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Dyspepsia in Pregnancy

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81. CRACKCast E095 – Large Intestine

, or electrolyte disturbances” — Quotation from Uptodate 2017 ● Nocturnal diarrhea, anorexia, onset > 50 yrs of age However, here are features that are typical for IBS: One out of three days of: Bloating Abdominal pain (relieved with defecation) Constipation OR diarrhea OR both Upper GI symptoms (dyspepsia / nausea) Mild abdominal tenderness The strict definition is made by the ROME IV criteria – check out the show notes! Check out Box 85.2 – ddx for IBS based on symptoms – diarrhea, constipation, pain (...) % of population have this anatomic variant RF: Usually needs coexisting trauma, adhesions, lymph nodes or malignancy, Pregnancy 20% risk for gangrene Sigmoid Needs Long redundant section of sigmoid w/ narrow mesentery attachment to abdo wall The narrow attachment allows mesentery to twist on itself = luminal obstruction After obstruction, the proximal colon continues to force gas and liquid into the obstructed segment = sometimes massive dilation of the distal colon RF: A high fiber diet / Chronic

2017 CandiEM

82. CRACKCast E089 – Esophagus, Stomach & Duodenum

complications of GERD Some physiologic GER occurs in everyone, when it becomes symptomatic then it is “GERD”. Conditions associated with GERD: (ie. anything that causes the LES to relax of become overwhelmed) – this comes from Box 79-2 Decreased LES pressure Meds: CCB, nitrates, anticholinergics, albuterol, benzos, Fatty meals / Chocolate / Caffeine / Ethanol / Peppermint / nicotine Pregnancy Estrogen / progesterone Increased gastric emptying time / Increased intra-abd. Pressure Anticholinergic drugs (...) Pregnancy Obesity Coughing / bending / Supine position Gastroparesis / neuromuscular disease leading to gastric outlet obstruction Decreased esophageal motility Achalasia DM Scleroderma GEeRD = “gastric emptying; esophageal relaxation drugs” mnemonic Complications of GERD Esophagitis Progressing to Barrett’s metaplasia, erosion, ulcerations, scarring Stricture formation due to persistent scarring and inflammation Reflux induced asthma Microaspiration of Adenocarcinoma of the esophagus Esophageal

2017 CandiEM

83. Alcohol: Adult Unhealthy Drinking

in a guideline does not imply coverage. A decision to adopt any particular recommendation must be made by the provider in light of the circumstances presented by the individual patient. 2 Summary of Changes as of October 2016 Added recommendations for screening and intervention for PREGNANT WOMEN: • Abstinence is recommended for pregnant women and for women planning pregnancy. • Pregnant women should be screened with the AUDIT-C at least once per trimester and at the 6- week postpartum visit. o The timeframe (...) for the questions should be the last 3 months rather than the last year. o The threshold for “binge drinking” in the third question is 4 or more drinks on one occasion. • Pregnant women should be screened for alcohol use disorder (AUD) using the Alcohol Symptom Checklist if: o They score a 3 or greater on the AUDIT-C, or o They are currently drinking at any level since learning of their pregnancy, regardless of their AUDIT-C score. • Pregnant women who are negative for AUD should receive brief behavioral

2016 Kaiser Permanente Clinical Guidelines

84. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Gui

Annular VA e242 7.2. Papillary Muscle VA e242 7.3. Interfascicular Reentrant VT (Belhassen Tachycardia) e242 7.4. Idiopathic Polymorphic VT/VF e242 8. PVC-Induced Cardiomyopathy e243 9. VA and SCD Related to Specific Populations e243 9.1. Pregnancy e243 9.2. Older Patients With Comorbidities e243 9.3. Medication-Induced Arrhythmias e243 9.4. Adult Congenital Heart Disease e243 10. Defibrillators Other than Transvenous ICDs e246 10.1. Subcutaneous Implantable Cardioverter-Defibrillator e246 10.2

2017 American Heart Association

85. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Hea

(Belhassen Tachycardia) e335 8.4. Idiopathic Polymorphic VT/VF e336 9. PVC-Induced Cardiomyopathy e337 10. VA and SCD Related to Specific Populations e338 10.1. Athletes e338 10.2. Pregnancy e338 10.3. Older Patients With Comorbidities e339 10.4. Chronic Kidney Disease e340 10.5. Valvular Heart Disease e340 10.6. Sex-Related Differences in the Risk of SCD e340 10.7. Medication-Induced Arrhythmias e341 10.8. Adult Congenital Heart Disease e342 11. Defibrillators Other than Transvenous ICDs e347 11.1

2017 American Heart Association

87. Dyslipidaemias

. Autoimmune chronic inflammatory conditions such as rheumatoid arthritis, systemic lupus erythematosus (SLE) and psoriasis are associated with increased CV risk and dyslipidaemia. Furthermore, in women, diabetes or hypertension during pregnancy are risk indicators, and in men, erectile dysfunction. Patients with CKD are also at increased risk for CVD events and should be screened for dyslipidaemias. Clinical manifestations of genetic dyslipidaemias, including xanthomas, xanthelasmas and premature arcus

