Introduction: Office Treatment of Common Diseases
This section deals with the treatment of the most common disease the author has encountered in over 50 years of the practice of medicine. You, the clinician may have included or excluded other conditions based on your experience! Also, your management of each of the Common Diseases may be slightly different than the authors. Therefore, the treatment discussed here is a list of recommendations not orders.
There are however certain principles that are useful to follow in the treatment of all these common diseases.
First of all tailor your treatment to fit each patient. We are all as different as our fingerprints suggest. Therefore, one drug may work with one patient but the same drug may not work with another. That is why you will find alternatives to the drugs recommended in the body of the text in Appendix 2A. When your favorite drug to treat a certain disease is not getting results, try another in the same class. For example, the author’s favorite NSAID is naproxen but he has found Ibuprofen or Meloxicam to be more suitable in some patients.
It is always wise to explain your treatment to the patient and when they can expect results as well as the most common complications or side effects.
Follow-up visits should be scheduled very close to the initial visit so that you can immediately alter treatment if there is no improvement. This is especially important in patients with bacterial infections. For example, a child with otitis media should be scheduled for a following visit within 1 to 2 days to evaluate the results of treatment, not a week later. A lot can happen in the latter period of time. The same goes for a patient with significant hypertension and many other acute conditions. If you are treating someone with an invasive procedure such as a joint injection, you may want to see them in 2 or 3 days or even 24 hours after the injection.
In primary care practice, you will often encounter a condition that you have limited experience in treating. In these cases, follow the principle: “When in doubt, refer it out.” Section 4B identifies many conditions that the author feels may require a referral at the outset.
The same principle applies when you are not getting the results you expect from your treatment. Do not hesitate to refer the patient to a specialist.
There are also times when you feel certain you are offering the patient the best treatment but you can see they are skeptical. This is another example of a situation where a referral should be made and may help you avoid a law suit.
In the author’s experience, many patients with chronic conditions such as diabetes and hypertension are given follow-up visits too far apart (3 to 6 months in many cases). These patients often need to be seen at intervals of 1 to 2 months.
Laboratory results should be given to the patient as soon as they are received. Your office staff can be authorized to handle this for you, but, if they are abnormal, perhaps you should be the one to call the patient, or have them scheduled for an immediate appointment to discuss the results in person. Instructing the patients to call for their results is not the best practice but, certainly, patients can be so instructed to do so if they do not hear from the office staff within a week of having the test.
Avoid polypharmacy at all cost! In this day and age when patients are often seeing multiple specialists in addition to their primary care provider, there is often unnecessary duplication of drugs for the same condition. Consequently, it is wise to have the patient bring all the bottles of medicine they are taking with them to each office visit. Alternatively, you can have them keep a current list of the drugs they are taking which you can update at each visit. Your list in the computer or chart needs to be frequently updated. One of the first things you need to do when a patient presents with a new complaint is to determine if it is caused by a side-effect of a drug they are taking or a drug interaction.
If you are not getting the results you expect from your treatment, ask the patient if they are really taking the
drug you prescribed or taking it correctly! Often, the patient cannot afford the medicine or their insurance does not cover it and they are embarrassed to tell you. That’s why, I recommend keeping a supply of commonly used drugs in your office for most such circumstances. Moreover, unless you explain how to take the drug or write clear instructions on the prescription, they may not be taking it correctly. For example, proton pump inhibitors (i.e., omeprazole) must be taken before breakfast to be effective. So simply writing “caps one qd” is not sufficient.
Be sure you have treated the patient with the maximum dose of the first drug you prescribe in a class before trying a new drug. For example, Ibuprofen may be started at 400 to 600 mg tid, but should be given at 800 mg tid before trying another NSAID. Gabapentin is often prescribed at 300 to 600 mg tid, but you should not give up on this drug until the patient has had the benefit of 900 to 1,200 mg tid provided that significant side-effects have not been experienced by the patient. The author has frequently found patients being treated for hypothyroidism with 25 to 50 μg of levothyroxine qd, when the recommended maintenance dose is 1.6 μg/kg/day (provided the patient has no cardiovascular condition which would be a contraindication to the standard dose).
