Family Medicine Core Rotation - Acute Complaints_1 Flashcards
What feature of a history of abdominal pain would lead you toward an emergent evaluation?
the fact that the pain began suddenly
the first priority when evaluating abdominal pain is what?
to determine whether the pain is acute or chronic
RLQ abdominal pain is suspicious for what?
acute appendicitis
a gnawing sensation in the abdomen is often described with what disease?
ulcer disease
abdominal pain that worsens after eating is associated with what?
pancreatitis • gallbladder disease • reflux
what symptom added to abdominal pain that worsens after eating would prompt emergent evaluation?
hemodynamic instability
does emesis with abdominal pain by itself warrant emergent evaluation?
no
recent onset abdominal pain that starts in the midepigastric region and radiates to the back. • nausea and vomiting • what is the most likely diagnosis?
pancreatitis
location and radiation of acute appendicitis?
starts from periumbilical region before moving to right lower quadrant
location and radiation of pain in pancreatitis?
settles in midepigastric region with radiation to the back • associated with nausea and vomiting
location and radiation of gallbladder pain?
epigastric or RUQ radiating to the scapula
location and radiation of esophageal spasm pain?
referred higher in the chest
location and radiation of GERD?
midepigastric and generally does not radiate
80yo m • mild • crampy • bilateral lower quadrant pain • decreased appetite • low grade fever • most likely diagnosis?
appendicitis
how does pain perception change with age?
10-20% reduction in the perceived intensity of pain per decade after age 60
what percentage of elderly patients with appendicitis present with classic symptoms?
22%
what symptom, combined with bilateral lower quadrant abdominal pain and decreased appetite should decrease suspicion of constipation and SBO?
fever
how does IBS differ from appendicitis in the elderly?
IBS is chronic and generally not associated with fever
how does pancratitis differ from appendicitis in the elderly?
pancreatitis is associated with food intolerance but the associated pain is usually in the epigastric region
Patient stopping inspiratory effort during deep palpation of the RUQ is suggestive of what?
cholecystitis
difference between physical exam findings in hepatitis or gallstones and cholecystitis?
murphy sign present in cholecystitis, tenderness present in hepatitis and gallstones but no murphy sign
pain from renal calculi often radiates to where?
shoulder
patient complaining of gnawing abdominal pain in the center of upper abdomen associated with a sensation of hunger. has long hx of etoh abuse. darker stool over last 3 weeks. most likely cause?
H pylori infection–> PUD
second most common cause of PUD?
NSAIDs
do alcoholism and gallstones cause PUD?
no they cause pancreatitis
does gastroparesis cause PUD?
may cause dyspepsia, but is a less likely cause of PUD
what is the appropriate next step if you suspect GERD in a patient?
treat with an H2-receptor blocker, PPI, or prokinetic agents and evaluate the response
reflux can be appropriately diagnosed by what?
medical history and evaluating the response to treatment
how often does upper endoscopy fail to reveal GERD?
36-50% of patients who have been found to have GERD by pH probe
when should EGD be ordered for a patient with potential reflux?
if bleeding, weight loss, or dysphagia is present, especially in an elderly patient
endoscopy should always be performed if which certain alarm symptoms are present?
bleeding • abdominal mass • weight loss • dysphagia • vomiting, • especially if in an elderly patient
what is the gold standard for diagnosis and treatment of choledocolithiasis?
ERCP
ERCP is usually performed in the setting of which clinical picture?
acute cholecystitis with increased liver enzymes, amylase, or lipase
Ultrasound can show gallstones, but is less sensitive for which related conditions?
choledocolithiasis or complications (abscess, perforation, pancreatitis)
which imaging studies are better than U/S to detect choledocolithiasis and its complications?
CT or MRI
a negative result on which test rules out cholecystitis?
cholescintigraphy
when is ERCP a better choice than cholescintigraphy?
in the setting of elevated liver enzymes
what causes the majority of cases of pancreatitis?
gallstones
alcohol causes what percentage of cases of pancreatitis?
30%
what percentage of cases of pancreatitis are idiopathic?
10-30%
what are the less common causes of pancreatitis?
hypercalcemia • hyperlipidemia • abdominal trauma • medications • infections • instrumentation (ERCP)
what are the 5 ranson criteria for pancreatitis that suggest a poor prognosis?
- age>55 • 2. WBC>16k • 3. glucose >200 • 4. LDH>350 • 5. AST>250
which 6 ranson criteria reflect the development of complications of pancreatitis?
