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PART I: ENDOCRINOLOGY

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1. Disorders of the Pituitary Gland and Clinical Manifestations

Anatomy and Overview

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A. Hypopituitarism

• Most common in adults: intrasellar pituitary tumors (adenomas)
• Second most common: Sheehan syndrome - postpartum pituitary necrosis from ischemia (excessive blood loss, enlarged oxygen-demanding gland during pregnancy)
• Parasellar masses: craniopharyngiomas, meningiomas, optic gliomas, germinomas, metastatic cancer
• Infiltrative disease: sarcoidosis, Langerhans cell histiocytosis, tuberculosis, lymphocytic hypophysitis
• Radiation injury, head trauma, pituitary surgery
• Immunomodulatory drugs (checkpoint inhibitors) can cause hypophysitis
• Infectious: meningitis, septic shock, fungal CNS infections, syphilis
• Idiopathic; rare familial forms

• Measure target hormones + pituitary hormones simultaneously: free T4, TSH, morning cortisol, LH, FSH, testosterone/estradiol, IGF-1, prolactin
• Plasma cortisol <3 µg/dL at 8 AM on two occasions (with low/normal ACTH) = secondary adrenal insufficiency
• Cortisol >18 µg/dL virtually excludes ACTH deficiency
• ACTH reserve: insulin hypoglycemia test (0.1-0.15 U/kg IV); normal = cortisol increment ≥6-10 µg/dL or absolute >20 µg/dL
• Alternative: metyrapone test (blocks 11β-hydroxylase); normal = 11-deoxycortisol >7-10 µg/dL
• GH deficiency: GH fails to rise above 5 ng/mL with two provocative stimuli
• MRI of hypothalamic-pituitary region is mandatory; formal visual field testing if mass suspected

• ACTH deficiency: hydrocortisone 20-30 mg/day; increase 2-3x during illness/stress
• TSH deficiency: levothyroxine (do NOT give before glucocorticoids in combined deficiency)
• Gonadotropin deficiency: estrogen + progesterone in premenopausal women (OCP convenient); testosterone replacement in men (topical gel 40-50 mg/day or IM testosterone enanthate/cypionate 100-200 mg every 2 weeks)
• GH deficiency in children: recombinant hGH 0.04 mg/kg/day SC; in adults 0.1-0.3 mg/day starting dose
• GH also indicated for Turner syndrome, Prader-Willi, chronic renal disease
• Macroadenomas: transsphenoidal surgical resection (except prolactinomas)

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B. Hyperfunctioning Pituitary Adenomas

Prolactinoma (most common functioning adenoma)

• Women: amenorrhea, irregular menses, infertility, galactorrhea (only ~50%); prolonged estrogen deficiency increases osteoporosis risk
• Men: androgen deficiency, infertility (NOT gynecomastia); mass effects and hypopituitarism common with macroadenoma

• Pregnancy and lactation
• Drugs: phenothiazines, atypical antipsychotics, metoclopramide, verapamil
• Primary hypothyroidism
• Chronic renal failure
• Hypothalamic lesions, nonsecretory pituitary macroadenomas

• Dopamine agonists are first-line: cabergoline (preferred - 90% normalization) or bromocriptine (preferred in women wishing pregnancy)
• Bromocriptine discontinued after pregnancy confirmed; monitor for headache/visual changes (10% of micro-, 30% of macroprolactinomas may enlarge in pregnancy)
• Medication withdrawal may be considered after 2 years of normal prolactin + MRI showing no/minimal tumor
• Surgery (transsphenoidal): for medical failure, intolerance, very large tumors threatening visual pathways, or apoplexy. ~30% of macroadenomas successfully resected.

Acromegaly / Gigantism

• Insidious course over months-years
• Enlargement of hands, feet, jaw (prognathism), frontal bossing
• Coarse facial features, macroglossia, hyperhidrosis
• Arthropathy, carpal tunnel syndrome
• Cardiovascular: hypertension, cardiomyopathy, diastolic dysfunction, arrhythmias (2x mortality risk from CV events)
• Visceromegaly (thyroid, heart, liver, prostate)
• Increased risk of colon polyps and possibly colon cancer
• Glucose intolerance/diabetes

• Best single screening test: elevated serum IGF-1 (age/gender-matched)
• Confirmatory: failure to suppress GH below 1 ng/mL after 75g oral glucose load (GH measured at 1-2 hours)
• MRI pituitary for tumor localization

• First-line: transsphenoidal surgery to remove adenoma
• Medical: octreotide (somatostatin analogue) - normalizes GH and IGF-1 in many; pegvisomant (GH receptor antagonist) - approved for acromegaly
• Radiation therapy if surgery fails and medical therapy inadequate

Cushing Disease

• Central/truncal obesity, moon face, buffalo hump
• Hypertension, diabetes/glucose intolerance
• Thinning skin, easy bruising, violaceous abdominal striae
• Proximal muscle weakness, osteoporosis
• Hirsutism, acne, menstrual irregularity
• Ectopic ACTH: rapid hyperpigmentation, hypokalemia, metabolic alkalosis

• Screening: 24-hour urinary free cortisol (good screening test); late-night salivary cortisol; overnight 1-mg dexamethasone suppression test
• Compare serum ACTH with cortisol to determine ACTH dependence
• ACTH-dependent with pituitary source: CRH stimulation + inferior petrosal sinus sampling