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2016 European Society of Cardiology

88. Musculoskeletal Strains and Sprains - Guidelines for Prescribing NSAIDs

ASA ( < 325 mg) co-therapy is associated with fewer GI ulcers and serious upper GI disorders. Regular use of NSAIDs, in particular ibuprofen, might interfere with the antiplatelet effect of ASA. ASA should be taken an hour before the NSAID Pregnancy : NSAIDs are not recommended during the first and third trimesters of pregnancy due to risk of miscarriage in the first trimester and interference with closure of the ductus arteriosis in the third trimester. Lactation: Ibuprofen is a preferred drug (...) . NSAIDs should be taken with a full glass of water to facilitate dissolution. Encourage patients on NSAIDs to drink fluids to maintain adequate hydration (to prevent kidney dysfunction). Taking NSAIDs with food is often recommended to prevent GI symptoms, although there is no evidence this reduces the incidence of dyspepsia or ulceration. Expect onset of pain relief with analgesics in 30 - 60 minutes. Patients with a sprain or strain should be advised to seek further medical advice

2017 medSask

90. Lymphangioleiomyomatosis Diagnosis and Management Part I: An Official ATS/JRS Clinical Practice Guideline

of LAM before consideration of proceeding to diagnostic lung biopsy (strong recommendation based on moderate-quality evidence). The purpose of vascular endothelial growth factor D testing is noninvasive diagnostic con?rmation of LAM. Other con?rmatory features of LAM include tuberous sclerosis complex, angiomyolipomas, chylous pleural effusionsorascites,andcystic lymphangioleiomyomas. Other questions pertaining to the management of LAM, such as issues regarding pregnancy, safety of air travel (...) / kPa-min, respectively), or quality of life. More adverse effects were reported by the doxycycline group, but only dyspepsia and photosensitivity were attributed to the drug. Bene?ts No bene?cial effects due to doxycycline therapy were con?rmed in patients with LAM who had respiratory impairment. Harms Potential adverse effects due to doxycycline include dyspepsia, photosensitivity, and possibly also nausea and diarrhea. Other Considerations The guideline panel’s judgments regarding the effects

2016 American Thoracic Society

91. Screening and Management of Lipids

sequestrants, protease inhibitors, retinoic acid, anabolic steroids, sirolimus, raloxifene, tamoxifen, beta blockers (not carvedilol), thiazides Diseases Biliary obstruction, nephrotic syndrome Nephrotic syndrome, chronic renal failure, lipodystrophies, Cushing's syndrome Disorders and altered states of metabolism Hypothyroidism, obesity, pregnancy* Diabetes (poorly controlled), hypothyroidism, obesity, inactivity; pregnancy* * Cholesterol and triglycerides rise progressively throughout pregnancy (...) ; treatment with statins, niacin, and ezetimibe are contraindicated during pregnancy and lactation. Adapted from 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol Table 2. 10-Year Risk Assessment for ASCVD Ten-year risk is defined as the risk of developing a first ASCVD event (nonfatal MI, CHD death, fatal or non fatal stroke) over a 10-year period among people free from ASCVD at the beginning of the period Pooled Cohort Equations estimate 10-year ASCVD risk in individuals age 40 to 79 years

2016 University of Michigan Health System

93. Acne clinical guideline

of the iPLEDGE program on isotretinoin fetal exposure in an integrated health care system. J Am Acad Dermatol . 2011 ; 65 : 1117–1125 | | | | | , x 144 Collins, M.K., Moreau, J.F., Opel, D. et al. Compliance with pregnancy prevention measures during isotretinoin therapy. J Am Acad Dermatol . 2014 ; 70 : 55–59 | | | | | Miscellaneous therapies and physical modalities Chemical peels B II, III x 145 Grover, C. and Reddu, B.S. The therapeutic value of glycolic acid peels in dermatology. Indian J Dermatol

2016 American Academy of Dermatology

94. Diverticular disease

removed. September 2017 — minor update. SPC update on quinolones to align all CKS topics prescribing advice. Prostatitis – chronic, Gonorrhoea, Pyelonephritis, Diarrhoea – prevention and advice for travellers, Dyspepsia – unidentified cause, Dyspepsia – proven functional, Dyspepsia – proven peptic ulcer, Diverticular disease, Gastroenteritis and Scrotal pain and swellings. July 2017 — reviewed. A literature search was conducted in June 2017 to identify evidence-based guidelines, UK policy, systematic (...) , stabbing lower abdominal or pelvic pain with nausea and vomiting. Ectopic pregnancy — see the CKS topic on for more information. Urological Urinary tract infection, including pyelonephritis — see the CKS topics on , , and for more information. Urinary tract obstruction, including ureteric stone — see the CKS topic on for more information. Basis for recommendation Basis for recommendation The information on differential diagnosis of diverticular disease and diverticulitis is based on expert opinion

