A 34-year-old African-American female patient was seen for a routine health check-up related to new employment. Her history, physical examination and routine laboratory results (urinalysis, lipid profile, complete blood count, glucose, creatinine, BUN, and electrolytes) were all within normal limits. Her blood pressure was found to be 142/92 mm/Hg. EKG was performed and demonstrated normal sinus rhythm.
She was advised to come for a second visit within two weeks to re-check her blood pressure. On this occasion blood pressure was 140/90 mm/Hg. Which one of the following is the best management for this patient?
Educational objective: understanding of the diagnostic process for hypertension.
Many patients are anxious when visiting the physician’s office, and blood pressure values measured on these occasions may be significantly higher than during normal daily activities (so called “white-coat” hypertension). It has been shown that patients diagnosed as hypertensive at the first office visit have a mean 15/7 mm/Hg fall in blood pressure by the third visit, and some patients do not reach stable value until the sixth visit.
In light of the above data, it is recommended that, in the absence of end-organ damage, a patient not be diagnosed with mild or moderate hypertension unless the blood pressure remains elevated after three to six visits (even with these criteria about 20-25% of patients with mild hypertension in the office will have normal blood pressures at home).
Educational objective: Review clinical presentation of primary HIV infection.
Primary HIV infection is symptomatic in 50-90% of patients, but is frequently unrecognized because of the nonspecific symptoms. Following are symptoms identified as part of the presentation of primary HIV infection:
o Fever – 96% o Adenopathy – 74% o Pharyngitis – 70% o Rash – 70% o Myalgias and arthralgias – 54% o Diarrhea – 32% o Headache – 32% o Nausea and vomiting – 27% o Hepatosplenomegaly 14% o Thrush – 12%
Another sign consistently seen is weight loss (5 kg in average). Hematuria is, however, not part of the presenting picture of primary HIV infection.
Educational objective: Understand epidemiology of HIV epidemic.
Mode of transmission for HIV infection for U.S. adult and adolescent population (2004):
It is important to note that in the developing world the most common mode of transmission is heterosexual contact.
Educational objective: Review indications for 3-day antibiotic therapy for urinary tract infection.
Using a single large dose of antibiotics for 3 days in a young woman with an uncomplicated urinary tract infection is appropriate. However, a short course of therapy is contraindicated in diabetics, men, pregnancy, urologic abnormalities, immunosuppression diseases, and older age groups.
Educational objective: Review risk factors for cardiovascular disease.
High HDL, which is defined as HDL cholesterol > or = 60 mg/dL, reduces risk of CHD by one and is known as a negative risk factor. Positive risk factors include: Male > or = 45 years, female > or = 55 years or premature menopause without estrogen replacement therapy, family history of premature CHD (male sibling or father who died of CHD before 55 years of age or female sibling or mother who died of CHD before 65 years of age), current cigarette smoking, hypertension (whether taking medications or not), diabetes mellitus and low HDL, which is defined as HDL< 35 mg/dL.
A 32-year-old homosexual man was seen in the office for whitish plaques inside his mouth. On examination typical lesions of the oral candidiasis were found on buccal mucosa. In addition he reported having occasional fever and diarrhea. The HIV serologic testing was ordered and came back positive.
In which stage of HIV infection is this patient most likely to be?
Educational objective: Review natural history of HIV infection.
The HIV-1 infection is divided in the following stages:
Early symptomatic HIV infection is characterized by the following conditions (all of which may occur in association with other disorders, but are more frequent or severe with HIV infection):
Educational objective: Review diagnostic criteria for rheumatoid arthritis.
The American College of Rheumatology criteria for rheumatoid arthritis includes: morning stiffness for at least one hour, present for at least 6 weeks; symmetric joint swelling; swelling of the wrist, metacarpophalangeal or proximal interphalangeal joints for six or more weeks; rheumatoid nodules; serum rheumatoid factor by a method positive in less than 5% of normals; hand roentgenogram changes typical of rheumatoid arthritis that must include erosions or unequivocal bony decalcification.
Educational objective: Understand natural history of HIV infection.
The average life expectancy for HIV-infected patients in the absence of treatment is about 10 years. The rate of progression may depend on the mode of transmission (faster for transfusion mode than for intravenous drug users or homosexual men). In addition it appears that age at infection is also a major determinant of progression. In one study, time from seroconversion to AIDS was 15 years for patients infected in age group 16-24 years and 6 years for those infected after age of 35.
Characteristics of the virus itself may also influence the rate of progression (a cohort of patients from Australia � 1 blood donor and 8 recipients � have very slow progression and virus has deletion of part of genetic material).
Educational objective: Review risk factors for DVT.
Obesity, malignancy, previous DVT, prolonged immobilization, trauma, estrogen therapy and surgery > 30 minutes are all significant risk factors for DVT.
Educational objective: Review cancers associated with CEA.
CEA is associated with colorectal, gastric, pancreatic, breast, lung, bladder, ovarian, and prostate malignancies; whereas hepatocellular carcinoma and choriocarcinoma are associated with alpha fetoprotein and beta HCG markers respectively.
Educational objective: Review indications for PCP prophylaxis.
PCP remains the leading initial AIDS-defining illness and an important cause of death in patients with AIDS. Widespread use of prophylaxis has diminished the incidence of PCP.
Risk factors for the development of PCP include (and indicate need for prophylaxis): - A history of previous PCP - A CD-4 count below 200 mm3 (about 95% of cases occurs below this level) - Recurrent undiagnosed fever, night sweats, oropharyngeal thrush, and unintentional weight loss among patients with CD-4 count above 200 mm3. - Primary prophylaxis can be safely discontinued in patients whose CD4 cell count rises above 200/mm3 for 3 months on combination antiretroviral therapy. Secondary prophylaxis (maintenance therapy) in patients with a history of PCP can also be stopped in this context.
Prophylaxis reduces both the incidence of PCP infections and mortality in those patients who do develop PCP. It has been repeatedly shown that prophylaxis for PCP is cost-effective.
Educational objective: Review features of gouty arthritis.
Synovial fluid analysis is the only definitive method of diagnosing gouty arthritis. Joint fluid aspiration and demonstration of characteristic needle shaped negatively birefringent monosodium urate crystals by polarizing microscopy confirms the diagnosis. Gram stain and culture should be performed on all fluid to rule out infection. Urinary uric acid excretion of more than 800 mg/day suggests overproduction, and normal serum uric acid level does not rule out gout.
Joint X-rays may demonstrate erosions in late disease. In the United States renal stones are caused by uric acid in 10% of the cases; if history suggests, abdominal flat plate should be obtained and possibly IV pyelography (since stones are often radiolucent).
Educational objective: Review therapy for gouty arthritis.
Colchicine inhibits neutrophil activation by inhibiting crystal-induced protein tyrosine phosphorylation and thus diminishes inflammatory reaction in gout. Colchicine may be given orally and intravenously. Most patients can�t tolerate oral colchicine therapy because of GI side effects. Intravenous administration is potentially dangerous (agranulocytosis, aplastic anemia, myopathy and alopecia. A fatal dose of colchicines can be as little as 8 mg in 24 hours). Nonsteriodal anti-inflammatory drugs and intraarticular glucocorticoids may also be used in the therapy of acute gouty arthritis.
During acute attack of gouty arthritis, administration of allopurinol is contraindicated. Acute attacks of gout are more frequent during initial therapy with allopurinol. This may be due to active dissolution of microcrystalline deposits of sodium urate (tophi) resulting in a transient period of hyperuricemia and crystal deposition in joint tissue.
Educational objective: Review options for PCP prophylaxis.
Several different regimens have established the efficacy of PCP prophylaxis. Trimethoprim-sulfamethoxazole has a number of advantages when used for PCP prophylaxis. It is active not only against PCP, but also toxoplasma gondii, isospora, salmonella, listeria, nocardia, legionella, haemophilus influenzae, streptococcus pneumoniae, staphylococcus aureus, and many gram-negative bacilli. The major risk factor for the prophylaxis failure is a CD-4 count below 50 mm3. Aerosolized pentamidine, dapsone and atovaquone are also efficient in preventing PCP, but are second-line drugs and used when there is allergy to TMP-SMX or therapy cannot be tolerated due to side effects (25-50% of cases � fever, rash, bone marrow suppression, and transaminases elevations).
Clindamycin with pyrimethamine appears not to be effective and is often complicated by diarrhea.
The correct answer is A: Medial collateral ligament sprain Educational objective: Review differential diagnosis for Baker's cyst rupture.
Differential diagnosis of popliteal swelling includes the following conditions: Phlebitis (superficial) Neoplasm (lipoma, neurofibroma, osteogenic sarcoma, fibrosarcoma, etc.) Lymphadenitis Aneurysm of the popliteal artery Trauma (fractures, contusions, traumatic neuromas) Ruptured tendon DVT Osteomyelitis Ruptured varicose vein Popliteal abscess Baker's cyst
An 82-year-old man is brought to the office by his family because of recent urinary incontinence. The patient has gradually lost functions of daily living over the past 10 years. He has problems with his memory, understanding what his family says, agitation, and is getting lost outside the home. He needs assistance with the activities of daily living.
The patient's medical history includes constipation, hypertension and angina. He is taking HCTZ, metoprolol and lorazepam. On examination, he is quiet, in no distress, and appears unchanged from previous visits. The patient had a urinalysis and urine culture and results were normal.
The first recommendation you should make is:
Educational objective: Review common causes and treatment of urinary incontinence in the elderly population.
Urinary incontinence is common in elderly persons: About than 30% of the elderly report difficulty holding urine until they go to the bathroom some of the time, and 8% report difficulty most or all of the time. Urinary incontinence affects quality of life and contributes to institutionalization.
An efficient approach to transient or recent-onset incontinence consists of evaluation for commonly occurring precipitants, as specified by the mnemonic DIAPPERS: Delirium, Infection, Atrophic vaginitis, Pharmaceuticals, Psychological factors (depression etc), Excess urine output (excess fluid intake, alcohol, caffeine, diuretics, peripheral edema, hyperglycemia, hypercalcemia), Restricted mobility, and Stool impaction.
This patient appears to have a slowly progressive dementia with features typical of Alzheimer�s dementia. Urinary incontinence occurs in the course of this illness, most likely due to apraxia, decreased awareness, decreased mobility, inability to find the bathroom, and other factors. A vital function of the physician caring for persons with dementia is to minimize "excess disability" from medications, medical conditions, and other causes.
Benzodiazepines are commonly associated with confusion, particularly in patients with chronic cognitive impairment, and are therefore best avoided. In addition, these medications are frequently associated with urinary incontinence, most likely through decreased mental functioning.
A condom catheter may eventually be useful in the management of this patient's incontinence, but it is inappropriate to treat the symptom of incontinence without addressing potential treatable acute and chronic causes.
B-blockers are not commonly associated with incontinence.
Although excess disability due to medical illness occurs in demented patients, it is not efficient to investigate occult problems with blood tests before treating likely causes of new onset incontinence. Although prompted voiding has been successful in improving urinary incontinence in nursing home patients who initially respond to this approach, it would be more appropriate first to remove common precipitating factors.
Educational objective: Review assessment of functional capability among the elderly population.
Assessment of the activities of daily living is an integral part of the assessment of the elderly patient. Activities of daily living include the following:
Basic activities of daily living Dressing, Eating, Ambulating, Toileting, Hygiene (DEATH) Instrumental activities of daily living Shopping, Housekeeping, Accounting, Food preparation, Transportation (SHAFT)
It is enough to first inquire about one or two instrumental activities of daily living. If the patient is capable of those, there is no need for further inquiry.
Educational objective: Review causes of presbycusis.
Presbycusis is characterized by gradual hearing loss with aging that is manifested by difficulty understanding speech in noisy surroundings. Hearing loss is sensorineural with loss of the neuroepithelial cells, lesions of the neurons and of the stria vascularis. Hearing aids are the most common modality of treatment.
Match the following type of lung cancer to commonly associated clinical syndromes:
Adenocarcinoma
Educational objective: Review different clinical syndromes occurring in association with malignant neoplasms.
Adenocarcinoma is the one lung cancer most commonly associated with hypertrophic osteoarthropathy (clubbed fingers, etc.) and bronchioalveolar carcinoma is often characterized by the production of a large amount of watery sputum. Squamous cell cancer often causes hypercalcemia and hypophosphatemia due to production of PTH or PTH-related peptides. Small cell lung cancer is associated with SIADH, secretion of the atrial natriuretic hormone and ACTH. Large cell lung cancer is associated with gynecomastia and galactorrhea.
Educational objective: Emphasize the importance of pelvic inflammatory disease.
Pelvic inflammatory disease (PID) comprises a spectrum of inflammatory disorders of the upper genital tract among women and may include any combination of endometritis, salpingitis, tuboovarian abscess and pelvic peritonitis. PID is, by definition, a community- acquired infection initiated by a sexually transmitted agent. This distinguishes PID from pelvic infections caused by medical procedures, pregnancy or other primary abdominal processes. It is estimated that PID in the USA accounts for approximately 2.5 million outpatients visits, 200,000 hospitalizations, and 100,000 surgical procedures per year. PID is the most frequent gynecologic cause for emergency room visits at 350,000 visits per year. It is also estimated that the annual total expense for this disorder is over $5 billion.
Educational objective: Review risk factors for pelvic inflammatory disease.
Risk factors that increase probability of PID include: 1- Age less than 25 years 2- New, multiple or symptomatic sexual partners 3- Oral contraception 4- African-American ethnicity 5- Nonbarrier contraception 6- Previous episode of PID
Educational objective: Review clinical features of pelvic inflammatory disease.
Lower abdominal pain is the cardinal presenting symptom in women with PID although the character of the pain may be quite subtle. Recent onset of pain that occurs during menses or coitus or with jarring movement may be the only presenting symptom of PID--onset of pain during or shortly after menses is particularly suggestive. Pain is usually bilateral and rarely of more than 2-3 weeks duration.
Abnormal uterine bleeding occurs in one-third or more of patients with PID. New vaginal discharge, urethritis, proctitis, fever, and chills can be associated signs but are neither sensitive nor specific for the diagnosis. The presence of PID is less likely in symptoms referable to the bowel or urinary tract predominates.
On physical examination, only about one-half of patients with PID have fever. Abdominal examination reveals diffuse tenderness greatest in the lower quadrants, which may or may not be symmetrical. Decreased bowel sounds and rebound tenderness are common. Marked tenderness in the right upper quadrant may represent perihepatitis (Fitz-Hugh Curtis syndrome), which occurs in about 10% of patients. Pelvic examination may reveal a purulent endocervical discharge and/or marked acute tenderness of the uterine cervix (this finding is strongly suggestive of PID) Rectovaginal examination reveals uterus and adnexa as a focus of tenderness. Diagnosis of PID should be seriously questioned if there is no uterine or adnexal tenderness on rectovaginal examination. Significant lateralization of the adnexal tenderness is uncommon in PID.
A 34-year-old patient with HIV infection who is taking highly effective antiretroviral therapy very compliantly was seen for routine control. The CD-4 cell count and viral load were ordered and came back as 189 cells/mm3 and 5000 copies/ml. His previous measurements of CD-4 cell counts were as follows -403 cells/mm3, 350 cells/mm3, 370 cells/mm3 and 385 cells/mm3 starting with earliest to the latest. His viral load results were (in the same order): 30,000 copies/ml, 23,000 copies/ml, 11,000 copies/ml and 7000 copies/ml.
Which of the following is the best course of action in this case?
Educational objective: Understand variability and significance of changes in CD-4 cell count measurements.
The CD-4 cell count is measured by flow-cytometry, and a number of factors other than HIV infection influence CD-4 cell count. These factors include seasonal and diurnal variations, some viral infections, corticosteroids, tuberculosis, and analytic variation. Awareness of the causes of fluctuations in the CD-4 cell count is particularly important for both the care provider and patient. Test results that present �milestones� for therapeutic decisions or classification of a patient as having AIDS based on CD-4 cell count below 200 cells/mm3 should be repeated immediately. This should especially be done if the values do not correlate well with prior results (like in this patient). The degree of variability was demonstrated in a multicenter AIDS cohort study where 95% confidence ranges were 297-841 mm3 for a true content of 500 mm3 and 118-337 mm3 for true content of 200 mm3.
Educational objective: Understand interpretation of changes in HIV-RNA (viral load) measurements in HIV infected patients.
All three viral load assays have a low intra-assay variation on repeated testing of a single specimen (between 0.12-0.2 log10). On the other hand, in clinically stable patients (with no change in antiretroviral therapy), the biologic variability of viral RNA measurements is about 0.3 log10. Keeping those facts in mind, changes in viral count of at least 0.5 log10 (or threefold) usually reflect biologically relevant changes in the level of viral replication. It is important not to over-interpret small increases or decreases in the viral load.
Educational objective: Reinforce the most common reason for esophageal reflux.
Although very low LES pressures are associated with esophageal reflux, the concept that one must have an incompetent LES in order to have gastroesophageal reflux disease (GERD) has changed. Ambulatory esophageal manometry has revealed that the majority of GERD occurs in patients with normal pressure lower esophageal sphincters that simply relax inappropriately without stimulation by a swallow or esophageal distention.
Ref: 1. Dent J: Patterns of Lower Esophageal Sphincter Function Associated with Gastroesophageal Reflux. American Journal of Medicine. 103:298-235, 1997. 2. Hunt R H: Importance of pH Control in the Management of GERD. Archives of Internal Medicine. 159:649-57, 1999.
The correct answer is E: Urea breath test after therapy Educational objective: Highlight the different diagnostic tests for H. pylori.
Serology will remain positive for a prolonged period, possibly years, after eradication of H. pylori. Histology and culture require repeat endoscopy and biopsy, which is not indicated in duodenal ulcer follow-up. Urea breath tests are the proper tests for follow up of H. pylori eradication, but they need a lush growth of bacteria in order to avoid a false-negative test. Proton pump inhibitors suppress the growth of H. pylori; therefore the breath test should only be done if the patient has been off these medications for at least 7 days
Educational objective: Understand the risk for HIV transmission after parenteral and mucosal and skin exposures.
The risk of becoming infected with HIV after exposure to body fluids from an HIV-infected patient is low. From the review of 23 studies of needle stick injuries, mucosal and skin exposures to an HIV-infected source, the following data have emerged: o After needle stick injuries HIV transmission occurred in about 0.33% of cases. o There was only one HIV transmission among more than 1000 exposures on the mucosal surface (0.09%) o There was no HIV transmission after more than 2500 skin exposures.
The majority of health workers affected by HIV exposure (and infection) are nurses and laboratory technicians. There are no documented seroconversions with exposure to a suture needle.
Educational objective: Illustrate some common misconceptions about peptic ulcer disease.
Individuals become infected with H. pylori during childhood. The rate of infection is higher in developing countries than in the United States. The rate of infection in the United States is falling, along with the rate of peptic ulcer and gastric cancer of the gastric corpus.
Alzheimer's disease has a well-known association with advanced age. It has been found to be more frequent in women and in persons who have suffered severe head injury (including injuries occurring up to 35 years prior to diagnosis of Alzheimer's disease in 15-20% of cases). There is also possible, but yet unproven, association with thyroid gland disorders. Epidemiological data on the risk in patients with a family history of sporadic cases are conflicting, and as of today this is not a separate risk factor. However, some families do carry specific genes that increase the incidence of Alzheimer's disease in the affected family.
A 32-year-old male presented with complaints of easy fatigue, feeling cold, constipation, and muscle cramping. Physical examination revealed a cool, rough, dry skin; puffy face and hands; hoarse voice; and slow reflexes. Blood pressure was 116/72, pulse 54 min and respiration rate was 11 min. ECG revealed low voltage QRS. Routine urinalysis, complete blood cell count, electrolytes, glucose, BUN, and creatinine were in the normal range.
