272 terms

FM Case Studies part 2

Case 11
74-year-old female with knee pain - Ms. Roman
Summary of Clinical Scenario 11: (read)
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.
Knee pain (read)
Osteoarthritis is a leading cause of disability.
An estimated 21.6% of the adult U.S. population (46.4 million persons) had
doctor-diagnosed arthritis.
Arthritis is expected to affect an estimated 67 million adults in the United
States by 2030.
Both white and black races are at equal risk for the disease.
Patient's age (read)
Children and adolescents: Patellar subluxation, Tibial apophysitis (Osgood-Schlatter)
Patellar tendonitis
Patellofemoral pain syndrome
Diagnosis of exclusion for anterior knee pain
Pes anserine bursitis
Traumatic injuries
Ligamentous sprains
Anterior cruciate, medial collateral, lateral collateral and
meniscal tears
Inflammatory arthropathies
Rheumatoid arthritis
Septic arthritis
Reiter's syndrome
Lachman's test: assess stability of? Position? Maneuver? Postive test?
-Assess stability of the anterior cruciate
-Position: .Laying supine
with the injured
knee raised and
slightly flexed to
30 degrees.
-Maneuver: The distal femur is
stabilized by the
physician with one
hand, while the
proximal tibia is held
by the other hand.
Force is applied to
move the tibia
Positive test: Excessive motion
of the tibia.
Anterior and posterior drawer signs: assess? position? Positive test?
Assess anterior
cruciate and
posterior cruciate
Position: Lying supine,
knee bent to 90
degrees, and the
foot stabilized,
most easily done
by the physician
sitting on the
Maneuver: The physician's
thumbs are placed on
the tibial tubercle,
while the fingers are
placed on the
posterior calf.
The physician then
attempts to displace
the tibia, either
anteriorly or
Positive test: excess movement
Valgus and varus stress tests: assess? position/maneuver? positive test?
functioning of
the medial and
lateral collateral
Position: Leg in extension
with the knee
flexed to about
30 degrees.
Maneuver: The physician places
his/her hand on the
lateral knee joint to
apply a valgus stress
to the distal tibia, or
on the medial knee
joint to apply a varus
stress to the distal
Positive test: Excessive motion
of the knee
signifies instability
of the
McMurray test: assess? maneuver? positive test?
Assess the
medial and
lateral menisci.
Position: Knee is flexed as
much as
Maneuver: The physician holds
the patient's heel with
one hand and grasps
the knee over the
medial and lateral
joint lines with the
other hand.
The tibia is rotated
either internally (tests
lateral meniscus) or
externally (tests
medial meniscus) as
the knee is extended
to about 90 degrees.
Varus stress (lateral
meniscus) or valgus
stress (medial
meniscus) is applied
across the knee joint
while the knee is
being extended.
Positive test: Clunk or click is
felt, or if testing
reproducible knee
Carpal tunnel evaluation: look for? tests (2) diagnostic test of choice? helpful findings in prediction dx of carpal tunnel syndrome?
and atrophy of the thenar eminence (the raised fleshy area on the palm of
the hand near the base of the thumb)
Check radial pulse, strength of hand and wrist, and sensation bilaterally.
Tap over the median nerve at the wrist to reproduce symptoms
Sensitivity 50%
pecificity 77%
Phalen's test
Flex wrist by having patient place dorsal surfaces of hands together in
front of him for 30 to 60 seconds to reproduce symptoms. Sensitivity 68%
Specificity 73%
Nerve conduction velocity study (EMG)
Diagnostic test of choice for carpal tunnel syndrome
Sensitivity of 48 - 84%
Specificity of 95-99%
The three most helpful findings in predicting the electrodiagnosis of carpal
tunnel syndrome are:
Hand symptom diagrams
Patient indicates symptoms in at least 2 of digits 1, (thumb) 2,
and 3 ("classic" pattern), or with palmar symptoms as long as
not confined only to ulnar aspect of palm ("probable" pattern)
Hypalgesia (decreased sensitivity to pain)
Weak thumb abduction strength testing
Osteoarthritis: symmetric vs asymetric? mono vs poly? stiffnes occur when?
The joints are usually asymmetrically involved in osteoarthritis, particularly
the large joints.
Osteoarthritis can be monoarticular in young adults if due to trauma or a
congenital defect, but more commonly presents as polyarticular or
generalized arthritis.
Stiffness (if present) is typically worse after effort.
Rheumatoid arthritis: joints affected? What else is present? stiffness occurs when?
Rheumatoid arthritis
Bilateral, polyarticular, particularly in the hands and feet.
Rheumatoid nodules
Subcutaneous nodules that are firm and nontender, located at
pressure points.
Common to have joint stiffness for more than thirty minutes in the morning.
Gout: poly vs mono? location? tophi?
Usually monoarticular, often in the great toe
Tophi are visible or palpable nodules on the ears or in the soft tissue, form
in the bones, joints, and cartilage, are typically not painful, and take years
to appear.
Psoriatic arthritis: number of joints affected? asst with?
Usually oligoarthritis, meaning that it affects 2-4 joints, or polyarthritis,
when 5 or more joints are involved.
Associated with psoriatic plaques, or thickened silvery scaly plaques, located
on the extensor surfaces.
*Psoriasis must be present to make this diagnosis, but the arthritis
sometimes appears before the skin lesions in 13-17% of cases, and skin*
lesions are present but undiagnosed in about 15% of cases.
Less Likely: lyme disease: cause? presents with? Septic arthritis: presents with? Dx? Popliteal/Bakers cyst: location?
-Lyme disease
Caused by Borrelia burgdorferi
Typically presents with acute monoarticular joint pain.
Usually a history of possible exposure to a tick bite,
Other symptoms are rash, fever, or migratory arthralgias
-Septic arthritis
Typically presents with a single painful, swollen, warm joint.
Patients are typically febrile.
Risk factors:
Rheumatoid arthritis
Prosthetic joints
Recent surgery
Preceding skin infection or trauma
Age over 80
Often resembles gout or pseudogout, but can be differentiated from either
by joint aspiration.
Popliteal/Baker's cyst
Arise in association with underlying disease, including rheumatoid arthritis or osteoarthritis.
Patients often experience posterior knee pain if the cyst is large, and can
also have difficulty fully flexing the knee.
Symptomatic cysts can often be palpated on exam in the posterior fossa.
Ankylosing sponylititis: associated genotype? Age? What occurs? SLE: asst with? physical exam? type of arthritis?
Ankylosing spondylitis
Form of spondyloarthritis commonly associated with the HLA-B27 genotype
Typically occurs in young adults.
A chronic inflammatory process of the axial skeleton, resulting in chronic
back pain and progressive loss of motion of the spine.
Hips are sometimes affected as well, knees less so.
Systemic lupus erythematosis
Usually other signs and symptoms accompany the joint pain, including
fever, skin rashes, Raynaud's phenomenon, pleuritis, or chest pain.
Malar "butterfly" rash: erythematous maculopapular rash over the nose and
cheeks that spares the nasolabial folds, and typically occurs in conjunction
with sun exposure.
Discoid lesions: discrete erythematous plaques with scaling.
SLE arthritis is usually migratory.
DDX pain
look at chart
Simple joint effustion: etiology? synovial fluid finding? hemarthrosis: etiology? fluid? hemarthrosis with fat globules: etiology? fluid? septic arthritis: fluid? inflammation athrocentecis findings?
Simple joint effusion: etiology: Osteoarthritis, Degenerative meniscal injury Synovial fluid findings: Clear, straw-colored transudative
Hemarthrosis- Etiology: Acute meniscal tear, Anterior or posterior cruciate ligament
tear (i.e. knee sprain). Fluid- Dark, discolored bloody aspirate
Hemarthrosis with fat globules- etiology- Osteochondral fracture Fluid- Dark, discolored fluid with fat globules
Infected etiology- Septic arthritis. Fluid- Turbid to very turbid fluid, high white
cell count (15K to > 200K)
inflammation: etiology- Systemic lupus
erythematosis (SLE), Gout, Rheumatoid
arthritis. Fluid- Slightly turbid to turbid, moderate
white cell count (3K - 50K).
Presence of crystals in gout or
Knee x-ray for osteoarthritis?
X-ray is not required to diagnose osteoarthritis (OA).
Knee x-rays are insensitive for detecting early OA and do not correlate well
with the degree of symptoms.
If there is any question as to the diagnosis, or you are interested in
assessing the severity of knee (OA), an x-ray would not be unreasonable.
Ottawa Knee Rules help decide whether
The major radiographic features of OA include:
1.Joint space narrowing (best predicts disease progression.)
2. Subchondral sclerosis: Hardening of tissue beneath the cartilage. In
osteoarthritis, there is increased periarticular bone density.
3. Osteophytes: Also known as bone spurs; bony projections arising from
the joint (patellofemoral and tibiofemoral joint osteophytes correlate
best with pain)
4. Subchondral cysts: Fluid-filled sacs in the bone marrow
MRI of knee: preferred for? when to order?
Preferred test to diagnose meniscal or ligamentous damage
Order in the setting of locking, popping, or joint instability
Osteoarthritis Management (read)
Treatment: 1. Water- or land-based exercise,
aerobic walking, quadriceps
strengthening, resistance
exercise, tai chi, Reduces pain and disability. Evidence rating B
2. Glucosamine; May provide some
benefit for persons with moderate to severe pain,B Evidence for this benefit
is mixed
3. Chondroitin; Does not decrease
pain; B
4. Acupuncture; May provide some
benefit; B
Evidence is
5. Acupuncture; May provide some
benefit; B
Evidence is
6. S-adenosylmethionine (SAM-e); As effective as NSAIDs
in reducing pain and
disability; B
7.NSAIDs and acetaminophen Reduce
pain A
8. Tramadol (Ultram)
Older patients with
moderate to severe
pain may experience
modest benefit; use is
limited by side effects
9. Intra-articular corticosteroid
Short-term benefit
with few adverse
10. Hyaluronic acid injections Evidence is mixed B
Osteoarthritis meds: first choice medicaiton? dosing? other options? Moderate to severe pain?
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
side effects.
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.
Intra-articular steroid injections osteoarthritis: How often? drug of choice? instruction?
Intra-articular steroid injections
Consider if the knee joint is inflamed, as evidenced by swelling and pain.
No more than 3 injections per year, and no more than 1 injection per
Long-acting triamcinolone preferred over methylprednisolone
Combine 1 ml of steroid with 3-4 ml local anesthetic.
24 hours of immobilization following the injection helps maximize the
effects, but prolonged rest should be avoided.
Referral to orthopedic surgeon for osteoarthritis
Not necessary if conservative treatment helps control the pain and improves
Arthroscopic debridement hasn't been proven to help pain or functioning.
Total knee replacement may become an option *once pain is uncontrollable
or functional goals can't be met.*
Chronic pain (read)
Patients need to be educated about expectations for their pain control and should
not expect to be entirely pain-free. Instead, attainable functional goals should be
set, and patients should judge their pain control based upon their ability to
perform activities of daily living and leisure activities.
Inject one ml of steroid combined with 3-4 ml of local anesthetic.
24-hours of immobilization following the injection helps maximize the
effects, but prolonged rest should be avoided.
Can reduce pain, limit the need for other medications, and improve function.
Fewer side-effects than NSAIDS or opiates.
Medications for chronic osteoarthritis (2) Most common sideeffect?
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
(propoxyphene, codeine).
Long-acting opiods
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.
Tricyclic antidepressants
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
myocardial infarctions.
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.
Carpal tunnel management: initial treatment?
Initial treatment:
Nocturnal wrist splint for a month, and then re-assess symptoms.
Nerve conduction velocity study
Not necessary to make the diagnosis of carpal tunnel syndrome.
It may be helpful if:
Symptoms fail to improve with conservative treatment
Motor dysfunction is present
Thenar atrophy is seen on physical exam
Preventive medicine: breast cancer screening? colorectal cancer screening? cervical cancer screening? lipid screening? HTN? abdominal US? carotid artery stenosis? thyroid disease?
1. Breast cancer screening
Biennial screening mammography for women ages 50-74
Evidence is insufficient to make any recommendation for screening
over the age of 75.
2.Colorectal cancer screening
Fecal occult blood test (FOBT), flexible sigmoidoscopy, or colonoscopy
is recommended for patients age 50 to 75 years old.
The USPSTF recommends against screening for colorectal cancer after
the age of 75 years.
3.Cervical cancer screening
Women over the age of 65 should not be screened for cervical cancer if they have had adequate recent screening with normal Pap smears,
and are not otherwise at high risk for developing the disease.
4.Lipid disorder screening
The USPSTF strongly recommends screening women over 45 years old
for lipid disorders if they are at increased risk of coronary heart
The USPSTF makes no recommendation about screening women over
the age of 20 who do not have an increased risk of coronary heart
The USPSTF strongly recommends screening men over 35 years old
for lipid disorders.
The USPSTF recommends screening adults for depression in clinical
practices that have systems in place to assure accurate diagnosis,
effective treatment, and follow-up.
Patients 18 years old and older should be screened for elevated blood
Abdominal ultrasound
One-time ultrasound to screen for an abdominal aortic aneurysm
(AAA) is recommended in *men 65-75 year olds who have any history
of smoking.
The USPTF recommends against routine screening for AAA in women.*
Carotid artery stenosis screening
The USPSTF recommends against screening for carotid artery stenosis
in asymptomatic patients.
Low-back pain
Evidence is insufficient to make recommendations about the routine
use of interventions to prevent low back pain in adults in the primary
care setting.
Thyroid disease
There is not sufficient evidence to recommend for or against screening
for thyroid disease.
Immunizations for adults (4)
Zoster vaccine available to patients 60 and older.
Tetanus booster every 10 years.
Pneumococcal vaccine once at 65-years-old.
Annual flu shot.
Case 12
16-year-old female with vaginal bleeding and UCG -
Savannah Bauer
Summary of Clinical Scenario 12 (read)
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.
Chlamydia: epidemiology? Sx (5) Screening test?
Most common sexually transmitted bacterial infection in the United States.
In 2007, more than 1.1 million chlamydia cases were reported to the Center
for Disease Control (CDC).
Another million cases of chlamydia remain unreported.
Risk factors
Age - Women and men aged 24 and younger are at greatest risk.
History of chlamydial or other sexually transmitted infection.
New or multiple sexual partners.
Inconsistent condom use.
Exchanging sex for money or drugs.
African American and Hispanic women and men have higher prevalence
rates than the general population in many communities.
Course of disease & complications
Chlamydia is often insidious and asymptomatic.
Women may develop:
Pelvic inflammatory disease (PID)
Ectopic pregnancy
Chronic pelvic pain
Pregnant women may develop adverse pregnancy outcomes:
Premature rupture of membranes
Preterm labor
Low birth weight
Infant mortality
Screening test
Nucleic acid amplification tests (NAATs) have high specificity and sensitivity
and can be used with urine and vaginal swabs.
US Preventive Services Task Force chlamydia screening recommendations for men and woment
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.
Recommends; (B)
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.
Characteristics of a good screening test (read)
-An effective test is:
Sensitive - Able to identify most or all potential cases.
Specific - Labels incorrectly as few as possible potential cases.
-The condition screened for must have:
High prevalence in the population
Even a test with a sensitivity of 95% will lead to many false
positives when the prevalence of the condition is very low.
Latent stage of the disease when patients are asymptomatic. Effective treatment
-The potential benefits of early detection and treatment of a condition need
to be weighed against many factors including:
Adverse side effects of the screening test.
Time and effort required (of both the patient and the healthcare
system) to take the test.
Financial cost of the test.
Potential psychological and physical harm of false positive results
(such as labeling and overtreatment).
Adverse effects of the treatment.
Immunizations in adulthood: If a live MMR, rubella or varicella vaccine is given how long must a patient wait before conceiving? Pneumocochal vaccine? Annual?
Utilize every opportunity to update vaccinations.
See the Center for Disease Control (CDC) for a vaccination schedule.
If a live, attenuated vaccine (MMR, Rubella, or Varicella vaccine) is
administered, the patient must wait 3 months before conceiving to provide
adequate protection from embryonic and/or fetal complications.
If a patient is engaging in unprotected sex without contraception, some
might consider testing for Rubella immunity as a part of this "functional"
pre-conception visit.
Pneumococcal vaccine (PPSV) required if high risk (such as cochlear
implants or aspenia). Administer the influenza seasonal vaccine
Preconception Health Care supplement
1. Folic acid supplement:
The USPSTF recommends that all women "planning or capable of
pregnancy" take a daily supplement containing 400 - 800 mcg of folic
The dose is increased for the following high-risk scenarios:
*1 mg in patients with diabetes or epilepsy
4 mg in patients who bore a child with a previous neural tube defect
Carrier screening (ethnic background):
sickle cell anemia
Tay-Sachs disease
Carrier screening (family history):
cystic fibrosis*
nonsyndromic hearing loss (connexin-26)
Prego and diabetic? (3) HTN? epiepsy? DVT? Depression/anxiety?
Diabetes: optimize control, folic acid, 1 mg per day, off ACE-inhibitors
Hypertension: avoid ACE inhibitors, angiotensin II receptor antagonists,
thiazide diuretics
Epilepsy: optimize control; folic acid, 1 mg per day
DVT: switch from warfarin (Coumadin) to heparin
Depression/anxiety: avoid benzodiazepines
Lifestyle modifications (read)
Recommend regular moderate exercise
Avoid hyperthermia (hot tubs, overheating)
Caution against obesity and being underweight
Screen for domestic violence
Assess risk of nutritional deficiencies (vegan, pica, milk intolerance, calcium
or iron deficiency)
Avoid overuse of Vitamin A (recommendations are to 750 mcg (2500 IU per
day) with daily upper intake limit of 3,000 mcg [10,000 IU])
Avoid overuse of Vitamin D (recommendations are 600 IU per day, tolerable
upper intake is 4000 IU)
Caffeine (limit to the equivalent of two cups of coffee or six glasses of soda
per day)
Note: the sugar intake in six glasses of soda is not recommended.
Pregnancy symptoms (3)
1. Amenorrhea
Only 68% of pregnant adolescents report having missed a menses.
Anovulatory cycles are normal in the early postmenarcheal years.
