disease (GERD) has had intermittent right knee pain and achiness for several
months. The pain is alleviated with rest and acetaminophen, but it interferes with
her hobbies. Her family history is significant for osteoarthritis. On exam, there is
mildly decreased range of motion of the right knee with palpable crepitus and mild
effusion, but no erythema or warmth. She is given a presumptive diagnosis of
osteoarthritis and acetaminophen is recommended.
When she returns for follow-up, she reports that her pain is not well controlled
with the acetaminophen, and she is counseled regarding various pharmacological
and non-pharmacological treatments for osteoarthritis. On this visit, she also
notes intermittent right wrist symptoms, including aching and tingling in her palm,
thumb, and first two fingers. Her exam is normal, except for a positive Phalen's
test. She is diagnosed with carpal tunnel syndrome and given a wrist splint.
When she returns for an annual physical exam, United States Preventive Services
Task Force recommended screening and immunizations are addressed. She
reports that she is still not able to control her pain despite some relief with a knee brace, heat, and Tramadol, and chronic pain control is addressed.
First choice analgesic for both short and long-term treatment of mild
to moderate pain related to osteoarthritis because of its tolerability
and low side-effect profile.
Dosing is up to 4 grams per day in divided doses, though some
recommend lower doses (2-3 grams/day in divided doses) if long-term
use is desired.
There is little risk of nephrotoxicity, and hepatotoxicity is a rare side
effect if taken appropriately.
2. Nonsteroidal anti-inflammatories (NSAID)
Elderly patients are at an increased risk of developing gastric ulcers
when using NSAIDs chronically.
Prolonged bleeding times present additional risk if patient is at risk of
Other NSAID side effects include decreasing the effectiveness of
hypertension medications, and increasing the effect of sulfonylureas.
Patients who use NSAIDs chronically, taking 5,000 or more pills, are
at an increased risk of developing end-stage renal disease.
NSAIDs, aspirin, and acetaminophen can all cause hepatotoxicity, and
contribute to coagulopathy.
NSAID creams appear to work better than placebo and have fewer
COX-2 inhibitors: Celecoxib( Celebrex), Valdecoxib (Bextra) Rofecoxib (Vioxx)
Less risk of gastrointestinal bleeding, but increased cardiovascular risk, which is why several were removed from the market.
Monoamine uptake inhibitor is a centrally-acting analgesic that
appears to have actions at the μ-opioid receptor as well as the
noradrenergic and serotonergic systems.
Less potential for abuse than opioids.
Appropriate for moderate to severe pain.
C1. entrally acting analgesic with effects on mu-opioid receptors.
Also stimulates release of serotonin and inhibits reuptake of
Effective in alleviating moderate to severe pain.
Lower abuse potential than opiods.
2. Short-acting opioid
Given first to see how much is needed to control pain adequately over
a 24-hour period, and then converted to a long-acting alternative.
Act on several different receptors, including mu receptors in the
central nervous system.
Side effects: euphoria, bradycardia, sedation, physical dependence,
nausea, vomiting, and respiratory depression.
More risk of tolerance than long-acting opiods because of their short
half-life of 3-4 hours. Patients need to use them more frequently to
control their pain adequately.
Helpful for flares of acute pain, but if daily use is needed, long-acting
opioids should be considered.
A meta-analysis showed that strong opioids (oxycodone and
morphine) were more effective than naproxen or nortriptyline for
treating chronic non-cancer pain, but not the weaker opioids
For daily use to treat chronic pain.
Most common side effect: constipation. Treat with laxatives, stool
softeners, exercise, and a high water and fiber diet.
If the long-acting opioid alone is not sufficient, can add either
acetaminophen for breakthrough pain, or a short-acting opioid.
The goal should always be to use the smallest sufficient dose for the shortest period of time to achieve adequate pain control.
Anticholinergic side effects: dry mouth, constipation, urinary
retention, blurred vision and paralytic ileus.
Other side effects: gastrointestinal, sedating, and neurologic (ataxia,
tremors, paresthesias, and mental clouding).
Relatively contraindicated in patients with severe cardiovascular
disease or conduction problems because they can contribute to
tachycardia, arrhythmias, hyper- or hypotension, heart block, and
Helpful for trigeminal neuralgia, but evidence is lacking for other
chronic pain syndromes.
Lamotrigine (Lamictal) was shown to be ineffective for treating chronic
neuropathic pain in a meta-analysis.
Some anticonvulsants require blood level monitoring as well, and have
severe side effects like megaloblastic anemia.
Carbamazepine (Tegretol) can interfere with other medications
because it is a cytochrome P-450 inducer, including decreasing the
effectiveness of hormonal contraception.
Several are also known teratogens.
Savannah is a healthy 16-year-old girl who presents with her mother for a routine
pre-participation sports exam. The visit includes development of a trusting
doctor-patient relationship to facilitate adolescent health promotion and disease
treatment. Immunizations are updated and an adolescent interview is conducted,
which reveals that Savannah is engaging in unprotected sex. Birth control and
preconception counseling are provided, and Savannah is scheduled to return for
Depo-Provera, a pelvic exam, and a chlamydia test.
When Savannah returns to the clinic two weeks later, she reports 5 weeks since
her last menstrual period, morning sickness, breast tenderness, and tiredness.
Urine pregnancy test is positive. She is given unintended pregnancy options counseling.
A week later, Savannah returns due to vaginal bleeding. Her pulse and blood
pressure are normal and pelvic exam is unremarkable. Quantitative beta-hCG is
1492 mIU/mL. Ultrasound does not reveal intrauterine pregnancy, but a left
ovarian cyst is noted. After reviewing the differential diagnosis, it is determined
none of the top three diagnoses (spontaneous abortion, ectopic pregnancy, or
idiopathic bleeding in a normal pregnancy) can be currently ruled out.
However, two days later, her serial beta-hCG has doubled, the bleeding has
subsided, and transvaginal ultrasound reveals an appropriately developing fetus
with a heartbeat. Ten days later, at 7 weeks and 4 days gestation, Savannah
presents to the emergency department with vaginal bleeding, some clots, and a
fair amount of pain. Pelvic exam reveals the cervical os opened 1-2 cm with
pooled blood in the vaginal vault. On ultrasound, the fetus no longer has a heart
beat, and the inevitable abortion is appropriately managed.
1.Strongly Recommends screening; (A)
All sexually active non-pregnant young women aged 24 and younger
(chlamydia and gonorrhea)
2.Non-pregnant women age 25 and older at increased risk (chlamydia,
gonorrhea, hepatitis B, HIV, and syphilis)
High pretest probability with risk factors, including age <25.
Screening can reduce the incidence of PID.
All pregnant women aged 24 and younger (chlamydia, gonorrhea,
hepatitis B, HIV, and syphilis)
Pregnant women age 25 and older at increased risk (chlamydia,
gonorrhea, hepatitis B, HIV, and syphilis)
Pregnant women have a relatively high prevalence of infection.
Fair evidence of improved pregnancy and birth outcomes for pregnant
women who are treated for chlamydial infection.