↓Hct>10 • ↑BUN>5 • Ca<8 • PaO2<60 • Base Deficit>4 • Fluid sequestration >6L
IBS is typified by what?
symptoms of abdominal pain or discomfort associated with disturbed defecation
what are the Rome Consensus Committee for IBS diagnostic criteria?
symptoms present in at least 12 (needn’t be consecutive) weeks of the last 12 months, and pain characterized by 2 of these 3: • 1. relieved by defecation • 2. onset associated with change in stool frequency • 3. onset is associated with a change in the form or appearance of stool
even in the presence of Rome criteria for IBS, some clinicians would be reassured by the presence of what?
normal CBC and ESR
‘dyspepsia’ refers to what?
a set of symptoms: • chronic or recurrent discomfort around the upper abdomen– • can be associated with heartburn, belching, n/v
what are the common causes of dyspepsia?
GERD • PUD
no specific etiology is found for what percentage of patients presenting with dyspepsia?
50-60%
what percentage of patients with dyspepsia have ulcer disease?
15-25%
what percentage of patients with dyspepsia have GERD?
5-15%
what are the rare causes of dyspepsia?
gastric or pancreatic cancers
what can you do when a pap smear comes back with ASCUS?
repeat test in 4-6mo and 1y • perform HPV testing on the sample • proceed to colposcopy
what does it mean when HPV comes back negative after a Pap smear with ASCUS?
patient is at low risk for cancer
what do you do next when HPV comes back negative after a pap smear with ASCUS?
repeat pap in 1 year, especially if the patient is monogamous
when the results of a pap smear are reported as ASCUS and HPV is positive, what should you do next?
proceed to colposcopy
colposcopy involves what?
cervical examination under stereoscopic magnification and biopsy of abnormal appearing areas
what is the definitive test for assessing pap smear abnormalities?
colposcopy
what is Imiquimod(Aldara)
an immune modulator that can treat genital warts
what should you do when a repeat pap after a normal pap comes back again as ASCUS and HPV testing is unavailable?
proceed to colposcopy
if after a pap smear comes back as ASCUS and HPV testing is unavailable, you do colposcopy that shows no CIN, what do you do next?
repeat pap in 1 year then resume pap smears at normal intervals
if a pap smear comes back as ASCUS on a postmenopausal woman who is not taking estrogen replacement therapy what do you do?
4 week course of vaginal estrogen cream, then repeat pap smear 1 week after course is complete
in a postmenopausal woman who isn’t on hormone replacement who has a pap result of ASCUS and then another after 4 weeks of vaginal estrogen cream, what do you do next?
colposcopy
what do you do when the results of a pap smear come back ASCUS, favoring low-grade squamous intraepithelial lesion (LSIL)?
proceed to colposcopy
what do you do when a healthy young monogamous woman on OCP gets a pap smear result of atypical glandular cells with no specification as to whether they are endocervical or endometrial in origin?
when the results of a pap smear are reported as atypical glandular cells, proceed to colposcopy
what do you do when a pap smear result is reported as atypical glandular cells or endometrial origin in the absence of abnormal vaginal bleeding??
when the results of a pap smear are reported as atypical glandular cells of endometrial origin, an endometrial biopsy is required to rule out endometrial cancer
what is the most likely cause of microcytic anemia with an increased RDW?
iron deficiency
causes of microcytic anemias include what?
iron deficiency • anemia of chronic disease • thalassemia • sideroblastic anemia
why is RDW elevated in iron deficiency anemia?
variation in RBC size
which CBC findings are associated with sideroblastic anemia?
MCV- normal, high, or low • dimorphic red cells (usually ↑RDW)
what is the RDW in thalassemia?
normal, because cells are uniformly small
cell size in aplastic anemia and chronic renal insufficiency?
generally normocytic
what is the most common cause of iron deficiency anemia in a 60yo male?
blood loss
what are the less common causes of iron deficiency anemia in a 60yo man?
poor nutrition • inadequate absorption
Iron panel findings in anemia of chronic disease?
high/normal ferritin • low TIBC
what do you suspect/order for an african american male with mild anemia with disproportionate microcytosis and normal RDW?
think thalassemia, order hemoglobin electrophoresis
which clinical features are common to all megaloblastic anemias?
anemia • pallor • weight loss • fatigue • glossitis
which symptoms are specific to B12 deficiency?
neurologic symptoms
what is the typical treatment for B12 deficiency?
parenteral B12 administration weekly for a month, with concurrent administration of folic acid, then oral supplementation once levels are established
most often, B12 deficiency is the result of what?
inadequate absorption
which groups of people might be B12 deficient from a dietary standpoint?
strict vegans or those not consuming animal products
how does alcohol intake affect B12/folate?
alcohol can affect intracellular processing of folate, but not B12
what can you do for a sickle cell disease having child to prevent future pain crises?
adequate hydration
what is the most common presentation of sickle cell anemia?
pain crisis before age 9
prophylaxis for SCD pain crisis includes what?
ensuring adequate oxygenation and hydration
what abx prophylaxis is recommended in SCD children?
daily penicillin prophylaxis until age 5
can scheduled transfusions and chronic use of analgesics prevent pain crisis in SCD children?
no
what is the most likely cause of a rashin a young man that starts as pink spots on the extremities that coalesce and become purple after a trip in the mountains?