The initial dose of a drug should also be adjusted to fit the size and other characteristics of each patient. Ask the question: “Does a little do a lot, or does it take a lot to do a little?” And regardless of whether the chart shows NKA (no known allergies) ask the patient about drug allergies every time you start a new drug, especially an injection.
For chronic conditions, such as diabetes, hypertension, and seizure disorders, write the prescription for a year’s supply if possible. You do not want these patients running out of their medicine on a weekend or when they are out of town because the results could be catastrophic. If you have ever waited at a pharmacy for a refill, you know the aggravation and colossal waste of time it may take.
When in doubt about the dosage of a drug, do not hesitate to look it up, “When in doubt, check it out.” That is why the author carries Gomella’s “Clinician’s Pocket Drug Reference1” with him at all times.
To reiterate what has been mentioned in the introduction to this edition, there are many common conditions requiring more than just a simple drug prescription to treat properly. These conditions need explicit instructions for the patient to follow. You can either write your own on a prescription pad or refer to appendix 2C for the author’s lists of instructions for the most common diseases.
Well, there you have it. Instead of just laying out a cook book presentation of treatment of the common diseases, the author has given you solid principles that you may want to apply no matter what disease you are treating.
Alphabetical Listing of Common Diseases and Their Treatment
Topical Benzoyl Peroxide 2.5%.
Topical antibiotics: Erythromycin 2%, Clindamycin 1%: Apply bid after cleansing.
Oral antibiotics: Tetracycline 500 mg bid–qid (also Minocin, doxycycline, and erythromycin). For women of childbearing, age a trial of birth control pills or 150–250 mg of Depo-Provera every 3 months.
Topical Tretinoin (Retin-A, etc.).
Adapalene 0.1% (Differin).
Isotretinoin (Accutane) administered by special license only, refer to Dermatologist.
Metronidazole gel 0.75% bid and systemic tetracycline—antibiotic: 250–500 mg bid.
Anemia, Iron Deficiency
Ferrous sulfate: 325 mg tid.
Alternative, Ferrous Gluconate (Fergon): 325 mg tid.
Treat same as mild.
Alternatively (Venofer) iron sucrose: 200 mg IV for 5 doses over 2 weeks.
Transfusion of packed cells followed by the regime for mild or moderate.
Anemia, Blood Loss
Find source of bleeding.
Transfusions of whole blood or packed cells to bring hemoglobin above 9 g followed by treatment for iron deficiency anemia.
Albuterol inhaler (Proventil): puffs 2 q2–4hrs PRN.
Ipratropium inhaler (Atrovent): Puffs 2 bid–tid.
Albuterol + Ipratropium (Combivent): puffs 2 qid.
Above plus fluticasone (Flovent): puffs 2–4 bid.
Fluticasone propionate combined with salmeterol (Advair Diskus HFA): puffs 1–2 bid (metered dose inhaler).
Prednisone 5–15 mg orally qod (consider referral to specialist at this point) or first 4 days of each week.
Theophylline (Theo 24): 100–400 mg q12hrs. Must monitor drug levels until minimum effective dose is established.
Cromolyn sodium (Intal): 20 mg as powder in capsule puffs 2 qid.
Loratadine (Claritin): 10 mg daily or other antihistamines.
Epinephrine: 0.3–0.5 mL of 1:1,000 solution subcutaneously or 5 mL of 1:10,000 solution lV q5–15min.
Diphenhydramine (Benadryl): 25–50 mg lV or 1M q6hrs.
Cimetidine (Tagamet): 300 mg lV over 3 to 5 minutes followed by 400 mg bid p.o.
Dexamethasone (Decadron): 8–12 mg lV or methylprednisolone (Solu-Medrol): 125 mg IV.
Bolus of 500 cc normal saline lV and repeat q10min for 3 doses.
Treatment: See anaphylaxis.
Nano filtered plasma-derived C1 IMH derivative (Cinryze): 1,000 units/10 mL IV q3–7days.
Danazol: 50–200 mg daily. Monitor with hemogram and hepatic function testing.
Ankylosing Spondylitis (Rheumatoid Spondylitis)
Naproxen (Naprosyn): 500 mg bid–tid.
Indomethacin (Indocin): 25–50 mg qid.