Which of the following tests would be most likely to help in the diagnosis of his condition?
Educational objective: Review clinical and laboratory features of hypothyroidism in adults.
This patient presents with the clinical signs and symptoms characteristic of hypothyroidism in an adult patient. Of the all tests listed, the serum TSH level is the one to be used in this patient. In fact, TSH measurements should be combined with determination of the free thyroxin (FT4). The reason for this is that he has a typical presentation, and both tests have the ability to distinguish between primary hypothyroidism (low FT4, and high TSH) and secondary (or tertiary) hypothyroidism (low FT4, and low TSH).
Empty sella syndrome occurs when the subarachnoidal space extends into the sella turcica, partially filling it with cerebrospinal fluid. This process causes remodeling and enlargement of the sella and flattening of the pituitary gland.
Primary empty sella syndrome is caused most commonly by a congenital defect of diaphragma sellae (5-23% incidence on autopsy), and also by pituitary surgery, radiation, and postpartum pituitary infarction (Sheehan's syndrome). In addition, prolactin-secreting or growth hormone-secreting pituitary adenomas may undergo subclinical hemorrhagic infarction and cause contraction of the overlying suprasellar cistern downward to the sella. Therefore, the presence of an empty sella does not exclude the possibility of a coexisting pituitary tumor.
Most patients are middle-aged women. Many have hypertension. Serious clinical manifestations are uncommon. Spontaneous cerebrospinal fluid rhinorrhea and visual field impairment may rarely occur.
Educational objective: Review diagnostic work-up in cases of galactorrhea.
Prolactin hypersecretion is the most common endocrine abnormality due to hypothalamic-pituitary disorders, and prolactin is the hormone most commonly secreted in excess by pituitary adenomas.
The clinical manifestations of prolactin excess are the same regardless of the cause. The classic features are galactorrhea and amenorrhea in females and galactorrhea and decreased libido or impotence in men. Although the sex distribution of prolactinomas is approximately equal, microadenomas (up to 1 cm in size) are more common in females, presumably because of earlier recognition of the endocrine consequences of prolactin excess.
Educational objective: Review causes of prolactinemia.
There are many causes of hyperprolactinemia besides pituitary tumor (and those causes must be excluded in the workup of a patient with high prolactin (PRL) levels). Physiologic causes of high PRL are pregnancy, nursing, nipple stimulation, exercise, stress, and sleep. Pharmacologic causes are TRH, estrogen, VIP, all dopamine antagonists (phenothiazines, haloperidol, metoclopramide, reserpine, methyldopa, amoxapine and opiates), MAO inhibitors, verapamil and licorice. Hypothalamic/pituitary stalk lesions, neuraxis irradiation, chest wall lesions (through nipple stimulation reflex), spinal cord lesions, hypothyroidism, chronic renal failure and severe liver disease are also causes of hyperprolactinemia.
Lymphocytic hypophysitis is a rare condition leading to hyposecretion of PRL (other causes are hypophiseal destruction, pseudohypoparathyroidism, GABA, and dopamine agonist administration).
A 33-year-old female is diagnosed with pituitary adenoma (8 mm) secreting prolactin. Her symptoms are classic: galactorrhea and amenorrhea. She is about to start therapy with prolactin. She wishes to know what the chance is that this therapy will be successful.
Which one of the following describes her prognosis accurately?
Educational objective: Review prognosis of patients with prolactin secreting pituitary adenomas.
In patients with microadenomas, bromocriptine successfully reduces prolactin (PRL) levels to normal in about 80% of the cases. Approximately 10% of patients cannot tolerate the drug long-term because of persisting side effects. Another 10% are resistant to the effects of bromocriptine. Correction of hyperprolactinemia allows the recovery of normal gonadal function (mechanical contraception should be advised if pregnancy is not desired). In patients with microadenomas who become pregnant, the risk of expansion of the adenoma is less than 5% (patient and physician should be aware of this risk).
At present there is no evidence that bromocriptine causes permanent resolution of PRL-secreting microadenomas, and virtually all patients have resumption of hyperprolactinemia following discontinuation of therapy even after several years.
Educational objective: Review clinical features of acromegaly.
This patient has classic symptoms of acromegaly (hypersecretion of the growth hormone � GH). Excessive GH secretion may be secondary to hypothalamic dysfunction, but in most cases it is due to primary pituitary disorder. Pituitary adenomas are present in virtually all patients and are usually greater than 1 cm in diameter. Hyperplasia alone is rare, and nonadenomatous anterior pituitary tissue does not exhibit somatotroph hyperplasia when examined histologically. In addition, there is a return of normal GH levels and dynamic control of GH secretion following selective removal of pituitary adenoma.
Patients with acromegaly (GH secreting pituitary adenoma) have glucose intolerance in 70% of the cases, and hyperinsulinism in 50% of the cases. GH-induced insulin resistance elicits these abnormalities. Other disturbances of the endocrine system include:
Irregular or absent menses Decreased libido or impotence Hypothyroidism Galactorrhea Gynecomastia Hypoadrenalism
Local manifestation of the pituitary adenoma includes enlarged sella turcica, headache, and visual disturbances.
Educational objective: Review therapeutic options for acromegaly.
The initial therapy of choice is transsphenoidal microsurgery because of its high success rate, rapid reduction of growth hormone (GH) levels, the low incidence of postoperative hypopituitarism, and low surgical morbidity rate. Normalization of GH levels is achieved in over 80% of patients with small adenomas (less than 2 cm), whereas in those with larger tumors and basal GH levels greater than 50 ng/mL (2325 mmol/L), and particularly in those with major extrasellar extension of the adenoma, success rate may be as low as 30-60%.
Conventional external beam supervoltage irradiation is successful in 60-80% of patients, although GH levels may not return to normal until years after irradiation. The incidence of hypopituitarism is also higher than with surgery. Because of these reasons irradiation is reserved for those with persistent elevated GH levels after surgery. Heavy particle irradiation is more rapidly effective than the conventional method, but because of the irradiation field size limitation, it can be used only in patients with smaller tumors and with no extrasellar expansion. Incidence of hypopituitarism has been reported up to 40%.
Therapy with radioactive implants is limited to a few centers, and because of development of hypopituitarism, CSF rhinorrhea, and meningitis it has not gained acceptance. Octreotide acetate is effective in about 65% of cases, it is given as subcutaneous injection three times a day, and it is expensive. Therefore, it is mostly used in patients who have had incomplete response to surgery or who are awaiting the effect of radiotherapy.
Educational objective: Review changes that occur in patients with acromegaly after successful therapy.
In patients with successful reduction of growth hormone hypersecretion (acromegaly or gigantism), there is cessation of bone overgrowth. In addition these patients experience considerable clinical improvement, including reduction in soft tissue bulk of the extremities, decreased facial puffiness, increased energy, and cessation of hyperhidrosis, heat intolerance, and oily skin. Headache, carpal tunnel syndrome, arthralgias, and photophobia are also reversible with successful therapy. Glucose intolerance and hyperinsulinemia as well as hypercalciuria are also reversed in most cases.
Educational objective: Review endocrine abnormalities in Cushing's disease and the most common cause.
Cushing's disease is a primary pituitary disorder. The endocrine abnormalities in Cushing's disease are as follows: 1. Hypersecretion of ACTH with bilateral adrenocortical hyperplasia and hypercortisolism 2. Absent circadian periodicity of ACTH and cortisol secretion 3. Absent responsiveness of ACTH and cortisol to stress (hypoglycemia or surgery) 4. Abnormal negative feedback of ACTH secretion by glucocorticoids 5. Subnormal responsiveness of GH, TSH, and gonadotropins to stimulation
Iatrogenic disease is the most common cause of Cushing's syndrome, which is a state of hyperglucocorticoidism regardless of the cause.
Educational objective: Review features of Nelson's syndrome.
The clinical appearance of an ACTH-secreting pituitary adenoma following bilateral adrenalectomy in patents with Cushing's disease was initially described by Nelson in 1958.
It seems likely that Nelson's syndrome represents clinical progression of a preexisting adenoma after restraint of hypercortisolism on ACTH secretion and tumor growth is removed. The pituitary tumors in patients with classic Nelson's syndrome are among the most aggressive and rapidly growing of all pituitary tumors. These patients present with hyperpigmentation and with manifestation of expanding intrasellar mass lesion. Visual field defects, headache, cavernous sinus invasion with extraocular muscle palsies, and even malignant changes with local and distant metastases may occur. Pituitary apoplexy may also complicate the course of these tumors.
Elevated ACTH levels and radiographic changes of sella turcica (MRI may accurately define extent of tumor) establish the diagnosis.
Educational objective: Review features of TSH secreting pituitary adenoma.
Thyrothropin-secreting pituitary adenomas are rare tumors manifested as hyperthyroidism with goiter in the presence of elevated TSH. Patients with TSH-secreting tumors are often resistant to routine ablative thyroid therapy, requiring large, often multiple doses of I131 and several operations for control of thyrotoxicosis. Tumors are often large and cause visual impairment, which alert the physician to pituitary abnormality. These patients do not have extrathyroidal systemic manifestations of Graves� disease such as ophtalmopathy or dermopathy. In a few patients pituitary TSH hypersecretion may be present without a detectable adenoma.
Treatment should be directed initially at the adenoma via transsphenoidal microsurgery. However, additional therapy is usually needed due to the large size of these tumors. Octreotide acetate therapy normalizes TSH and T4 levels in more than 70% of these patients and the tumor may shrink in about 40% of patients. Pituitary irradiation is also an option, and this patient may also require thyroid ablation to control the thyrotoxicosis.
Educational objective: Review factors influencing final body height.
Genetic factors clearly influence the final height of an individual, and good correlation between average parental height and the child's height exists.
Worldwide, the most common cause of short stature is poverty and its effects. Poor nutrition, poor hygiene, and poor health influence growth both before and after birth. In people of the same ethnic group and the same geographic location, variation in stature is often attributable to these factors. Malnutrition accounts for most of this effect, but it is important to keep in mind that malnutrition may occur in the midst of plenty and should be suspected in any disorder of growth (dieting, anorexia, bulimia, etc.).
Aberrant intrafamilial dynamics, psychologic stress, or psychiatric disease can inhibit growth either by altering endocrine function or by secondary effects on nutrition.
Chronic diseases also interfere with growth (asthma, congestive heart failure). In some cases final height may be normal because of prolongation of growth period. Acute febrile illnesses have no measurable effect on final height.
Physicians have recognized the right of the patient to participate in medical decision-making for the last 25 years. The principle of autonomy, or the right to make choices about one's own life, has now become the centerpiece of modern American biomedical ethics.
Approximately 50% of individuals over 85 have dementia, which usually precludes their understanding of the medical issues and requires surrogate decision-making. In addition, many cognitively intact elderly are delirious during an acute illness and are incapable of complex discussions about their care at the time when many important decisions must be made. In these cases when a patient can't make a decision, a surrogate decision maker must be identified.
The physician must assess the patient's decision-making capacity before concluding that the patient cannot speak for himself or herself.
Educational objective: Review appropriate diagnostic procedures for thyroid nodule evaluation.
Fine-needle aspiration biopsy of a thyroid nodule has proved to be the best method of differentiation of benign and malignant thyroid disease. It is performed as an outpatient procedure and requires no preparation. A No. 25 - 1.5-inch needle is inserted into the nodule and moved in and out until a small amount of bloody material is seen in the hub of the needle. The needle is then removed, and the content of the needle is expressed onto the clean slide. A thin smear is prepared using another clean glass slide.
The slides are fixed and stained (Wright's, Geimsa's or Papanicolau's stain). The sensitivity of the technique is about 95%, and specificity also about 95%. For best results this method requires an adequate tissue sample and a trained cytologist to interpret it.
Educational objective: Review different thyroid autoantibodies.
Thyroid autoantibodies include -Thyroglobulin antibody (Tg Ab) -Thyroid peroxidase antibody (formerly called microsomal antibody) (TPO Ab) -TSH receptor stimulating antibody (TSH-R Ab stim) -TSH receptor blocking antibody (TSH-R Ab block)
Tg Ab and TPO Ab have been measured by hemagglutination, ELISA and RIA assays. Hemagglutination is much less sensitive than the later two.
TSH-R Ab stimulating and blocking are measured by a bioassay using human thyroid cells in culture and measuring the increase in thyroid cAMP following incubation with serum of IgG. The test for stimulating TSH-R Ab is positive in 90% of patients with Graves' disease and negative in Hashimoto's disease, nontoxic goiter, or toxic nodular goiter.
Educational objective: Review clinical features and pathophysiology of neonatal hypothyroidism when mother has Hashimoto's thyroiditis.
This infant presents with a clinical picture suggestive of hypothyroidism. Neonatal hypothyroidism may result form endemic goiter (due to iodine deficiency), failure of thyroid to descend and develop during embryonic development, and also from placental transfer of TSH receptor blocking antibodies from a mother with Hashimoto's thyroiditis, which may result in thyroid agenesis (athyreotic cretinism). Other rare causes include administration of iodides, antithyroid drugs, or radioiodine during pregnancy.
The introduction of routine screening of newborns for TSH or T4 has been a major achievement in the early diagnosis of neonatal hypothyroidism. A serum T4 below 6 ìg/dL or serum TSH over 30 ìU/ml is indicative of neonatal hypothyroidism.
Educational objective: Review appropriate monitoring of patients on levothyroxine therapy.
In primary hypothyroidism, the goal of therapy is to maintain plasma TSH within the normal range. Plasma TSH should be measured 2-3 months after initiation of therapy. The dose of thyroxine then should be adjusted in 12- to 25-mcg increments at intervals of 6-8 weeks until plasma TSH is normal. Thereafter, annual TSH measurement is adequate to monitor therapy.
Educational objective: Review causes of thyrotoxicosis.
Conditions associated with thyrotoxicosis: Diffuse toxic goiter (Graves� disease) Toxic adenoma (Plummer�s disease) Toxic multinodular goiter Subacute thyroiditis Hyperthyroid phase of Hashimoto�s thyroiditis Thyrotoxicosis factitia Rare forms � ovarian tumors, metastatic thyroid carcinoma (follicular), hydatiform mole, �hamburger thyrotoxicosis�, TSH-secreting pituitary tumor, pituitary resistance to T3 and T4
Educational objective: Review clinical features of Graves� disease.
This person presents with the classic clinical signs of hyperthyroidism and dermopathy suggestive of Graves� disease. Common manifestations of Graves� disease include palpitations, nervousness, easy fatigability, hyperkinesias, diarrhea, excessive sweating, intolerance to heat, and preference for cold. There is often a marked weight loss without loss of appetite. Thyroid enlargement, thyrotoxic eye signs (described below), and mild tachycardia commonly occur. More rare manifestation includes thyroid osteopathy (subperiostal bone formation � especially on metacarpal bones), and onycholysis.
Dermopathy of Graves� disease is also rare (2-3% of the patients) and is usually associated with ophtalmopathy and a very high titer of the TSH-R stimulating antibody. The skin is markedly thickened and cannot be picked up between the fingers, it is most pronounced over distal tibias, and it is due to accumulation of glycosaminoglycans.
Thyroid ophtalmopathy is due to infiltration of the extraocular muscles with lymphocytes, and edema in an acute inflammatory reaction, which causes proptosis of the ocular globe and impaired muscle movement causing diplopia.
Educational objective: Recognize signs of neutropenia in patients taking PTU.
Besides the rash that occurs in about 5% of patients, the most important side effect of the antithyroid therapy with propylthiouracil or methimazole is agranulocytosis, which occurs in approximately 0.5% of patients. Agranulocytosis requires immediate cessation of all antithyroid drug therapy, institution of appropriate antibiotic therapy, and shifting to an alternative therapy, usually radioactive iodine.
Agranulocytosis is usually heralded by sore throat and fever. Thus, all patients receiving antithyroid drugs are instructed that if sore throat and fever develop, they should stop the drug, obtain a white blood cell and differential count, and see their physician. If the white blood cell is normal, the antithyroid drug can be resumed.
Cholestatic jaundice, angioneurotic edema, hepatocellular toxicity, and acute arthralgia are other serious but rare side effects that also require cessation of therapy. Skin rash usually can be managed by a simple administration of antihistamines, and unless it is severe it is not an indication for discontinuation of the therapy.
Educational objective: Review consequences of thyroid surgery.
Subtotal thyroidectomy is the treatment of choice for patients with very large glands or multinodular goiters. The patient is prepared with antithyroid drugs until euthyroid (usually about 6 weeks). In addition, starting 2 weeks before the day of the surgery, the patient is given saturated solution of potassium iodide, 5 drops twice daily. This regimen has been shown empirically to diminish the vascularity of the gland and to simplify surgery.
Total thyroidectomy is usually not necessary unless the patient has severe progressive ophtalmopathy. However, if too much thyroid tissue is left behind, the disease will relapse. Most surgeons leave 2-3 g of thyroid tissue on either side of the neck. Many patients, however, require thyroid supplementation after surgery because of hypothyroidism.
Hypoparathyroidism and recurrent laryngeal nerve injury occur as complications of surgery in about 1% of cases. Carotid sinus is well outside the operative field and is not affected by it.
Educational objective: Review therapy for Plummer's disease.
A functioning adenoma hypersecreting T3 and T4 will cause hyperthyroidism (Plummer's disease). These adenomas start out as a "hot nodule" on the thyroid scan, slowly increase in size, and gradually suppress the rest of the thyroid. The typical patient is an older individual (usually over 40) who has noted recent growth of a long-standing thyroid nodule. Symptoms of weight loss, weakness, shortness of breath, palpitations, tachycardia, and heat intolerance are noted. Infiltrative ophtalmopathy is never present. Physical examination reveals a definitive nodule on one side with very little thyroid tissue on other side.
Laboratory studies usually reveal suppressed TSH and marked elevation in serum T3 levels, often with only borderline high thyroxin level. Toxic adenomas are almost always follicular adenomas and almost never malignant. They are usually easily managed by administration of antithyroid drugs (PTU or methimazole) followed by treatment with radioactive iodine or unilateral thyroid lobectomy. Radioactive iodine in doses 20-30 mCi is usually required to destroy a benign neoplasm.
Educational objective: Emphasize the risk of amiodarone for development of thyrotoxicosis.
Amiodarone is an antiarrhythmic drug that contains 37.3% iodine. It is stored in fat, myocardium, liver and lung. The half-life of the amiodarone in the body is approximately 50 days. About 2% of patients treated with amiodarone develop iodine-induced thyrotoxicosis, which presents a very difficult problem.
Patients taking amiodarone usually have a serious underlying heart disease, and in many cases amiodarone cannot be discontinued. If the thyrotoxicosis is mild, it can often be controlled with methimazole (40-60 mg/day) while amiodarone therapy continues. If the disease is severe, KCIO4 in a dose of 250 mg every 6 hours may be added to saturate the iodide trap and prevent further uptake of iodide. Long-term therapy with KCIO4 has been associated with aplastic anemia and requires careful monitoring. The only way to eliminate the large store of intrathyroidal hormone would be to surgically remove the goiter. This would be feasible only if the patient could withstand the stress of a thyroidectomy.
Educational objective: Review the etiology of nontoxic goiter.
Etiology of nontoxic goiter Iodine deficiency � rare in developed countries Goitrogens in the diet � iodide itself (amiodarone), lithium carbonate, etc. Hashimoto�s thyroiditis Subacute thyroiditis
Inadequate hormone synthesis due to inherited defect in thyroidal enzymes necessary for hormone synthesis Generalized resistance to thyroid hormone � rare Neoplasm � benign or malignant The common feature of all these conditions is a low level of thyroid hormones and a consequent high level of TSH, which induces thyroid cell hyperplasia.
