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Hypertension
1. Maintain a healthy weight, weight loss is a priority
2. Low sodium diet, < 2.4g sodium per day
3. Maintain adequate dietary potassium from fresh fruits and vegetables
4. Exercise, 30 min a day, 5 days a week
5. Limit daily alcohol intake (2 drinks for male per day, and 1 drink for female)
6. Stop smoking and reduce the intake of dietary saturated fat
7. Home monitor, check BP daily till stabilized especially in winter
8. Better taking the pill in the evening than in the morning
Diabetes
Standard Care
1. Diabetes is a worldwide epidemic (415 million in 2015), causing 5 million death in 2015
2. 90% of DM are type 2 DM. Up to 50% of T2D remain undiagnosed, Some T2D patients already have kidney, eye or neurology complications when diagnosed.
3. Many T2DM cases can be prevented by adopting a healthy lifestyle. High-risk factors are age > 45, obesity, increased wairst circumference, hypertension and family history of DM.
4. Lifestyle change: reduce the carbohydrate (calerie intake cut by 600 kcal), avoid snacks and sweets, reduce the frequency of eating out, increase physical activity (>150 min per week), weight reduction (>5-7%).
5. Self-monitoring of blood glucose at home
6. HbA1c check every 3 month, generally targeting <7%, and avoid hypoglycemia (glucose < 70mg/dl)
7. Keep LDL low, targeting < 70 mg/dl if age between 40 and 75 years
Foot check
1. Monofilament test
2. Podiatry follow up yearly for neuropathy prevention
Fatty liver
Non-alcoholic fatty liver disease (NAFLD) : simple deposition of adipose tissue in the liver.
1. Incidence of NAFLD: 20%-30% in Western countries and 5%-18% in Asia
2. NAFLD was 10% higher in overweight individuals compared to lean persons
3. Will be the major cause of liver related morbidity and mortality as well as a leading indication for liver transplantation
4. Highest risk: Hispanic population; Increasing risk: Asian population
5. Independent risk factor: Diet, cigarette smoking, sedentary behavior
6. Workup: rule out alcoholic, viral, medication use, parenteral nutrition, Wilson’s disease, biliary disease, autoimmune hepatitis, and malnutrition.
7. Treatment: early diagnosis is the KEY. Weight reduction, Diet modification, Exercise.
Non-alcoholic fatty liver (NAFL)
Steatosis of the liver, involving greater than 5% of parenchyma, with no evidence of hepatocyte injury
Mild: 5%-33%
Moderate: 34%-66%
Severe: > 66%
Non-alcoholic steatohepatitis (NASH)
Liver cells become injured in a background of steatosis
Lower Back pain
1. 80% if the back pain is lumbar strain, mostly seen in ages 30-60, associated with overuse.
If shooting down the leg, consider pinch nerve due to herniated disc (3-4%);
If >70 yr female with osteoporosis, consider compression fracture (3-4%);
If worse walking upright, consider spinal stenosis (3%);
If in ages 20-30 and better with activity, consider spondyloarthritis (<1%);
If losing weight with history of cancer, consider cancer;
If developing fever in immunocompromised patient, consider infection/abcess.
2. Red Flags: Age>50, history of cancer, fever, pain worse at night or lying down, morning stiffness, urinary symptoms, bilateral sciatica, numbness in the pelvis, steroid use, injection drug use.
3. Localizing lesion based on symptoms
L3 - anterior thigh and knee;
L4 - anterior shin;
L5 - dorsum of the foot;
L5/S1 - lateral and posterior calf
S1 - heel.
4. Localizing lesion based on physcial exam
L4 nerve root - decreased patellar reflex, weak rising from squat
L5 nerve root - weak great toe dorsiflexion, weak heel walk
S1 nerve root - decreased ankle reflex, weak toe walk
Joints pain
1. Shoulder Pain, front part pain with combing hair and reaching in back seat of car--- Rotator cuff impingement/tear; excruciating pain and not able to lift the shoulder without assitance, usually occurs around 50s --- Frozen Shoulder (Adhesive capsulitis). Active Test and Passive Test to differentiate.