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C. Posterior Pituitary Disorders

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2. Endocrine Disorders in Children and Adolescents

Growth Hormone Deficiency (Pediatric)

• GH deficiency in children causes growth failure (short stature), delayed bone age, increased fat, decreased lean mass
• Screening: IGF-1 and IGFBP-3; confirmed with two pharmacologic GH stimulation tests
• GH fails to rise above 5 ng/mL to two or more stimuli
• Treatment: recombinant hGH 0.04 mg/kg/day SC; serum IGF-1 and growth rate monitored for effectiveness
• GH also used in Turner syndrome, Prader-Willi syndrome, chronic renal disease, and SGA children with failure to catch up

Precocious Puberty

• Central (GnRH-dependent) vs. peripheral (GnRH-independent)
• Girls <8 years, boys <9 years with signs of puberty
• Workup: bone age, LH, FSH, sex steroids, GnRH stimulation test, MRI brain
• Central: GnRH agonist therapy (leuprolide) to suppress HPG axis

Type 1 Diabetes Mellitus in Children

• Autoimmune destruction of beta cells; peak incidence 5-7 and 10-14 years
• Presents with polyuria, polydipsia, weight loss, diabetic ketoacidosis
• Diagnosis: fasting glucose ≥126 mg/dL, random ≥200 mg/dL with symptoms, HbA1c ≥6.5%
• Management: insulin (basal-bolus regimen), carbohydrate counting, glucose monitoring, education
• Target HbA1c <7.5% (pediatric)

Congenital Hypothyroidism

• Most common preventable cause of intellectual disability
• Screened by neonatal TSH/T4 at 48-72 hours of age
• Clinical features if missed: prolonged jaundice, constipation, hypotonia, large fontanelle, coarse features
• Treatment: levothyroxine started ASAP; goal TSH in normal range

Pediatric Thyroid Disorders

• Hashimoto thyroiditis: Most common cause of acquired hypothyroidism in children; goiter, elevated TSH, positive TPO antibodies
• Graves disease: Autoimmune hyperthyroidism; exophthalmos, goiter, TSH low, elevated T3/T4, TSI positive. Treatment: antithyroid drugs (methimazole), radioiodine, or surgery

Congenital Adrenal Hyperplasia (CAH)

• 21-hydroxylase deficiency (>90%): cortisol + aldosterone deficiency, androgen excess
• Classic salt-wasting form: life-threatening adrenal crisis in neonates (hyponatremia, hyperkalemia, hypotension)
• Virilization of female genitalia (ambiguous genitalia)
• Screened by neonatal 17-hydroxyprogesterone
• Treatment: hydrocortisone + fludrocortisone

Obesity and Metabolic Syndrome in Adolescents

• Increasing prevalence; associated with type 2 diabetes, dyslipidemia, hypertension, PCOS
• Screen with fasting glucose, lipid panel, blood pressure
• Management: lifestyle modification, family-based intervention, pharmacotherapy if needed

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3. Screening, Early Diagnosis, and Prevention of Endocrine Diseases

Principles

1. Population screening of asymptomatic individuals (e.g., neonatal screening)
2. Targeted case-finding in high-risk groups
3. Opportunistic screening during routine clinical encounters

Neonatal Screening (Mandatory in Most Countries)

Diabetes Mellitus

• Type 2 DM: Fasting plasma glucose or HbA1c every 3 years starting at age 45; earlier and more frequently in high-risk individuals (BMI ≥25, family history, hypertension, dyslipidemia, gestational diabetes history)
• Gestational diabetes: OGTT at 24-28 weeks; or early testing for high-risk women
• Prediabetes: IFG (fasting glucose 100-125 mg/dL) or IGT (2-h OGTT 140-199 mg/dL) - lifestyle modification reduces progression by 58% (DPP trial); metformin in high-risk individuals

Thyroid Disease

• TSH screening recommended for women >50 years and for all with symptoms
• Neonatal TSH screening universal
• High-risk screening: family history of autoimmune thyroid disease, Down syndrome, Turner syndrome, type 1 DM

Osteoporosis Prevention

• DEXA scan at age 65 in women; earlier with risk factors
• Calcium (1000-1200 mg/day), vitamin D (600-800 IU/day), weight-bearing exercise
• FRAX tool to estimate 10-year fracture risk

Adrenal Incidentaloma

• Incidentally discovered on imaging; evaluate for functional excess (cortisol, catecholamines, aldosterone) and malignancy
• Nonsecretory microadenomas with imaging features of benignity: no resection, serial imaging

Pituitary Incidentaloma

• Nonsecretory microadenomas: found in 10-20% of normal population on MRI; no therapy needed if no hormone excess
• Evaluate for prolactin, IGF-1, and Cushing features; macroadenomas usually require treatment

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PART II: EAR, NOSE, AND THROAT (ENT)

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4. Diseases of the External, Middle, and Inner Ear

External Ear

Otitis Externa (Swimmer's Ear)