Six criteria for evaluation of any preventive health care intervention proposed by Frame: 1. Condition needs to have significant impact on quantity or quality of life. 2. Effective treatment must be available. 3. There must be an asymptomatic period during which detection and treatment can significantly reduce morbidity and mortality. 4. Treatment during asymptomatic period must yield a therapeutic result superior to that if treatment is delayed until symptoms appear. 5. Tests to detect condition in asymptomatic period must be acceptable to the patient and available at a reasonable cost. 6. The incidence of the condition must be sufficient to justify the cost of a screening program.
Educational objective: Review laboratory findings in subacute thyroiditis.
Laboratory studies in subacute thyroiditis vary with the course of the disease. Initially, T3 and T4 are elevated and TSH is low. As the disease progresses T3 and T4 will drop to low levels, and TSH will rise. During the acute phase the most consistent laboratory finding is elevated erythrocyte sedimentation rate (sometimes as high as 100 mm/h by the Westergren scale) and extremely low radioactive iodine uptake (after the acute phase radioiodine uptake will gradually rise to normal levels, reflecting the recovery of the gland from the acute insult). Thyroid antibodies are not usually detected in the serum.
A 37-year-old female presents with an enlarged and tender thyroid gland for the last 1 week. Physical examination reveals modest enlargement of the thyroid but exquisite tenderness on palpation; there is no erythema of the overlying skin and no fluctuation that would suggest abscess.
Heart rate is 72 min, blood pressure 117/67 mm/Hg, T3 and T4 are in the normal range. ESR is 78 mm/h, and radioiodine uptake is 3%. Which of the following medications would be the most appropriate for this patient?
Educational objective: Review therapy for subacute thyroiditis.
This patient has symptoms, signs, and laboratory results consistent with subacute thyroiditis. In most cases, only symptomatic treatment is necessary. In mild cases acetaminophen (500 mg four times daily) is a good choice. If pain, malaise, and fever are more disabling, a short course of nonsteroidal anti-inflammatory drug (eg, ibuprofen) or a glucocorticoid such as prednisone for 7-10 days may be necessary to reduce the inflammation. Levothyroxine (0.1-0.15 mg/day) is indicated during the hypothyroid phase of the illness in order to prevent re-exacerbation of the disease induced by the rising levels of TSH. In about 10% of patients, permanent hypothyroidism ensues and long-term levothyroxine therapy is necessary.
Educational objective: Emphasize importance of B-blockers in therapy of hyperthyroidism.
In many tissues, hyperthyroidism is associated with an enhanced number of �-adrenergic receptors. The ensuing increase in B-adrenergic activity is responsible for many of the symptoms associated with this disorder. It also explains the ability of �-blockers to ameliorate many of the symptoms, including palpitations, tachycardia, tremulousness, anxiety, and heat intolerance. Propranolol in high doses (above 160 mg/day) can also decrease the plasma T3 concentration by as much as 30%, probably via inhibition of the 5�-monodeiodinase the converts T4 to T3 (propranolol has a short half-life and this severely limits its clinical utility). Atenolol, and metoprolol cause minimal reduction in plasma T3 level, while sotalol and nadolol produce no reduction.
The �-blockers should be given to all hyperthyroid patients who do not have a contraindication to their use. They are typically co-administered with anti-thyroid drugs.
The risk of developing alcoholic cardiomyopathy is related to both the mean daily alcohol intake and the duration of drinking. Most patients in whom alcoholic cardiomyopathy develops have been drinking more than 80 g of ethanol per day for more than 5 years. This corresponds to approximately one liter of wine, eight standard sized beers, or one-half pint of hard liquor each day. The risk is based upon the absolute amount of ethanol so that alcoholics who prefer less strong types of alcoholic beverage (such a beer) are not protected. However, individual susceptibility is important since many heavy drinkers do not develop either cardiomyopathy or liver disease.
The prevalence of alcoholic cardiomyopathy is similar in men and women with no significant differences in age or nutrition. However, when patients were matched for left ventricular ejection fraction, women consumed a significantly lower lifetime dose and lower daily dose of ethanol than men. Thus, women appear to have increased sensitivity for cardiac toxicity of ethanol.
The degree and duration of the anticoagulation are determined in part by the history (acute or chronic) and whether or not a transesophageal echocardiogram (TEE) is performed. If TEE cannot be performed, the following approach should be followed.
The patient should receive four weeks of warfarin anticoagulation (INR 2.0-3.0) prior to attempted cardioversion, and this should be followed with an additional four weeks of anticoagulation after the cardioversion.
The most common complication of the MVP is mitral regurgitation. Bacterial endocarditis is 3-8 times more common in people with MVP than in the general population. The risk of TIA and stroke secondary to embolic phenomena by fibrin and platelet thrombi in a young patient with MVP is <0.05% per year. Of the cardiac arrhythmias complicating MVP, supraventricular arrhythmias are most common, although in the rare instance of sudden death in patients with MVP, ventricular arrhythmias are most commonly implicated.
The incidence of complications in MVP is very low (<1% per year) and generally associated with an increase in mitral leaflet thickness to >5 mm. Young patients (age<45 years) with absence of the mitral systolic murmur or mitral regurgitation on Doppler echocardiography are at low risk for any complications.
Congenital stenosis of the aorta, idiopathic calcification of the aortic valve, rheumatic inflammation of the valve, and progressive stenosis of the bicuspid valve are all established etiologic mechanisms of aortic stenosis.
Syphilitic involvement of the aortic root usually results in the dilatation of the aortic root resulting in aortic insufficiency and the development of an aneurysm of the ascending part of the aortic arch.
Educational objective: Review lipid abnormalities in hypothyroidism.
Many hypothyroid patients have high serum concentrations of total cholesterol and low-density lipoprotein (LDL) cholesterol, and some have high serum concentrations of triglycerides, intermediate-density lipoproteins, apoprotein A-1, and apoprotein B. Using Frederickson�s classification it has been shown that about 56% of hypothyroid patients have type IIa dyslipidemia (hypercholesterolemia), 34% have type IIb (hypercholesterolemia and hypetriglyceridemia), 1.5% type IV (hypertriglyceridemia), and 8.5% no abnormality.
HDL cholesterol concentrations have been reported as high, normal, and low in different series.
Educational objective: Review pathophysiology of Hashimoto's disease.
Hashimoto's thyroiditis is thought to be an immunologic disorder in which lymphocytes become sensitized to thyroidal antigens. There are three most important thyroid autoantibodies: thyroglobulin antibody (Tg Ab), thyroid peroxidase antibody (formerly known as microsomal antibody) (TPO Ab), and TSH receptor-blocking antibody (TSH-R Ab block). During the early phases of Hashimoto's thyroiditis, Tg Ab is markedly elevated and TPO Ab is slightly elevated. Later Tg Ab may disappear, but TPO Ab will be present for many years. TSH-R Ab-block is found in patients with atrophic thyroiditis and myxedema and in mothers giving birth to infants with no detectable thyroid tissue (athyreotic cretins).
Antimitochondrial antibodies are present in patients with primary biliary cirrhosis and autoimmune hepatitis.
Educational objective: Review pathohistologic findings in Hashimoto�s disease.
This patient has clinical and laboratory features of Hashimoto�s thyroiditis. The pathology of Hashimoto�s thyroiditis involves heavy infiltration of lymphocytes totally destroying the thyroidal architecture. Lymphoid follicles and germinal centers may be formed. The follicular epithelial cells are frequently enlarged and contain basophilic cytoplasm (Hurtle cells).
Extensive fibrosis of the thyroid gland extending outside the gland and involving overlying muscle and surrounding tissues is characteristic of the Riedel�s struma.
Marked atypia of the follicular epithelium with visible mitoses is only a part of histologic picture of the thyroid cancer.
Infiltration of the glandular tissue with polymorphonuclear leucocytes and areas of the necrosis may be seen in rare pyogenic thyroiditis (bacterial seeding of the thyroid tissue).
Educational objective: Emphasize increase in the older age groups in the U.S.A.
Between 1980 and 1991 the population of those over 85 grew by 41% to a total of 3.2 million people, while those 75 to 84 experienced a 33% increase to total of 10.3 million. Overall, U.S. population grew 11% in same time period. An even faster acceleration of increase in the older population will begin around 2010 when the group that was part of the sharply increased birth rate following the end of World War II (�baby boomers�) begin to age and become part of the population 65 and over. Between then and 2030, it is expected that the older population will increase 75%, while those under 65 will increase only 6.5%. Since 1960 the age group 85 and older has increased 232%.
Educational objective: Review important epidemiologic characteristics of the elderly in U.S.A.
Most older men are married, and most older women are not. In 1990, among those aged 65 and older, almost twice as many men were married (74% versus 40%). More than three times as many women were widowed (14% of men, 49% of women). These differences result from the fact that women have longer life expectancy and that men are likely to marry younger women. One important consequence of this pattern is that men are more likely than women to have a spouse to assist them in the face of disability and frailty.
This same dynamic is reflected in the living arrangements of American older persons and is greatly influenced by age and race. For example, in 1990, among those aged 65 to 74, the highest proportion of the population was married and living with a spouse. White men made up the majority of this group; 80.3% were married and living with a spouse. Black women were the least likely to be married and living with a spouse (29.6%). In 1990 more than 9 million persons over 65 were living alone (79% of them were women).
Educational objective: Emphasize education as an important health-related factor.
Education is not only considered to be an indicator of economic status but it has also been shown to be associated with better health. Those aged 65 and over are less likely than younger adults to have high levels of education. Only 55% of the current older population has at least a high school education, whereas 82% of those 25 to 64 do. The tendency of younger cohorts to have higher educational attainment is apparent when the whole is broken down into smaller age categories.
Of those aged 65 to 69, 63% have completed high school, but of those 70 and over, only 46% have done so. In the coming decades more and more elderly persons are expected to have attained higher levels of education. This trend has many positive implications for health, the use of health care, change of health habits, and an increase in positive attitudes and behaviors associated with greater education.
Educational objective: Emphasize importance of functional capacity in elderly.
The presence of multiple chronic conditions increases the difficulty of measuring and describing health status. This is why the assessment of functional limitation is used to diagnose a person's overall need for health and health-related care, to monitor improvement, and to measure effect of health care and associated services on outcome. Functional capacity is subdivided into activities of daily living, including ability to transfer (in the household), bathe, feed, toilet, and dress. Instrumental activities of daily living encompass more complex tasks such as cooking, shopping, housekeeping, managing money, and social activities. Though the results from the many national and regional surveys of this approach vary, they all find similar trends of these parameters being useful in assessing and planning health care.
Educational objective: Review clinical features of delirium.
The most prominent feature of delirium is disturbance of consciousness and attention. This is usually evident when observing patient�s behavior during the medical interview. Easily distracted patients, and those who have difficulties focusing, have a high likelihood of delirium (it is important to have in mind, however, that a variety of behavioral problems can be seen in patients with delirium).
In milder cases of delirium, bedside tests of attention may be helpful. The digit span test and vigilance `A' test are examples of such tests. Patients who are unable to recall and repeat a sequence of 5 digits (meaning, they have digit span less than 5) have a high likelihood of delirium.
In milder cases of delirium, bedside tests of attention may be helpful. The digit span test and vigilance `A' test are examples of such tests. Patients who are unable to recall and repeat a sequence of 5 digits (meaning they have digit span less than 5) have a high likelihood of delirium.
Angry outbursts may be a sign of delirium, but these are much less likely in older patients who tend to have "quiet" forms of delirium. Delirium also may alter the sleep-wake cycle but in hospitalized patients this disturbance is most commonly caused by a noisy and interruptive hospital environment, as well as by acute disease itself. The Mini-Mental Status exam has poor specificity for delirium.
Both ulcerative colitis and Crohn's disease can involve the rectum but only Crohn's disease can skip the rectum. Both have an increased cancer risk that depends on the amount of mucosa involved and the duration of disease. Crohn�s disease can show skip lesions but removal of the diseased segment is not curative in Crohn's disease.
Ref: 1. Fiocchi C: Inflammatory Bowel Disease: Etiology and Pathogenesis. Gastroenterology. 115:182-205, 1998. 2. Das K M: Relationship of Extra-Intestinal Involvements in Inflammatory Bowel Disease: New Insights into Autoimmune Pathogenesis. Digestive Disease and Sciences. 44:1-13, 1999.
Educational objective: Review the features of progeria.
There are two distinct syndromes of accelerated aging: Progeria is characterized with wrinkled skin, stooped posture, and growth retardation that is recognizable by the age of 2. Patients also display striking degrees of atherosclerosis involving almost all major vessels. Myocardial infarction is the most common cause of death, usually by the age of 30. Lipofuscin has been found in unusually high concentrations within the cells of many tissues. Preliminary studies reveal results that suggest genetically directed production of �senescent enzymes� that speed up the process of aging. This disorder is rare and is caused by tiny, point mutation in a single gene, known as lamin A (LMNA) Parents and siblings of children with progeria are virtually never affected by the disease.
Werner�s syndrome is an autosomal recessive inherited disorder. Patients have short stature and develop premature cataracts, skin wrinkling, glucose intolerance, menopause, and atherosclerosis by the third decade of life. There is predisposition to rare sarcomatous tumors. Cataract of the Warner�s syndrome affects posterior surface of the lens in both eyes. Other characteristics include laryngeal atrophy and ulcerations of the skin on extremities. It appears that DNA replication is impaired (but DNA repair is normal) in this disorder.
Educational objective: Review decrease in protective function of the skin with aging.
Aging brings a number of alterations in skin and mucous membranes that diminish their effectiveness as barriers. A decrease in the surface acidity and an increase in the dryness of skin due to a decrease in the eccrine gland secretion may alter the microbial flora. The skin itself is thinner, and so older persons are more likely to sustain pressure ulcers, lacerations, or abrasions in response to minor trauma. These lesions provide portals of entry for skin bacteria to cause tissue infection or bacteremia.
The mucous membranes of the genitourinary tract and respiratory tree also appear to be less effective in their barrier function. The colonization of both areas by gram-negative organisms is increased. Alterations in secreted mucous in both areas may lead to increased bacterial adherence. Those alterations include changes in the surface glycosaminoglycans, modifications of fibronectins such that adherence is facilitated and secreted antibodies to bacterial fimbria are decreased. Alterations in cilliary function in the respiratory tree also occur.
Educational objective: Review factors that make the elderly more susceptible to infections.
As a result of the age-related impairments in swallowing, older persons normally aspirate very small amounts of mouth content. The cough mechanism is impaired with age, with the result that the force of the cough is decreased and the closing volume of the lung is earlier because of a loss of elasticity and modification of the lung architecture. This earlier closing volume appears to prevent adequate clearance of the portions of the lung with a cough (impairment of the cilliary action in the respiratory tract is also important).
The urine is less acidic, less concentrated, may have less urea, and appears to have a lower concentration of bacterial adherence-blocking proteins such as the Tamm-Horsfall mucoprotein. The prostatic fluid has less antibacterial activity, and there is less prostatic fluid in the urine of the older man. The bladder of the older person is less completely emptied, which allows pooling of the residual urine and incomplete dismissal of contaminating bacteria. The older person also has a higher potential for obstruction of the urinary tract as a consequence of benign prostatic hyperplasia (BPH), uterine prolaps, urethral stricture, and renal or bladder calculi.
Neutrophil count does not decline with advancing age.
Educational objective: Review physiological changes occurring with aging.
Presbyopia is an age-related change in vision where the closest distance of focusing increases due to loss of the elasticity of the lens and atrophy of the cilliary muscle.
Presbyacusis is the loss of hearing in both high and low frequencies due to loss of the cochlear neurons, stiffening of the basilar membrane, loss of the hair cells in the organ of Corty, thickening of the capillaries of the stria vascularis (which is the source of endolymph), and degeneration of the spiral ligament.
Body height starts to diminish after reaching its peak in the ages between 30-40. Height loss is on average 5 cm by the age of 75. This loss is due to increased hip and knee flexion, decreased vertebral body height, vertebral disk compaction, and the flattening of the foot arch.
Although changes in the muscle vary significantly between individuals there is an average relative muscle mass loss between 30-40% from age 30 to age 80.
Change of the heart with aging consists of an increase of the left ventricle mass, diminishing mass of the sinus node, calcium deposition in valves, and lipofuscin in the myocardium. Also, there is a decrease in the intrinsic sinus rate and in spontaneous heart rate variability. Systolic and diastolic blood pressures increase, maximum heart rate diminishes, but ejection fraction and resting cardiac output remain unchanged. 138GMPC
Educational objective: Review the changes in intellectual capabilities with aging.
Cross-sectional research often finds that older people perform less well than younger people on typical, standardized intelligence tests. Such studies show that intellectual abilities as measured by such tests peak in the early 40s and then gradually decline. However, cross-sectional studies confound aging effects with cohort effects. People in the older cohorts generally had fewer years of education and fewer test-taking experiences than younger people sampled in these studies. When the comparisons are corrected for education levels, the differences in intelligence test scores of different age groups are much smaller.
Longitudinal studies present a more optimistic picture of intelligence and aging. The best of these use sequential designs in which successive cohorts are followed over time. To show a true age effect, different cohorts must show the same changes at about the same age regardless of the historical period. These studies found that decrements in the intelligence testing performance are not observed until after the age of 67, and they remain fairly modest until age of 81. Furthermore, much of the decline seen in late life is attributable to the slowing of processing and increasing response times. When slowing is extracted from the data analyses, age decrements are significantly attenuated. It appears that healthy elderly may need a little more time to complete intelligence tests, but do as well as younger people if allowed extra time.
Both ulcerative colitis and Crohn's disease can involve the rectum but only Crohn's disease can skip the rectum. Both have an increased cancer risk that depends on the amount of mucosa involved and the duration of disease. Crohn's disease can show skip lesions but removal of the diseased segment is not curative in Crohn's disease.
A 91-year-old male suffered a massive hemorrhagic stroke. He has been treated in the intensive care unit. He required intubation and ventilation. His heart rate has been irregular, blood pressure dropped during the first 12 hours of treatment to less than 80 systolic. Blood pressure has been maintained for the last 6 hours with a maximal dose of dopamine. His two sons arrived in the hospital from the other part of the country. Both are very distressed. They have not seen their father for more than 4 years and plans were being made to have a family reunion in a couple of months. Patient's wife of the last 2 years is also in the hospital. She holds a durable power of attorney for health care for the patient and states that his wish would be to stop these aggressive measures of life support.
Patient's sons strongly disagree and wish to continue life support as long as possible. Which of the following is the appropriate action to be undertaken?
Educational objective: Review decision-making process in cases when incapacitated patient has designated decision maker by power of attorney.
A durable power of attorney for health care, which takes written form, is authorized by statute in practically every state. It enables a decisional person to appoint someone else (the agent) to make future medical treatment choices for him or her in the event of decisional incapacity. The agent may, but need not, be a family member. A durable power of attorney, unlike a living will, supplies an actual person who is available when decisions must be made and who is authorized to advocate for and interpret the expressed and inferred wishes of the patient. The availability of such an agent is advantageous both to the patient who needs advocacy and the physician who is trying to act according to the wishes of the incapacitated patient.
In this case the patient's wife acts as the patient's agent, and her instructions take precedence over all other wishes of the family members.
Educational objective: Review the staging of pressure ulcers.
Pressure ulcers are staged as follows: Stage I � Nonblanchable erythema of intact skin, the heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators.
Stage II � Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.
Stage III � Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
Stage IV � Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with stage IV pressure ulcers.
A 67-year-old female patient was admitted to the hospital from home for fever and increased confusion. She has been bed-bound for the last 6 months after a hip fracture. During the examination, a 4x6 cm pressure ulcer was noted in the sacral area. It was partially (about 80%) covered with thick black eschar adhering to underlying tissue.
What is the best method of debridement for this ulcer?
Educational objective: Review different methods of debridement for pressure ulcers.
Moist, devitalized tissue supports the growth of pathological organisms. Therefore, the removal of such tissue favorably alters the healing environment of a wound (this has, however, not been studied in randomized trials).
