Family Medicine Core Rotation - Acute Complaints_2 Flashcards
what therapy can be a very successful behavioral treatment for nocturnal enuresis?
moisture sensitive alarms
how do moisture sensitive alarms for nocturnal enuresis work?
the first drops of urine complete a circuit, activating an alarm that will wake the child and parents, and then the parents help the child complete the voiding in the toilet. over time, a conditioned response develops, and the child awakens voluntarily with the sensation of full bladder
what is the gender bias of efficacy of moisture sensitive alarms for nocturnal enuresis?
there is no gender difference in success rates
what are the success rates for appropriately used moisture sensitive alarms for nocturnal enuresis?
75-84%
how long does a moisture sensitive alarm for nocturnal enuresis take to work?
weeks or months
should a child take responsibility for their treatment with a moisture sensitive alarm for nocturnal enuresis?
no. without parental involvement, success rates drop
when should you be concerned about a child having failure to thrive?
when a child drops more than 2 percentile brackets on a growth curve and does not maintain at that area
in the USA, the vast majority of failure to thrive is secondary to what?
inadequate nutrition
how good is albumin at revealing recent undernutrition?
albumin has a long half life and is a poor indicator of recent undernutrition
how sensitive is prealbumin for undernutrition?
prealbumin is decreased in acute inflammation and undernutrition and is therefore insensitive
organic disease, including hypothyroidism, is found in how many cases of failure to thrive?
<10%
how are IgA levels related to undernutrition?
IgA levels are sensitive to undernutrition and would be decreased in failure to thrive
in a child with failure to thrive, diarrhea, and recurrent respiratory infections what Dx must be considered?
CF
what should you order for a child with failure to thrive, diarrhea, and recurrent respiratory infections?
sweat chloride test
what tests may be indicated in the workup of failure to thrive, but only with a reasonable degree of clinical suspicion?
- mantoux test for TB • 2. HIV test • 3. stool for ova and parasites • 4. RFT
what features will you see in a child with esophageal reflux contributing to failure to thrive?
- wet burps • 2. frequent emesis or cough with eating • 3. occasional wheezing
what is the best test to diagnose esophageal reflux causing failure to thrive in a child?
esophageal pH probe
if a child has failure to thrive with diarrhea or melena what should you think and order?
think IBD • order hemoccult
if a child has failure to thrive and diarrhea, abdominal pain, and foul smelling stools, what do you think and order?
think lactose intolerance • order lactose tolerance test
what would cause you to suspect pyloric stenosis in a child?
projectile vomiting • abdominal distention • perhaps palpable mass
what do you order on a child in which you suspect pyloric stenosis?
US
what do you do for a 9mo child with failure to thrive, signs of minimal smiling and vocalization?
no tests, likely related to infant behavior and/or ineffective maternal-child bonding
children with familial short stature have a growth curve that shows what?
simultaneous changes in height and weight
what do you see on the growth curve of a child with failure to thrive and constitutional growth delay?
weight decreases first, then height
what do you see on the growth chart of a child with hypothyroidism?
height velocity slows first and may plateau before weight changes
what do you see on the growth chart of breast fed infants?
weight decreases relative to peers after 4-6 months, but catches up after 12 mo
when is hospital admission indicated for failure to thrive?
in the face of hypotension and bradycardia
what are the signs of severe malnutrition that necessitate hospital admission for a child with failure to thrive?
hypotension and bradycardia
mononucleosis is often mistaken for what?
streptococcal pharyngitis
both mononucleosis and streptococcal pharyngitis have which symptoms in common?
sore throat • fatigue • fever • adenopathy
what happens if you give ampicillin to a patient with mononucleosis?
diffuse symmetrical erythematous maculopapular rash, not to be confused with penicillin allergy or scarlet fever
how does scarlet fever rash compare to what happens when you give ampicillin to a patient with mononucleosis?
the rash of scarlet fever is more confluent, and has a sandpaper like texture
what does the rash of measles look like?
erythematous flat papules, first appearing on the face and neck, then spreading to the arms and trunk in 2-3 days
fatigue lasting < month is likely what?
result of a physical cause: • infection • endocrine imbalance • CV disease • anemia • medications
fatigue lasting >3mo is more likely to be related to what?
psychologic factors: • depression • anxiety • stress • adjustment reactions
physiologic fatigue happens because of what?
overwork • lack of sleep • pregnancy
how long does fatigue have to be present to diagnose chronic fatigue syndrome and chronic idiopathic fatigue
> 6mo
what is one of the most common diagnoses in patients presenting with fatigue, especially when denying weakness or hypersomnolence?
depression
what should you screen for in a patient complaining of fatigue that has a negative depression screening?
sleep apnea • anemia • hypothyroidism • pregnancy
what are the 3 general categories of fatigue?
physiologic • physical • psychologic
what historical feature should lead you to look for a physical cause of fatigue lasting >6mo?
progressively worsening
initial lab workup for an uncertain diagnosis of fatigue includes what?
