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80 Cards in this Set
- Front
- Back
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Tension headache
Clinical features |
often described as vise-like, encircling entire hand- tight band around head
- usually generalized, may be pain in the posterior neck and cervical muscles - associated with depression and anxiety |
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Tension Headache
Treatment |
- evaluate for depression and anxiety
- NSAIDs, acetaminophen and aspirin |
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Emergency evaluation of Headache
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Non-contrast CT to r/o bleed- especially if sudden onset
- small bleeds may be missed so if high suspicion, LP may be needed |
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Cluster headache
General characteristics and clinical features |
- very rare, most often middle aged men
unilateral lacrimation, peri-orbital pain, nasal congestion, facial flushing - pain is often intense and lasts 30-90 min - often occurs at night and wakes patient from sleep - attacks occur nightly for 2-3 months and then disappear for several months to years |
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Cluster headache treatment
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Acute-100% Oxygen, Sumatriptan
Prophylaxis- Verapamil =#1, ergotamine, lithium, steroids |
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Migraine
General Characteristics |
- Inherited (AD)
- More common in women - May have aura - classic migraine = 15%- neurologic- visual (scotomata, flashing lights), paresthesia, hemiparesis, dysphasia - migraine without aura 85% - menstrual migraine- within 2 days before and end of menses, linked to estrogen withdrawal - statous migrainous- lasting > 72 hours - provoking factors- hormones, stress, lack of sleep, certain foods (chocolatem alcohol, OCP) - linked to serotonin |
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Migraine
Clinical Features |
- photophobia
- phonophobia - may have prodome of CNS excitation or inhibition- elation or irritability and sleepiness - severe throbbing pain, usually unilateral 4-72 hours. - worsened by physical activity, bending down - n/v - increased sensitivity to smell |
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Migraine
Acute Treatment |
Acute
Mild- NSAIDs Severe- serotonin receptor agonists- Dihydroergotamine (SQ, IV, IM, nasal)- CI- CAD, pregnancy, TIAs, PVD or Sumatriptan- oral-rapid, within 1 hr, very effective- CI- CAD, SSRI, MAOI (serotonin storm), uncontrolled HTN, hemiplegic migraine - if none of these treatments work then the patient likely does not have a migraine |
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Migraine Prophylaxis
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- daily med for patients with weekly HA interfering with activities
- First line: TCAs- amitriptiline, propanolol - Second line: verapamil, Valproic acid - Menstrual migraine- NSAIDs |
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When to order imaging for patients with headaches
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1. Trauma
2. Change in pattern, severity of HAs 3. Wakes from sleep 4. New onset HA > 40 yo 5. Focal Neurologic signs or sx 6. Onset with exertion, cough, sex 7. Progressive worsening depsite appropriate treatment |
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Acute vs chronic cough
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Acute- lasts < 3 weeks, Chronic > 3 weeks
If benign usually resolves within 1 month, if lasts longer-- need further eval |
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Causes of cough
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1. URI - most common acute
2. Pulmonary disease- pneumonia, lung cancer, COPD, asthma, pulmonary fibrosis, lung abscess, TB 3. Smoking- morning cough 4. Post nasal drip- URI, allergies 5. GERD- especially if at night and when supine 6. Asthma- may be only sx in 5% 7. Lung cancer 8. ACE-inhibitors |
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Diagnosis of cough
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- usually no tests indicated
- CXR only if pulmonary cause suspected, chronic, or smoker in whom COPD or lung cancer are possibilities - CBC if infection suspected - PFTs if asthma suspected - Bronchoscopy isf above is negative- to r/o cancer, esophageal webs or FB |
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Treatment of cough
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treat underlying cause
1. smoking cessation 2. PND- 1st generation antihistamine- diphenhydramine, vistiril, if allergic rhinitis- non-sedating, long acting- loratidine, fexofenadine 3. Non-specific anti-tussive - Codeine - Dextromethorphan - Benzonatate (tessalon perles) 4. expectorant- guaifenesin |
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Acute bronchitis
Cause, CXR need? |
Majority are viral- no CXR needed unless pneumonia suspected based on exam- fever, consolidation (dec breath sounds), egophony, dullness to percussion, crackles, tachypnea
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Acute bronchitis
Clinical Features |
1. cough (+/- sputum)- predominant symptom- usually lasts 1-2 weeks, but may last longer than 1 month
2. Chest discomfort 3. +/- Fever |
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Acute Bronchitis Treatment
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1. Abx usually not needed as most are viral. If pneumonia considered- amoxicillin
2. Cough suppressant- dextromethorphan, expectorant- guanifesen 3. Bronchodilator - albuterol |
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Common Cold
1. cause 2. Transmission 3. Course/duration 4. Complication |
common cold = acute rhinosinusitis- inflammation and congestion of nasal and sinus passages
1. most- rhinovirus (many strains- why repeat infxn). Other- parainfluenza, coronavirus, adenovirus, coxackievirus, RSV 2. hand-to-hand 3. usually 1 week- but up to 10-14 days 4. secondary infection- pneumonia or sinus infxn |
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Common cold
clinical features |
- non-productive cough, congestion, rhinorrhea, sore throat, malaise
- fever is uncommon in adults, but not unusual in kids |
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Treatment of common cold
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Supportive
- adequate hydration - inhale steam to loosen secretions - NSAIDs or tylenol - nasal decongestant spray- neo-synephrine- less than 3 days or rebound runny nose - 1st gen antihistamine |
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Cause of most cases of sinusitis?