Mechanical methods of debridement include wet-to-dry dressing, hydrotherapy, wound irrigation, use of dextranomeres, enzymatic debridement, and sharp surgical debridement.
Surgical debridement should be used to remove areas of thick, adherent eschars and devitalized tissue in extensive ulcers. As the most rapid means of debridement, it is urgently indicated when there are signs of advancing cellulitis or sepsis (bone biopsy should be done at same time if osteomyelitis is a consideration).
Both ulcerative colitis and Crohn's disease can involve the rectum but only Crohn's disease can skip the rectum. Both have an increased cancer risk that depends on the amount of mucosa involved and the duration of disease. Crohn's disease can show skip lesions but removal of the diseased segment is not curative in Crohn�s disease.
A 52-year-old female has a history or GERD for many years. It is under good symptomatic relief while taking lansoprazole but returns when she attempts to stop therapy. At endoscopy, a biopsy is obtained from the distal esophagus in an area of salmon-pink mucosa. It reveals a columnar epithelium with goblet cells.
She has an increased risk for:
Educational objective: Identify the biopsy and major complications of Barrett's esophagus.
Barrett's esophagus is a pre-malignant lesion defined as specialized columnar epithelium lining in the lower esophagus and pre-disposing to adenocarcinoma of the esophagus.
Ref: 1- Morales T G, Sampliner R E: Barrett's Esophagus: Update on Screening, Surveillance and Treatment. Archives of Internal Medicine. 159:1411-1416, 1999.
Educational objective: Review the mechanism by which wet-to-dry dressing accomplishes debridement of devitalized tissue.
Wet-to-dry dressings adhere to devitalized tissue. Once the dressings are dry � usually within 4-6 hours � they can be removed and the devitalized tissue will be removed with them. The debriding function of the dressing is at least partly defeated if the dressing is moistened prior to removal. One disadvantage of wet-to-dry dressings is that they adhere to the viable tissue also so that some of the healthy granulation tissue can be removed along with the necrotic debris. The process of dressing removal may be painful; thus adequate analgesia is required. Once the wound is clean and granulating, moist dressing can be used to promote healing by secondary intention, or the wound can be repaired surgically.
Educational objective: Recall various extra-intestinal manifestations of inflammatory bowel diseases.
Arthritis associated with inflammatory bowel diseases (IBD) is a migratory asymmetrical arthritis of the elbows, wrists, hips, knees, and ankles that follows the disease activity in the bowel and responds to therapy of the IBD. Ankylosing spondylitis can be unresponsive to therapy of the IBD and have a relentlessly progressive course.
Ref: 1. Das K M: Relationship of Extra-Intestinal Involvements in Inflammatory Bowel Disease: New Insights into Autoimmune Pathogenesis. Digestive Disease and Sciences. 44:1-13, 1999.
Educational objective: Review mechanism of enzymatic debridement of devitalized tissue.
Enzymatic debridement is accomplished by applying topical debriding agents to devitalized tissues on the wound surface. This option should be considered when individuals cannot tolerate surgery or are in long-term care facilities or receiving care at home (it is important to note that this recommendation holds only if the ulcer is not infected). Collagenase is a Food and Drug Administration (FDA) approved preparation used for enzymatic debridement. Research findings indicate that collagenase promotes debridement and growth of granulation tissue within 3-30 days. Enzymes can be used alone to break down the eschar, or after sharp surgical debridement, or in conjunction with any other form of mechanical debridement (wet-to-dry dressings, wound irrigation, hydrotherapy, etc.).
A 24-year-old male presents with three weeks of diarrhea. He has noted 10 stools per day with mucous and blood but has developed a new fever and right lower quadrant abdominal pain over the last 3 days. You find him to have a fever of 38.0ºC, blood pressure of 110/70 mm/Hg, respirations 22. His abdomen is soft but diffusely tender. Stool is positive for blood and white cells but cultures and ova and parasite exams are negative. Clostridia difficile toxin is negative.
An abdominal series reveals no free air, and multiple air fluid levels and a distended colonic lumen to 6 cm. His white blood count is 15,000. Treatment for this man could involve all of the following except:
Educational objective: Review contraindications for use of anti-diarrheal agents in inflammatory bowel diseases (IBD).
This patient has a toxic presentation for his first bout of IBD. He has a risk of having a toxic mega-colon, which can be precipitated by using anticholinergics and antidiarrheal agents.
Ref: 1-Roy, M A: Inflammatory Bowel Disease. Surgical Clinics of North America. 77:1419-31, 1997. 2-Sheth, S G, LaMont J T: Toxic Megacolon. Lancet 351: 509-13, 1998.
A 33-year-old male patient with HIV infection was seen for a routine follow-up. In the interim he has been feeling fine and taking his highly effective antiretroviral therapy compliantly. He had one episode of herpes simplex infection on his lips about two weeks ago, but this resolved without difficulties and without therapy. He only took a couple of extra strength acetaminophen tablets (500 mg each) for one episode of headache during last 4 weeks. Now he feels completely healthy.
Physical examination was all within normal limits. Laboratory results revealed virtually unchanged CD-4 cell count and fivefold increase in the viral load (viral RNA measurement). Which of the following is the best course of action in this patient?
Educational objective: Review factors that may influence HIV-RNA measurements in HIV infected patients.
Although threefold change in the viral load (HIV-1 RNA levels) is considered significant in patients with HIV infection, there are certain situations when even greater change may not be significant.
It was shown that viral RNA levels could rise transiently during acute illnesses (any of the opportunistic infections � for example), an outbreak of herpes simplex infection, or after vaccination against a variety of pathogens including influenza, pneumococcus, and tetanus. These increases may be quite dramatic, up to tenfold (rarely, even greater), and may persist for a month or more. Thus, plasma HIV-1 RNA levels should not be measured within one month of any of these events.
Educational objective: Review important clues to inability of patients to swallow safely after stroke.
After a stroke about 25-45% of all patients develop dysphagia. The main problem that stems from dysphagia is aspiration pneumonia, which, if it develops, greatly complicates the clinical course and contributes to mortality. The patient in question had an attack of cough after an attempt to eat. This is a common sign of dysphagia. Physical examination of this patient revealed several findings that suggest dysphagia (facial nerve paresis and dysarthria). It is a common misconception that presence or absence of a gag reflex correlates with the risk of aspiration. This is not true. More important in the assessment of the aspiration risk are speech articulation, ability to swallow, and tongue movement. This patient has enough signs and symptoms to justify formal swallowing evaluation prior to beginning oral intake.
Many patients with dysphagia aspirate silently without coughing or choking. Nurse�s supervision during the feeding may not ensure that successful suction will be possible if patient aspirates while eating.
Dysphagia after stroke commonly improves. Hence, a permanent form of enteral feeding, such as a gastrostomy tube, is not necessary. Modification of the diet structure (giving clear liquid diet, etc.) may be a part of the dysphagia management in some circumstances, but liquids have the greatest potential for aspiration.
A nasogastric tube also may be used in certain circumstances, but it carries the risk of paranasal sinuses infection as well as aspiration of regurgitated gastric content or from malpositioned tube.
Educational objective: Review significance of the clock-drawing test.
The clock-drawing test is a sensitive means of detecting dementia of Alzheimer�s type in patients with suspected dementia. This test has two components. Patients are asked first to draw only the clock face and in the second phase to draw the hands of the clock indicating a specific time. The exact technique for conducting and scoring the test varies, but difficulty drawing the face of the clock and setting the hands of the clock has been shown to be highly sensitive and specific in differentiating among older persons who are cognitively intact and those with probable dementia of Alzheimer type.
Early onset of the disease can be detected only by sequential and detailed neuropsychological testing. There is no screening tool for detection of early Alzheimer�s dementia. Differentiation of vascular from Alzheimer�s dementia is based on patient�s history, physical examination, and laboratory assessment.
Educational objective: Review vascular lesions of the intestine.
Colonic vascular ectasia or angiodysplasia is the correct answer. They are multiple degenerative lesions of aging and are diagnosed by colonoscopy or angiography. They are caused by obstruction of the submucosal vein and subsequent dilatation of the capillary bed. Hemangiomas are the second most common vascular lesion and are usually small red-purple mounds but may be large and cavernous. Dieulafoy's ulcer is really a large artery in the mucosa or submucosa that erodes a small area of overlying mucosa and bleeds massively. Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease) is a familial disease (autosomal dominant) with skin and mucus membrane involvement with telangiectasias. Watermelon stomach is unusual and seen in older women with atrophic gastritis. It is also associated with cirrhosis.
Reference: 1-Reinus J F, Brandt L J: Vascular Ectasias and Diverticulosis Common Causes of Lower Intestinal Bleeding. Gastroenterology Clinics of North America. 23:1-20, 1994.
Eleven days after a massive stroke, patient does not have spontaneous respirations or response to any stimuli. Neurologic evaluation indicates that he is unlikely to regain consciousness. He has appointed his common law spouse to make the decisions about his health care by means of a living will in which he indicated that he does not want his life to be maintained using futile medical care. This was executed one and a half years ago while they lived in another state. Patient's spouse has requested that his hydration and nutritional support be withdrawn. The doctor treating the patient has strong moral convictions against terminating any kind of life support.
In this situation which of the following scenarios would be appropriate for the physician to follow?
Educational objective: Emphasize the rights of physicians when confronted with morally unacceptable situations.
According to the Patient Self-determination Act, physicians are obligated to comply with reasonable requests of competent patients or their appointed agents (most commonly by the durable power of attorney for health care or by the living will). There is no time limit to the validity of such appointment, and advance directive executed in one state is valid in all others.
If, despite all other conditions being met, the physician still has moral disagreement with the decisions being made he is obligated to transfer the care of the patient to a physician who is ready to comply with those decisions.
A hospital ethics committee may be useful in providing a physician with counseling but it is not necessary in this situation.
Educational objective: Review causes of falls in nursing home residents.
-Causes of Falls Among Nursing Home Residents (N- 1076 falls, 4 studies) Gait or balance disorder or weakness 26% Dizziness or vertigo 25% "Accident" or environment-related 16% Other specified causes* 12% Confusion 10% Unknown 4% Visual disorder 4% Postural hypotension 2% Drop attack 0.3% Syncope 0.2% * arthritis, acute illness, drugs, alcohol, pain, epilepsy, and falling from bed
Accidents are the fifth leading cause of death among older adults, and falls constitute two thirds of these accidental deaths.
Educational objective: Review measures that decrease the incidence of falls in the elderly.
Important measures to assure the safety of the elderly include elimination of home hazards such as frayed rugs, trailing electrical cords, and furniture that is unstable or that obstructs movement. Adequate lightning in the living space, bathroom grab rails, raised toilet seats, secure stairway banisters, and beds at comfortable and safe heights are other measures that may be employed to prevent falls.
Alarm systems activated when a patient tries to get out of bed, ambulate unassisted, or wander away can also be helpful for family members who care for cognitively impaired patients. Protective pads over the trochanteric areas are showing promising results in early studies of the prevention of fracture in falls.
The most dramatic results have been reported with in-home intervention targeting such risk factors as postural hypotension (adequate hydration, and avoidance of unnecessary medications), multiple medications (to avoid interactions, and to avoid medications that increase risk of fall such as sedatives, antihistamines, etc.), impairment in transferring, strength, balance, and gait (with the use of physical therapy exercises, occupational therapy, etc.) This approach led to a 26% decrease in falls in the intervention group when compared with a control group.
Educational objective: Review the importance of pressure relief in therapy of pressure ulcers.
The relief of pressure is the single most important aspect of pressure ulcer treatment. It can be accomplished in a variety of ways, including mobilizing the patient as much as possible, frequent repositioning, and the use of various pressure-reducing cushions or mattresses. Those patients who cannot reposition themselves should be repositioned at least every 2 hours. It may be helpful to position bed-bound patients at 30-degree angles to the bed to avoid pressure to the sacrum. Although there is no substitute for frequent repositioning and inspection of the skin, there are a myriad of devices such as foam pads, air mattresses, and waterbeds that lower the skin pressure at the interface with the bed or chair.
All other options are also important in various circumstances, but nothing can replace pressure relief.
An 81-year-old female who is otherwise healthy and not taking any medications complains of inability to fall asleep after going to bed. It sometimes takes up to 1.5 hours for her to fall asleep. This has been happening for the last 4 months since she moved to a new apartment. She complains of getting more and more tired. For the last 2 weeks she has started taking a daily nap, but this only worsens the situation when she goes to bed in the evening. She wishes for some pharmacologic agent that would help her fall asleep.
Physical examination reveals a healthy, energetic elderly woman with no functional limitations. Which of the following management tactics is most appropriate?
Older patients should not be started on a sedative hypnotic agent without a careful clinical assessment to identify the cause of sleep disturbance. Transient, situational insomnia (which is likely in this case � change of apartment) may respond to improvement in sleep hygiene (or short-term hypnotic therapy).
Commonly Recommended Measures to Improve Sleep Hygiene - Maintain regular rising time - Maintain a regular sleeping time but don�t go to bed unless sleepy. - Decrease or eliminate naps unless they are a necessary part of the sleeping schedule. - Exercise daily, but not just before going to sleep. - Don�t read or watch television in bed. - Relax mentally before going to sleep; don�t use bedtime as worry time. - If hungry, have a light snack before going to bed (unless there are symptoms of gastroesophageal reflux or it is otherwise medically contraindicated), but avoid heavy meals at bedtime. - Limit or eliminate alcohol, caffeine, and nicotine, especially before bedtime. - Relax before bedtime and maintain a routine period of preparation for bed, e.g. washing up, going to the bathroom, and so forth. - Control the nighttime environment with comfortable temperature, quietness, and darkness. - If it helps, use soothing noise (fan, �white noise� machine and so forth). - Wear comfortable bedclothes. - If unable to fall asleep in 30 minutes, get out of bed and perform a soothing activity such as listening to soft music or reading (but avoid bright light during this time). - Get adequate exposure to bright light during the day.
Educational objective: Review neoplasms of the stomach.
Malt lymphoma or mucosa-associated lymphoid tissue lymphoma is associated with H. Pylori; first line therapy is against this bacteria.
Leiomyosarcoma is a connective tissue tumor and presents as a submucosal mass with ulceration.
Reference: 1- Fuchs C, Mayer R: Gastric Carcinoma. New England Journal of Medicine. 333:32-41, 1995. Review Article -- NEJM 1995; 333: 32-41
Gastric cancer has been declining in the United States since the 1930�s. However, proximal and distal gastric adenocarcinoma seem to be two different diseases with incidence rates moving in opposite directions. The incidence of gastric cancer in Japan and China is among the highest in the world, and interestingly decreases as populations move from high to low risk areas of the world.
Educational objective: Review different medications used in therapy of insomnia in elderly.
Benzodiazepines remain the most commonly suggested agents for sleep. These should be used as briefly as possible, not to exceed 2-3 weeks of therapy or, if used longer, for only 2-3 nights per week. Care must be taken to avoid dependence with these agents, since continued use results in increasing tolerance and increasing doses. Short-acting agents are recommended for problems initiating sleep (as is the case with the patient in question), and intermediate-acting agents are recommended for problems with sleep maintenance. Long acting agents (e.g., flurazepam � with an active metabolite with a half-life of more than 100 hours in the elderly person) should not be used in older patients because of associated daytime sedation, lethargy, ataxia, falls, and cognitive and psychomotor impairment. The use of shorter-acting agents greatly reduces the frequency of these effects. Temazepam is an intermediate-acting benzodiazepine as is diazepam. Barbiturates are not indicated for insomnia, although the clinician may still encounter a patient who has been receiving barbiturates for years for this purpose. Psychiatric consultation may be necessary for these patients.
Zolpidem is a short-acting hypnotic (imidazopyridine), and it is at least as effective as triazolam (benzodiazepine). After 3 weeks of treatment, older persons receiving zolpidem had no evidence of rebound insomnia, agitation, or anxiety with cessation of therapy, and therapeutic effects outlasted the duration of therapy. Other medications that may be used are chloral hydrate, low dose sedating antidepressants (e.g., trazodone, nefazodone), and sedating antihistamines (these are not widely recommended because of anticholinergic side effects).
Gastric cancer has been declining in the United States since the 1930's. However, proximal and distal gastric adenocarcinoma seem to be two different diseases with incidence rates moving in opposite directions. The incidence of gastric cancer in Japan and China is among the highest in the world, and interestingly decreases as populations move from high to low risk areas of the world.
Leiomyosarcoma is a connective tissue tumor and presents as a submucosal mass with ulceration. Reference: 1- Fuchs C, Mayer R: Gastric Carcinoma. New England Journal of Medicine. 333:32-41, 1995. Review Article -- NEJM 1995; 333: 32-41
A 72-year-old patient who recently moved to town is seen for the first time. He has been taking flurazepam 30 mg at bedtime for insomnia for the last 3 years. Now he is running out of the medication and has scheduled this appointment to request a refill.
In the interview he states that occasionally he needs to take two pills to fall asleep. Which of the following is the most appropriate tactic in the management of this patient?
Educational objective: Review method for discontinuation of benzodiazepine after long-term use.
This patient is taking the benzodiazepine that is long-acting (has a long-acting metabolite) and is associated with significant daytime sedation, lethargy, ataxia, falls, cognitive impairment, etc. Also this patient has been taking the medication for years. Benzodiazepines are recommended for short-term therapy (2-3 weeks), and if used for longer periods should be used only 2-3 nights per week because of development of tolerance. Also benzodiazepines should not be discontinued suddenly because this results in worsening of the insomnia (rebound insomnia), and symptoms of withdrawal (e.g., anxiety and tremulousness). There is no significant difference between flurazepam and diazepam; substituting them offers no advantage. Continuing flurazepam for some time to allow for a social adaptation also has no merit because the patient�s insomnia appears not to be situational.
Educational objective: Review the evaluation of the pain in elderly.
The evaluation of pain in older patients should address the severity and character of pain, pain-associated functional impairment, the cause of pain, mechanism of pain production, and presence of aggravating factors.
An assessment of pain-related functional impairment helps determine the aggressiveness of evaluation and therapy. Severe functional impairment due to patient�s desire to avoid pain requires prompt intervention, even if pain is mild or moderate. Inactivity of the patients, even for a short period of time, may significantly diminish their abilities (deconditioning). This may aggravate the pain by itself and also have grave consequences for the quality of life; it also increases the health risks (falls, infections, aspiration, etc.).
When treating nonterminal patients for pain with opioid analgesics, it is important to keep the dose low enough not to produce iatrogenic functional impairment.
A 73-year-old female patient still has pain in the left lateral aspect of her thorax after herpes zoster eruption several months ago. Her skin appears clear, but she reports constant pain that disrupts her sleep, makes her tired, and disrupts her usual daily routine. She wishes for some topical pain therapy since she takes six different other medications for hypertension, diabetes, congestive heart failure and depression.
Which of the following is the best option for this patient?
Educational objective: Review the usefulness of capsaicin cream for topical pain relief.
The topical analgesic agent capsaicin has emerged as an effective agent for a wide range of localized pains both neuropathic and nonneuropathic. It is FDA approved for pain associated with postherpetic neuralgia, rheumatoid arthritis, osteoarthritis, diabetic neuropathy, and postsurgical pain. Successful use has also been reported in cases of pain associated with psoriasis, chronic neuralgias unresponsive to other forms of therapy, and intractable pruritus.
Capsaicin works by stimulating the release of substance P from nociceptive nerve endings. At first, this produces a burning or itching sensation. With repeated applications, the nerves are depleted of substance P and local analgesia develops. Medication must be applied minimally 3-4 times a day for a week or more to achieve maximal analgesic effect, and the patient can experience uncomfortable skin sensations in the interim. A capsaicin therapy is more likely to be continued by the patient if adequate alternative analgesia is offered during the first two weeks. In addition, some patients will tolerate capsaicin better if lidocaine ointment (2.5% or 5%) is applied to skin along with capsaicin during the first few days of treatment.
