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In-service 2007 General Internal Medicine. A2: Choose the appropriate study to diagnose Strongyloides stercoralis infection Parasite is able to persist.

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Presentation on theme: "In-service 2007 General Internal Medicine. A2: Choose the appropriate study to diagnose Strongyloides stercoralis infection Parasite is able to persist."— Presentation transcript:

1 In-service 2007 General Internal Medicine

2 A2: Choose the appropriate study to diagnose Strongyloides stercoralis infection Parasite is able to persist and replicate within host for decades. Uncommon in U.S., endemic foci in southeastern states and the Appalachia region. Strongyloidiasis is endemic in tropical and subtropical countries. Risks are immunosuppression Lower extremity itch/fever in acute infection

3 A2: Choose the appropriate study to diagnose Strongyloides stercoralis infection Abdominal pain, diarrhea weight loss is chronic infection Eosinophilia common in acute infection can be absent in severe forms Strongyloides serology is 90-95% sensitive for infection; continue stool studies as there is cross reactivity Treat with ivermectin for 14 days for chronic infection Treat with thiabendazole for 14 days for disseminated infection

4 A7: Treat symptomatic osteoarthritis even when Pagets disease of the bone is inactive OA involves the entire joint organ, including the subchondral bone and synovium Pain is usually the initial and principal source of morbidity in OA DIP and PIP joint involvement resulting in Heberden's and Bouchard's nodes is more common in women Morning stiffness in the joint usually lasts for less than half an hour Stiffness at times of rest (gelling) may develop

5 A7: Treat symptomatic osteoarthritis even when Pagets disease of the bone is inactive Diagnosis usually can be made on clinical grounds. The initial goal is to differentiate OA from other arthritides (eg, rheumatoid arthritis [RA]). Secondary OA must be considered in individuals with chondrocalcinosis, joint trauma, metabolic bone disorders, hypermobility syndromes, and neuropathic diseases. Nonpharmacologic interventions are the cornerstones of OA therapy If clinical response to acetaminophen is not satisfactory or if clinical presentation is inflammatory, consider nonsteroidal anti- inflammatory drug (NSAIDs). Contemplate intraarticular injections of glucocorticoids to improve symptoms.

6 A22: Manage an acetaminophen overdose maximum daily dose of APAP is 4 g in adults The antidote for APAP poisoning is N- acetylcysteine most effective when administered within 8 hours of ingestion Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) begin to rise within 24 hours postingestion and peak at about 72 hours. Toxicity is defined as serum AST or ALT levels greater than 1000 IU/L.

7 A22: Manage an acetaminophen overdose antidotal therapy is most effective when initiated within 8 hours postingestion Oral activated charcoal avidly adsorbs acetaminophen and should be administered if the patient presents within 1 hour of ingestion. N-acetylcysteine (Mucomyst, Acetadote), 140 mg/kg loading dose, followed by 70 mg/kg q4h for 17 additional doses (total 1330 mg/kg over 72 h) Transfer patients with fulminant hepatic failure to a facility capable of intensive care monitoring and evaluation for potential transplantation.

8 A27: Diagnose lithium toxicity on the basis of history and clinical presentation Lithium used in tx of bipolar and depression thus already at risk patients of overdose CNS major system affected but other systems can be affected Half life is hours Symptoms of nausea, vomiting, lethargy, confusion, weakness, fatigue, tremor and seizure Severe tremor, muscle fasciculations, choreoathetosis, hyperreflexia, clonus, opisthotonos, stupor, seizures, coma, signs of cardiovascular collapse

9 A27: Diagnose lithium toxicity on the basis of history and clinical presentation Chronic lithium toxicity is frequently associated with depressed ST segments and T wave inversion unassociated with symptoms or significant sequelae. Lithium intoxication may result in dysrhythmias, including complete heart block. Check lithium levels Lavage and charcoal if presenting early In general, consider dialysis in patients with chronic toxicity and serum lithium concentrations higher than 4 mEq/L; also consider dialysis in unstable chronic patients with lithium levels higher than 2.5 mEq/L.

10 A34: manage suspected inflammatory bowel disease in a patient with an anal fissure One half of patients with crohns disease present with perianal disease In UC, a barium enema (BE) may reveal a shortened colon, with loss of haustrations and destruction of the mucosal pattern (ie, lead pipe colon). Skip areas and rectal sparing are noted in CD. BE is contraindicated in patients with moderate- to-severe colitis because it risks perforation or precipitation of a toxic megacolon.