Rocky Mountain Spotted Fever
the lesions of rocky mountain spotted fever are typically what?
red macules on peripheral extremities that become purpuric and confluent
lyme disease typically presents how?
a slowly spreading anular lesion- erythema chronicum migrans
tularemia is characterized by what?
pain and ulceration at the bite site
brown recluse spider bites most often present as what?
local pain and itching, then a hemorrhagic bulla with surrounding erythema and induration
the black widow bite is characterized by what?
a mild prick followed by pain at the bite site
how do you treat early localized lyme disease?
PO amoxicillin or doxycycline for 14-21 days
how do you treat disseminated lyme disease?
2-3 weeks of IV ceftriaxone, cefotaxime, or chloramphenicol
what abx do you give for rocky mountain spotted fever?
chloramphenicol that continues 2-3 days after the patient is afebrile
how do you treat tularemia?
streptomycin IM
what is the typical presentation and physical examination finding in head lice?
itching scalp with erythematous papules and small black bulbs at the base of hair follicles
what are the treatment options for head lice?
premethrin and lindane
what is the first choice treatment for head lice?
premethrin 1%
what is the second option preferred treatment for head lice?
premethrin 5%
what is the 3rd choice preferred treatment option for head lice?
lindane 1%
if treatment failure occurs in a case of head lice, what is the second line treatment?
0.5% malathion
what is an effect oral treatment for scabies?
PO ivermectin
pruritic erythematous papules in between the fingers, on the wrists, and around the waist is the characteristic distribution for what?
scabies
what is the cause of scabies?
Sarcoptes scabiei burrow into intertriginous areas, wrists, or where clothing is tight next to the skin
what is the characteristic distribution of chigger bites?
linear pattern over wrists, ankles, and legs
what is the characteristic distribution of bed bug bites?
bed bugs typically infest unclothed areas- the neck, hands, and face
fleas typically bite which part of the body?
lower extremities
how do insect bites typically present?
erythematous papules or vesicles and are sometimes difficult to differentiate
what are the helpful differentiators in the identification of insect bites?
location and distribution
how do flea bites occur?
in clusters and typically on the lower extremities
where do you typically see bed bug bites?
hands, face and neck
do spiders bite in clusters?
no
scabies are typically found where?
where clothing is tight against skin-belt and wrist line • where skin touches skin- between the fingers
when does the itching from lice begin?
2-3 weeks after infestation
what should you do for a cat bite that has a jagged laceration, erythema, purulent discharge, no tendon involvement?
treat with amoxicillin/clavulanic acid as an outpatient for 5 days
typical local reactions to stings (bees) include what?
swelling, erythema, and pain at and around the site of the sting
in general what happens to typical stings?
they resolve quickly and minimal analgesia is all that is necessary
what are the additional features of large local reactions to stings?
extended areas of swelling that lasts several days
what is the allergic nature of large local reactions to stings?
they are not allergic in origin and carry a minimal risk of anaphylaxis upon re-exposure
with regard to bee stings, toxic systemic reactions are associated with what?
nausea, vomiting, headache, vertigo, syncope, convulsions, fever. • pruritis, erythema, and urticaria are less common
what is the risk of anaphylaxis with subsequent stings after a systemic toxic reaction to a bee sting?
they are at risk
what is the workup for gynecomastia in a 15 year old?
if it presents at the time of puberty, history, PE and reassurance are enough if there are no abnormalities found
what is the workup for gynecomastia in a male outside of puberty?
assessment of hepatic, renal, and thyroid functions may help uncover a cause • sex hormones are only tested if progressive enlargement is noted.
what is the most common benign condition of the breast?
fibrocystic changes
how big are the lesions in fibrocystic changes of the breast?
1mm->1cm
what is the typical presentation of a breast fibroadenoma?
rubbery, smooth, well-circumscribed, nontender, freely mobile
why are mammograms not necessary in young women?
mammograms are not necessary in women <30yo because they are less sensitive in younger women with denser breast tissue
mastitis generally occurs when?
nursing
mastitis is characterized by what?
inflammation, edema, and erythema in areas of the breast
what percentage of breast cancers are mammographically silent?