Capsaicin cream comes in two strengths (0.025% and 0.075%). Both strengths have shown efficacy in clinical trials, and the lower potency cream may be less likely to produce intolerable early symptoms. Effects of capsaicin are additive to effects of acetaminophen or NSAID's, so combinations are appropriate. Carbamazepine and amitriptyline are also effective systemic therapy. No other topical therapy is effective in this setting.
A 43-year-old female patient whose first cousin was diagnosed with colon cancer at age 50 wants to be screened for colorectal cancer. A friend told her about the possibility of screening by testing the stool for blood, but on TV she has seen reportage on sigmoidoscopy as a screening tool. She wants to know about those two techniques.
Which of the following statements is accurate about these two screening methods?
Educational objective: Review important features of colon cancer screening methods.
The FOBT is performed by obtaining 6 samples from three consecutive bowel movements after an appropriate diet for 48 hours to avoid false positive (red meat, horseradish) or false negative (Vitamin C) results. Mortality is reduced by approximately one third.
Sigmoidoscopy examines the large bowel up to splenic flexure, and may miss up to 50% of colonic lesions (however it may be performed after only simple bowel preparation and by the primary care physician in the office). It has been shown that mortality might be decreased by two thirds in the examined part of the colon.
There are theoretical reasons for combining FOBT and sigmoidoscopy. The FOBT is less sensitive for the detection of colorectal cancer in the distal bowel (bleeding is more common with proximal cancers), while sigmoidoscopy offers the ability to carefully examine the distal bowel. In addition, there are several studies demonstrating better results with the combination than with sigmoidoscopy alone (there are still no randomized studies dealing with this question, however).
Educational objective: Review different exercise programs for elderly.
There are several types of exercise, and they need to be prescribed according to the goal that is to be achieved. Endurance improvement in elderly patients can be achieved by daily exercising for 30 minutes a day (as a weekly average). Exercise should improve the balance of the patient, independent of strength and endurance. Repeated dance movements and practice of transfers of the body to different positions as well as practicing the turns of the body also may be used as a means of improving balance.
A son who lives in the same city as his father brought this elderly patient who lives independently in his own house to the office. The son is concerned because the patient is more and more dependent on his help. He or other members of the family have lately done all grocery shopping. They have also noted that his gait is getting slower, he takes much longer to rise from the chair, and spends most of the day sitting in his favorite chair watching television.
The patient has been healthy throughout his life and states that he is simply too weak to take care of himself as he used to. Physical examination and laboratory workup do not reveal any general medical or neurologic condition responsible for his functional decline, and screen for depression is also negative. Which of the following interventions is likely to improve his life quality the most?
Educational objective: Review importance of deconditioning as a cause of functional decline in the elderly.
This patient has no evidence of any medical condition that explains his functional decline. His sedentary lifestyle suggests deconditioning as a primary reason for decline. Muscle weakness is associated with slow gait speed, slow chair raise, dependence on instrumental activities of daily living, poor balance, and fall risk. Short-term supervised strengthening exercises (resistance training) increase strength significantly and are well tolerated by independent and frail elderly people. Programs of about 12 weeks' duration are shown to increase maximal strength of the muscles and double the weight that patients can lift.
Resistance training can be performed with resistive machines, free weights, or bands. The specificity of training suggests that improvements of functional status require the training to approximate the functional tasks that a patient faces in terms of joint speed, range of motion, and the type of force generated.
It is important to include types of training other than resistance because increased endurance, flexibility and balance also contribute significantly to functional status.
Educational objective: Review serious warning signs in patients with headache.
There are several historic features in patients with headache that should prompt investigation into possible serious underlying pathology.
Sudden onset - reaching maximum intensity in seconds or minutes warrants aggressive investigation. Subarachnoid hemorrhage would be a possibility. Cluster headaches may reach maximum within minutes, but those are transient and accompanied by ipsilateral autonomic signs. No similar headaches in the past - The "first" or "worst" headaches in the life sometimes are associated with intracranial bleeding or CNS infections. Concomitant infection - non-intracranial locations may serve as sources for development of meningitis or intracranial abscesses. Altered mental status - in any extent suggests serious underlying pathology. Headache with vigorous exercise - especially when minor trauma has occurred - raises the possibility of carotid artery dissection or intracranial hemorrhage. Location of pain - Pain that spreads between the shoulders and into the lower neck may be a sign of spinal meningeal irritation by infection or blood and is not typical of a benign process.
Educational objective: Review serious signs on physical examination of patient with headache.
Physical findings suggestive of serious CNS causes of headache are as follows: o Nuchal rigidity -indicating meningitis or subarachnoid hemorrhage o Toxic patient - with headache may indicate systemic illness affecting the CNS o Decreased level of consciousness -increases the likelihood of meningitis, encephalitis, intracranial hemorrhage, or other space-occupying lesion o Papilledema - indicative of increased intracranial pressure (tumor etc.) o Neurologic abnormalities - if new, must be evaluated for serious illness. Subtle signs only may be seen, such as slight pupillary asymmetry, unilateral pronator drift, or extensor plantar response. Neurologic deficits may also be seen with migraine, but those are usually perceived by the patient (symptom) rather than demonstrated on exam (sign), and are usually recurrent and short lived (less than 60 min)
However, it is important to recognize true neurologic signs of those produced by patients with malingering, conversion disorders, etc. Such signs may be sensory deficits that do not follow dermatomal distribution as in this question.
Educational objective: Review the features of morphine as pain medication for elderly.
A number of pervasive myths have given morphine and other opioids a stigma among prescribers and patients. Chronic use of morphine for pain control rarely leads to addiction. It is likely that this use will lead to physiologic dependence and tolerance, but no addiction. Addiction involves a psychologic component wherein a person craves the medication enough to risk harm or participate in self-destructive and dangerous behavior in order to obtain and use the medication.
Patients who experience nausea and vomiting while taking the morphine are likely to resolve those symptoms as tolerance develops. Constipation is one adverse effect of opioids that can be expected to persist, and plans to ensure adequate bowel movements and maintenance of adequate hydration must be made. Unlike non-opioid medications, the opioids have no ceiling; that is, the dosage can be increased as tolerance develops or pain worsens. Tolerance also develops to depression of the respiratory center, and slow increase in dose due to tolerance is unlikely to produce respiratory drive problems.
A 34-year-old man presented with headaches of three days' duration. Headache is left-sided, starting around the eye, usually in the late evening. Pain is excruciating and keeps him awake and walking around the house for about one hour. He had an episode of headache very similar to this last year when it repeated every day for about four weeks. He took many different over-the-counter pills at that time but it appeared that none of them made a significant difference in his headache pattern. Now he is worried that something is seriously wrong with his health since the headaches have returned.
Which of the following is the best management approach to this patient's headache?
Educational objective: Review the features and therapy of cluster headache.
This patient has headache typical of cluster headache. Treatment is divided into abortive and preventive aspects.
Abortive therapy can be difficult because of the brief nature of the episodes, but several medications have been successful. Inhalation of 100% oxygen (7 L/min for 15 minutes) aborts the episode in a majority of patients. Sumatriptan appears to be helpful also, as well as indomethacin and other NSAID's in some patients.
Prophylactic therapy should be started as soon as possible at the onset of a cluster episode. Prednisone is highly effective but should not be used chronically because of side effects. Lithium is particularly effective for the chronic form of cluster headaches. Ergotamine, cyproheptadine, and indomethacin are also effective. Methysergide is effective and does not cause fibrosing syndromes in these patients due to intermittent use of the drug.
Educational objective: Emphasize danger of sexual dysfunction with SSRI's.
Although studies have reported sexual dysfunction in the <20% range, clinical experience seems to point to a higher incidence of same, particularly as patients become educated to the symptoms of sexual dysfunction and become aware of the presence of these symptoms in their experience. Although men do report a higher incidence of sexual dysfunction than women, the incidence may well be equal in both sexes. Multiple factors likely contribute to the "reporting", including social/personal inhibitions to the open discussion of such matters. Due to multiple factors including that patients are so grateful to be feeling hopeful and happy again that they consider sexual dysfunction symptoms to be worth accepting for the benefits derived from the antidepressants, patients may not be aware of reduced interest in sexual activity.
A 33-year-old female presented with headaches that have been occurring over several months. Pain is unilateral, on the left side, and located in the area of the ear. Pain is dull, deep, continuous, and is worse in the morning and after eating. She has noticed limitation of jaw movement and slight deviation of the jaw when mouth is open. She denies any fever.
Physical examination is significant for tenderness in preauricular region. All of the following are possible therapeutic options employed in the management of this patient except:
Educational objective: Review the features and therapy of TMJ dysfunction.
Clinical features of this patient suggest temporomandibular joint dysfunction syndrome (TMJ). This condition is characterized by acute or chronic musculoskeletal pain with dysfunction of the masticatory system. Many patients complain of headache. The typical headache associated with TMJ presents as unilateral ear or preauricular pain that radiates to the jaw, temple, or neck. The pain is dull, deep, continuous, and usually worse in the morning. It is typically associated with a limitation of jaw motion and deviation of the jaw upon opening. Physical examination may demonstrate tenderness of the muscles of mastication, and sometimes clicking of the joint.
Condition may be hard to differentiate from tension-type headache. The treatment primarily involves therapy of the joint disorder itself. Most cases can be treated with local heat, physical therapy, dental hygiene, NSAID's, and dietary measures. Occasional patients may require surgery.
Antibiotics are not indicated in this patient since there is no suggestion of infection (no fever, long history, mild, relatively non-progressing pain).
Educational objective: Review the indications for treatment of asymptomatic bacteriuria.
There is no measurable benefit of treatment of asymptomatic bacteriuria in individuals with diabetes, or in elderly individuals (and, of course, in otherwise healthy subjects). Also there is no evidence that treatment of asymptomatic bacteriuria in men confers any benefit (and is also hard to treat) in terms of prevention of subsequent renal failure or hypertension.
Those who should be treated include the following: - Pregnant women - Those scheduled for a urologic procedure - Those having had a bladder catheter removed - Young children with gross vesicoureteral reflux - Some patients with struvite stones (removal of the stones is preferable)
A 50-year-old married white woman comes in to see you, her internist, with a report of feeling weak and having no energy for the past several months. She has difficulty getting out of bed in the morning and getting to work on time. She falls asleep as soon as she sits down to rest on breaks at her job of running a punch press. She sleeps poorly at night, often taking an hour or more to fall asleep and then wakening in a few hours, again with much difficulty falling back to sleep. She reports a 10-pound weight loss during this period with considerable anorexia. Knowing the family, you are aware of serious conflicts among members; you know that they make enormous demands upon her; and you know they are not supportive of her when she's ill. Which of the following are reasonable strategies?
Educational objective: Review common inappropriate strategies in depressive patients.
The first option is not reasonable in that given the degree of her distress and that you know nothing about her suicidality, giving her a hypnotic is risky and not likely to be of much help. It may be even more of a danger to her. In addition, you have not checked her labs for any possible underlying dysfunction. She runs a press and is at risk when drowsy.
Option 2 is not reasonable although it may be defensible if you inform your psychiatrist colleague that you have done no physical exam or lab evaluation and that you expect him to arrange such.
The third option may be reasonable in that you know something of the strains she faces at home and the lack of support she gets when ill. Hospitalizing her may serve the purpose of getting her out of the situation such that an intervention is possible and the psychiatrist can do an evaluation in that setting. However, you will likely face a denial of coverage by her insurance company.
Option 4 is not reasonable since referring her in this way makes it highly unlikely that she will get the comprehensive physical, metabolic evaluation that she needs and likely expects from you.
The fifth option might be reasonable but is somewhat risky in that you don't know the presence and/or significance of suicidal ideation. At least you have done the physical and metabolic evaluation and a trial of an antidepressant is initiated. A one-week follow up or a phone call in a few days after asking about suicidality might be a sound strategy. If suicidality is present, then an emergent referral to your psychiatrist colleague is highly warranted.
A 35-year-old newspaper reporter becomes aware that over the preceding 3 months she has become more and more distressed at having to travel increased distances to gather data for her articles. Even though this was a frequent route, she one day had to stop her car on the high-level bridge over the river that ran through downtown because she became dyspneic and tachycardic. She worries about her heart, thinking about her mother who recently had an MI. In addition she has been having increasing difficulty with sleep. She frequently feels exhausted on wakening, often wondering if she's slept at all. She had several nights where she awoke frightened but not knowing the source of her fear. She also notes that she had some disturbing, unwanted thoughts breaking into her mind unpredictably.
When she found herself thinking about driving off the pier near the shopping center she often visited, she stopped shopping at that site. From what you know now, which of the following are true?
Educational objective: Review features of panic disorder.
It is not an adjustment disorder since her symptoms are so pervasive and serious, with the disturbing thoughts suggesting significant internal disruption and instability. With the varied nature of her symptoms she exudes an air of fragility and instability of mental functioning. Something major is in the offing, and it needs to be taken very seriously. Suicide risk is high and must be attended to in any diagnostic and treatment situation.
Educational objective: Review features of Mini Mental Status examination of Folstein.
Folstein's Mini Mental Status Examination is heavily weighted on the orientation of the patient since 10 points are related to temporal and spatial orientation. Three points are assigned to registration (ability to repeat three objects). Attention and calculations are tested by serial 7's subtractions from 100 and are worth 5 points. Recall is tested by repeating three objects from the first part of the test and may bring three points. Language is tested by naming two common things, repetition of �No ifs, ands, or buts� and by following a three-step command. All these tasks are worth 6 points. Obeying written command brings one point, as well as writing the sentence and copy design (intersecting pentagons or clock face).
A 57-year-old man with past medical history and benign prostate hypertrophy of hypertension treated with doxazosin is brought to the emergency room after a motor vehicle accident. Both his legs are broken on the level of tibia; his left humerus is also broken. His blood pressure is 150/100 mm/Hg and pulse rate is 115 minute. He is in sinus rhythm. His laboratory results are:
Educational objective: Review the self-limited hyperkalemia in patients with trauma.
Self-limited hypokalemia occurs in 50-60% of trauma patients--perhaps related to enhanced release of epinephrine. The above effect is transient. Other causes of hypokalemia are extrarenal potassium loss and renal potassium loss. Urinary potassium is low (< 20 meq/l) as a result of extrarenal loss (diarrhea, vomiting) and inappropriately high (40 meq/l) with urinary loss (mineralocorticoid excess). Hematoma formation cannot cause hypokalemia. Respiratory alkalosis can cause hypokalemia by intracellular shift but this patient's ABG is not consistent with respiratory alkalosis.
Educational objective: Review features of Korsakoff's psychosis.
Korsakoff's psychosis usually appears during or right after Wernicke's encephalopathy appears. Loss of past memories (retrograde amnesia) is part of the syndrome. Confabulation, although often present, may not be seen as part of the presentation and can result from the partial holding of some memories but having no sense of where they exist in time.
A 47-year-old African-American female presents to the emergency room with right flank pain with radiation to the right groin, frequent urination, and nausea. She has had complaints for the last 12 hours.
Physical examination is positive for right costovertebral angle tenderness to percussion and mildly elevated blood pressure. Her past medical history is remarkable only for abdominal surgery with jejunoileal bypass for treatment of morbid obesity, which was performed two years ago. Urinalysis was ordered. Which one of the following findings on urinalysis is most likely in this condition?
Educational objective: Review the features of different renal calculi.
This patient presents with renal colic. The jejunoileal bypass surgery she had two years ago puts her at risk of oxalate stone formation. Calcium oxalate dihydrate crystals are bipyramidal and only weakly birefringent. Calcium oxalate monohydrate crystals usually grow as biconcave ovals that resemble red blood cells in shape and size. Urine positive for protein and oval fat bodies is typical for persons who suffer nephritic syndrome.
Struvite crystals are rectangular prisms. They are usually associated with urinary tract infection with urease-producing bacteria, usually proteus species. Cystine crystals appear in the urine as flat, hexagonal plates. Uric acid dihydrate tends to form teardrop-shaped crystals and square plates. Strong birefringence is typical for both of them.
Educational objective: Review therapy of diuretic-induced hyponatremia.
The goals of therapy are threefold: 1-to raise the plasma Na by restricting free water intake and promoting free water loss 2-to replace the Na or K deficit or both 3-to correct the underlying disorder.
Mildly symptomatic hyponatremia is treated by Na repletion, generally in the form of normal saline, in order to avoid rapid changes in fluid volumes. The plasma Na should be raised by no more than 0.3 mmol/l/hour and should not exceed 8 mmol/l during the first 24 hours. Hypertonic saline is reserved for treatment of acute and severe symptomatic hyponatremia.
A 72-year-old man with a more than 20-year history of hypertension and diabetes mellitus presents to the emergency room with complaints of headache, nausea and proximal muscle weakness. He has not been compliant with the therapy of hypertension and diabetes mellitus. Also he states that 10 years ago he was told that his kidneys "were not doing well".
Physical examination is remarkable for elevated BP-170/105 mm/Hg and decreased sensation for light touch and pin prick below the knees. His laboratory studies are as follows: Na-144 meq/l, K-4.6 meq/l, CO2-19 meq/l, Cl-109 meq/l, BUN-61 mg/dl, Cr-5.4 mg/dl, Ca-8.1 mg/dl, P-5.6 mg/dl, albumin-3.4 g/dl, alk. Phosphatase-370 IU/l, and AST-23 IU/l.
Which of the following tests is most likely to uncover the cause for this patient's elevation of alkaline phosphatase?
Educational objective: Review the features of renal osteodystrophy.
This 72-year-old patient with a long history of hypertension, diabetes mellitus, and renal problems of at least 10 years' duration, presents with chronic renal insufficiency (CRF). The CRF is associated with several disorders of mineral metabolism. Those disorders are referred to as renal osteodystrophy. The most common disorder is osteitis fibrosa cystica, the bony changes of secondary hyperparathyroidism. The two main sources of elevated serum alkaline phosphatase are liver problems and bone disease. The fact that gamma glutamil transferase and AST are normal makes liver a highly unlikely source in this case. The way to prove bone problems related to renal insufficiency is to perform bone densitometry.
This patient has hyperphosphatemia, which leads to hypocalcemia, which in turn stimulates secretion of parathyroid hormone. High parathyroid hormone levels lead to high bone turnover with osteoclastic bone resorption. Clinically, patients experience bony pain and proximal muscle weakness.
Radiographically lesions are most prominent in the phalanges and in the lateral ends of clavicles.
A 53-year-old man presents to the emergency room with right side flank pain radiating to the groin. Also he complains of nausea--he has vomited three times in the last 8 hours. He has had the same problem twice in the last 18 months. On examination his abdomen is soft and not painful to palpation. He is afebrile. His blood pressure and pulse rate are slightly elevated. His past medical history is significant only for chronic low back pain after an injury sustained during a motor vehicle accident 10 years ago.
His laboratory findings are as follows: BUN - 26 mg/dl, Cr - 1.6 mg/dl. Urinalysis shows specific gravity of 1.011 g/ml, mildly positive protein (1+), 4-5 red blood cells, and 20-25 leucocytes per high power field. There was no growth in urine cultures. Which of the following is the most likely diagnosis?
Educational objective: Review features of analgesic nephropathy.
This man with chronic low back pain most probably uses analgesic medications on a regular basis. Analgesic nephropathy is a distinct clinicopathologic syndrome that has been described in heavy users of analgesic mixtures containing phenacetin in combination with aspirin, acetaminophen or caffeine. Morphologically analgesic nephropathy is characterized by papillary necrosis and tubulointerstitial inflammation. The intake of 1.0 g phenacetin per day for one to three years or the total ingestion of 2 kg phenacetine in combination with other analgesics appears to represent minimum requirements for the development of analgesic nephropathy. More than half of patients with analgesic nephropathy have pyuria, which, if persistently associated with sterile urine, provides an important clue to the diagnosis. Proteinuria, if present, is typically mild (less than 1 g/day).