Meloxicam (Mobic): 7.5–15 mg daily. Other NSAIDs may be tried (Appendix 2A).
Physiotherapy—posture training, etc.
2nd Line: (a Rheumatology Consult would be wise at this point).
Infliximab (Remicade): 5 mg/kg IV initially and repeat in 2 weeks and 6 weeks; maintenance: 5 mg/kg IV q8wks.
Surgical procedures: Total hip replacement, vertebral osteotomy, etc.
Warm saline sitz baths qid and after each BM.
Metamucil: 1 teaspoon tid in glass of water.
Docusate sodium (Colace): Caps 1–2 bid to qid.
Clear liquid diet.
Gentian violet 1% apply after each BM.
If it persists refer to Proctologist or General Surgeon.
Escitalopram (Lexapro): 10–20 mg daily.
Paroxetine (Paxil): 10–50 mg daily.
Duloxetine (Cymbalta): 30–120 mg daily.
Lorazepam (Ativan): 0.5–1 mg tid.
Alprazolam (Xanax): 0.25–1 mg tid.
Diazepam (Valium): 2–10 mg tid.
Hydroxyzine (Vistaril): 50–100 mg qid.
Prednisone: 30 mg bid × 6–8 weeks; then taper by 5 mg a week.
Prednisone: 20–30 mg bid × 7 days and taper over the next 7 days.
Prednisolone: 25 mg bid × 7 days and taper over next 7 days.
Valacyclovir: 1,000 mg daily × 5 days (optional) unless Ramsay-Hunt syndrome present.
Benign Positional Vertigo
Epley maneuver: Start with patient sitting up and head turned 45 degrees toward the suspected affected ear. Lower head rapidly below the horizon and wait 15 seconds. Then turn the head 45 degrees to the opposite side (90-degree turn); and wait 20 seconds. Now turn head and body together 90 degrees toward the unaffected ear and wait 30 seconds before sitting up and finishing the maneuvers.
Meclizine hydrochloride: 12.5–25 mg tid.
Diazepam (Valium): 5–10 mg tid.
Consider amantadine (Symmetrel): 200 mg daily if Influenza A suspected.
Consider Oseltamivir (Tamiflu): 75 mg bid × 5 days.
Azithromycin: 500 mg stat and 250 mg daily for next 4 days (Z-pak) and may repeat.
Amoxicillin: 500 mg tid × 7–10 days.
Suitable expectorant to manage cough.
Chest x-ray, CBC, etc. if symptoms persist.
Naproxen: 500 mg bid–tid or other NSAIDs for symptomatic relief.
Consult Orthopedist or Podiatrist for definitive treatment.
Burns, 1st and 2nd Degree
Silver sulfadiazine (Silvadene): apply bid to affected areas.
Neosporin Ointment: apply bid to affected areas especially useful on face.
Hydrocodone/acetaminophen (Vicodin): 5/325–7.5/325 PRN for pain.
Consult general surgeon if burn appears to be 3rd degree.
Appropriate fluid replacement therapy based on serum electrolytes and osmolality.
Naproxen: 500 mg bid–tid, or Ibuprofen: 400–800 mg q8hrs. Other NSAIDs may be tried (Appendix 2A).
Antibiotics if infection suspected.
Inject with Lidocaine 1–2%, 3–5 cc and 40–80 mg of methylprednisolone acetate (Depo-Medrol) once infection ruled out.
Blood chemistries, ANA and R-A titer if condition persists as well as x-rays, etc.
Orthopedic or rheumatology consult in resistant cases.
Fluconazole (Diflucan): 150 mg, one dose but may repeat.
Miconazole (Monistat): vaginal suppository 100–200 mg h.s. × 7 days.
Clotrimazole (Gyne-Lotrimin): One applicator full intravaginally h.s. × 6 days.
In persistent cases, look for diabetes mellitus or other etiologies of vaginitis or consult gynecologist.
Establish airway and IV line. Ventricular fibrillation or ventricular tachycardia: shock with 120–200 J.
Begin chest compression 100/min with 2 breaths every 30 compressions.
Second shock with 200–300 J.
No response, resume CPR.
Shock again with 200–400 J.
No response, give 1 mg epinephrine (1:10,000) IV or IO.
