Mksap 16 General Medicine 06 Common Symptoms

Front 1

Based on findings from the history and physical examination, a patient's pain should be classified into one of five types:

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neuropathic pain, muscle pain, inflammatory pain, mechanical/compressive pain, and mixed

Front 2

Caution is necessary when initiating tramadol in patients who are taking

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serotonin reuptake inhibitors, as cotreatment can increase the risk for serotonin syndrome.

Front 3

For patients with high cardiovascular risk, this drug may be a safer choice

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naproxen than diclofenac or ibuprofen. Diclofenac associated with increased cardiovascular risk compared with other NSAIDs, ibuprofen interferes with antiplatelet effects of aspirin

Front 4

pregabalin dose that provides substantial pain relief for postherpetic neuralgia, diabetic neuropathy, and fibromyalgia

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at 600 mg/d

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patients with postherpetic neuralgia and diabetic neuropathy, this treatment produces better pain relief with fewer adverse reactions.

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combination therapy with gabapentin and nortriptyline, as compared with monotherapy with each agent,

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a physician-completed risk-stratification tool that can be helpful for determining which patients are most suitable for opioid therapy

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DIRE score (Diagnosis, Intractability, Risk, and Efficacy) ; higher scores (more severe disease, clearly intractable pain, lower psychosocial risk, no chemical dependence history, and higher efficacy of opioids already used) predict greater success with treatment

Front 7

caution when using methadone

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QT-interval prolongation, hypotension, and cardiac arrhythmias. obtain baseline EKG, after 30d treatment, then annually thereafter

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define acute cough

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cough < 3weeks

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most common cause of rhinosinusitis (the common cold) and acute bronchitis

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viruses (influenza A and B, parainfluenza, coronavirus, rhinovirus, and RSV)

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Nonviral causes of common cold / acute bronchitis

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Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Bordetella pertussis (whooping cough)

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ACE-induced cough

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~15% of patients on ACE, begins within 1 wk of therapy, d/c meds, cough abates in 1-4 weeks

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most common cause of subacute cough

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post-infectious

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differentials for cough if infectious origin unlikely

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upper airway cough syndrome (UACS, previously postnasal drip syndrome), asthma, pertussis, acid reflux, or acute exacerbation of primary lung disease

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define chronic cough / most common causes

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cough > 8 weeks; UACS, asthma, nonasthmatic eosinophilic bronchitis (NAEB), GERD

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first line therapy for UACS

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first-generation antihistamines and decongestants

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treatment for UACS

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=unless symptoms point to specific diagnosis or definitive finding on CXR, empiric therapy x 2-3 weeks; if no response, evaluate and treat for asthma, NAEB, and GERD

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sputum eosinophilia but are without airway hyperreactivity

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NAEB, inhaled corticosteroids

Front 18

Effective treatment modalities for GERD

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dietary and lifestyle modification + PPI x 1-3 months

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treatment for chronic cough

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(When disease-based specific therapy fails) centrally acting narcotic (morphine or codeine) or nonnarcotic (dextromethorphan) medications; peripherally acting antitussives may also be beneficial

Front 20

In addition to being at risk for the common community-acquired infections seen in the immunocompetent host, the immunocompromised patient is at risk for various opportunistic infections that may present with cough, such as

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tuberculosis, Pneumocystis jirovecii pneumonia, and aspergillosis.

Front 21

The most common causes of hemoptysis

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infection (airway inflammation) and malignancy

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all patients with hemoptysis should undergo

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CXR and if indicated CT chest / bronch

Front 23

define chronic fatigue syndrome (CFS)

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distinct entity of fatigue that persists for 6 months or more

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define idiopathic chronic fatigue.

