INTERNAL MEDICINE BOARDS - PART 2 doc

AMBULATORY MEDICINE 54 ■ Empiric therapy is often indicated in the absence of a suspected organic etiology. Oral phosphodiesterase inhibitors (sildenafil, vardenafil, tadalafil) are first-line therapy but are contraindicated with nitrates or ac- tive cardiac disease (can cause hypotension and sudden death). ■ Psychosexual counseling is first-line therapy for psychogenic ED. ■ Second-line therapies include intraurethral alprostadil suppositories, vac- uum constrictive pumps, and penile prostheses. Prostatitis The differential includes acute bacterial prostatitis, chronic bacterial prostati- tis, nonbacterial prostatitis, and prostatodynia. See Table 2.15 for key features of each. SYMPTOMS/EXAM Presents with irritative voiding symptoms and perineal or suprapubic pain. Acute bacterial prostatitis is notable for the presence of fever and an exqui- sitely tender prostate. TREATMENT Table 2.15 outlines the treatment of prostatitis and prostatodynia. Genital Lesions Table 2.16 outlines the differential diagnosis and treatment of STIs that pre- sent as genital lesions. Figures 2.23 through 2.26 illustrate genital HSV le- Rapid onset of ED suggests psychogenic causes or medication side effects. More gradual onset is associated with medical conditions. Low libido along with ED suggests a psychogenic, medication- related, or hormonal cause. TABLE 2.14. Medical Conditions Associated with ED CONDITION EXAMPLES/COMMENTS Psychogenic disorders Performance anxiety, depression, mental stress. Obesity, physical inactivity Diabetes mellitus ED is seen in up to 50% of cases. Peripheral vascular disease Endocrine disorders Hypogonadism, hyperprolactinemia, thyroid abnormalities. Pelvic surgery Spinal cord injury Drugs of abuse Amphetamines, cocaine, marijuana, alcohol, tobacco. Medications Antihypertensives: Thiazides, β-blockers, clonidine, methyldopa. Antiandrogens: Spironolactone, H 2 blockers, finasteride. Antidepressants: TCAs, SSRIs. Other: Antipsychotics, benzodiazepines, opiates. All patients with genital lesions should be screened for syphilis (serology). AMBULATORY MEDICINE 55 sions, genital warts, syphilitic chancre, and chancroid, respectively. Refer to the Women’s Health chapter for a detailed discussion of gonorrheal and chlamydial infections (cervicitis, PID). The diagnosis and treatment of ure- thritis in men follow the same principles as those of cervicitis in women. ORTHOPEDICS Rotator Cuff Tendinitis or Tear The spectrum of pathology ranges from subacromial bursitis and rotator cuff tendinitis to partial or full rotator cuff tear. Due to excessive overhead motion (e.g., baseball players). SYMPTOMS Presents with nonspecific pain in the shoulder with occasional radiation down the lateral arm that worsens at night or with overhead movement. Motor weakness with abduction is seen in the presence of a tear. TABLE 2.15. Treatment of Prostatitis and Prostatodynia ACUTE BACTERIAL CHRONIC BACTERIAL NONBACTERIAL PROSTATITIS PROSTATITIS PROSTATITIS PROSTATODYNIA Fever +− −− UA +− −− Expressed Contraindicated. ++− prostatic secretions Bacterial culture ++ −− Prostate exam Very tender. Normal, boggy, or Normal, boggy, or Usually normal. indurated. indurated. Etiology Gram- ᮎ rods (E. coli); Gram-ᮎ rods; less Unknown; perhaps Varies; includes voiding less commonly gram- ᮍ commonly enterococcus. Ureaplasma, dysfunction and pelvic organisms (enterococcus). Mycoplasma, Chlamydia. floor musculature dysfunction. Treatment IV ampicillin and TMP-SMX; Erythromycin × 3–6 α-blocking drugs (e.g., aminoglycosides until fluoroquinolones × weeks if response at two terazosin) for bladder organism sensitivities 6–12 weeks. weeks. neck and urethral are obtained; then spasms; switch to benzodiazepine and fluoroquinolones × 4–6 biofeedback for pelvic weeks. floor dysfunction. Adapted, with permission, from Tierney LM et al. Current Medical Diagnosis & Treatment, 43rd ed. New York: McGraw-Hill, 2003: 914. AMBULATORY MEDICINE 56 TABLE 2.16. Differential Diagnosis of Genital Lesions GENITAL WARTS (CONDYLOMATA HSV ACUMINATA)1° SYPHILIS CHANCROID Cause HSV-2 > HSV-1. HPV. Treponema pallidum. Haemophilus ducreyi. Incubation 1°: +/− asymptomatic; 1–6 months; triggers 2–6 weeks. 