Shock again with maximum voltage.
Repeat epinephrine 1 mg every 3 to 5 minutes.
Try Vasopressin 40 units IV or IO.
Shock again with maximum voltage.
Amiodarone: 300 mg IV or IO, or Lidocaine: 50–100 mg IV or IO.
Consider IV calcium gluconate 100 mg/kg IV or magnesium loading 1–2 g.
Sodium bicarbonate: 1 amp IV if acidosis suspected.
Asystole—establish airway and IV line.
Begin CPR 100 compressions/min and 2 breaths every 30 compressions.
1 mg epinephrine: 1:10,000 IV or IO and repeat every 3 to 5 minutes while continuing CPR.
Try vasopressin: 40 units IV or IO.
Consider atropine: 1 mg IV or IO.
Carpal Tunnel Syndrome
Avoid repetitive injury and try splinting at night.
Treat conservatively with pyridoxine: 100 mg tid for 3 to 6 months unless objective evidence is striking.
May inject carpal tunnel with 1 cc 1% lidocaine and 20 mg of methylprednisolone acetate for patients who object to surgery.
When conservative measures fail, refer to neurosurgeon or orthopedic surgeon for carpal tunnel release.
If visual acuity is 20/40 in affected eyes or better nothing need be done.
Manage condition such as overexposure to sunlight, smoking, and diabetes mellitus that may accelerate progression of the cataracts.
Refer to ophthalmologist if vision gets worse than 20/40 or patient insists.
Cellulitis, Carbuncles, and Abscesses
Try to obtain material for culture and sensitivity if possible.
Warm saline soaks qid.
Treat conservatively with one of the following:
Dicloxacillin (Dynapen): 250–500 mg qid.
Erythromycin: 250–500 mg qid.
Cephalexin (Keflex): 500 mg qid.
If MRSA is suspected, treat with trimethoprim/sulfasoxazole DS (Bactrim DS): 1 tab bid or ciprofloxacin 500 mg bid.
Once there is clear evidence of suppuration perform or have general surgeon perform I&D.
Resistant cases (MRSA, etc.) may need hospitalization and treatment with vancomycin 1 g IV q12hrs.
Naproxen (Naprosyn): 500 mg bid–tid.
Alternatively Meloxicam: 7.5–15.0 mg bid or diclofenac (Voltaren) 50–75 mg bid.
Prednisone: 10–30 mg first 4 days of each week.
Cervical collar latched in front to be worn particularly at night.
Cervical exercises in 3 plains (flexion, extension, lateral bending and rotation): 5–15 min bid.
Facet or trigger point injections with 1–2 cc 1% Lidocaine and 20–40 mg of methylprednisolone acetate q4–6wks by a specialist trained in this procedure.
Cervical traction horizontal or over the door beginning with 7–10 lb for 30 minutes bid and gradually increasing to 15 lb for 1 hour bid. Enlist help of physiotherapist to initiated this or refer to physiotherapist for treatment.
If there is clear evidence of radiculopathy or spinal cord compression clinically or by imaging studies (MRI, etc.) refer to neurosurgeon for evaluation and laminectomy, etc.
Consider narcotic analgesics only after failure of the above.
Naproxen (Naprosyn): 500 mg bid–tid.
Mobic: 7.5 mg–15 mg bid.
Muscle relaxant such as cyclobenzaprine (Flexeril): 10 mg tid, diazepam (Valium): 5–10 mg tid, or carisoprodol (Soma): 350 mg tid.
Fit with cervical collar to be latched in front and worn while driving and at night.
Physiotherapy or chiropractic consult and treatment recommendations.
Complete bed rest for 2 to 3 weeks may be tried.
Cervical traction as outlined under “Cervical Spondylosis” may be tried.
MRI and evaluation by neurologist or neurosurgeon in refractory cases.
Narcotic analgesics should be considered only after above measures have been tried except in acute stage.
Doxycycline (Vibramycin): 100 mg bid p.o. × 7 days or a single dose of Azithromycin (Zithromax): 1 g p.o.
Treat all sexual partners in the previous 2 months.
Abstain from intercourse during treatment.
Laboratory tests for syphilis, HIV, herpes genitalis, and other venereal diseases is wise
Vaginal cultures for gonorrhea.