15%, so palpable mass deserves workup
what is the workup for a mammographically silent breast mass?
ultrasound and possible biopsy
when should biopsy follow breast ultrasound and aspiration of cystic mass?
if mass is palpable after aspiration, if the fluid is bloody, if the mass reappears within 1 month
when is genetic testing for breast cancer of value?
no value in workup of breast mass, but can be considered with family history of breast cancer by experienced genetic counselor
what is the protocol for mastitis in a nursing mother?
continue nursing and start on an antibiotic that covers streptococcal and staphylococcal infections
what recommendations can be made for women with fibrocystic breast changes to improve their symptoms?
reducing caffeine and methylxanthines, • using evening primrose oil
do you recommend heat or ice for mastitis relief?
applying heat may help symptoms, but ice will not have the desired effect
what characteristic of nipple discharge would be most suspicious for breast cancer?
spontaneous unilateral discharge
what types of nipple discharge deserve a workup?
bloody • serous • serosanguinous • watery
what is BI-RADS?
breast imaging reporting and data system
what is BI-RADS 0?
test was incomplete
what do BI-RADS 1 and 2 mean?
mammogram is benign and routine screening can be conducted at normal intervals
what does BI-RADS 3 mean?
the lesion is probably benign, but that diagnostic mammogram should be performed in 3 months
what do BI-RADS 4 and 5 mean?
suspicious and highly suggestive of cancer and that tissue diagnosis is needed
hand cellulitis following a cat bite puncture wound is most likely caused by infection with which organism?
Pasteurella multocida
most skin infections are due to which pathogens?
Strep pyogenes • Staph aureus
which organism can lead to gangrene and is associated with crepitus on physical exam for cellulitis?
Clostridium Perfringens
H. influenzae can infect the skin of which population?
younger children
high school wrestler comes in with pruritic erythematous patch with central clearing. what’s the cause?
tinea corporis
how can tinea infections be spread?
close person to person contact
what confirms the diagnosis of tinea?
skin scraping and demonstration of hyphae under microscope after KOH prep
where does tinea cruris occur on the body?
in the groin
which factor included in a history of chest pain decreases the likelihood of cardiac etiology?
pain is worse with inspiration, • also sharp/stabbing pain, positional chest pain
what is the likelihood ratio of pain radiating to the left arm being associated with acute MI?
2.3
what is the likelihood ratio of chest pain radiating to the right arm being associated with acute MI?
2.9
what is the likelihood ratio of chest pain associated with nausea or vomiting being associated with acute MI?
1.9
what is the likelihood ratio of chest pain associated with diaphoresis being associated with acute MI?
2
what is the likelihood ratio of pleuritic chest pain being associated with acute MI?
0.2
unless a competing diagnosis can be confirm, what test is warranted in the initial evaluation of most patients with acute chest pain?
ECG
which ECG feature, if present, would most markedly increase the likelihood of an acute MI?
any ST segment elevation greater than or equal to 1mm
what is the lieklihood ratio that any ST segment elevation is associated with acute MI?
11.2
what is the likelihood ratio that any ST segment depression is associated with an acute MI?
3.2
what is the likelihood that any Q-wave is associated with an acute MI?
3.9
what is the likelihood ratio that any conduction defect is associated with an acute MI?
2.7
what is the likelihood that a new conduction defect is associated with an acute MI?
6.3
what is the ECG finding that is the strongest predictor of acute MI?
ST-segment elevation
what percentage of patients with acute coronary syndrome can have a normal ECG?
20%
what do you need to get for a patient with no acute changes, but ECG findings of LVH are present?
treadmill stress echo
why get stress test with imaging on a 43 yo female instead of a treadmill stress ECG?
for women in her age group, stress ECG are often false positive
a crescendo-decrescendo systolic murmur with carotid pulsus parvus et tardus are very suggestive what?
aortic stenosis
angina frequently occurs in aortic stenosis due to what?
underperfusion of the endocardium
what is the presentation of syncope associated with aortic stenosis?
typically exertional and is a late finding
what cardiac problems, other than aortic stenosis, cause syncope associated with chest pain?
aortic dissection • PE • LVH • MVP
what is the most commonly used noninvasive procedure for evaluating whether chest pain is due to angina?
exercise ECG
when weighing stress testing options, what is the recommended initial procedure in low risk patients without baseline ECG abnormalities? why?
exercise ECG because of it’s low cost and convenience
myocardial stress imaging (scintigraphy or echocardiography) is indicated when?
- if the resting ECG makes an exercise ECG hard to interpret, • 2. for confirmation of the results of the exercise ECG, • 3. to localize the region of ischemia, • 4. to distinguish ischemic from infarcted myocardium, • 5. to assess the completeness of revascularization following an intervention
the electron beam CT can quantify what?
coronary artery calcification
is electron beam CT helpful to evaluate agnina?
no
constipation is generally defined as what?
infrequent bowel movements of straining to achieve a bowel movement
when is a laboratory evaluation for constipation necessary?
