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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3063_Библиотеки_им_академика_М_И_Перельмана
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functional or actual asplenia and patients with terminal complement deficiencies should also
receive the vaccine. Meningococcal vaccine is now routine to give at age 11.
Diarrhea
To prevent traveler ’s diarrhea, patients should be educated regarding the advisability of
avoiding salads and unwashed fruit and drinking tap/ice water. Patients who experience loose
stools without fever or blood can safely take loperamide. Treatment with a fluoroquinolone or
azithromycin is reserved for patients with moderate to severe symptoms (bloody diarrhea).
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Immunizations
Influenza Vaccine
Influenza vaccination is recommended annually for all adults, regardless of age. Additionally,
those who have a history of cardiopulmonary disease, DM, or hemoglobinopathy, or who are
residents of a chronic care facility should receive an annual influenza vaccination, regardless
of age.
Pregnant women who will be in their second or third trimester during the influenza season
should also receive the vaccine.
Pneumococcal Vaccine
Pneumococcal vaccination with the pneumococcal polysaccharide vaccine (PPSV23) is
indicated for all adults age >65. Additionally, the following should receive the vaccine at any
age:
Additionally:
Those with history of sickle-cell disease or splenectomy
Those with history of cardiopulmonary disease, alcoholism, or cirrhosis
Alaskan natives and certain Native American populations
Those who are immunocompromised (hematologic malignancy, chronic renal failure,
nephrotic syndrome, HIV-positive; or taking immunosuppressive medications)
Those age >65 who received PPSV23 earlier than age 65 also need a booster shot if it has
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Varicella Vaccine
Varicella vaccine is a live, attenuated vaccine recommended for use in all adults who lack a
history of childhood infection with varicella virus. Being a live, attenuated vaccine, varicella
vaccine should not be given to immunocompromised patients, HIV-positive patients when
symptomatic, those with <200 CD4 cells, or pregnant women.
Shingles Vaccine
The shingles (zoster) vaccine is recommended routinely in order to reduce the risk of shingles
and its associated pain in people ≥60. Only one dose of zoster vaccine is typically given.
Persons who report a previous episode of zoster and persons with chronic medical condition
(chronic kidney disease, diabetes) can be vaccinated.
Zoster vaccination is not indicated to treat acute zoster, to prevent those with acute zoster from
developing post-herpetic neuralgia, or to treat ongoing post-herpetic neuralgia. Before routine
administration of zoster vaccine, it is not necessary to ask patients about their history of
varicella (chickenpox) or to conduct serologic testing for varicella immunity. The zoster
vaccine is a lyophilized preparation of live, attenuated VZV.
HPV Vaccine
The quadrivalent human papilloma virus (HPV) vaccine prevents against 4 types of HPV (types
6, 11, 16, 18) that are associated with genital warts and cervical cancer. It is given in 3 doses
and it is recommended for those age 11–12, but can be given at age 9.
been more than 5 years since being vaccinated
Those with high risk of fatal infection (asplenic patients, immunocompromised patients,
kidney disease, chemotherapy, long-term steroids, cancer including leukemia and lymphoma,
organ transplant) should be revaccinated 1x after 5 years
No one gets more than 1 booster shot per lifetime
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It is also recommended for those who did not complete the series or were never vaccinated
from age 13–26. Males age 9–26 might get the vaccine to prevent genital warts. Cervical
cancer screening with Pap smear should continue after vaccination.
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Smoking Cessation
Smoking cessation is the most preventable cause of disease. Smoking is responsible for 1 in
every 5 deaths in the United States. There are 5 steps a physician can take to help patients stop
smoking.
U/S should be given once in male smokers age >65 in order to screen for abdominal aortic
aneurysm. There are no screening recommendations in male nonsmokers and women,
regardless of smoking history.
ASK about smoking at every visit.
ADVISE all smokers to quit at every visit.
ATTEMPT to identify those smokers willing to quit.
ASSIST smokers in quitting by setting a quit date (usually within 2 weeks) and using
nicotine patches/gum or the oral antidepressant bupropion as supportive
therapy. Varenicline, a nicotinic receptor partial agonist, can also be used to treat nicotine
addiction.
ARRANGE follow-up. Provide positive reinforcement if the quit attempt was successful. If
the quit attempt was not successful, then determine why the patient smoked and elicit a
recommitment to smoking cessation. Most patients will require several attempts before
being successful.
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Osteoporosis Prevention
All women age >65 should be given a DEXA scan. Screening should begin at age 60 if there is
low body weight or increased risk of fractures.
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Prevention of Alcohol Abuse
Physicians should screen for alcohol abuse by using the CAGE questionnaire:
A positive screen is 2 “yes” answers. One “yes” should raise the possibility of alcohol abuse.
Have you ever felt the need to: Cut down on your drinking?
Have you ever felt: Annoyed by criticism of your drinking?
Have you ever felt: Guilty about your drinking?
Have you ever taken a morning: Eye opener?
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Prevention of Violence and Injury
Injuries are the most common cause of death age <65. The role of the physician is to advise
patients about safety practices that can prevent injury. Advising the patient about the
importance of seat belts, bicycle helmets, not driving after one drinks alcohol, and
understanding the risks that firearms pose in the home can all reduce the risk of serious injury.
Identifying women who are at increased risk of physical or sexual abuse is an essential role for
physicians. Simply asking women if they have been hit, kicked, or physically hurt can increase
identification by more than 10%.
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2
Infectious Disease
Case 1
Chief Complaint
Fever, cough, and chest pain
History and Physical Examination
A 32-year-old man comes to the emergency department with 5 days of fever, a cough that
is sometimes productive of blood, and pleuritic chest pain. He is an active IV drug user
and last used yesterday. He denies being HIV positive. Past medical history is significant
for skin abscesses in the past, but recently he has been quite well. He uses no medications
and has no allergies. His T is 39 C (102.2 F), BP is 112/72 mm Hg, and pulse is 110/min.
Physical examination reveals a thin, weak-appearing man lying on his side in the stretcher.
Examination of the head, eyes, ears, nose, and throat shows petechiae in his mouth and in
the conjunctivae. Eye grounds are normal. The chest is bilaterally clear to auscultation. A
2/6 systolic ejection murmur is audible over the lower left sternal border. There is no
radiation of the murmur. The abdomen is benign and the extremities have no clubbing, but
thin red lines are visible under the fingernails in the distal 1/3.
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Differential Diagnosis
CCS NOTE
Many cases that appear on the CCS are not diagnostically difficult. The diagnosis is
often obvious, with the emphasis on testing and treatment.
Initial Management
Setting: emergency department
Diagnostic/Therapeutic Plan
Test Results
CCS NOTE
Pneumonia
1.
Infective endocarditis (IE)
2.
Sepsis
3.
Bronchiectasis
4.
Chest x-ray
Blood cultures
Methicillin-sensitive Staphylococcus aureus
Multiple nodular lesions visible bilaterally
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