CRC • ESR • UA • Chemistry panel • TSH • HCG • age/gender appropriate cancer screening
what should you order in a patient with uncertain diagnosis of fatigue if all initial tests are negative?
CXR • ECG • HIV • drug screen
what is the second most common cause of lower GI bleeding in children?
intussusception
what is the most common cause of significant GI bleeding in children?
Meckel diverticulum
do anal fissures, colitis, and juvenile polyposis cause significant bleeding in children?
no
what is the best diagnostic testing option in the setting of acute upper GI bleed?
upper endoscopy
what is the use of an upper endoscopy in acute upper GI bleed?
localize the source of bleeding • potentially allow therapeutic intervention • allow for tissue diagnosis when necessary
how does gastric lavage compare to EGD for acute upper GI bleed?
less useful
what is the limitation of using barium study for acute upper GI bleed?
might interfere with subsequent intervention
why not order a red cell scan for acute upper GI bleed?
they are better to locate bleeding sources in the lower GIT
why not order angiography for acute upper GI bleed?
may miss slower bleed
what is the most common congenital abnormality of the GIT?
Meckel diverticulum- 2% of the population
how does meckel diverticulum present?
most are asymptomatic, but a common presentation is painless large volume intestinal hemorrhage
how is a meckel diverticulum often diagnosed?
incidentally at laparotomy
what is the noninvasive diagnostic test for meckel diverticulum?
technetium scan
what percentage of patients with colonic diverticulosis develop severe diverticular bleeding?
5-15%
can you localize diverticular bleeding using colonoscopy?
yes but it is unusual
what is the next step if you can not localize the source of bleeding in diverticulosis on colonoscopy?
tagged RBC scan, which will help guide segemental resection if necessary
when is a subtotal colectomy necessary for bleeding diverticulosis?
recurrent severe bleeding with no source identified
external hemorrhoids are defined as what?
hemorrhoids arising distal to the dentate line
when external hemorrhoids thrombose, they are associated with what?
acute pain and are hard and nodular on physical exam
what do you do for thrombosed external hemorrhoids?
the excision can be safely done in the office under local anesthesia
what are the advantages of local excision of thrombosed external hemorrhoids under local anesthesia?
it eliminates pain immediately and eliminates the risk of recurrence
what is the use of hydrocortisone for thrombosed external hemorrhoids?
not useful
what are the indications for rubber band ligation and sclerotherapy for hemorrhoids?
should be reserved for internal hemorrhoids
what are the risks of incision and drainage of an external hemorrhoid?
increases the risk of recurrence and can lead to infection of the retained clot
what is an anal fissure?
a split in the anoderm of the anal canal
when does an anal fissure occur?
generally after the passage of a hard bowel movement
how do patients with anal fissure present?
excruciating pain with defecation with blood on the toilet paper–> complaint of ache or spasm that resolves after a couple hours
when are internal hemorrhoids painful?
internal hemorrhoids are generally not painful, unless they are thrombosed because of an unreducible prolapse- pain does not resolve
would a perianal abscess cause bleeding like anal fissure?
a perianal abscess may not present with bleeding, but would likely be associated with systemic signs of infection
what are are the most studied and effective prophylactic agents for migraines?
β blockers
what is the only Ca channel blocker that is effective at migraine prophylaxis?
verapamil
when are ergotamines used for migraines?
for abortive therapy
the goal of prophylactic migraine therapy is what?
to reduce the frequency of headache by 50%
of the anti-depressants used for migraine prophylaxis, which has the strongest evidence for efficacy?
amitriptyline
what is the dosing of amitriptyline for migraine prophylaxis?
begin with low dose 10mg at night, then titrate up to the most effective dose that does not cause side effects (up to 150mg)
what are the red flags in headache necessitating additional workup?