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complication common cold or URI- however only 1% of URIs lead to sinusitis
- may also be caused by nasal obstruction, polyps or foreign body |
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Classification of sinusitis and most common location
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Acute bacterial- usually due to S. pneumo, or H. influenza
Viral, fungal, or anaerobic are other possibilities - location- maxillary sinuses |
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Clinical features of acute sinusitis
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- congestion
- purulent nasal discharge - cough - pain and pressure over sinuses- frontal or maxillary- worsens with percussion or bending down - ethmoid- pain in lateral, upper nose or retro-orbital pain |
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Clinical features of chronic sinusitis
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- nasal congestion
- post nasal drip - sinus pain and headache are usually absent, fever is uncommon - by definition must last 2-3 months - in addition to s. pneumo and h. flu, S. aureus and gram neg rods may be implicated |
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Diagnosis of sinusitis
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- based on clinical findings. Consider if patient has cold for longer than 8-10 days or congestion for prolonged period
- physical exam- purulent nasal discharge from turbinates, decreased transillumination when holding light to sinus in completely dark room, pain to palp over sinuses (not reliable) - Conventional sinus radiographs- look for air fluid levels - CT coronal if complications or surgery |
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Complications of sinusitis
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- polyps
- osteomyelitis- maxillary or frontal bones - orbital cellulitis - rare- brain abscess, cavernous sinus thrombosis, meningitis, |
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Treatment of Acute purulent sinusitis
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1. Nasal rinses with saline- as often as go to bathroom
2. decongestants- pseudoephedrine- limit to 3 days 3. Antibiotics - amoxicillin, bactrim, levofloxacin, moxifloxacin, and cefuroxime 4. Antihistamines- only for patients with allergies as may have drying effect and make secretions thicker - loratidine, fexofenadine, 5. nasal steroids- fluticasone or beclomethasone if due to allergic rhinitis |
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Treatment of chronic sinusitis
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1.abx- broad spec penicillinase resistant abx - cephalosporin
2. refer to ENT- drainage |
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Laryngitis
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most common cause = virus
- may have other URI sx - tx: voice rest until better to avoid formation of vocal nodules |
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Sore Throat
ddx evaluation - if exudates present?? |
- most common viral cause
- biggest concern is for strep throat (s. pyogenes)- untreated- rheumatic fever - mononucleosis (EBV, rarely CMV) - Bacterial tonsillitis- corynebacterium diptheria (gray pseudomembrane), chlamydia, gonorrhea, candida in ICH - in cough present and no fever- unlikely to be strep - only 50% of pts with strep have exudates and only 50% of pts with exudates have strep |
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Diagnosis of sore throat
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- throat culture- takes 24 hours- but better than rapid strep test
- rapid strep test- takes 1 hour- but only tests for strep - monospot if mono suspected |
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Treatment of sore throat
1. strep throat 2. viral 3. mononucleosis 4. symptomatic |
1. penicillin - if allergy then erythromycin
2. symptomatic tx 3. supportive tx- avoid contact sports for 4 weeks 4. ibuprofen, acetaminophen, warm salt water, humidifier |
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Causes of dyspepsia
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GERD, PUD, IBS, lactose intolerance, cholecystitis, biliary obstruction, DM (gastroparesis), malabsorption
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Diagnosis of dyspepsia
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Endoscopy is the test of choice. - especially if weight loss, anemia, dysphagia, or older age
- may do H. pylori serology for PUD |
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Treatment of H. pylori
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triple therapy - Metronidazole, Tetracycline, PPI +/- bismuth
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Cause of GERD
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inappropriate relaxation of the LES- reflux of gastric contents, worsened by chocolate, EtOH, tobacco etc
- may have hiatal hernia |