2019 NICE Clinical Knowledge Summaries

95. Gonorrhoea

arthralgia, tenosynovitis, or septic arthritis. In men, if left untreated, complications include epididymitis, infertility and prostatitis. In women, complications include pelvic inflammatory disease (PID). Gonorrhoea in pregnancy is associated with spontaneous abortion and other complications. A diagnosis of gonorrhoea may be suspected on the basis of history, symptoms, and examination. In men, symptoms (such as urethral discharge and dysuria) usually develop 2–5 days after exposure. Examination (...) , Diarrhoea – prevention and advice for travellers, Dyspepsia – unidentified cause, Dyspepsia – proven functional, Dyspepsia – proven peptic ulcer, Diverticular disease, Gastroenteritis and Scrotal pain and swellings. May to June 2017 — reviewed. A literature search was conducted in May 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. Previous changes Previous changes December 2016 — minor update

2019 NICE Clinical Knowledge Summaries

97. Pyelonephritis - acute

in pregnancy. Emphysematous pyelonephritis. Acute pyelonephritis should be diagnosed by taking a detailed medical history and conducting a physical examination. Acute pyelonephritis should be suspected in people with signs or symptoms of a urinary tract infection (for example, dysuria, frequency, urgency) accompanied by any new signs or symptoms of pyelonephritis (including fever, nausea, vomiting, or flank pain). A midstream or catheter specimen of urine should be sent for culture and sensitivity. A urine (...) pyelonephritis (acute): antimicrobial prescribing. September 2017 — minor update. SPC update on quinolones to align all CKS topics prescribing advice. Prostatitis – chronic, Gonorrhoea, Pyelonephritis, Diarrhoea – prevention and advice for travellers, Dyspepsia – unidentified cause, Dyspepsia – proven functional, Dyspepsia – proven peptic ulcer, Diverticular disease, Gastroenteritis and Scrotal pain and swellings. December 2016 — minor update. The adverse effects section for ciprofloxacin has been updated

2019 NICE Clinical Knowledge Summaries

98. Gastroenteritis

of disabling and potentially long-lasting or irreversible side effects [ ]. January 2019 — minor update. Aortic aneurysm and dissection is now listed as an adverse effect of ciprofloxacin. October 2018 — minor update. Adverse effects updated within prescribing information - metronidazole. September 2017 — minor update. SPC update on quinolones to align all CKS topics prescribing advice. Prostatitis – chronic, Gonorrhoea, Pyelonephritis, Diarrhoea – prevention and advice for travellers, Dyspepsia (...) – unidentified cause, Dyspepsia – proven functional, Dyspepsia – proven peptic ulcer, Diverticular disease, Gastroenteritis and Scrotal pain and swellings. November 2016 — minor update. Adverse effects of loperamide have been updated to include information in a U.S. Food and Drug Administration (FDA) Drug safety communication, warning that exceeding the maxium dose can cause serious cardiac problems including QT interval prolongation, Torsades de Pointes or other ventricular arrhythmias, syncope, and cardiac

2019 NICE Clinical Knowledge Summaries

99. NSAIDs - prescribing issues

of people with dyspepsia in people taking NSAIDs. There are separate CKS topics on ), , , , and the management of low-dose aspirin is discussed in the CKS topic on . This CKS topic does not cover the indications and effectiveness of NSAIDs. These are addressed in separate CKS topics on , , , , , , , , , , , , , , , , , and . The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare. How up-to-date is this topic (...) ( ) have been updated. October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic. May 2011 — minor update. Text updated to include more detailed advice about the use of paracetamol in pregnancy. The 2010/2011 QIPP options for local implementation have been added to this topic. Issued in June 2011. March 2011 — technical update. The management section of this topic has been simplified to improve clarity and navigation. There have been no changes

2019 NICE Clinical Knowledge Summaries

100. Pelvic inflammatory disease

(such as anaerobes). Risk factors for developing PID include: Factors related to sexual behaviour, such as: Young age (younger than 25 years). Early age of first coitus. Multiple sexual partners. Recent new partner (within the previous 3 months). History of STI in the woman or her partner. Recent instrumentation of the uterus or interruption of the cervical barrier, such as due to: Termination of pregnancy. Insertion of an intrauterine device (within the past 4–6 weeks, especially in women with pre-existing (...) gonorrhoea or C. trachomatis infection). Hysterosalpingography. In vitro fertilization and intrauterine insemination. Complications of PID include tubal infertility, ectopic pregnancy, and chronic pelvic pain. Symptoms of PID include: Pelvic or lower abdominal pain (usually bilateral). Deep dyspareunia. Abnormal vaginal bleeding (intermenstrual, postcoital, or 'breakthrough'). Abnormal vaginal or cervical discharge. Right upper quadrant pain. Secondary dysmenorrhoea. Signs of PID include: Lower abdominal

2019 NICE Clinical Knowledge Summaries

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