Chronic Fatigue Syndrome
Rule out other causes of fatigue with a battery of laboratory tests including CBC, sedimentation rate, chemistry panel, arthritis panel, serum TSH, serum cortisol, heterophil antibody titer, monospot test, HIV titer, and liver function tests. Imaging studies such as bone scans, and CT scans maybe necessary. Skin testing for tuberculosis and other infectious diseases may be needed.
Order a battery of psychological tests such as the MMPI, Thematic Apperception Test, etc.
A consult with a psychiatrist may be indicated.
Supportive psychotherapy, graded exercise therapy, and cognitive behavior therapy may be tried.
Antidepressants such as paroxetine (Paxil): 10–60 mg daily, escitalopram (Lexapro): 10–20 mg daily, or Trazodone (Desyrel): 50–150 mg h.s. may be helpful.
In women of menopausal age, a trial of estrogen replacement RX may help unless there are contraindications.
Chronic Obstruction Pulmonary Disease (COPD)
Counseling to eliminate smoking in the patient and family or other members of the household is essential.
Careful evaluation of toxic fumes or cigarette smoking at the job site should be evaluated.
Careful testing to eliminate asthmatic or allergic factors in the condition should be done as well as α-1 antitrypsin deficiency.
Ipratropium (Atrovent HFA): 2–4 puffs qid.
Tiotropium (Spiriva): one inhalation daily.
Albuterol (Proventil): 2 puffs qid or salmeterol (Serevent): one inhalation bid may be tried.
A trial of inhaled corticosteroids such as fluticasone (Flovent): 2–4 puffs bid or oral corticosteroids such as prednisone: 2.5–15 mg on alternate days or 4 days weekly may be beneficial.
Continuous O2 2–4 L/mm may be needed.
It is wise to consult a pulmonologist at the outset.
Make sure these patients get enough fluid as there is a trend toward dehydration because of hyperventilation.
Clostridium Difficile Gastroenteritis
Metronidazole (Flagyl): 500 mg tid × 14 days.
Vancomycin: 125 mg p.o. qid × 14 days.
Immune globulin: 100–200 mg/kg IV to bolster response to above drugs.
Before prescribing, be sure visual acuity is normal and pupil are ERLA (If there is any question of iritis or glaucoma refer to ophthalmologist).
If there is unilateral involvement the etiology is usually bacterial, so treat with one of the following:
Sodium sulfacetamide ophthalmic drops (Sulamyd): 1–2 gtt in each eye q2–3hrs (be sure patient is not allergic to sulfa).
Tobramycin ophthalmic drops (Tobrex): 1–2 gtt q4hrs.
Ciprofloxacin ophthalmic drops (Ciloxan): 1–2 drops q2–3hrs.
If infection is bilateral and you are not sure it is allergic conjunctivitis, treat with Cortisporin ophthalmic drops gtt 2 in each eye q4hrs or Tobramycin/dexamethasone drops.
If certain it is allergic conjunctivitis, treat with dexamethasone ophthalmic drops gtt 2 in each eye q3–4hrs.
In the absence of visual difficulties, poor response to antibiotics or steroids suggests viral conjunctivitis which can be treated with artificial tears.
In refractory cases, refer to ophthalmologist.
Bisacodyl (Dulcolax): suppository 1 stat per anum and may repeat in 2 hours if no result.
Glycerin: suppository 1 stat and may repeat in 2 hours if no result.
Fleet phosphate or tap water enema.
Look for the cause (drugs, etc.).
Docusate sodium (Colace): 1–2 capsules daily or bid.
Psyllium (Metamucil) smooth texture: 1–2 teaspoon in glass of water daily to bid.
Find the cause: Diet? Drugs? Laxative habit?
Study with colonoscopy or barium enema.
In refractory cases: Look for neurologic or psychiatric disorder.
Triamcinolone cream or ointment (Aristocort) 0.1%: Apply tid to affected areas.
Alternatively fluocinonide 0.05% cream or gel (Lidex): Apply tid to affected areas.
For more diffuse lesions, use Prednisone 10–20 mg daily for 5 days, or methylprednisolone acetate (Depo-Medrol) 40 mg IM.