- if alarm symptoms are present • 2. if a specific medical disorder is likely given history and physical • 3. if the person doesn’t respond to initial treatment
what are the alarm symptoms that should prompt laboratory evaluation for constipation?
- hematochezia • 2. fam hx colon CA • 3. fam hx IBD • 4. positive FOBT • 5. weight loss • 6. new onset constipation in pt >50yo
what is the best first line treatment for a young healthy female with chronic constipation?
psyllium (metamucil)
chronic use of milk of magnesia can lead to what?
hypermagnesemia
why not give bisacodyl long term for chronic constipation?
stimulant laxatives work well in the short term, but research is not available to support their routine use for the treatment of chronic constipation
what is the treatment of choice for impaction?
enemas
can you use enemas for chronic constipation?
no
what is the use of lubiprostone?
it is beneficial in the treatment of adults with chronic constipation, but not as a first line
for whom should lubiprostone be reserved?
those refractory to other treatments for chronic constipation
what are the most common causes of chronic cough?
asthma • postnasal drainage • smoking • GERD
If chronic cough is caused by asthma, what will it likely respond to?
a bronchodilator
If chronic cough is caused by pertussis, what will it likely respond to?
azithromycin
which associated historical findings suggest that a chronic cough is due to GERD?
sore throat • worse when lying down • worse with alcohol or caffeine
side effect of which medication is likely to cause chronic cough?
ACE inhibitors
what is the differential diagnosis for acute cough?
asthma exacerbation • acute bronchitis • aspiration • exposure to irritants (cigarette smoke, pollutants) • allergic rhinitis • uncomplicated pneumonia • sinusitis with postnasal drip • viral upper respiratory infection
what is the most common cause of acute cough?
viral URI
what is the most frequent illness in humans?
viral URI, with a prevalence of 35%
what are the criteria for chronic bronchitis?
productive cough for at least 3 months of the past 2 years
what is the most common cause of chronic cough in smokers?
chronic bronchitis
what is the most common cause of chronic cough in nonsmokers?
postnasal drainage
how often do lung cancers present solely with cough?
rarely. • typically associated with hemoptysis and weight loss
what is the best course of treatment for a patient with a cough persisting 4 weeks after initial treatment for acute bronchitis?
oral steroid taper
what are the CDC guidelines for use of antibiotics in acute bronchitis?
abx are not indicated for uncomplicated acute bronchitis, regardless of the duration of the cough
which patients should get antibiotics for acute bronchitis?
- patients with significant COPD and CHF • 2. those who are very ill appearing • 3. the elderly
what is a likely cause of persistent cough 4 weeks after uncomplicated acute bronchitis?
hyperresponsive airways, AKA postbronchitic cough
what is the best treatment for a postbronchitic cough?
inhaled steroid or oral steroid taper
what is the recommended treatment for pertussis?
5 day course of azithromycin or 14 day course of erythromycin
antibiotics do not alter the course of pertussis unless what?
they are initiated early in the illness
why should you give antibiotics in later pertussis infection?
they prevent transmission and decrease the need for respiratory isolation from 4 weeks to 1 week
are amoxicillin/clavulanate effective against pertussis?
no
viral infections account for what percentage of acute infectious diarrhea?
70-80%
what is the most frequent cause of acute infectious diarrhea?
rotavirus
what are the second most common viruses that cause acute infectious diarrhea?
enteric adenoviruses
when does rotavirus occur?
in the winter months and most cases occur between the ages of 3mo and 2 years
how do you acquire norwalk virus and get acute infectious diarrhea?
contaminated water, salads, or shellfish
most acute diarrhea occurs when?
after ingestion of contaminated food or water, or direct person to person contact
acute diarrhea is defined as what?
an increased number or decreased consistency of stool lasting 14 days or less
giardiasis is more common in which children?
children in daycare centers
acute infectious diarrhea caused by Salmonella is generally due to what?
raw or undercooked meat
what is the most common cause of traveler’s diarrhea?
enterotoxigenic E coli
what % of patients that get traveler’s diarrhe have to alter their plans due to symptoms?
40%
what % of patients that get traveler’s diarrhea will be bed bound for at least 1 day?
20%
what % of patients that get traveler’s diarrhea will require hospitalization?