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Clinical features of GERD
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- worse at night or when supine
- retrosternal burning pain - may mimic cardiac disease - cough - hoarseness, sore throat - early sateity |
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Diagnosis of GERD
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usually can be diagnosed by clinical history alone and trial of therapy
- Endoscopy with biopsy is test of choice (should be done when there is weight loss, anemia etc) - need to monitor for development of cancer after 5 yrs - 24 hour pH monitoring = gold standard but rarely needed -esophageal manometry |
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Complications of GERD
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- Barrett's esophagus- squamocolumnar metaplasia- transition to intestinal mucosa. Screening every 3 yrs. Tx: long term PPIs
- stricture- fibrotic rings |
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Tx of GERD
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1st - Behavior mod - elevated bed, avoid meals before bed + Antacid with meals
2- H2 blocker 3- PPI 4- promotility- metochlopramide or bethanecol 5- PPI + promotility 6- nissen fundoplication |
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Diarrhea- acute vs chronic
Common of causes of acute |
acute- 2-3 weeks, chronic > 4 weeks
Causes: Viral is most common - rotavirus and norwalk. - Bacterial is more severe- Shigella, salmonella, clostridium perfringens, E. coli - Protozoa- giardia, entamoeba, cryptosporidium - medication related- antibiotics- C. difficile - malabsorption- lactose intolerance, celiac, pancreatic insufficiency - rapid onset = s. aureus- preformed toxins |
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Antibiotic associated diarrhea?
Treatment? |
Mild- metronidazole (flagyl)
Severe- vancomycin |
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Elderly person with PVD, bloody diarrhea and abdominal pain
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ischemic colitis/bowel
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Keys to ddx of diarrhea
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bloody?
recent travel undercooked food sick contacts assoc sx: n/, fever Any other medical probs- HIV, hyperthyroidism? medications |
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Laboratory tests for diarrhea
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CBC, fecal leukocytes, only need cultures if leuks present
- culture for ova and parasites |
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Dysentery
cause? Treatment? |
Severe diarrhea with fecal pus or blood and rectal tenesmus
- caused by shigella - ampicillin |
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Most frequent acid/base status in diarrhea?
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metabolic acidosis + hypokalemia
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Indications for hospitalization in severe diarrhea?
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- dehydration
- unable to tolerate PO. - toxic appearing, high fever - bloody stools, brisk bleeding |
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Treatment of severe diarrhea
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Abx will shorten duration of illness by 24 days
- Ciprofloxacin x 5 days - only use loperamide (anti-diarrheal) in mild to moderate diarrhea without fever or blood-- want to eliminate toxin |
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Causes of constipation
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1. low fiber
2. medications- SSRIs, calcium channel blockers, narcotics (no tolerance), anticholinergics (antipsychotics, diphenhydramine, oxybutinin (ditropan)) |
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Acute onset of diarrhea (within 1-6 hours after exposure and resolves within 24 hours)?
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s. aureus- preformed toxins
- do not give abx- want to get rid of the toxin - mayonaise containing food- potato salad |
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most common cause of acute bacterial diarrhea?
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camplobacter
tx: erythromycin |
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E. coli O157: H7
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- bloody diarrhea
- undercooked meat - swimming - associated with hemolytic uremic syndrome and TTP |
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voluminous "rice water" stool
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vibrio cholera
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Causes of constipation
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medications- narcotics
hypercalcemia hypothyroidism diabetic autonomic neuropathy Parkinson's obstruction |
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If you suspect abdominal obstruction what test should you get?