3–5 days. period/ prodrome consists of include pregnancy and triggers malaise, genital immunosuppression. paresthesias, and fever. Reactivation: Most commonly occurs with symptoms; triggers include stress, fever, and infection. Symptoms Painful, grouped vesicles; Warty “cauliflower” Painless, clean-based Pustule or pustules tingling, dysesthesia. growths or none. ulcer (“chancre”). erode to form a painful Asymptomatic shedding ulcer with a necrotic base. is common. Exam Groups of multiple, small Warty growths or none. Ulcer on genitalia; Usually unilateral, vesicles. nontender regional tender, fluctuant, matted lymph nodes. nodes with overlying erythema. Diagnosis Mostly clinical; ᮍ viral Clinical if wartlike; 4% Serology: RPR ᮍ 1–2 Culture of lesion on culture or DFA or Tzanck acetic acid applied to the weeks after the special media. smear with ᮍ intranuclear lesion turns tissue white 1° lesion is first inclusions and with papillae. seen. multinucleated giant cells. Immunofluorescence or darkfield microscopy of fluid with treponemes. Treatment Acute episodes: Acyclovir Trichloroacetic acid; Benzathine penicillin Azithromycin 1 g PO × 1 400 mg TID, famciclovir podophyllin G IM × 1; in penicillin- or ceftriaxone 250 mg 250 mg TID, valacyclovir (contraindicated in allergic patients, IM × 1. 1000 mg BID × 10 days pregnancy); imiquimod. doxycycline or tetracycline (first episode) or × 5 PO × 2 weeks. days (recurrence). Suppression: Acyclovir 400 mg BID or famciclovir 250 mg BID or valacyclovir 500 mg BID or 1 g QD. AMBULATORY MEDICINE 57 E XAM ■ Exam reveals pain with abduction between 60 and 120 degrees. Tears lead to weakness on abduction (“drop arm test”). ■ Pain elicited by 60–120 degrees of passive abduction (impingement sign) suggests impingement or trapping of an inflamed rotator cuff on the over- lying acromion. DIFFERENTIAL ■ Bicipital tendinitis: Due to repetitive overhead motion (e.g., throwing, swimming). Exam reveals tenderness along the biceps tendon or muscle. ■ Degenerative joint disease. ■ Systemic arthritis: RA, pseudogout. FIGURE 2.24. Penile warts. Note the multiple soft, filiform papules on the glans penis and prepuce. (Reproduced, with permission, from Wolff K et al. Fitzpatrick’s Color Atlas & Synopsis of Clinical Der- matology, 5th ed. New York: McGraw-Hill, 2005: 888.) FIGURE 2.23. 1° HSV infection in a female. Note the multiple, painful, grouped vesicles. (Reproduced, with permission, from Wendel GD, Cunningham FG: Sex- ually transmitted diseases in pregnancy. In Williams Obstet- rics, 18th ed. (Suppl 13). Norwalk, CT: Appleton & Lange, August/September 1991.) FIGURE 2.26. Chancroid. Note the multiple painful, punched-out ulcers with under- mined borders on the labia. (Reproduced, with permission, from Kasper DL et al. Harrison’s Principles of Internal Med- icine, 16th ed. New York: McGraw-Hill, 2004.) FIGURE 2.25. Syphilitic chancre. This dry-based, painless ulcer with indurated borders is typ- ical for a 1° chancre in a male patient. (Reproduced, with permission, from Bondi EE et al. Dermatology: Diagnosis & Treatment. Stamford, CT: Appleton & Lange, 1991: 394.) AMBULATORY MEDICINE 58 ■ Referred pain: May be derived from a pulmonary process (e.g., pul- monary embolism, pleural effusion), a subdiaphragmatic process, cervical spine disease, or brachial plexopathy. ■ Adhesive capsulitis (frozen shoulder): Presents with progressive loss of range of motion (ROM), usually more from stiffness than from pain. Can follow rotator cuff tendinitis; more common in diabetics and older