*Advises against screening women age 25 and older if not at
increased risk, regardless of pregnancy status*.
Overall benefit of screening would be small given the low prevalence of
infection among women not at increased risk.
Positive test is more likely to be a false positive than a true positive, even
with the most accurate tests available, in a low prevalence population.
Insufficient evidence for or against screening men.
Initial pregnancy evaluation
1. Serum hCG
When urine hCG is positive, it is not necessary to obtain a serum hCG.
It is possible to have a positive serum hCG result, even with a
negative urine hCG result, as early pregnancy urine hCG
concentrations are lower than serum hCG concentrations.
Specify a qualitative (positive vs. negative) vs. a quantitative serum
Quantitative serum hCG levels rise at a predictable rate, so
serial testing of serum hCG levels can be useful to determine
viability or to diagnose an ectopic pregnancy, although one
measurement alone is not sufficient to accurately estimate
Detect various nutritional and congenital anemias6. 3. Blood type
Detect rhesus antibody presence.
Rh D negative women should receive *50mcg dose of Rho(D) Immune
Globulin (e.g., RhoGAM) to prevent hemolytic disease of the newborn at 28 weeks.*
When an Rh negative mother detects enough fetal Rho-D antigen, she
forms antibodies to this antigen.
This immune response is usually not robust enough to impact the first
gestation, but subsequent gestations are at significant risk of an
When this occurs, the maternal antibodies attack the fetus' red blood
cells, causing hemolytic anemia, which can lead to fetal hydrops and
even fetal death.
Rho(D) Immune Globulin administered at appropriate times interrupts
the maternal immunologic process.
You can visualize this process by imagining the RhoGAM attaching to
all of the fetal Rho-D antigenic load, making it immunologically
"invisible" to the maternal immune system.
Assess the presence of IgG antibodies. If the patient is NOT immune, they should receive a postpartum
The Rubella and the MMR vaccine is a live-virus vaccine and should
not be used during pregnancy.
5. Hepatitis B
Tests for Hepatitis B surface antigen
A major risk to the newborn.
Tests for syphilis
Risk of transplacental infection of the fetus.
Congenital infection is associated with several adverse outcomes in
Low birth weight
Active congenital syphilis
Status should be checked as the risk of perinatal transmission can be
reduced from 15-40% without treatment to less than 2% with
antiretroviral therapy and avoidance of breastfeeding and labor.
1. Complete blood count (CBC)
Red blood cell count provides the hemoglobin and hematocrit.
White blood cell (WBC) count
Limited in its usefulness to detect infection (and thus a septic
abortion) during pregnancy because most pregnant patients have a
If significantly elevated, or associated with a bandemia, this test
would need to be factored into the consideration of a septic abortion.
2.Wet mount preparation for Gonorrhea, Chlamydia, and Trichomonas
All sexually transmitted infections can cause vaginal bleeding.
These tests should be obtained in this clinical context, despite a
previously normal recent result.
Culture should not be obtained as it is very expensive.
Chlamydia cultures should only be used in cases of forensic
investigation, such as rape or child abuse.
Type and screen
Knowing Rhesus status is critical, as all Rh negative women who are
pregnant need to be given RhoGam during any episode of bleeding.
When the history, vital signs, and physical exam
consistent with a major bleed.
To estimate the quantitative amount of fetal hemoglobin
in the maternal circulation and help with dosing RhoGam.
3.Quantitative beta-human chorionic gonadotropin (quant. beta-hcg)
In isolation, one beta-hCG can be challenging to interpret.
Combined with pelvic ultrasound, has definitive diagnostic modalities.
Human chorionic gonadotropin is secreted by the trophoblastic cells
very early in embryonic life (day 7, post-ovulation).
Testing for the beta-subunit is exquisitely sensitive (down to 5
mIU/mL) and specific (the placenta is the only normal tissue that
The velocity of increase or decrease is a more useful diagnositic
modality than a point value in a stable patient.
If the patient is stable, 1-2 serial hCG measurement(s) can prove
diagnostically useful and often conclusive when combined with a
A crown-rump length is measured.
The accuracy and precision of this measurement is +/- 1 week.
If the estimated gestational age (EGA) & estimated delivery date (EDD)
from the ultrasound measurements are within 1 week of the EGA / EDD
calculated from the last known menstrual period (LNMP), then the
estimated gestational age today, as well as the estimated due date, should
be based on the calculations using the LNMP.
If, however, the ultrasound measurements suggest an EGA & EDD that is >7 days from the EGA & EDD calculated from the LNMP (or, in some cases,
if the LNMP is historically inaccurate), then the estimated gestational age
today, as well as the estimated due date, should be changed to reflect the
ultrasound measurements and estimates.
Four measurements are taken:
The accuracy and precision increases to +/- 2 weeks. The same rules
apply to keeping or changing the EGA / EDD.
Third trimester (i.e., after 24 weeks),
Accuracy and precision falls to a range of +/- 3 weeks.
Additionally, fetal size cannot be used accurately to assess EGA or
EDD and should not change a due date.
Acute sinusitis: Fever, Colored nasal drainage, Headaches, Facial pain, Toothache, Failure to respond to decongestants, Failure to improve after a
viral upper respiratory infection, Nasal
congestion or obstruction, ·Initial improvement after a viral upper respiratory infection and then a reoccurrence of worsening symptoms.
Viral rhinosinusitis: Nasal congestion
and drainage. Mild generalize headache
Symptoms < 10 days and not worsening
Chronic sinusitis: Must have at least
2 of the following: ·Nasal obstruction
/congestion; Mucopurulent drainage
Facial pain, pressure, or
fullness Decreased sense of smell
Some patients may have only minimal
symptoms such as worsening
nasal congestion or fatigue. Symptoms last
≥ 12 weeks.
Upper airway cough syndrome (UACS): May present with upper airway
symptoms (rhinitis), cough, and wheezing, but no objective findings on
spirometry and no relief with typical asthma medications, including
bronchodilators and inhaled oral corticosteroids.
Asthma: Reversible obstructive findings on spirometry is the distinctive
diagnostic abnormality in patients with asthma, especially early in the
course. Patients with chronic, severe asthma may have less or no
reversibility of their obstructive findings, very similar to patients with
chronic obstructive pulmonary disease.
Non-asthmatic eosinophilic bronchitis: Pa 3. tients respond to inhaled corticosteroids similarly to patients with asthma, but they will have normal
spirometry and a normal chest x-ray. The diagnostic finding for this
condition is sputum eosinophilia (on induced sputum or bronchial wash
obtained at bronchoscopy).
Vocal cord dysfunction: Patients may have flattening of the inspiratory
loop on spirometry (in contrast to the reversible obstructive findings on
spirometry in patients with asthma). The diagnostic finding of this condition
is visualizing abnormal vocal cord movement during an episode of wheezing.
Chronic obstructive pulmonary disease (COPD): Obstructive findings
on spirometry that are not significantly reversible. Criteria for staging
patients with chronic obstructive pulmonary disease based on the FEV1/FVC
ratio are available.