11 A34: manage suspected inflammatory bowel disease in a patient with an anal fissure In CD, areas of segmental narrowing with loss of normal mucosa, fistula formation, and the string sign (a narrow band of barium flowing through an inflamed or scarred area) in the terminal ileum are typically observed. Because of the degree of sensitivity, a colonoscopy is recommended for making the diagnosis and for evaluating the extent and severity of disease. Findings on sigmoidoscopy may be diagnostic in UC because the rectum is always involved. Treat perirectal disease-Sitz baths, soap and water after stooling, surgical drainage of perirectal abscesses, surgical treatment of recurrent fistulas if medical management fails

12 A35: Follow the principles of preconception counseling when advising a patient with type 1 diabetes mellitus about pregnancy Prepregnancy counseling is critical for all women of childbearing potential. optimize glycemic control, if Type 2 diabetic on oral agent, switch to insulin if necessary, provide instruction regarding self-monitoring of blood glucose a nutritional assessment completed which includes an evaluation for nutritional adequacy, make adjustments as needed assess exercise program,

13 A35: Follow the principles of preconception counseling when advising a patient with type 1 diabetes mellitus about pregnancy Laboratory evaluations should include: hemoglobin A1c levels,assessment of renal function – serum creatinine and urinary excretion of total protein and/or albumin, thyroid function tests, lipid profile for Type 2 diabetics and obese women, ECG for those women diagnosed with diabetes for 10 years or more or who have other coronary artery disease risk factors, and Speak about management goals during pregnancy - normal glycemia, the role of self-monitoring of blood glucose (SMBG) and hemoglobin A1c levels, possible maternal and fetal risk complications Follow up visits are crucial

14 A35: Diagnose and manage myoclonus associated with vasovagal syncope Vasovagal syncope has three distinct phases: a prodrome, loss of consciousness, and a postsyncopal phase. A precipitating event or situation (e.g., emotional stress, trauma, pain, sight of blood, prolonged standing) usually is identifiable. The prodrome, characterized by diaphoresis, epigastric discomfort, extreme fatigue, weakness, yawning, nausea, dizziness, and vertigo, results from increased parasympathetic tone and may last seconds to several minutes. Lying down or removing the stimulus may abort the syncopal episode. The postsyncopal phase may last hours or, rarely, days and may include protracted confusion, disorientation, nausea, dizziness, and a general sense of poor health.

15 A35: Diagnose and manage myoclonus associated with vasovagal syncope If associated with prolonged asystole may result in myoclonic jerking and tonic-clonic activity Can be mistaken as generalized seizure Absence of post-ictal period and lack of neurological signs Should prompt a tilt-table exam

16 A36: Manage low back pain Obtain thorough history and physical with attention to red flags If red flags are present consider additional testing/imagining studies or consultation Because acute low back pain typically does not have a serious etiology, and because most cases resolve with conservative treatment, immediate imaging is rarely indicated. In the absence of red flag findings, four to six weeks of conservative care is safe and appropriate, and imaging is not indicated. Nonsteroidal anti-inflammatory drugs, acetaminophen, and skeletal muscle relaxants are effective first-line medications in the treatment of acute, nonspecific low back pain.

17 A36: Manage low back pain Bed rest for more than two or three days in patients with acute low back pain is ineffective and may be harmful. Patients should be instructed to remain active. Diagnostic imaging of the spine has a high rate of abnormal findings in asymptomatic persons. Imaging should be used in carefully selected patients and interpreted with appropriate clinical correlation. Specific back exercises for patients with acute low back pain are not helpful. Spinal manipulative therapy for acute low back pain may offer some short-term benefits but probably is no more effective than usual medical care.