2. Elbow Pain, medial part pain with carrying suitcase or shaking hands --- Golfer's Elbow; Pitcher's Elbow (medial epicondylitis)
3. Elbow Pain, lateral part pain when turning door knob or using screwdriver --- Tennis Elbow (lateral epiconylitis)
4. Thumb Pain, dorsal part while grasping --- DeQuervain tenosynovitis
5. Hip Pain, lateral thigh pain while sleeping --- Trochanteric burstitis; groin area pain while getting in/out of car or putting on shoes/socks --- Hip arthritis
6. Knee Pain, over the patella while kneeling --- Housemaid's knee (prepatellar bursitis); front knee while walking up or down stairs, squatting or getting up from low seat --- Patellofemoral arthritis
7. Ankle Pain, back of the heel with stretching ankle or standing on toes --- Achilles tendonitis
8. Foot Pain, bottom of the feet with the first steps in the morning --- Plantar fasciitis
9. Lower back pain, buttock or leg with walking and improved with leaning forward --- Spinal stenosis
Ankle sprain
1. Stop the current exercise, ice packs intermittently (15 min every 2-3 hours while awake) for the first 72 hours, keep the injured area elevated at night
2. Rule out a fracture with Xray, hairline fx needs a second x-ray in 1 week,
2. Pain management with aspirin, Tylenol, ibuprofen or prescribed pain medications.
3. Warm compression after the first 72 hours.
4. If using Ace bandage, make sure not too tight. Watch for numbness, coldness, increasing pain, or a blue color
5. Rest well and NO weight-bearing
Belly Pain
Gallbladder stone
RUQ belly pain
Appendicitis
RLQ belly pain
GYN problem
Lower belly, can be bilateral
Bowel Obstruction
No gas or bowel movement
Bowel Infection
Diarrhea
Others
others
GERD (acid reflex)
1. The acid helps to digest food, but it may go in the wrong direction, causing acid reflex and burning
2. Eat: a low-fat diet
3. Do not eat: chocolate, tomatoes, tomato sauces, oranges, pineapple and grapefruit, mint, coffee, alcohol, carbonated beverages, and black pepper
4. Quit drinking and smoking and Weight loss will help.
4. Mild: try Tums or Pepcid/Moderate: try omeprazole/Severe: see your family doctor
Kidney stone
1. Adequate hydration every day
2. Diet improvement, reduce consumption of spinach, tomato, chocolate, peanut, etc
3. High Calcium diet to reduce the absorption of oxalate
4. Low sodium diet
5. Avoid too much supplement of vitamin C
6. Reduce sugar intake
Gout
1. Low-fat dairy and reduced meat and seafood intake
2. Protein intake from soy and legumes was associated with reduced risk
3. Avoidance of sugar-sweetened beverages
4. Fresh cherry fruit once or twice daily
5. Reduction in alcohol intake, Better wine than beer or liquor
6. Weight reduction if you are overweight or obese
7. For hypertension patients, recommend losartan, avoid diuretics
8. Allopurinol to lower the uric acid (goal < 6 mg/dL )
9. Colchicine to reduce the frequency of recurrent gout flares
Vitamin D defficiency
1. About 1.3 million osteoporosis-related fractures occur every year in the US
2. Annual check for serum 25-hydroxyvitamin D (recommend range 20 - 40 ng/mL (50 to 100 nmol/L))
3. Vitamin D insufficiency <20ng/mL; Vitamin D deficiency <12ng/mL. Experts agree that levels lower than 20 ng/mL are suboptimal for skeletal health. 30 ng/mL is necessary for the elderly to prevent falls and fractures
4. Risk factors: Age, Dark skinned, Limited sun exposure, Obese, Malabsorption, Phenytoin intake, Hospitalized
5. Food to choose: Milk, Cheese, Yogurt, Salmon,Tuna, Saldine, Liver, Mushroom, etc
6. Vitamin D supplementation may have some protection for acute URI, especially in those with Vit D deficiency
7. Supplimentation: Vitamin D2 is cheaper, but Vitamin D3 is better. Severe cases needs to start with bolus and followed with maintenance dose. Malabosorption needs to be considered if not responding well to appropriate supplemention
Headache
Tension headache
Tightness on both sides of the head
Stress-related
A trial of Tylenol or Ibuprofen
Migraine
Often affect just 1 side of the head, pounding or throbbing
Nausea, vomit, sensitive to light and sound
Recommend to lie down in a cool, dark, quiet room
Cluster
Male dominant, tearing
See a doctor immediately
1. "the worst headache of your life"
2. Fever with neck stiffness
3. Weakness, numbness, or trouble seeing
Doctors may ask:
duration, severity, quality of the headache, unilateral or bilateral, nausea/vomit, sensitive to light, etc
Dizziness
Vertigo
1. With the room spinning
2. If positional related, the patient could try maneuver supervised by a doctor
3. If associated with ear symptoms, check with an ENT doctor
4. If not able to point precisely to the target, check with a neurologist
Cardiogenic
1. If associated with low BP, check for black/bloody stool, get adequate hydration and re-check BP
Others
others
Pink eye
Conjunctivitis
1. No vision loss
2. Can be virus, allergy or bacterial
3. Check with family doctor for differential
Cornea infection
1. Vision loss, pain, fear of light
2. Check with an eye doctor for treatment ASAP
Eyeball infection
1. Vision loss, pain, fear of light
2. Check with an eye doctor for treatment ASAP
3. May need to check immune disease
Foreign body
1. Adequate saline/Tap water irrigation
2. Check with an eye doctor for treatment ASAP
Nose bleeding
1. Lean forward, not back
2. Pinch the patient's nose for 5-10 min, below the bony bridge but not nostrils. Make sure you can still breathe while holding the nose.