• Diffuse inflammation of the external auditory canal; usually bacterial (Pseudomonas aeruginosa, Staphylococcus aureus)
• Symptoms: otalgia (worse with traction on pinna), otorrhea, pruritus, canal edema
• Management: aural toilet, topical antibiotic-steroid drops (ciprofloxacin-hydrocortisone or neomycin-polymyxin-HC); oral antibiotics if cellulitis extends beyond canal
• Malignant (necrotizing) otitis externa: invasive infection in diabetics/immunocompromised; Pseudomonas; facial nerve palsy possible; requires IV antipseudomonal antibiotics, surgical debridement

Furunculosis

• Staphylococcal abscess in outer 1/3 of canal; treat with incision + drainage and antibiotics

Ear Canal Foreign Bodies

• Common in children; remove with gentle irrigation or instrumentation; refer if impacted or difficult to remove

Middle Ear

Acute Otitis Media (AOM)

• Most common bacterial infection in children; peak age 6-24 months
• Pathogens: Streptococcus pneumoniae (most common), Haemophilus influenzae, Moraxella catarrhalis
• Symptoms: otalgia, fever, hearing loss, irritability; otoscopy shows bulging, erythematous tympanic membrane with decreased mobility
• Management:
  • Children <6 months: amoxicillin 90 mg/kg/day
  • Children ≥6 months with mild-moderate disease: watchful waiting for 48-72h acceptable; amoxicillin if treatment chosen
  • Severe disease or age <2 years: antibiotics immediately
  • Amoxicillin-clavulanate if failure after 48-72h of amoxicillin, recent exposure, or in daycare
  • Penicillin allergy: cefdinir, cefuroxime, or IM ceftriaxone
  • Recurrent AOM (≥3 episodes/6 months): consider tympanostomy tubes

Otitis Media with Effusion (Glue Ear)

• Fluid in middle ear without signs of acute infection; common in children
• Can affect balance - "clumsy child with poor balance"
• Most resolve spontaneously; persistent effusion (>3 months) with hearing loss: refer for tympanostomy tubes consideration

Chronic Suppurative Otitis Media (CSOM)

• Persistent otorrhea through a tympanic membrane perforation for >2 weeks
• Can influence general balance; CSOM with cholesteatoma carries risk of fistula to lateral semicircular canal or oval window, causing dizziness or suppurative labyrinthitis
• Management: aural toilet, topical antibiotics; surgical repair (tympanoplasty) for persistent perforation; cholesteatoma requires surgical excision

Cholesteatoma

• Destructive epithelial-lined sac in middle ear; can erode ossicles, mastoid, and cause intracranial complications
• Features: chronic foul-smelling discharge, hearing loss, conductive hearing loss
• Management: surgical excision (mastoidectomy)

Otosclerosis

• Abnormal bone remodeling of the stapes footplate causing progressive conductive hearing loss; often bilateral; familial
• Stapedectomy (surgical treatment) or hearing aid

Inner Ear

Sensorineural Hearing Loss (SNHL)

• Causes: noise-induced, presbycusis (age-related), ototoxic drugs (aminoglycosides, cisplatin, loop diuretics), viral (mumps, CMV), Meniere's disease, acoustic neuroma, meningitis
• Diagnosis: audiometry, ABR, MRI for asymmetric SNHL
• Management: hearing aids for moderate SNHL; cochlear implants for profound bilateral SNHL

Menière's Disease

• Endolymphatic hydrops; triad of episodic vertigo, fluctuating SNHL, and tinnitus
• Childhood onset uncommon (<3% sporadic, >9% familial); early onset = more aggressive disease with earlier bilateral involvement
• Management: low-sodium diet, diuretics, vestibular suppressants (meclizine) during attacks; intratympanic gentamicin or steroids for refractory cases; surgery (endolymphatic sac decompression, labyrinthectomy)

Benign Paroxysmal Positional Vertigo (BPPV)

• Most common cause of vertigo; canalith dislodgement in semicircular canals
• Diagnosis: Dix-Hallpike maneuver (posterior canal BPPV)
• Treatment: Epley canalith repositioning maneuver (highly effective)

Enlarged Vestibular Aqueduct Syndrome

• Rare congenital anomaly; vestibular disturbance in ~4% of patients
• Fluctuating/progressive bilateral SNHL; found in 50% of Waardenburg syndrome (types 1 and 2)
• Also seen in Pendred syndrome and branchio-otorenal syndrome (often with Mondini deformity)

Acoustic Neuroma (Vestibular Schwannoma)

• Unilateral SNHL, tinnitus, imbalance; examine cranial nerves V, VI, VII
• Diagnosis: MRI with gadolinium
• Management: surveillance (small), stereotactic radiosurgery (Gamma Knife), or microsurgical excision

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5. Diseases of the Nose and Paranasal Sinuses

Acute Bacterial Rhinosinusitis

• Viral URI is the most common predisposing factor; 8% of viral URIs in children become complicated by acute bacterial sinusitis
• Most common in 12-23 month age group
• Pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis
• Clinical features: persistent symptoms >10 days without improvement, severe symptoms (fever ≥39°C + purulent discharge for ≥3-4 days), or worsening after initial improvement ("double-sickening")
• Diagnosis: primarily clinical; CT/MRI not required for uncomplicated acute sinusitis
• Complications: periorbital/orbital cellulitis, intracranial extension (meningitis, epidural abscess, cavernous sinus thrombosis), Pott's puffy tumor (osteomyelitis of frontal bone)