- onset after age 50yo • 2. very sudden onset • 3. increase in severity or frequency • 4. signs of systemic disease • 5. focal neurologic symptoms (except aura) • 6. papilledema • 7. headache after trauma
migraines often occur how?
in a consistent location, are severe and frequent, include a visual aura, and may be associated with severe nausea
when is abortive acute therapy for migraines appropriate monotherapy?
if attacks occur less than 2-4x/mo
what should be the first choice abortive treatment for migraine?
a triptan (because of receptor specific action)
what are good alternatives to triptans in abortive treatment of migraines?
ergot alkaloids
what do you do for migraines that fail triptans and ergot alkaloids?
rescue medications (simple analgesics)
when should narcotics be used for migraine?
although frequently used in emergency settings, narcotics are rarely needed in the treatment plan for migraines
though Ca channel blockers other than verapamil have not been shown to be effective against migraines, they be helpful with which type of headache?
cluster headaches
what is the rationale of therapy for cluster headaches?
provide relief from the acute attacks, then use therapy to suppress headaches during the symptomatic period
which medications have been shown to be effective against cluster headaches?
nifedipine • prednisone • indomethacin • lithium
when is ergotamine good for cluster headache?
generally only helpful in the acute stage, not for prophylaxis
cluster headaches characteristically develop how?
rapidly, achieving peak intensity within 10-15 minutes lasting with intense pain for about 2 hours without treatment
the mainstay of treatment for cluster headaches is what?
oxygen
which parenteral drugs help with cluster headaches?
subQ or intranasal serotonin antagonists • IV/IM ergotamine
many physicians diagnose tension type headaches how?
by exclusion
what is the most frequent of all headaches encountered in clinical practice?
TTH
how long does a TTH episode last?
30 min- several days
how often should TTH occur per months?
<15x
TTH diagnosis requires which characteristics?
at least 2 of the following: • 1. pressure/tightening • 2. bilateral • 3. mild to moderate • 4. not aggravated by activity
what is the relationship between TTH and nausea?
there is generally no nausea
what is the relationship between TTH and photophobia/phonophobia?
either photophobia or phonophobia may be present but not both
what is the treatment for TTH?
trial of NSAID’s with follow up if there is no improvement
what is the role of narcotics in TTH treatment?
narcotics should be avoided, since the condition is generally chronic and overuse is likely
what is the most common presentation of bladder carcinoma?
painless hematuria without other symptoms
what are the risk factors for bladder carcinoma?
- being male • 2. smoking • 3. working with aromatic amines used in dye, paint, aluminum, textile, and rubber industries
acute prostatitis and UTIs are associated with which symptoms?
dysuria • fever • frequency • urgency
pseudohematuria can be derived from what?
chemical agents, foods, vaginal bleeding
what are the common foods that cause pseudohematuria?
beets • blackberries • certain food dyes
what are the medications that discolor the urine?
chloroquine • metronidazole • phenytoin • rifampin • sulfasalazine
in patients <40yo with hematuria but a normal IV pyelogram, what is the next step?
urine culture and cytology, periodic monitoring, and reassurance
when do you order cystoscopy for hematuria?
any patient >40yo with normal IVP
what do you order to diagnose post streptococcal glomerulonephritis?
ASO titer
what should you think causes phenomenon where patient falls asleep fast but then wakes up and can’t return to sleep despite d/c caffeine use?
alcohol or drugs
how does obesity affect quality of sleep?
obesity is a risk factor for sleep apnea, but that generally does not cause inability to return to sleep after waking
how does propranolol affect sleep?
propranolol is known to cause nightmares
how does HCTZ affect sleep?
can cause nocturia that inhibits sleep
how does naproxen affect sleep?
naproxen is not known to interfere with sleep
how does alcohol affect sleep?
alcohol is known to cause excessive wakefulness, and often allows people to fall asleep, but interferes with the ability to stay asleep
what is essential for treating insomnia?
good sleep hygeine
important aspects of sleep hygiene include what?
- awakening at a regular hour • 2. exercising daily • 3. control of the sleep environment • 4. eat a light snack before bed time (not meal) • 5. limit or eliminate alcohol, caffeine, and nicotine • 6. go to bed when sleepy • 7. use your bed for sleep and intimacy only • 8. get out of bed if you aren’t asleep within 15-30 minutes
when can pharmacologic agents be used for sleep problems?
in select cases of transient sleep disorders unassociated with more serious problems
before using any pharmacologic agents for sleep it is important that the patient maintains what?
excellent sleep hygiene
what are the drugs of choice for transient sleep onset problems?
zolpidem (ambien) • eszopiclone (lunesta)
what drug can be used for sleep maintenance problems?
zaleplon (Sonata)
what is the use of melatonin?
help with adjustments of the sleep wake cycle (jet lag, shift work)
what is the use of benadryl for sleep?
can cause excessive somnolence and may help with sleep onset but not sleep maintenance
what is the most commonly reported hepatitis virus?
HAV
how is HAV spread?
via the fecal-oral route, most commonly through the ingestion of contaminated food or water
can HAV cause chronic hepatitis?
causes acute hepatitis only and never results in chronic hepatitis
are HAV relapses common?
lifelong immunity is expected for all patients that recover, therefore relapses are uncommon
when is a patient with HAV contagious?
fecal shedding of the virus occurs early, and declines once jaundice develops so jaundiced patients are less contagious than those in prodrome
symptoms of HAV infection change with what?
age
what percentage of patients <5yo infected with HAV are asymptomatic?