Bleeding can occur in early pregnancy around the time of the missed
menses as a result of an invasion of the trophoblast into the decidua
(implantation bleed). Some adolescents mistake this bleeding for a
menses, leading to a delay in diagnosis of pregnancy and potential
misdating of the pregnancy.
Young women who have not yet menstruated, but are sexually active,
may be at risk for pregnancy because ovulation can occasionally occur
before the first menstrual period.
2. Fatigue, nausea, and/or vomiting as well as breast changes, including
tenderness are the classic symptoms of pregnancy.
3. Urinary frequency can also occur.
Gestational develpment: fetal heart sounds on hand held doppler? uterine above pubic symhsis? uterine enlargment?
Gestational age Findings
5 weeks
Embryo is an eighth of an inch in size, but most
likely has a heartbeat.
The brain and spinal cord are also rapidly
developing during this stage.
8 weeks
Enlargement of uterus detected on bimanual
10-12 weeks Fetal heart tones elicited by hand-held Doppler.
12 weeks
Uterine fundus palpated above the symphysis
18-20 weeks
Fetal movement ("quickening") detected by the
20-36 weeks
Uterine enlargement, measured in centimeters,
approximates gestational age and will be
Estimate delivery date (EDD)or estimated date of confinement (EDC)
Use an obstetric wheel calculating from the last menstrual period"
Use an electronic calculator - http://www.mdcalc.com/pregnancydue-
Use Naegele's Rule is commonly described as starting with the first day of
the last normal menstrual period, then:
Add 1 year
Subtract 3 months
Add 1 week
Reproductive choice couns
Pregnancy signs: Goodells sign? Hegars sign? Chadwix sign?
Goodell's sign - Softening of the cervix
Hegar's sign - softening of the uterus
Chadwick's sign - The bluish-purple hue in the cervix and vaginal walls is
caused by hyperemia.
An unremarkable pelvic exam does not rule out either a spontaneous
abortion, ectopic pregnancy, or a normal pregnancy.
A cervical os dilated with obvious bleeding lends support to the diagnosis of
a spontaneous abortion.
A distended, acute abdomen may turn one's attention to the immediate
possibility of a ruptured ectopic pregnancy.
When the central part of the cervix appears red from the mucus
producing endocervical epithelium protruding through the cervical os
onto the face of the cervix.
No clinical significance. Common in women taking oral contraceptive pills.
abortion types: Inevitable abortion? Incomplete abortion? Missed abortion? Septic abortion? Complete abortion? Threatened abortion?
Inevitable abortion Dilated cervical os
Incomplete abortion
Some but not all of the
intrauterine contents (or products
of conception) have been expelled
Missed abortion
Fetal demise without cervical
dilatation and/or uterine activity
(often found incidentally on
ultrasound without a presentation
of bleeding).
Septic abortion
With intrauterine infection
(abdominal tenderness and fever
usually present).
Complete abortion
The products of conception have
been completely expelled from
the uterus.
Threatened abortion
Simply a pregnancy complicated
by bleeding before 20 weeks
gestation, and is - in some ways -
a "catch-all" descriptive
Initial pregnancy evaluation (7)
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
gestational age.
2. CBC
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
immune response.
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.

4. Rubella
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.
6. RPR
Tests for syphilis
Risk of transplacental infection of the fetus.
Congenital infection is associated with several adverse outcomes in
the neonate:
Perinatal death
Premature delivery
Low birth weight
Congenital anomalies
Active congenital syphilis
7. HIV
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.
First trimester bleeding studies
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
mild leukocytosis.
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.
Warranted for:
Potential transfusion
When the history, vital signs, and physical exam
consistent with a major bleed.
Kleihauer-Betke testing
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
excretes beta-hCG).
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
repeat ultrasound.
Beta-hCG level atgestational age or condition: conception until first 7 week? pregnancy detectable on transvaginal US? abdominal U? higher than normal?
Gestational age or condition Beta-hCG level
Expected date of menses >= 100 mIU/ml
Conception until first 6-7 weeks
Levels double every 48 hours
Conclusive pregnancy by transvaginal
1500-1800 mIU/ml
Pregnancy detected by transabdominal
Ectopic gestations and spontaneous
hCG levels are usually lower than
normal and increase at less-thannormal
rates during early gestation
Molar pregnancy and multiple gestations Higher-than-normal hCG levels
Progesterone levels: level for evolving miscarriage? level for stustainable intrauterin pregnancy?
Laboratory testing for progesterone is most useful in extreme
Levels <5 nmol/L have been highly associated with an evolving
miscarriage or ectopic pregnancy with a high level of sensitivity and
Levels >25 nmol/L have been associated with a sustainable
intrauterine pregnancy.
Levels between 5 and 25 have minimal diagnostic value in
distinguishing intrauterine from ectopic pregnancy.
Algorithms for the diagnosis of ectopic pregnancy emphasizing
progesterone measurements have been associated with:
Higher use of surgical management
Often miss ectopic pregnancy since 85% of ectopic pregnancies
will have a normal progesterone level.
Nevertheless, the test remains valuable because of its positive and
negative predictive value at the extremes of the reference range.
In many labs, it is a common and quick test, which makes it
frequently ordered.
Ultrasound and estimating date of delivery: fist trimester? second?
First trimester
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.
Second trimester,
Four measurements are taken:
Biparietal diameter
Head circumference
Abdominal circumference
Femur length
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.
Spontaneous abortion?
Intrauterine contents (e.g., gestational sac, fetal pole, etc.) are not
expected to be seen until the quantitative beta-hCG reaches > 1500 IU/L,
so a serial reading (in the stable patient) is needed.
In a stable patient without active bleeding, *serial readings every 48-72
hours would be appropriate.*
At each lab reassessment, a clinical assessment should be done as well.
At any time, a spontaneous abortion can cause hemodynamic instability
requiring a dilitation and curettage.
At any time, a ruptured ectopic can prove life threatening, requiring a
diagnostic laparoscopy or laparotomy.
Inevitable abortion management (3)
Expectant management
Watchful waiting with precautions regarding unusual amounts of bleeding or
pain, or fever is effective in over 75% of cases in this setting.
Process can take up to a month for the products of conception to be
completely expelled.
Process can be complicated by sadness, grief, and even guilt and can
delay emotional closure.
Surgical management
Dilatation and curettage (D&C), with or without vacuum aspiration; Main indication for suction D&C:
Unusually heavy bleeding
Patient preference
Main contraindication:
Active pelvic infection and patient refusal
Manual or electric vacuum aspiration
These choices depend on a variety of factors, including primarily local
resources and the surgeon's preference and experience
Medical management
Despite being off-label, medical management with misoprostol is a useful
third option that is becoming more common
The most common protocol involves the vaginal administration of 800 mcg
of misoprostol (Cytotec), possibly repeated on day three
Success with this method is generally around 95%
Time to completion is generally 3-4 days (but may take up to 2 weeks), as
opposed to 2-6 weeks with expectant management
RH-negative patients
Confirming the receipt of rhesus immune globulin (RhoGam) is critical. If it
was not given previously, it should now be administered
Case 13
40-year-old male with a persistent cough - Mr.
Summary of Clinical Scenario 13
Mr. Dennison is a 40-year-old male with a
history of allergic rhinitis that is uncontrolled with current medications. He has
had a persistent cough accompanied by wheezing at night for two
months. Physical exam reveals he is afebrile with swelling of the inferior nasal
turbinates, clear nasal drainage, no sinus tenderness, with no other remarkable
findings. During the evaluation of these findings, students consider the
differentiation of viral vs. bacterial and acute vs. chronic sinusitis. A wide
differential for persistent cough is generated. Spirometry demonstrates reversible
obstructive findings diagnostic of asthma, and students learn how to conduct an
initial evaluation and formulate a treatment plan for asthma.
Common conditions that lead to a persistent cough (read)
Upper airway cough syndrome (UACS, previously called postnasal drip)
Vocal cord dysfunction
Gastroesophageal reflux disease (GERD)
Cough due to medications such as angiotensin-converting enzyme (ACE)
Tobacco-related cough
Post-infectious cough
Chronic obstructive pulmonary disease (especially the chronic bronchitis
Non-asthmatic eosinophilic bronchitis
Serious, less common causes of persistent cough:
Pulmonary conditions, such as bronchogenic carcinoma of the lung,
sarcoidosis, and tuberculosis
Cardiac conditions, such as congestive heart failure
Etiologies of wheezing: most common cause of persistent cough and wheezing/
Most common cause of persistent cough and wheezing
Asthma is a chronic breathing problem caused by swelling of the
airways in the lungs. It cannot be cured, but it can be prevented and
21% of adults who have asthma have aspirin- induced asthma and
should avoid non-steroidal anti-inflammatory drugs (NSAIDs).
Upper airway cough syndrome (UACS)
Chronic obstructive pulmonary disease
Congestive heart failure
Foreign body aspiration
Persistent bronchitis
Vocal cord dysfunction
Pulmonary embolism
Asthma: conditions that may req treatment to improve control of asthma? diagnosis? (3)
Co-morbidities: Conditions that may require treatment to improve the
control of asthma:
Gastroesophageal reflux disease (GERD)
Obesity or overweight
Obstructive sleep apnea
Rhinitis or sinusitis
Stress and depression
Presence of episodic symptoms of airflow obstruction or
At least partially 2. reversible obstructive airflow
3. Exclusion of alternative diagnoses
Pathophysiology of astma?
Chronic inflammatory disease of the airways
Involves mast cells, eosinophils, T-lymphocytes, macrophages, neutrophils,
and epithelial cells
Chronic inflammation leads to airway hyperresponsiveness and limitation of
airway flow (obstruction).
Persistent inflammation can lead to airway edema.
Long-term inflammation can lead to airway remodeling and permanent loss
of lung function.
Sinusitis: acute sinusitis? viral rhinosinustitis sx (3) chronic sinustitis?
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.
Differential diagnosis cough: upper airway cough syndrome: present with? asthma dx feature? non-asthmatic eosinphilic bronchitis: dx? COPD finding? GERD? CHF?
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.
Spirometry: what does it measure? how is the test performed? two important measurements?
Measures how much air patient can inhale and exhale as well as the velocity of
exhalation. For this test, patient breathes into a mouthpiece attached to a
recording device called a spirometer. The information collected by the spirometer
is captured on a chart called a spirogram. The test is repeated at least three times
to make sure that it is reliable. First, tests are done to establish a baseline. Next,
an inhaled bronchodilator is administered. Finally, patient performs tests again to
determine presence or absence of improvement.
Spirometry data
FEV1 (Forced
exhalation volume in
one second)
Volume of air exhaled during the first second
of forced exhalation following maximal
FVC (Forced vital
Maximal volume of air forcibly exhaled from
the point of maximal inhalation.
Interpretation of spirometry: decrased FEV1/FVC ratio? normal or increased? measure?
Decreased FEV1/FVC ratio
(decreased FEV1 value
with a slightly increased
FVC value)
Obstructive lung disease
Improvement in the FEV1
value by ≥ 12%, or
Increase in % of
predicted FEV1 value by
10% after bronchodilator
Reversible obstructive lung
disease, diagnostic for
FEV1/FVC ratio normal or
increased (decreased
FEV1 and decreased FVC
Restrictive lung disease
Additional tests to measure
the total lung capacity (TLC)
may be needed to confirm
the diagnosis.
Pharmaceutical management: initial managment? maintenance medications: step two? step 3? step 4? step 5?
Quick-acting rescue medication 1. as needed:
For patients at Step 1: Short-acting beta-2 agonist (needed for asthma
patients at all stages)
2. Maintenance medication:
For patients at Step 2: Add daily low-dose inhaled corticosteroid
For patients at Step 3: Daily low-dose inhaled corticosteroid plus a
long-acting beta-2 agonist inhaler or a medium-dose inhaled corticosteroid
For patients at Step 4: Increase dose of inhaled corticosteroid and continue the long-acting beta-2 agonist
For patients at Step 5: High-dose corticosteroid. (This dose is reserved for
severe asthma, as risk of adverse effects increases with dose, although it is
well-tolerated and safe at the recommended doses.)
Theophylline may be used in conjunction with low-dose inhaled
corticosteroids, but are not used that often due to difficulty in titrating the
theophylline dose to the correct level.
Leukotriene receptor antagonists may be used in conjunction with low-dose
inhaled corticosteroids, but they are expensive.
Exacerbation management?
Oral corticosteroids
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
Interpretation of peak flow: Greenzone? yellow zone? red zone? How often do you do peak flow?
Green Zone (doing well): Peak flow should be > 80% of personal best
Yellow Zone (getting worse): Peak flow 50-79% of personal best
Red Zone (medical alert): Peak flow < 50% of personal best. Clinical
symptoms of the red zone include:
Very short of breath
Quick relief medicines have not helped
Cannot do usual activities
Symptoms are same or get worse after 24 hours in yellow zone

*Peak flow readings twice per day at home to measure levels of asthma
control. Manage comorbid conditions*
Case 14
35-year-old female with missed period - Ms. Rios
Summary of Clinical Scenario 14 (read)
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.
Classic signs of pregnancy (6) and calculating the due date
Knowledge: Classic signs of pregnancy
Delayed menstrual period
Symptoms of nausea
Breast tenderness
Bluish discoloration of the cervix from venous congestion (Chadwick's sign),
usually visible by 8-10 weeks gestation.
Palpably gravid uterus, usually easily discerned by 10-12 weeks gestation.
Calculating the due date
The due date is the day 40 weeks after the beginning of the last menstrual
period (LMP).
Naegle's Rule is to subtract three months from the LMP and add 7 days.
About 5% of babies are born on their due date, with most deliveries
occurring within 2 weeks of the due date (either before or after).
Gestational age is also recorded as the time elapsed since the first day of
the LMP.
If the LMP is not known or there is uncertainty due to a lack of regular
periods, ultrasound can be used to estimate gestational age.
Pregnancy diagnosis: FDA HCG threshold for home tests? blood trest?HCG trend/?
Home pregnancy tests
Reliable indication of pregnancy.
The sensitivity and specificity of home pregnancy tests may vary between
brands and manufacturers; however, most tests are highly sensitive at the
time of a missed period in a woman with previously regular periods and may
even be positive up to several days prior to a missed period.
The FDA threshold for home tests at the time of a missed period is 50
mIU/mL, and most home urine pregnancy tests are positive at
concentrations of ≥ 25 mIU/mL.
The presence of even a very faint line along with the control strip is
considered a positive test.
However, most clinicians will repeat a urine pregnancy test in the office for
Blood tests of human chorionic gonadotropin (hCG)
Detect levels as low as 5 mIU/mL
Potential for false positives
Not used for initial diagnosis
Helpful in determining the viability of a pregnancy since hCG levels rise
predictably in early pregnancy.
Levels of hCG double approximately every 2.2 days over the first few
Double more slowly, approximately every 3.5 days by 9 weeks. Peak at 10-12 weeks
Decline rapidly until 22 weeks, when levels then gradually rise until
Transvaginal ultrasound (TVUS): gestational sac? Dating determined by ultrasound is generally chosen over other
methods for any discrepancy of? umbilical height?
More sensitive than transabdominal ultrasound in detecting early pregnancy.
Gestational sac often visualized by 4-5 weeks' gestation; a fetal pole by 5-6
In women who have irregular periods or have other risk factors, such as
vaginal bleeding, TVUS can be a useful tool for dating pregnancy as well as
evaluating for ectopic (tubal) pregnancy and other abnormalities.
Determining gestational age:
If LMP is unknown or uncertain, or there are size/date discrepancies,
an ultrasound can be used to estimate the gestational age of the
When used for dating, ultrasound is most accurate during early
pregnancy and should be performed as early as possible (and no later
than 20 weeks).
Dating determined by ultrasound is generally chosen over other
methods for any discrepancy of:
More than one week in the first trimester
More than two weeks in the second trimester
More than three weeks third trimester (In the third trimester,
ultrasound dating is generally no more accurate than dating by
estimated fundal height alone.)
At 20 weeks, the top of the uterine fundus is usually at the level
of the umbilicus, and after 20 weeks, elevates approximately 1
cm above the umbilicus for each week of pregnancy.
Routine studies pregnancy? ask about? US?
Baseline screening for anemia
2.Blood type/Rh status
Assess risk of maternal-fetal transfusion reactions (i.e. hemolytic anemia in
the newborn due to the presence of maternal antibodies) should the baby's
blood type be different than the mother's.
Anti-Rh antibodies (RhoGam) can be given to mothers who are Rh negative
to prevent sensitization of the maternal immune system to Rh antigens if
the baby's blood type is Rh positive.
3.HIV test
Recommended for all pregnant women.
Opt-out" voluntary testing strategies may improve screening rates.
Blood type/Rh status
Assess risk of maternal-fetal transfusion reactions (i.e. hemolytic anemia in
the newborn due to the presence of maternal antibodies) should the baby's
blood type be different than the mother's.
Anti-Rh antibodies (RhoGam) can be given to mothers who are Rh negative
to prevent sensitization of the maternal immune system to Rh antigens if
the baby's blood type is Rh positive.
Baseline screening for anemia
HIV test
Chicken pox
Women should be asked about a history of chicken pox; women with no
history can have serologic testing for varicella zoster IgG.
Non-immune women should be offered preconception or postpartum
varciella vaccination.
Varicella vaccination is contraindicated in pregnancy.
Bacterial vaginosis
Universal screening NOT recommended.
Symptomatic women should be treated.
Screening may be considered in women with risk factors for pre-term
Routine ultrasound screening
In pregnancy has not been linked to improved perinatal outcomes.
Ultrasound can be useful for accurately determining gestational age early on
in pregnancy.
Most experts agree that pregnant women should be offered routine
ultrasound screening for structural anomalies between 18-20 weeks'
Dietary recommendations during pregnancy: iron? folic acid? avoid? (7)
-Daily prenatal vitamin:
Provide recommended iron (30 mg per
day) and folic acid (0.4 to 0.8 mg per
day), especially important during the
first few months of pregnancy.
-Moderate amounts of
caffeine are safe
1. High caffeine consumption may be
associated with spontaneous abortion
and low-birth-weight infants as seen in
observational studies.
2. Avoid large ocean fish such
as shark, swordfish, king
mackerel, tilefish, and
tuna steaks
Contains high levels of mercury which
can lead to neurologic abnormalities iin
women and their infants.