1%
what is the antibiotic of choice for traveler’s diarrhea?
fluoroquinolone
what are the acceptable alternatives to a fluoroquinolone in the treatment of traveler’s diarrhea?
trimethoprim/sulfamethoxazole • azithromycin
for acute viral diarrhea, adults should be encouraged to eat what?
potatoes • rice • wheat • noodles • crackers • bananas • yogurt • boiled vegetables • soup
what foods should adults with acute viral diarrhea avoid?
dairy products • alcohol • caffeine
when should a patient with acute viral diarrhea drink oral rehydration salts?
when vomiting is a problem
is fasting indicated in acute viral diarrhea?
no
what effect can fruit juices have on acute viral diarrhea?
exacerbation of diarrhea
what is vertigo?
a rotational sensation where the room spins around the patient
what is orthostasis?
light-headedness upon rising, common with orthostatic hypotension
what is presyncope?
feeling of impending faint
what is disequilibrium?
a senstation of unsteadiness, or a loss of balance “in the feet”
light-headedness is often vaguely described as what?
a ‘floating’ sensation
acoustic neuroma typically presents with what?
constant and slowly progressive unilateral tinnitus and hearing loss followed by vertigo, facial weakness, ataxia with tumor growth
vestibular neuronitis presents with what?
an acute onset of severe vertigo lasting several days, with symptoms improving over several weeks
benign positional vertigo typically only involves symptoms in what situation?
with position changes only
Meniere disease presents with what?
discrete attacks of vertigo lasting for several hours, associated with nausea and vomiting, hearing loss, and tinnitus
how would a cerebellar tumor typically present?
dysequilibrium as opposed to tinnitus
the dix-hallpike maneuver is often useful to distinguish what?
central from peripheral causes of vertigo
with a peripheral cause of vertigo, during dix-hallpike, what is the finding?
3-10 seconds, with severe symptoms, and fixed nystagmus–> lessening of symptoms with repetition of maneuver
with a central cause of vertigo what is the dix-hallpike finding?
no latency to onset of symptoms, no lessening of symptoms with repetition of maneuver, direction of nystagmus changes, symptoms are of mild intensity
what is a central cause of vertigo?
stroke
what are 4 peripheral causes of vertigo?
vestibular neuronitis • benign positional vertigo • meinere disease • acoustic neuroma
what is a first line treatment for symptomatic relief of peripheral vertigo?
antihistamines
how do antihistamines provide symptomatic relief of vertigo?
they suppress the vestibular end organ receptors and inhibit activation of the vagal response
what are the commonly recommended choices for treatment of peripheral vertigo?
meclizine (antivert) 25mg po q4-6h • diphenhydramine (benadryl) 50mg po q4-6h
when do you use antiemetics to treat peripheral vertigo?
when nausea or vomiting are a problem
can you use benzodiazepines to treat peripheral vertigo?
they can provide symptom reduction, but are usually second line agents
are antibiotics and NSAIDs useful in the treatment of peripheral vertigo?
no
those at risk for obstructive lung disease include who?
- pediatric patients (asthma, bronchitis, bronchiolitis) • 2. adults with asthma • 3. adults with chronic cigarette smoking
dyspnea due to restrictive lung disease is more likely with which cases?
- occupational exposures (farmers, cotton dust, grain dust, hay mold) • 2. severe scoliosis • 3. morbidly obese • 4. pregnancy
what are the signs and symptoms of CHF?
- abnormal heart sounds (murmur or additional heart sound) • 2. cardiomegaly • 3. JVD • 4. basilar rales • 5. dependent edema
what do you give an elderly man with SOB, orthopnea, DOE, basilar crackles, large apical impulse, JVD?
diuretics
what is the most likely diagnosis in a 3 yo boy with recurrent SOB, nasal flaring, sternal retractions with accessory muscle use, bilateral expiratory wheezes?
asthma
asthma in children is characterized by what?
recurrent episodes of wheezing
how do you differentiate between asthma and bronchiolitis or pneumonia in a child?
all three cause wheezing but typically only asthma causes recurrent wheezing
B-type natriuretic peptide evaluates for the presence of what?
CHF
how do you interpret a B-type natriuretic peptide level <80?
high (99%) negative predictive value to rule out CHF
how do you interpret the results of a D dimer ordered on an obese woman with SOB and tachycardia?
if it is low, reassure the patient because a low D dimer rules out, if elevated, then order confirmatory test- spiral CT, VQ scan, or pulmonary angio
what do you give a terminal cancer patient for shortness of breath?
opioids
what is the most likely diagnosis in a 23 yo female with 2 day hx of dysuria with frequency, back pain, pink discoloration of urine?
acute bacterial cystitis
what are the 4 factors that correlate significantly with a diagnosis of acute bacterial cystitis?
frequency • hematuria • dysuria • back pain
what 4 factors decrease the likelihood of UTI?