pa- tients. DIAGNOSIS ■ Diagnosis is made by the history and exam. ■ An MRI can be obtained if a complete tear is suspected or if no improve- ment is seen despite conservative therapy and the patient is a surgical can- didate. TREATMENT ■ ↓ exacerbating activities; NSAIDs. ■ Steroid injection is a common treatment but is no more effective than NSAID therapy. ■ ROM exercises and rotator cuff strengthening can be initiated once acute pain has resolved. ■ Refer to orthopedics for possible surgery if there is a complete tear or if no improvement is seen with conservative therapy after several months. Knee Pain Table 2.17 outlines the etiologies and clinical characteristics of common knee injuries. DIAGNOSIS ■ In a patient who presents after acute trauma, the Ottawa Knee Rules identify situations in which x-ray imaging is necessary to rule out a knee fracture. These guidelines recommend that an x-ray be obtained if any of the following is present: ■ Patient age ≥ 55 years. ■ Tenderness at the head of the fibula. ■ Isolated patellar tenderness. ■ Inability to bear weight both immediately after trauma and on exam. ■ Inability to flex the knee to 90 degrees. ■ MRI is most sensitive for soft tissue injuries (e.g., meniscal and ligament tears). Foot and Ankle Pain A common reason for 1° care visits; may be acute or chronic. DIFFERENTIAL See Table 2.18 for common causes of foot pain. DIAGNOSIS In acute ankle or foot pain after trauma, use the Ottawa Ankle Rules to deter- mine the need for x-ray imaging (see Figure 2.27). Knee swelling immediately post-trauma suggests a ligamentous tear (with hemarthrosis). Swelling occurring hours to days after trauma suggests meniscal injury. The thin female teenager who is an “exercise nut” is particularly prone to stress fractures. AMBULATORY MEDICINE 59 Lower Back Pain (LBP) Extremely common, with up to 80% of the population affected at some time. Three-quarters of LBP patients improve within one month. Most have self- limited, nonspecific mechanical causes of LBP. EXAM ■ A 1° goal of initial evaluation is to rule out serious conditions as indicated by neurologic or systemic findings (see below). ■ A straight-leg raise test is ᮍ and indicates nerve root irritation if passively straightening the leg in the supine or seated position causes radicular pain at less than a 60-degree angle. Has poor specificity (40%) but excellent sensitivity (80%) for lumbar disk herniation. TABLE 2.17. Common Knee Injuries ILIOTIBIAL PATELLOFEMORAL MEDIAL MENISCUS BAND SYNDROME ANSERINE BURSITIS PAIN SYNDROME TEAR ACL TEAR Those Runners; Runners, obese or Runners/ Twisting of the knee Twisting trauma, affected/ deconditioned deconditioned deconditioned while the foot is often in noncontact mechanism patients. patients, people patients, often with firmly planted on sports (e.g., who work on their chondromalacia of the ground (soccer, skiing). knees. the patella. More football). common in women. Symptoms Lateral knee pain Pain medial and Anterior knee pain; Pop or tear at time Audible “pop” and that is gradual; inferior to the knee often exacerbated of injury; severe giving way; tightness after joint. by walking up and pain with “locking,” immediate running. down stairs/hills. “catching,” and swelling. swelling that peaks the next day. Exam Tenderness over Localized Pain on patellar Medial joint line ᮍ anterior drawer the lateral femoral tenderness. compression while tenderness; pain sign, ᮍ Lachman’s epicondyle. the patient contracts on hyperflexion and test, effusion. the quadriceps. hyperextension; Exam is often effusion; ᮍ nonspecific. McMurray’s test. Treatment Rest and abstain Avoid exacerbating Quadriceps Treat conservatively: Conservative; ACL from running until activities. Hamstring strengthening, avoid RICE (rest, ice, reconstruction if symptoms subside. stretches and flexion loads, compression, the patient has a Then resume gentle