Chronic Rhinosinusitis

• Inflammatory process lasting >3 months
• Risk factors: older age, allergic rhinitis, recurrent viral URIs, immunodeficiency, ciliary dyskinesia, anatomical abnormalities, fungal colonization
• Pathogens: alpha-hemolytic Streptococcus, H. influenzae, S. pneumoniae, S. aureus, anaerobes; rarely fungi (Aspergillus, Fusarium, Bipolaris)
• Linked to asthma; treatment of chronic sinusitis reduces asthma symptoms
• Management:
  • Antibiotics covering acute pathogens + beta-lactamase producers: amoxicillin-clavulanate 20-25 mg/kg BID; clindamycin 8 mg/kg TID; moxifloxacin 400 mg/day (adolescents)
  • Duration: at least 4 weeks for chronic bacterial sinusitis
  • Nasal saline irrigation
  • Intranasal corticosteroids
  • Referral for nasal endoscopy and surgery (adenoidectomy, balloon catheter dilation, endoscopic sinus surgery/FESS) if antibiotics + saline fail

Allergic Rhinitis

• IgE-mediated inflammatory response; affects 2.2-14.6% of children 6-7 years; 4.5-45.5% of adolescents
• 80% of asthmatic children have allergic rhinitis
• Pathophysiology: allergen → IgE + mast cells → histamine release → H1 receptor activation → itch, sneeze, rhinorrhea, obstruction
• Seasonal (pollen) vs. perennial (dust mites, animal dander, mold)
• Clinical: clear rhinorrhea, nasal pruritus, sneezing; "allergic salute" horizontal nasal crease; pale/bluish turbinates; Dennie-Morgan folds
• Management:
  • Intranasal corticosteroids (most effective first-line)
  • Oral/intranasal antihistamines (second-generation preferred: loratadine, cetirizine, fexofenadine)
  • Intranasal antihistamines (azelastine)
  • Leukotriene receptor antagonists (montelukast)
  • Allergen immunotherapy for severe/refractory cases
  • Environmental control measures

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6. Acute and Chronic Diseases of the Pharynx and Larynx

Pharynx

Acute Pharyngitis / Tonsillitis

• Most commonly viral (rhinovirus, adenovirus, EBV, influenza); bacterial in 15-30% of adults, up to 37% in children
• Group A Streptococcus (GAS) is most important bacterial pathogen (risk of rheumatic fever)
• Centor Criteria (modified McIsaac): tonsillar exudate, tender anterior cervical lymphadenopathy, fever, absence of cough. Score 0-1: no testing/antibiotics; score ≥2-3: rapid strep test (RADT); score ≥4: empiric antibiotics or RADT
• Treatment of GAS: penicillin V 500 mg BID-TID x 10 days (first choice) or amoxicillin 500 mg TID x 10 days; benzathine penicillin G IM single dose for compliance issues; penicillin allergy: azithromycin (5-day) or clindamycin
• Goal: prevent rheumatic fever, peritonsillar abscess; eradicate pharyngeal carriage

Peritonsillar Abscess

• Most common deep neck space infection; unilateral; Streptococcus and oral anaerobes
• Features: severe odynophagia, trismus, uvular deviation, muffled "hot potato" voice
• Management: aspiration or incision and drainage; IV penicillin/clindamycin; ENT referral; tonsillectomy if recurrent

Retropharyngeal/Parapharyngeal Abscess

• Life-threatening deep neck infection; children or immunocompromised
• Features: fever, drooling, dysphagia, neck stiffness, respiratory distress
• CT neck with contrast for diagnosis; IV antibiotics + surgical drainage; airway management priority

Chronic Tonsillitis/Tonsillar Hypertrophy

• Indications for tonsillectomy: recurrent GAS tonsillitis (≥7 episodes/year, ≥5/year x 2 years, or ≥3/year x 3 years), obstructive sleep apnea, peritonsillar abscess, suspected malignancy

Larynx

Acute Laryngitis

• Viral (most common), overuse of voice; hoarseness, dysphonia
• Management: voice rest, steam inhalation, hydration; antibiotics only if bacterial superinfection

Croup (Laryngotracheobronchitis)

• Viral (parainfluenza virus most common); children 6 months to 3 years
• Features: barking cough, stridor, hoarseness; worse at night
• Diagnosis: clinical; X-ray shows "steeple sign" (subglottic narrowing)
• Management:
  • Mild: single dose dexamethasone 0.6 mg/kg PO/IM
  • Moderate-severe: nebulized racemic epinephrine + dexamethasone; monitor 3-4 hours post-epinephrine for rebound
  • Humidified air/cool mist (minimal evidence but commonly used)

Epiglottitis

• Potentially life-threatening supraglottic infection; previously H. influenzae type b (now rare due to HiB vaccine); now Streptococcus and Staphylococcus in adults
• Features: abrupt high fever, severe odynophagia, drooling, stridor, "tripod position"
• Do NOT examine oropharynx in children without airway secured
• Management: immediate airway management (intubation or tracheotomy if needed), IV ceftriaxone; ENT/anesthesia team involvement

Chronic Laryngitis

• Causes: GERD (most common), voice overuse, smoking, allergies, chronic sinusitis/postnasal drip
• Treatment: treat underlying cause (PPI for GERD), voice therapy, smoking cessation