In refractory cases, refer to dermatologist or do more thorough investigation for cause:
What materials is patient exposed to?
There are excellent blood tests for allergy available especially if food allergy is suspected.
(A wide selection of methods are now available)
Oral: Ethinyl estradiol + levonorgestrel (Seasonale): 1 tab daily × 91 days—beginning first Sunday after onset of menses and repeat same process after 91 days. Other cyclical hormones are still available (see Appendix 2A).
Patch: Ethinyl estradiol + norelgestromin (Ortho Evra): Apply patch to abdomen, buttocks, etc. weekly at onset of menses for 3 weeks and 4th week is patch free; repeat same cycle every 4 weeks.
Levonorgestrel (Mirena): Intrauterine system. Insert into uterus and lasts up to 5 years at a time.
Etonogestrel implant (Implanon): A tiny plastic rod implanted into the subcutaneous tissue of the upper arm provides constant contraception up to 3 years. Unfortunately, there have been significant side effects including unwanted pregnancy. You must be trained and certified to provide this form of contraception.
IUD—ParaGard (Copper+) is inserted into the uterus and provides contraception up to 10 years.
Medroxyprogesterone (Depo-Provera): 150 mg IM can provide contraception for 3 months at a time and also stops the menses during that time.
All of the hormonal contraceptives may increase thromboembolic phenomena and incidence of endometrial carcinoma, although the risk is slight. They are also contraindicated in women with any history of breast cancer, migraine, and thromboembolic phenomena whether arterial or venous in origin.
(Tietze Syndrome—A cause of chest pain that is frequently confused with angina but is due to inflammation of the costochondral junctions)
Naproxen (Naprosyn): 500 mg bid—tid × 7 doses or other NSAIDs.
Injection of lidocaine: 1% 2–4 cc around the painful costochondral junction.
Mist therapy (vaporizer, etc.).
Nebulizer solution of racemic epinephrine 0.05 mL/kg/dose of a 2.25% solution in normal saline: 3 mL q2–4hrs.
Dexamethasone (Decadron): 0.15–0.6 mg/kg IM or IV STAT AND MAY REPEAT IN 6 HOURS.
Admit to hospital and consult anesthesiologist if above measures do not succeed immediately.
Consider tracheostomy if condition fails to improve or O2 sats drop.
Cutaneous Drug Reaction
(In all cases identify and withdraw offending drug)
Topical corticosteroids such as triamcinolone acetonide 0.1% cream (Kenalog): apply tid to affected areas
Diphenhydramine (Benadryl): 25–50 mg qid.
Diphenhydramine (Benadryl): 25–50 mg qid.
Prednisone: 40–60 mg daily and taper over 3- to 6-week period.
Topical corticosteroids as above.
Epinephrine: 0.01 mL/kg of 1:1,000 solution SC q2–3hrs or sooner.
Dexamethasone (Decadron): 4–12 mg IV q12hrs.
Diphenhydramine (Benadryl): 50 mg IM or IV q4hrs PRN.
De Quervain Tenosynovitis
(Other tendon sheaths of the hand and wrist may become inflamed and present with similar symptoms and signs, e.g., trigger finger)
First, try rest and immobilization with an NSAID such as Naproxen (Naprosyn) 5 mg bid–tid or Ibuprofen 600 mg qid. Other NSAIDs may be tried: 59, 97, 184 (Appendix 2A).
If above is unsuccessful, inject tendon sheath with lidocaine 1% ½–1 cc and methylprednisolone acetate (Depo-Medrol) ½ cc (20 mg).
When above measures fail refer patient to an orthopedic surgeon for surgical release of the tendon.
Consult a dentist as soon as possible.
Penicillin VK (Pen-Vee K, etc.): 250–500 mg qid. For children give 40–50 mg/kg/day, in divided doses if patient not allergic to penicillin.
Alternatively, give clindamycin 150–300 mg qid. If duration of treatment more than 4 days, add metronidazole (Flagyl) 500 mg tid to prevent pseudomembranous colitis.
Ibuprofen (Motrin): 600 mg q6hrs PRN for pain or hydrocodone/acetaminophen (Vicodin) 1 tab q4hrs PRN for pain.
