therapy: The goal is to control rather than cure the chronic disease. Use mild cleansers, azelaic acid, and/or metronidazole topical gel ± oral antibiotics as initial therapy.- Persistent symptoms: Treat with oral antibiotics (doxycycline, minocycline) and tretinoin cream.- Maintenance therapy: → Topical metronidazole may be used once daily.→ Clonidine or α-blockers may be effective in the management of flushing, and patients should avoid triggers.→ Consider referral for surgical evaluation if rhinophyma is present and is not responding to treatment.→ Any patient with ocular symptoms (e.g., grittiness, dryness) should be started on oral or topical local antibiotics and ocular lubricants.
• Erythema multiforme An acute inflammatory disease that is sometimes recurrent (type IV hypersensitivity). The most common etiologic factors are HSV and Mycoplasma pneumoniae. May also be caused by medications such as sulfa drugs. Many cases are idiopathic and recurrent. Symptoms/Exam:- May be preceded by malaise and fever or by itching and burning at the site where the eruptions will occur.- Presents with sudden onset of rapidly progressive, symmetrical lesions.- Targetoid papules are typically located on the back of the hands and on the palms, soles, and limbs. However, they can be found anywhere. Lesions recur in crops for 2-3 weeks. Diagnosis: Typically a clincial diagnosis. Treatment:- Mild cases can be treated symptomatically with histamine blockers for pruritus.- If many targetoid lesions are present, patients usually respond to prednisone for 1-3 weeks.- Azathioprine has been helpful in cases that are unresponsive to other treatments.- When HSV causes recurrent EM, maintenance acyclovir or valacyclovir can ↓ recurrences of both.
• Pemphigus vulgaris An autoimmune disease in which blisters are formed as a result of autoantibodies targeting desmoglein 3 and 1 in the desmosomal complex in skin cells. Pemphigus vulgaris is the most common subtype of pemphigus. Symptoms/Exam:- Presents with flaccid bullae and with erosions where bullae have been unroofed. Oral lesions usually precede skin lesions. - If it is not treated early, the disease usually generalizes and can affect the esophagus.- Nikolsky's sign is elicited when gentle lateral traction on the skin separates the epidermis from underlying tissue. Diagnosis: Skin biopsy Treatment: Corticosteroids and immunosuppressive agents.
• Bullous pemphigoid An autoimmune disease characterized by antibodies against basement membrane proteins that lead to subepidermal bullae. More common than pemphigus vulgaris, and typically occurs in those > 60 years of age (the median age at onset is 80 years). Symptoms/Exam:- Presents as large, tense bullae with few other symptoms. Differential: Pemphigus vulgaris, dermatitis herpetiformis Diagnosis: - Diagnosis is made with skin biopsy, with confirmation via immuno- and histopathology. Treatment: Topical steroids
• Acne vulgaris Results from ↑ pilosebaceous gland activity, Propionibacterium acnes, and plugging of follicles. Symptoms/Exam:- Characterized by a variety of lesions, including closed comedones (whiteheads), open comedones (blackehads), inflammatory papules, nodules, and scars. Lesions are typically seen over the face, back, and chest. Differential: Rosacea, folliculitis Diagnoisis: Clinical Treatment:- Begin with topical benzoyl peroxide, topical retinoids, or topical antibiotics such as erythromycin.- A 2° line of treatment includes addition of oral antibiotics such as minocycline or doxycycline.- Isotretinoin (Accutane) can be used but is teratogenic and should thus be prescribed with caution in women of childbearing age. Concomitant contraception and pregnancy tests are necessary.
• Herpes zoster (shingles) Caused by reactivated varicella-zoster virus (VZV), which remains dormant in the dorsal roots of nerves. Risk factors include ↑ age and immunosuppression. After the eruption, patients can develop postherpetic neuralgia, a painful disorder. Symptoms/Exam:- Presents with the cutaneous finding of painful vesicles evolving into crusted lesions in a dermatomal distribution. Lesions are typically preceded by paresthesias in the area of distribution. Differential: Contact dermatitis Diagnosis:- Largely clinical- PCR or culture can be confirmatory. Treatment:- Pain management- If initiated within 72 hours of rash onset, antiviral treatment with acyclovir, valacyclovir, or famciclovir can ↓ the duration of illness and may also ↓ the occurence of postherpetic neuralgia. Use of glucocorticoids is controversial and is generally not recommended.- Patients are infectious until crusts have formed over the vesicles. Keep the area covered to prevent the spread of virus to immunocompromised patients.- Vaccination is recommended for people ≥ 60 years of age and helps ↓ the risk of both shingles and postherpetic neuralgia.