Congestive heart failure (CHF): May on occasion have cough or
wheezing, but no relief with bronchodilators or corticosteroids. There are
more common symptoms and signs, which aid in the diagnosis of congestive
heart failure, including shortness of breath on exertion, extra heart sounds,
jugular venous distension, peripheral edema, and findings on
Gastroesophageal reflux disease (GERD): Present with either heartburn
symptoms or findings of esophagitis on upper endoscopy. Gastroesophageal
reflux may occur singly with symptoms or cough and wheezing or serve as a
co-morbid condition of patients with asthma. If a patient with asthma fails
to improve with standard treatment, it is reasonable to consider whether
gastroesophageal reflux is present.
Suppress, control, and reverse airway inflammation.
Side effects with chronic administration include: Osteoporosis, adrenal
suppression, growth suppression, dermal thinning, hypertension,
Cushing's syndrome, cataracts, increased emotional lability,
psychosis, peptic ulcer disease, atherosclerosis, aseptic necrosis of the
bone, diabetes mellitus, and myopathy.
Minimize systemic corticosteroid use and maximize other modes of
When oral corticosteroids are given (e.g., for an asthma
exacerbation), they are given for a short duration only, and side
effects are monitored.
Multiple courses of oral systemic corticosteroids (more than three
courses annually) should prompt re-evaluation of patient's asthma
Ms. Rios is a 35-year-old woman who stopped
taking birth control six months ago. After missing her usual period, a urine
pregnancy test confirms her pregnancy. Throughout her pregnancy, appropriate
counseling and studies are offered at each visit. Early in the pregnancy,
conversation focuses on diet, exercise, activity, weight gain, and nausea/vomiting during pregnancy. As the pregnancy progresses, prenatal genetic screening is
addressed, and a serum quad screen reveals an increased risk of Down's.
Ultrasound at 20 weeks does not display any fetal anomalies, but does reveal
placenta previa, which appears to resolve by 24 weeks, as shown on a subsequent
ultrasound. At 27 4/7 weeks, Ms. Rios' blood pressure is briefly elevated,
prompting follow-up measurements and consideration of gestational hypertension
and its complications. At 37 weeks, bacterial vaginosis is diagnosed and treated.
At 39 2/7 weeks, the baby is delivered and found to have Down's syndrome. At
subsequent follow-up visits, postpartum depression, contraception, breastfeeding,
and other routine health maintenance issues are addressed.
Consists of measuring three or four chemical markers present in the
mother's blood during pregnancy:
Human chorionic gonadotropin (hCG)
only in the quad screen) dimeric inhibin A
Abnormal levels of these serum markers may indicate increased risk for
neural tube defects, trisomy 21, and trisomy 18.
Serum screening is not usually performed until 15-21 weeks' gestation, but
it would be appropriate to begin a conversation about this at 10 weeks.
Sensitivity of these tests is not ideal, as false positives and negatives occur.
If a serum triple or quad screen is positive, it identifies patients at
higher risk but does not rule disease in or out.
False positives - Although they do occur, it would be misleading
to minimize the potential meaning of the test or provide "false
If a clinician has encountered a particular situation many times
before and feels it is "routine," it may also be tempting to
dismiss the patient's concerns prematurely
Patients should be given accurate information about the test, the
potential for Down's, as well as the possibility of false-positive results.
Patients should be offered genetic counseling and further testing,
including ultrasound for evaluation of fetal anatomy and
Lab error is a common reason for an elevated triple or quad screen,
and rechecking the dates and timing of the test is prudent.
The triple screen detects Down's syndrome in about 69% of cases,
and the quad screen detects Down's in about 81% of cases with a
false-positive rate of 5%.
Primary skin lesion: Uncomplicated lesion representing initial pathologic
change, uninfluenced by secondary alterations such as infection, trauma, or
Secondary skin lesion: A lesion in which a change has occurred as a
consequence of progression of disease, scratching, or infection of the primary
Macule: A change in the color of the skin. It is flat, and if you were to close your
eyes and run your fingers over the surface of a purely macular lesion, you could
not detect it. Size definition varies from < 1 cm to <5 mm in diameter.
Sometimes it refers to flat lesion of any size.
Patch: A macule > 1 cm in diameter.
Papule: A solid, raised lesion that has distinct borders and < 1 cm in diameter.
Plaque: A solid, raised, flat-topped lesion > 1 cm in diameter. It is analogous to
the geological formation, the plateau.
Nodule: A raised, solid lesion and may be in the epidermis, dermis or
Tumor: A solid mass of the skin or subcutaneous tissue; it is larger than a
Vesicle: A raised lesion < 1 cm in diameter and filled with clear fluid.
Bulla: A circumscribed, fluid-filled lesion > 1 cm in diameter.
Pustule: A circumscribed, elevated lesion that contains pus.
Wheal: An area of elevated edema i
Surgical excision: Most widely used treatment for cutaneous squamous-cell carcinomas
(SCCs), particularly high-risk lesions
Well-defined, small (< 2 cm) SCC lacking any high-risk features require a *4
mm* margin of normal tissue around the visible tumor to result in 95%
histologic cure rate.
Mohs microscopic surgery
Surgeon can immediately review the pathology to confirm complete excision
during a staged excision.
Indicated in cosmetically sensitive areas.
Useful for lesions with indistinct margins where more tissue than clinically
apparent may require removal.
Patients with any non-melanoma skin cancer greater than 2 cms,
lesions with indistinct margins, recurrent lesions, and those close to
important structures (including eyes, nose, and mouth) should be
considered for referral for complete excision via Mohs micrographic surgery,
with possible plastic repair.
Topical 5-fluorouracil (5-FU)
Approved by the U.S. Food and Drug Administration (FDA) for the treatment
of actinic keratoses.
Although topical 5-FU is not approved for the treatment of Bowen's disease
(squamous-cell carcinoma in-situ) and superficial SCCs, it is widely used in
these diseases when other treatment modalities are impractical and for
patients who refuse surgical treatment.
Destroys malignant cells by freezing and thawing
Useful for small, well-defined, low-risk, invasive SCCs and Bowen's disease
Does not permit histologic confirmation of the adequacy of treatment
margins; thus, a substantial amount of training and experience is required
to achieve consistently high cure rates.
*Option for the initial management of small, well-defined, primary SCCs,
especially in older patients and those who are not surgical candidates.*
Contraindicated on tumors located on trunk and extremities. These areas
are subjected to greater trauma and tension than skin on the head and
neck, and they are more prone to break down and ulcerate as a result of the
atrophy and poor vascularity of irradiated tissue.
1. Tinea capitis
Oral therapy is required to adequately treat tinea capitis, as topical
therapies are unable to penetrate the infected hair shaft.
*Griseofulvin: The only oral antifungal treatment approved for use in
20-25 mg/kg/day using the microsize formulation, for 6-12
10-15 mg/kg/day using the ultramicrosize formulation (more
rapidly absorbed than the microsize form)*
2. Tinea unguium (onychomycosis)
Griseofulvin is approved for tinea infection of the nails, but its affinity for
keratin is low, and long-term therapy is required.