Laryngeal Polyps / Nodules

• "Singer's nodules" from voice abuse; bilateral, mid-cord
• Treatment: voice rest, voice therapy; surgical removal if refractory

Laryngeal Cancer

• Strong association with smoking and alcohol; squamous cell carcinoma
• Persistent hoarseness >3 weeks in smoker/drinker: refer urgently to ENT for laryngoscopy

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7. Acute and Chronic ENT Infections and Treatment

Summary Table of Key ENT Infections

Principles of ENT Infection Management:

1. Watchful waiting is appropriate for mild AOM in children ≥6 months before prescribing antibiotics
2. De-escalate from broad-spectrum antibiotics once culture results available
3. Topical therapy preferred for otitis externa to reduce systemic side effects
4. Viral infections (pharyngitis, laryngitis, croup) do not require antibiotics; antivirals rarely indicated
5. Surgical drainage for abscess formations (peritonsillar, deep neck, mastoid)

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8. Indications for Referral to an Otorhinolaryngologist

Ears

• Persistent or recurrent AOM (≥3 episodes/6 months or ≥4/year)
• Suspected cholesteatoma (foul-smelling discharge, hearing loss)
• Acute mastoiditis unresponsive to antibiotics
• Hearing loss (unexplained, asymmetric, or progressive SNHL)
• Sudden SNHL (urgent - treat within 72 hours)
• Suspected acoustic neuroma
• Chronic tympanic membrane perforation
• Tinnitus (persistent, unilateral, or pulsatile)
• Vertigo unresponsive to medical management
• Malignant otitis externa

Nose and Sinuses

• Chronic sinusitis failing medical treatment (antibiotics + saline + steroids)
• Recurrent acute sinusitis (≥4 episodes/year)
• Unilateral nasal obstruction or polyps (exclude neoplasm)
• Epistaxis not controlled by first-line measures
• Suspected septal perforation
• Nasal trauma with suspected fracture or septal hematoma
• Complications of sinusitis (orbital, intracranial)
• Suspected intranasal foreign body

Pharynx and Larynx

• Hoarseness persisting >3 weeks (especially in smokers - exclude malignancy)
• Suspected epiglottitis (emergency)
• Recurrent tonsillitis meeting surgical criteria
• Obstructive sleep apnea/snoring - surgical evaluation
• Peritonsillar abscess
• Dysphagia or persistent sore throat without clear cause
• Neck mass (any age) - lymphoma, metastatic disease
• Any suspicion of head and neck malignancy

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PART III: INFECTIOUS DISEASES IN OUTPATIENT PRACTICE

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9. General Characteristics, Diagnosis, Prevention, and Treatment of Infectious Diseases

General Characteristics

• Distinguishing bacterial from viral etiologies
• Identifying patients requiring antibiotics vs. supportive care
• Preventing complications and transmission
• Recognizing serious infections requiring hospitalization or specialist referral

Clinical Approach to Diagnosis

1. History: symptom duration and progression, fever pattern, contact exposures, travel, vaccination status, immunocompromise, medications
2. Examination: vital signs (fever, tachycardia, hypotension = sepsis alert), focus examination by system
3. Investigations:
   • CBC with differential (leukocytosis with left shift suggests bacterial; lymphocytosis = viral)
   • CRP, ESR, procalcitonin (elevated in bacterial sepsis)
   • Blood cultures: before starting antibiotics in suspected bacteremia/sepsis
   • Specific cultures (throat, urine, wound) to guide targeted therapy
   • Rapid antigen tests (Group A strep, influenza, SARS-CoV-2, RSV)
   • Serology for EBV, CMV, Toxoplasma, HIV, hepatitis
   • Chest X-ray when pneumonia suspected
4. Sepsis Recognition: Any fever with altered mental status, hypotension, tachycardia, or organ dysfunction warrants immediate intervention - "sepsis 6": blood cultures, lactate, IV access, IV fluids, oxygen, broad-spectrum antibiotics within 1 hour

Prevention

• Vaccination (see Section 11)
• Hand hygiene and respiratory etiquette
• Antimicrobial stewardship to prevent resistance
• Barrier protection for sexually transmitted infections
• Food and water safety for gastrointestinal infections
• Vector control for malaria, dengue, Lyme disease
• Post-exposure prophylaxis (HIV, rabies, hepatitis B, meningococcus contacts)

Indications for Hospitalization

• Hemodynamic instability (septic shock)
• Inability to tolerate oral medications/fluids
• Immunocompromise with serious infection
• Failure of outpatient treatment
• Complications requiring IV antibiotics (pyelonephritis in pregnancy, pneumonia needing IV therapy)

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10. Urinary Tract Infections

Etiology

• Most common pathogen: Escherichia coli (80-85% of community-acquired UTI)
• Other pathogens: Staphylococcus saprophyticus (young sexually active women), Klebsiella pneumoniae, Proteus mirabilis, Enterococcus faecalis
• Hospital-acquired: Pseudomonas, Candida, resistant gram-negatives

Classification

Diagnosis

• Urinalysis: pyuria (≥10 WBC/hpf), bacteriuria, positive nitrites; leukocyte esterase
• Urine culture: gold standard; ≥100,000 CFU/mL significant; lower counts (1,000-10,000) significant with symptoms
• Culture recommended for: complicated UTI, pyelonephritis, recurrent UTI, treatment failure, pregnancy
• Imaging (ultrasound, CT) for: pyelonephritis with suspected abscess, obstruction, recurrent infections, males, children

