My Family Medicine Teaching & Learning Resources

Pharmacist Letter: Asthma Inhaler Comparison Chart 

2014 AHA/ACC/HRS Guideline for A.fib 

2019 AHA/ACC/HRS Update Guidelines for A.fib 

Bacteremia Slides_AHRQ 

Molecular Diagnosis of Bacterial Vaginosis: an Update 

Vaginitis: Diagnosis and Treatment 

Chronic Pain Update_Lancet 2021: 3 types of chronic pain

SGLT-2i for CKD: Are you a Flozinator? 

• infographics are great!

• Mythri Shankar's renal infographics 

ATS/IDSA 2019 Guidelines: Community Acquired Pneumonia 

ESC: 2016 Guidelines for diagnosis and treatment of acute and chronic heart failure

AHA/ACCF: 2013 Guideline for Management of Heart Failure: Executive Summary  

What is New in Heart Failure Management in 2017? Update on ACC/AHA Heart Failure Guidelines 

Medical Management of Constipation Review Article

• Table 2: Treatment algorithm for chronic constipation 

Constipation: Behavioral and Integrative Therapies for Constipation 

Pharmacist Letter: COPD Inhaler Comparison Chart 

COVID Updates 3.2023 Conversations in Primary Care NACE 

Dave Putrino's Autonomic Rehab Protocol 

Early vs. Delayed MRI s/p TIA 

Stanford Medicine General Dermatology: Learning the language  

JAAD: Guidelines of care for the management of acne vulgaris

• Table V: Recommendations for topical therapies 

Differential Diagnosis Algorithm

• scroll down for algorithm

• STAR*D Trial: next step in treatment of depression study 

  • • Step 1: citalopram: ~30% remission 

    • Step 2: no difference in remission rates when switching to another agent (sertraline, venlafaxine, and bupropion all had ~30% remission

      • augmentation with bupropion with less dropout (~12%) vs. buspirone (~20%)

    • Step 3: switch to mirtazapine or nortriptyline OR Augment (level 2 with either T3 or lithium)

    • Step 4: switch to mirtazapine + venlafaxine or tranylcypromine (more dropout due to SE)

• Practical tips from psychiatry group: 

  • • start at lowest dose and ensure adequate time given to meds on therapeutic dose (can increase to therapeutic dose after 2 weeks --> and continue for 4 weeks before making adjustments)

    • ADHD features: wellbutrin, venlafaxine

    • Insomnia: zoloft (SE of sedation)

    • OCD features: TCAs

    • aripripazole: augment if improving on SSRI but not at remission, start 1-2 mg 

    • buspar: anxiety 

• Antidepressant-like Effects of Representative Types of Food and Their Possible Mechanisms 

• https://ottawadepressionalgorithm.ca/en/start 

Type 2 Diabetes Therapies: A STEPS Approach 

Pharmacist Letter: 2020 Diabetes Medications Chart 

• My FAVORITE chart for diabetes medications!

GLP-1 Agonist Comparison Chart 

NEJM: CV and Renal Outcomes with Empagliflozin in Heart Failure 

Decision Algorithm for SGLT-2i and GLP-1A in DKD 

NEJM: Dapagliflozin in patients with CKD 

• Population: ~4,000 patients with eGFR 25-75 + albuminuria randomized to dapa or placebo

• NNT 19 

• HR 0.56: for the composite of a sustained decline in eGFR of at least 50%, ESRD, or death from renal cause

  • HR interpretation: ~little over 1/2 as many patients with events in treatment group 

• HR 0.71 for the composite of CHF hospitalization or death 2/2 CVD

• Trial was stopped early due to efficacy 

Comparision of SGLT-2i and GLP agonists on CV and renal outcomes in DM 

Insulin Initiation and Titration in Patients with Type 2 Diabetes 

GLP-1 agonists in cardiorenal outcomes meta-analysis 

GLP-1 agonist + basal insulin as a synergistic strategy 

GLP-1 STEPS Trials Summary: GLP-1s data for weight loss

 GLP-1 + GIP combo = Tirzepatide 

• 1.8 mg liraglutide = 0.5 mg semaglutide

• 3 mg liraglutdie = 1 mg semaglutide = 4.5 mg dulaglutide 

• Can use clicks to mitigate side effects (10 clicks between saxenda doses, 19 clicks between ozempic doses) 

GLP-1 and insurance: 

• insurance considerations: ozempic (ICD 10 if pt does not have DMII: insulin resistance or prediabetes; can try cardiovascular risk reduction) 

• insurance may require dose escalations to continue use

• insurance may also require proof of at least 5% total body weigh tloss at 3 months to oncintue coverage 

SGLT2-i: Practical Points for Prescribing Medication 

Encephalitis

-acute or subacute onset (chronic is not feature of encephalitis)

-CSF: pleocytosis (higher cells infectous, mild-mod autoimmune)

-infecious is most common identified causes (40-70% of cases have no identified causes)

AFP: EBM Toolkit

ACCESSSS: Smart Search. Answers to: What is the best available evidence to support clinical decisions? 