3. Avoid unpastuerized milk
products as well as
unwashed fruits and
Associated with toxoplasmosis and
4. Avoid soft cheeses such as
feta, brie, veined,
Camembert, and Mexican
queso fresco
Associated with listeriosis
5. Avoid raw eggs Associated with salmonella
6. Use caution when consuming
foods with saccharin
Crosses the placenta
7. Women with (PKU)
phenyketonuria should avoid
Adverse effects from aspartame during
pregnancy in women without PKU have
not been demonstrated.
What to expect during pregnancy: how much weigh should be gained?
Average BMI, should expect a 25-35 pound weight gain.
Nausea, fatigue, and breast tenderness are normal and most women usually
begin feeling better by the end of the first trimester.
In the last trimester of pregnancy, most women begin feeling some aches and pains as the baby gets bigger
Prenatal visit schedule?
Every 4 weeks until 28 weeks
Every 2 weeks from 28-36 weeks
Weekly from 36 weeks until delivery
Nausea and vomiting during the first trimester: time period?
Usually self-limited beginning 4-7th week and resolving by the 20th week.
Recommend continuing to eat small, frequent meals and avoid smells or
foods that don't seem appetizing.
Try high carbohydrate, low fat foods.
Salty foods are better tolerated in the morning and sour or tart liquids
(like lemon-lime soda) are sometimes better tolerated than water.
1 in 200 women develop persistent vomiting, which leads to dehydration,
ketosis, electrolyte disturbances, and weight loss, a condition called
hyperemesis gravidarum.
Weight gain during pregnancy: normal weight? overweight?
Normal weight: 25 - 35 pounds
Overweight (BMI 25.0 - 29.9
Monitor blood pressure 15 - 25 pounds
Fundal height measurement:at pelvicbrin?level of umbilicus? trend?
Subject to inter- and intra-observational error, but it is a simple and
inexpensive test that can assess appropriate growth of the fetus.
At 10 weeks, the fundus may be just palpable at the pelvic brim.
At 20 weeks, the top of the uterine fundus is at the level of the
After 20 weeks, the top of the uterine fundus elevates approximately
1 cm above the umbilicus for each week of pregnancy.
Prenatal screening and diagnosis? Urine culture?
Ultrasound for fetal nuchal (neck) translucency and screening for several
serum biomarkers (free-hCG, pregnancy-associated protein plasma A)
Screen at 10-14 weeks as an additional method for screening for
neural tube defects.
The advantages of both early detection and slightly improved
sensitivity for detecting congenital defects with early biomarker and
fetal nuchal translucency testing should be balanced with their cost
and availability.
Invasive prenatal genetic testing includes chorionic villus sampling in the
first trimester and amniocentesis in the second trimester.
Many women will choose non-invasive screening tests as a first line to
establish their risk.
Urine Culture? All pregnant women should also be screened for asymptomatic bacteriuria at
12-16 weeks' gestation.
Prenatal maternal ("triple" or "quad") serum screening: markers? indicate increased risk for? when is it done
Consists of measuring three or four chemical markers present in the
mother's blood during pregnancy:
Alpha-fetoprotein (AFP)
Human chorionic gonadotropin (hCG)
Unconjugated estriol
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%.
US recommendaton? and amniocentesis risk of abortion?
Most experts agree that pregnant women should be offered routine
ultrasound scanning for structural anomalies between 18-20 weeks'
Risk of spontaneous abortion 1:400 - 1:200
Gestational diabetes screening: when is it done? how? normal? abnormal? positive test?
Screening for individuals at average risk for gestational diabetes (most
women) should be completed at 24-28 weeks.
Measure serum glucose 1 hour after oral ingestion of a 50g glucose solution
(the 1-hour glucose tolerance test).
Normal result if;
Fasting glucose is < 126
One-hour glucose is < 140
Abnormal result;
Three-hour glucose tolerance test should be performed.
Measure the patient's glucose after fasting and then one, two
and three hours after ingesting a 100-gram glucose load.
Gestational diabetes is defined by the Fourth International Workshop on
Gestational Diabetes as the presence of two or more of the following serum
glucose values:
Fasting serum glucose conc. ≥ 95 mg/dL (5.3 mmol/L)
One-hour serum glucose conc. ≥ 180 mg/dL (10 mmol/L)
Two-hour serum glucose conc. ≥ 155 mg/dL (8.6 mmol/L)
Three-hour serum glucose conc. ≥ 140 mg/dL (7.8 mmol/L)
Group B strep (GBS) screening and prevention: feature? screening done when? rx?
Most common cause of life-threatening infection in newborns including
sepsis, meningitis, and newborn pneumonia.
Premature infants have a higher risk of GBS infection, but most cases occur
in full term infants.
1/2 of the cases occur during the first week of life, and most of these cases
are preventable by giving intravenous antibiotics to women in labor who are
infected with or at high risk for GBS.
Universal prenatal screening for vaginal and rectal group B strep
colonization of all pregnant women at 35-37 weeks' gestation.
Women with group B strep bacteriuria during their current pregnancy or
who previously gave birth to an infant with early-onset group B strep
disease should receive intrapartum antimicrobial prophylaxis.
If positive, penicillin is the first line agent for intrapartum antibiotic
prophylaxis, with ampicillin an acceptable alternative if penicillin is
Placenta previa: what s it? presents as? risks (5) rx?
Placenta attached low in the uterus, potentially covering the cervical os,
leading to excessive bleeding at or prior to delivery, jeopardizing the health
of the fetus.
Should be suspected in any woman beyond 24 weeks' gestation who
presents with painless vaginal bleeding.
Present in 0.3 to 0.5% of pregnancies.
Bleeding more often occurs late in the second or in the third trimester.
Risks for placenta previa:
Prior pregnancy
>35 years old
Previous twins or a higher multiple pregnancy
Uterine surgery, including prior Cesarean section
Usually diagnosed before a woman has any bleeding due to the use of
routine ultrasound.
More likely to resolve when detected earlier in pregnancy.
Marginal or incomplete previas are more likely to resolve than complete
Subsequent ultrasound surveillance is indicated to document progression or resolution.
In the absence of any symptoms, women with previa can be at home;
however, they should be counseled about the risk of bleeding and seek
prompt attention with any bleeding.
If placenta previa does not resolve, delivery by Cesarean is usually required.
Bacterial vaginosis (BV): cause? sx? dx? rx?
Caused by a shift in the normal bacterial flora of the vagina.
Associated with a thin clear or mildly colored discharge, often with a foul
Related itching or burning may make it difficult to distinguish from urinary
infection or candidiasis on the basis of the patient's history.
Associated with recent intercourse or the use of douches or other artificial
substances in the vagina.
Diagnosis: prepare a vaginal wet mount; clue cells typically present.
Standard treatment for BV is metronidazole, 500 mg twice per day for one week.
Vaginal candidiasis: presents as? dx? treat?
Presents as;
Itching in the vaginal and labial area
With or without thick white discharge from the vagina
Associated with intercourse
Common in pregnancy
Diagnosis: KOH prep
Treatment: Clotrimazole
Urinary tract infection (UTI): sx? dx? rx?
Commonly associated with burning upon on urination and abdominal pain.
Intercourse has been associated with UTIs.
Not commonly associated with vaginal discharge.
Diagnosis: urinalysis
Treat based on patterns/resistance of organisms
Note: Ciprofloxacin (and any quinolone antibiotic) is contraindicated in
pregnancy due to its potential effects on the fetal bone growth plates.
Placental abruption: presents with (4) what is it? rx?
Presents with uterine contractions, vaginal bleeding, abdominal tenderness
and a non-reassuring fetal heart tracing.
Occurs when the placenta peels away from the inner wall of the uterus
before delivery.
Can vary in size, from small & self-limited to near-complete separation of
the placenta from the uterus.
Can occur spontaneously or after trauma.
Requires immediate medical attention, monitoring, and potential delivery, as
it can deprive the fetus of oxygen and cause heavy bleeding in the mother.
Less Likely dx of bleeding (read)
Premature rupture of membranes (PROM)
Rupture of the fetal membranes prior to the onset of labor.
Can occur at any gestational age.
Large gush or steady trickle of clear vaginal fluid.
Occurs in 8% to 10% of term pregnancies prior to the onset of uterine
Preterm PROM (PROM prior to 37 weeks of gestation)
Leading identifiable cause of premature birth and accounts for
approximately 18% to 20% of perinatal deaths in the United States.
Preterm labor (prior to 36 weeks)
Leading cause of infant mortality in the United States.
Uterine rupture
Serious, but uncommon cause of second and third trimester vaginal
Occurs more often during delivery than prior to it. Uterine rupture is defined
as a full-thickness separation of the uterine wall and the overlying serosa.
Associated with:
Clinically significant uterine bleeding
Fetal distress
Expulsion or protrusion of the fetus, placenta, or both into the
abdominal cavity
The need for prompt cesarean delivery, uterine repair or
Rhogam immunization given when (3)
If the patient is Rh-negative, routine Rhogam immunization should be
At 28 weeks' gestation
Within 72 hours after delivery
With any episodes of vaginal or intrauterine bleeding.
Hypertension during pregnancy: chronic HTN? getational htn? preeclampsia?
Chronic hypertension
Blood pressure elevation persisting beyond 12 weeks postpartum, which
persists > 12 weeks postpartum.
Gestational hypertension
Persistent systolic blood pressure of >140 mmHg and/or diastolic blood
pressure of > 90 mmHg, without proteinuria, in a previously normotensive
pregnant woman at or after 20 weeks of gestation.
Tends to recur in subsequent pregnancies.
Increases the risk of developing hypertension later in life.
The presence of persistent systolic blood pressure of *>140mmHg and/or
diastolic blood pressure of >90 mmHg, with proteinuria of 0.3 grams or
greater in a 24-hour urine specimen.*
Preeclampsia is a more specific category of gestational hypertension
(comprising women with gestational hypertension who subsequently
demonstrate proteinuria).
Women who develop gestational hypertension earlier in pregnancy are more
likely to develop preeclampsia.
Severe gestational hypertension (without proteinuria)?
Elevation in systolic blood pressure of ≥160 mmHg and/or diastolic blood
pressure of ≥110 mmHg for at least six hours
Women with severe gestational hypertension and mild or severe
preeclampsia have an increased risk of pregnancy complications including:
Preterm delivery
Small for gestational age infants
Placental abruption
Women with mild gestational hypertension have not been shown to carry
similar risks.
Eclampsia: definition? risk factors?
Describes the occurrence of one or more convulsions in the presence of
preeclampsia without the presence of another underlying neurologic
0.5% of women with mild preeclampsia will develop eclampsia
2-3% of women with severe preeclampsia will develop eclampsia
Cause of seizures is unknown, but may be due to altered cerebral
regulation of blood flow.
Risk factors for preeclampsia and eclampsia are similar:
White, nulliparous women from lower socioeconomic
Incidence higher in younger (teenage and low twenties) and
older (>35 years) women.
The most common skin eruptions in pregnancy: (read)
Pruritic urticarial papules and plaques of pregnancy (PUPPP):
papulovesicular lesions on the trunk and extremities
Prurigo of pregnancy: usually appears as excoriated areas on the trunk or
Pruritic folliculitis: centered around hair follicles and have an associated
pustular appearance
Treatment goal: relief of symptoms
Topical emollients and glucocorticoids
Generally, oral steroids are not needed
Antihistamines can also be helpful, but also cause sedation
Distinguish these conditions from others that may be due to underlying
disease, such as:
Cholestasis of pregnancy: women usually develop severe, whole-body
itching with secondary skin changes due to scratching. If suspected,
further work-up, including serum bile acids, may be indicated.
Pustular psoriasis
Pemphigoid gestationis
Down's Syndrome diagnosis (10)
Most infants with Down's have between 4 and 6 of the following signs:
1.Flat facial profile
4. Excessive skin at nape of the neck
2.Slanted palpebral fissures
5. Hypotonia
6. Hyperflexibility of joints
7. Dysplasia of pelvis
3.Anomalous ears
8. Dysplasia of midphalanx of fifth finger
9. Transverse palmar (Simian) crease
10 Poor Moro reflex (elicited by moving the head quickly downward from
its resting or upright position. In a normal infant, symmetric
extension and abduction of the arms as well as opening of the hands
is followed by flexion of the upper extremities back across the chest.)
Postpartum Visit: when does it occur?
Two weeks - For women who have had a Cesarean delivery in order to
assess a return to daily activities as well as healing of the surgical wound.
Six weeks - For women who deliver vaginally.
Women at risk for postpartum depression should receive closer follow-up.
Screening for post-partum depression should also occur at the post-partum
One screening tool is the Edinburgh postnatal depression scale.
Postpartum blues: peaks? and depression: occur?
Postpartum blues
Mild, though often rapid fluctuations in mood within the first two weeks postpartum, often peaking at about day five.
Usually resolve over time with support, reassurance, and rest.
Counsel women to seek care if symptoms worsen or are not improved by
two-weeks postpartum.
Postpartum depression
Occurs in about 5% of women.
Onset of clinical depression (using the same criteria as for those who are
non-pregnant) within the first four weeks postpartum.
In clinical practice, onset within the first year after delivery of an infant is
often referred to as postpartum depression.
Risk factors:
Stressful life events over the preceding year
Unplanned pregnancy
Lack of spousal or partner support
Personal history of mental disorders
Having an infant with a congenital malformation
Contraception followng pregnancy? disadvantages? when? IUD? combined?
Progestin-only pills, injectable progestin (Depo-Provera), and progestin
implants (Implanon)
Can be started immediately post partum
Minimal effect on blood pressure, coagulation factors, or lipid levels
Lack of increased risk of stroke, myocardial infarction, or venous
Potential disadvantages:
Need to take a daily pill at the same time every day (for maximum
Irregular bleeding, particularly within the first few months.
Due to theoretical concerns about the role of progestins in the
initiation and production of breast milk, agencies such as WHO and
ACOG recommend that women not begin progestin only contraception
until six weeks if exclusively breastfeeding.
Intrauterine device (IUD)
Copper containing IUDs are the only type of IUD approved for use
May be inserted immediately, although earlier insertion has a slightly higher
expulsion rate compare to insertion at 4-6 weeks post-partum.
Combined oral contraceptives
Women may benefit from reduced coagulation-related risks (from estrogen)
by waiting 4 or more weeks post-partum.
Have been shown to suppress milk production in the early post-partum
Clinical trials have shown mixed results with regard to the effect of
combined oral contraceptives on milk supply and infant growth.
A Cochrane review concluded that no evidence-based recommendation can
be made about the use of combined oral contraceptives in lactating women.
Case 15
42-year-old male with right upper quadrant pain - Mr.
Summary of Clinical Scenario 15
Mr. Keenan is a 42-year-old man with a mild
history of gastroesophageal reflux disease (GERD) and a remote history of an
appendectomy, presenting with an acute onset of significant right upper-quadrant
abdominal pain and vomiting that began after a large meal and was unrelieved by
a proton-pump inhibitor. A thorough review of systems is negative and physical
exam is within normal limits. After initial tests come back with normal results, an
abdominal ultrasound demonstrates gallstones, confirming a diagnosis of biliary
colic. Mr. Keenan is referred for surgical consultation for cholecystectomy. During
evaulation it is clear that patient is engaging in risky/hazardous drinking behavior
and a plan is generated for abstinence.
Alcohol-use diagnoses: hasardous vsabuse vs dependence?
Risky/Hazardous drinking
Alcohol consumption exceeds the thresholds listed above, but does not yet
show signs of alcohol abuse or dependence.
Alcohol abuse
A maladaptive pattern of use with one or more of the following:
Failure to fulfill work, school, or social obligations
Recurrent substance use in physically hazardous situations
Recurrent legal problems related to substance use
Continued use despite alcohol-related social or interpersonal problems
Alcohol dependence
Three or more of the following: Tolerance
Substance taken in larger quantity than intended
Persistent desire to cut down or control use
Significant time spent obtaining, using, or recovering from alcohol use
Social, occupational, or recreational tasks are sacrificed
Use continues despite physical and psychological problems.
Screening for alcohol abuse and/or dependence: questionare? ()% sensitivity and specificity? Positive screen for number of drinks per wee: men? women?
Modified CAGE
Have you ever felt:
1. The need to Cut down on drinking?
2. Annoyed with criticisms about your drinking?
3. Guilt about your drinking?
4. The need to drink an Eye opener in the morning?
Positive answers to two or more of the CAGE questions are sufficient to
identify individuals who require more intensive evaluation.
A positive answer to the question, "Have you ever had a drinking problem?"
plus evidence of alcohol consumption in the previous 24 hours provides >
90% sensitivity and specificity as a screening tool for identifying alcoholism.
American Society of Addiction Medicine has developed standards for a
positive screen based on the number of drinks ingested per week.
Positive screen:
>14 drinks per week or > 4 drinks per occasion for men
> 7 drinks per week or > 3 drinks per occasion for women
Physical exam techniques to rule out appendicitis: psoas sign? obturatory sign?
Psoas Sign
Passive extension of patient's thigh as they lie on their side with their knees
extended, or asking the patient to actively flex their thigh and hip causes
abdominal pain, often indicative of appendicitis.
Obturator Sign
Examiner has patient supine with right hip flexed to 90 degree.
Cholecystitis: lenght of sx? asst sx?
Similar pathophysiology to biliary colic but represents a stone that cannot
be dislodged from the cystic duct. Consequently, the symptoms in
cholecystitis, though similar in nature, typically last longer than 4-6 hours
May be associated with increased severity, fever, and elevated white count
from the inflammation in the gallbladder wall.
The inflammatory changes found with cholecystitis can be acute or chronic.
The condition of acalculous cholecystitis is recognized, particularly in the
elderly and the very-ill ICU patient.
Biliary colic: feels like? accompanied by? sx result from?
Right upper quadrant pain, epigastric pain or chest pain that is constant (the term "colic" is a misnomer), typically lasts 4-6 hours or less, radiates to
the back classically under the right shoulder blade.
It is often accompanied by nausea or vomiting and often follows a heavy,
fatty meal.
These symptoms are a result of a stimulated gallbladder (e.g., from a fatty
meal) contracting, but a gallstone obstructs the outlet of the cystic duct.