• Dermatophytoses Dermatophytes attach to and proliferate on the superficial layers of the epidermis, nails, and hair.  Tinea capitis:- Erythema and scaling of the scalp with thickened, broken-off hairs and scalp keroin- Etiology: Trichophyton tonsurans, Microsporum canis- Treatment: Griseofulvin, itraconazole Tinea corporis:- Annular plaques with a thin scale and central clearing- Etiology: Trichophyton mentagrophytes, Microsporum canis- Treatment: Griseofulvin, itraconazole, clotrimazole cream Tinea pedis:- Red scaley soles with maceration and fissuring between the toes ± blisters- Etiology: Trichophyton rubrum- Treatment: Griseofulvin, terbinafine, itraconazole, antifungal powders Onychomycosis:- Hyperkeratosis and yellowing of the nail plate; scaling- Etiology: Trichophyton rubrum, Trichophyton mentagrophytes- Treatment: Terbinafine Tinea versicolor:- Hypopigmented macules in areas of sun-induced pigmentation; reddish-brown appearance in winter- Etiology: Malassezia globosa, Malassezia furfur- Treatment: Itraconazole, topical selenium sulfide/ketoconazole
• Basal cell carcinoma The most common skin cancer. Slow growing and rarely metastasizes. Caused by excessive sun exposure. Symptoms/Exam: Pearly papules with central depression that may be ulcerated. Most commonly found on sun-exposed areas. Diagnosis: Skin biopsy shows palisading cells with retraction. Treatment:- Curettage, cryosurgery, radiation, or excision by surgery depending on the sizes, location, and histology of the tumor as well as on prior treatment and cosmetic considerations.- Mohs' micrographic surgery for lesions on areas of the face that are difficult to reconstruct.
• Squamous cell carcinoma The second most common skin cancer. Actinic keratoses are premaligant precursors. Risk factors: History of actinic keratosis, immunosuppression, smoking, arsenic exposure, and exposure to industrial carcinogens Symptoms/Exam:- Actinic keratosis: Presents as gritty or scaly plaques occuring in areas of sun exposure.- Squamous cell carcinoma: Pink plaques with scale or erosion; may spread to regional lymph nodes. Diagnosis: Skin biopsy shows irregular masses f anaplastic epidermal cells proliferating down to the dermis. Treatment:- Surgical excision for larger lesions; actinic keratoses may be treated with topical chemotherapeutics or liquid nitrogen.- Mohs' micrographic surgery for lesions on areas of the face that are difficult to reconstruct.