*Terbinafine 250 mg/day for 12 weeks (toenails) or 6 weeks (fingernails
Itraconazole 200 mg twice daily as "pulse" therapy (one pulse=1 week of
itraconazole followed by 3 weeks off)
For fingernails only, use 2 pulses
For toenails, use 3 pulses
3. Tinea pedis, tinea magnum, tinea corporis, and tinea cruris
Treat with topical antifungal medications.
Available in cream, gel, lotion, and shampoo formulations
Two drug families highly effective against dermatophytes:
*"Azole" family: Clotrimazole, miconazole, econazole,
coiconazole, ticonazole, etc.
"Allylamine" family: Terbinafine and naftifine
Infections should resolve within two to four weeks of topical therapy.*
Definition: The permanent absence of menses, defined as twelve months without
a cycle. For women in the U.S., this occurs at a median age of 52 years.
Etiology: When the ovaries are depleted of follicles, estrogen levels decrease,
leading to the majority of postmenopausal symptoms.
1. Hot flashes or vasomotor symptoms (up to 80% of menopausal patients)
2.Atrophic vaginitis (vaginal dryness, vaginal pruritis, dyspareunia)
3. Urinary symptoms (recurrent urinary tract infections, urinary frequency,
dysuria, and stress incontinence)
Sexual dysfunction, sleep disturbance, mood disturbance, and concentration
Recent recommendations from ACOG have decreased the frequency of Pap
smears to include first Pap at age 21, a biennial Pap from age 21-30, and
for those over 30 years of age who have had three consecutively normal
Pap smears, screening can be every three years.
For women with certain risk factors—such as human immunodeficiency virus
(HIV), immunosuppression, diethylstilbestrol (DES) exposure, or history of
cervical cancer—more frequent Pap smears may be indicated.
A CA-125 level is not indicated as a screening tool for ovarian cancer by the
USPSTF. Although it may detect ovarian cancer at an earlier stage, it does
not lower mortality rates. In addition, the prevalence of ovarian cancer is
low, giving the test a low positive predictive value, which makes this a poor
1. Cervical polyps:
Common in postpartum and perimenopausal women
Rare in pre-menstrual and uncommon in postmenopausal women
Ruled out via pelvic exam
2. Endometrial hyperplasia:
Simple hyperplasia progresses to cancer in < 5% of patients.
Atypical complex hyperplasia is a premalignant lesion that progresses to
cancer in 30-45% of women.
3. Endometrial cancer: Fourth most common cancer in women, accounting for ~ 6,000 deaths per
90% of patients with endometrial cancer have abnormal vaginal bleeding
Main diagnosis to consider in a woman presenting with postmenopausal
bleeding; also must be considered in women > 35 with symptoms
suggestive of anovulatory bleeding (spotting, menorrhagia, metrorrhagia)
Any characteristic that increases exposure to unopposed estrogen
(including unopposed estrogen therapy, tamoxifen, obesity,
anovulatory cycles, estrogen-secreting neoplasms, early menarche
[before age 12], late menopause [after age 52], menstrual cycle
irregularities, and nulliparity)
Age (incidence more than doubles from 2.8 cases per 100,000 in
those aged 30 to 34 years to 6.1 cases per 100,000 in those aged 35
to 39 years)
Smoking seems to decrease estrogen exposure, thereby decreasing
the cancer risk
Oral contraceptive use increases progestin levels, thus providing
Proliferative 4. endometrium:
In premenopausal women, this is the normal response to estrogen
May also be seen in postmenopausal women, particularly in higher estrogen
No increased risk of endometrial cancer
5. Iatrogenic causes:
These include anticoagulants, selective serotonin reuptake inhibitors,
antipsychotics, corticosteroids, and hormonal medications.
Transvaginal ultrasound (TVUS):
Most cost-effective initial test in women with abnormal uterine bleeding at
low risk for endometrial cancer
Highly sensitive for the detection of endometrial cancer (96%) and
endometrial abnormality (92%)
If the endometrium is > 5 mm on ultrasound (some sources say > 4 mm), it
is significant, and more workup is required.
TVUS also reveals leiomyomas (fibroids), focal uterine masses, and ovarian
pathology (although may miss endometrial polyps and submucosal fibroids).
Endometrial biopsy: Tissue sample for histologic evaluation of the
Gold standard for evaluation of postmenopausal bleeding or for abnormal
bleeding in younger women at high risk for endometrial cancer.
Sensitivity of up to 99% for detecting endometrial cancer in postmenopausal
Widely done in the outpatient setting:
A small pipelle is inserted into the cervix and samples of the lining of
the uterus are aspirated.
Ibuprofen, 800 milligrams, 30 minutes before the procedure is
recommended for cramping.
1. Complete blood count and liver function studies:
Looks for anemia, thrombocytopenia, and hepatic function abnormalities
that may could account for bleeding.
2. Thyroid function tests:
Thyroid hormone exerts negative feedback control over the hypothalamus
and gonadotropin hormone release.
Thus, thyroid disorder can interfere with the hypothalamic-pituitary-gonadal
axis and cause postmenopausal bleeding.
Test thyroid function using thyroid-stimulating hormone (TSH).
3. Gonadotropins (follicular stimulating hormone [FSH] and luteinizing
Sufficiently elevated FSH levels can be used to confirm menopause (during
menopause, ovarian granulosa cells produce less inhibin—the negative
feedback regulator of pituitary FSH secretion and synthesis; with less inhibin
production, FSH and LH levels increase)
1. Vitamin D
Vitamin D plays a major role in calcium absorption, bone health, muscle
performance, balance, and risk of falling.
Adults age 50 and over should consume at least 800 IU of vitamin D daily.
Dietary sources: Fortified milk and cereals, egg yolks, salt-water fish, and
Adequate intake of vitamin D and calcium in the preteen and teen years is
necessary in order to boost peak bone density.
Most adults should consume 1000 mg of calcium per day.
Men and women older than age 50 should consume *1200 mg of calcium
Increasing dietary calcium intake should be the first- line approach, but
supplements should be used when adequate dietary intake cannot be
3. Life-long weight-bearing exercise and muscle strengthening
Can improve agility, strength, posture, and balance, which may reduce the
risk of falls.
May modestly increase bone density.
Examples include walking, jogging, Tai-Chi, stair climbing, dancing, and
4. Limit smoking and excessive alcohol intake: Both increase the risk of
Sarah is a 24-year-old female with a past
history of headaches, previously controlled with ibuprofen, who is here today
because her headaches have worsened and because she is anxious about missing
a more serious problem before her insurance runs out next month. Upon further
questioning, we discover that her severe headaches are primarily unilateral and
throbbing, with associated photo- and phonophobia. She also has tension-type
headaches with associated occipital tenderness. An appropriately thorough
neurological exam is performed. The student considers and rules out each of the
three most troublesome potential diagnoses: bacterial meningitis, increased
intracranial pressure, and brain tumor. After comparing and contrasting the key
features of the most common types of headaches, using the International
Headache Society's classification system, the student decides that the patient is most likely suffering from both migraine headache and tension headache. The
preceptor, student, and patient discuss a functional goal and negotiate a
management plan that involves non-pharmacological strategies, acute-treatment
medications, and prophylactic therapy. During this discussion, the student learns
about classification, mechanism of action, and side effects of commonly used
Reflect a rebound of a primary headache following chronic use of any
analgesic (opioids, acetaminophen, aspirin, analgesic-codeine, analgesicbarbiturates,
NSAIDs, ergotamies, triptans).