90%
what percentage of adults infected with HAV are symptomatic?
80%
what is the mode of transmission of HBV?
transfer of blood or body fluids, vertically
what happens if HBV is acquired early in life?
the infection is silent, but up to 90% of those infected develop chronic disease
what type of patients develop chronic hepatitis from HBV easier than others?
immunocompromised patients
what is the percentage of adults with HBV that have spontaneous resolution?
95%
what percentage of patients with HAV or HBV develop fulminant liver disease?
small percentage
HBsAg positivity means what?
either chronic infection or early infection
what rules out early infection in the face of positive HBsAg?
negative IgM anti-HBc
HBeAg is correlated with what?
replication
positivity of anti-HBs indicates what?
either exposure with immunity, recovery phase, vaccination
what rules out past exposure or infection in a patient with positive anti-HBs?
negative IgG anti-HBc
what stage of disease is a patient with positive HBsAg and positive IgM anti-HBc?
early infection
what is the HBsAg finding in a patient in the recovery phase?
negative
does asymptomatic bacteriuria cause incontinence?
asymptomatic bacteriuria is common in otherwise well elderly, and does not cause incontinence
does a symptomatic urinary infection cause incontinence in the elderly?
it may
how does hyperglycemia cause secondary incontinence?
because of polyuria
how do you treat incontinence caused by hyperglycemia?
tighter control of blood sugar levels
what is the relationship between fecal impaction and urinary incontinence?
stool impaction is thought to be a causative factor in up to 10% of patients
can atrophic vaginitis cause urinary incontinence?
yes
what is the most common type of incontinence in the elderly?
urge incontinence
what causes urge incontinence?
destrusor hyperactivity
functional incontinence refers to what?
limitation that does not allow the patient to void in the bathroom
what are some causes of functional incontinence?
bed rest • paralysis • severe dementia
what is stress incontinence?
loss of urine associated with ↑ intra-abdominal pressure
overflow incontinence is due to what?
overdistention of the bladder
what is the gender bias of stress incontinence?
much more commonly seen in women than men
stress incontinence is most often caused by what?
urethral hypermobility resulting from weakness of the pelvic floor musculature
patients with stress incontinence complain of what?
involuntary loss of urine associated with increase in intraabdominal pressure (sneezing, coughing, laughing, exercising)
overflow incontinence is primarily what?
a loss of the ability to empty the bladder
what are the causes of overflow incontinence?
- neurogenic bladder • 2. outlet obstruction
what are some causes of neurogenic bladder?
longstanding diabetes • alcoholism • disk disease
what is a cause of overflow incontinence due to outlet obstruction?
prostatic enlargement
in the case of overflow incontinence the patient typically complains of what?
frequent or constant leakage of a small amount
what is the interpretation of a postvoid residual less than 50mL?
normal
a postvoid residual greater than 200 mL indicates what?
inadequate bladder emptying and is consistent with overflow incontinence
what is the volume of an indeterminant postvoid residual?
50-200mL
Kegel exercise are designed to do what?
strengthen the pelvic floor musculature
how do you instruct a patient to do kegel exercises?
ask the patient to squeeze the muscles in the genital area as if they were trying to stop the flow of urine from the urethra. hold for 10 seconds. repeat many times a day
for what types of incontinence are kegel exercises useful?
stress incontinence and mixed incontinence
kegel exercises are not useful for what types of incontinence?
functional • urge • overflow
when is pharmacologic therapy indicated for incontinence?
if a behavioral approach is ineffective
what are the drugs of choice for urge incontinence?
anticholinergic: • oxybutinin (ditropan) • tolterodine (detrol)
what drug helps with stress incontinence?
pseudophedrine
what drug helps with prostatitis incontinence?
trimethoprim-sulfamethoxazole
what drugs help frequent voiding caused by BPH?
finasteride and terazosin
which drugs can cause urinary incontinence?
- α blockers- urethral sphincter relaxation→leakage but not urgency • 2. β blockers- inhibit bladder relaxation →leakage and urgency
how do Ca channel blockers affect the urinary system?
cause urinary retention
how do diuretics affect the urinary system?
increased frequency and urgency, but usually not leakage
what urinary symptoms can alcohol cause?
diuretic effect → polyuria, incontinence
what urinary symptoms can decongestants and diet pills cause?
urinary retention if they include α-agonists
what urinary symptoms can antihistamines cause?
urinary retention or functional incontinence
what urinary symptoms can caffeine cause?
diuretic effect → polyuria
does marijuana abuse contribute to urinary symptoms?
no
in evaluating childhood jaundice it is important to differentiate between what?
conjugated and unconjugated hyperbilirubinemia
if jaundice occurs in childhood and is associated with unconjugated hyperbilirubinemia, what diseases should be considered?
