Acute Complaints

Question 1

Peripheral Edema Ddx:

Answer 1

Bilateral edema:

CHF (dyspnea, rales, or JVD) would necessitate a chest x-ray to rule in the diagnosis, followed by an echocardiogram.

Liver Failure: Ascities; Dx: Liver function studies are needed. If these are absent, the clinician should check an urinalysis. If the sediment is abnormal, nephritic syndrome or acute tubular necrosis (ATN) is the likely diagnosis.

Medications:Antihypertensives (ACE), such ascalcium channel blockersare well known to cause this, butdirect vasodilators,β-blockers,centrally acting agents, and antisympathetics also can cause edema. Of the diabetic medications, insulin sensitizers, such as rosiglitazone often cause edema. Hormones, corticosteroids, andNSAIDs also cause problems.

Unilateral Edema:

Angioedema

Hereditary:

Dx: C4 level and C1 esterase

Drug-induced:

Urticaria

Chronic spontaneous Hx:

Question 2

Pretibial myxedema

Answer 2

Localized nonpitting thickening and induration of the skin over the lower legs, pretibial area, or the dorsum of the feet in patients with Graves’ disease.

Question 3

Fatigue

Answer 3

Fatigue lasting 1 month or less is likely the result of a physical cause (infections, endocrine imbalances, cardiovascular disease, anemia, or medications)

Physiologic fatigue is because of overwork, lack of sleep, or a defined physical stressor like pregnancy.

Fatigue lasting 3 months or more is more likely to be related to psychologic factors (depression, anxiety, stress, or adjustment reactions).

Chronic fatigue syndrome and chronic idiopathic fatigue are distinct diagnoses that both require more than 6 months of symptoms.

Dx: The initial laboratory workup for an uncertain diagnosis of fatigue included a CBC, sedimentation rate, urinalysis, chemistry panel, thyroid testing, pregnancy testing (for women of childbearing age), and age/gender appropriate cancer screening. +PSA. Chest x-ray, ECG, HIV test, and a drug screen would be appropriate if the initial screen is negative.

Question 4

Nausea

Answer 4

The symptoms and characteristics of nausea and vomiting can often be clues to the etiology. When nausea happens

• *before eating** in the morning, likely etiologies include pregnancy, uremia, alcohol withdrawal, and increased intracranial pressure (meningitis or space-occupying
  lesions) .

Gastroparesis and pancreatitis are usually associated with nausea after eating.

Vestibular disorders cause nausea without any clear association with meals or time of day.