Present similarly to primary headaches, only they occur daily, frequently
present on awakening, and are refractory to treatment.
Tolerance develops to abortive medications, and there is decreased
responsiveness to preventive medications.
Associated with restlessness, nausea, forgetfulness, and depression
Criteria for diagnosis includes:
*> 15 headaches per month
Regular overuse of an analgesic for > three months
Development or worsening of a headache during medication overuse*
Main treatment is stopping the overused medication.
Ergot alkaloids: ergotamine (Ergostat), ergotamine and caffeine (Cafergot), dihydroergotamine (DHE)
Contraindications: Triptans, Many possibly
serious drug interactions, Heart disease or
angina, Hypertension, Peripheral vas- cular
disease, Pregnancy, Renal insufficiency, Breastfeeding, Severe reactions possible, MI, Ventricular tachyarrhythmias, Stroke, Hypertension, Rash, Nausea, Vomiting, Diarrhea,Dry mouth
Propanolol (20-160 mg): FDA approved. Good effeicacy. Contraindications- asthma, depression. Side effects- fatigue
Timlol (10-30mg) : FDA approved, excellent/cheap. Contraindications: severe CAD, DM requiring insuling, Reynauds disease
Side effects:light headedness, insomnia, bradycardia, depression, sexual dysfunction
Divalproex sodium (500- 1500 mg)
Topiramate (25-200 mg): good/expensive. Contraindications: pregnancy. SEs: divalproes: birth defects, weight gain, alopecia, pancreatitis, varian cysts
Topiramate renal stones, weight loss
Amitriptyline (10-150 mg): not FDA apprved. Excellent/cheap. Also works for fibromyalgia and tension type HA
Contraindications: cardiac conduction defects
SEs: drowsiness, weight gain, dry mouth
Mr. Rodriguez is a 39-year-old uninsured Latino
immigrant with no significant past medical history who presents with a worsening
pain in his upper abdomen over the last year, now occurring daily. His symptoms
sometimes improve with meals and other times worsen with meals or with spicy
foods. He denies vomiting, hematemesis, hematochezia, or melena as well as any
general, cardiovascular, respiratory, and genitourinary symptoms. He occasionally
takes ibuprofen when sore or tired after work. He recently quit smoking and
consumes alcohol occasionally. His father has hypertension, and his mother has
diabetes. His physical exam is unremarkable.
A differential diagnosis of abdominal pain is generated and Mr. Rodriguez is given
a trial of omeprazole to test and treat his dyspepsia. Four weeks later, he returns
with his symptoms unchanged. Fecal immunochemical testing (FIT) is performed to check for occult gastrointestinal bleeding and is negative. Blood serum testing
for H. pylori IgG is positive. He is given standard proton pump inhibitor (PPI) triple
therapy to eradicate suspected H. pylori infection.Nine weeks later, Mr. Rodriguez
returns to the clinic with no change in his symptoms. An H. pylori fecal antigen
test is positive, and he is given salvage therapy. Two weeks later he reports he is
Reflux through the lower esophageal sphincter (LES) into the esophagus or
Abnormal LES pressure and increased reflux during transient LES
relaxations are believed to be key etiologic factors.
Spicy and fatty foods and chocolate
Drinking alcohol and caffeinated beverages
Eating large portions
Lying flat in close temporal proximity to a meal
Wearing tight clothing around the waist
Medications (calcium channel blockers, beta-agonists, alpha-adrenergic
agonists, theophylline, nitrates, and some sedatives)
Atypical signs and symptoms
When severe reflux reaches the pharynx and mouth or is aspirated, it can
Dental enamel loss
Non-cardiac chest pain
Recurrent sore throat
These symptoms may point to (but do not sufficiently support by themselves) a
diagnosis of GERD.
While GERD generally does not progress (up to 90% of cases of GERD are
non-erosive reflux disease [NERD]), some cases are associated with
development of complications.
*Symptom frequency, duration, and severity do not help to differentiate the
grade of esophagitis and cannot be used to reliably diagnose complications
Reported health-related quality of life is lower than age-matched patients who
have untreated angina pectoris, diabetes mellitus, or chronic heart failure.
Dyspepsia due to GERD: Classic symptoms of heartburn
and regurgitation (burning in the
chest with sour or bitter taste)
clearly dominating patient's
history indicates diagnosis of
GERD with high specificity; Epigastric burning that
sometimes radiates to the
Esophageal spasm: Sharp,
stabbing, substernal pain; Most likely to occur:
When gastric volume is
increased (after meals)
When gastric contents are
located near the
(due to recumbency or
When gastric pressure is
increased (with obesity,
pregnancy, binding clothes,
Dyspepsia due to PUD: Difficult to separate PUD from
other etiologies of dyspepsia
based on symptoms alone.; Episodic or recurrent
"gnawing," or "hunger-like"
pain or discomfort arising
from the proximal
gastrointestinal tract; There may be differences in timing of
symptoms based on ulcer location:
Gastric ulcer pain often
occurs 5-15 minutes after
eating and remains until
the stomach empties,
which may be up to several
hours in duration; pain
may be absent during
times of fasting.
Pain from duodenal ulcers
is often relieved by eating,
drinking milk, or taking
antacids, and may return
anywhere from 90 minutes
to 4 hours after eating a
Both gastric and duodenal
ulcers may be associated
with nausea and vomiting
occurring any time from
shortly after eating to
several hours later.
Varies across geographic regions, ethnic groups, and household conditions
Rare in developed countries, and worldwide prevalence is decreasing
80-90% of all adults, regardless of age, in developing nations
(including Latin and Central America), are infected with H. pylori.
Results of study of Latinos in San Francisco Bay Area:
Immigrants (31% infected with H. pylori)
First-generation U.S.-born Latinos (9%)
Second-generation U.S.-born Latinos (3%)
Both household and birth-country environment have probably
contributed to declining H. pylori prevalence among successive
generations of Latinos.
In underdeveloped nations, thought to occur fromfecal-oral transmission
Mechanism of action
H. pylori is uniquely adapted to life in the stomach. Its location in the gastric
mucosa, where it does not invade the gastric epithelium, provides the
organism with protection from the host immune mechanisms, which creates
challenges in the delivery of antimicrobial agents to eradicate infection.
Colonization renders underlying gastric mucosa more vulnerable to peptic
acid damage by disrupting the *mucous layer, liberating enzymes and toxins,
and adhering to the gastric epithelium.
Host immune response to H. pylori incites an inflammatory reaction, which
further perpetuates tissue injury.*
Chronic inflammation leads to chronic gastritis (in most cases,
asymptomatic and nonprogressive).