Patients with analgesic nephropathy are usually unable to generate maximally concentrated urine, reflecting the underlying medullary and papillary damage. Transitional cell carcinoma may develop in urinary pelvis or ureters as a late complication of analgesic abuse.
Educational objective: Review causes of falls in community-dwelling residents.
Causes of Falls Among Community-Dwelling Persons (N - 2312 falls, 7 studies) "Accident" or environment-related 41% Other specified causes * 17% Gait and balance disorders or weakness 13% Drop attack 13% Dizziness or vertigo 8% Unknown 6% Confusion 2% Postural hypotension 1% Visual disorder 0.8% Syncope 0.4% * arthritis, acute illness, drugs, alcohol, pain, epilepsy, and falling from the bed
Educational objective: Review the features of meperidine as pain medication in elderly patients.
Meperidine should be avoided for pain treatment if possible, especially in elderly patients because of the increased risk for seizures. This is because of metabolite normeperidine that lowers the seizure threshold and is being excreted so slowly that significant amounts remain in the body beyond the analgesic effect of meperidine. Repeated dose given to control pain leads, then, to increased levels. In addition, chronic use of meperidine is associated with increased frequency of falls and delirium; it has a poor oral absorption. Also, when given with hydroxizine, which is anticholinergic, it causes an increased incidence of orthostatic hypotension and confusion.
All other medications in question may be used. Acetaminophen is safe if the daily dose does not exceed 4 g (which is also the analgesic ceiling for this medication). Nabumetone, and etodolac are shown to produce less gastric irritation than other nonsteroidal anti-inflammatory medications. Oxycodone is a long-acting opioid that is given no more than every 8 hours.
Educational objective: Review the appropriate use of oxycodone.
Controlled release morphine and oxycodone should not be prescribed more frequently than every 8 hours. If breakthrough pain occurs in 3-4 hours after the dose, the amount of medication given should be increased and the same dosing schedule maintained. It is also desirable to maintain the pain control regimen stably and simply. Introduction of other drugs is not desirable and not absolutely necessary. In addition, in the beginning of the regimen it may take a long time until the full effect of the long-acting preparation is achieved, and use of a short acting preparation of same medication may be desirable at this time.
Educational objective: Review the guidelines for cholesterol screening in elderly.
There is increasing evidence that suggests the benefit of screening and actively reducing elevated cholesterol in middle-aged men. Cholesterol is not as strongly related to coronary artery disease after age of 70. There is little evidence either for or against screening and treating those over 65 years of age. The U.S. Preventive Services Task Force (USPSTF) and the American College of Physicians (ACP) do not recommend for or against screening of patients between 65 and 74 years, and both bodies advise against screening those over 75 years of age.
All other options in the questions should be offered to this patient.
Educational objective: Review the most effective way of diagnosing smoking.
Smoking remains an important preventable cause of morbidity and mortality in elderly persons. Even individuals older than 70 years of age are shown to have decrease in the mortality risk after quitting smoking. The majority of smokers who quit relapse later, but many succeed, particularly after more than one attempt. Counseling by the physician and provision of nicotine patch or gum for assistance have been shown to be effective methods to improve abstinence rate. Asking patients if they have smoked in the preceding 3 months should be an established routine in medical practice and is more sensitive than asking if the individual smokes at present.
A 69-year-old man who is seen for routine yearly check-up and who has no medical complaints inquires about aspirin use. He was told by a friend who is a physician that everybody should take one aspirin a day, so he started taking one 325 mg aspirin a day several weeks ago. He is not taking any other medications. His physical examination is completely normal. His lipid panel is within normal limits as well as his electrolyte panel and complete blood count. His blood pressure is 127/67, temperature 36.8ºC, weight 72 kg, and height 182 cm.
He asks what you recommend about aspirin use. Which of the following is the answer that is in accordance with available data at this time?
Educational objective: Review appropriate use of aspirin for prevention of cardiovascular incidents.
Aspirin is effective in preventing stroke in those patients who have transitory ischemic attacks and also in prevention of nonfatal myocardial infarction and cardiovascular mortality in those with prior myocardial infarction and unstable angina. Some physicians believe that everybody should take daily aspirin as a means of prevention of cardiovascular morbidity and mortality, even those without any evidence of disease.
There are two trials that examined this issue. The U.S. trial was conducted on physicians and showed a significant decrease in fatal and nonfatal myocardial infarction, but not in total cardiovascular mortality. The other study was conducted in Great Britain and showed no difference (sample size was smaller than that of U.S. study). Both studies found somewhat increased incidence of stroke in those taking aspirin, but difference was not statistically significant.
The U.S. Preventive Service Task Force does not recommend for or against aspirin use in primary prevention of myocardial infarction in asymptomatic men or women. Those with multiple risk factors but no signs or symptoms of cardiovascular disease should be counseled about benefits and risks of the daily aspirin therapy (cerebral and gastrointestinal hemorrhage, gastrointestinal distress). Patients with existing coronary artery disease or transient ischemic attack or previous stroke are candidates for therapy if there are no contraindications.
Educational objective: Review the strategies for influenza A prevention and therapy.
Infections caused by influenza virus cause significant morbidity and mortality in the elderly population. Vaccination is at least moderately effective in preventing infections among the community-dwelling elderly. Serious adverse reactions are rare. The data for nursing homes is less clear but suggests that decreased infection rates and decreased illness severity occur in highly vaccinated populations. An interesting recent study suggests that vaccination of the staff was the most effective way to prevent influenza morbidity and mortality among nursing home residents. Health care workers, including physicians, should also be immunized. In the event of an influenza A outbreak in the community, prophylactic amantadine or rimantadine for nursing home residents is appropriate. Doses of amantadine should be adjusted for age and renal function (100 mg/day is usual dose in elderly nursing-home residents).
Annual influenza vaccination for individuals over 65 years of age is widely recommended.
Educational objective: Learn to use and interpret "Up and Go" test.
One of the brief screening instruments that has been validated for gait assessment among elderly patients is the timed "Up and Go" test. The test is a quantitative evaluation of general functional mobility. Persons are timed on their ability to rise from a chair, walk 10 feet, turn, and return to the chair. Most adults complete this task in about 10 seconds, and most frail elderly persons in 11-20 seconds. Individuals who require more than 20 seconds should be referred for the comprehensive gait evaluation. In addition, strong association exists between performance on this test and a person's functional independence in activities of daily living.
Gait speed assessment is another instrument used in screening for gait disturbances in the elderly (normal 0.9-1.3 m/sec � frail elderly less than 0.6 m/sec). An inverse relation between gait speed and performance of activities of daily living, and instrumental activities of daily living has been demonstrated.
A 69-year-old female suffered cardiac arrest in the emergency room. After prolonged cardiopulmonary resuscitation, spontaneous heartbeat was achieved. However, she remained unresponsive. Seven days later she is still unresponsive, and it has been assessed that her condition is not reversible.
She had completed an advance directive about her health care several years prior to this event. In this document she appointed her husband to have durable power of attorney for health care and specified that she did not want her life to be maintained by artificial means for longer than 1 week. She also specified that she prefered to be allowed to die even if this meant cessation of nutritional support, ventilation, and hydration. Her husband requests that her care continue unchanged with full hydration, parenteral nutrition and ventilatory support.
Which of the following is the appropriate action to be taken?
Educational objective: Emphasize the importance of a patient's autonomy in medical decision-making.
The patient has executed a durable power of attorney for health care. This power is delegated to her husband and his wishes should be followed - as long as those wishes are not contrary to the wishes of the patient. Since this patient, however, had specified in her advance directive that she did not want to be maintained beyond one week by means of ventilation, artificial nutrition and hydration, those measures should be stopped. Transferring the patient to another physician's care does not change the situation in any way. Invoking the hospital ethical committee may help a physician deal with the situation but should not change the outcome. There is no need for a court decision in this case since the patient has explicitly stated her wishes in advance directive form.
Educational objective: Review diagnostic criteria for major depression.
Diagnostic Criteria for Major Depression --Depressed mood or loss of interest or pleasure of 2 weeks' duration accompanied by four or more of the following: o Appetite change or weight loss o Insomnia or hypersomnia o Psychomotor agitation or retardation o Loss of energy o Feelings of worthlessness or guilt o Difficulties with concentration or decision-making o Recurrent thoughts of death or suicide
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition - 1994.
Educational objective: Emphasize myositis as a side effect of HMG-CoA reductase inhibitors.
HMG-CoA reductase inhibitors are generally well tolerated, but the risk of myositis increases with the accompanying use of niacin, gemfibrozil, erythromycin and certain immunosuppressive agents such as cyclosporins. HMG-CoA reductase inhibitors and cholestyramine can be combined without much risk of myositis.
Educational objective: Review recommendations for colorectal cancer screening.
The American cancer society recommendations for colorectal cancer screening are as follows: 1. Annual digital rectal exam beginning at age 40 2. Annual FOBT beginning at age 50 3. Flexible sigmoidoscopy every 3-5 years beginning at age 50
Patients at greater than average risk for colorectal cancer should undergo colonic surveillance which is individualized according to the risk of cancer: 1. Previous history of adenomatous polyps - once polyps are removed colonoscopy should be performed in 3years. 2. Previous history of colorectal cancer - colonoscopy 6 months to 1year after surgery, then in 3 years and if negative every 5 years thereafter. 3. Patients with familial adenomatous polyposis should undergo yearly flexible sigmoidoscopy beginning at puberty 4. Patients with hereditary nonpolyposis colon cancer should undergo colonoscopy every 1-2 yrs beginning at age 25 or 10 yrs younger than the age of the youngest relative with colon cancer. 5. Patients with inflammatory bowel diseases (IBD) - colonoscopy is performed every 1-2 years after 8-10 years of pancolitis and after 15 years of left sided colitis. 6. First degree relative with colon cancer diagnosed less than age 50 - colonoscopy beginning at 35-40 years of age.
A 65-year-old black female with a history of hypertension and smoking (1 pack per day since age 30) comes in for follow-up. She is not a diabetic and has no personal or family history of coronary artery disease. Her fasting lipid profile is as follows: Triglyceride: 198 Total Cholesterol: 257 HDL: 55 LDL: 151
What therapy would you initiate for this patient?
Educational objective: Review recommendation for treatment of hyperlipidemia.
The following are guidelines for the treatment of hyperlipidemia: Initiate diet Initiate meds No CAD; less than 2 risk factor >160mg/dl >190mg/dl No CAD; 2 or more risk factor >130mg/dl >160mg/dl Patient with CAD >100mg/dl >130mg/dl
Educational objective: Review the formula for calculation of LDL.
LDL cholesterol is calculated according to the following formula: LDL=total cholesterol-HDL cholesterol-triglycerides/5
In the above question if you calculate using this formula, LDL cholesterol is 178.
A 23-year-old woman comes to your office for a blood sugar checkup. She is currently 22 weeks pregnant and is healthy with no complaints. Her blood pressure is 110/70 mm/Hg and her blood sugar is 96 mg/dl.
Screening urinalysis reveals the following: Specific gravity - 1010, no glucose or protein, leucocytes - 5-7 per high power field, bacteria - numerous. Which one of the following will you recommend?
Educational objective: Review therapy for asymptomatic bacteriuria during pregnancy.
The prevalence of asymptomatic bacteriuria in pregnancy is about 7%. Treatment of asymptomatic bacteriuria should last 7-10 days. Ampicillin and nitrofurantoin are effective and safe. Cultures should be repeated 1 week after therapy. Sulfamethoxazole-trimethoprim is known to be teratogenic.
A 24-year-old woman, 33 weeks pregnant, comes to your office because of nausea, anorexia and vomiting. She thinks her skin has turned yellow. Her blood pressure is 110/74 mm/Hg, she is icteric and has tenderness in the right upper quadrant. Bilirubin is 10 mg/dl and AST is 350 U/ml. Hematocrit is 34%. Platelet count is 250,000 and the prothrombin time is prolonged. Gall bladder examination by ultrasound is normal.
What is the most probable diagnosis?
Educational objective: Review features of acute fatty liver of pregnancy.
Acute fatty liver of pregnancy occurs in the third trimester and is associated with anorexia, nausea, vomiting and increase in AST, hyperbilurubinemia and prolonged prothrombin and partial thromboplastin time. Intrahepatic cholestasis is usually manifested by severe itching and often with steatorrhea and modest hyperbilurubinemia. This entity is treated with cholestyramine. HELLP syndrome is characterized by hemolysis, elevated liver enzymes and low platelets. Prothrombin time is usually normal. In acute fatty liver of pregnancy and in HELLP syndrome, delivery should be done as soon as feasible.
Educational objective: Review causes of hypochromic microcytic anemia.
G6PD is an X linked disease. It causes a hemolytic anemia with a normochromic normocytic picture. This condition provides some protection against falciparum malaria. Heinz bodies seen on supravital staining of the peripheral blood is a good screening test. In the steady state there is no anemia or RBC defect. There is an increased risk of hemolysis in patients with concurrent renal or hepatic disease, viral or bacterial infections, diabetic acidosis, and low levels of blood glucose.
Educational objective: Review features of anemia associated with chronic disease.
Anemia of chronic disease is normochromic normocytic, microcytic or hypochromic microcytic.
Educational objective: Review genetics of hemophilia A.
Hemophilia A is an X-linked recessive disease. If a hemophiliac male has children from a normal female, all daughters are obligatory carriers and all sons are normal. If a normal male marries a carrier, each daughter has a 50% chance of being a carrier and each son has a 50% chance of having hemophilia.
A 55-year-old male with no significant past medical history presents to you because of pain and swelling in his right calf following a vigorous game of basketball. He denies any chest pain or shortness of breath. He smokes a pack of cigarettes per day and drinks socially.
Physical exam is normal except for edema and tenderness of his right calf. Pulses are intact. A complete blood count, prothrombin time, and PTT are normal. Ultrasonography shows a deep venous thrombosis (DVT) involving the calf and popliteal veins on the right. An appropriate regimen of outpatient treatment for DVT would include:
Educational objective: Emphasize usefulness of low molecular weight heparin for outpatient treatment of DVT.
Low molecular weight heparin (Enoxaparin) has been repeatedly shown to be safe and effective for treatment of patients with DVT. Enoxaparin 1mg/kg every 12hrs and Dalteparin 200U/kg daily have been used in clinical trials. Subcutaneous Heparin in prophylactic doses would be insufficient to prevent a recurrent thrombosis in this patient. Aspirin has not been shown to be effective in DVT.
A 55-year-old man comes to your office for evaluation of abnormal hemoglobin of 17.8 g/dl and dyspnea. Three years ago he underwent uvuloplasty because of snoring and had complete relief of his symptoms. He quit smoking 5 years ago and is a social drinker. On physical exam he is 175 centimeters tall, weighs 70 kg and his blood pressure is 124/86 mm/Hg. Examination of the abdomen reveals an enlarged spleen. Laboratory studies are as follows: Hb - 17.8 g/dl, MCV - 85 fL WBC - 13, 000 microliter Platelet count - 500, 000 O2 saturation - 96% PH - 7.42, PCO2 - 40, PO2 - 88 Venous blood P50 - 27 mm/Hg Erythropoietin - 2 mU/ml RBC mass - Increased
What is the most likely diagnosis?
Educational objective: Review diagnostic criteria for polycytemia rubra vera.
Criteria for diagnosing polycytemia rubra vera include: Category A - increased red blood cell (RBC) mass, splenomegaly and normal oxygen saturation. Category B - platelet count more than 400,000/microliter, white blood cell count (WBC) more than 12,000 /microliter, leukocyte alkaline phosphatase score more than 100. Serum level of vitamin B12 more than 900 ng/L.
The presence of all three criteria in category A establishes the diagnosis. If the patient has increased RBC mass with either of the other two category A criteria, then 2 of the 4 category B criteria are necessary to establish the diagnosis.
Erythropoietin levels are elevated in patients with secondary polycytemia seen in the other conditions listed.
Educational objective: Review common causes of Coombs positive anemia.
The three most common causes of Coombs positive hemolytic anemia are idiopathic, drugs, and malignancies such as those outlined above. Hereditary spherocytosis and paroxysmal nocturnal hemoglobinuria (PNH) are associated with Coombs negative hemolytic anemia.
Educational objective: Review important facts about Alzheimer's disease.
Although the data represents caregiver reports, only 38% of primary care physicians conveyed that the diagnosis was being entertained at first visit. This may represent physicians' ignorance of diagnostic criteria.
Educational objective: Review presenting picture of Alzheimer's disease.
Though there may be retrospective evidence of symptoms for a much longer period of time, 12-18 months is the usual time before the diagnosis is entertained by the average primary care physician following the earliest noted symptoms by patients' caregivers. Much of the blame appears to be delay in seeking medical help.
Ref. Knopman, D., et al., JAGS; 48:300-304, Mar. 2000
Aluminum exposure as a cause of dementia of any sort was a theory that failed to be proven.
Educational objective: Review diagnostic studies required for evaluation of atrial fibrillation.
Although ischemic events may be associated with atrial fibrillation, they are not an etiology of chronic atrial fibrillation. Over-the-counter medications like pseudoephedrine may precipitate paroxysmal atrial fibrillation, as may alcohol and caffeine, valvular heart disease, and hyperthyroidism.
Educational objective: Recognize appropriate surrogate decision maker for health care.
The patient's common law husband is her legal proxy. So long as his decisions appear reasonable and in the patient's best interests, they ought to be followed.
Educational objective: Review important epidemiological facts about alcoholism.
53% of all Americans use alcohol at least once a month. The remaining statements are all correct.
Educational objective: Review important facts about Wernicke-Korsakoff syndrome.
All describe Wernicke-Korsakoff syndrome.
Educational objective: Recognize importance of adequate antiretroviral therapy.
There is also, with the advent of highly effective antiretroviral therapy, marked decrease in the incidence of the three major opportunistic infections � pneumocystis carinii, mycobacterium avium complex, and cytomegalovirus.
Improvement in preventive measures is observed in certain populations at risk (gay men), but not in others (intravenous drug users), and decreases in the mortality or incidence of opportunistic infections cannot be explained by these changes.
Also there is no shift in epidemiology to HIV-2, or to the less virulent HIV-1.
This patient presents with the clinical picture and EKG presentation of acute inferior myocardial infarction. Different types of rhythm disturbances may occur in this setting. Most commonly seen is sinus bradycardia (40% of patients within first 2 hours and decreasing to 20% by the end of the first day). First degree AV block may also occur and is usually due to occlusion of RCA supplying AV node and is commonly transient, generally resolving in 5-7 days with no therapy.
Second degree AV block in inferior myocardial infarction is typically the more benign Wenckebach type (Mobitz type 1). This block is usually transient, resolving in most cases within 5 days. Mobitz type II is uncommon in this setting and occurs more commonly with anterior MI.
Complete heart block with inferior MI generally results from intranodal lesion, and it is associated with narrow QRS complex and develops in a progressive fashion from first to second to third degree block. It often results in an asymptomatic bradycardia (40-60 beats per minute) and is usually transient, resolving within five to seven days.
High degree AV block that is located below the AV node is associated with anterior MI; it is usually symptomatic and has been associated with mortality rate approaching 80% (this is mostly due to big losses of functioning myocardium).
This blood smear demonstrates intracellular malarial parasites. In humans, malaria is caused by 4 species of Plasmodia (P. vivax, P. ovale. P. malariae, and P. falciparum). Incidence of the infection has been increasing in recent years because of increasing resistance of the parasites to chemotherapy, increasing resistance of the Anopheles mosquito to insecticides, increased international travel, and possibly changes in the climate and ecology of the malarial areas. Transmission of malarial parasites occurs most commonly by the bite of the female Anopheles mosquito, but other potential routes include congenital acquisition, blood transfusion, organ transplantation, and sharing of contaminated needles.