Consult psychiatrist or psychologist to determine risk of suicide and the type of depression and provide psychotherapy.
Paroxetine (Paxil): 10–50 mg daily or citalopram (Celexa): 20–60 mg daily.
If above ineffective, try venlafaxine (Effexor) 25–125 mg tid or bupropion (Wellbutrin) 100–150 mg h.s. or tid.
Alternatively, try trazodone (Desyrel) 50–150 mg h.s. or qid.
Look for organic causes of depression such as dementia, multiple sclerosis, hyperthyroidism, hypothyroidism, Cushing syndrome, menopause, and nutritional disorders.
For refractory cases, consult a psychiatrist to consider lithium or electroconvulsive therapy.
Psychiatric consult to determine risk of suicide and establish a definitive diagnosis.
Counseling by psychiatrist or psychotherapist.
Urine drug screen.
Fluoxetine (Prozac): 10–60 mg daily. (Monitor for increased suicidal ideation.)
Alternatively, sertraline (Zoloft): 25–200 mg daily (Monitor closely for increased suicidal ideation.)
Refer to psychologist for psychometric testing.
Triamcinolone 0.1% cream or ointment (Aristocort): Apply to affected areas.
Flurandrenolide cream or ointment 0.025% (Cordran): Apply tid to affected area
(Avoid use of high potency preparations on face.)
Do not use these corticosteroid preparations for more than 3 weeks at a time. Must use less potent creams for face.
For severe flare-ups prescribe prednisone 60 to 80 mg a day and taper once inflammation under control.
Refer to dermatologist in refractory cases.
Avoid alcoholic beverages, skin irritants, carbonated beverages, frequent baths, or use of soaps.
Elimination diets may be helpful (chocolate, etc.).
Culture exudates to determine if antibiotic therapy is appropriate.
If arterial circulation is adequate, elevate affected extremity.
Ultrasound study to rule out deep vein thrombophlebitis.
If no evidence of infection is found, apply triamcinolone 0.1% ointment (Aristocort) tid and follow that with warm saline soaks and elevation.
Alternatively, apply flurandrenolide 0.05% ointment (Cordran) tid followed by warm saline soaks.
Multivitamins bid and vitamin C 1,000 mg a day may be helpful.
Once patient is able to ambulate, apply ace bandages over dressing or fit with compression stockings if the inflammation has subsided.
In refractory cases, consider intermittent pneumatic compression pumps.
Diabetes Mellitus, Type II
Seek control of blood sugar first with diet modification and regular exercise.
Many of these patients are obese so, a low calorie ADA diet is indicated where the main ingredients are fruits and vegetables.
When diet is insufficient to bring the HbA1C to 7.0 or less, add metformin (Glucophage) 500–1,000 mg bid.
If metformin alone is unable to bring the HbA1C to 7.0% or below, add glipizide (Glucotrol) 2.5–5 mg a day, gradually increasing to 40 mg a day.
Alternatively glyburide (Micronase) 1.25–10 mg daily may be given instead of glipizide.
Other hypoglycemic agents may be tried: 219, 262, 281, 285 (Appendix 2A)
In patients who are resistant to oral hypoglycemic agents be sure to look for UTI and other systemic infections before starting on insulin.
Consult an endocrinologist before starting insulin.
A combination of low dose insulin therapy such as insulin glargine (Lantus) 0.2–0.4 units/kg/day and metformin (Glucophage) 500–1,000 mg bid may suffice at first. Insulin dosage can be gradually increased to bring the HbA1C to 7.0% or below.
Annual checks for retinopathy, nephropathy, and neuropathy as outlined under Type 1 Diabetes Mellitus should be made.
Brittle diabetics may benefit from low dose corticosteroids or estrogen replacement therapy (in menopausal women) or testosterone replacement therapy (in men with possible male climacteric).
Look for common complications of diabetes such as hypertension, coronary artery disease, cholelithiasis, hyperlipemia, glaucoma, and PVD.
In cases of symmetrical polyneuropathy, try multiple B vitamins as follows:
Niacin: 50 mg tid.
Thiamin: 50 mg tid.
Pyridoxine: 100 mg tid.
B12: 1,000 units sublingual daily or IM weekly.