- hemolytic diseases - G6PD, HS • 2. Gilbert disease • 3. Crigler-Najar
if jaundice occurs in childhood and is associated with conjugated hyperbilirubinemia, what should be considered?
- viral hepatitis- MCC • 2. wilson disease • 3. milder forms of galactosemia
viral hepatitis accounts for what percentage of adult jaundice?
75% in pt <30yo • 5% in pt >60yo
extrahepatic obstruction accounts for what percentage of jaundice in patients >60yo?
60%
what are the cause of conjugated hyperbilirubinemia jaundice due to extrahepatic obstruction in >60yo?
gall stones • strictures • pancreatic cancer
CHF accounts for what percentage of jaundice in patients >60yo?
10%
metastatic disease accounts for what percentage of jaundice in patients >60yo?
13%
when biliary obstruction is suspected, what is the most appropriate initial first test?
US or CT
what should you do in a patient with suspected biliary obstruction with findings of dilated ducts?
ERCP or PTC
in a patient with suspected biliary obstruction but no dilated ducts, so unlikely obstruction, what should you do?
evaluate for hepatocellular or cholestatic disease
what do you do if you still suspect biliary obstruction after negative CT and US?
MRCP
what is the advantage of MRCP over ERCP?
no postprocedure pancreatitis
primary amenorrhea is defined as what?
absence of menses at age 16 in the presence of normal secondary sex characteristics, or absence of menses at age 14 in the absence of secondary sex characteristics
primary amenorrhea is usually the result of what?
genetic or anatomic abnormality
what is the most common cause of primary amenorrhea?
gonadal dysgenesis (50% of cases)
what is the most well known type of gonadal dysgenesis?
Turner syndrome
hypothalamic failure in a girl with amenorrhea is often a result of what?
anorexia nervosa • excessive exercise • chronic or systemic illness • severe stress; • all→suppression of hypothalamic GnRH secretion
pituitary failure in a girl with amenorrhea may result from what?
inadequate GnRH stimulation
pituitary failure in a girl with amenorrhea is often associated with a history of what?
head trauma • shock • infiltrative process • pituitary adenoma • craniopharyngioma
how do you differentiate pituitary from hypothalamic failure in a girl with amenorrhea?
pituitary failure is accompanied by deficiency of other pituitary hormones
what is the relationship between PCOS and primary amenorrhea?
PCOS may cause primary amenorrhea, but is generally associated with normal breast development
what is the gender prevalence of constitutional delay of puberty?
common in boys, uncommon cause of primary amenorrhea in girls
what is the most common cause of secondary amenorrhea?
pregnancy
PCOS accounts for what percentage of secondary amenorrhea?
30% of cases
PCOS is characterized by what?
androgen excess • irregular/absent menses • hirsutism • acne • virilization
functional hypothalamic amenorrhea is usually a result of what?
anorexia • rapid weight loss • rigorous exercise • significant emotional stress
what are the less common causes of secondary amenorrhea?
hypothyroidism • hyperprolactinemia
anovulatory bleeding is caused by what?
continuous unopposed endometrial estrogen stimulation
what is the most common cause of dysfunctional uterine bleeding in women younger than 20yo?
anovulatory bleeding (95%)
when is anovulatory bleeding especially common?
when women are within 2 years of menarche
what can you do for a young woman with anovulatory bleeding?
- watch expectantly • or • 2. OCP to regulate periods
ovulatory bleeding due to fluctuations in estrogen and progesterone levels accounts for what percentage of abnormal bleeding?
10%
what do you need to do for any postmenopausal woman with vaginal bleeding?
she needs an endometrial biopsy to rule out endometrial cancer after examination performing the examination and ruling out STI/anatomic abnormality
what are the contraindications for endometrial biopsy?
pregnancy • acute infection • PID • known bleeding disorder
primary dysmenorrhea is caused by what?
release of prostaglandin from the endometrium at the time of menstruation
treatment of primary dysmenorrhea focuses on what?
reduction of endometrial prostaglandin production
how do you reduce endometrial prostaglandin production?
- inhibition of prostaglandin synthesis by medication • 2. suppressing ovulation
what is the first line therapy for dysmenorrhea?
NSAIDs
how should NSAIDs be used for primary dysmenorrhea?
start NSAIDs day before menstruation. No benefit of continuous daily use
what is the role of SSRIs in menstrual problems?