In some cases, altered gastric secretion coupled with tissue injury leads to
PUD, while in other cases, gastritis progresses to atrophy, intestinal
metaplasia, and eventually gastric carcinoma.
Rarely, persistent immune stimulation of gastric lymphoid tissue leads to gastric lymphoma.
90% of patients worldwide with duodenal ulcers are infected withH. pylori.
The strongest evidence to support the role of H. pylori as an etiology of PUD
is the elimination of ulcer recurrence after eradication.
A test-and-treat strategy for both GERD and PUD is the most widely
accepted initial therapeutic intervention.
Often, patients begin a self-directed trial of over-the-counter
anti-secretory therapy (AST): either a histamine-2 receptor antagonist
(H2RA) or a PPI. Patients consult their primary care physicians
because their symptoms have persisted or because they would like a
prescription (to reduce out-of-pocket cost).
1. "PPI test" (short-term trial of a PPI)
Sensitive and specific for diagnosing GERD and can significantly
reduce the need for upper endoscopy/EGD and 24-hour pH
Saves over $350 per patient evaluated, reduces upper
endoscopies by 64%, and reduces the number of esophageal
monitoring tests by 53%
Anti-secretory therapy should be stopped after a successful 4 to
8-week course, or used on demand (only when symptoms recur).
Refer for upper endoscopy/EGD to rule out significant disease if:
There are alarm or extra-esophageal symptoms, or
In cases that do not respond to the test-and-treat strategy after 8
Endoscopy should include biopsies of gastric body and antrum to test
for H. pylori
Lifestyle modifications for patients with GERD (although there is little
evidence to support improvement in symptomatic outcomes in the absence
Avoid large meals
Avoid acidic foods (citrus- and tomato-based products), alcohol,
caffeinated beverages, chocolate, onions, garlic, and peppermint
Decrease dietary fat intake
Avoid lying down within 3-4 hours after a meal. Avoid medications that may potentiate GERD symptoms, including
calcium channel blockers, beta agonists, alpha-adrenergic agonists,
theophylline, nitrates, and some sedatives
Elevate head of bed 10 to 20 cm (4-8 inches)
Avoid wearing clothing that is tight around the waist
Ms. Bell is a 28-year-old woman with a past
medical history significant for atypical squamous cells of undetermined
significance (ASCUS) on Pap smear without follow-up presenting with a chief
complaint of abdominal pain of two weeks' duration. Her current abdominal
symptoms occur in 2 areas: non-focal across the upper abdomen, and more
localized in the suprapubic/pelvic region. Further history reveals dyspareunia, past
Trichomonas vaginalis infection, and recurrent references to stress aggravating
her symptoms. She is accompanied by her 4-year-old son, Cooper, who is also
experiencing stomach pains, enuresis, and exceptional clinginess and has recently
been hitting other children at daycare. This history, coupled with her responses to
domestic violence screening raise concern regarding Ms. Bell's home situation.
Evaluation reveals she has trichomoniasis, and she admits to domestic violence.
She is prescribed antibiotics and screened for sexually transmitted infections
(STIs). Her safety is assessed, she is encouraged to contact support agencies
while in the office to set up a safety plan, and follow-up plans are made.
Domestic violence is a pattern of increasing episodes of violence in which one
partner exerts control over another through intimidation, physical and/or
emotional violence, and threats. It is common for there to be a tension-building
phase, a crisis phase—when overt violence is likely to occur—followed by a calmer
phase, when the abuser might ask for forgiveness and even be affectionate.
Unfortunately, in most cases, the cycle begins again, and often the violence is
25% of women in the U.S. report being victimized by an intimate partner at
some point in their lifetime.
Anyone is at risk for domestic violence, regardless of his or her education or
socioeconomic status. Domestic violence is based on issues of power and
While the majority of intimate partner violence (IPV) victims are women,
IPV victims are both male and female, occur in both heterosexual and
same-sex relationships, and cross all socioeconomic, age, and ethnic
In addition to the trauma incurred, the rates of chronic disease—including
heart disease, diabetes, depression and suicide—is significantly higher in
victims as well as in adults who were victimized as children as a result of
direct abuse and exposure to domestic violence.
Escaping is not always the best answer to domestic violence. Victims are at
their highest risk immediately around the time of escape, when the
perpetrator feels the power shift.
Domestic violence is a vicious cycle. Children tend to identify with the
same-sex parent. A girl exposed to domestic violence may identify with the
"victim mentality," that she should expect to be abused later in life because
her mother accepted this treatment. Similarly, a young boy who observes
abusive behavior may feel that it is okay to be an abuser, and may display
acting-out behavior. The risk to a child in a household where a parent is being abused is that the
child may be verbally abused, beaten, or worse by the abuser. Observing
and/or hearing physical abuse is especially devastating to children.
While alcohol and drugs do not cause domestic violence, violent offenders
are more likely to inflict harm when under the influence and when weapons
are readily available.
Gastritis: Mid-epigastric pain may be exaggerated by stress/emotions, diet,
medication—particularly non-steroidal anti-inflammatory drugs. Patients
frequently give a history of tobacco or alcohol use; they may use NSAIDs.
Patients may state that spicy foods seem to aggravate the pain. May have
nausea and decreased appetite. Bowels are usually not affected, unless
there is a component of irritable bowel syndrome and stress, in which case
there may be either decreased or increased stooling.
Irritable bowel syndrome (IBS):
Loose stools or diarrhea
Mucus in stools
Diagnosis of exclusion
Symptoms can be initiated by gastroenteritis and can be aggravated
by stress, dietary changes or change in activity, often unpredictable.
Often starts with dull visceral pain in periumbilical region
Presentation hallmark: Fairly acute onset of moderate to severe right
lower quadrant pain.
Vomiting, nausea, loss of appetite, mild fever, and decreased stooling
Because of its morbidity and mortality, it is important to rule this out
with more history and a good physical exam.
Look for positive psoas sign, rebound tenderness.
Pelvic inflammatory disease (PID):
Abdominal or pelvic pain that is worse with sexual intercourse or with
activities such as running or jumping, which cause jarring of the pelvic
*Pathognomonic: Cervical motion tenderness, known as a positive
Mild menstrual irregularities
Significant morbidity, which increases with the severity of the disease
and length of time to diagnosis.
1 in 4 women who have a single episode of PID later experience tubal
infertility, chronic pelvic pain, or an ectopic pregnancy (as a result of
scarring and adhesions).
Tubal adhesions leading to infertility in 33% of women after their first
episode of PID, and up to 50% after the second pelvic infection.
Need sexual history for both partners, pelvic exam, labs, and imaging
Growth of the uterus and stretching of the broad ligaments during a normal pregnancy can cause mild to moderate discomfort in the lower
Symptoms of nausea and vomiting could be caused by pregnancy.
This is more a diagnosis of exclusion, but you would not want to miss
a pregnancy. (Certain medications should not be given to women who
are pregnant. Fetuses should not be exposed to radiation.)
History and labs may be needed.