3. Cold pack over the bridge of the nose can constrict the blood vessels
4. Don’t blow nose after successfully stop bleeding
Rhinitis
Non-allergic Rhinitis
- Nasal congestion (stuffiness), rhinorrhea, and postnasal drainage
- Onset at a later age
- Triggers including irritant odors and strong fragrances, air pollution or temperature changes
- Absence of nasal and ocular itching and prominent sneezing
- Treatment, an intranasal spray of antihistamine or steroid (Afrin, Flonase, etc) or pseudoephedrine. Daily nasal saline irrigation is a helpful adjunctive therapy
Allergic Rhinitis
- Allergy test availabe
Bee/Wasp/Hornet bite
1. Most people only has minor local reactions, people with venom allergy (about 3%) may develop systemic allergic reactions and could be life-threatening (ie, anaphylaxis)
2. Immediate stinger removal in seconds if possible
3. A typical local reaction is a painful swelling red area (1 to 5 cm) that develops within minutes and resolves in a few hours
4. Large local reactions peak at about 48 hours and then gradually resolve over 5 to 10 days.
5. Ice compression on the skin, don't unroof the pseudopustules that may increase the risk of infection
6. OTC: antihistamine for the itching; ibuprofen/tylenol to reduce pain
7. Prescription: steroid cream/ointment or pills if no improvement; antibiotic if develops a secondary bacterial infection
8. A tetanus booster is not necessary following a "clean" sting
9. If develops SOB, call 911 instead of driving to the ED, Epipen backup at home
poison ivy/oak
1. Leave of three, let it be
2. About 25 to 40 million Americans require medical treatment annually
3. Clinical symptoms occurs in 4 to 96 hours and peak between 1 and 14 days
4. Most common presenting signs--intense pruritus and rash, vesicles or bullae sometimes
5. Prevention: Cover the skin while having outdoor activities, Apply IvyBlock to skin 15 minutes prior to potential exposure, Wash the contact skin immediately with soap and lots of water
6. Mild rash: OTC Burow’ Solution for the itching
7. Moderate to severe: better see a doctor for steroid cream or pills
8. Make sure the duration of steroid treatment more than 10 days
9. Usually resolves in 1 to 3 weeks
Lyme disease
1. Most commonly reported vector-borne disease in the US
2. Transmission of Borrelia species that cause Lyme disease requires more than 24 hours of attachment of ticks
3. Preventions: wearing protective clothing (using tick repellents, like DEET), checking for ticks after outdoor activities, showering within two hours of potential exposures, placing dry clothes in dryers on high heat for 4 minutes
4. Long pants only or light-colored clothing is not helpful, recommend permethrin-treated clothing
5. Remove the tick with a profession tick remover to totally get rid of it after the bite
6. If you see a target skin rash, see a doctor for an antibiotic
recurrent UTI
1. Female much easier to get infected
2. Typical symptoms: lower belly pain, burning pain when peeing, urinary urgency, and frequency
3. Watch for fever and flank pain for a complication of kidney infection (pyelonephritis)
4. Usually improving fast with appropriate antibiotics