18 A47: Confirm a suspected diagnosis of primary biliary cirrhosis in a patient with pruitus PBC is a chronic and progressive cholestatic disease of the liver Etiology is unknown, although it is presumed to be autoimmune in nature First-degree relatives have a 570- to 1000-fold increased chance of developing this disease most frequently a disease of women and occurs between the fourth and sixth decades of life Of patients with PBC, 25% are incidentally diagnosed during a routine blood evaluation

19 A47: Confirm a suspected diagnosis of primary biliary cirrhosis in a patient with pruitus Fatigue (65%), Pruitis (55%), RUQ pain (8-17%) Elevation of ALT and AST may be identified in most patients with PBC, but significant elevations of the alkaline phosphatase, GGTP, and immunoglobulin (mainly IgM) levels are usually the most prominent findings increased bilirubin level is an ominous sign of disease progression, and liver transplantation must be considered. hallmark of this disease is the presence of antimitochondrial antibodies (AMAs) in the sera The diagnosis of the disease should be established or confirmed by performing a percutaneous or laparoscopic liver biopsy

20 A50: Diagnose domestic abuse on the basis of multiple somatic symptoms Domestic violence may occur in as many as one of every four U.S. families Women rarely volunteer a history of abuse when they see their physicians Domestic violence is associated with various factors that include age; marital status; socioeconomic status Currently abused patients have more physical symptoms; higher levels of depression, anxiety, and somatization; and lower levels of self-esteem. Currently abused patients are also more likely to be abusing alcohol or street drugs, to have attempted suicide, to have visited an emergency department in the 6 months before presentation, and to have had a partner who abused drugs or alcohol.

21 A50: Diagnose domestic abuse on the basis of multiple somatic symptoms In a recent study only 15.7% of patients reported discussing their history of violence with a physician Presence of many specific physical symptoms was associated with an increased risk for current abuse Face, neck, and torso are considered to be frequently involved in abuse Many women experiencing domestic violence have unrecognized and untreated emotional distress Physicians should be especially motivated to inquire about the possibility of current domestic violence when a woman presents with multiple somatic symptoms or emotional distress

22 A52: Diagnose and treat tinea pedis Dermatophyte infection of the soles of the feet and the interdigital spaces Commonly, patients describe pruritic, scaly soles and, often, painful fissures between the toes Less often, patients describe vesicular or ulcerative lesions. Some patients, especially elderly persons, may simply attribute their scaling feet to dry skin Patients with tinea pedis have the following 4 possible clinical presentations: Interdigital, Chronic hyperkeratotic, Inflammatory/vesicular or Ulcerative. Patients may have other associated dermatophyte infections

23 A52: Diagnose and treat tinea pedis Order direct potassium hydroxide (KOH) staining for fungal element A fungal culture may be performed to confirm the diagnosis and to identify the pathogenic species can be treated with topical or oral antifungals or a combination of both Topical agents are used for 1-6 weeks Oral antifungals should be considered in patients with extensive chronic hyperkeratotic or inflammatory/vesicular tinea pedis or with patients in whom topical treatments have failed, patients with diabetes or peripheral vascular disease, and patients with immunocompromising conditions

24 A65: Diagnose angioedema in a patient taking angiotensin-converting enzyme inhibitors Angioedema is a well-recognized side effect of angiotensin- converting enzyme (ACE) inhibitor therapy There are a number of case series in the literature demonstrating that ACE inhibitor-related angioedema is responsible for as many as 40% of angioedema episodes Any area of the body may be involved with angioedema Occurs more commonly in black patients Can be life threatening but more times than not its occurrence can be managed with conservative treatment measures including discontinuation of the medication and/or administration of an antihistamine

25 A65: Diagnose angioedema in a patient taking angiotensin-converting enzyme inhibitors Occasionally, epinephrine and/or steroid therapy may be warranted In a patient having experienced ACE inhibitor- related angioedema, angiotensin receptor blockers should be used cautiously if at all. If ARB therapy is used there should be some justification for the use such as CHF

26 A71: Diagnose chronic venous insufficiency Congenital absence of or damage to venous valves in the superficial and communicating systems can cause CVI Venous incompetence due to thrombi and formation of thrombi favored by the Virchow triad also can cause CVI Clinical manifestations include the following: Varicose veins, leg discomfort, non healing ulcers, leg edema, lipodermatosclerosis Peak incidence occurs in women aged years and in men aged years Surgical treatment is reserved for those with discomfort or ulcers refractory to medical management

27 A71: Diagnose chronic venous insufficiency Workup by checking Doppler bidirectional-flow studies and Doppler color-flow studies are used to assess venous flow, its direction, and the presence of thrombus Medical therapy includes leg elevation, compression stockings, una boots for ulcers, injection sclerotherapy Surgical treatment is reserved for those with discomfort or ulcers refractory to medical management Surgical treatment includes vein ligation, bypass, valvuloplasty Anticoagulation with heparin (or low molecular weight heparin) in the immediate postoperative period and long-term prophylaxis with Coumadin are recommended