Asymptomatic Bacteriuria in Pregnancy

• Screen with urine culture at 12-16 weeks gestation (or first prenatal visit if later) - USPSTF Grade A recommendation
• Prenatal screening identifies ~95% of those at risk for subsequent bacteriuria
• Up to 30% untreated will develop pyelonephritis; treatment also may reduce preterm delivery and low birth weight
• Treat with 7-10 days of a safe antibiotic: cephalexin 500 mg BID, nitrofurantoin 100 mg BID, amoxicillin 500 mg TID, or TMP-SMX (avoid in third trimester)

Treatment

• Nitrofurantoin 100 mg BID x 5 days (first-line)
• Trimethoprim-sulfamethoxazole 160/800 mg BID x 3 days (if local resistance <20%)
• Fosfomycin 3g single dose
• Fluoroquinolones: effective but reserve to minimize resistance

• Cephalexin 500 mg BID x 3-7 days
• Nitrofurantoin 100 mg BID x 3-7 days
• Amoxicillin 500 mg TID x 7 days
• TMP-SMX (avoid third trimester - risk of neonatal kernicterus)

• Ciprofloxacin 500 mg BID x 7 days
• TMP-SMX x 14 days (if susceptible)

• IV ceftriaxone 1 g IV daily (preferred, given high E. coli ampicillin resistance)
• IV hydration, obstetric consultation, urine cultures
• Transition to oral based on culture sensitivity; repeat culture post-treatment; close monitoring for recurrence

Prevention of Recurrence

• Adequate fluid intake (>2L/day)
• Void after sexual intercourse
• Avoid spermicides and diaphragms (increase colonization)
• Wipe front to back
• Cranberry products: modest evidence for reduction in recurrent UTI in women
• Prophylactic antibiotics: low-dose continuous (nitrofurantoin 50-100 mg/day; TMP-SMX half tablet/day) or post-coital single dose in women with frequent recurrent UTI
• Vaginal estrogen for postmenopausal women with recurrent UTI
• Manage underlying anatomic/functional abnormalities

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11. Rational Antibiotic Therapy and Vaccination in Family Medicine

Principles of Rational Antibiotic Prescribing (Antimicrobial Stewardship)

1. Selecting the appropriate drug (narrowest effective spectrum)
2. Choosing the correct dosage and route
3. Optimal duration (no longer than needed)
4. Reducing adverse effects, C. difficile infection, resistance selection, and cost

1. Prospective audit and feedback: review of broad-spectrum antimicrobial orders by ID physicians/pharmacists with recommendations for alternatives
2. Formulary restriction: limiting indiscriminate use of certain antibiotics
3. Preauthorization: requiring approval before prescribing high-risk agents (carbapenems, vancomycin)

• Diagnose before prescribing: obtain cultures, use rapid tests (strep, flu)
• Choose narrow-spectrum agents when pathogen/susceptibility known
• Reserve broad-spectrum antibiotics (carbapenems, vancomycin, fluoroquinolones) for serious or resistant infections
• Educate patients that viral infections (most colds, most sore throats, most coughs) do NOT require antibiotics
• Use local antibiograms to guide empiric therapy
• De-escalate once culture results available
• Adhere to recommended treatment durations; do not extend unnecessarily
• Prophylaxis: use only in specific, evidence-supported circumstances (surgical, recurrent UTI, meningococcal contact); do not extend beyond the risk period

• Surgical prophylaxis: deliver within 1 hour before incision; redose for prolonged procedures; stop at wound closure
• Preoperative nasal decolonization with mupirocin reduces S. aureus surgical site infections in high-risk procedures
• Prophylaxis for cardiac/orthopedic procedures in high-risk patients
• Non-procedural: meningococcal contacts (rifampicin/ciprofloxacin), HIV post-exposure prophylaxis, rabies, recurrent UTI, recurrent GAS, infective endocarditis prophylaxis for high-risk cardiac lesions during bacteremic dental procedures

Vaccination in Family Medicine

• Tdap: one dose in adulthood; Td booster every 10 years
• Influenza: annual for all ≥6 months
• COVID-19: per current guidelines
• Pneumococcal (PCV20 or PPSV23): adults ≥65, high-risk conditions
• Shingles (RZV/Shingrix): adults ≥50 years (2 doses)
• HepB: unvaccinated adults; all adults ≥19 by ACIP
• MMR: susceptible adults
• HPV: up to age 26 routinely; shared decision to age 45

• Assess vaccine status at every visit
• Follow recommended schedules; most missed doses can be "caught up"
• Educate patients on vaccine safety and the rarity of serious adverse effects
• Live vaccines (MMR, varicella): avoid in immunocompromised (except HIV with CD4 >200)
• Document vaccines in the patient record
• Observe for 15-30 minutes post-vaccine for anaphylaxis (epinephrine must be available)
• Defer live vaccines in pregnancy; inactivated vaccines (influenza, Tdap) recommended in pregnancy

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PART IV: EMERGENCY CONDITIONS IN FAMILY MEDICINE

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12. Emergency Conditions and Prehospital Management