quadriceps bicycling may be elevation); high activity level. stretching, strengthening. well tolerated. quadriceps especially before strengthening with running. physical therapy; surgery only if symptoms persist. New-onset back pain in a patient with a previous diagnosis of cancer represents metastasis until proven otherwise. Spinal cord compression is a neurosurgical emergency. AMBULATORY MEDICINE 60 TABLE 2.18. Common Causes of Foot and Ankle Pain CAUSE SEEN IN/ETIOLOGY SYMPTOMS DIAGNOSIS TREATMENT Plantar Obese patients, Plantar pain, especially Tenderness over insertion ↓ prolonged standing; fasciitis prolonged standing, with first steps in of the plantar fascia at arch supports; NSAIDs; runners. morning. the medial heel. Bone stretches. In 80% of spurs on x-ray are cases, symptoms neither sensitive nor resolve within one year. specific for plantar fasciitis. Stress fracture Runners, especially Foot pain that worsens X-ray may miss early Hard-soled shoe or women. with weight bearing. fractures. Obtain bone walking cast for 3–4 scan or MRI in the weeks. Avoid presence of high exacerbating activities suspicion and when x-ray until fully healed. is ᮎ. Metatarsalgia Seen in those with Pain in the area of the Clinical diagnosis; Avoid offending shoes; prolonged pressure on metatarsal heads (one exclude other etiologies. NSAIDs. the anterior feet, or multiple). especially from high heels. Morton’s Entrapment of the Forefoot pain and Usually a clinical diagnosis Broad-toed shoes, neuroma interdigital nerve. Affects paresthesias radiating (tenderness in affected orthotics, corticosteroid women more than men. to toes; the third web web space); MRI can injections. Surgery should space is classic. Patients confirm when surgery is be reserved for feel pain while wearing a consideration. refractory cases. shoes but not when barefoot. Bunions Those who use ill-fitting Foot pain in the area of Deformity of the first Pain control and well- (hallux footwear. Women are the first metatarsal. MTP joint with valgus fitting shoes for early valgus) affected more than deviation of the great toe. bunions; surgical men. correction (osteotomy) when pain/functional impairment are severe. Gout Those with risk factors Sudden onset of Inflammatory signs at NSAIDs, colchicine, oral for gout. Men are exquisite pain in the the first MTP. Other joints or intra-articular affected more than first MTP with redness/ or risk factors for gout corticosteroids. women. swelling. Can also may be present. present as midfoot or Achilles tenosynovitis. AMBULATORY MEDICINE 61 ■ A wide-based gait and a ᮍ Romberg sign are specific signs of spinal steno- sis. ■ Exam may also localize the origin of the nerve root syndrome (see Table 2.19). DIFFERENTIAL ■ Serious causes of back pain can be distinguished as follows: ■ Cancer: Age > 50, a previous cancer history, unexplained weight loss. ■ Compression fracture: Age > 50, significant trauma, a history of osteo- porosis, corticosteroid use. ■ Infection (epidural abscess, diskitis, osteomyelitis, or endocarditis): Fever, recent skin or urinary infection, immunosuppression, IV drug use. ■ Cauda equina syndrome: Bilateral leg weakness, bowel or bladder in- continence, saddle anesthesia. ■ Less urgent causes of back pain include herniated disk; spinal stenosis; sciatica; musculoskeletal strain; and referred pain from a kidney stone, an intra-abdominal process, or herpes zoster. Table 2.20 outlines the distin- guishing features of herniated disk and spinal stenosis. DIAGNOSIS ■ The history and clinical exam are helpful in identifying the cause. ■ A plain x-ray is indicated only if fracture, osteomyelitis, or cancer is being considered. Plain films are insensitive for metastasis, infection, and disk disease. ■ MRI (or CT) is indicated urgently in cases of suspected cauda equina syn- drome, cancer, or infection. For patients with suspected disk