28 A 90: Treat a postmenopausal patient with Pap smear findings of atypical squamous cells of undetermined significance 1 in 1,000 women with atypical squamous cells of undetermined significance (ASCUS) already has invasive cervical cancer. HPV-positive ASCUS dramatically raises risk Options for women with ASCUS are immediate colposcopy Accelerated repeat PAP tests HPV testing

29 A 90: Treat a postmenopausal patient with Pap smear findings of atypical squamous cells of undetermined significance Evidence-based review found all 3 options safe and effective Immediate colposcopy: Low predictive value, high anxiety and expense The sensitivity of HPV triage for high-grade CIN is essentially equivalent to colposcopy, and reduces the need for colposcopy by half HPV testing identifies clear risk

30 A106 Diagnose and treat tension headache Episodic tension headache usually is associated with a stressful event. This headache type is of moderate intensity, self-limited, and usually responsive to nonprescription drugs Chronic tension headache often recurs daily and is associated with contracted muscles of the neck and scalp. This type of headache is bilateral and usually occipitofrontal. Tension-type headache is the most common type of chronic recurring head pain.

31 A106 Diagnose and treat tension headache Vital signs and neurological exam should be normal Tenderness may be elicited in the scalp or neck, but no other positive physical exam findings should be noted. Medications used include NSAIDS, analgesics, barbiturates, ASA, ergot alkaloids Various modalities are used in the treatment of tension headaches. These include hot or cold packs, ultrasound, electrical stimulation, improvement of posture, trigger point injections, and occipital nerve blocks. Headache may become chronic if life stressors are not changed.

32 From MKSAP 14 A 109: Interpret results of a study, recognizing that the size of a confidence interval is determined by the sample size (power) Confidence intervals are used to indicate the reliability of an estimate Most studies now provide estimates of event rates in terms of CI This number is a real calculation of events that occurred in a study, indicates that if a study were repeated 100 times, a result within the specified range of values would be expected 95% of the time. When using 95% CI

33 From MKSAP 14 A 109: Interpret results of a study, recognizing that the size of a confidence interval is determined by the sample size (power) This is typically represented by a number, followed by a parenthetical range of two other numbers 4.5 (95% CI, 3.8 to 5.4) This translates to if the result was 4.5 and the study were repeated 100 times, 95% of the results would be between 3.8 and 5.4 Larger studies typically have narrower CIs

34 A119: Predict the finding of osteopenia in a patient with anorexia nervosa Anorexia nervosa in adolescence interferes with peak bone mass acquisition thereby increasing the risk for osteoporosis Osteopenia is a precursor of osteoporosis, and more than 90% of adolescents and young women with anorexia nervosa have reduced BMD at one or more sites Reduction in bone mass can develop after a relatively short duration of illness Bone loss in women with this disorder is multifactorial; in part to estrogen deficiency and to direct effects of undernutrition Degree of osteopenia is more severe than that found in women with hypothalamic amenorrhea who are of normal weight

35 A119: Predict the finding of osteopenia in a patient with anorexia nervosa Osteopenia in anorexia nervosa is persistent and sometimes progressive and is associated with increased long-term risk of fracture Studies have shown no association between calcium or vitamin D intake and BMD Fracture risk doubles with each decrease of 1 SD in BMD Bisphosphonates may be effective in minimizing and reversing bone loss Current weight is the best and most consistent predictor of BMD at several skeletal sites, independent of indices of estrogen deficiency

36 A123: Diagnose Achilles tendinitis induced by fluoroqunolone antibiotics The most common cause of tendinitis is overuse and repetitive motion from recreational, athletic, or occupational activities Tendinitis and tendon rupture are unusual and unexpected side effects of drugs Classic risk factors for spontaneous rupture of tendons include steroid therapy, hypercholesterolemia, gout, rheumatoid arthritis, advanced age, long-term dialysis, and renal transplantation. Since 1983, fluoroquinolones have also been reported to be associated with disruption of tendons Tendon disorders associated with fluoroquinolones have been estimated to occur at a rate of approximately 15 to 20 per 100,000 patients