absent dysuria • absent back pain • history of vaginal discharge • history of vaginal irritation
how do you differentiate acute bacterial cystitis from pyelonephritis?
pyelonephritis is often associated with fever
how do differentiate interstitial cystitis from acute bacterial cystitis?
interstitial cystitis tends to be more chronic in nature and is generally not associated with back pain
how do you differentiate vulvovaginitis from acute bacterial cystitis?
vulvovaginitis is a common cause of dysuria, but is associated with vaginal irritation or discharge
when is urine culture indicated?
when acute bacterial cystitis is suspected, but the urinalysis leaves the diagnosis in question
what is an acceptable prophylactic measure for a young woman with recurrent UTI that has failed voiding after intercourse, d/c diaphragm, and acidification of urine with vitamin C?
single dose antibiotic therapy after intercourse
if post coital antibiotics cannot prevent frequent UTI what is the next step?
daily single dose antibiotic prophylaxis for 3-6 months, or 1-2 years if that fails
what do you do for a 36 yo female with recurrent UTI that resolves with abx, but is continuously negative on urine culture?
order cystoscopy to diagnose interstitial cystitis
what is a common cause of dysuria without pyuria in a postmenopausal woman?
atrophy
what is a common cause of recurrent dysuria without pyuria in a young female?
bladder irritants- caffeine and acidic foods
what should you suspect if you see recurrent dysuria without pyuria with associated hematuria?
interstitial cystitis
what findings on cystoscopy suggest interstitial cystitis?
presence of ulcerations and fissures in the bladder mucosa and absence of bladder tumors
in interstitial cystitis, urodynamic studies often demonstrate what?
small bladder capacity, with urge to void with as little as 150 mL of fluid in the bladder
when is treatment for asymptomatic bacteriuria indicated?
a pregnant woman
acute prostatitis is seen most commonly in who?
30-50yo men
symptoms of acute prostatitis include what?
frequency, urgency, and back pain in an acutely ill man with pyuria
DRE of a man with acute prostatitis reveals what?
boggy, tender, and warm prostate
what should you do for a young woman complaining of a left sided earache with deep pain that worsens with eating and tenderness and crepitus of the left TMJ?
treat with NSAIDs
what is a common cause of referred otalgia?
temperomandibular joint dysfunction
what are the first line therapies for TMJ dysfunction?
- nsaids • 2. heat • 3. mechanical soft diet • 4. referral to a dentist if there is no improvement in 3-4 weeks
is antibiotic therapy indicated in TMJ dysfunction?
no
what is a cause of referred otalgia in which ESR would be elevated?
temporal arteritis
what physical exam findings are sufficient on their own to diagnose acute otitis media in a 9 mo?
- opaque TM • 2. bulging TM • 3. impaired TM mobility • 4. purulent discharge in the ear canal
what TM finding is insufficient to diagnose acute otitis media in a 9mo?
erythematous TM
irritable baby with 100F Tm, clear runny nose and cough, what is the likely Dx?
acute otitis media
what can cause erythematous TM in an irritable baby?
increased intravascular pressure associated with crying
what is the positive predictive value for acute otitis media when opacity, bulging, and decreased mobility of the TM are all present?
90%
how should you interpret purulent discharge in the ear canal on PE?
it may indicate a TM perforation, and in the face of an otherwise normal canal is more indicative of acute otitis media than otitis externa
how long does TM effusion from otitis media take to resolve?
up to 3 months
are antibiotics indicated for persistent post otitis media TM effusion in the absence of acute otitis media?
no
what do you do for a persistent TM effusion lasting >3mo after acute otitis media?
refer to otolaryngologist
what is the role of antihistamines in the treatment of persistent TM effusion after acute otitis media?
have never been documented to help effusions, but may be symptomatically helpful
what is the first line antibiotic therapy for acute otitis media in most cases?
amoxicillin
what is the first line antibiotic therapy for acute otitis media in a child with severe illness (moderate to severe otalgia with fever >102F)?
high dose amoxacillin-clavulanate • (90mg/kg/d in 2 divided doses)
what is the role of azithromycin in the treatment of acute otitis media?
it is often used as a first line choice in 1, 3, or 5 day doses, but it should be reserved as a second line therapy
fundamental to the treatment of external otitis is what?
protection from additional moisture and avoidance of further mechanical injury from scratching
what is a very effective treatment for external otitis?
otic drops containing antibiotics and corticosteroids
what is the role of oral antibiotics and steroids in external otitis?
reserved for recalcitrant cases
is external otitis generally localized or systemic?
generally localized, demonstrating good response to local therapy
what should you do for any case of persistent otitis externa in an immunocompromised or diabetic individual?
refer for specialty evaluation
which drugs are known to cause peripheral edema as a side effect?