Patients present with divergent symptoms ranging from no pain and
normal menses to intense pain and irregular or absent menses
Medical emergency. Early medical treatment reduces need for
surgery, but if a fallopian tube is in danger of rupture, surgical
intervention may be necessary.
Need date of the patient's last menstrual period (LMP), her menstrual
history, most recent intercourse dates, types of contraception used in
past few years, history of any vaginal or pelvic infections, and history
of previous ectopic or normal pregnancies
Patients who are pregnant, or even those in whom there may be the
suspicion of pregnancy, are at increased risk of being victims of
The stress of being the victim of domestic violence may cause
irregular menses in some women.
Abdominal pain and cramping may come, not only from the inflicted
trauma, but also from the patient's somatization of her stress.
Bruises, of various colors, denoting various stages of healing, can be
seen on any part of the body, but especially on the abdomen as this
would cause trauma to a fetus, and because they would be less visible
to the general public.
Careful history: Be aware of the patient's body language and response
to touch. Consider the consistency of the history with the exam.
Examine the patient thoroughly in a gown so that all areas can be
If patient is trying to hide the diagnosis, serious injuries may be
missed, such as ruptured internal organs or fractures. There is always
a risk of recurrent violence. The source of the trauma should be
determined, because, for example, it might be life-saving to uncover
that the patient is at increased risk due to weapons in the home.
Generally a moderately severe to severe epigastric pain accompanied
by nausea and vomiting.
Usually a history of alcohol use/abuse or a family history of
Other causes include gallstones or hypertriglyceridemia.
Acute attacks generally require hospitalization.
KOH/Saline wet prep: Quick test. Could indicate inflammation (white blood
cells) or diagnose trichomoniasis, bacterial vaginosis, or yeast vaginitis.
Chlamydia/gonorrhea DNA probe: Preferred method for diagnosis of
chlamydia and gonorrhea because both can be performed with the same sample.
Sample can be endocervical, urethral, vaginal, or urine. Both diseases can present
with a yellow discharge, abdominal pain, and dyspareunia.
Gonorrhea culture: Good test for gonorrhea. Separate tests need to be done on
vaginal or urine samples. However, this is still the preferred method for sexual
assault tests, for tests of cure, and for oral and rectal specimens.
Urine dipstick: May help rule out a urinary tract infection (UTI).
Pap smear: Performed to detect cervical cancer, which is caused by the human
papilloma virus (HPV), a sexually transmitted disease
Urine pregnancy test: All women of childbearing age
Human chorionic gonadotropin beta subunit (HCG beta sub, or qualitative
beta HCG): Generally not indicated because of the sensitivity of the urine
pregnancy test. If results of a urine pregnancy test are inconclusive, a blood test
such as HCG beta sub would be needed.
Rapid plasma regain (RPR): Part of the STI screen to rule out syphilis
Human immunodeficiency virus (HIV): Part of the STI screen. Human Papilloma Virus (HPV):
Follow-up of Atypical Squamous Cells-Undetermined Significance (ASCUS)
ASCUS is an abnormal Pap smear result (atypia without clear evidence
of intraepithelial lesions).
Early stage is treatable and may prevent progression to cervical
Reflex HPV: An abnormal Pap will automatically be tested for HPV. If the Pap is
normal, the HPV testing will not be done.
Colposcopy: Not indicated until second abnormal pap result, and/or if HPV is
Perform risk assessment for domestic violence, give patient information about
resources, and find out about local laws in regard to reporting exposure to
Address the level 1. of risk and safety issues for the patient.
Give contact information to the patient and offer a means for them to
contact services while in your office (since it may be impossible for them to
access these resources from home).
o Local resources: National Domestic Violence Hotline at (800)
799-SAFE, TTY (800) 787-3224.
Acknowledge the abuse, recognize health implications, and share this with
Even if not always in agreement with the decisions made by the patient, it is
important that you support her or his decisions.
Couple's therapy has been shown to increase the level of risk for the victim.
(Victim exposes the abuse, perpetrator feels like they are losing control and
tries to regain it through further violence.)
Cultural differences can give the appearance of abuse. Practicing sensitivity
in caring for patients from different backgrounds is key to a supportive
Laws differ from state to state. Know what the local laws are.
Whenever a child is abused, either intentionally or unintentionally, as
a result of intimate partner violence, all state law requires health care providers to report this abuse to child protection services.
Clinicians must also report any high-risk situation of intimate partner
violence in which children are at risk.
State laws are less consistent about whether exposure to domestic
violence in the absence of injury or serious risk of injury to the child
requires a report to children's protective services.
In some states, physicians must notify child protection services
whenever a child is in the home and has been exposed to a
parent's abuse, whether or not the child has been directly
In other states, a child's exposure to intimate partner violence
does not automatically require a mandatory child protection
The rules for victims who are adults and are not disabled vary
dramatically from state to state, from mandatory reporting for
evidence of abuse to reporting only if the victim asks the clinician to
Document abuse history as reported by patient in the subjective. Use
patient's own words in quotes and fill in names after pronouns are
used. Use neutral language.
Give a detailed description of the patient's appearance, behavioral
indicators, injuries and stages of healing, and health conditions. If
patient consents, use photos to document injuries; one with a face
included in the photo, and then close-ups of the injury. If photos are
not possible, draw and describe injuries on a body map in blue ink, as
this is difficult to alter or reproduce.
Document results of health and safety assessments, recommendations
for support, and plans for follow-up as well as referrals and materials
given to the patient.
Include any laboratory and radiology tests ordered and results.
Maintain strict confidentiality.
Marissa, a 12-year-old female accompanied by
her mother, presents with a 3-day history of high fever, cough, sore throat,
myalgias, and decreased appetite. She has been exposed to sick children at
school and secondhand smoke in her home. She did not receive an influenza
immunization. Findings on exam include rhonchi, occasional wheezing, hyperemic
oropharynx, cervical adenopathy, and fever of 38.3 degrees Celsius. Based on
these clinical findings and a positive rapid influenza test, she is diagnosed with
influenza complicated by bronchitis and sent home with supportive treatment.
When Marissa returns for follow-up, the opportunity is taken to perform general
preventative care. Marissa's Body Mass Index (BMI) is calculated and interpreted
using the Centers for Disease Control (CDC) growth chart for BMI for age. The
potential complications of her obesity are discussed, and a behavior change
treatment plan is negotiated.
Age? When to admit? Most common pathogen? Treatment?
Infants <3 weeks: Admit all infants; E. coli,Group B
3 weeks to 6 months:
Admit if suspect
3 monthsto 5 years
Admit if: Breathing > 70 breaths per minute,
Hypoxemic,Having difficulty breathing,Intermittent
apnea, Grunting, Poor feeding
to attend to the
Virulent pathogen (e.g.
or penicillin G. If
or child isn't fully
Breathing > 50
If they appear
to be in
to attend to
IV antibiotic (e.g.,
ampicillin or penicillin
G. If area of high
child is afebrile, then
oral antibiotics to
Mr. Wright is a 70-year-old functionally
independent African-American male with poorly controlled systolic hypertension,
hyperlipidemia, and osteoarthritis, who fell while working in his yard. His fall was
preceded by the abrupt onset of lightheadedness, numbness in his left hand, and
vague visual disturbance, without appreciated loss of consciousness. After 10-15
minutes, all symptoms were resolved, and he was able to get up unaided. He has since felt fine. The physical exam is unremarkable except for hypertension, a
newly detected irregular heart rhythm, and equivocal proximal left arm weakness.