• Melanoma Malignant proliferation of melanocytes. Risk factors: Sun exposure, fair skin, a ⊕ family history, a large number of nevi, and dysplastic nevi. Symptoms/Exam: Look for nevi with an irregular appearance (ABCDE = Asymmetry, Border irregularity, Color irregularity, Diameter > 6 mm, Evolution) Diagnosis: - Skin biopsy (melanocytes with cellular atypia). Pathology shows S100-protein positive, epithelioid cells with fine granules in cytoplasm.- Imaging (MRI, ultrasound) may be warranted for metastatic evaluation. Treatment: Surgical excision; adjuvant therapy for patients with advanced disease. Melanoma in situ → 0.5 cm safety marginBreslow stage I (≤ 1.0 mm) → 1 cm safety marginBreslow stage II (1.01-2 mm) → 1-2 cm safety marginBreslow stage III (2.01-4 mm) → 2 cm safety marginBreslow stage IV (≥ 4 mm) → 2 cm safety marginIf tumor thickness > 1 mm (Breslow stage ≥ II): perform sentinel lymph node biopsy
• Erectile dysfunction Inability to achieve or maintain an erection sufficient for penetration and ejaculation. Affects 30 million men. Associated with age; some degree of ED is seen in 40% of 40-year-olds and 70% of 70-year-olds.  Etiology:- Psychological→ Symptoms often have a sudden onset. → Patients are unable to sustain or sometimes even obtain an erection.→ Patients have normal nocturanl penile tumescence (those with organic causes do not).- Organic:→ Endocrine: DM, hypothyroidism or thyrotoxicosis, pituitary or gonadal disorders, ↑ prolactin→ Vascular: Atherosclerosis, vascular steal→ Neurologic: Stroke, DM, MS, spinal surgery, neuropathy→ Exogenous: β-blockers, SSRIs, α-blockers, clonidine, CNS depressants, anticholinergics, chronic opioids, TCAs Exam:- Look for exam findings suggesting an organic cause – e.g., small testes, evidence of Peyronie's disease, perineal sensation/cremaster reflex, or evidence of peripheral neuropathy/vasculopathy.- Assess peripheral pulses, look for skin atrophy, hair loss, and low skin temperature. Diagnosis:- Assess testosterone; if there is concern about 2° causes, check TSH, prolactin, and glucose (to assess for diabetes). Treatment:- Treat underlying disease- PDE-5a inhibitors (sidenafil, tadalafil, vardenafil) inhibit cGMP-specific phosphodiesterase type 5a, thereby improving relaxation of smooth muscle in the corpora cavernosa. Side effects include flushing, headache, and ↓ BP. Patients cannot be on nitrates or α-blockers.- Injectable therapies such as alprostadil may also be used.- For those who fail medical therapy, an external penile pump or an inflatable penile prothesis can be tried.- Testosterone for hypogonadism; behavioral treatment for depression and anxiety. A PDE-5a inhibitor may be effective for patients with psychogenic causes.- Vascular surgery if indicated.
• Benign prostatic hyperplasia Hyperplasia of the prostate that leads to bladder outlet obstruction. Incidence ↑ with age. Common in patients > 45 years of age. In those < 45 years of age with urinary retention, consider an alternative diagnosis such as urethral stricture or a neuropathic etiology. Symptoms/Exam:- Patients complain of frequency, urgency, nocturia, ↓ force an size of the urinary stream, and incomplete emptying leading to overflow incontinence.- Exam reveals a firm, rubbery, smooth prostatic surface (vs. rock-hard areas that suggest prostate cancer). Diagnosis:- Diagnosed by history of exam. Check UA for infection or heaturia, both of which should prompt further evaluation.- PSA is ↑ in up to 50% of patients but is not diagnostically useful. Treatment:- α-blockers (terazosin), 5α-reductase inhibitors (finasteride)- Avoid anticholinergics, antihistamines, or narcotics- If the condition is refractory to medications, consider surgical options such as transurethral resection of the prostate (TURP). An open procedure is appropriate if gland size is 75 g. In general, indications for TURP include recurrent UTIs, bladder stones, hematuria, episodes of acute urinary retention, and renal failure 2° to obstruction.