A. Acute Cardiovascular Emergencies

Acute Coronary Syndromes (ACS)

• Aspirin 300 mg crushed PO immediately (unless true allergy)
• Nitroglycerin sublingual (0.4 mg) every 5 minutes x 3 if pain persists (avoid if hypotension, right ventricular MI, or recent PDE-5 inhibitor use)
• Morphine 2-4 mg IV (use cautiously - some evidence of harm in NSTEMI)
• Oxygen: only if SpO2 <94%
• IV access, 12-lead ECG, continuous monitoring
• Rapid transport to PCI-capable facility

Acute Heart Failure / Pulmonary Edema

• Features: severe dyspnea, orthopnea, pink frothy sputum, bilateral crackles, S3 gallop
• Management: upright positioning, oxygen/CPAP/NIV, IV diuretics (furosemide 40-80 mg IV), IV nitrates, ACE inhibitor/ARB, admit

Hypertensive Emergency

• BP ≥180/120 with end-organ damage (encephalopathy, ACS, aortic dissection, pulmonary edema, acute kidney injury)
• Target: reduce MAP by 15-25% in first hour, not to normal
• IV labetalol, IV nicardipine, IV sodium nitroprusside (use with caution)
• Aortic dissection: target SBP <120 with IV beta-blocker + vasodilator

Cardiac Arrest (OHCA)

• Immediate recognition: unresponsive, no normal breathing
• Call for help/AED
• High-quality CPR: 100-120 compressions/min, depth 5-6 cm, full chest recoil, minimize interruptions
• Defibrillation ASAP for shockable rhythms (VF/pulseless VT) - every minute delay reduces survival ~10%
• Epinephrine 1 mg IV every 3-5 minutes (non-shockable rhythms: after first shock for VF)
• Amiodarone 300 mg IV for refractory VF/pVT
• Treat reversible causes (4 Hs and 4 Ts): hypoxia, hypovolemia, hypo/hyperkalemia, hypothermia; tension pneumothorax, tamponade, toxins, thromboembolism

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B. Anaphylactic Shock

1. Acute onset illness with skin/mucosal involvement + respiratory compromise or reduced BP
2. Two or more of: skin, respiratory, GI symptoms, or hypotension - after exposure to likely allergen
3. Reduced BP after exposure to known allergen

1. Epinephrine 0.3-0.5 mg (0.3-0.5 mL of 1:1000) IM into the anterolateral thigh - FIRST and most important step; repeat every 5-15 minutes if needed
2. Position: supine with legs elevated (or sitting upright if respiratory distress)
3. Remove trigger if possible
4. 100% oxygen by face mask
5. IV access + IV fluids (1-2 L normal saline rapidly for hypotension)
6. H1 antihistamine: diphenhydramine 50 mg IV/IM
7. H2 antihistamine: ranitidine/famotidine IV
8. Corticosteroids: methylprednisolone 125 mg IV or dexamethasone (does NOT work immediately - prevents biphasic reaction)
9. Bronchospasm: salbutamol (albuterol) nebulized
10. Glucagon 1-5 mg IV for patients on beta-blockers (epinephrine less effective)
11. Monitor for biphasic reaction (4-12 hours later): observe 4-8 hours minimum

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C. Acute Allergic Reactions (Non-Anaphylactic)

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D. Respiratory Distress - Prehospital Management

1. Assess and secure airway (A-B-C)
2. High-flow oxygen targeting SpO2 94-98% (COPD: 88-92%)
3. Position upright
4. Identify cause rapidly

• Nebulized salbutamol (albuterol) 2.5-5 mg every 20 minutes x3 or continuous
• Ipratropium bromide nebulized (add to salbutamol)
• Oral/IV prednisolone or dexamethasone
• IV magnesium sulfate 2g (adults) if severe
• Heliox, IV salbutamol, CPAP/NIV for critical cases
• Intubation only if arrest imminent (high risk)

• Life-threatening; deviated trachea away from affected side, absent breath sounds, hypotension, distended neck veins
• Immediate needle decompression (2nd intercostal space, midclavicular line) followed by chest tube

• Sudden dyspnea, pleuriticchest pain, hemoptysis, syncope, tachycardia, hypoxia
• If hemodynamically unstable: IV thrombolysis (alteplase 100 mg over 2 hours); anticoagulation (LMWH or UFH)

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E. Trauma and Bleeding (Prehospital)

ATLS Primary Survey (ABCDE)

1. Airway with C-spine protection: jaw thrust, oral airway, intubation if GCS ≤8
2. Breathing and ventilation: bilateral chest auscultation, 15L/min O2; needle decompression for tension pneumothorax; occlusive dressing for open chest wounds
3. Circulation with hemorrhage control: IV access (two large bore), fluid resuscitation, direct pressure on bleeding wounds, tourniquet for limb hemorrhage
4. Disability: GCS, pupils, gross motor/sensory
5. Exposure and environment: undress patient, prevent hypothermia

• Direct sustained pressure is first-line for external bleeding
• Tourniquets for life-threatening limb hemorrhage; note time of application
• Hemostatic dressings (Combat Gauze with kaolin or chitosan) for junctional wounds where tourniquet cannot be applied
• Permissive hypotension in penetrating trauma (target SBP 80-90 mmHg until surgical hemostasis)
• Massive transfusion protocol: packed RBCs : FFP : platelets in 1:1:1 ratio
• Tranexamic acid (TXA) 1g IV over 10 minutes as soon as possible (within 3 hours of injury) - reduces mortality from hemorrhage significantly