During this episode, as mentioned above, the pain (from increased pressure
in the gallbladder) is constant, but the hallmark of biliary colic is that the
stone is mobile and eventually moves away from the outlet allowing a
resumption of gallbladder function.
Duodenal ulcer: classical presentation?
The classic duodenal ulcer is epigastric pain (possibly right or left upper
quadrant pain) that is relived by food and/or antacids.
While indigestion and/or nausea are common, vomiting and radiation to the
back can occur but are uncommon.
However, there is significant variation and overlap with other causes of
dyspepsia like gastroesophageal reflux and heartburn.
Furthermore, a gastric ulcer may have a significantly different constellation
of symptoms.
A high index of suspicion for the variety of etiologies of dyspepsia must be
kept in mind when differentiating the upper abdominal pain syndromes.
Hepatitis sx: timing? sx? halmarks?
The clinical manifestations of hepatitis vary somewhat by their etiology, but
most types are more insidious in onset than the diseases of the gallbladder
While RUQ pain and nausea and even vomiting are frequently encountered,
many cases are distinguished by malaise, anorexia, itching, and icterus /
Many times the clinical presentation is difficult to distinguish from other
causes of RUQ / epigastric pain.
Hepatomegaly and the elevated transaminases could be other hallmarks.
Pancreatitis: top 2 etiologies? presents with? physical exam signs? (2)
Distinguishing acute pancreatitis from biliary colic - and any other upper
abdominal disease - can be challenging, particularly because the top 2
etiologies of acute pancreatitis are either alcoholic pancreatitis or... gallstone
Thus, gallstone pancreatitis may be preceded by an episode of biliary colic.
With the onset of acute pancreatic inflammation, the severity is profound,
the onset is rapid (less than an hour), and the radiation is to the back.
Nausea and vomiting are hallmarks of both biliary and pancreatic disease.
In addition to the extreme severity of pain, some classic - albeit rare -
physical exam signs are worth mentioning:
Grey-Turner's sign: ecchymotic discoloration in the flank; Cullen's sign: ecchymotic discoloration in the periumbilical region.
Shock and/or coma may occur.
Less likely diagnosis abdominal pain (read)
Pneumonia or pleurisy
Respiratory symptoms such as cough or pleuritic pain and signs such as
crackles on the pulmonary auscultation portion of the exam are common.
Fever and night sweats suggest pulmonary TB as a possible cause.
Myocardial infarction
Deserves serious consideration and should be ruled out by history and
physical, with absence of chest pain.
Renal pain or colic
Fluctuating colicky pain
Associated with fever and cost-vertebral angle tenderness.
Herpes zoster
Can present without visible skin lesions in the earliest stages.
However, the absence of skin lesions makes this diagnosis less likely and a
prodromal phase would be associated with worsening pain progressing to
visible skin lesions and to hyperasthesia of the skin of that particular
dermatome on examination.
Studies abdominal pain lab? imaging test of choice?
1.Complete blood count
Assess the white blood cell count (WBC)
2. Electrolytes
Assess for possible alterations due to his vomiting
3. Liver function testing (transaminases)
Assess for acute or chronic liver damage, often showing up in the
transaminsases (ALT and AST) and to assess for biliary tract involvement
(alkaline phosphatase and total bilirubin)
4.EKG and Troponin I: Neither of these tests would rule out coronary artery disease, but would
provide reassurance in proceeding further with a RUQ pain workup and
deferring the CAD considerations.
Assess the pancreas and the possibility of pancreatitis.
Rule out renal involvement in the right-sided pain.
Abdominal ultrasound
General, real-time ultrasonography is the preferred study to evaluate the
right upper quadrant because it is inexpensive, noninvasive, and widely
It provides a good evaluation of the liver and other viscera such as the
gallbladder, and it is accurate in the detection of gallstones and dilation of
the biliary tree.
Biliary colic: sx? atypical sx? when to do HIDA? ERCP? MRCP?
Untreated symptomatic gallstones/biliary colic - 70% risk of progression
over two years to complications such as:
Gallstone ileus
Mirizzi syndrome (gallstone compression of the hepatic duct).
*Surgical consultation for cholecystectomy
Indication: Symptomatic gallstones should have surgical evaluation
within the month.*
*Ursodiol (Actigal) - three month trial
Indication: atypical symptoms of biliary colic with visible stones.*
If symptoms resolve, then there may have been from the
gallstones and subsequent therapy can be planned.
If symptoms do not resolve, then plans can likewise be made.
HIDA scan
Functional study of gallbladder.
May reproduce pain.
Indication: *typical symptoms of biliary colic but no visible stones on
the gallbladder ultrasound.*
Indication: Jaundice and/or gallstone pancreatitis suggestive of a common
duct stone (choledochocholelithiasis)
Postoperative patient who did not have an intraoperative
cholangiogram (assessing the common duct at the time of
surgery) and who presents with a repeat episode of biliary colic
and/or jaundice and/or pancreatitis.
Similar diagnostic modality that uses magnetic resonance.
Unlike ERCP - where treatment can take place at the time of
diagnosis... MRCP is a diagnostic modality only.
Case 16
68-year-old male with skin lesion - Mr. Fitzgerald
Summary of Clinical Scenario 16 (readO
Mr. Fitzgerald is a 68-year-old Caucasian retired
brick worker with a past medical history of seizure disorder who presents with a
slightly itchy skin lesion on his left forearm for a three to four-year duration.
Dermatology terminology is reviewed, and the lesion is described as an
erythematous, oval, 18 x 16 mm patch on the flexor aspect of his left forearm.
Various conditions are considered in the differential diagnosis, including basal cell
carcinoma, melanoma, and squamous cell carcinoma. The skin lesion is punch
biopsied, and pathology reveals squamous cell carcinoma in-situ. Treatment
options are presented to the patient. The patient opts for surgical excision and is
educated about preventing further sun damage and monitoring his skin.
Review of systems also reveals decreased stream and dribbling of urine for the
past four to five months, which leads to an evaluation of suspected BPH and
patient education regarding behavior modifications to decrease symptoms.
Dermatology terminology: primary vs seconary?
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
subcutaneous tissue.
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
Basic features of skin lesions: psoriasis location? atopic eczema location? erythema multiforme, secondary syphillis, eczema location? example of annular lesions (3) which size of nevi ten to me more malignant?
Distribution: Many conditions have typical patterns or affect specific regions:
Psoriasis (extensor surfaces)
Atopic eczema (flexor areas of the extremities)
Erythema mutliforme, secondary syphilis, and eczema (palms and soles)
Shape: Oval, round, linear, etc.
Linear: Contact reaction to an exogeneous substance brushing across the
Zosterform: Cutaneous distribution of spinal nerve
Annular: Circular lesion with normal skin in the center
drug eruptions
secondary syphilis
lupus erythematosus
Iris lesions: Type of annular lesion in which an erythematous annular
macule or papule develops a second ring or a purplish papule or vesicle in
the center ("target" or "bull's eye" lesion).
Squamous cell carcinoma of the skin > 2 cm in diameter: high risk for
recurrence and metastasis.
Nevi > 6 mm in diameter tend to be more malignant than the smaller nevi
Skin cancer screening?
Annual skin cancer screening by full body skin examination by health care
provider is an I recommendation by USPSTF (current evidence is insufficient to
assess the balance of benefits and harms) for the early detection of skin cancers.
American Cancer Society mentions a cancer-related check up by a physician,
including a skin examination, during a periodic health examination .
The American Academy of Dermatology promotes free skin examinations by
volunteer dermatologists for the general population through the Academy's
Melanoma/Skin Cancer Screening Program. It also encourages regular
self-examinations by individuals.
In the context of apparently conflicting recommendations by different
organizations and when there is no sufficient evidence for the benefit or harm of
certain recommendations, (like USPSTF I recommendation), the best policy may
be to discuss the recommendation with patients and ask their preference.
ABCDE rule for increased suspicion of skin cancer:
Asymmetry: Asymmetry in two or more axes
Border: Irregular border
Color: Two or more colors
Diameter: Six millimeters or larger
Enlargement: Enlargement of the surface of the lesion
Tinea pedis ("athlete's foot"): prevalence? dx?
Ubiquitous dermatophyte infection
Most common superficial fungal infection
Risk factors:
Local friction, warmth, moisture between toes
Diagnosis usually made clinically, but can be aided by microscopy
Squamous cell
carcinoma: description? % of skin cancer? risk of progression? common sites? risk factors?
Description: Scaly Tend to grow thicker than actinic keratosis. Pink macular to
papular area develops into an erythematous raised base. Lesions may
take the form of a patch, plaque, or nodule,
sometimes with scaling or an ulcerated center. Borders often are irregular and
bleed easily. Unlike basal cell carcinomas, the heaped-up edges of the lesions are fleshy rather than clear in appearance.
Distribution: 20% of all cases
of skin cancer
Risk of
progression: If > 2 cm in diameter,
regarded to be high risk for recurrence and
Common sites: Occurs on sun-exposed
Risk factors: Long history of
sun exposure
Basal cell carcinoma: description? % of skin cancer? risk of progression? common sites? risk factors?
Description: May be plaque-like or
nodular with a waxy, translucent
appearance, often with ulceration and
telangiectasia. Usually no itching or change in skin color.
Distribution: 60% of primary
skin cancers
Risk of
progression: Slow-growing and invades
tissue, but rarely metastasizes.
Common sites: Common on face and other exposed skin surfaces, but
may occur anywhere
Risk factors: Long history of
sun exposure
Melanoma: description? distribution? median age?common site? risk factors?
Description: Growing, spreading, or
pigmented lesions. Dark brown or black.
In initial phase they have a slowly spreading irregular outline. Some areas may be a lighter shade.Since not all
malignant melanomas are visibly pigmented,physicians should be suspicious of any lesion that is growing or that bleeds with minor
Distribution: 1% of skin cancers (but
accounts for >60% of skin cancer deaths)
Risk of
progression: In the U.S.,
median age at
diagnosis is 53,
with about one in
four new cases
occurring in those
< 40 years.
Common sites: Occurs on
exposed areas of
skin. In women >
50% of
located on the
factors: History of
intense sun
Prevalence of
increases with
proximity to the
Risk increases
with red or blond
hair, freckles and
fair skin that
burns easily and tans with
Risk factors for
non-melanoma skin cancer
1.Percent of lifetime sun
exposure obtained before
18 years of age (single
greatest risk factor)
Episodic sun exposure
"probably does not
increase risk"
2.White race
Celtic ancestry
3. Fair complexion
People who burn easily
People who tan poorly
and freckle
4. Red, blonde or light
brown hair
Increasing age
Use of coal-tar products
5. Tobacco use
Psoralen use (PUVA
No significant family
6. Male >>> female
Whites near equator (UV
Outdoor work
Chronic osteomyelitis
sinus tracts
Burn scars
Chronic skin ulcers
Xeroderma pigmentosum
Human papillomavirus
Previous skin cancer of
any type gives 36-52%
5-year risk of second skin cancer
Risk factors for melanoma skin
cancer include: (read)
Cumulative sun exposure
"probably does not increase
White race
Celtic ancestry
Fair complexion
People who burn easily
People who tan poorly and
Red, blonde or light brown
Early adulthood and later in
Intense, intermittent
exposure and blistering
sunburns in childhood and
Radiation exposure
Melanoma in 1st or 2nd
degree relative
Familial atypical
mole-melanoma syndrome
Male > female (slight)
Whites near equator (UV
Indoor work
Higher incidence in those
with more education and/or
Nonfamilial dysplastic nevi
Large number of benign
pigmented nevi
Giant pigmented congenital
Nondysplastic nevi (markers for risk, not precursor
Xeroderma pigmentosum
Previous nonmelanoma skin
Other malignancies
Previous melanoma
Less likely diagnoses skin lesions: psoriasis: location?lochen planus: location? seborrheic keratoses?
Psoriasis:Usually bilateral and involving extensor surfaces of elbows and knees.
While psoriasis can present with a patch, it usually is scaly and elevated, which
makes it more aptly described as a plaque.
Lichen planus: Common in middle age. The primary lesion is a 2 to 10 mm
flat-topped papule with an irregular angulated border (polygonal papules)
commonly located on the flexor surface of wrists and and on legs immediately
above the ankles. Lesions are usually multiple.
Seborrheic keratoses: Usually elevated, hyperpigmented lesions on the face
and trunk. Vary considerably in appearance, but characteristics common to all
seborrheic keratoses are the well-circumscribed border, the stuck-on appearance,
and the variable tan-brown-black color.
Skin biopsy types? (4) method of choice?
Incisional biopsy: Removing a part of the skin lesion.
Punch biopsy: A specific incisional biopsy using a cylindrical dermal biopsy tool.
Disposable punch 2-8 mm. Lesion < 3 mm does not need stitches.
Excisional biopsy: Removing the whole lesion with a 2 to 3 mm margin,
depending on the nature of the lesion.
If lesion is larger than 2 cms, excisional biopsy requires a large incision and is not
the best option for an initial diagnostic procedure unless there is a strong
suspicion of *malignant melanoma, in which case it would be the diagnostic
method of choice.*
Shave biopsy: Feasible when the lesion is elevated above the surface. (In certain circumstances, some experts will elevate flatter lesions with lidocaine and obtain a
shave biopsy to avoid stitches.)
Evaluation of suspected BPH (5):
Rule out other conditions with similar symptoms:
urinary tract and prostatic infections
prostatitis (acute and chronic)
medication side effects
overactive bladder
prostate cancer
Consider complications of untreated BPH:
urinary tract infections
acute urinary retention
obstructive nephropathy
1. Urinalysis: Detects urinary tract infection and blood (possibly indicating bladder
cancer or stones).
2. Serum prostate specific antigen (PSA): Obtain if:
Life expectancy > 10 years
PSA level will influence BPH treatment (e.g., patient considering treatment
with a 5-alpha reductase inhibitor)
3. Serum blood urea nitrogen (BUN) and creatinine: Assesses the presence of
complications, such as obstructive nephropathy.
4. Maximal urinary flow rate:
Test is considered optional by American Urological Association
> 15 mL/sec excludes clinically important bladder outlet obstruction
< 15 mL/sec is compatible with obstruction due to prostatic or urethral
disease (not diagnostic, since low flow rate may also result from bladder
To reduce variability in flow rates, voided volume should be > 150 mL.
5. Post-void residual urine volume: May be determined by in-out catheterization,
radiographic methods, or ultrasonography. The bladder scanner, which can be
used in an office, has made this measurement simple because it does not require
bladder catheterization or radiologic assistance.
Skin cancer treatment: squamous cell carcinoma? mohs micrographic sugery? actinic eratosi? cyrotherapy? radiation?who?contraindication?
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.
Radiation therapy
*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.
Medical management vs surgical managment BPH(2)? Severe sx, large prostat (<40g), and those who fail monotherapy? surgical managment/
1. Alpha-adrenergic antagonists (tamsulosin, alfuzosin, terazosin and
doxazosin) decrease symptoms of LUTS in most men with mild to moderate
2.5-alpha-reductase inhibitors (finasteride and dutasteride) are more effective
in men with larger prostates. Their effect on preventing acute urinary
retention and reduction in need of surgery requires long-term treatment for
more than a year.
In men with severe symptoms, those with a large prostate (> 40 g), and
those who do not get an adequate response to maximal dose monotherapy
with an alpha-adrenergic antagonist, combination treatment with an alphaadrenergic
antagonist and a 5-alpha-reductase inhibitor may be desirable.
Surgical management:
If bladder outlet obstruction is creating a risk for upper urinary tract injury
(such as hydronephrosis or renal insuffiency) or lower urinary tract injury
(such as urinary retention, recurrent urinary tract infection, or bladder
decompensation), surgical intervention is needed. Surgery also should be
considered if combination pharmacologic treatment fails to improve symptoms of BPH.
Treatment of tinea capitis? Tinea ungium? Tinea edis, tinea mangum, tinea corpori and tinea cruris?
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
North America.
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.*
Topical corticosteroids
Indications for use: (read(
Effective for conditions characterized by hyperproliferation, inflammation,
and immunologic involvement.
Provide symptomatic relief for burning and pruritic lesions.
Anti-inflammatory properties of topical corticosteroids result in part from
their ability to induce vasoconstriction to the small blood vessels in the
upper dermis.
Once or twice daily application. More frequent administration does not
provide better results.
Vehicle, or base: Substance in which the active ingredient is dispersed
Determines rate at which active ingredient is absorbed through the skin
May be cream, ointment, lotion, or gel
Steroid examples
(see chart)
Steroid side effects: most common? others? (5)
Skin atrophy (most common)
Hypopigmentation (more apparent with darker skin tones)
Topically applied high and ultra-high potency corticosteroids can cause
systemic side effects, including:
hypothalamic-pituitary-adrenal suppression
glaucoma, septic necrosis of the femoral head
Case 17
55-year-old, post-menopausal female with vaginal
bleeding - Mrs. Parker
Summary of Clinical Scenario 17 (read)
Mrs. Parker is a 55-year-old postmenopausal
woman with a past medical history of hypertension, hypothyroidism, and obesity
who has been on continuous hormone therapy for two years and now presents
with two weeks of vaginal bleeding. During her work-up for abnormal
postmenopausal uterine bleeding, pelvic exam, Papanicolaou (Pap) smear, uterine
ultrasound, and an endometrial biopsy are performed, which confirm a final
diagnosis of endometrial proliferation. Simultaneous to the evaluation of abnormal
uterine bleeding, the patient also receives counseling regarding prevention of
osteoporosis and mammogram screening procedures.
Menopause: definition? median age? Etiology? (4)
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
Osteoporosis: def? risk it poses? Mortality? Risk factors (7) screening recommendation?
Definition: Loss of bone density
Increased risk of fractures. Most commonly, vertebrae, hip, distal radius,
and proximal humerus
Hip fracture mortality and loss of independence:
Average one-year mortality rate following fracture of 20-25%
15-25% of previously independent patients require nursing home
placement for at least one year.
Less than 30% regain their pre-fracture level of function.