End of Life Medications Chart (Pharmacist's Letter) 

https://neurosymptoms.org/en/ 

JAMA- Mobility Limitation in the Older Patient: A Clinical Review 

• Table 3: Types of mobility devices and clinical situations in which they might be helpful 

SPIKES Method: Delivering Bad News 

AFP: Delivering Bad or LIfe-Altering News

• SPIKES, BREAK, ABCDE Protocols summarized 

AFP: Geriatric Assessment: An Office-Based Approach

• eTable A: pre-physician visit geriatric assessment forms  

Protein + Exercises for frailty  

Trazodone  

Gout Diagnostic Calculator

• The Acute Gout Diagnosis Rule can help rule in or rule out gout, reducing the need for synovial fluid in highly likely patients and encouraging a broad differential in gout-unlikely patients.

AFP GOUT EBM Review 

2017 ACC/AHA/etc HTN Guidelines

• Table 13: secondary causes of HTN with clinical indications and diagnostic screening test recommendations

• Section 9: HTN in patients with specific comorbidities 

• Figure 10: Treatment of resistant hypertension

• Patients with DMII, strive for SBP < 130 

  • reduced stroke by 39%, no sig risk reduction in MI (meta-analysis of 73,913 patients with DM)

  • SPRINT and ACCORD trials demonstrated CV benefit from intensive BP tx with goal < 120 vs. 140

Integrative therapies for HTN 

Sleep and Resistant Hypertension

Treatment of Resistant and Refractor Hypertension (RHTN, RfHTN)  

Wide Pulse Pressure: A Clinical Review 

• elderly patients, 2/2 degenerative arterial stiffening

• can trial thiazide diuretic or imdur for tx of isolated SBP 

• independent predictor of mortality, increase r/o CAD, CVA, CHF 

Hypertension Management in Older and Frail Older Patients 

• Table 3: med mngt and precautions in elderly patient 

2017 Update ACC Expert Consensus Decision Pathway on the Role of Non Statin Therapies for LDL Lowering in Management of ASCVD Risk

• see tables: statin recommendations, LDL targets, statin intensity chart, non statin meds chart 

Pharmacotherapy options beyond statins for HLD 

REDUCE-IT Trial: vascepa lowers CV risk, all cause mortality in statin treated patients with hyperTG 

Omega n-3 Supplementation: Exploring the Cardiovascular Benefits Beyond Lipoprotein Reduction (Vascepa review) 

Hyperlipidemia Update NACE Conversations in Primary Care slides 

Cholesterol Guidelines FAQ_Pharmacist Letter 

Journal of Clinical Sleep Medicine: Chronic Insomnia Guidelines 

• Table 4, 5 are excellent to review when prescribing medications

JAMA: Insomnia  

• Table 1: CBT interventions broken down with useful tips to incorporate into patient care

AFP: Insomnia- Pharmacologic Therapy

Apps for CBT-I

CBT-i Coach by US Department of Veterans Affairs (VA)

Insomnia Coach by Palo Alto Veterans Institute for Research 

Sleep Cycle: smart alarm clock 

Sleep as Android Unlock 

Sleep Center Free 

Good Morning Alarm Clock 

Patient Handouts

Family Doctor: Sleep Changes in Older Adults 

Healthy Sleep Tips for Women from National Sleep Foundation

Patient Facts: Insomnia from American College of Physicians 

Sleep Self Care from University of California, Berkley

Sleep Diary from National Sleep Foundation

Sleep Diary from American Academy of Sleep Medicine

Proposed research classification criteria for Lyme disease in infection associated chronic illness studies 

ILADS: Basics of Lyme  

Fallon et, al. A randomized, placebo-controlled trial of repeated IV antibiotic therapy for Lyme encephalopathy

IDSA Guidelines: most conservative

• Insufficient evidence to recognize chronic/persistent lyme disease

• Emphasis on consideration of alternative causes

• Avoid antibiotic treatment due to negative side effects

• Research is messy: heterogeneity of patients and symptoms --> can't make recommendations

• doxy x 10 days, amox/cefuorxime x 14 d

ILADS Guidelines

• recognize persistent lyme symptoms

• recommend antibiotics based on symptoms and impairment

• trial of various combination of antibiotics for persistent sx

• Research is heterogenous because patients are heterogenous and treatment should be individualized, research is inadequate 

• Abx x 4-6 wks

NICE Guidelines

• Do not routinely offer more than 2 courses of antibiotics

• Consider alternative diagnoses, co/other infections

• Provide social and supportive care for patients with slow recovery

• Abx x 21 days

Post-treatment Lyme Disease as a Model for Persistent Symptoms in Lyme Disease 

PTLDS herb protocols Excel Sheet 

Horowitz Lyme Disease Questionnaire (likelihood of lyme/tick borne disease based on sx)  

https://www.ccfmed.com/lyme-disease 

https://www.ccfmed.com/blog/manage-inflammation-in-lyme-disease 

https://www.rupahealth.com/post/functional-medicine-approach-to-treatment-of-chronic-fatigue-syndrome-symptoms 