• Epididymitis/Orchitis Epididymitis is defined as an acute infection that results in posterior and superior testicular tenderness. It is the most common cause of scrotal pain in adults.Orchitis is associated with diffuse testicular pain.- In men > 35 years of age, E coli is the most common cause.- In men < 35 years of age, Chlamydia is most common. Positive Prehn sign: reduced pain when the affected hemiscrotum is elevated Diagnosis: CBC, UA, and urine culture, Gram stain for gonococcal infection and trichomoniasis, nucleic acid amplification tests for Neisseria gonorrhoeae and Chlamydia trachomatis, Doppler ultrasound (shows ↑ blood flow). Treatment: Antibiotics and supportive therapy (analgesics, ice packs, scrotal support, and elevation)- Suspected UTI (with enteric organisms): fluoroquinolones (e.g., ofloxacin or levofloxacin)- Suspected STI (with chlamydia or gonorrhea): ceftriaxone and doxycycline
• Testicular torsion A urologic emergency that requires immediate intervention owing to the potential for resulting infertility. Peak incidence: neonatal period (first 30 days of life) and during puberty Symptoms/Exam: - The affected testicle sits higher and is painful.- Absent cremasteric reflex- Prehn sign: negative Diagnosis: CBC, UA and urine culture, Gram stain, nucleic acid amplification tests, Doppler ultrasound (shows ↓ blood flow) Treatment: - Immediate surgical exploration of the scrotum with reduction (untwisting) and orchidopexy- Orchidopexy of the contralateral side is recommended
• Cancer screening Cervical cancer: A Pap smear is recommended starting at age 21 until age 75. Patients may be screened every 3 years if they have had a normal Pap. Those > 30 years of age may ↑ the screening interval to 5 years if the Pap is performed with HPV PCR testing. Breast cancer: Mammography should be conducted every 2 years after age 50 (may begin earlier if there is a ⊕ family hisotry at a young age).The age at which mammographic screening should begin is controversial. The USPSTF recommends biennial screening mamography for women 50-74 years of age. For patients in ther 40s, it is recommended that the decision to begin screening be thoroughly discussed with their doctors. Colon cancer: Hemoccult annually (especially in patients > 50 years of age); flexible sigmoidoscopy (every 3-5 years in those > 50) or colonoscopy (every 10 years in those > 50).If a first-degree relative has colon cancer, begin screening at age 40 or when the patient is 10 years younger than the age at which that relative was diagnosed, whichever comes first. Prostate cancer: Controversial. Some groups (e.g., the USPSTF) recommend no screening; others recommend a yearly rectal exam and PSA beginning at age 45, especially for African Americans, patients with a strong family history, or those with any changes in urinary symptoms. Lung cancer: Controversial. The USPSTF recommends annual screening for lung cancer with a low-dose CT scan at 55-80 years of age if the patient has a 30-pack-year smoking history and is currently smoking or quit within the last 15 years.
• Routine screening Hypertension: BP screening should be done every 2 years in normotensive adults and every year for those with a systolic BP of 120-139 or a diastolic BP of 80-90. For young patients (age < 50) with an ↑ BP, look for 2° causes of hypertension, such as chronic kidney disease, pheochromocytoma, thyroid/parathyroid disease, sleep apnea, renovascular disease, Cushing's syndrome, coarctation of the aorta, and 1° hyperaldosteronism. Hyperlipidemia: The US Preventive Services Task Force (USPSTF) strongly recommends screening men ≥ 35 years of age and women ≥ 45 years of age (20-45 years of age in the setting of CAD risk factors) for lipid disorders. Risk factors that modify LDL goals include:- Cigarette smoking- Hypertension- Diabetes- Age (men ≥ 45 years; women ≥ 55 years) and male gender- Obesity Diabetes: The ADA recommends testing for diabetes or prediabetes in all adults with a BMI ≥ 25 kg/m2 and 1 or more additional risk factors for diabetes. For those without risk factors, testing should begin at age 45. A fasting plasma glucose, a 2-hour oral glucose tolerance test, or an HbA1c (≥ 6.5%) is appropriate. Additional risk factors for diabetes are as follows:- A family history of DM in a first-degree relative- Habitual physical inactivity- Belonging to a high-risk ethnic or racial group (e.g., African American, Hispanic, Native American, Asian American, Pacific Islander)- A history of delivering a baby weighing > 4.1 kg (9 lbs) or of gestational diabetes- Hypertension- Dyslipidemia- Polycystic ovarian syndrome- A history of vascular disease Osteoporosis: The USPSTF recommend that women ≥ 65 years of age be screened no more than every 2 years. Screening should begin earlier for postmenopausal women who are at ↑ risk for osteoporotic fractures (e.g., low weight, low estrogen state, long-term use of oral or injected steroids). DEXA is the screening test of choice. Abdominal aortic aneurysm (AAA): The USPSTF recommends 1-time screening for AAA in men 65-75 years of age who have smoked at any time. Abdominal ultrasound is the screening test of choice.