Electrocardiogram confirms that Mr. Wright is in atrial fibrillation with left
ventricular hypertrophy. He is admitted to the hospital for further evaluation of a
possible transient ischemic attack (TIA) and secondary prevention of recurring
thromboembolic event. While in the emergency room, Mr. Wright develops new
left arm weakness. A CT rules out contraindications to anticoagulation and rtPA
therapy is initiated. Two days later, repeat CT confirms the presence of a right
parietal infarct and warfarin therapy is started. At release, a discharge plan
emphasizing secondary prevention of recurrent stroke is formulated. Two weeks
following hospital discharge, Mr. Wright returns to the clinic exhibiting symptoms
of post-stroke depression, which is appropriately addressed.
3. Stroke: A foremost consideration in patients with risk factors who describe
symptoms suggestive of a significant brain dysfunction.
Signs and symptoms vary depending on the part of the brain involved
Most common symptoms include:
Sudden numbness or weakness of face, arm, or leg, especially on one
side of the body
Sudden confusion, trouble speaking, or understanding
Sudden trouble seeing in one or both eyes (visual disturbance is
common if the stroke occludes a retinal artery, produces ischemia in a
visual cortex, or affects the right brain hemisphere, which governs
visual spatial orientation)
Sudden trouble walking, dizziness, loss of balance or coordination
Sudden severe headache with no known cause
Dizziness or lightheadedness
Consciousness may not be impaired, or a stroke patient may rapidly
progress to coma and death depending on stroke type, infarct location
4. Transient ischemic attack (TIA): A transient (typically < 1 hour) episode of
neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia,
without evidence of acute brain infarction.
Similar to stroke
Consciousness not impaired (area of brain function affected by a TIA
is, by definition, limited)
These studies to identify systemic conditions that may mimic or cause stroke or
that may influence therapeutic options.
1.Multimodal CT and MRI of brain: May provide additional information that will
improve diagnosis of ischemic stroke. While it can confirm the diagnosis, it cannot
elucidate the etiology (i.e., thrombotic [85%] vs. embolic 15%]). Imaging of the
brain is recommended before initiating any specific therapy to treat acute
ischemic stroke. (Class I, Level of Evidence A.)
2.Blood glucose: Checked to rule out hypoglycemia and, if present, treat in
patients with acute ischemic stroke. Goal is to achieve normoglycemia, while
avoiding extremes of low or elevated blood glucose levels. (Class I, Level of
3. Renal function or electrolyte disturbances: Prevalent in patients who have
risk factors for stroke and should be addressed. (Class I, Level of Evidence B.)
4. 12-lead electrocardiogram (ECG): Detects abnormalities of QT interval,
conduction abnormalities, and ST changes suggestive of paroxysmal arrhythmia
or myocardial ischemia producing transient central nervous system hypoperfusion.
ECG is recommended because of the high incidence of heart disease in patients
with stroke. General agreement supports use of cardiac monitoring to screen for
AF and other potentially serious cardiac arrhythmias that would necessitate
emergency cardiac interventions. Cardiac monitoring should be performed during
the first 24 hours after onset of ischemic stroke. (Class I, Level of Evidence B.)
1. Viral pharyngitis
Most common cause of a sore throat, often the first symptom of a viral
upper respiratory infection
Rhinorrhea and/or cough
Etiology: Epstein-Barr virus (EBV) or cytomegalovirus (CMV)
Low-grade fever, pharyngitis, and lymphadenopathy
Posterior cervical adenopathy is common and specific for
Palatal petechiae of the posterior oropharynx distinguish infectious
mononucleosis from other causes of viral pharyngitis but do not
distinguish it from group A streptococcal pharyngitis, in which palatal petechiae may occur.
May have early appearance of faint nonpruritic maculopapular
generalized rash that rapidly disappears
Suspicion for this diagnosis usually occurs after a negative rapid strep
or throat culture in a patient who is ill for more than 7-10 days.
If misdiagnosed as strep and treated with amoxicillin or ampicillin,
90% of patients will develop a classic prolonged, pruritic,
3. Group A Beta-hemolytic streptococcal (GABHS) pharyngitis
Anterior cervical lymphadenopathy
Palatal petechiae (7% sensitive; 95% specific for GABHS pharyngitis)
Tongue may be bright red with white coating (strawberry tongue)
Usually no rhinorrhea, cough, or conjunctivitis
Scarlet fever: Diffuse, punctate, blanching, erythematous,
sandpaper-like texture accentuated in body folds and creases (Pastia's
lines). Begins around the neck, axillae, and groin and then spreads
over the trunk and extremities.
Non-suppurative (rare but serious): Rheumatic fever,
Suppurative: Peri-tonsillar abscess, bacteremia, endocarditis,
pneumonia, mastoiditis, meningitis, otitis media, and cervical
4. Peri-tonsillar abscess
Neck or ear pain
Muffled "hot potato" voice
Asymmetric tonsillar enlargement and deviation of the uvula
Etiology: Haemophilus influenzae type B, which is rare since the introduction
of the conjugate HiB vaccine in the late 1980s; however, it is important to
consider because of the potentially lethal consequences if missed.
Age 1-6 years old
Ill-appearing, high fever (>103 degrees F)
Inspiratory stridor, "hot potato" (muffled) voice, dysphagia, drooling
Classically seated in "tripod" position
Upper airway obstruction, stridor, cough, fever, dyspnea, irritability.
Initial symptoms are nonspecific and include runny nose, low-grade
fever, and mild cough—similar to the common cold
Consider diagnosis of pertussis when cough has worsened and has
been present for at least 14 days.
Prodrome of mild fever
Barking cough, inspiratory stridor, and hoarse voice
Diagnosis is made clinically
Steeple sign on x-ray is suggestive, but is only present in 50% of
children with croup.
Sore throat, sneezing, itchy and watery eyes, clear rhinorrhea, and
Timing may be seasonal but can be perennial
Common in the first year of life
Regurgitation: an effortless dribbling of milk out of an infant's mouth with
common volumes of 15-30 milliliters.
Episodes occur from one to several times daily.
In 80% of infants, it gradually resolves by six months and in 90% of infants,
resolves by twelve months.
Physiologic lower esophageal sphincter laxity, which improves as the infant matures. Clinically, infants with regurgitation are happy during, and
following, episodes of regurgitation, and show no evidence of distress.
True reflux is extremely rare in infants and though some authors promote a
short- term trial of ranitidine for "possible" reflux, most agree that when the
clinical presentation is consistent with colic, prescription medication is not
Infection should almost always be in the differential for young infants
Infants < 2 months of age with documented fever above 101 degrees
Fahrenheit (38 degrees Celsius) require, in most cases, full sepsis work up