Risk factors:
Family history of osteoporosis (especially if a first-degree relative has
fractured a hip)
Previous fragility fracture (low-impact fracture)
Heavy alcohol use
Corticosteroid use
Caucasian race
Lower body weight (weight < 70 kg); however, obesity is not protective
against osteoporosis
Risk calculation: The FRAX, developed by the World Health Organization, is a tool to help
calculate the risk of fracture (adjusts for gender, ethnicity, and locale)
Screening: Recommendations of the U.S. Preventive Services Task Force
All women over the age of 65 via bone density (DEXA) scan
Younger women with equivalent risk to an average 65-year-old white female
(9.3% ten-year risk of any osteoporotic fracture as calculated by the FRAX
USPSTF found insufficient evidence to recommend screening in men
Diagnosis osteoperosis? Normal? Osteopenia? Osteoporosis?
A DEXA scan is a bone densitometry study that usually looks at the
lumbar spine and hip density to determine if someone has osteoporosis. This is
quantified using a T-score (a statistical measure that compares a person's bone
mass density in standard deviations to the average peak bone mass density in a
young healthy person).
T-score of 0 to -1 = Normal
T-score of -1.0 to -2.5 = Decreased bone density, or osteopenia
T-score of less than -2.5 indicates osteoporosis
Treatment recommendations are based on the patient's risk for fracture and
her T-score
Starts in childhood
For 95% of people, maximum bone density is reached in the teenage years
Vital to discuss with parents and children the importance of adequate intake
of vitamin D and calcium in the preteen and teen years in order to boost
peak bone density
Cancer screening recommendations: breast cancer? (Upstf vs acog vs American cancer society) colon cancer?
Breast cancer:
There are varying recommendations for breast cancer screening. The
USPSTF recommends biennial mammography for women aged 50-74; the
decision to begin mammography prior to 50 years of age should be
individualized; there is insufficient evidence to assess the benefits and
harms for women over age 75.
American College of Obstetrics and Gynecology (ACOG) recommends
mammography every 1-2 years for women aged 40-49 and annually
American Cancer Society recommends annual mammography for all women
over 40 years of age.
Colon cancer:
Colon cancer screening is recommended for everyone over the age of 50 continuing to age 75
Various ways to screen for colon cancer, including annual fecal occult blood
tests (FOBT) and colonoscopy.
Colonoscopy is preferred if the patient has a family history of colon cancer,
a change in bowel habits, or any reported rectal bleeding. It allows for
biopsy if needed.
A positive FOBT screen must be evaluated with a more definitive test.
Cancer screening recommendations: cervical cancer? Ovarian cancer?
Cervical cancer:
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.
Ovarian cancer:
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
screening tool.
Endometrial cancer
Endometrial cancer (7) protective factors?
Risk factors: Any increased exposure to unopposed estrogen increases the risk
of uterine hyperplasia, which may lead to endometrial cancer:
1. Unopposed estrogen therapy
2. Tamoxifen (Nolvadex)
3. Obesity
4. Anovulatory cycles
Estrogen-secreting neoplasms
5. Early menarche (before age 12)
6. Late menopause (after age 52)
Other risk factors include:
History of breast or colon cancer
Menstrual cycle irregularities
Age 30-34 years: 2.8 cases per 100,000
Age 35-39 years: 6.1 cases per 100,000
Protective factors:
Smoking (decreases estrogen exposure)
Oral contraceptive use (increases progestin levels, thus providing
differential is for abnormal uterine bleeding in a postmenopausal woman (5)
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)
Risk factors:
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)
Protective factors:
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.
Systemic disorders:
Studies abnormal uterine bleeding: test of choice? Work up needed if? Gold standard for diagnosis (3) used to confirm menopause?
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
hormone [LH]:
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)
Osteoporosis prevention: (4)
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
2. Calcium
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
Osteoporosis treatment: 1)MOA? Drugs (4) who? Admin? Efficacy? 3) use?
1. Biphosphanates
Inhibit bone resorption and reduce bone turnover, increasing bone mineral
Decrease risk of vertebral and non-vertebral fractures
Generic (more affordable): alendronate (Fosamax) and risedronate
Trade name only (more expensive): Ibandronate (Boniva)
Zoledronic acid, an intravenous preparation given annually, can be used in
patients who do not tolerate oral bisphosphonates
2. Parathyroid hormone (Forteo)
Approved by the FDA for those with osteoporosis at high risk for fracture
Given subcutaneously
Decreases fracture risk by 50-65%
No demonstrated efficacy and safety beyond two years
3. Estrogen replacement therapy
Decreases fracture risk by 20-34%.
Given concerns raised by studies, indicated only for short-term treatment of
moderate to severe vasomotor symptoms; not recommended for long-term
4. Calcitonin
Shown to reduce vertebral fractures, but not hip or other fractures
Menopause Hormone Therapy (HT): what sx improve? (3) drugs?
Use only for short-term treatment of bothersome symptoms of menopause.
Known benefits:
Improves health-related quality of life by improving vasomotor and
atrophic symptoms
Helps prevent osteoporosis, especially when started in the first five
years after menopause
Possible benefits (no conclusive studies):
Relief of cognitive and depressive symptoms
Women's Health Initiative (WHI) revealed greater than expected risks
of HT for women in their study
While particular risks are still being defined, key practice guidelines
Combined estrogen and progestogen use beyond three years
increases the risk of breast cancer
Use of unopposed systemic estrogen in women with a uterus
increases endometrial cancer risk
Beginning HT after age 60 increases the risk of coronary artery
HT increases the risk of stroke at least for the first one to two
years of use
Use the lowest effective dose for the shortest possible time.
Systemic estrogen- Most effective treatment for vasomotor symptoms.
Patients with an intact uterus must also be covered with
progesterone to decrease the risk of endometrial cancer related
to unopposed estrogen.
Topical estrogen
Best treatment for atrophic vaginitis
May improve urinary symptoms
When obtained through a pharmaceutical company, is safe in
low doses and probably does not require coverage with
progesterone even in women with an intact uterus
Available in form of either a vaginal cream or an E-ring, an
estrogen-impregnated ring inserted into the vagina.
Case 18
24-year-old female with headaches - Ms. Payne
Summary of Clinical Scenario 18
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
Primary headaches: migraine: number needed to dx? pain? character? assoc sx? location?aura? durayion? aggravated by physical activity?
Number needed for diagnosis: 5 episodes
Pain: Moderate to severe
Character: Pulsating
Associated symptoms: Nausea, Vomiting, Photophobia, Phonophobia
Location Unilateral
Aura Possible
Duration 4 to 72
by physical
Tension HA: number needed to dx? pain? character? assoc sx? location? durayion? aggravated by physical activity?
-10 episodes needed for diagnosis
- Mild to moderate pain
Character: pressing
PROS: photobiia, phonobia
Location: bilateral; occiptal tenderness possible
Aura: no
Duration 30 min to 7 days
Not aggravated by physical activity
Cluster: number needed to dx? pain? assoc sx? location?aura? duration? aggravated by physical activity?
-5 episodes needed for diagnosis
- severe pain:
PROS: autonomic features: rhonorrhea, lacrimation, facial sweating, miosis. eyelid edema, conjunctival injection, ptosis
Location: unilateral, orbital, periorbital, supraortbital, temporal
Aura: no
Duration 15-180 min
Not aggravated by physical activity
Secondary headaches: what are they? features similar to? wat is eential?
Headaches as a result of another underlying medical or psychological
diagnosis, such as anxiety or depression.
High rate of comorbidity between depression or anxiety and primary
Features of the more common secondary headaches may be exactly like
those of tension headaches, so other aspects of history—such as sleep
disturbance or feelings of sadness or anxiety—provide vital clues to the
actual diagnosis.
Appropriate neurological exam is essential. Observe for:
Altered mental status
Signs of meningeal irritation (Kernig's or Brudzinski's signs)
Focal neurologic deficits
Medication overuse (analgesic rebound)-induced: what is it? symptoms? Criteria for dx: # per month? use of? Rx?
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.
Potentially life-threatening diagnoses to consider with headache: (3)
Bacterial meningitis:
Symptoms include:
Acute headache
Stiff neck
Other signs that might make you consider this include:
Symptoms of upper respiratory infection
A new rash
Recent exposure to infections
Abnormal thinking
Abnormal neurologic exam
Intracranial hemorrhage: Consider this if you discover a recent history
of trauma or an acute change in the pattern or severity of headaches. Red
flags that accompany intracranial hemorrhage include:
Findings of a first or worst headache
A change in an existing headache
Abnormal neurologic exam
History of recent trauma to the head
Brain tumor: Brain tumors rarely cause headache as the only presenting
symptom. A brain tumor will, by definition, not cause head pain unless the
tumor affects the dura mater, since the brain itself does not contain fibers
that detect painful stimuli. Red flags that accompany brain tumors include:
First headache in a patient over 50 years old
Abnormal thinking
Abnormal neurologic exam
oWeight loss or other systemic symptoms
Neuroimaging? (3) lumbar puncture?
The American Academy of Neurology and the U.S. Headache
Consortium guidelines recommend neuroimaging only if: 1.Patient has migraine with atypical headache patterns or 2.neurologic signs
Patient is at higher risk of a significant abnormality
3.Study results would alter the management of the headache
Symptoms that increase the odds of positive neuroimaging results include:
Rapidly increasing frequency of headache·
Abrupt onset of severe headache
Marked change in headache pattern
History of poor coordination, focal neurologic signs or symptoms, and a
headache that awakens patient from sleep
Headache that is worsened with use of a Valsalva maneuver
Persistent headache following head trauma
New onset of headache in a person age 35 or over
History of cancer or human immunodeficiency virus (HIV)
Lumbar puncture: Indicated in presence of meningeal signs.
Non-pharmacologic? kety to treating migraine?
In a headache diary, patient keeps daily notes of presence
of headache, severity, treatment, and alleviation. This helps to monitor triggers
and daily stressors that may be modified.

Acute-treatment (abortive) medications: An attempt to stop the headache as
soon as it starts. The key to treating a migraine is to catch it at the first sign of
abortive medication?
1. Triptans: sumatriptan (Imitrex), naratriptan
(Amerge), rizatriptan (Maxalt), zolmitriptan
(Zomig), frovatriptan(Frova), almotriptan
(Axert), eletriptan (Relpax)
Contraindications: Use of ergotamine
MAOI use
History of hemiplegic
or basilar migraine
Heart disease/history
of stroke/
In combination with
selective serotonin
reuptake inhibitors
(SSRIs) may cause
serotonin syndrome
Side effects: Dizziness
Throat tightness or
Chest pressure
2. *Ergot alkaloids
3. Aspirin, bultabil, cafeine
alkaloids (readO
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
caffeine (Fiorinal) (read)
Contraindications: History of por- phyria, History of peptic ulcers, Allergy to aspirin,
Renal/hepatic insufficiency, Caution in drug abuse
Side effects: Anaphylaxis, Toxic epidermal
necrolysis, Stevens- Johnson syndrome, Myelosuppression, Thrombocytopenia
GI bleed
Prophylactic therapies:Prophylactic therapies prevent overuse of the acutetreatment
(abortive) medicines and development of resistant headaches.: 1. dose? FDA approved? contrainidications? side effects? 2. dose? fda approved? contraindication? (3) ? 4? 5. dose? FDA approved? works for? contraindication?
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
Appropriate use of narcotics for chronic pain: short acting narcotics: durg? use? wen you use narcotics what is the goal?
Understand underlying cause of pain.
Use as many non-pharmacologic remedies as possible.
Discuss with patients that you cannot take the pain away but will try to
improve the patient's functional abilities and help them live with their pain.
When you use medicines, first select those non-narcotic options that work
for the cause of pain (anti-epileptic drugs for neuropathic pain,
anti-inflammatories for musculoskeletal pain, and so on).
*Most short-acting narcotics such as acetaminophen/hydrocodone (Lortab)
and acetaminophen/oxycodone (Percocet) are indicated for use only in acute
pain or for breakthrough pain when long-acting agents are insufficient to
control symptoms.*
These drugs are to be used cautiously, since they cause effects like euphoria
that are not related to their ability to control pain. It is because of these
effects that narcotics are frequently overused or diverted for other
*When you must use narcotics, the goal is to use long-acting agents along
with the other agents and use the lowest possible dose that improves
patients' function.*
Once patients have started narcotics, the nature of their care changes. In
addition to office visits for their other conditions, like diabetes, they are required to keep separate office visits just for the pain.
Have patient sign a narcotic contract. Expect compliance; check urine drug
screens, check with the state's reporting system whether patient has
received drugs from other providers.
Keep an open line of communication and prescribe the medicines
Case 19
39-year-old male with epigastric pain - Mr. Rodriguez
Summary of Clinical Scenario 19
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
Dyspepsia: definition? asst with? Prevalence?
Literally, "bad digestion"
Upper abdominal pain or discomfort that is episodic or persistent
Often associated with belching, bloating, heartburn, nausea, or vomiting
About 25% adults are affected by it; many self-diagnose and self-treat it
Accounts for approximately 5% of all visits to family practitioners
The most common reason for a referral to a gastroenterologist in the U.S.
Functional (non-ulcer) dyspepsia (NUD): No identifiable etiology (~50%)
Peptic ulcer disease (PUD) (15-25%)
GERD (5-15%)
Gastric or esophageal cancer (<2%)
Pancreatitis (rare
Peptic ulcer disease (PUD): Risk factors (6)
Risk factors: No evidence to support a cause-and-effect association between
acetaminophen, psychosocial stress, caffeine intake, or cigarette smoking and
1. Pharmacological agents:
Non-steroidal anti-inflammatory drugs (NSAIDs)
Chronic NSAID use is a leading cause of morbidity in the elderly
Chronic anticoagulation with warfarin
Chronic corticosteroid therapy
Cigarette smoking
Decreases vascularity to gastric mucosal cells, resulting in decreased rates
of mucosal healing after insult.
Moderate to severe physiologic stress
Especially intensive care unit (ICU) patients
Gastroesophageal reflux disease (GERD): definition? etiology? risk factors? may cause? NERD?quality of life?
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
Chronic cough
Dental enamel loss
Globus sensation
Non-cardiac chest pain
Recurrent laryngitis
Recurrent sore throat
Subglottic stenosis
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
of GERD.*
Reported health-related quality of life is lower than age-matched patients who
have untreated angina pectoris, diabetes mellitus, or chronic heart failure.
Distinguishing dyspeptic symptoms of GERD? and PUD gastric ulcer pain: wen does it occur? what about duodenal ulcer pain? both may be asst wit?
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
gastroesophageal junction
(due to recumbency or
When gastric pressure is
increased (with obesity,
pregnancy, binding clothes,
or girdles)
Dyspepsia due to PUD: Difficult to separate PUD from
other etiologies of dyspepsia
based on symptoms alone.; Episodic or recurrent
epigastric "aching,"
"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.
Complications of GERD (4)? and PUD (3):
Complications of GERD:1. Esophagitis (develops when
the mucosal defenses are
overwhelmed by refluxed
acid, pepsin, or bile)
2. Peptic strictures from
fibrosis and constriction
3.Barrett's esophagitis
(replacement of the
squamous epithelium of the
esophagus by columnar
2-5% of Barrett's
esophagitis may be further
complicated by adenocarcinoma
Complications of PUD: 1. Hemorrhage
2. Perforation into the
peritoneal cavity or
adjacent organs (causes
severe, persistent
abdominal pain)
Ulcer scar healing or
inflammation with impaired
gastric emptying can lead
to 3. gastric outlet obstruction
Alarm symptoms related to GERD or PUD: These symptoms require
immediate referral of patient to a gastroenterologist. (8)
1 Dysphagia (difficulty
swallowing)-Suggests development of
peptic stricture; rapidly
progressive dysphagia
potentially indicates
Onset of heartburn and
regurgitation in patient >
55 years old-Increased chance of cancer
2. Early satiety- May be associated with
gastroparesis or gastric outlet
obstruction due to stricture or
3. Hematemesis (vomiting
blood)- Bleeding ulcer, mucosal
erosions, esophageal tear
(Mallory-Weiss tear),
esophageal varices
4. Hematochezia (passage of
blood with stool)- Rapidly bleeding ulcer or
mucosal erosions
5. Iron deficiency anemia- May indicate possible bleeding
from a peptic ulcer,
GERD-related mucosal
erosions, or Barrett's ulcer
6. Odynophagia (painful
swallowing)- Associated with infections,
erosions, or cancer
7. Recurrent vomiting- Suggestive of gastric outlet obstruction
8. Weight loss- Associated with malignancy
Helicobacter pylori (H. pylori) infection: % of adults? transmisino? mecanism of action? asst with dudonenal ulcers? complications of infections?
Varies across geographic regions, ethnic groups, and household conditions
Rare in developed countries, and worldwide prevalence is decreasing
§ ri.
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
during childhood
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.
Differential diagnosis abd pain (4)
1. Anxiety: May be associated with 1. different types of body pain. Patients who have anxiety disorders may self-medicate with alcohol, which may
contribute to gastrointestinal disorders.
2. Gastroesophageal reflux disease (GERD): May present with mild
epigastric abdominal pain. Symptoms commonly worsen with meals.
Hematemesis in the setting of GERD represents an alarm symptom
indicative of an upper GI bleed or tumor and warrants prompt GI
referral for evaluation and upper endoscopy.
Hematochezia and melena are not typically associated with GERD.
Abdominal wall muscle strain: Commonly associated with upper
abdominal and epigastric pain.
Dyspepsia due to peptic ulcer disease (PUD): Epigastric abdominal pain
that improves with meals is the hallmark of dyspepsia due to PUD. However,
in some cases, symptoms may worsen with meals.
Hematemesis suggests more complicated disease, including bleeding
ulcer, and warrants prompt GI referral and endoscopy.
Hematochezia and melena commonly occur in the setting of an upper
GI bleed secondary to PUD.
Evaluation of dyspepsia:(1) use? 2. use (3)? 3. when to use? 4. ue? 5? 2 other?