• Adult immunizations Tetanus: Give 1° series in childhood followed by boosters every 10 years. Hepatitis B: Administer to all infants and to patients at ↑ risk (e.g., IV drug users, health care providers, those with chronic liver disease). Pneumococcal: Give to those ≥ 65 years of age or to any patient at ↑ risk (e.g., patients with splenectomy, COPD, or diabetes; alcoholics, or immunocompromised patients such as those on chemotherapy, posttransplant, or HIV ⊕). Influenza: Give annualy to all patients > 6 moths of age. Hepatitis A: Give to those traveling to endemic areas, those with chronic liver disease (HBV, HCV), and IV drug abusers. Zoster: Recommended for all patients > 60 years of age who have no contraindications, including those who report a previous episode of zoster or who have chronic medical conditions. Meningococcal: Not recommended for routine use. Used in outbreaks. The CDC recommends that all children 11-12 years of age be vaccinated and that a booster dose be given at age 16.
• Conjunctivitis treatment Bacterial conjunctivitis:- Erythromycin ointment- Polymyxin-trimethoprim drops- Azithromycin drops- Preferred agent in contact lens wearers: fluoroquinolone drops Viral conjunctivitis:- Warm or cold compresses- ± Antihistamine/decongestant drops Allergic conjunctivitis:- Over-the-counter antihistamine/decongestant drops for intermittent symptoms- Mast cell stabilizer/antihistamine drops for frequent episodes
• Otitis externa Pathogens:- Bacterial infections (most common cause of otitis externa)→ Pseudomonas aeruginosa (∼ 40% of cases), commonly from swimming activities→ Staphylococcus aureus, Proteus mirabilis, Escherichia coli- Fungal infections (less common): Aspergillus (accounts for 90% of all fungal otitis externa), Candida Risk factors:- Injury to the skin of the external auditory canal (e.g., cleaning, insertion of foreign objects such as hearing aids or earplugs, excessive itching)- Increased moisture in the external auditory canal (e.g., swimming, humid climate) Clinical features:- Severe ear pain, particularly at night- Otorrhea- Intense itching in the external auditory canal- The tragus is tender to touch- Pulling up and back on the auricle causes pain- Conductive hearing loss- Otoscopic findings:→ Localized OE: Furuncle→ Diffuse OE: Edematous and reddened external auditory canal Diagnostics:- Otitis externa is primarily a clinical diagnosis.- Check blood glucose levels to rule out diabetes- Culture and sensitivity tests are not routinely performed; they may be indicated if antibiotic treatment is not effective. Treatment:- Topical treatment→ Antibiotic eardrops (typically ofloxacin, ciprofloxacin, or gentamycin) → Topical hydrocortisone to control itching and inflammationAural toilet: clean the external auditory canal and keep it dry using an ear wick and/or astringents (e.g., mixture of isopropyl alcohol and acetic acid)- Systemic treatment: oral ciprofloxacin→ Indications: Immunosuppression, Diabetes mellitus, Severe otitis externa with cellulitis of the face and neck, Topical administration of antibiotics is not possible (e.g., severe edema of the external auditory canal) or is ineffective.- NSAIDs for pain relief
• Bacterial conjuncitivitis – Treatment Trimethoprim-polymyxin B  or Erythromycin
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• Allergic conjuncitivitis – Treatment Olopatadine ophthalmic drops
• Pneumococcal vaccine PPSV23 alone:- Chronic heart, lung, or liver disease- Diabetes, current smokers, alcoholics Sequential PCV13 + PPSV23 (very-high-risk patients)- Age ≥65- CSF leaks, cochlear implants- Sickle cell disease, asplenia- Immunocompromised status (e.g., HIV, malignancy)- Chronic kidney disease
• Sinusitis – Treatment - Uncomplicated viral sinusitis is usually self-limiting.   - Topical, intranasal steroids (fluticasone, beclomethasone) - Nasal, saline lavage - Decongestive nose drops to relieve pain and blockage (e.g., oxymetazoline) - In the case of confounding allergyAntihistamines (loratadine, fexofenadine, chlorpheniramine) - Avoid exposure to irritants: cigarette smoke, dust, molds, and chemical irritants

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