SSRI therapy is sometimes used for premenstrual dysphoric disorder, but is not a first line therapy for dysmenorrhea
what is a second line therapy for primary dysmenorrhea?
OCP
what medications can cause hyperprolactinemia leading to amenorrhea?
- psychotropics- benzodiazepines, SSRI, TCA, phenothiazines, buspirone • 2. neurologic- • sumatriptan, valproate, ergot derivatives • 3. estrogens and contraceptives • 4. cardiovascular drugs- atenolol, verapamil, reserpine, methyldopa
what is the purpose of the progestin challenge test?
separates patients with estrogen deficiency from those with normal or excess estrogen
any bleeding in the week after the administration of Provera indicates what?
the patient has sufficient estrogen to menstruate, and that amenorrhea is likely due to anovulation as in PCOS
would patients with premature ovarian failure have a withdrawal bleed after progestin challenge test?
no
patients with amenorrhea and elevated testosterone and DHEA-S levels need what workup?
CT scan of adrenals and US of ovaries to rule out neoplasm
hysteroscopy and hysterosalpingogram are involved in workup of what conditions?
menstrual irregularities or infertility
when evaluating primary amenorrhea in patients with normal secondary sexual characteristics and normal hcg, TSH, and prolactin, it is appropriate to perform what test?
progestin challenge test
what can you use to differentiate between inadequate estrogen and outflow obstruction in a patient with no withdrawal bleeding after a progestin challenge test for primary amenorrhea?
estrogen-progestin challenge
no withdrawal bleeding after an estrogen-progestin challenge indicates what?
an outflow tract obstruction or anatomic defect
what is a physical exam finding seen in hypertensive encephalopathy
papilledema
hyperalert confusion is common with what?
alcohol withdrawal
amphetamine withdrawal is associated with what presentation?
psychomotor slowing
what is the test you order to diagnose bacterial meningitis?
lumbar puncture
what can you give for diabetic gastroparesis?
metoclopramide
mild pain followed by the acute onset of distension, nausea, and vomiting is consistent with what?
ileus or obstruction
what PE finding can differentiate between obstruction and ileus?
hyperactive bowel sounds → obstruction • absent bowel sounds → ileus
when should you suspect psychogenic vomiting?
in patients who are able to maintain adequate nutrition despite chronic symptoms
when is psychogenic vomiting seen?
usually during times of social stress or in patients with a past history of psychiatric disorder
how do you differentiate psychogenic vomiting from bulimia?
bulimia sufferers usually do not seek medical attention or treatment until concerned others bring the condition to medical attention
how do you differentiate psychogenic vomiting from CNS malignancy?
CNS malignancy of vomiting center causes nutritional defecit
what are common causes of viral gastroenteritis?
norwalk virus • reoviruses • adenoviruses
what is the general course of viral enteritis?
self limited and likely to resolve in 5 days
in the presence of pancreatitis, ↑ALT points to what?
gallstone pancreatitis
when is ↑ALT less likely in pancreatitis?
when alcohol or ↑TG are the cause
when nausea happens before eating in the morning, likely etiologies include what?
pregnancy • uremia • alcohol withdrawal • ↑ICP
gastroparesis and pancreatitis cause nausea with what timing?
after eating
what is the nature of nausea associated with cholelithiasis?
n/v and pain after eating fatty foods
what is the nature of nausea in vestibular disorders?
nausea without any clear association with meals or time of day
children with pyloric stenosis typically present how?
with weight loss • dehydration • occasional palpable olive mass in the epigastrium
when is pyloric stenosis usually identified?
before 7 weeks of age
how do you differentiate pyloric stenosis from reflux?
reflux less likely to be associated with weight loss and dehydration
how do you differentiate pyloric stenosis from intussusception?
intussusception is associated with significant abdominal pain and hemoccult positive stools
how do you differentiate SBO from pyloric stenosis?
SBO is less likely and is associated with high pitched bowel sounds
pancreatitis is associated with the acute onset of what?
significant nausea, vomiting, and epigastric pain
what is the timing of the symptoms of pancreatitis?
symptoms occur after eating, and are improved when the patient does not eat
what are the typical laboratory findings in pancreatitis?
amylase and lipase are likely to be abnormal, but the CBC is likely to be normal along with hemoccult, AXR, and EGD
what is the typical presentation of cholelithiasis?
nausea, vomiting, and pain after eating fatty meals
what is the diagnostic test of choice for cholelithiasis?