Microhematuria: AUA/SUFU Guideline

AFP: Assessment of Asymptomatic Microscopic Hematuria in Adults  

Cervical radiculopathy vs. polyneuropathy vs. myelopathy: Differentiating diagnoses based on clinical presentation  

 ME/CFS guidelines 

• should routinely have orthostatics and pulse pressure (difference between SBP - DBP) to eval for NMH

• Meds that can be trialed: midodrine, fludrocortisone, pyridostigamine, valacyclovir, adderall, LDN or enlyte, desmopressin 

• cardiopulmonary parameters abnl, orthostatic intolerance, Intrinsic disruption of sleep: PSG is non-diagnostic, neurocog sx w/moderate severity, PEM (post exertional malaise- can be cognitive, physical

Images below: ME/CFS and microbiome, viral infections, neuroinflammation through dysbiosis, vagus nerve inflammation, and communication with dorsal brainstem which contain nuclei that control the sickness behavior response, pain, nausea, and autonomic signaling

Goals of treatment options: immunosuppression, address root cause 

https://www.lifeextension.com/protocols/immune-connective-joint/chronic-fatigue#:~:text=The%20illness%20follows%20a%20variable,L%2Dcarnitine%2C%20and%20magnesium. 

ACOG: Methods of estimating due date  

5 Minute Tutorial Videos 

Preterm birth

-ask about RFs in current pregnancy

-make sure treat BV if clinically meets diagnostic criteria (earlier in preg w/stronger assoc with PTB)

-cervical length 

• https://www.endocrinepractice.org/article/S1530-891X(25)00977-2/fulltext 

Johns Hopkins: Osteoporosis Review 

Osteoporosis- Wisconsin Bone Health

• start with pretest questions, confidence levels

• objectives --> activity/patient cases--> summarize 

• include farrell data in talk (panel management?)

• interpret DEXA reports and tailor treatments accordingly 

• Assess risk of fracture 

• med mngt, when to do "holiday" with bisphosphonates

• when to refer to endo 

• attentiveness to discussion points for patients

• falls prevention, lifestyle recommendations , vit D and calcium recommendations

Powerpoint slides: Pediatric Joint Pain Evaluation 

2014 ACC/AHA Guideline on Perioperative Evaluation Noncardiac Surgery 

2014 ESC/ESA Guidelines on non-cardiac surgery  

Periprocedural Management of Anticoagulation 

JAMA State of the Art Review: Management of Acute and Recurrent Pericarditis

• Table 1, Figure 1, Table 2, Central Illustration, Figure 3

ANXIETY: Pharmacotherapy of Anxiety Disorders: Current and Emerging Treatment Options 

Trauma: 

JAMA: Clinical Decision Rule (BCDR) to Predict Abuse in Children < 4 y/o 

AFP: What to order after POS ANA 

https://neuromuscular.wustl.edu/ 

NIDA Quick Screen: https://archives.drugabuse.gov/nmassist/ 

AUDIT-C for Etoh use: https://www.mdcalc.com/audit-c-alcohol-use 

CRAFFT screening tool for adolescents (12-17 y/o): https://njaap.org/wp-content/uploads/2018/03/COMBINED-CRAFFT-2.1-Self-Admin_Clinician-Interview_Risk-Assess-Guide.pdf 

NIDA Quick Screen for SUD 

Laboratory Diagnosis of Thalassemia 

Tri-phasic Model of Trauma Treatment

• Phase 1: work to maintain safety!!, they can control their safety (engaging in abusive relationship, self harming/cutting, restrictive eating, this can take a long time (or lifetime) for severe dissociative symptoms

  • • DBT, CBT, ACT, Seeking Safety (skills training: build stress tolerance, life functioning

• Phase 2: Confronting, working through, and integrating traumatic memories

  • • plan which memories, when, and how

    • ensure to maintain safety 

    • encourage permissive amnesia between sessions

    • not every appt is processing new traumatic memories

    • over time material is transformed from traumatic memory to narrative memory 

    • Integration: bringing together aspects of the traumatic experience that have been dissociated--> help patient relaize trauma is in the past (not happening hear and now)

Meds

• naltrexone: can help minimize reinforcement of self harm behaviors

• prazosin/doxazosin: can help with nightmares 

• Careful with meds that can make symptoms worse: benzo (maybe required), topamax, stimulants, cannabis (can make it harder to get better form dissociation) 

Lancet Review Article: Hyperthyroidism 

AFP: Thyroid Disease in Pregnancy including postpartum thyroiditis 

University of Wisconsin Guidelines PDF 

Vaccines Special Situations

• TABLE 9-1. Vaccine recommendations for persons from outside the United States who have no (or questionable) vaccination records

Apps: 

• SHOTS

• PneumoRecs (from CDC): tool to help determine which pnemococcal vaccines children and adults need

  • plug in patient's info (DOB, previous vaccines, medical condtions) and get recs 

Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9th Ed.

Author: Judith E. Tintinalli et al. Year

E-book available through CU Health Sciences Library

R2C2 Model for Coaching  

Coproduction with learners 

Family Doctor Spring 2023: MEDICAL EDUCATION 

• integrating medical students into outpatient primary care practices 

• medical podcasts for primary care doctors

• Effective Feedback