disease, imag- ing is not indicated unless symptoms persist for > 6 weeks or significant neurologic findings are present, particularly if surgery is being considered. ■ The specificity of MRI is low, and care should be taken to intervene only when symptoms and physical findings can clearly be attributed to the ab- normalities found on imaging. TABLE 2.18. Common Causes of Foot and Ankle Pain (continued) CAUSE SEEN IN/ETIOLOGY SYMPTOMS DIAGNOSIS TREATMENT Achilles Athletes. Consider Pain with running or Tenderness at the Achilles NSAIDs, stretches, tendinitis Achilles tendon tear and jumping that worsens insertion on the avoidance of offending spondyloarthropathies in with dorsiflexion of the calcaneus. Consider an activity. the differential. foot. MRI if Achilles tendon tear is suspected. Tarsal tunnel Entrapment of the Heel/plantar foot pain Tinel’s sign— NSAIDs, corticosteroid syndrome posterior tibial nerve and paresthesias. Pain reproduction of injections, orthotics. under the medial flexor at night and after symptoms by tapping the retinaculum. Can be prolonged weight tibial nerve posterior and post-traumatic or from bearing. inferior to the medial chronic overuse. malleolus. X-ray is indicated to rule out associated bony abnormalities. Back pain causes— DISC MASS Degeneration (DJD, osteoporosis, spondylosis) Infection/Injury Spondylitis Compression fracture Multiple myeloma/Mets (cancer of the breast, kidney, lung, prostate, or thyroid) Abdominal pain/Aneurysm Skin (herpes zoster), Strain, Scoliosis, and lordosis Slipped disk/ Spondylolisthesis AMBULATORY MEDICINE TREATMENT ■ For mechanical causes of acute LBP, conservative therapy with NSAIDs and muscle relaxants, education, and early return to ordinary activity are indicated in the absence of major neurologic deficits or other alarm symp- toms, as most cases of LBP resolve within 1–3 months. Bed rest is ineffec- tive. ■ Massage and manipulation by a chiropractor or physical therapist are safe and effective for benign, mechanical causes of LBP. ■ Spinal stenosis can be treated with exercises to ↓ lumbar lordosis. Epidural corticosteroid injections provide some relief. Decompressive laminectomy may provide at least short-term symptom improvement for a majority of patients. Surgery for lumbar disk herniation is reserved for refractory radic- ular symptoms (duration > 6 weeks) or severe motor deficits. FIGURE 2.27. Ottawa Ankle Rules for x-rays in ankle/foot trauma. (Reproduced, with permission, from Tintinalli JE et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 6th ed. New York: McGraw-Hill, 2004.) TABLE 2.19. Nerve Root Syndromes (Sciatica) NERVE ROOT STRENGTH SENSORY REFLEXES S1 Ankle plantar flexion (toe walking). Lateral foot. Achilles. L5 Great toe dorsiflexion. Medial forefoot. None. L4 (less common) Ankle dorsiflexion (heel walking). Medial calf. Knee jerk. 62 “Red flags” in the history of a patient with new-onset back pain: ■ Age > 50 ■ History of cancer ■ Fever ■ Weight loss ■ IV drug use ■ Osteoporosis ■ Lower extremity weakness ■ Bowel or bladder dysfunction [...]... TAMPONADE 120 Electrophysiology 121 VENTRICULAR TACHYCARDIA AND VENTRICULAR FIBRILLATION 121 ATRIAL FIBRILLATION 123 ATRIAL FLUTTER 125 PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA 126 83 Copyright © 20 08 by Tao Le Click here for terms of use WOLFF-PARKINSON-WHITE SYNDROME 126 CARDIAC SYNCOPE 128 BRADYCARDIA 130 INDICATIONS FOR PERMANENT PACING 131 SUDDEN CARDIAC DEATH 1 32 IMPLANTABLE CARDIOVERTER-DEFIBRILLATORS... VALUES (PPV AND NPV), LIKELIHOOD RATIOS TA B L E 2 32 2 × 2 Table, Assuming 20 % Disease Prevalence DISEASE PRESENT Test ᮎ TOTALS 180 40 22 0 a Test ᮍ DISEASE ABSENT b AM BU LATORY M E DIC I N E Totals ■ ■ + Disease − + a − c ■ b d Test Sn = a a+c Sp = d b+d ■ ■ c d 20 760 20 0 800 780 1000 From this table, one can calculate PPV and NPV: ■ PPV = a / a + b = 180 /22 0 = 81.8% ■ NPV = d / c + d = 760/780 = 97.4%... hypertension (see Table 2. 