RUQ U/S
when are amylase and lipase elevated in the presence of cholelithiasis?
if the patient develops secondary pancreatitis
what are the hemoccult, AXR, and EGD findings in cholelithiasis?
likely normal
what are the side effects of the phenothiazines?
drowsiness, • dry mouth • dizziness
what are the side effects of tigan?
drowsiness, dry mouth, dizziness as in phenothiazines
what are the side effects of zofran?
dizziness and headache
what are the side effects of reglan?
diarrhea and extra pyramidal reaction
what is the lifetime prevalence of at least one episode of neck pain in the adult population?
40-70%
neck pain aggravated by movement, worse after activities, associated with a dull ache and with limited range of motion is consistent with what?
spondylosis or osteoarthritis
if neck pain were due to chronic mechanical problems, there would be what?
tenderness to palpation on examination
if neck pain were due to cervical nerve root irritation, there would be what?
radiation of symptoms, weakness, numbness, or paresthesias
in neck pain from whiplash injury, one would expect a history of what?
an acceleration injury
what is the presentation of neck pain due to cervical dystonia (torticollis)
neck would be laterally flexed and rotated
what is the presentation of spinal stenosis?
older individual • axial stiffness • paresthesias over several dermatomes
what is the best test to order for spinal stenosis?
CT scan
when are C-spine radiographs indicated?
after injury, or if there are red flags
what is the use of MRI for spine problems?
MRI provides the best anatomic assessment of disk herniation and soft tissue or spinal cord abnormality
what is the use of EMG for spine problems?
helps localize radiculopathy
what are the 3 questions to ask in the canadian cervical spine rules?
- is there 1 high risk factor? • 2. is there one low risk factor • 3. is the patient able to voluntarily actively rotate the neck 45 deg to left and right regardless of pain
what are the high risk factors in the canadian cervical spine rules for radiographic imaging?
- > 65yo • 2. dangerous mechanism (↑speed MVA) • 3. numbness or tingling in extremities • – if one yes, then radiography
what are the low risk factors in the canadian rules for cervical spine radiography?
- simple rear end collision • 2. pt ambulatory at the scene • 3. absence of C-spine tenderness on exam • – one NO requires imaging
the Spurling test is also called what?
the neck compression test
the spurling test requires what?
patient must bend their head to the side and rotate the head toward the side of pain while the tester exerts downward pressure
how do you interpret a neck compression test?
the maneuver reproduces symptoms in the affected upper extremity in the case of nerve root injury
what are the sensitivity and specificity of the neck compression test for cervical radiculopathy?
high specificity but low sensitivity
how do you interpret a spurling test when the maneuver results in neck discomfort only?
dx: nonspecific mechanical pain
what are the ways that torticollis in the adult is managed?
PT • stretching • gentle manipulation • use of cervical collars • ice/heat • botox
the most evidence points to efficacy of what treatment for torticollis?
botox injection
what are the characteristics of palpitations that can help you determine whether the symptoms are from a cardiac cause?
- male sex • 2. description as irregular heart beat • 3. personal history of heart disease • 4. event duration >5min
when a patient describes their heart beat as rapid and irregular, it suggests what?
either atrial fibrillation or atrial flutter
both ectopy and atrial fibrillation can cause what?
irregular pulse
how is the pulse in PSVT and stable ventricular tachycardia?
rapid and regular
how is the pulse in stimulant abuse?
generally a sinus tachycardia
what arrhythmia is caused by hyperthyroidism?
hyperthyroidism may cause Afib, premature beats
Ventricular premature beats often occur how?
random, episodic, and instantaneous beats, often described as a flip flopping sensation
how do patients describe Afib?
rapid and irregular rate or fluttering in the chest
hypertrophic cardiomyopathy can be associated with which arrhythmias?
Afib or Vtach
what is the characteristic heart murmur of hypertrophic cardiomyopathy?
systolic ejection murmur worsening with Vasalva maneuver
what do you do for a patient with palpitations and normal H&P, 12 lead ECG, labs?
reassure the patient and continue observation
what is the likely cause of palpitations in a patient with normal H&P, ECG, and labs?
benign supraventricular or ventricular ectopy
what do you order for a patient whose arrhythmia seems to occur with exercise?
stress test
when are patients with WPW treated?
if they have symptomatic arrhythmia
what is the treatment for WPW?
usually radiofrequency ablation, but also drugs
classically, ovarian cysts present with what?
unilateral dull pain that can become diffuse and severe if the cyst ruptures
what do you feel on PE of a patient with ovarian cyst?
smooth mobile adnexal mass (with peritoneal signs if it ruptures)
how do you differentiate PID from ovarian cyst?