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Chronic fatigue >6 months' duration that does not meet criteria for CFS

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Diagnostic criteria developed for chronic fatigue syndrome. The International CFS Study Group definition

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medically unexplained fatigue >6 months' after evaluation, + 4 or more of: subjective memory impairment, sore throat, tender lymph nodes, muscle or joint pain, headache, unrefreshing sleep, and postexertional malaise lasting longer than 24 hours; exclusion criteria include the presence of substance abuse, an eating disorder, an underlying psychiatric disorder, dementia, or severe obesity (BMI ≥ 45)

Front 26

four categories of dizziness:

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(1) vertigo, (2) presyncope, (3) dysequilibrium, and (4) other causes

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Central causes of vertigo

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vascular disease and stroke, mass lesions of the brainstem and cerebellum, multiple sclerosis, migraine, and seizures

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Peripheral causes of vertigo

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BPPV, vestibular neuronitis, Meniere disease

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Dix-Hallpike maneuver,

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sit upright, turn head 45 degrees, keep both eyes open. examiner supports head and, patient instructed to lie down, rapidly place head below table. note nystagmus and subjective symptoms. repeated on opposite side

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most common cause of vertigo

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BPPV

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in BPPV, hearing affected,

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labyrinthitis

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classic triad of Meniere disease (idiopathic endolymphatic hydrops)

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vertigo, unilateral low frequency hearing loss, and tinnitus

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treatment for BPPV

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Epley maneuver

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three major drug classes that may modify the intensity of symptoms of BPPV

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Vestibular suppressants and antiemetic drugs (antihistamines, benzodiazepines, and phenothiazines) steroids not beneficial

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preferred diagnostic test for central vertigo

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MRI of the brain with angiography

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NOTE: CBT has been to shown to be more effective for both primary and secondary insomnia than drug therapy

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x

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Nonbenzodiazepine GABA-receptor agonists

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zolpidem and zaleplon

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Zolpidem is associated with cases of somnambulism, such as nocturnal eating, driving, and walking

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x

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antidepressants that are most efficacious for use in insomnia are low-dose trazodone or mirtazapine

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x

Front 40

Dopaminergic agents may be helpful for patients with insomnia associated with restless legs syndrome

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x

Front 41

OTC melatonin is available, and in this form is a nonspecific agonist of melatonin receptors. It may be helpful for short-term use for jet lag and other circadian rhythm disorders; however, its effectiveness compared with specific melatonin receptor agonists available by prescription for acute and chronic insomnia is not known

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x

Front 42

Carotid sinus syncope occurs after mechanical manipulation of the carotid sinuses, altering sympathetic and parasympathetic tone; it may be reproduced by carotid sinus massage and is more common in the elderly, in men, and in those with underlying structural heart disease.

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x

Front 43

Neurocardiogenic syncope, the most common type, is predominantly a clinical diagnosis

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x

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Without the surge in vagal tone, bradycardia is absent; this variant is called vasodepressor syncope

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x

Front 45

Orthostatic hypotension is characterized by an abnormal drop in blood pressure with standing (greater than 20 mm Hg systolic or 10 mm Hg diastolic

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x

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unique variant of orthostatic intolerance is postural orthostatic tachycardia syndrome, usually seen in young women and related to inadequate venous return with significant tachycardia; patients may experience symptoms of lightheadedness and palpitations, but not syncope

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x

Front 47

Clues to arrhythmia include brief or absent prodrome, palpitations immediately preceding the episode, and syncope occurring in the supine position. (An exception is ventricular tachycardia, which usually has a warning prodrome of more than 5 seconds and associated diaphoresis).

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x

Front 48

Clues to structural heart disease include relationship to exercise or exertion, sensitivity to volume status, and association with medications

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x

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Despite its low diagnostic yield, a 12-lead electrocardiogram (ECG) remains the first and most widely recommended test to perform in patients being evaluated for syncope, partly owing to its noninvasive nature, availability, and low cost.

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x

Front 50

Echocardiography is recommended in patients suspected of having structural heart disease. If an arrhythmia is suspected, documentation of the arrhythmia is indicated either by inpatient telemetry or ambulatory monitoring

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x

Front 51

For neurocardiogenic causes, management may consist of patient education with specific instructions on abortive and preventive strategies. These isometric counter-pressure maneuvers include leg crossing, hand-grip, squatting, and muscle tensing. β-Blockers are no longer indicated in vasovagal syncope

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x

Front 52

High-risk patients requiring immediate in-hospital telemetry are those with exertional or supine syncope, palpitations before the event, a family history of sudden death, nonsustained ventricular tachycardia, and abnormal ECG findings (conduction abnormalities, bradycardia)

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x

Front 53

In a meta-analysis describing the value and limitations of the chest pain history in the evaluation of patients with suspected acute myocardial infarction, radiation to the right arm or shoulder and radiation to both arms or shoulders had the highest positive likelihood ratios (LR+) of 4.7 and 4.1, respectively.

