• elderly (decreased estrogen --> lose bone mass)
• family hx of fracture (1st degree relative)
• personal hx of fracture
• current smoking
• EtOH
• thin (<125lbs)
• corticosteroids >3mos
• low physical activity
• anticonvulsants - can interfere wtih Vitamin D
• white women at higher risk than Af Amer

DXA scan:

T score & Z score?

T score - use healthy young women as standard.

Z score - age matched, sex matched

osteopenia: T score -1 to -2.5

osteoporosis: T score <-2.5

• Women over 65, men over 70 (regardless of risk factors)
• Postmenopausal women with 1 or more RF (other than being white, postmenopausal and female)
• pts on glucocorticoids >3 mos
• adults who have fracture after 50

• Quit smoking, EtOH
• weight bearing exercise
• calcium supplementation: 1,200-1,500 mg daily
• vitamin D: 800-1,000 IU daily
• fall prevention
• estrogen therapy (HRT) - but WHI found increased risk MI, stroke, breast ca, PE, DVT during tx with estrogen and medroxyprogesterone

Treatment options for osteoporosis

• calcium 1200-1500mg/day
• vitamin D 800-1,000IU/day
• weight bearing exercise
• bisphosphonates (alendronate/Fosamax, risedronate/Actonel, ibandronate/Boniva, zoledronic acid/Reclast)
• raloxifene - SERM with beneficial effects on bone, lipids
• calcitonin - inhibits osteoclasts

Postmenopausal women and men over 50 with:

1. hip or verterbral fracture

2. T score <-2.5 at femoral neck or spine

3. T score -2.5 to -1 and increased 10year probability of fracture (based on WHO algorithm)

esophagitis

osteonecrosis of jaw

Take on empty stomach with water.

Stay upright at least 30 min to avoid esophageal irritation.

• kidney stones
• infection - UTI, pyelonephritis
• bladder or kidney ca!!
• glomerular disease (eg IgA nephropathy)
• trauma (eg Foley placement)
• strenuous exercise
• fever
• systemic diseases - SLE, RA, HSP, Wegener's granulomatosis, HUS, Goodpasture's
• bleeding disorders - hemophilia, thrombocytopenia
• sickle cell disease
• meds - cyclophosphamide, anticoagulants, salicylates, sulfonamides
• analgesic nephropathy
• polycystic kidney dz
• BPH

• TCAs - inhibit NE and serotonin uptake (low starting dose - not the same doses as for depression)
• duloxetine (Cymbalta) - SNRI
• pregabalin (Lyrica) and gabapentin (Neurontin)- bind to Ca channels and inhibit Ca influx; reduce K evoked glutamin release and agonist of GABA receptors
• Antiepileptics: carbamazepine (Tegretol)

Pain = the hardware

Suffering = the meaning the pt places on condition and teh degree to which they feel isolated or abandoned.

• Evaluate for conditions that may have been overlooked.
• Validate pt's concerns.
• Establish that there are no quick miracle cures, but you will stick with them.
• Systematic trial of PT and therapeutic agents (including opiates).
• Adjuvant therapy with TCAs.
• Psych support, counseling.
• Vigilance and availability are key.

Anticholinergic: dry mouth, urinary retention, constipation

Anti-histamine: sedation

Anti-adrenergic: orthostatic hypotension

Desiprarmine has the fewest anticholinergic and sedative side effects of all the TCAs.

• Worrisome!
• Gradual onset
• Mild intensity
• Mild n/v
• Associated neuro signs usually present.
• mild nystagmus
• Direction of nystagmus: multidirectional and even vertical
• position change has no effect
• no refractoriness - can repeat tilt test and pt responds every time.
• Pt falls to same side of lesion.

• Sudden onset
• severe intensity
• intense n/v
• no associated neuro findings
• relatively intense nystagmus
• direction of nystagmus: unilateral, never vertical.
• position change has intense effect
• rapidly refractory - cannot repeat the  Dix-Hallpike test - sx fatigue with maneuver
• -pt falls to same side as lesion

BPV treatment

• Canolith repositional procedures (eg Epley) --> direct otoconia back into utricle where it is reabsorbed.
• Meclizine or diphenhydramine to tx nausea/vomiting.

Women>men

unilateral

throbbing

aura

photophobia

nausea

relieved by sleep

men>women

precipitated by EtOH

unilateral

lacrimation

rhinorrhea

very severe - want to die

occipital-frontal headache (band-like)

squeezing

constant

relieved by relaxation

(may have n/v, photophobia)

migraine:

common v. classical v. complicated

common - no aura

classical - with aura

complicated - with neuro sx

• 2 Extra Strength Excedrin (acetaminophen, ASA & caffeine) as soon as h/a starts.
• NSAIDS (as soon as starts)
• tryptans (eg sumatriptan)
• ergotamines (eg dihydroergotamine) - good abortive agents for pts who get aura

First line: beta blocker (propranolol), TCAs (amitriptyline).

Second line: verapamil, valproic acid

Women over 50: annual mammogram

Women in 40s: controversial b/c of false positive mammograms (dense breasts).

• cervical ca screening guidelines

• start at age 18 or 1st sex - yearly
• 2 neg Paps in a row - every 3 years
• higher risk sex or HPV+ - yearly
• can stop at 60/65/70 (guidelines vary) if negative screening hx and no high risk sexual activity.

• Over 50, low risk - FOB q 1 yr + colonoscopy q 10 yrs or flex sig q 5 yrs
• Pt with polyps, personal hx CRC - initial colonoscopy, repeat at 3 yrs, if normal then q 5yrs.
• FHx of CRC or adenomatous polyps - colonoscopy at age 40 or 10 yrs younger than first case in family; if nl repeat q 3-5 years.
• Families with FAP - genetic testing at age 10, consider colectomy if + or polyposis confirmed; if not, colonoscopy q 1-2 yrs beginning at puberty.
• Families with HNPCC - genetic testing at age 21; if pos, colonoscopy q2 yrs until 40, then q 1yr thereafter.

Pneumovax indications

• Everyone >65
• Other indications: DM, CRF, COPD, HIV, asplenia, sickle cell dz
• One-time revaccination after 5 years for pts with CRF, nephrotic syndrome, asplenia, ummunosuppressed.
• Pts >65, one-time revaccination if vaccinated >5 yrs ago and they were under 65 when vaccinated.
• Revaccination following a second dose not recommended (lack of safety data with 3 or more doses).

• yearly in adults over 50
• adutls <50 with chronic medical problems (CHF, DM, lung dz, ESRD)
• health care workers
• pregnant women in 2nd or 3rd trimester
• anyone who wants it

Pts with end-stage renal dz

pts with STDs (high risk sex)

HIV

chronic liver dz

health care personnel

multiple partners (>1 in last 6 mos)

IVDU

MSM

Td booster every 10 years

Substitute one Tdap for Td for pts who haven't gotten Tdap.

women <26

3 doses: 0, 2, 6 months

• Adults born before 1957 considered immune to measles, mumps.
• Given as primary series in kids.
• Adults born after 1957 w/o proof of immunization or immunity should get shot.
• Women of childbearing age w/o proof of rubella immunity or vaccinations should get shot.
• Second dose recommended for adults 1) recently exposed to mumps or measles, 2) previously vaccinated with killed measles vaccine, 3) vaccinated with unknown type of vaccine 1963-67, 4) college students, 5) work in health care, 6) plan to travel internationally.

Asplenia

First-year college students, military recruits, travel to epidemic areas

adults >60 regardles of prior episode of herpes zoster

1 dose