PID is associated with fever and vaginal discharge
how do you differentiate ectopic pregnancy from ovarian cyst?
ectopic pregnancy may present with similar symptoms, but menses would not be normal
how do you differentiate leiomyoma from ovarian cyst?
uterine leiomyoma are generally asymptomatic if present in this age group, would classically be associated with low midline pressure and menorrhagia or metorrhagia
how do you differentiate appendicitis from ovarian cyst?
appendicitis would be associated with fever, nausea, and anorexia
PID is classically described as which presentation?
lower abdominal pain that is gradual in onset and bilateral
what symptoms may be associated with PID?
fever • vaginal discharge • dysuria • occasionally abnormal vaginal bleeding
treatment for PID should provide coverage for what?
N. gonorrhoeae, C. trachomatis, anaerobes, enteric gram negative rods
what is the CDC recommended regimen for treatment of PID?
ceftriaxone 250mg IM, + doxycycline 100mg BID x 14 days +/- metronidazole 500mg BID x 14 days
when is inpatient treatment for PID indicated?
- pregnant women • 2. pt w/ severe illness with fever + vomiting • 3. when you can’t rule out surgical emergency • 4. those who fail appropriate outpatient therapy
pain associated with ectopic pregnancy is often described as what?
colicky, may radiate to the shoulder if there is significant hemoperitoneum
what symptom is a diagnostic clue for ectopic pregnancy?
nausea, a sign of pregnancy
when should you get a CBC in a suspected case of endometriosis?
if the signs are suggestive of an infectious process
how often is ESR elevated in PID?
75% of the time but nonspecific
when should you order CA-125 in a patient with symptoms of endometriosis?
if you are concerned about an ovarian mass
what imaging should you order for endometriosis?
transvaginal US may be helpful, but MRI is more sensitive for localization of endometriosis
what percentage of ovarian masses in girls younger than 15 are malignant?
80%
what is the protocol for ovarian mass in a girl <15yo?
bc of high potential for malignancy, any adnexal mass should be evaluated by transvaginal US and referral for surgical removal
in many women of child bearing age, adnexal masses are what?
commonly cysts
what is the protocol for adnexal mass in adult if the pain is not acute or recurrent, palpable cyst is
monitor with repeat pelvic exam
when should you get US for an adnexal mass in an adult?
those masses that do not resolve, or those that increase in size
with exudative pharyngitis, palatal petechiae suggest what?
group A streptococcal infection or infectious mononucleosis
how do you differentiate infectious mononucleosis from group A streptococcal infection?
posterior cervical adenopathy should point to IM as the correct Dx
when associated with pharyngitis and anterior adenopathy, edema swollen uvula is suggestive of what?
group A hemolytic streptococcal infection
what is the first line treatment for group A hemolytic streptococcal pharyngitis?
amoxicillin
why give liquid amoxicillin for group A hemolytic streptococcal pharyngitis?
penicillin resistance has not been seen in group A β-hemolytic strep, but liquid amoxicillin taste better than liquid penicillin
what should you give to a penicillin allergic patient with group A β hemolytic strep pharyngitis?
first generation cephalosporin
what percentage of school age children are carriers of group A β hemolytic strep?
20%
what is the cause and treatment of laryngitis with pharyngitis?
generally associated with a viral infection, and only supportive care is needed
what are the Centor criteria for adults used to determine the probability of group A β hemolytic strep infection?
1 point for each: • 1. tonsillar exudate • 2. tender anterior cervical adenopathy • 3. fever • 4. lack of cough
what is the most cost effective approach to treating patients with all 4 Centor criteria for gAβh- strep?
give antibiotics without lab testing
how likely is it that someone with 3/4 Centor criteria has strep?
40-60%
epididymitis is generally caused by what?
retrograde spread of prostatitis or urethral secretions through the vas
in sexually active males <35yo, epididymitis is usually associated with what and caused by what?
associated with urethritis and caused by N gonorrhoeae or C trachomatis
what are the less likely causes of epididymitis in sexually active males <35yo?
ureaplasma • mycoplasma
what is the more common cause of epididymitis in men >35yo who are monogamous?
enteric gram negative rods (enterobacter) associated with prostatitis
what is the protocol for testicular torsion?
requires emergent surgical referral
why does testicular torsion require immediate surgical referral?
after 12 hours without treatment, there is only a 20% chance the testicle can be saved
what is the nature of the reflex associated with testicular torsion?
the cremasteric reflex is absent
how is the cremasteric reflex elicited?
by pinching or brushing the inner thigh which causes the ipsilateral testicle to retract toward the inguinal canal
what is a positive prehn sign?
if pain is relieved upon elevation of the testicle when the patient is supine
is testicular torsion associated with a positive prehn sign?
no
when are the cremasteric reflex and prehn sign present?
epididymitis • hernias • orchitis • cancer