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x

Front 54

In aortic dissection: Asymmetric intensity of peripheral pulses (pulse deficit) is a strong predictor (LR+ 5.7), and the chest radiograph may demonstrate a widened mediastinum.

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x

Front 55

PE findings in pulmo HTN

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jugular venous pressure is often elevated, there may be a parasternal heave, the S2 heart sound is widely split, and the P2 (pulmonic valve) component of S2 is loud.

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Causes of bilateral edema

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heart failure, nephrotic syndrome, cirrhosis, hypoproteinemia, constrictive pericarditis, chronic venous insufficiency, lymphedema, and medications

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medications that cause bilteral edema

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minoxidil, nifedipine, amlodipine, thiazolidinediones, NSAIDs, and fludrocortisone

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most common causes of unilateral leg edema

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eep venous thrombosis, cellulitis, and malignant lymphedema

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treatment of chronic venous insuff (stasis edema) or lymphedem

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Sodium restriction, leg elevation, and compressive stockings; avoid diuretic therapy

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straight-leg raise test

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reproduction of pain extending below the knee with 10 degrees to 60 degrees of leg elevation

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associated with increased pain when walking and relief when sitting, often called neurogenic claudication or pseudoclaudication

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Lumbar spinal stenosis

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preferred imaging in patients with rapidly progressive neurologic symptoms (but not stable mild neurologic symptoms), cauda equina syndrome, or suspicion for epidural abscess or osteomyelitis

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MRI, (CT myelography is alternative)

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First-line pharmacotherapy for most patients with acute low back pain

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acetaminophen and NSAIDs

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When is surgery beneficial in LBP?

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only in patients with disk herniation causing persistent radiculopathy, patients with painful spinal stenosis, and patients with cauda equina syndrome

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Tx of cauda equina syndrome?

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medical emergency - prompt surgical decomperssion

Front 66

how to differentiate rotator cuff injury vs AC joint pathology?

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Pain that occurs between 60 and 120 degrees of abduction suggests a rotator cuff impingement syndrome, whereas pain with more than 120 degrees of abduction favors AC joint pathology.

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preferred imaging modality (>90% sensitivity) for rotator cuff pathology

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MRI

Front 68

treatment of ulnar nerve entrapment?

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splinting, NSAIDs, and surgical decompression when severe

Front 69

when to image wrist and hand pain

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all patients with wrist or hand pain with both a history of trauma and localized tenderness to palpation to exclude fracture. Radiographs are also helpful in patients with suspected osteoarthritis

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diagnostic standard for carpal tunnel syndrome (sensitivity >85%, specificity >95%)

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Nerve conduction studies

Front 71

first line therapies for CTS

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avoidance of repetitive motions involving the wrist and hand and nocturnal splinting of the wrist at a neutral angle; 2-week course of oral corticosteroids appears to be effective on at least a short-term basis

Front 72

when is surgery indicated in CTS?

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patients with at least moderately severe disease with persistent symptoms (6 or more months), severe motor impairment, and nerve conduction studies that confirm the diagnosis

Front 73

NOTE: If clinical suspicion for a scaphoid fracture is high, treatment

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should not be delayed even if radiographs are normal, as lack of treatment can lead to avascular necrosis.

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most frequent cause of lateral hip pain

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trochanteric bursitis

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treatment of trochanteric bursitis

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correction of the underlying etiology, heat, stretching, and corticosteroid injection

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ntrapment of the lateral femoral cutaneous nerve

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meralgia paresthetica

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anterior, lateral, posterior hip pain differentials

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anterior = OA; lateral = troch bursitis / meralgia paresthetica; posterior = sacroiliitis, lumbosacral disk disease