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AAFP: Review September 2008, Emory Family Medicine . Susan Schayes M.D. Assistant Professor-CT Family Medicine, Emory University School of Medicine. Learning objectives. Review Sept 1, Sept 15 AAFP highlights Health Maintenance for Post Menopausal women Shoulder Osteoarthritis

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aafp review september 2008 emory family medicine

AAFP: Review September 2008, Emory Family Medicine

Susan Schayes M.D.

Assistant Professor-CT

Family Medicine, Emory University School of Medicine

learning objectives
Learning objectives
  • Review Sept 1, Sept 15 AAFP highlights
  • Health Maintenance for Post Menopausal women
  • Shoulder Osteoarthritis
  • Aortic Stenosis
  • Mastitis in Breastfeeding Women
health maintenace for postmenopausal women
Health Maintenace for Postmenopausal Women
  • Symptom management
  • Preventive Care Recommendations


-Nutrition and Lifestyle

-CHD and medical issues

-Cancer Prevention


health maintenace for postmenopausal women1
Health Maintenace forPostmenopausal Women
  • Symptom Management

- Oral HRT therapy is highly effective in

relieving hot flashes and night sweats.

-Post menopausal vaginal symptoms can be treated with topical estrogen therapy

  • Use of HRT has declined since WHI

-low dose, shortest time, do not use

for prevention of chronic conditions

such as CVA, OP, Dementia

  • USPTF- screen women older than 65 year
  • AAFP- screen women older than 65 or starting at 60 with women at high risk of

osteoporotic fractures

nutrition and lifestyle
Nutrition and Lifestyle
  • Calcium and Vit D
  • Obesity/Physical Activity

USPT: screen/counsel/intervene to

all adults to achieve weight loss

USPT: evidence is insufficient to

recommend for or against

counseling for exercise

  • Tobacco Use

Screen for tobacco and provide


chd and medical conditions
CHD and medical conditions
  • ASA
  • Blood pressure
  • Cholesterol
  • Diabetes
cancer prevention
Cancer Prevention
  • Breast Cancer
  • USPT: 1-2 years over 40, over 70 if good life expectancy
  • Cervical Cancer
  • USPT: every 3 yrs in women

who have been sexually active

Stop at age 65

  • Colorectal Cancer

USPT: Screen adults over age 50,discontinue?

  • Influenza
  • Pneumococcal vaccine
  • TdaP
  • Zoster vaccine
shoulder osteoarthritis oa
Shoulder Osteoarthritis (OA)
  • Leads to pain and stiffness
  • Loss of articular cartilage and formation of osteophytes
  • Subchrondral bone remodels, loss

sphericity and congruity, joint

  • Loss of shoulder rotation
risk factors for shoulder oa
Risk factors for Shoulder OA:
  • Genetics
  • Joint instability/dislocations
  • Periarticular muscle


  • Sports injury
  • Occupational factors
  • Obesity
  • Age
classification of oa
Classification of OA
  • Primary (idiopathic) unidentified causes
  • Secondary precipitating factors
shoulder osteoarthritis oa secondary causes
Shoulder Osteoarthritis (OA)secondary causes
  • Atraumatic osteonecrosis

-alcohol, corticosteroid, cytotoxic drugs

  • Gaucher’s disease, lipid metabolism disorders
  • Obesity, radiation, sickle cell
  • Postinflammatory

-crystal arthropathies, infection,

  • Surgery

-prior arthroplasty, hardware,

over tightening anterior capsule

shoulder pathologies history
Shoulder pathologiesHistory
  • Morning stiffness improved

with activity : RA

  • Night time shoulder pain:

Rotator cuff problem

  • Pain or clunking with overhead
  • movement- Labral disorder
shoulder pathologies physical
Shoulder pathologiesPhysical
  • Painful crepitus
  • Joint enlargement

and swelling

  • Progressive

functional limitations

non pharmacologic therapy
Non-pharmacologic therapy
  • Activity modification
  • Rest
  • Ice
  • Physical therapy
  • Strength training
  • Aerobic exercise
acetaminophen acet
Acetaminophen (ACET)
  • First line pharmacotherapy
  • No gastric irritation
  • Inexpensive
  • Use 3-4 grams daily
  • NSAIDs both analgesic and anti-inflammatory
  • Non-selective NSAIDs inhibit both COX-1 and COX-2 enzymes – Ibuprofen, diclofenac, naproxen
  • The COX-2 drugs, celecoxib , selectively inhibit o
  • SE- GI, PUD, renal failure
shoulder injection
Shoulder injection
  • Advanced Shoulder OA
  • Inject with triamcinolone acetonide 40 mg-80 mg with lidocaine 1% every 3-4 months
shoulder surgery
Arthroscopic debridement

Capsular release

Corrective osteotomies

Interpositional arthroplasty

Shoulder arthroplasty

Severe OA

Pain/ Loss of function unresponsive to conservative therapy

Shoulder Surgery
shoulder surgery1
Shoulder Surgery
  • Post op rehab- 6 weeks of stretching- flexibility and ROM
  • Strengthening- 2 weeks
aortic stenosis
Aortic Stenosis
  • Affects 3% of people over 65
  • Survival is 2-3 years is symptomatic patients
  • Become symptomatic when

LVH, and atrial augmentation

of preload can not compensate for afterload

  • Heart failure, angina, syncopy
aortic stenosis1
Aortic Stenosis
  • Prolonged latent phase, become symptomatic as it worsens
  • Become symptomatic when cardiac output can not increase with exercise, and leads to hypotension and syncopy
aortic stenosis2
Aortic Stenosis
  • Normal valve area 3-4 cm in area
  • As it decreases to 1 cm- size of the head of a golf tee- symptomatic
  • Symptomatic = Surgery
  • Asymptomatic= Watch with serial echos
aortic stenosis3
Aortic Stenosis
  • Classic symptom: Dyspnea
  • Classic harsh crescendo- decrescendo systolic murmur, heart loudest at the second right intercostal space, and radiates to the carotids
aortic stenosis4
Aortic Stenosis



aortic stenosis5
Aortic Stenosis
  • ACC/AHA recommend echo in asymptomatic patients with grade 3/6 or louder murmur
  • Echo initial recommended test
aortic stenosis6
Aortic Stenosis
  • Mortality dramatically increases in

symptomatic aortic stenosis.

  • Medical management has

not been shown to improve

mortality in symptomatic


aortic stenosis asymptomatic patients
Aortic StenosisAsymptomatic patients
  • Distinguish between asymptomatic, and activity

decreased below symptom


  • Treat their HTN
  • Sensitive to changes in:

preload, contractility,

vascular tone

aortic stenosis asymptomatic patients1
Aortic StenosisAsymptomatic patients
  • HTN: ACEI- well tolerated, improve effort tolerance, reduce dyspnea
  • Beware diuretics- reduced

LV diastolic filling, which

reduces cardiac output

  • Beware alpha-blockers too
mastitis in breast feeding women
Mastitis in Breast feeding Women
  • Diagnosed with localized, unilateral breast

tenderness and erythema, with fever, malasie,

fatigue, body aches, and headache

Treat with Amoxil/clavulinic acid,

cephalexin, clindamycin,

  • Complication is development of


mastitis in breast feeding women1
Mastitis in Breast feeding Women
  • Mastitis occurs in

10 % of breast feeding women

  • Risk can be reduces with frequent,

complete emptying of the breast

  • Risk increased by anything that

can damage/crack nipples

mastitis in breast feeding women2
Mastitis in Breast feeding Women
  • Risk increased if yeast infection- if infant has thrush- treat both mom and infant
  • Continue to breast feed with