1. Upper GI series: Useful in diagnosing complications of GERD (e.g., esophageal stricture)
Poor utility in diagnosing GERD
*May reveal gastric or duodenal ulcer, but not considered the diagnostic gold
2.24-hour pH probe
Most appropriately utilized when the diagnosis of GERD cannot easily be
When patients desire referral for surgical treatment of their GERD/hiatal
hernia (Nissen fundoplication)
When patients with classic symptoms of GERD (heartburn, regurgitation) do
not improve after appropriate trials of PPIs
3. Fecal immunochemical testing (FIT) and fecal occult blood testing
Consider one of these tests if no improvement with PPI test-and-treat
FIT more sensitive and specific than FOBT for detecting occult lower GI
FIT is not suitable for detecting gastric bleeding and should not be used if
the suspected source of bleeding is proximal to the ligament of Treitz
4. Guaiac-based FOBT (including Hemoccult II SENSA) best used to check for
occult upper GI bleeding
Multiple negative FOBTs or FITs do not exclude the presence of either upper
or lower GI blood loss
Diets high in red meat, iron, and vitamin C may cause false positive results
with guaiac-based tests.
Multiple negative FOBTs or FITs do not exclude presence of either upper or
lower GI blood loss
Diets high in red meat, iron, and vitamin C may cause false positive results
in guaiac-based tests
5. Complete blood count: Useful to evaluate for anemia, but neither sensitive nor
specific for GI bleeding
6. H. pylori testing: Should be performed only if clinician plans to offer treatment
for positive results.
7. H. pylori IgG serologic test:
A useful first-time test in population with high prevalence of active infection
Confirms evidence of past infection and an immunologic response
Cannot be used to confirm eradication of H. pylori after treatment
Urease breath test: detects? expense? less accurte when? and Fecal antigen testing: use?
Urease breath test: Accurately detects active infection
More expensive than serologic testing
Less accurate during PPI therapy (stop PPI for at least 2 weeks and bismuth
for at least 4 weeks prior to breath test)
May be used as confirmatory test after positive serologic test
Fecal antigen testing:
Accurate, but more expensive and less convenient than serologic testing
and may not be available in all settings
May be used to evaluate eradication after pharmacotherapy for H. pylori
gastritis, which may be a more cost-effective strategy than performing a
urease breath test
GERD rx? First step? how long? when to refer?
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
of pharmacotherapy):
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
Lose weight
Stop smoking
Functional dyspepsia: Therapies are similar to those for PUD. (read))
PPI therapy superior to placebo treatment with regard to relative risk
reduction of functional dyspepsia (number needed to treat [NNT] = 9).
Empiric trial of histamine-2 receptor antagonists may or may not be
A subset of patients with functional dyspepsia will not respond favorably to
any form of anti-secretory therapy and will continue to experience
10% reduction in dyspepsia symptoms 12 months after H. pylori eradication
therapy in patients with functional dyspepsia (NNT = 17).
Therapies reserved for use after H. pylori infection is ruled out:?
Tricyclic antidepressants (a systematic review determined that there is
insufficient evidence to support the efficacy of psychological therapies for
the treatment of functional dyspepsia; however, individual trials have
reported some modest clinical benefits in symptomatic improvement.)
Alternative therapies: Capsaicin, peppermint oil, caraway oil, and artichoke
leaf may improve symptoms. (Peppermint oil, however, decreases lower
esophageal sphincter pressure and may worsen GERD symptoms in some
Patients should be cautioned that herbal remedies are not regulated by the
U.S. Food and Drug Administration (FDA), may not have been studied for
safety, and can have adverse side effects.
Current recommended first-line regimens forH. pylori eradication: triple therapy: duration of rx? therapy? pcn allergy? quadrupple therapy?
PPI triple therapy for 10-14 days (70-85% eradication rate):
1.PPI standard dose twice daily (esomeprazole is dosed once daily (20mg)), plus
2.Clarithromycin 500 mg twice daily, plus
3. Amoxicillin 1 gram twice daily
Alternative PPI triple therapy for 14 days (70-85% eradication rate):
(Consider in patients with penicillin allergy.)
PPI standard dose twice daily, plus
Clarithromycin 500 mg twice daily, plus
Metronidazole 500 mg twice daily
Quadruple therapy for 10-14 days (75-90% eradication rate)
PPI standard dose once or twice daily OR ranitidine 150 mg twice
daily, plus
Tetracycline 500 mg 3 times daily, plus Metronidazole 250 mg 4 times daily, plus
Bismuth subsalicylate 525 mg 4 times daily
Accepted indications for testing to prove H. pylorieradication after
antibiotic therapy? To evaluate eradication of H. pylori? if ositive? if sx continue to persist? if negative but still sx?
Accepted indications for testing to prove H. pylorieradication after
antibiotic therapy:
Patients with H. pylori-associated ulcers
Individuals with persistent dyspeptic symptoms despite the test-and-treat
Individuals with H. pylori-associated MALT (mucoid-associated lymphoid
tissue) lymphoma
Post-resection of early gastric cancer
If needed to document clearance in patients planning to resume chronic
NSAID therapy
To evaluate eradication of H. pylori:
Perform fecal antigen testing
If fecal antigen test positive:
Patient requires re-treatment with salvage therapy for a resistant
If symptoms continue to persist:
Upper endoscopy/EGD to rule out ulcer disease and obtain
mucosal biopsy for evaluation of persistent H. pylori infection
Prolonged PPI therapy for symptomatic control
If fecal antigen testing negative (or unavailable) and the patient continues
to have symptoms:
Perform urease breath testing
If urease breath testing negative, patient should be referred to a
gastroenterologist for upper endoscopy/EGD and mucosal biopsy for
evaluation of persistent H. pylori infection
Case 20
28-year-old female with abdominal pain - Ms. Bell
Summary of Clinical Scenario 20
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: (read)
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
increasingly severe.
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.
Differential diagnosis abdominal pain (7)
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):
Abdominal pain
Loose stools or diarrhea
Abdominal bloating
Increased flatulence
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
or constipation.
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
"chandelier sign"*
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
Normal pregnancy
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.
Ectopic pregnancy
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
domestic violence.
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.
Studies abdominal pain female: STD tests?(5) 3 others
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)
on Pap
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
Trichomoniasis: (2)
Screen for other STIs (e.g., chlamydia, gonorrhea, HIV, hepatitis)
Follow up results. 2 g orally single dose
Treat patient and partner with antibiotic (metronidazole)
Domestic violence mngt : what may y increase risk?
Perform risk assessment for domestic violence, give patient information about
resources, and find out about local laws in regard to reporting exposure to
domestic violence.
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
the patient.
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
patient/physician relationship.
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
do so.
Documenting abuse:
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.
Case 21
12-year-old female with fever - Marissa Payne
Summary of Clinical Scenario 21
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.
Influenza: how lng does it last? Most common complications?
influenza each year. It is usually self-limiting, and patients improve in 2-5 days.

Most common complications:
Otitis media (10-50% of children with influenza develop otitis media)
Streptococcal pneumonia (2-3% of outpatient and up to 14% of
hospitalized children)Other complications:
Lower respiratory tract infections, including laryngotracheobronchitis and
bacterial pneumonia (streptococcus or staphylococcus aureus)
Neurologic (aseptic meningitis, Guillain-Barré syndrome, and febrile
Myositis and myocarditis (rare)
Obesity in children epidemilogy: in last 20 years number of children who are obese has? adolescent?
Approximately 15% of children and adolescents aged 6-19 years are
In the last 20 years, the number of children who are obese has doubled and
the number of adolescents who are obese has tripled.
obesity in children complications (1) risk factors? (2) strongest risk factor?(3) risk factor? (4) (5 more)
1. Type II diabetes: Has become more common among 6-19 year olds (comprises 8-45% of all
new cases of diabetes).
The prevalence of diabetes mellitus in persons < 20 years old is about 1 in
Risk factors for diabetes in children include BMI ≥ 85%, an increased fasting
glucose level of ≥ 100 mg/dL, and an elevated fasting insulin level.
2.High cholesterol
10% of children 2-19 years of age have high cholesterol. This is higher
than it was previously.
The strongest risk factor for elevated cholesterol is elevated BMI.
3. Hypertension
Incidence in children has increased from 1-3% to currently up to 5-11% of
The strongest risk factor for hypertension in children is obesity.
Hypertension in children can lead to hypertension in adults and put them at
risk for cardiovascular complications.
4. Metabolic syndrome
Adults with at least 3 of the following:
Low high-density lipoprotein (HDL)
Elevated fasting blood glucose levels
Excessive waist circumference
Affects 20% of adults ages 20-40 and 40% of adults > 40 years of age
Increased risk for cardiovascular disease and diabetes
If we apply the diagnostic criteria to children, substituting elevated BMI for
waist circumference, we have started to see increased rates in adolescents.
Meeting criteria for metabolic syndrome and facing increased health risks
7% of overweight adolescents
29% of obese adolescents
50% of severely obese adolescents
Smoking also increases risk of metabolic syndrome.
5. Musculoskeletal disorders
Blount's disease
Slipped femoral epiphysis
Gastrointestinal disorders
Gallbladder disease
Early menarche
Polycystic ovary syndrome
Acanthosis nigricans
6. Psychosocial
Low self-esteem
Obstructive sleep apnea
Pseudotumor cerebri
Body Mass Index (BMI):
BMI is calculated by weight (kg)/height (cm)/height (cm) x 10,000. kg/m2
For children and teens, use the BMI for Age Percentiles chart to determine
percentile for age.
Children (BMI for age); Adult (BMI in kg/m2): healthy? overweight? obese?
Healthy Weight 5-85%-ile 18.5-24.9
Overweight 85-95%-ile 25-29.9
Obese ≥95%-ile ≥30
Differential diagnosis upper respiratory sx: influenza: characterized by? typically occurs when? 2_pneumonia: cardinal features?
1. Influenza: Characterized by upper and lower respiratory tract symptoms
accompanied by systemic symptoms such as severe myalgias, high fever
(102-104 degrees F) and chills, headache, and weakness.
Fever > 39 degrees C is often the first sign in younger children.
Older children can have a constellation of systemic symptoms, which
may present prior to the upper respiratory symptom of cough.
Very young children can present with febrile seizures.
Abrupt onset: Patients can often report the precise time of onset.
Typically occurs in outbreaks during the winter months.
Pneumonia (typical, atypical, or viral)
Crackles (also known as rales) are a cardinal feature of pneumonia but not all children with pneumonia have crackles.
Focal crackles in a febrile child without underlying lung disease
is pneumonia until proven otherwise.
Fine crackles at mid-inspiration indicate acute pneumonia.
Coarse late-inspiratory crackles indicate resolving pneumonia.
Other findings suggestive of pneumonia:
Respiratory distress or tachypnea
Focal wheezing or whistling
Decreased breath sounds in one field
pneumonia: etiology? onset of sx? age? sx? lung finding? 50% have?
Etiology: strep pneumonia
Onset of prodromal sx: Often an
abrupt onset
No prodromal
symptoms such
as rhinorrhea
or myalgias
Age: Young children and
older adults (rare in
Symptoms: Pleuritic chest pain
Chills, Dyspnea
Temperature > 38
degrees C (100.4 F)
Cough usually
present but not
findings: Pan-inspiratory
50% of patients
have a pleural
Atypical pneumonia: etiology? onset and prodromal sx? age? sx? lung finding? CXR?
Etiology: Mycoplasma or
Onset and
symptoms: Headache
Age: Young adults and
Symptoms: In addition
to other
may have constitutional
such as:
abdominal pain
findings: Late
on CXR
pneumonia: etiology? (5) age? sx? lung findings?
Etiology: Influenza
Onset and
symptoms: Prodromal
Age: Younger children
4 months to
5 years
Symptoms: Chills
of extrapulmonary
findings: Crackles
Acute bronchitis: definition? etiology? lungexam?
Self-limited inflammation of the large airways in the lung,
characterized by cough persisting > 5 days
Leads to excessive tracheobronchial mucus production sufficient to
cause purulent sputum in 50% of patients.
Usually viral etiology
Symptoms in the first few days hard to distinguish from an upper
respiratory infection
Lung exam may be normal or include rhonchi or scattered wheezes.
McIsaac score: what is it? original criteria(4) rule modifier?treatment decsions?
Indicates whether to evaluate for Group A beta-hemolytic
streptococcal pharyngitis with a strep antigen test (rapid strep) or culture.
Original criteria
Fever > 38 Celsius (+1 point)
Cough absent (+1 point)
Tonsillar exudates (+1 point)
Tender, anterior cervical
adenopathy (+1 point)
McIsaac rule modifiers
Age < 15 years (+1 point)
Age 15-45 years (0 points)
Age > 45 years (-1 point)
Treatment decisions
Total ≤1 point: Symptomatic
Total = 2-3 points: Order a
rapid strep antigen test
Total ≥ 4 points: Order throat
culture or start empiric
Rapid influenza testing: (read)
More predictive of the diagnosis when there is an increased prevalence of
the disease.
Can produce both false positive and false negative results.
If a result is positive, the test being used has a high specificity, and the rate
of influenza in the community is moderate, then it will accurately predict
disease about 90% of the time.
Chest x-ray: when to do?
In the setting of community-acquired pneumonia, chest x-ray is only
warranted if the patient is hypoxic or isn't responding to treatment.
All children admitted to the hospital for pneumonia should have a PA and
lateral chest x-ray.
Influenza: drugs? antiviral use? fever lasts? cough and tiredness? followup?
Antivirals: Zanamivir, oseltamivir, amantadine, and rimantadine can
decrease the duration of influenza symptoms by approximately 24 hours,
but they are recommended only when given within the first 48 hours of
illness. The only situation appropriate for starting antivirals after 48 hours of
onset of illness are if the child has moderate to severe community-acquired
pneumonia with findings consistent with influenza or if they are clinically
worsening at the time of the initial outpatient visit.
Supportive treatment:
Cough syrup or tea with honey and lemon juice for cough
Ibuprofen for myalgias and fever
Add acetaminophen if ibuprofen does not bring fever down
Encourage fluids and rest
Fever lasts 3-5 days. Cough and tiredness can last 2 weeks.
Immediate follow-up if no improvement in a few days, difficulty
breathing, cough worsens or lack of hydration. Otherwise, follow-up in
1 week.
To prevent transmission: Cover mouth and nose with cough and
sneeze, and wash hands often.
May immunize contacts at greater risk of having complications.
Bronchitis mngt? beta 2 agonists? pneumonia rx? (2)
90% of acute bronchitis is nonbacterial, and antibiotics are not indicated.
Treatment is supportive as above.
Beta-2 agonist therapy is recommended for patients who are wheezing, but
not for those who are coughing only.
For children 1. three months to adolescence, the first-line treatment for
uncomplicated pneumonia is amoxicillin because it covers streptococcal
pneumonia infections, which are most common in this age group.
(Amoxicillin is given 90 mg/kg/day divided in 3 dosages for 7-10 days.)
For school-aged children with symptoms more concerning for atypical
pneumonia, use a macrolide such as azithromycin (*Azithromycin is given 10
mg/kg on day 1 followed by 5 mg/kg on days 2-5.*)
Erythromycin and clarithromycin may be used in children as well, but
because azithromycin has fewer gastrointestinal side effects and is easier to
administer, it tends to be prescribed more often.
Bronchitis: infant less than 3 weeks? etiology? rx? Admit if? rx? 3 monts to 5 years: admit if? rx?
Age? When to admit? Most common pathogen? Treatment?
Infants <3 weeks: Admit all infants; E. coli,Group B
streptococci, Listeriamonocytogenes
-Ampicillin and
3 weeks to 6 months:
Admit if suspect
Influenza virus
cefotaxime or
3 monthsto 5 years
Admit if: Breathing > 70 breaths per minute,
Hypoxemic,Having difficulty breathing,Intermittent
apnea, Grunting, Poor feeding
Family unable
to attend to the
infant's care
Virulent pathogen (e.g.
Influenza virus
children or
infants ampicillin
or penicillin G. If
local resistance
or child isn't fully
immunized, use
ceftriaxone for
7-10 days.
Amoxicillin for
7-10 days
5 years
Breathing > 50
breaths per
If they appear
to be in
Family unable
to attend to
child's care
Strep pneumonia
IV antibiotic (e.g.,
ampicillin or penicillin
G. If area of high
ceftriaxone) until
child is afebrile, then
oral antibiotics to
complete treatment
Obesity mngt: general recommendation of weight loss? children less than 7 with BMI>95&% and no secondary complications? complications? children greater than 7 wth BMI 85-95%ile?
Use motivating terminology with patients such as "unhealthy weight" or
"weight problem"; not stigmatizing terminology such as "fat", "obese", or
"extremely obese".
Advise that the whole family change their habits (5-2-1-0 plan).
5 fruit and vegetable servings a day
2 hours or less of television viewing per day
1 hour of physical activity per day
0 sugary drinks in the house
Other suggestions include: Low-fat (≤ 1%) dairy products; snacks are
okay in moderation; twice-weekly family walks or physical activity
Weight loss
Set reasonable goals. The general recommendation is about 1 pound
per month.
Children < 7 years old who have a BMI ≥ 95%-ile and have no
secondary complications should attempt to maintain their weight.
Those who have complications should pursue weight loss until their
BMI is ≤ 85%-ile .
In children > 7 years old with a BMI between 85%-ile and 95%-ile,
weight loss is recommended to achieve a BMI ≤ 85%-ile.
Specific rx mngt: (5-2-1-0 counseling? )
Stage Treatment specifics
1. Prevention Plus
- starting place for all children
and adolescents who are
overweight and obese
(5-2-1-0) couseling
5 servings of fruit and
2 hours of screen time
1 hour of physical activity
0 sugar-sweetened beverages
2. Structured Weight
- next step for all children with
BMI >85-94 percentile
Above plus:
Reduce energy-dense foods
Structured meals
1 hour of screen time
Diet and activity monitoring for
3-6 months
Monthly office visits
Additional support by dietician,
counselor, or exercise therapist
as needed
3. Comprehensive
Multidisciplinary Intervention
-next step for children 2-5 >95
percentile or ages 6-8 95-99
Above plus referral to
multidisciplinary obesity care team
and behavior modification
4. Tertiary Care Intervention
- for ages 6-18; final step
Above plus referral to pediatric
tertiary weight management center
Screening for obesity complications: diabetes screening: who? how often?
Researchers recommend diabetes screening for all 10-year-olds with:
BMI >85%-ile and risk factors for diabetes
BMI >95%-ile without risk factors
Re-check every two years
Hyperlipidemia mngt: check on who? cholesterol goal? LDL goeal? Drug treatment for children older than 10 who are either Tanner Stage 2
(male) or post-menarche and:
Check fasting lipid profile on every child with BMI >85%-ile
Children with a family history of high cholesterol or who are overweight or
obese should have their cholesterol checked.