Several hemoglobinopathies protect against severe malaria: sickle cell disease, á-thalassemia, á-thalassemia, and Southeast Asian ovalocytosis.
Although new techniques are being developed, the mainstays of malaria diagnosis are still thick and thin blood smears. The conventional method is light microscopy of Geimsa-stained smears. Smears should be taken every 6-12 hours for 48 hours before the diagnosis is ruled out (this is due to cyclic nature of the disease). Thick smear is more sensitive, but thin smear allows for morphologic examination of the parasites and quantification of the number of infected cells.
Complications of malaria include anemia and bleeding, hypoglycemia, ARDS, renal failure, and cerebral malaria. Cerebral malaria most commonly presents as impaired state of consciousness and seizures, and may result in coma and death. Without treatment cerebral malaria is universally fatal, and even with treatment mortality is about 20% in the adult population and 15% in children. In addition, about 10-13% of the patients who survive cerebral malaria will have residual neurologic abnormalities.
Approximately 50% of the individuals over 85 have dementia, which usually precludes their understanding of the medical issues and requires surrogate decision-making. In addition, many cognitively intact elderly are delirious during an acute illness and are incapable of complex discussions about their care at the time when many important decisions must be made. In those cases in which a patient can't make decisions, a surrogate decisionmaker must be identified.
The physician must assess the patient's decision-making capacity before concluding that a patient cannot speak for himself or herself.
A 45-year-old female patient noticed that her urine has turned red. Examination of the urine sediment and urinalysis revealed no red cell casts. Red cells visible in the sediment were mostly deformed and of different sizes. There were 4+ proteinuria and no signs of urinary tract infection.
Which of the following is the most likely source of the blood?
Educational objective: Understand characteristic findings in hematuria from different parts of the urinary tract.
One of the first steps in the evaluation of a patient with hematuria is try to distinguish between glomerular and extraglomerular bleeding. Careful evaluation of the urine may help to establish the correct diagnosis.
The presence of red cell casts is virtually diagnostic of glomerulonephritis or vasculitis. Absence, of course, does not exclude glomerular disease.
Evaluation of red cell morphology also may be helpful because the cells are typically uniform and round if bleeding is extraglomerular, and dysmorphic (marked variability of the size, and change of shape) with a glomerular source of bleeding.
Heavy protein excretion (above 500 mg/day) is also strongly suggestive of a glomerular lesion (hematuria alone does not cause increase in the proteinuria).
Blood clots, if present, are almost always indicative of extraglomerular bleeding.
Urine color also may be suggestive; extraglomerular bleeding causes red to pink color while glomerular bleeding tends to give a brownish "Coca Cola" color.
A 78-year-old man presented in the office with back pain. Pain was in the lower thoracic spine and was aggravated by pressure applied over the area and movement of the body. He had been healthy throughout his life and was not taking any medications. Laboratory results were as follows: Na- 137 K- 4.3 Cl- 112 CO2- 26 BUN- 26 Cr- 1.5 Gluc- 98 WBC-4.5 RBC- 2.87 Hb- 8.3 Hct- 24.2 Total protein- 11.2 Albumin- 2.9 Ca-12.4 Bilirubin- 0.6 AST- 25 Alk.P- 98 Urinalysis- Protein 3+
Which of the following is the most likely diagnosis?
Educational objective: review of characteristic features of multiple myeloma.
This presentation and laboratory findings are suggestive of multiple myeloma. Median age at diagnosis is about 65 years. About two thirds of patients have bone pain at presentation. Pain is most common in the back and chest, and less often in extremities. Pain is usually aggravated by movement and is usually absent during the night except with change in position. Weakness and fatigue are also common symptoms.
Pallor is the most frequent physical finding. Liver is palpable in about 20% and spleen in 5% of patients. Bone metastases are most commonly osteolytic (thought to be mediated by cytokine production) and may result in hypercalcemia (20-30% of patients). Renal failure is common and may be a presenting manifestation of multiple myeloma.
Elevated serum proteins with proteinuria (light chains) are one of the hallmarks of multiple myeloma and may result in amyloidosis. Metastatic disease is unlikely to be associated with either hyperproteinemia or osteoarthritis, which is more widespread and tends to be located in lower lumbar spine. Epidural abscess is usually associated with systemic signs of infection and elevated WBC.
Vertebral compression is common in patients with multiple myeloma but those are caused by the bony destruction by masses of plasma cells rather than osteoporosis.
Educational objective: Understand hypokalemia of diuretic therapy.
Hypokalemia is a relatively common problem with diuretic therapy. Increased delivery of sodium and water to the aldosterone sensitive potassium secretory site in the collecting tubule is partially responsible for hypokalemia. Another mechanism is increased aldosterone secretion due to hypovolemia induced by diuretics. As with other diuretic-induced fluid and electrolyte complications, potassium loss occurs only during the first two weeks before a new steady state is established.
So, a patient with normal potassium levels at the end of the third week is not at risk for late hypokalemia unless the diuretic dose or extrarenal potassium loss is increased or the dietary potassium intake is reduced.
Hypokalemia can lead to cardiac arrhythmias (especially in patients on digitalis therapy) and is thus especially dangerous in patients with underlying heart disease (also hypertension and hepatic cirrhosis).
Loop diuretics are more potent than thiazide ones in diuretic effects but produce less hypokalemia (exact reason for this is not known).
Educational objective: Understand skin manifestation of SLE.
The classic acute butterfly rash, characterized by erythema in a malar distribution over the cheeks and bridge of the nose, is the most common skin manifestation of SLE. It is seen in about one-half of the patients and usually appears after exposure to sun (due to UV-B exposure). The rash usually lasts for hours to a few days, rather than months, but it frequently recurs. The rash may precede other signs and symptoms of SLE for months or even years, or may be accompanied with other signs and symptoms of acute SLE. The affected skin appears slightly edematous, and is warmer than surrounding nonaffected skin. Rubbing the alcohol into affected skin may aggravate the rash (important to know since many sunscreens contain alcohol).
Educational objective: Review of drugs that may induce lupus erythematosus.
Drugs may aggravate existing lupus, but more common and well defined is the syndrome of the drug-induced lupus. This syndrome is similar to spontaneous lupus but also has some different clinical and immunologic features. A variety of drugs may induce lupus-like syndrome - medications that are metabolized by acetylation. The disease is more likely to develop and to develop sooner in patients who are slow acetylators because of a genetically mediated decrease in the hepatic synthesis of N-acetyltransferase (acetylation is not a risk factor for spontaneous lupus).
Medications that definitely may cause drug-induced lupus are Procainamide, hydralazine, isoniazid, methyldopa, chlorpromazine and quinidine
Medications that possibly can cause drug-induced lupus are phenytoin, mephenytoin, trimethadione, ethosuximide, quinidine, lithium, nitrofurantoin, captopril, glyburide, cimetidine, carbamazepine, sulfasalazine, hydrochlorothiazide, beta-blockers, antithyroid drugs, sulfonamides, and interferon-alpha.
Educational objective: Review autoantibodies associated with lupus erythematosus.
All of the above-mentioned autoantibodies are associated with lupus. The ANA is one of the most sensitive autoantibodies for detection of lupus, but it is not specific enough to allow for diagnosis. Double stranded anti DNA antibodies are much more specific, but are not so sensitive. The Anti-Ro antibodies appear to confer risk from chronic pneumonitis and fibrosis of the lungs in the patients with SLE.
Antihistone antibodies are important immunologic characteristics of drug-induced lupus and are present in more than 95% of cases, particularly in those patients who take procainamide, hydralazine, chlorpromazine, and quinidine. All other autoantibodies are uncommon in this disorder. Antihistone antibodies are also seen in about 80% of patients with idiopathic lupus.
Educational objective: Clarification of basis for false positive results on STS in patients with antiphospholipid syndrome.
Many patients with antiphospholipid antibody syndrome (APL) have a false positive serologic test for syphilis (STS). Some patients with systemic lupus erythematosus also have a false positive STS. Such patients have increased incidence of thrombotic events, livedo reticularis, and migraine as well as fewer successful pregnancies.
One of the four antibodies seen in APL is anticardiolipin antibody, and false positive reaction occurs because the syphilis antigen used for the serologic test is embedded in cardiolipin to which the antibody then reacts to produce a false positive result. However, STS should not be used to screen for APL since it has a low sensitivity and specificity.
Educational objective: Review of anticoagulation guidelines in patients with antiphospholipid syndrome.
Yearly incidence of the arterial or venous thrombosis in those patients who are not anticoagulated is about 30%.
Attempts to use aspirin for therapy were unsuccessful. In the studies using warfarin and maintaining INR below 3.0 (with or without aspirin) some protection from thrombosis was found.
High-intensity dose warfarin therapy where INR was kept over 3.0 (with or without aspirin) resulted in marked decrease in new thrombotic events to 1.3% of patients per year. It is important to know, however, that with such therapy incidence of major bleeding is higher and if therapy is stopped major thrombotic events recur (incidence is highest in the first 6 months after cessation of therapy).
Educational objective: Review causes of pseudohyperkalemia.
Pseudohyperkalemia refers to elevation of the measured plasma potassium level because of the potassium movement out of cells during or after a blood specimen has been drawn. The most common cause is mechanical trauma to red blood cells during the venipuncture (hemolysis). It can also occur in hereditary spherocytosis and in familial pseudohyperkalemia in which there is increased temperature-dependent leakage of potassium out of red blood cells after the specimen is collected.
Potassium also moves out of white blood cells and platelets after clotting has occurred (0.1-0.5 meq/l in normal subjects). In cases of marked leukocytosis (100,000 per mm3) and thrombocytosis (400,000 mm3) as in the cases of leukemia or myeloproliferative disease, the measured potassium may be up to 9 meq/l. For every 100,000 mm3 increases in platelets, count serum potassium rises for about 0.15 meq/l.
Pseudohyperkalemia should be suspected in all patients in whom there is no apparent reason for potassium level elevation, and in asymptomatic patients.
A 56-year-old female patient with a history of diabetes mellitus type 2 and hypertension presented in the emergency room with sudden swelling of the upper lip. This is the first such episode, and the patient is very disturbed because she had a neighbor who had occasional swelling of the lips and then went on to develop several episodes of inability to breathe. She is afraid that this is now happening to her. She has no known allergies and has been taking her medications regularly and without any significant side effects. Her routine laboratory findings (complete blood count with differential and electrolytes with BUN and creatinine) are all within normal limits. Measurements of the complement system components C1q, C2, C4, and C1-INH (functional/antigenic C1) are also within normal limits.
Which of the following is most likely the cause of her disorder?
Educational objective: Emphasize angioedema as an important side effect of ACE inhibitor therapy.
Angiotensin converting enzyme (kininase II) promotes degradation of angiotensin II, but also the degradation of bradykinin. Therapy with angiotensin converting enzyme (ACE) inhibitor results in decreased levels of angiotensin II and increased levels of bradykinin. This may result in angioedema. This mechanism is equal for all ACE inhibitors, and all of them are known to cause angioedema (0.1-0.7% of patients treated). Since large numbers of patients are treated with ACE inhibitors (especially hypertensive diabetic patients), this is a common cause of angioedema seen in emergency rooms. The main distinguishing feature of ACE inhibitor-induced angioedema is the older age of patients and absence of any allergic history.
In this patient there are also normal results of the complement components measurements (including C1-inh-functional/antigenic), which virtually exclude hereditary or acquired angioneurotic edema due to C1 inhibitor deficiency. There is no history of allergy, and no exposure to any substance that is known to cause anaphylaxis in this patient. Although about 15% of patients with hypereosinophilic syndrome exhibit angioedema, in this patient all routine laboratory results were within normal limits, thus excluding hypereosinophillia.
Ref. Clifton OB III. Angioedema, Up To Date - Version 8.1 February 2000.
A 34-year-old Caucasian man was seen in the office for an ulcer on the dorsum of his penis. Patient stated that initially 2 weeks ago there was a little red lump in this place, but now it has burst open and drained some pus. The ulcer is painful. On examination of the dorsum of the penis, there is an ulcer 1.5 cm in diameter with sharp borders and an erythematous bottom covered partially with grayish-yellowish exudate. There is also a new erythematous papule on the glans penis. Inguinal lymph nodes are enlarged and tender. Some of them appear fluctuant. A gram-stain of material from the ulcer reveals small gram-negative rods.
The patient is sexually active with multiple partners and had several encounters with prostitutes within the last month. Which of the following is the most likely diagnosis?
Educational objective: Review clinical features and emphasize chancroid as an important cause of genital ulcers in sexually active individuals.
Chancroid is a genital infection relatively rarely diagnosed in the U.S. (Only about 7% of clinics for sexually transmitted diseases test patients for haemophilus ducreyi). However, it is important to entertain this option in a differential diagnosis of patients with genital ulcers. The fact that this patient has a clinical picture characteristic of chancroid is not enough for diagnosis, but a gram-stain revealing small gram-negative rods is highly suggestive. For definite diagnosis, isolation of haemophilus ducreyi is necessary. This microorganism is fastidious and requires the presence of hemin and usually serum in the culture media to grow. (PCR techniques are developed for rapid diagnosis).
Syphilis is less likely in this patient as its ulcers are characteristically painless. Genital herpes is a common cause of recurrent genital ulcers that are painful, but these are usually smaller, multiple, and without marked lymphadenopathy. Lymphogranuloma venereum is caused by chlamydia trachomatis and it cannot be detected by gram stain. Granuloma inguinale (donovanosis) is caused by calymmatobacterium granulomatis and may appear as chancroid, but it is a much rarer condition.
A 43-year-old moderately obese male patient with a three-year history of asthma has a hard time controlling his symptoms. During the day he usually has no significant problems, but every night he is awakened once or twice with severe shortness of breath, wheezing and cough. This resolves after administration of inhaled -agonists within 20-30 minutes, but it leaves the patient exhausted and with difficulty concentrating during the day.
Patient has no known allergies, and allergy testing conducted 2 years ago in another institution revealed no sensitivity to common antigens. Patient is compliant with his medications and follow-up visits. His medications include inhaled corticosteroid (two puffs twice daily), inhaled --agonist (two puffs when needed), and occasional antacid for heartburn. Previous attempts to improve control of his asthma by using zafirlukast, and theophylline were unsuccessful.
Which of the following is most likely to improve his symptoms?
Educational objective: Emphasize clinical features of patients whose asthma is associated with gastroesophageal reflux disease. Gastroesophageal reflux disease (GERD) should be considered as a potentially important contributing factor in any patient with poorly controlled asthma. In a majority of these patients reflux can be diagnosed by measurement of esophageal pH testing. However, only a minority of patients will have significant GERD symptoms. Patients who are most likely to benefit from antireflux therapy are those who have significant nocturnal asthma and symptomatic GERD. These patients should be started on either an H2-blocker or a proton pump inhibitor and instructed in conservative management of GERD. Patients who are currently on theophylline may benefit from lowering the dose to diminish blood level and thus diminish the detrimental effect on lower esophageal sphincter function. Ref: Hamilos DL. Gastroesophageal reflux and sinusitis in asthma. Clinics in Chest Medicine, 1995 December: 683-97.
Educational objective: Emphasize clinical features of patients whose asthma is associated with gastroesophageal reflux disease.
Gastroesophageal reflux disease (GERD) should be considered as a potentially important contributing factor in any patient with poorly controlled asthma. In a majority of these patients reflux can be diagnosed by measurement of esophageal pH testing. However, only a minority of patients will have significant GERD symptoms. Patients who are most likely to benefit from antireflux therapy are those who have significant nocturnal asthma and symptomatic GERD. These patients should be started on either an H2-blocker or a proton pump inhibitor and instructed in conservative management of GERD. Patients who are currently on theophylline may benefit from lowering the dose to diminish blood level and thus diminish the detrimental effect on lower esophageal sphincter function.
A 47-year-old female presented in the office with several months' history of right shoulder pain and weakness. She stated that initially she was unable to raise her right hand over her head without pain and for the last several weeks she has not been able to lift her right arm unless she pushes it with her left.
On physical examination tenderness was elicited by pressure under the acromion. Passive abduction of the arm produced pain starting when the arm was about 80 degrees abducted. There was inability to abduct arm actively for more than 60 degrees despite lack of pain. There was also weakness of external rotation. There was no muscle atrophy or swelling of the shoulder, and x-ray of the shoulder did not reveal any abnormalities. Which of the following is the most likely diagnosis? A- Rotator cuff tear B- Rotator cuff tendinitis C- Frozen shoulder syndrome D- Acromioclavicular osteoarthritis E- Biceps tendinitis Answer 5 A- Rotator cuff tear Educational objective: Review important clinical features of rotator cuff tendinitis and tear. Weakness of abduction and external rotation is highly suggestive of a rotator cuff tear. Tendinitis of the rotator cuff presents with all of the above symptoms except weakness. The fact that weakness is of relatively recent onset in comparison with pain suggests initial tendonitis complicated with tear. Both conditions affect the tendons of the supraspinatus and infraspinatus muscles; and in the case of long-standing tear, muscle atrophy may be seen. Frozen shoulder syndrome is characterized by limitation of passive range of motion; associated pain may or may not be present. Acromioclavicular osteoarthritis is characterized by pain and swelling over the acromioclavicular joint and aggravation of pain with downward traction and forced passive adduction. Biceps tendonitis is characterized by anterior shoulder pain aggravated by lifting and overhead pushing and pulling. Tenderness is located in the bicipital groove. However, sometimes there is referred pain in the anterior aspect of the shoulder with rotator cuff tendonitis, and local injection of anesthetic should be used to differentiate the real source of pain and tenderness. Ref: Anderson BC. Office orthopedics for primary care: Diagnosis and treatment. 1995:11-25.
Educational objective: Review important clinical features of rotator cuff tendinitis and tear.
Weakness of abduction and external rotation is highly suggestive of a rotator cuff tear. Tendinitis of the rotator cuff presents with all of the above symptoms except weakness. The fact that weakness is of relatively recent onset in comparison with pain suggests initial tendonitis complicated with tear. Both conditions affect the tendons of the supraspinatus and infraspinatus muscles; and in the case of long-standing tear, muscle atrophy may be seen.
Frozen shoulder syndrome is characterized by limitation of passive range of motion; associated pain may or may not be present. Acromioclavicular osteoarthritis is characterized by pain and swelling over the acromioclavicular joint and aggravation of pain with downward traction and forced passive adduction.
Biceps tendonitis is characterized by anterior shoulder pain aggravated by lifting and overhead pushing and pulling. Tenderness is located in the bicipital groove. However, sometimes there is referred pain in the anterior aspect of the shoulder with rotator cuff tendonitis, and local injection of anesthetic should be used to differentiate the real source of pain and tenderness.
Ref: Anderson BC. Office orthopedics for primary care: Diagnosis and treatment. 1995:11-25.
A 76-year-old male patient with diabetes type 2, a long history of hypertension, and several episodes of congestive heart failure in the last year, is on his routine follow-up in the office. He has had no problems with shortness of breath for the last several months. He is taking his therapy regularly and tolerates it well. His therapy consists of 40 mg furosemide daily, 10 meq of KCl, and captopril 25 mg three times a day. His only complaint is that he has a chronic nonproductive dry cough.
On physical examination his lung fields reveal normal vesicular breathing sounds bilaterally, there is no peripheral edema, and he is afebrile. Auscultation of the heart reveals no abnormal findings. The ECG reveals normal sinus rhythm and all laboratory findings are within normal limits.
Which of the following is the most likely reason for his cough?
Educational objective: Emphasize cough as an important side effect of all ACE inhibitors.
