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77 Cards in this Set

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

neuropathic pain, muscle pain, inflammatory pain, mechanical/compressive pain, and mixed
Caution is necessary when initiating tramadol in patients who are taking
serotonin reuptake inhibitors, as cotreatment can increase the risk for serotonin syndrome.
For patients with high cardiovascular risk, this drug may be a safer choice
naproxen than diclofenac or ibuprofen. Diclofenac associated with increased cardiovascular risk compared with other NSAIDs, ibuprofen interferes with antiplatelet effects of aspirin
pregabalin dose that provides substantial pain relief for postherpetic neuralgia, diabetic neuropathy, and fibromyalgia
at 600 mg/d
patients with postherpetic neuralgia and diabetic neuropathy, this treatment produces better pain relief with fewer adverse reactions.
combination therapy with gabapentin and nortriptyline, as compared with monotherapy with each agent,
a physician-completed risk-stratification tool that can be helpful for determining which patients are most suitable for opioid therapy
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
caution when using methadone
QT-interval prolongation, hypotension, and cardiac arrhythmias. obtain baseline EKG, after 30d treatment, then annually thereafter
define acute cough
cough < 3weeks
most common cause of rhinosinusitis (the common cold) and acute bronchitis
viruses (influenza A and B, parainfluenza, coronavirus, rhinovirus, and RSV)
Nonviral causes of common cold / acute bronchitis
Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Bordetella pertussis (whooping cough)
ACE-induced cough
~15% of patients on ACE, begins within 1 wk of therapy, d/c meds, cough abates in 1-4 weeks
most common cause of subacute cough
post-infectious
differentials for cough if infectious origin unlikely
upper airway cough syndrome (UACS, previously postnasal drip syndrome), asthma, pertussis, acid reflux, or acute exacerbation of primary lung disease
define chronic cough / most common causes
cough > 8 weeks; UACS, asthma, nonasthmatic eosinophilic bronchitis (NAEB), GERD
first line therapy for UACS
first-generation antihistamines and decongestants
treatment for UACS
=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
sputum eosinophilia but are without airway hyperreactivity
NAEB, inhaled corticosteroids
Effective treatment modalities for GERD
dietary and lifestyle modification + PPI x 1-3 months
treatment for chronic cough
(When disease-based specific therapy fails) centrally acting narcotic (morphine or codeine) or nonnarcotic (dextromethorphan) medications; peripherally acting antitussives may also be beneficial
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
tuberculosis, Pneumocystis jirovecii pneumonia, and aspergillosis.
The most common causes of hemoptysis
infection (airway inflammation) and malignancy
all patients with hemoptysis should undergo
CXR and if indicated CT chest / bronch
define chronic fatigue syndrome (CFS)
distinct entity of fatigue that persists for 6 months or more
define idiopathic chronic fatigue.
Chronic fatigue >6 months' duration that does not meet criteria for CFS
Diagnostic criteria developed for chronic fatigue syndrome. The International CFS Study Group definition
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)
four categories of dizziness:
(1) vertigo, (2) presyncope, (3) dysequilibrium, and (4) other causes
Central causes of vertigo
vascular disease and stroke, mass lesions of the brainstem and cerebellum, multiple sclerosis, migraine, and seizures
Peripheral causes of vertigo
BPPV, vestibular neuronitis, Meniere disease
Dix-Hallpike maneuver,
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
most common cause of vertigo
BPPV
in BPPV, hearing affected,
labyrinthitis
classic triad of Meniere disease (idiopathic endolymphatic hydrops)
vertigo, unilateral low frequency hearing loss, and tinnitus
treatment for BPPV
Epley maneuver
three major drug classes that may modify the intensity of symptoms of BPPV
Vestibular suppressants and antiemetic drugs (antihistamines, benzodiazepines, and phenothiazines) steroids not beneficial
preferred diagnostic test for central vertigo
MRI of the brain with angiography
NOTE: CBT has been to shown to be more effective for both primary and secondary insomnia than drug therapy
x
Nonbenzodiazepine GABA-receptor agonists
zolpidem and zaleplon
Zolpidem is associated with cases of somnambulism, such as nocturnal eating, driving, and walking
x
antidepressants that are most efficacious for use in insomnia are low-dose trazodone or mirtazapine
x
Dopaminergic agents may be helpful for patients with insomnia associated with restless legs syndrome
x
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
x
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.
x
Neurocardiogenic syncope, the most common type, is predominantly a clinical diagnosis
x
Without the surge in vagal tone, bradycardia is absent; this variant is called vasodepressor syncope
x
Orthostatic hypotension is characterized by an abnormal drop in blood pressure with standing (greater than 20 mm Hg systolic or 10 mm Hg diastolic
x
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
x
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).
x
Clues to structural heart disease include relationship to exercise or exertion, sensitivity to volume status, and association with medications
x
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.
x
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
x
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
x
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)
x
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.
x
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.
x
PE findings in pulmo HTN
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.
Causes of bilateral edema
heart failure, nephrotic syndrome, cirrhosis, hypoproteinemia, constrictive pericarditis, chronic venous insufficiency, lymphedema, and medications
medications that cause bilteral edema
minoxidil, nifedipine, amlodipine, thiazolidinediones, NSAIDs, and fludrocortisone
most common causes of unilateral leg edema
eep venous thrombosis, cellulitis, and malignant lymphedema
treatment of chronic venous insuff (stasis edema) or lymphedem
Sodium restriction, leg elevation, and compressive stockings; avoid diuretic therapy
straight-leg raise test
reproduction of pain extending below the knee with 10 degrees to 60 degrees of leg elevation
associated with increased pain when walking and relief when sitting, often called neurogenic claudication or pseudoclaudication
Lumbar spinal stenosis
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
MRI, (CT myelography is alternative)
First-line pharmacotherapy for most patients with acute low back pain
acetaminophen and NSAIDs
When is surgery beneficial in LBP?
only in patients with disk herniation causing persistent radiculopathy, patients with painful spinal stenosis, and patients with cauda equina syndrome
Tx of cauda equina syndrome?
medical emergency - prompt surgical decomperssion
how to differentiate rotator cuff injury vs AC joint pathology?
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.
preferred imaging modality (>90% sensitivity) for rotator cuff pathology
MRI
treatment of ulnar nerve entrapment?
splinting, NSAIDs, and surgical decompression when severe
when to image wrist and hand pain
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
diagnostic standard for carpal tunnel syndrome (sensitivity >85%, specificity >95%)
Nerve conduction studies
first line therapies for CTS
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
when is surgery indicated in CTS?
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
NOTE: If clinical suspicion for a scaphoid fracture is high, treatment
should not be delayed even if radiographs are normal, as lack of treatment can lead to avascular necrosis.
most frequent cause of lateral hip pain
trochanteric bursitis
treatment of trochanteric bursitis
correction of the underlying etiology, heat, stretching, and corticosteroid injection
ntrapment of the lateral femoral cutaneous nerve
meralgia paresthetica
anterior, lateral, posterior hip pain differentials
anterior = OA; lateral = troch bursitis / meralgia paresthetica; posterior = sacroiliitis, lumbosacral disk disease