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abdominal xray looking for air fluid levels
(CT may show transition points) |
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Treatment of constipation
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1- behavioral changes- increased exercise, inc fiber, inc fluid
2. senna- softener 3. enema 4. suppository |
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Irritable bowel syndrome
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At least 3 weeks of abdominal pain and bloating relieved by passing stool with:
- alternation of constipation and diarrhea - mucus in stool - straining or urgency- incomplete emptying - bloating or distention |
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Irritable bowel syndrome
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At least 3 weeks of abdominal pain and bloating relieved by passing stool with:
- alternation of constipation and diarrhea - mucus in stool - straining or urgency- incomplete emptying - bloating or distention |
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Treatment of IBS
- diarrhea predominant - constipation predominant |
- diarrhea- loperamide, diphenoxylate
- constipation- colace (softener), psyllium (bulk forming-metamucil), cisapride - probiotics- bifidobacterium - zelnorm- serotonin agonist |
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most common causes of n/v
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viral gastroenteritis, food poisoning
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Causes of n/v
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- pregnancy
- DKA - chemo drugs - viral gastroenteritis - bowel obstruction - EtOH - acute MI - PUD, GERD - acute visceral conditions- pancreatitis, cholecystitis, appendicitis - ileus - increased ICP, vertigo, migraine |
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Approach to n/v- key questions
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- relation to eating
- anyone else sick - blood in vomit - fever, diarrhea - medications - history of abdominal surgery (most common cause of obstruction is adhesions) |
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What does bilious vomitting tell you?
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obstruction is beyond the ampulla of Vater in the 2nd portion of the duodenum
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Coffee-ground emesis?
Feculent emesis? projectile vomiting? vomiting of undigested food? |
1. signifies GI bleed
2. distal intestinal obstruction 3. pyloric stenosis or inc ICP 4. esophageal stricture, achlasia |
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Approach to n/v- tests
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- CBC and electrolytes
- glucose anf LFTs - abd xray- if obstruction suspected - preg test - head CT - upper GI endoscopy if PUD or esophageal varices - RUQ US if cholecystitis suspected |
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What acid base disorder would you see in vomiting? What type of fluids would you give?
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metabolic alkalosis with hypokalemia
- fluids: 1/2 NS + K |
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Tx of n/v
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procloperazine (compazine), promethazine (phenergan)
- small meals or pure liquid diet - NG suction |
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Types of hemorrhoids
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Internal- above pectinate line- no sensation/pain - assoc with cirrhosis
- External- below pectinate line- painful |
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Risk factors for hemorrhoids
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- constipation
- obesity - cirrhosis - pregnancy - prolonged sitting or standing |
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Sx of hemorrhoids
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bleeding and rectal prolapse
- if external hemorrhoid becomes thrombosed- sudden onset of pain |
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Tx of hemorrhoids
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- Sitz baths
- stool softeners - high fiber/ high fluid diet - rubber band ligation - surgery |
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Causes of low back pain- how do you differentiate
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1. musculoligamentus strain- immediate onset of pain, pain with twisting or bending. Pain to palpation over paraspinal muscles pain does not radiate distal to knee because no nerve root is injured.
2. Degenerative disc disease- Osteoarthritis- see osteophytes, chronic low back pain, pain caused by activity and relieved by rest 3. disc herniation- 95% occur at L5-S1 or L4-L5, low back pain with stiffness and radiculopathy 4. Vertebral compression fracture- acute back pain caused by minimal stress in an elderly person, people with osteoporosis, on long term steroids 5. lumbar spinal stenosis- often caused by degenerative disc disease, neurogenic claudication- pain is worse with extension and relieved with flexion-- leaning forward 6. malignancy - night pain is key feature, most often metastatic from lung, breast (osteoblastic), prostate (osteoclastic), kidney, thyroid 7. infection- osteomyelitis- infection in the disc space, source could be UTI, IV drug abuse, skin abscess- if neuro deficits then surgical emergency 9. cauda equina syndrome- loss of bowel and bladder- S2,3,4 (parasympathetic, S2-4 keeps the poop off the floor), impotence, saddle anesthesia- surgical emergency |
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most common cause of blindness worldwide
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chlamydia trachomatis
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bilateral red, itchy eyes, nasal discharge
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allergic conjunctivitis
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Treatment of bacterial conjunctivitis
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erythromycin, ciprofloxacin
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Treatment of gonorrheal conjunctivitis
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ceftriaxone 1g IM
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Treatment of chlamydia
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erythromycin, doxycycline, tetracycline
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Clinical features of obstructive sleep apnea
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daytime tiredness, hypertension, morning headache, polycythemia
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diagnosis of OSA
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polysomnography (overnight sleep study)
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