• Avoid hypotension (SBP <90 mmHg) and hypoxia - major secondary brain injury
• C-spine immobilization
• CT head for suspected intracranial injury

• Stop the burning process, cool with cool (not iced) water for 20 min
• Estimate burn surface area (%TBSA - Rule of Nines)
• Fluid resuscitation: Parkland formula: 4 mL/kg/%TBSA in 24h (50% in first 8 hours, 50% in next 16 hours)
• Analgesia, wound care, tetanus prophylaxis

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F. Prehospital Management Principles

1. Scene safety - ensure safety of rescuers and patient
2. Triage in mass casualty events (START system: Simple Triage And Rapid Treatment)
3. DRSABCD approach: Danger, Response, Send for help, Airway, Breathing, CPR, Defibrillation
4. Do no further harm: stabilize fractures, maintain spinal precautions until excluded
5. Transport: determine appropriate receiving facility (PCI-capable for STEMI, trauma center for major trauma)
6. Communication: pre-alert receiving hospital with patient details, vital signs, interventions
7. Handover using SBAR (Situation, Background, Assessment, Recommendation) or MIST (Mechanism, Injuries, Signs, Treatment)
8. Analgesia: do not withhold analgesia for fear of masking signs; IV morphine titrated in trauma, IV/intranasal fentanyl
9. Documentation: time of events, medications given, vitals trend
10. Avoid hypothermia: cover patient, warm IV fluids

• Scoop and run (immediate transport): penetrating trauma, airway obstruction, STEMI for PCI, major hemorrhage
• Stay and play: cardiac arrest (CPR before transport), tension pneumothorax decompression, airway management

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Summary Reference Table

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What's Covered

Part I - Endocrinology

1. Pituitary Disorders - Full discussion of hypopituitarism (causes, hormone-specific manifestations, Sheehan syndrome, pituitary apoplexy, diagnosis, and treatment), prolactinoma (dopamine agonists, surgical indications), acromegaly (IGF-1 screening, glucose suppression test, surgery + octreotide/pegvisomant), Cushing disease (24h UFC screening, transsphenoidal surgery), and posterior pituitary disorders (DI, SIADH, craniopharyngiomas)
2. Pediatric Endocrine Disorders - GH deficiency, precocious puberty, Type 1 DM in children, congenital hypothyroidism (neonatal screening), Hashimoto thyroiditis, Graves disease, congenital adrenal hyperplasia (salt-wasting crisis), adolescent obesity/metabolic syndrome
3. Screening and Prevention - Neonatal screening (TSH, 17-OHP), diabetes screening (prediabetes, gestational DM, USPSTF recommendations), thyroid disease, osteoporosis, pituitary and adrenal incidentaloma management

Part II - ENT

1. Ear Diseases - Otitis externa (including malignant), AOM (watchful waiting + antibiotic choices), glue ear, CSOM, cholesteatoma, otosclerosis, SNHL, Menière's disease, BPPV (Epley maneuver), enlarged vestibular aqueduct syndrome, acoustic neuroma
2. Nose and Sinuses - Acute bacterial sinusitis (antibiotic table by severity), chronic rhinosinusitis (pathogens, 4-week antibiotics, surgical indications), allergic rhinitis (IgE pathway, intranasal corticosteroids first-line, immunotherapy)
3. Pharynx and Larynx - GAS pharyngitis (Centor criteria, penicillin 10 days), peritonsillar abscess (I&D), retropharyngeal abscess, tonsillectomy criteria, acute laryngitis, croup (dexamethasone + racemic epi), epiglottitis (airway first - emergency), chronic laryngitis, laryngeal cancer (urgent ENT referral for persistent hoarseness)
4. ENT Infections Summary Table - Pathogens and treatments for all common ENT infections
5. ENT Referral Indications - Comprehensive criteria for ears, nose/sinuses, and pharynx/larynx

Part III - Infectious Diseases

1. Outpatient Infectious Diseases - Diagnostic approach, sepsis recognition, prevention principles, indications for hospitalization
2. UTI - Etiology, classification, USPSTF Grade A screening in pregnancy, treatment tables (cystitis, pyelonephritis, pregnancy), recurrence prevention (prophylactic antibiotics, vaginal estrogen in postmenopausal women)
3. Antibiotic Stewardship and Vaccination - Core stewardship strategies (audit/feedback, formulary restriction, preauthorization), rational prescribing principles, complete childhood immunization schedule, adult vaccination schedule

Part IV - Emergency Medicine

1. Emergency Conditions - ACS management (MONA, STEMI door-to-balloon 90 min, thrombolysis), acute heart failure, hypertensive emergency, OHCA CPR protocol (4Hs/4Ts), anaphylaxis (IM epinephrine anterolateral thigh as first step, biphasic reaction monitoring), non-anaphylactic allergic reactions (hereditary angioedema - no response to antihistamines/steroids), respiratory emergencies (severe asthma, tension pneumothorax, PE), trauma ATLS ABCDE, hemorrhage control (TXA within 3 hours), prehospital principles (scoop-and-run vs. stay-and-play)