All angiotensin-converting enzyme (ACE) inhibitors cause dry cough in patients taking them (6-25% of all patients). All of them are equal in ability to produce dry cough, and substituting one for another has no place in dealing with this side effect. However, in mild cases the medication may be continued. In more severe cases change to another antihypertensive agent may be advisable. Angiotensin II receptor inhibitors are considered the best replacement drug in patients with diabetes in whom the protective effect on proteinuria and renal failure is of great importance.
This patient has no history of coronary artery disease, and his normal physical examination and EKG finding make anginal equivalent unlikely as a cause for his cough. This patient also has no risk for recurrent aspiration, and has a normal examination of the lung, as well as a normal chest x-ray.
There are no signs of congestive heart failure (peripheral edema, shortness of breath, S3, crackles or rales on lung auscultation, etc.) or infection (fever, sore throat, productive cough, etc.).
Ref: Simon SR, Black HR, Moser M at all. Cough and ACE inhibitors Arch Intern Med 1992: 152(8), 1698-700.
A 34-year-old morbidly obese female presents in the office complaining of burning pain and occasional numbness in her right thigh. She is otherwise healthy. Her last office visit was a year ago and at that time no acute or chronic medical problem, besides obesity, was discovered. In the meantime the only change is a 13-kilogram weight gain. Her pain has been present for the last three months, but in the beginning was more a funny feeling when her clothes rubbed against this area; later it became painful. Pain is not limiting her activity but is getting worse, and she is worried.
Physical examination reveals an area on the lateral aspect of lateral thigh (approximately middle third) where light stroking of the skin by fingernail causes sensation of burning pain. Neurologic examination is otherwise entirely negative. Examination of hip, back and sacroiliac joints are also within normal limits.
Educational objective: Review clinical features of meralgia paresthetica.
Compression neuropathy of the lateral femoral cutaneous nerve (meralgia paresthetica) is a condition in which the nerve is compressed at the exit from the pelvis and entrance into the thigh. The main causes are scarring of the tissue in the vicinity of the lateral aspect of the inguinal ligament, tight garments around the waist, and obesity with an overlying panniculus.
Patients complain of burning pain in the specific area of the thigh (middle third of lateral aspect), or numbness and tingling or funny feeling when clothes rub over the same area.
Hypesthesia or dysesthesia of the area is found on examination, but the rest of the neurologic examination is entirely normal, as are hip, back, knee and sacroiliac joint examinations. Sometimes the area might be more anteriorly due to variation in distribution of the lateral femoral cutaneous nerve. X-ray examination is not indicated since the clinical picture is typical.
Avoidance of tight garments, loss of weight, and reassurance are the mainstays of therapy. In intractable cases carbamazepine or phenytoin may be used. In cases of long-term intractability (months to years) neurosurgical consultation should be obtained.
Ref: Anderson BC. Meralgia Paresthetica. In. Office Orthopedics for Primary Care, Diagnosis and Treatment. W.B. Saunders Company, 1995:76-77.
Ref: Rudy D R, Zoun M J. Update on Colorectal Cancer. American Family Physician. 61:1759-70, 1773-4, 2000 (Mar 15).
Educational objective: Understand significance of CD-4 cell count and HIV-RNA determination in HIV patients.
Two important laboratory determinants of the rate of the progression and ultimately prognosis in patients with HIV infection are the CD-4 cell count and the viral load (HIV-1 RNA quantitation). Rate of the CD-4 cell count decline is another important prognostic factor. Prognosis is worse in patients with lower CD-4 cell count, a faster rate of CD-4 count decline, and higher viral burden. Risk of progressing to AIDS is lowest for patients with an undetectable viral load and A CD-4 count of more than 500 mm3 (0% five year progression to AIDS in one study) and is much higher in patients with viral loads over 10 000 copies/ml and CD-4 count below 200 mm3 (81% in five years in the same study).
Educational objective: Review clinical features and significance of CMV retinitis in HIV infected patients
Cytomegalovirus (CMV) retinitis is the most common serious ocular complication of AIDS. It appears that highly effective antiretroviral therapy may prevent development of CMV retinitis. Most patients with CMV retinitis have CD-4 cell count below 50 mm3.
CMV retinitis is typically painless, can cause blurring or loss of central vision, scotomata, floaters, or photopsia (flashing lights). It may lead to acute retinal detachment and acute loss of vision. Diagnosis is made generally on clinical criteria, by demonstration of white, fluffy or granular retinal lesions, often close to retinal vessels and associated with hemorrhage. Small lesions may be hard to recognize and serial fundoscopic examinations are sometimes required to make the diagnosis.
A 20-year-old male noticed some blood in his urine. This has been happening after exercising, but he also noticed blood in the urine approximately one month ago during a flu-like illness. He is feeling good and has no other medical conditions. Also, he is not taking any medications, and denies any allergies. His physical examination is entirely within normal limits including blood pressure (117/69 mm/Hg).
Laboratory findings reveal the following: Na 140 meq/l, K - 3.8 meq/l, Cl -102 meq/l, CO2 - 28 meq/l, BUN - 12 mg/dl, Cr -0.6 mg/dl and Glucose -98 mg/dl. Urinalysis reveals a few white blood cells and red blood cells with some red blood cell casts.
What are the best treatment and prognosis for this patient at this time?
Educational objective: Recognize the most common presentation and form of IgA nephropathy.
This patient most likely suffers from IgA nephropathy - Berger's disease (most common glomerulopathy worldwide - 10-40%). There is no proven therapy for IgA nephropathy, although there is suggestion that fish oil may be beneficial. Berger's disease usually smolders for decades with episodes of exacerbations of hematuria and renal impairment during intercurrent infections. Long-term prognosis is generally good with 20-50% of patients developing end stage renal disease over a 20-year period. Clinical predictors of a more aggressive course of disease include male sex, advanced age, renal insufficiency, nephrotic range proteinuria and hypertension at presentation.
A 17-year-old male was diagnosed with aspirin sensitivity after developing two episodes of urticaria/angioedema and difficulty breathing after taking aspirin from his family's medication cabinet for headache. Symptoms also included audible wheezing and runny nose. He had to be hospitalized briefly after second episode.
Which one of the following medications may this patient use without danger of developing similar episodes?
Educational objective: Review important features of aspirin sensitivity.
Nonsteroidal anti-inflammatory medications (including the aspirin and indomethacin) may cause two types of allergic-like symptoms in some individuals. About 1% of all persons experience urticaria/angioedema and about one half of a percent will experience rhinosinusitis and asthma-like symptoms. Asthma-like symptoms develop rapidly after ingestion of offending substance (within 1 hour), while urticaria/angioedema may develop up to 24 hours after ingestion.
In patients with known sensitivity to nonsteroidal anti-inflammatory medications it is safe to use acetaminophen.
A 39-year-old moderately obese man (body mass index - 33.2) has been diagnosed with diabetes mellitus type 2 after complaining of excessive thirst and urination for the last several weeks. His HbA1C at the time of diagnosis was 8.7%. In the next three months he reduced his body weight significantly, reaching a body mass index of 27.1, by using an intense exercise program and strict diet. His repeated HbA1C was 7.4%, and most of his home glucose measurements were in the range of 80-160 mg/dl. His urine analysis at the follow up visit revealed significant microalbuminuria despite negative finding on first visit.
What is the most likely explanation for his microalbuminuria?
Educational objective: Illustrate importance of false positive findings of microalbuminuria. Recently it was recommended for increase in the reliability of the detection of the microalbuminuria in random urine samples of diabetic patients to use albumin-to-creatinine ratio. There are, however, two important caveats that must be considered to maximize the reliability of the test. Vigorous exercise may cause transient increase in albumin excretion and patients should refrain from exercise in the 24 hours prior to test. Correlation between results of random sample test and 24-hour urine collections is the best if random urine samples are taken in mid-morning. The fact that patient in question did not have microalbuminuria at the time of diagnosis (before institution of exercise program) suggests exercise as a cause. Diet and such a fast development of diabetic nephropathy are highly unlikely. Independent renal disease is also much less likely in this setting than exercise-induced microalbuminuria.
Educational objective: Illustrate importance of false positive findings of microalbuminuria.
Recently it was recommended for increase in the reliability of the detection of the microalbuminuria in random urine samples of diabetic patients to use albumin-to-creatinine ratio. There are, however, two important caveats that must be considered to maximize the reliability of the test.
Vigorous exercise may cause transient increase in albumin excretion and patients should refrain from exercise in the 24 hours prior to test.
Correlation between results of random sample test and 24-hour urine collections is the best if random urine samples are taken in mid-morning. The fact that patient in question did not have microalbuminuria at the time of diagnosis (before institution of exercise program) suggests exercise as a cause. Diet and such a fast development of diabetic nephropathy are highly unlikely.
Independent renal disease is also much less likely in this setting than exercise-induced microalbuminuria.
Educational objective: Review screening recommendation for microalbuminuria in diabetic patients.
Microalbuminuria represents the stage of diabetic nephropathy in which treatment is often successful in preventing progressive renal disease. The ability of angiotensin converting enzyme inhibitors to effectively slow progression of renal impairment in diabetic patients has led to development of recommendations for screening of both diabetics with type 1 and type 2 diseases in yearly intervals. However, screening can be deferred for five years after onset of the disease in type 1 diabetes because microalbuminuria is uncommon until that time. This is not the case with type 2 diabetes in which it is estimated that disease was present on average 5 to 7 years before diagnosis.
A 66-year-old man comes to your office complaining of intense whole body pruritus after bathing. He has a smoking history of 1 pack per day for 45 years. The rest of the past medical history consists only of one pain episode in his big toe but no recurrences after that several weeks ago. On physical examination he was found to have splenomegaly, and on pulmonary auscultation bilateral inspiratory rales can be heard. Selected laboratory results are as follows. WBC-12,000, Hb-18, Hct-64 Results of arterial blood gases: pH-7.37, PCO2-41, PO2-78
Which one of the following statements is correct about this condition?
Educational objective: Review features of polycytemia vera.
Polycytemia vera (PCV) presents with increased values of hemoglobin and hematocrit, granulocytosis, thrombocythemia associated with low erythropoetin levels and normal oxygen saturation of arterial blood. Uric acid levels are also increased. Some patients may have normal hemoglobin and hematocrit levels but all patients have increased red blood cells mass. Bone marrow is hypercellular in all patients. Bleeding is the major complication and is caused by marked thrombocytosis (platelets of over 1 000 000 are more commonly associated with bleeding than thrombosis). Hydroxyurea is a mainstay of therapy in addition to phlebotomy (to keep Hct<45%).
A 33-year-old female presented in the office complaining of bilateral pain in hands and wrists. On direct questioning she admits to pains in many other joints, but these are not as severe and her hands are bothering her the most. Pain is worst in the morning and there is also associated stiffness that improves with activity (usually after 1-2 hours).
On physical examination there is symmetrical involvement of metacarpophalangeal and proximal interphalangeal joints. These joints are erythematous and warm. There is no associated skin rash. What is the best choice for initial treatment of her condition?
Educational objective: Review initial treatment for rheumatoid arthritis.
The goals of therapy for RA are relief of pain, reduction of inflammation, maintenance of the joints structure and function, and control of systemic involvement. The first step in therapy should be use of aspirin or other nonsteroidal anti-inflammatory medication to control the symptoms and local inflammation. Disease modifying antirheumatic drugs (DMARDs) should be started as soon as the diagnosis is certain. It often produces a beneficial effect in 2-6 weeks and has become the first line of treatment among the DMARDs. S6teroids are effective in producing immediate effects but side effects limit its use. Gold salts are rarely used now because of the side effects.
A 68-year-old man with a history of large myocardial infarction associated with congestive heart failure (CHF) 6 months ago has been hospitalized with acute cholelithiasis complicated with development of acute pancreatitis. He has been treated with broad-spectrum intravenous antibiotics, intravenous meperidine and fluids. He has gradually become anxious, tachypneic and started complaining of feeling very short of breath. Portable chest x-ray reveals diffuse patchy alveolar and interstitial infiltrates affecting most of both lung fields.
What is the best method to distinguish between congestive heart failure and adult respiratory distress syndrome (ARDS) in this patient?
Educational objective: Review important pathophysiological differences between ARDS and CHF.
Educational objective: Review proper sequence of visual acuity testing in an office setting.
The standard test for visual acuity is reading of Snellen eye chart from a 20-foot distance. One eye should be covered while patient reads the lines with open eye until smallest line that patient can read with only a few mistakes. Chart is organized in such a way that top (biggest) line signifies acuity of 20/400 (average eye should be able to read that line from a distance of 400 feet) and bottom (smallest) signifies acuity of 20/10 (average eye should read this line from 10 feet).
If patient is unable to see a chart he should be asked to count examiner�s fingers from a distance of 3 feet, and the result should be recorded.
If patient cannot count fingers from 3 feet, he should be asked if he can see the waving motion of an arm in front of the eye at a 3-foot distance.
Educational objective: Review causes of painless vision loss.
Differential diagnosis of painless loss of vision includes the following conditions: � Central retinal artery occlusion � Central retinal vein occlusion � Retinal detachment � Retrobulbar neuritis � Snow blindness � Hysteria � Stroke
Every vision loss is an emergency and should be referred to an ophtalmologist as soon as possible.
Anterior uveitis is usually a painful condition and does not impair vision to the extent of the above conditions.
A 7-year-old girl was brought to the office by her mother for what appears to be an eye infection. Child is complaining of minimal pain but intense itching of both eyes. Child first complained of discomfort about one week ago, and since then it has been slowly progressing. Examination reveals red-rimmed eyelids with some scaling (some scales are clinging to the eye lashes); there are no visible ulcerations of the lids and there are no missing eyelashes. There is minimal injection of conjunctivas. Child was healthy in the past and has not been taking any medications.
Which one of the following microorganisms is most probably associated with this condition?
Educational objective: Review etiology of blepharitis.
Child is presenting with chronic inflammation of the eyelids (blepharitis). There are two types of blepharitis: Infectious, caused by Staphylococcus aureus or Streptococcus epidirmidis; and seborrheic, associated with Pityrosporum ovale infection (although it may also occur without infection).
Symptoms include irritation, burning and itching of the lid margins.
Physical examination reveals inflammation and erythema of lid margins with scaling. Infectious blepharitis also has associated small ulcerations of the lids, and lashes tend to fall out.
Seborrheic blepharitis has no associated ulcerations or lash fall-out, and tends to be less inflamed.
A 7-year-old boy is brought to the office by his mother with an apparent eye infection. The child is complaining of pain and intense itching of both eyelids. Child first complained of discomfort about one week ago and since that time it has been slowly progressing. Examination reveals red-rimmed, inflamed eyelids with scaling. There are some small ulcerations visible on the lids and apparently some missing eyelashes. There is minimal injection of conjunctivas. Child was healthy in the past and has not been taking any medications.
Which one of the following medications should be used in addition to eyelid cleansing in the treatment of this condition?
Educational objective: Review appropriate therapy for blepharitis.
This child is suffering from chronic inflammation of the eyelids (blepharitis) which is likely infectious (presence of ulcers and missing lashes).
This condition is treated by cleansing of eyebrows and lid margins using baby shampoo and removing debris from lid margins using cotton swabs. If there is ever suspicion of infection, sulfacetamide ophthalmic drops should also be used in therapy since they are effective in cases of staphylococcal infections.
A 15-year-old girl was seen in the office for itching, burning and some pain in the left eye for the last 48 hours. Physical examination revealed a slight swelling of the left lower lid and a small pointing abscess visible on inner surface of the lid.
Which of the following is appropriate treatment for this condition?
Educational objective: Review features and therapy of chordeloum.
Clinical presentation of this girl suggests abscess of the Meibomian gland (internal chordeloum). Another form of the disease is superficial chordeloum, which is an infection of the smaller superficial lid glands, Zeis or Moll’s glands.
Symptoms include pain, redness, and swelling of the eyelid.
Therapeutic measures include application of warm compresses to the eye to hasten recovery, and, in adults, erythromycin ophthalmic ointment every 3 hours.
Systemic antibiotics are only required in complicated cases (cellulitis) and surgical drainage may be considered if there is no resolution in 48 hours after initiation of therapy.
A 3-month-old infant was seen for swelling and erythema of the right eye in the area of medial canthus. There is also excessive tearing of the eye with purulent discharge present in medial angle. Infant has been irritable, sleeping poorly and feeding poorly for the last 24 hours.
Which one of the following microorganisms is most likely responsible for his condition?
Educational objective: Review causes of different forms of dacryocystitis.
Symptoms suggest acute dacryocystitis in this infant. This is an infection of the lacrimal sac; symptoms consist of pain and swelling in the area of the medial canthus, with excessive tearing and, sometimes, purulent discharge (compression of lacrimal sac may produce drainage from foramina lacrimalis). Acute infections in infants are most commonly caused by Haemophilus influenzae, while in adults these infections occur most commonly in postmenopausal women and are usually caused by Staphylococcus aureus. â-hemolytic streptococci are occasionally the culprit.
Chronic forms are usually caused by Streptococcus pneumoniae and Candida albicans.
Educational objective: Review appropriate management of corneal ulcers.
Corneal ulcer occurs when an infective organism invades the cornea and breaks down the protective epithelial layer. Bacteria causing corneal ulcers include staphylococci, streptococci, bacilli, pseudomonas, anaerobes, etc. The herpes virus is notorious in producing branched (dendritic) ulcers of the cornea. Fungal infections have also been implicated.
Ulcers develop more commonly in infections following burns, abrasions, contact lens overuse, and inappropriate use of topical anesthetics.
Before the decision is made on appropriate treatment, it is necessary to confirm the presence of the ulcer, and flourescein stain is the most appropriate method because the dye will be taken up in denuded areas. Examination with slit lamp will ease the examination but most often it is not necessary for ulcer confirmation.
Scrapings of the cornea should be stained by gram-stain and sent for cultures while topical antibiotic therapy is instituted immediately.
Covering of the eyes and steroid application should be avoided because of danger of perforation.
Educational objective: Review causes of herpes virus ceratoconjunctivitis.
Any of the herpes virus family can infect the eye. In neonates herpes simplex virus type 2 is the most common cause, and it is acquired during delivery. Later in life herpes simplex type 1 is more common. Both of these viruses can cause conjunctivitis or keratoconjunctivitis.
The Varicella-Zoster virus usually occurs in elderly or immunosuppressed patients and may be recurrent. This is a potentially dangerous infection if it affects the eye area (ophthalmic branch of fifth cranial nerve).
The Epstain-Barr virus may cause conjunctivitis or keratoconjunctivitis in association with mononucleosis.
The Cytomegalovirus may cause severe retinitis in patients with AIDS and severe immunosupression of other origin (chemotherapy).
Educational objective: Review diagnostic modalities for herpes ceratoconjunctivitis.
Differential diagnosis of herpes simplex includes bacterial keratoconjunctivitis, inclusion conjunctivitis (Chlamydia), traumatic corneal abrasions and erosions as well as uveitis.
Evaluation of the patient includes flourescein staining of the cornea with or without slit lamp examination (characteristic dendritic ulcers are visible).
Scrapings from the cornea may be stained by Rose-Bengal staining, which is positive in herpes simplex infections. In addition, Geimsa staining of the scrapings will show multinucleated giant cells.
Cultures of the virus have also been used for diagnosis, although this is a time-consuming technique. Electron microscopy has not been used in clinical management of patients with presumed herpes simplex keratoconjunctivitis.
Remember, permethrin is the most effective (and first line) topical agent for scabies, not lindane (which some of us used to use). Recognize scabies when overcrowding is mentioned in the question (housing projects, jails, nursing homes, etc.). Place the permethrin 5% cream after bathing or showering, applying it from the neck to the soles of the feet; then wash off after 8–14 hours. A 2nd application 1 week later is recommended if new lesions develop.