Goal total cholesterol is < 170 mg/dl; low-density lipoprotein level (LDL)
should be < 130 mg/dl.
nitial treatment: diet and exercise.
Drug treatment for children older than 10 who are either Tanner Stage 2
(male) or post-menarche and:
LDL >190 mg/dl
LDL >160 mg/dl with risk factors
Steatosis (fatty liver) mngt: who? when? when to refer to GI?
AST/ALT at age 10 if BMI >95%-ile, or if >85-94%-ile with risk factors and
every two years thereafter.
Refer to gastroenterology for levels that are twice the upper limit of normal.
Case 22
70-year-old male with new-onset unilateral weakness
- Mr. Wright
Summary of Clinical Scenario 22
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.
Atrial fibrillation (AF): definitions? presentation? prevalence? new onset? persistent? paroxysmal? with rapid ventricular resonse? complications?
Rapid, irregular, and chaotic atrial activity without definable p waves on
Dizziness, syncope, dyspnea, or palpitations.
Requires confirmation with electrocardiogram.
Most common arrhythmia, accounts for about one-third of hospitalizations
for arrhythmia
Increases with age and severity of congestive heart failure or valvular heart

New onset: if less than 72 hours total duration
Persistent: AF consistently present.
Paroxysmal: Episodic AF, with variable periods of normal sinus rhythm
between episodes. Ambulatory electrocardiogram monitoring may be
required to detect this.
With rapid ventricular response: physiologic or non-physiologic
(electrical) ventricular tachycardia in the presence of AF.
Hemodynamic instability, functional impairment, heart failure and ischemia
TIA (transient ischemic attack): definitions? clinical sx last? imaging? stroke? risk facotrs?
TIA Stroke
Brief episode of
dysfunction caused
by focal brain or
retinal ischemia
Clinical symptoms
typically lasting less
than one hour
No evidence of acute
brain infarction
A focal (or at times global)
neurological impairment of
sudden onset, and lasting
more than 24 hours (or
leading to death), and of
presumed vascular origin
Risk factors

Screening for cerebrovascular disease risk factors: (2) Asprin use?
The U.S. Preventive
Services Task Force recommends the following:
Screen all adults > 18 yrs for hypertension
Screen adults > 20 yrs for hyperlipidemia if at increased risk for CAD (i.e.,
diabetic, hypertensive, premature personal history of atherosclerosis or
family history of CAD in males < 50 yrs or females < 60 yrs)
In addition:
Ask all adults about tobacco use, and give all smokers tobacco cessation
Discuss aspirin chemoprevention with all men > 45 for primary prevention
of myocardial infarction.
Examples of functional impairment: RMCA? brainstem? LMCA?
Right middle cerebral infarct affecting right parietal hemisphere
Left hemiplegia
Spatial and perceptual difficulties resulting in misjudgment of
distances or attempts to read books upside-down
Inattention to people or objects in left visual field
Denial of stroke disability
Brain stem
Impairment of blood pressure, respiratory function, heartbeat, and
Left middle cerebral artery
Expressive and receptive aphasia
Left facial weakness
Post-stroke depression: prevalaence? dysthmia? management?
Prevalence: ~ 1/3 of stroke survivors.
Etiology: Multiple factors, including lesion location, social handicap, and family
Consequences: Impedes rehabilitation progress and is associated with impaired
functional outcome, cognitive decline, and increased mortality
Dysthymia: State of chronic depressed mood present for 2 or more years on most
days of the week
Management: Selective serotonin reuptake inhibitors (SSRIs) are accepted
first-line therapy and have been proven to improve clinical outcomes in sufferers
of post-stroke depression. Selection of a particular SSRI is guided by the potential
for drug-drug interactions and patient tolerance.
To evaluate orthostatic changes in blood pressure: how is it done? what indicates and orthostatic change?
Measure blood pressure and pulse with patient in supine position.
Then have patient sit or stand, wait 3 minutes and repeat measurements of
blood pressure and pulse.
A decrease of at least 20 mmHg in systolic blood pressure or 10 mmHg in diastolic
blood pressure indicates orthostatic change.
Some experts also consider the test to be positive if the pulse rate is increased by
≥ 20 beats per minute (≥ 16 beats per minute in the elderly).
Brain tumor: (read)
Symptoms are variable depending on tumor size and location
Sudden alterations in vision and paresthesias (up to 25% of patients)
Frequent behavioral and cognitive changes (impairment of memory,
decreased concentration, personality changes)
Dizziness and lightheadedness uncommon
May find electrocardiogram changes due to increased intracranial pressure,
but no significant association with cardiac arrhythmia
Impairment of consciousness or obtundation is a late finding (or sign of
acute hemorrhage)
Seizure disorder (idiopathic or due to an identified cause): halmark of seizrure disorder?
May be preceded by dizziness or lightheadedness or aura (aura is a
disturbance of vision, hearing, taste, or smell, or an altered body sensation;
arises from temporal lobe; signals impending seizure onset)
May occur with sudden and extreme elevations of blood pressure associated
with papilledema
Seizure may be followed by a brief period of temporary paralysis (Todd's
paralysis). Partial or complete paralysis is noted on one side of the body.
Speech and vision may also be affected. Average duration of paralysis is 15
hours, but can last from 30 minutes to 36 hours, at which point symptoms
resolve completely.
Amnesia for the event and alteration of consciousness is a hallmark of
seizure disorder.
Stroke and TIA: sx? risk factors? (5) what is the difference between a stroke and TIA?
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
and size
Risk factors:
Uncontrolled hypertension
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)
Risk factors:
Uncontrolled hypertension
Less likely diagnoses neuro changes (read)(4)
Hypoglycemic episode: Severe hypoglycemia may present with sweating,
altered consciousness, loss of coordination, paresthesias and focal neurologic
Temporal arteritis: This may present with amaurosis fugax (transient monocular
loss of vision) and cranial bruits. The incidence peaks in the early seventies, with
women representing 80% of the affected. Patients may present with symptoms
including headache, malaise, and scalp tenderness over the temporal artery,
intermittent jaw claudication, and low-grade fever.
Hypokalemic periodic paralysis: A rare syndrome characterized by episodes of
general or focal weakness. Episodes usually begin in childhood or adolescence.
Paralysis most often occurs during the rest period following—not during—vigorous
physical activity.
Hemiplegic migraine: A rare form of migraine that can present as headache
associated with hemiparesis with sensory deficits and motor weakness. Most
common during childhood and adolescence, with cessation of symptoms by
mid-adult life.
Studies potential stroke (4)
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
Evidence C.)
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.)
Markers for cardiac ischemia:
Important for all patients with suspected
ischemic stroke, as myocardial ischemia is a potential complication of acute
cerebrovascular disease.
Cardiac bio-markers: Troponins and other substances released into the
blood by ischemic or infarcting myocytes
Beta-natriuretic peptide (BNP): B-type (or brain) natriuretic peptide is a
32-amino-acid polypeptide secreted by the cardiac ventricles in response to
ventricular volume expansion and pressure overload. Levels are elevated in
patients with left ventricular dysfunction and correlate with severity of
symptoms and prognosis.
Atrial fibrillation (AF):
Intravenous diltiazem, intravenous beta-blockers or verapamil to slow heart
Cardioversion via electrical shock or medications (risk of stroke is greatest
in patients in AF > 48 hours, or who have not been given 3 weeks of anticoagulant therapy before shock)
Mngt stroke: complete evalutation and treatment plan within how long of arrival? if sx less than ___? Secondary prevention: non-cardioembolic event? for cardioembolic events? caratoid endorectomy?
Time is crucial.
Initial evaluationand treatment:
Triage patients with suspected stroke, regardless of severity of deficits
Complete evaluation and treatment plan within 60 minutes of patient's
arrival in the emergency department
If symptoms < 3 hours prior, preferentially route to a certified stroke center
Assess neurological deficits and possible co-morbidities:
The National Institutes of Health Stroke Scale (NIHSS) is awidely used
clinical assessment tool to help evaluate acuity of stroke patients, determine
appropriate treatment, and predict patient outcome.
*Evaluate for use of intravenous recombinant tissue plasminogen activator
Administration of rt-PA within 3 hours salvages hypoxic brain tissue.*
Emergency CT scan to look for:
Intracranial hemorrhage (contraindication for rtPA)
Nonvascular etiology of symptoms (e.g., brain tumor)
Early signs of infarction (correlated with a higher risk of hemorrhagic
transformation after treatment with thrombolytic agents)
While desirable to know the results of hematologic, coagulation, and
biochemistry tests before giving rtPA, thrombolytic therapy should not be
delayed while awaiting the results unless:
Clinical suspicion of a bleeding abnormality or thrombocytopenia
Patient has received heparin or warfarin
Use of anticoagulants is not known
Secondary prevention:
Antithrombotic therapy
For non-cardioembolic (atherothrombotic, lacunar) stroke or TIA:
Daily antiplatelet therapy:
Aspirin in combination with extended- release dipyridamole
(Aggrenox) reduces thrombotic stroke risk by 37% (compared to 18%
for aspirin alone).
Ticlopidine (Ticlid)
Marginally better than aspirin alone
Significant common side effects
Use in aspirin-sensitive patients*
Safety profile similar to aspirin
*Exceeds benefit of aspirin in stroke patients with co-morbid diabetes
and prior myocardial infarction*
For cardioembolic events:
*Warfarin (Coumadin) for long-term oral anticoagulation therapy
Goal = International normalized ratio (INR) of 2.5 (range 2.0-3.0)
Aspirin may be used if anticoagulation is contraindicated or unacceptable.*
Carotid endarterectomy or carotid artery balloon angioplasty and stenting is
recommended for patients with symptomatic carotid stenosis
Treatable risk factors: hypercholesterolemia: target goal? HTN? others?
Statin agents. Target goal:
LDL-C <100 mg/dL for those with CAD or symptomatic atherosclerotic
LDL-C <70 mg/dL for very-high-risk persons with multiple risk factors
Initiate therapy after the hyperacute period
Diuretics alone or with an angiotensin converting enzyme (ACE) inhibitor
Choice of specific drugs and targets should be individualized on the basis of
reviewed data as well as specific patient characteristics
Modifiable risk factors
Smoking cessation: Strongly encourage
Diet: Fruits, vegetables, and fish, low quantities of cholesterol and saturated
Alcohol: Eliminate or reduce consumption
If capable, at least 30 minutes of moderate-intensity physical exercise
most days
If disabled, a supervised therapeutic exercise regimen
Weight reduction: Goal BMI = 18.5-24.9 kg/m2 and a waist circumference
of < 35 inches for women and < 40 inches for men via appropriate balance
of caloric intake, physical activity, and behavioral counseling
Case 23
5-year-old female with sore throat - Althea Newman
Summary of Clinical Scenario 23
Althea Newman is a generally healthy
5-year-old African American girl with recent exposure to strep throat who now
presents with a four day history of subjective low-grade fever, sore throat, mild
cough, and decreased appetite. After a physical exam is performed and the
differential diagnosis is reviewed, Althea's Centor score is calculated.
Consequently, GABHS rapid testing is indicated and it confirms a diagnosis of
strep pharyngitis. Proper antibiotic treatment is discussed. Althea's immunizations
are also brought up to date. Two weeks later, Althea and her mother return and
all components of a well child check are performed. Additionally, Althea's teacher
requests that she be evaluated for ADHD. After reviewing the diagnostic criteria
for ADHD, the student and preceptor decide Althea does not meet criteria for
diagnosis at this time, but they refer her to a psychologist for further evaluation.
A 5-year-old should be able to?
Dress herself
Name colors
Draw a person with at least 6 body parts
Copy a square and triangle
Hold a pencil correctly when writing
Skip, hop, and stand on one foot
Talk in using complete sentences with correct tenses and pronouns
Have fully understandable speech
Speak in full sentences and paragraphs with correct tenses and pronouns
Most states require the following
vaccines prior to school entrance (5)? Not required for school admission, but
decrease mortality/morbidity (5)?
Hepatitis B (series of 3)
DTaP (series of 5)
Polio (series of 4)
MMR (series of 2)
Varicella (series of 2)
Not required for school admission, but
decrease mortality/morbidity: HiB (series of 4), Pneumococcal vaccine (series of 4), Rotavirus (series of 3), Hepatitis A vaccination (series of 3), Influenza (annually)
Immunization Contraindications? treatment with antimicrobials?
There are almost no absolute contraindications to immunizations.
Some conditions have cautions or contraindications for specific vaccines.
Allergy or sensitivity to a specific vaccine is a contraindication for only
that specific vaccine.
Immunodeficient states (either in the patient or in a household
member) such as HIV infection or chemotherapy are contraindications
for certain vaccines.
Vaccines should be postponed when patients have moderate to severe
illness, including fever, otitis, diarrhea, and vomiting. Patients with a mild
illness, with or without fever, should go ahead and get their vaccines.
Treatment with antimicrobials will not interfere with vaccines.
Lab screening
Selective screening for anemia (2), lead, or tuberculosis is based on risk factors (5):
Anemia risk factors:
Low-iron diet
Environmental factors (poverty, limited access to food)
Special health needs
Lead toxicity risk factors:
Does child live in or regularly visit a house or child care facility built
before 1950?
Does child live in or regularly visit a house or child care facility built
before 1978 that is being or has been remodeled recently (within past
6 months?)
Does child have a sibling or playmate with lead poisoning?
Tuberculosis (TB) risk factors:
Exposure to a family member or contact with TB
Family member with a positive tuberculin skin test
Birth in a high-risk country (i.e., countries other than U.S., Canada,
Australia, New Zealand, or those of Western Europe)
Travel to high-risk country
Children with HIV
Incarcerated adolescents
Attention Deficit Hyperactivity Disorder (ADHD): age? dx critereia(3)
Diagnosis usually not made until child > 6 years old
Symptoms must be:
More frequent or severe compared to other children the same age
Present in at least two settings, such as home and school
Present for at least six months
Childhood overweight and obesity (read0
Prevalence: More than doubled in the past 25 years
Health risks: Risk factors for heart disease (high cholesterol and high blood
pressure) occur with increased frequency in overweight children and
Medical conditions: Type 2 diabetes, closely linked to overweight and
obesity, has increased dramatically in children and adolescents.
Increased adult obesity: Overweight adolescents have a 70% chance of
becoming overweight or obese adults. This increases to 80% if one or more
parent is overweight or obese.
Effects on morbidity and mortality: Overweight or obese adults are at risk
for a number of health problems including heart disease, type 2 diabetes,high blood pressure, and some forms of cancer.
Social discrimination: Poor self-esteem and depression
Screening: The American Academy of Pediatrics (AAP) and the American
Academy of Family Physicians (AAFP) endorse universal screening using BMI
and use of BMI growth curves to identify obese and overweight children.
Classifying BMI for children is based on the percentile score (obtained from
a table or chart based on the child's BMI and age), not the raw BMI, as
BMI chart adult vs cildren: healthy? overweight? obese?
(BMI kg/m2)
(BMI% for Age)
Healthy weight 18.5-24.9 5-85%
Overweight 25-29.9 85-95%
Obese ≥ 30 ≥ 95%
DDX sore throat: most common cause of sore throat? mononucleosis: etiology (2) presentation (5)? what is common and specific for mono? suspicion arrises when? misdiagnoss? GABHS: sx? (6) scarlet fever? complications? peritonsillar abscess presents as?
1. Viral pharyngitis
Most common cause of a sore throat, often the first symptom of a viral
upper respiratory infection
Throat irritation
Non-descript rash
Rhinorrhea and/or cough
2. Mononucleosis
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,
maculopapular rash.
3. Group A Beta-hemolytic streptococcal (GABHS) pharyngitis
High fever
Anterior cervical lymphadenopathy
Tonsillar exudates
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,
post-streptococcal glomerulonephritis
Suppurative: Peri-tonsillar abscess, bacteremia, endocarditis,
pneumonia, mastoiditis, meningitis, otitis media, and cervical
4. Peri-tonsillar abscess
Difficulty swallowing
Neck or ear pain
Muffled "hot potato" voice
Asymmetric tonsillar enlargement and deviation of the uvula
Less likely diagnoses sore throat: epiglottitis: etiology? age? presents with? pertusus: consider when? croup: presentation? evaluation?
Life-threatening emergency
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
Rapid onset
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.
Viral croup
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.
Allergic rhinitis/pharyngitis
Sore throat, sneezing, itchy and watery eyes, clear rhinorrhea, and
post-nasal drip
No fever
Timing may be seasonal but can be perennial
Centor score/McIaac Rule? Treatment decisions: For patients with >2 points: rapid strep is negative?
Original Criteria
Fever > 38.0 Celsius (+1 point)
Cough absent (+1 point)
Tonsillar exudates (+1 point)
Tender anterior cervical adenopathy (+1 point)
McIsaac Rule
Age < 15 years (+1 point)
Age 15-45 years (0 points)
Age > 45 years (-1 point)
Total ≤1 point: Symptomatic treatment
Total = 2-3 points: Order a rapid strep test
Total ≥ 4 points: Order throat culture or start empiric antibiotics
For patients with > 2 points:
If the rapid strep test is negative, may choose to obtain culture to be
sure that the rapid test is accurate and not a false negative.
For adults, who generally have a lower risk of strep, a follow-up
culture is not considered necessary, while for children and
adolescents, it is generally recommended that a confirmatory strep
culture be done.
GABHS pharyngitis
Antibiotic treatment: abx of choice? if patient is unlikely to finish abx course? if non anaplyactic PCN allergy? If anaphylactic PCN allergy? Are they effective?
Penicillin VK is the antibiotic of choice due to low cost, narrow spectrum of
activity, safety and effectiveness.
Penicillin G IM is an appropriate choice when the patient is unlikely to finish
the entire course of oral antibiotics.
Amoxicillin liquid is often given to children instead of penicillin because it
tastes better. However, penicillin has a narrower spectrum of activity
effective against strep and is less likely to contribute to antimicrobial
antibiotic resistance.
First generation cephalosporins (cephalexin and cefadroxil) are as effective
as penicillins. They also have a broader spectrum of activity than penicillin.
Recommended for patients who have an allergy to penicillin that is not an
immediate-type hypersensitivity.