- Ca channel blockers • 2. β blockers • 3. centrally acting antihypertensives • 4. antisympathetic antihypertensives • 5. insulin sensitizers like rosiglitazone • 6. hormones • 7. corticosteroids • 8. NSAIDs
do SSRI’s cause peripheral edema?
no
do ACE inhibitors cause peripheral edema?
no
do thiazides cause peripheral edema?
no
in the workup of edema, the first thing to note is what?
if the edema is unilateral or bilateral
what is the work up for bilateral edema associated with signs and symptoms of CHF?
CXR to rule in the Dx, followed by echocardiogram
what do you need to order for a patient with bilateral edema when ascites is present?
liver function tests
what should you check in the case of bilateral edema with no signs of CHF or ascites?
urinalysis
what is the interpretation of a urinalysis with abnormal sediment in a patient with bilateral lower extremity edema?
nephritic syndrome or ATN is the likely diagnosis
does edema associated with hypothyroidism cause ascites?
no
for what type of edema would a lower extremity doppler study be indicated?
unilateral edema
unilateral edema not associated with trauma or signs of infection requires what workup?
Doppler US to evaluate for the presence of DVT
when do you order CT PE scan or V/Q scan in a patient with unilateral LE edema?
not unless there is suspicion of a PE
what signs point to cellulitis in a patient with unilateral LE edema?
signs of inflammation including erythema
how do you treat LE edema caused by cellulitis?
antibiotics
what do you do for a patient with unilateral LE edema and varicose veins?
vascular surgery referral
what do you do for LE edema caused by CHF?
diuretics
what do you do for LE edema caused by venous insufficiency?
treatment with compression stockings
what is the treatment of choice for LE edema caused by DVT?
anticoagulation
what can aid venous return in patients with chronic venous insufficiency?
knee length elastic stockings and leg elevation throughout the day
what should you limit in a patient with chronic venous insufficiency?
prolonged standing
unilateral edema will not respond to which treatments that work for bilateral LE edema?
diuresis, Na restriction, ACE inhibitor
how do you differentiate venous insufficiency LE edema from a DVT?
DVT is unlikely if the swelling is chronic in nature
the term ‘enuresis’ refers to what?
repeated spontaneous nocturnal voiding of urine into the bed or clothes at least 2x/wk for 3 consecutive months in a child who is at least 5yo
primary monosymptomatic enuresis is what?
bed-wetting without a history of nocturnal continence and is unassociated with other symptoms
what is secondary monosymptomatic enuresis?
recurrence of bed-wetting after at least 6 months of nocturnal continence
non-monosymptomatic enuresis is what?
bed-wetting associated with urinary urgency, frequency, straining, pain, chronic constipation, or encopresis
children who have involuntary or intentional urination into clothing while awake or asleep are said to have what?
daytime incontinence and enuresis
the cause of nocturnal enuresis is felt to be due to what?
decreased production of nocturnal antidiuretic hormone
nocturnal enuresis is associated with what?
maturational delay
what % of 5yo are enuretic?
25%
the numbers of nocturnal enuretic children decrease by how much each year?
15%
what % of bedwetters are female?
40-50%
what is the family association with nocturnal enuresis?
if one parent was enuretic, there is a 40% likelihood that the child will be • if both parents, then 70%
how many patients have an organic cause of nocturnal enuresis?
very few
what has been shown to be an effective treatment for nocturnal enuresis?
enuresis alarms
how effective are medications for nocturnal enuresis?
may be more effective than enuresis alarms in the short term, but there is a high relapse rate when medications are discontinued
what is a barrier to effectiveness to enuresis alarms?
compliance with frequent night time wakening
when is DDAVP appropriate in the treatment of nocturnal enuresis?
because of high relapse rate after d/c, it should be reserved for overnight visits or summercamp
how do TCAs compare to DDAVP in the treatment of nocturnal enuresis?
lower initial cure rate and a high relapse rate.
should you give TCAs for nocturnal enuresis?
no. can cause lethal overdose and aren’t that effective
how well does oxybutinin work for nocturnal enuresis?
high relapse rate and has not been proven to be more efficacious than placebo
in a child with monosymptomatic nocturnal enuresis, what needs to be evaluated?
thorough voiding history, PE, urinalysis, post void residual and nothing else
what is the normal bladder capacity of a child?
age + 2 in ounces
what is the normal post void residual in a child?
<10% of normal bladder capacity
when should you order an XR of lumbar and sacral spine in a child with bed-wetting?
if there is suspicion of spina bifida occulta
what should you order if you suspect anatomic abnormalities that would lead to enuresis?
renal US • VCUG
