AAFP: Review September 2008, Emory Family Medicine

1. AAFP: Review September 2008, Emory Family Medicine Susan Schayes M.D. Assistant Professor-CT Family Medicine, Emory University School of Medicine

2. Learning objectives • Review Sept 1, Sept 15 AAFP highlights • Health Maintenance for Post Menopausal women • Shoulder Osteoarthritis • Aortic Stenosis • Mastitis in Breastfeeding Women

3. Health Maintenace for Postmenopausal Women • Symptom management • Preventive Care Recommendations -Osteoporosis -Nutrition and Lifestyle -CHD and medical issues -Cancer Prevention -Immunizations

4. Health Maintenace forPostmenopausal Women • Symptom Management - Oral HRT therapy is highly effective in relieving hot flashes and night sweats. -Post menopausal vaginal symptoms can be treated with topical estrogen therapy • Use of HRT has declined since WHI -low dose, shortest time, do not use for prevention of chronic conditions such as CVA, OP, Dementia

5. Osteoporosis • USPTF- screen women older than 65 year • AAFP- screen women older than 65 or starting at 60 with women at high risk of osteoporotic fractures

6. Nutrition and Lifestyle • Calcium and Vit D • Obesity/Physical Activity USPT: screen/counsel/intervene to all adults to achieve weight loss USPT: evidence is insufficient to recommend for or against counseling for exercise • Tobacco Use Screen for tobacco and provide interventions

7. CHD and medical conditions • ASA • Blood pressure • Cholesterol • Diabetes

8. Cancer Prevention • Breast Cancer • USPT: 1-2 years over 40, over 70 if good life expectancy • Cervical Cancer • USPT: every 3 yrs in women who have been sexually active Stop at age 65 • Colorectal Cancer USPT: Screen adults over age 50,discontinue?

9. Immunizations • Influenza • Pneumococcal vaccine • TdaP • Zoster vaccine

10. Shoulder Osteoarthritis (OA) • Leads to pain and stiffness • Loss of articular cartilage and formation of osteophytes • Subchrondral bone remodels, loss sphericity and congruity, joint • Loss of shoulder rotation

11. Risk factors for Shoulder OA: • Genetics • Joint instability/dislocations • Periarticular muscle weakness • Sports injury • Occupational factors • Obesity • Age

12. Classification of OA • Primary (idiopathic) unidentified causes • Secondary precipitating factors

13. Shoulder Osteoarthritis (OA)secondary causes • Atraumatic osteonecrosis -alcohol, corticosteroid, cytotoxic drugs • Gaucher’s disease, lipid metabolism disorders • Obesity, radiation, sickle cell • Postinflammatory -crystal arthropathies, infection, • Surgery -prior arthroplasty, hardware, over tightening anterior capsule

14. Shoulder pathologiesHistory • Morning stiffness improved with activity : RA • Night time shoulder pain: Rotator cuff problem • Pain or clunking with overhead • movement- Labral disorder

15. Shoulder pathologiesPhysical • Painful crepitus • Joint enlargement and swelling • Progressive functional limitations

16. Non-pharmacologic therapy • Activity modification • Rest • Ice • Physical therapy • Strength training • Aerobic exercise

17. Acetaminophen (ACET) • First line pharmacotherapy • No gastric irritation • Inexpensive • Use 3-4 grams daily

18. NSAIDs____________ • NSAIDs both analgesic and anti-inflammatory • Non-selective NSAIDs inhibit both COX-1 and COX-2 enzymes – Ibuprofen, diclofenac, naproxen • The COX-2 drugs, celecoxib , selectively inhibit o • SE- GI, PUD, renal failure

19. Shoulder injection • Advanced Shoulder OA • Inject with triamcinolone acetonide 40 mg-80 mg with lidocaine 1% every 3-4 months

20. Arthroscopic debridement Capsular release Corrective osteotomies Interpositional arthroplasty Shoulder arthroplasty Severe OA Pain/ Loss of function unresponsive to conservative therapy Shoulder Surgery

21. Shoulder Surgery • Post op rehab- 6 weeks of stretching- flexibility and ROM • Strengthening- 2 weeks

22. Aortic Stenosis • Affects 3% of people over 65 • Survival is 2-3 years is symptomatic patients • Become symptomatic when LVH, and atrial augmentation of preload can not compensate for afterload • Heart failure, angina, syncopy

23. Aortic Stenosis • Prolonged latent phase, become symptomatic as it worsens • Become symptomatic when cardiac output can not increase with exercise, and leads to hypotension and syncopy

24. Aortic Stenosis • Normal valve area 3-4 cm in area • As it decreases to 1 cm- size of the head of a golf tee- symptomatic • Symptomatic = Surgery • Asymptomatic= Watch with serial echos

25. Aortic Stenosis • Classic symptom: Dyspnea • Classic harsh crescendo- decrescendo systolic murmur, heart loudest at the second right intercostal space, and radiates to the carotids

26. Aortic Stenosis Sounds http://depts.washington.edu/physdx/heart./demo/html

27. Aortic Stenosis • ACC/AHA recommend echo in asymptomatic patients with grade 3/6 or louder murmur • Echo initial recommended test

28. Aortic Stenosis • Mortality dramatically increases in symptomatic aortic stenosis. • Medical management has not been shown to improve mortality in symptomatic patients.

29. Aortic StenosisAsymptomatic patients • Distinguish between asymptomatic, and activity decreased below symptom level • Treat their HTN • Sensitive to changes in: preload, contractility, vascular tone

30. Aortic StenosisAsymptomatic patients • HTN: ACEI- well tolerated, improve effort tolerance, reduce dyspnea • Beware diuretics- reduced LV diastolic filling, which reduces cardiac output • Beware alpha-blockers too

31. Mastitis in Breast feeding Women • Diagnosed with localized, unilateral breast tenderness and erythema, with fever, malasie, fatigue, body aches, and headache Treat with Amoxil/clavulinic acid, cephalexin, clindamycin, • Complication is development of abscess

32. Mastitis in Breast feeding Women • Mastitis occurs in 10 % of breast feeding women • Risk can be reduces with frequent, complete emptying of the breast • Risk increased by anything that can damage/crack nipples

33. Mastitis in Breast feeding Women • Risk increased if yeast infection- if infant has thrush- treat both mom and infant • Continue to breast feed with mastitis

34. The End