Macrolides (erythromycin ethlysuccinate or erythromycin estolate) are
reserved for patients with penicillin allergy. Broader spectrum of activity
than penicillin. Azithromycin or clarithromycin may have fewer
gastrointestinal side effects than erythromycin.
Treatment considerations:
The antibiotic usually helps patients feel better only one day sooner than
they would otherwise. The most important part of the antibiotic treatment is
the prevention of complications.
Patient should stay home from school or child care until she has had 24 hours of antibiotics.
Case 24
4-week-old female with fussiness - Amelia Arlington
Summary of Clinical Scenario 24
Amelia Arlington is a four-week-old female
infant who has been very fussy late in the day for the last week to ten days; she
screams for two or three hours at a time, drawing her legs up. Review of systems
is negative and physical exam is unremarkable, although she has gained one
pound in the past two weeks. After the differential diagnosis is reviewed, it is
determined that Amelia has colic and the treatment is discussed.
In the process of evaluating Amelia, it becomes apparent that her mother may be
suffering from postpartum depression. Screening is performed and interpreted,
and follow-up care is established.
Apgar score: consists of? critically low? fairly low? generally normal? evaluate ate?
Rate each category (0-2) then sum the values.
< 3 Critically low
4 - 6 Fairly low
7 - 10 Generally normal
*Evaluate Appearance at 1 and 5 minutes postpartum.
Expected neonatal birth weight loss? should gain back by? when does milk production begine?
Normal infants lose up to 10% of their birth weight in the first several days
after delivery. By 2 weeks of age, infants should return to birth weight.
Significant volume of milk production typically begins around 48 -72 hours
following delivery, but some women (particularly those lactating for the first
time) might not establish a full milk supply until several days following
Infants are well designed to tolerate this delay in milk production.
Colostrum, the most concentrated human milk, is present from the time of
delivery on, and this helps tide neonates until the milk supply is established.
Developmental milestones (4 weeks old): (read)
More alert and responsive.
Bring their hands within range of their eyes and mouth.
Jerky body movements smooth out.
Listen when you talk to them.
Focus on you from a distance of 8-12 inches.
Respond to their mother or caregiver.
Move their head from side to side when lying on their stomach.
Head flops back if unsupported.
Keep their hands in tight fists.
Eyes continue to wander, and perhaps cross, but less often than in the
immediate newborn period.
Preference for the human face.
Show recognition for some sounds (e.g. mother's voice even if she is not
within their view range) and may turn toward familiar sounds or voices.
Importance of fussiness: 2 weeks? 6 weeks? 3 months?
Age of infang Typically cry
2 weeks 2 hours / day
6 weeks 3 hours / day
3 months 1 hour / day
Fever in infant under 2 months of age:
Potentially very serious sign of life threatening infection.
Thorough laboratory evaluation and cultures of blood, CSF, and urine.
Admit to the hospital for observation and possibly antibiotics.
Postpartum depression: affects what % of women? how is it done?
Postpartum depression affects 22% of women in the 12-month period
following childbirth.

PHQ -2 (Patient Health Questionnaire -2 questions): The shortest and most readily utilized rapid screen for depression validated to have a sensitivity of 96%
and a specificity range from 57-78%.
During the past two weeks, have you often been bothered by feeling down,
depressed, or hopeless?
During the past two weeks, have you often been bothered by having little
interest or pleasure in doing things?
If the additional question, "Is this something you would like help with?" is added,
the specificity increases to 94%. This data applies to general adult screening.
If the PHQ-2 answers are both positive, follow-up with the PHQ-9.
PHQ-9 (Personal Health Questionnaire Depression Scale): Over the last 2 weeks,
how often have you been bothered by any of the following problems? Response scales are as follows:
3 = nearly everyday
2 = more than half the days
1 = several days
0 = not at all
Interpretation: >15 major depression; >20 severe major depression.
Rooting reflex: what is it? when is it present? when does it disappear?
Stroke a newborn's cheek; he will turn his head toward the stimulus.
Present at birth and assists in breastfeeding.
Disappears around four months of age.
Colic: incidence? definition? age?
Incidence: 20-25% of all infant children; common in the first 2-12 weeks of
Wessel definition: unexplained paroxysmal bouts of fussing and crying that
lasts at least three hours a day, at least three times a week, for longer than
three weeks.
Symptoms: begin around the age of two weeks, peak at about six weeks,
and gradually improve over the next several weeks, with most infants
symptom-free by twelve weeks of life.
Pyloric stenosis:m vs f? presentation? dx? rx?
Most common cause of nonbilious vomiting in infants.
Incidence: 1-3/1,000 infants in the US.
Male:female ratio is 4:1. Genetic predisposition occurs in 20% of males and
10% of females whose mother had the condition.
Etiology: unknown.
Presents after three weeks of age and up to five months. It may present as
early as the first week of life. Vomiting may be projectile.
Diagnosis: palpation of a firm, mobile, 2 centimeter long, olive-shaped
pyloric mass located above and to the right of the umbilicus in the
mid-epigastrium beneath the liver edge, present in about 70% of cases.
Ultrasound is 95% sensitive for diagnosis and used when presentation
suggests the diagnosis, but a mass is not palpated.
Treatment: surgical.
Intussusception: what is it? feature? m vs f? presents at?
A portion of the alimentary tract is telescoped into an adjacent segment,
most often ileocolic.
Most common cause of intestinal obstruction in infants (3 months - 6
> 80% before the age of 24 months; rare in neonates.
Male to female ratio is 4:1.
Incidence is 1-4/1,000 live births.
Sudden onset of severe, paroxysmal, colicky pain, recurring at frequent
intervals, progressive lethargy, weakness, fever, and shock if not diagnosed
and treated. Current jelly stools/
Allergy to breastmilk: overall?
Extremely rare.
Prolonged irritability and failure to gain weight.
Rarely, the exclusion of milk products from the diet of the breastfeeding
mother may improve colic- like symptoms, but studies do not support doing
Gastroesophageal reflux: prevalence? prognosiss? when is hospitalization required?
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
with fussiness.
Infants < 2 months of age with documented fever above 101 degrees
Fahrenheit (38 degrees Celsius) require, in most cases, full sepsis work up
and evaluation.
Colic: food? medications?
Food: breast milk is by far the most readily digestible, efficient, and healthy food
for the baby. Many studies of babies with colic over many years have proven that,
in general, switching formulas, or going from breast milk to formula does not help
except in certain rare conditions.
Medications: lots of products like simethicone (Mylicon), which eliminates gas,
and dicyclomine (Bentyl), which slows down the activity of the gut have been
studied, but have never been proven to work or be safe enough.
Case 25
38-year-old male with shoulder pain - Mr. Chen
Summary of Clinical Scenario 25:
Mr. Chen, a 38-year-old male with past medical
history significant for prehypertension has recently taken up softball and presents
with three to five weeks of right shoulder pain when throwing overhead. He
cannot pinpoint a specific mechanism of injury and he denies any associated
symptoms. Thorough physical examination and considered differential diagnosis
lead to the conclusion that he has right rotator tendonopathy with mild right shoulder instability. He is counseled to give his shoulder relative rest, physical
therapy, and pain control.
Anatomic stabilizers of the shoulder joint: (3)
Glenohumeral ligaments
Rotator muscle group: supraspinatus, infraspinatus, teres minor, subscapularis?
Supraspinatus: inserts? function? Infrapinatus: inserts? functions? Teres minor:inerts? function? Subscapularis? function?
Muscle Origin Insertion Function
Supraspinatus: .Greater tuberosity of the humerus
Assists with abduction of the shoulder.
Infraspinatus: Greater tuberosity.Assists with
external rotation ofthe shoulder.
Teres Minor: Greater tuberosity. Assists the infraspinatous in external rotation ofthe shoulder.
Subscapularis: Inserts: Lesser tuberosity of the humerus
Assists with
internal rotation of
the shoulder.
Musculoskeletal causes of shoulder pain requiring urgent management? Etiology? DX? RX?
Septic glenohumeral arthritis or septic subacromial bursitis

Etiology: gram-positive organisms, primarily staph (including methicillinresistant
staph aureus—MRSA) and to a lesser extent strep species.

Urgent evaluation with ultrasound or MRI and consultation with orthopedic physician.
Aspiration and culture of related fluid.
Treatment of confirmed septic arthritis or bursitis entails surgical drainage
and tailored antibiotic therapy
Musculoskeletal causes of shoulder pain that restrict passive range of
motion (ROM): loss of active and passive ROM? los of only active ROM? Adhesive capsulitis: wha tis it/ mor common in? glenohumeral arthritis? biceps pathology does not limit?
Loss of active and passive ROM is more likely due to joint disease;
whereas loss of only active ROM is more likely due to muscle tissue
Adhesive capsulitis: Contracture of the joint capsule. More common in
diabetics and in patients with decreased movement of the shoulder
(following an injury or stroke).
Glenohumeral arthritis: Much less common site of osteoarthritis than the hip
and the knee.
Biceps pathology does not limit passive ROM.
Tinea pedis ("athlete's foot"): etiology? physical finding? dx? treatment?
Etiology: Dermatophyte infection. The most common of the superficial
tinea/fungal infections.

Physical findings: Dry, red skin with occasional cracks.
Diagnosis: Often clinical, but can be aided with scrapings from the affected
area examined under magnification after treatment with potassium
Treatment: tolnaftate (Tinactin) twice a day.
Findings on visual inspection- May indicate: Patient carrying the arm in an adducted
and internally rotated position? Poor posture or "rounded shoulders"? Boney deformity in the area of theclavicle or acromioclavicular (AC) joint:?A fullness of the anterior shoulder with a
large dimple in the posterior shoulder? Atrophy of larger shoulder muscles like
deltoid or pectoralis major? Atrophy of smaller shoulder muscles like
supraspinatous or infraspinatous:
Patient carrying the arm in an adducted
and internally rotated position:
Posterior dislocation
Poor posture or "rounded shoulders": Impingement syndrome
Boney deformity in the area of the
clavicle or acromioclavicular (AC) joint:
Fractured clavicle or
sprain of the AC joint
A fullness of the anterior shoulder with a
large dimple in the posterior shoulder:Anterior dislocation
Atrophy of larger shoulder muscles like
deltoid or pectoralis major: Immobilization or lack of
use of the joint
Atrophy of smaller shoulder muscles like
supraspinatous or infraspinatous:
Torn rotator cuff or nerve
Apley Scratch Test: how is it done? some pain/decreased ROM? unable to raise arm above head?significant pain/decreased ROM?
Action 1: The subject is instructed to touch the opposite shoulder with his/her hand. This motion checks Glenohumeral adduction, internal rotation, horizontal adduction and scapular protraction.
Action 2: The subject is instructed to place his/her arm overhead and reach behind the neck to touch his/her upper back. This motion checks Glenohumeral abduction, external rotation and scapular upward rotation and elevation.
Action 3: The subject puts his/her hand on the lower back and reaches upward as far as possible. This motion checks glenohumeral adduction, internal rotation and scapular retraction with downward rotation
Some pain/ decreased
ROM: rotator cuff
Unable to raise arm
above head: rotator cuff
pain/decreased ROM:
Empty Can
Test: maneuver? Positive result? Assess pathlogy of?
Place the patient's arms
approximately 30-degrees
of horizontal adduction
with the shoulders
abducted to 90-degrees.
The patient attempts to
resist downward
overpressure you apply. A
positive result occurs when
the patient is unable to
resist the force at which
point you are easily able to
push his affected arm
Assess pathology of the
supraspinatous muscle.
Neer Test: how is it done? positive test? indicates?
Place one hand atop the
patient's shoulder. With
the other hand, grasp the
elbow and raise his arm
forward, flexing his
shoulder with his arm
straightened. Move the
arm through a full
180-degree arc of forward
flexion. A positive sign is
pain at the full overhead
Subacromial space
(supraspinatous tendon,
long head of the biceps
muscle, and subacromial
Kennedy: how is it done? what does it test?
Position the patient with
his arm at 90-degrees of
flexion, flex his elbow to
90-degrees, and internally
rotate his shoulder.
Supraspinatous tendon
Translate: howis it done? minimal movement? head sublex?
Stabilize the patient's
shoulder with one hand,
grasping the head of the
humerus with the other
and attempt to anteriorly
and posteriorly translate
his humeral head on the
Minimal movement:
minor instability. Head
sublux out of glenoid:
major instability.
Sulcus Sign: what is done? indicates?
With the patient seated,
apply downward traction
on his arm as it hangs by
his side and watch for an indentation (or Sulcus
sign) to appear just below
the patient's acromion

Inferior glenohumeral
Test: what is done? assess?
Have the patient lie on the
exam table. Abduct and
rotate his arm to
90-degrees and externally
rotate to 90-degrees while
watching for signs of
apprehension or
Anterior glenohumeral
Test: how is it done? positive test/ aesses?
Provide posterior pressure
to the humeral shaft while
in the anterior
apprehension position. A
positive test is a sense of
Anterior glenohumeral
Speed's Test: how is it done? asesse?
Flex the patient's elbow 20
to 30-degrees with the
forearm supinated and the
arm in about 60-degrees of
flexion. Resist forward
flexion of the arm while
palpating the patient's
biceps tendon over the
anterior aspect of the
Biceps tendonitis.
Test: how i it done? assesses?
Flex the patient's elbow to
90-degrees with the thumb
up. Grasp the wrist and
resist attempts by the
patient to actively supinate
the arm and flex the
elbow. Anterior shoulder
pain is a positive finding.
Biceps tendonitis.
Clunk Test: how is it done? positive test? assesses for?
Position the patient supine
and press the head of the
humerus into the glenoid
and labrum, working the
shoulder through a range
of motion from extension
to flexion and external to
internal rotation in the overhead position. Check
for a popping or clicking
sensation arising from the
glenoid labrum.
Labral pathology
O'Brien Test: tests for?
1. Have the patient stand
with hands on his hips.
Place one of your hands
over the shoulder and the
other hand behind the
elbow. Apply anteriorsuperior
force and ask the
patient to push back
against the force.
2. Have the patient hold
his shoulder in 90-degrees
of forward flexion, 30 to
45-degrees of horizontal
adduction, and maximal
internal rotation. Grab the
patient's wrist and resist
his attempt to horizontally
adduct and forward flex
the shoulder.
Anterosuperior shoulder
pain, popping, or clicking
indicates a positive
SLAP lesion; a specific
superior labral tear.
False positive with
pathology or tendinitis.
Differential diagnosis shoulder pain: rotator cuff tendonitis: present with? rotator cuff tear: resents with? subacromial impingement or bursitis: present with? rule out with? shoulder instability indicated by?
Rotator cuff tendonitis: Possible to have preserved ROM and minimal pain
with this diagnosis. Positive Apley's scratch tests indicates this diagnosis.
Shoulder instability may lead this disorder and co-exist with it.
Rotator cuff tear: The difference between rotator cuff tear and tendonitis is
often a matter of degree. Limited ROM with significant pain is a hallmark of
the physical exam in the patient with a partial or complete rotator cuff tear.
In a complete tear, the patient will likely not be able to raise his arm above
his head. Expect significant weakness with strength testing on examination
with rotator cuff tear. Young athletes tend to present with insidious onset of
torn rotator cuff, whereas older people often tear a rotator cuff tendon
suddenly through trauma. After a couple of weeks, atrophy will likely be
Subacromial impingement or bursitis: Cause great pain with overhead
ranges of motion. Ruled out with negative Neer and Hawkins-Kennedy
Shoulder instability: Indicated by positive Sulcus sign and Anterior/Posterior
translation tests.
Labral pathology: Labral tears may occur through repetitive damage from
glenohumeral joint instability or secondary to frank dislocations or other
sudden trauma.
Studies rotator cuff: imaging?
No imaging studies are recommended in the initial evaluation of rotator cuff
X-ray indicated in the setting of acute injury if fracture and/or dislocation
are suspected. In a chronic setting, X-rays are warranted if there is concern
for a "red-flag" diagnosis such as infection or tumor. X-ray findings in the
setting of rotator cuff tendonitis or other pathology like impingement may
be normal or demonstrate calcium deposits in the region of the rotator cuff
attachment to the greater tuberosity of the humerus ("calcific tendonitis").
Rotator cuff tears may be indirectly suggested on plain film radiographs by
the narrowing of the subacromial space. Other areas of interest with plain
film radiographs of the shoulder include the acromioclavicular and
glenohumeral joints to check for degenerative or inflammatory changes.
Magnetic Resonance Imaging (MRI): The most commonly used
advanced imaging study of the shoulder used to evaluate for rotator cuff
and related soft tissue injury. The sensitivity of MRI imaging for rotator cuff
tears is excellent, though it should be noted that a number of older adults
will demonstrate tears of the rotator cuff on MRI imaging in the absence of
significant symptoms or dysfunction.
Computed Tomography (CT) imaging of the shoulder is indicated in the
setting of complicated fracture, suspected tumor, or in situations where MRI
is contraindicated. CT arthrograms are rarely performed on the shoulder,
though may be both diagnostic and therapeutic in the setting of adhesive
capsulitis and can indicate a rotator cuff tear.
Ultrasound imaging is becoming increasingly common in the US, and is
desirable for its lower cost and lack of radiation exposure.
Rotator cuff tendonitis and shoulder instability: (3)
Relative rest can limit further damage while you focus on more active forms
of treatment.
Physical therapy exercises to improve pain-free range of motion of the
shoulder, increase the strength of important stabilizers of the shoulder, and
increase stability of the glenohumeral joint.
Anti-inflammatory pain medication as needed in topical and/or oral form.
Topical nonsteroidal anti-inflammatory drugs (NSAIDs): decreased
systemic side effects and toxicity such as gastric ulcers, hepatic
inflammation, and renal failure.
Avoid NSAIDS if patient potentially pregnant.
Trial of acetaminophen (if no liver disease) 1000 mg, four times daily
as needed and tolerated; or trial of NSAID such as ibuprofen.
Subacromial injection is a viable and often very helpful option to rapidly
decrease pain and inflammation in this area. However, it is best to try the
above mentioned treatments first. A subacromial injection involves a
mixture of local anesthetic such as marcaine and corticosteroid such as
celestone or kenalog. This is a relatively simple injection and is certainly
something a family practitioner can perform in his or her office.