Getting PrEP'd
Population who CDC recommends discussion of PrEP
All sexually active adolescent and adult patients
Percentage of pregnant patients who experience a spontaneous remission in the intensity and frequency of migraine headaches by the second trimester
60- 80%
The percentage of reproductive aged people who experience PMS
20-30%
90% experience at least one premenstrual symptom
Global Period for Major Surgery
90 days
(cannot bill for related office visits/ consultations)
Ways (3) to make your practice more welcoming
- Increasing provider knowledge and comfort with providing care
- train front desk staff on the correct usage of names/ pronous
- ask all patients for pronouns
- ensure that one restroom is gender neutral
- provide checkboxes for all gender identity and sexual orientations as well as open area for write in responses
- documenting name/ pronouns in EMR and changing them in the records if applicable. (easy to do in Epic!)
Recommendations for individuals to prescribe PrEP
- HIV + partner w/ unk or detectable VL
- 1 or more partner w/ unknown HIV status and not consistent condom use
- Bacterial STI in last 6 months (GC/ syphilis if MSW OR WSM)
Non-pharmacologic methods to decrease headaches (3)
- avoidance of triggers
- relaxation techniques
- adequate sleep
- stress management
- adequate hydration
- cognitive behavioral therapy
Recommendations for diagnosis of PMS
Recommend symptom diary for at least 2 months. There is a validated questionnaire available if desired. (PMS/ PMDD limited to luteal phase and first few days of cycle)
If inconclusive, can trial 3-month trial of GnRH agonist to suppress hormone function to confirm
ICD-10 code: RLQ pain, nausea, fevers w/ LMP 6 wks ago
RLQ pain (R10.31)
- DO NOT code for r/o diagnoses (appy, ectopic)
Increased risk for unsatisfactory pap in transgender patient on long term testosterone
10x increased risk, increased risk of more than one abnormal pap
Labs to order prior to starting PrEP
HIV test, HBV, renal function, lipid panel
Medications for prevention of headaches
Specific meds that are recommended for first line:
Amlodipine, cyproheptadine, diphenhydramine, nifedipine, verapamil
Medications Recommended for treatment of PMDD
- SSRIs (sertraline, paroxetine, fluoxetine are FDA approved): can be used continuously or at start of luteal phase to start of menses
- COCPs. Yaz FDA approved (not as good for mood symptoms)
- GnRH agonists
(progesterone/ progestins, IUD not supported)
Definition of a 22 modifier
Procedure requiring significantly more work than typical.
What type of screening should a person who has undergone affirming mastectomy receive for chest screening?
American College of Radiologists recommends routine screening.
Usually this is with a routine chest exam and ultrasound if there are abnormal findings.
WPATH recommends discussion of family history of breast cancer prior to surgery with possible genetic counseling referral
Recommended Oral PrEP Medications
Truvada 200mg/ 300mg daily (HA, ab pain, wt loss)
(emtricitabine and tenofovir disoproxil fumarate)
Additional treatment (other than Tylenol) recommended for headaches in pregnancy
metoclopramide 10 mg (intravenous or enteral), alone or in combination with diphenhydramine 25 mg (intravenous or enteral)
Diagnostic criteria for PMDD
5 symptoms must be present:
- 1 or more: (marked lability, irritability/ anger, depressed mood, anxiety/ tension)
- 1 or more: (decreased interest in activities, difficulty in concentration, lethargy, marked appetite changes, hyper/insomnia, overwhelmed/ out of control, physical symptoms)
- Must has significant distress or interference in daily life
- Not an exacerbation of another disorder
Payment for multiple surgical procedures
100% for 1st procedure
50% for each procedure afterwards
*Important to know primary*
Percentage of patients who are denied insurance coverage for gender affirming surgical procedures
- 55%
- 25% were denied coverage for hormonal treatment
Clinical Follow up for PrEP
q3m: HIV, +/- STI testing, Hep B, +/- HepC, assess med adherence
q6m: renal function, assess desire to continue
q12m: lipid panel, weight assessment, and all above
Features of a secondary headache that warrant prompt evaluation (3)
'thunderclap” headache, rapid onset, high blood pressure, visual changes, neurologic deficits or altered consciousness, vomiting, and fever
Non-prescription treatment for PMDD
CBT (same efficacy as fluoxetine at 6m and more sustained improvement)
Exercise
Calcium supplementation
Acupuncture, NSAIDS
Difference between assistant surgeon and co-surgeon?
Assistant is in same specialty, co-surgeon is in different specialty
Absolute contraindications to testosterone therapy
- current pregnancy
- unstable coronary artery disease -
- polycythemia