For symptomatic therapy:
Amitriptyline: 50–150/mg h.s.
Gabapentin (Neurontin): 300–1,200 mg tid.
Pregabalin (Lyrica): 50–150 mg tid.
Check for peripheral vascular disease and Leriche syndrome.
Local treatment in the form of topical capsaicin 0.075% cream may be helpful.
Other AEDs and antidepressants: 75, 90, 111, 260 (Appendix 2A).
Calcium Lactate 600–1,200 mg tid.
Control cholesterol with statins: 21, 200, 292 (Appendix 2A).
Clear liquid p.o. for 24–48 hours.
Curtail physical activity.
Bisacodyl (Dulcolax) suppository to evacuate rectum but no enemas.
If there is fever or symptoms persist after 48 hours add antibiotics in the form of ciprofloxacin (Cipro) 500 mg bid or 200–400 mg IV q12hrs.
Alternatively may give cefuroxime (Ceftin): 250–500 mg bid or 750 mg IV q6hrs.
Cover anaerobes with metronidazole (Flagyl): 500 mg tid or 500 mg q8hrs IV.
Consult surgeon or gastroenterologist for resistant cases or if you suspect perforation, abscess, significant obstruction, or bleeding.
Prophylaxis (after acute attack):
Psyllium (Metamucil) smooth texture: 1–2 teaspoons bid in glass of water.
Lots of green leafy vegetables.
Dysfunctional Uterine Bleeding
(In women of childbearing age)
Thorough pelvic examination and Pap smear to rule out serious causes of vaginal bleeding. In patients where it is difficult to do a thorough pelvic (i.e., obese) get a sonogram. Remove IUD if one is present.
Pregnancy test to rule out pregnancy.
Medroxyprogesterone acetate (Depo-Provera): 150–250 mg IM to stop bleeding. It is the goal of therapy for regular periods (with normal menses) to be established once the exogenous hormones wear off.
Alternatively, especially if it is clear that the bleeding is cyclical, give 10–20 mg of Medroxyprogesterone (Provera) orally for the last week of each cycle to reduce bleeding during menses and re-establish a normal cycle.
If the above techniques are unsuccessful, look for anemia (especially iron-deficiency anemia), hypothyroidism or hyperthyroidism or refer the patient to a gynecologist for a D&C or other procedures (ultrasonogram, etc.).
Naproxen (Naprosyn): 500 mg bid to tid at onset of pain.
Ibuprofen: 600–800 mg q8hrs PRN.
Other NSAIDs: 59, 97, 173, 227, (Appendix 2A).
Medical D&C with Medroxyprogesterone (Provera): 10 mg daily for 21 days beginning 7 days after period began.
Refer to gynecologist for D&C, etc.
Cimetidine (Tagamet): 300–600 mg bid
Ranitidine (Zantac): 150 mg bid.
Omeprazole (Prilosec): 20–40 mg bid or esomeprazole (Nexium): 20–40 mg qd
If the above is ineffective refer to a gastroenterologist.
Rule out organic causes such as UTI.
Oxybutynin (Ditropan)—adults and children over 5 years old: 5 mg tid—qid.
Alternatively may give oxybutynin (Ditropan): 5–10 mg h.s.
Tolterodine (Detrol, Detrol LA): 1–2 mg bid or 2–4 mg of 10 mg acting preparation daily.
Dicyclomine (Bentyl): 10–20 mg qid.
Phenazopyridine (Pyridium): 100–200 mg tid.
If above ineffective, refer to urologist for cystoscopy and cystometric testing.
Elevate scrotum on sling or athletic support.
Initially, complete bed rest with ice packs and analgesics.
Ciprofloxacin (Cipro): 500–750 mg bid p.o. or 200–400 IV q12hrs.
Alternatively ceftriaxone (Rocephin): 1–2 g IV q12hrs.
Urine culture, sensitivity, and colony count and urethral smear and culture.
In men under 40, treat for chlamydia with doxycycline (Vancomycin): 100 mg bid × 14 days. Also treat for gonorrhea with ceftriaxone (Rocephin): 250 mg IM.
Order serologic tests for syphilis and HIV.
Test all recent sexual partners (within past 30 days) for gonorrhea and Chlamydia.
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