23) Other modifiable cardiovascular risk factors (diabetes, hyperlipidemia, smoking) should be screened for and treated in hypertensive individuals TA B L E 2 22 Lifestyle Modifications for Hypertension MEASURE Sodium restriction COMMENTS No added salt or low-sodium diet DASH diet (Dietary Approaches to Stop A diet rich in fruits, vegetables, and low-fat Hypertension) dairy... effective the treatment NNT = 1 / absolute risk reduction An example is as follows: TA B L E 2 33 2 × 2 Table, Assuming 2% Disease Prevalence DISEASE PRESENT Test ᮎ TOTALS 18 49 867 a Test ᮍ DISEASE ABSENT b Totals 78 c d 2 931 20 980 933 1000 ■ ■ ■ A randomized trial finds that subjects treated with a placebo have a 25 % incidence of adverse outcome X Subjects treated with drug A have a 14% incidence of... Differentiate between central and peripheral vertigo as indicated in Tables 2. 25 and 2. 26 Peripheral vertigo is often more severe than central Unintentional Weight Loss Defined as an unintended weight loss of > 5% of usual body weight over 6– 12 months Unintentional weight loss is associated with excess morbidity and TA B L E 2 25 vertigo but should not have any associated neurologic symptoms Causes... Bronchospasm; indications high-degree (type II second- or thirddegree) heart block 66 Pregnancy Pregnancy High-degree heart block TA B L E 2 24 Smoking Cessation Methods METHOD MECHANISM/USE SIDE EFFECTS CONTRAINDICATIONS Nicotine replacement (patch, Apply patch daily Chew gum Skin irritation (patch); gum, inhaler, nasal spray) or use nasal spray/inhaler mucosal irritation (nasal life-threatening arrhythmia,... the same diagnostic test with the same sensitivity and specificity, if the disease prevalence were 2% , the values in the 2 × 2 table would change (see Table 2. 33) In this population, the PPV and NPV are different: ■ PPV = a / a + b = 18/67 = 26 .9% ■ NPV = d / c + d = 931/933 = 99.8% In this population, only 26 .9% of ᮍ results occur in people who truly have the disease; 99.8% of ᮎ results occur in people... ■ the first-line agent of choice ■ ■ The goal of BP management is < 140/90, or < 130/80 in patients with diabetes, renal disease, or cardiovascular disease All patients with prehypertension and stages 1 and 2 hypertension should be counseled about lifestyle modification (see Table 2. 22) If a brief trial of nonpharmacologic therapy fails, medications should be added for those with stage 1 or 2 hypertension... screen-detected disease appear to have better outcomes than those with inherently aggressive disease diagnosed because of symptoms ■ ■ Screen-detected patients will always live longer than clinically detected patients even if early detection and treatment confer no benefit because of lead-time and length-time biases Hypothesis Testing ■ 80 p-value: A quantitative estimate of the probability that a particular... is 20 % Given a total population of 1000 individuals, the 2 × 2 table of disease status/test result can be constructed as shown in Table 2. 32 highly valuable diagnostic test LRs are applied to pretest probabilities (the likelihood, before performing a diagnostic test, that the patient has the disease in question) to either ↑ (ᮍ test) or ↓ (ᮎ test) the likelihood that disease is present TA B L E 2 31 . McGraw-Hill, 20 03: 914. AMBULATORY MEDICINE 56 TABLE 2. 16. Differential Diagnosis of Genital Lesions GENITAL WARTS (CONDYLOMATA HSV ACUMINATA)1° SYPHILIS CHANCROID Cause HSV -2 > HSV-1. HPV heart block. second- or third- degree) heart block. AMBULATORY MEDICINE DIAGNOSIS/TREATMENT Differentiate between central and peripheral vertigo as indicated in Tables 2. 25 and 2. 26. Unintentional. punched-out ulcers with under- mined borders on the labia. (Reproduced, with permission, from Kasper DL et al. Harrison’s Principles of Internal Med- icine, 16th ed. New York: McGraw-Hill, 20 04.) FIGURE