37 A123: Diagnose Achilles tendinitis induced by fluoroqunolone antibiotics Fluoroquinolone-associated tendinitis most commonly involves the Achilles tendon, but the quadriceps, peroneus brevis, extensor pollicis longus, the long head of the biceps, and rotator cuff tendons have also been reported Tendon rupture occurred in 31% and tendinitis in 69% in one study with 96 cases of Achilles involvement The average time between the start of treatment to the onset of symptoms was 13 days but can be as long as 90 days Rupture may occur after discontinuing the offending medication Animal models shows that fluoroquinolones may produce inflammation of the tendon within 1 day after their administration

38 A130: Manage hypothyroidism in pregnancy Frequent monitoring of thyroid function during pregnancy is essential due to studies showing a decreased intelligence in children born to mothers with increased TSH during pregnancy Increased estrogen levels lead to a doubling of circulating thyroid binding globulin Hypothyroid women cannot increase production of T4 and T3 in response to increased thyroid binding globulin Dose replacement hormone may have to be increased by up to 50% in ¾ of hypothyroid women Following delivery dose requirements generally return to prepregnancy levels

39 From MKSAP 14 A141: Interpret evidence-based terms (number need to treat) NNT represents the effect of treatments on patients, indicates how many patients must receive a treatment to produce one additional improved outcome compared with the control treatment. NNT is calculated from the absolute risk reduction This is the difference in outcome observed between the placebo and the active treatment NNT is calculated by taking the inverse of the ARR of patients who received treatment and those who did not

40 From MKSAP 14 A141: Interpret evidence-based terms (number need to treat) Example: If MI occurred in 10% of patients in a clinical trial who received an experimental medication designed to prevent MI, compared with 20% of patients who received placebo, the RRR would be 0.5 (0.1/0.2), the ARR would be 0.10 ( ), and the NNT would be 10, the inverse of 0.20 minus This mean 10 patients would need to be treated to prevent one MI with the use of the new medication The lower the NNT, the more effective the treatment

41 A 154: Identify a normal physiologic vaginal discharge In reproductive aged women, normal vaginal discharge consists of 1 to 4 mL fluid (per 24 hours), which is white or transparent, thick, and mostly odorless The discharge may become more noticeable at times, as an example during pregnancy, use of estrogen-progestin contraceptives, or at midmenstrual cycle close to the time of ovulation It can be somewhat malodorous and accompanied by irritative symptoms The pH of the normal vaginal secretions is 4.0 to 4.5 The acidic environment is hostile to growth of pathogens and inhibits adherence of bacteria to vaginal epithelial cells

42 A 154: Identify a normal physiologic vaginal discharge Microscopic examination reveals a predominance of squamous cells and rare polymorphonuclear leukocytes (PMNs) The most abundant normal isolates are lactobacillus, which produce hydrogen peroxide and lactic acid thereby maintaining the normally acidic vaginal pH Diphtheroids; and S. epidermidis. Age, phase of the menstrual cycle, sexual activity, contraceptive choice, pregnancy, presence of necrotic tissue or foreign bodies, and use of hygienic products or antibiotics can disrupt the normal ecosystem

43 A157: Diagnose and treat acute herpes genitalis infection Primary genital herpes is characterized by severe and prolonged systemic and local symptoms The symptoms of persons with a first episode of nonprimary HSV-2 infection are less severe and of shorter duration Women's symptoms are more severe, and women have a higher rate of complications than men The incubation period is 3-7 day Constitutional symptoms include fever, headache, malaise, and myalgia (prominent in the first 3-4 d); local symptoms include pain, itching, dysuria, vaginal and urethral discharge, and tender lymphadenopathy

44 A157: Diagnose and treat acute herpes genitalis infection Clinical features in women: Herpetic vesicles appear on the external genitalia, labia majora, labia minora, vaginal vestibule, and introitus. In moist areas, the vesicles rupture, leaving exquisitely tender ulcers Clinical features in men: Herpetic vesicles appear in the glans penis, the prepuce, the shaft of the penis, and sometimes on the scrotum, thighs, and buttocks In men and women, the ulcerative lesions persist from 4-15 days until crusting and reepithelialization occur Multinucleated giant cells and epithelial cells containing eosinophilic intranuclear inclusion bodies distinguish the lesions of herpesviruses Acyclovir and valacyclovir are used for treatment

45 A164: Manage urinary tract infection in a patient on multiple medications In women, asymptomatic bacteriuria should not be treated unless coexisting conditions increase the risk of symptomatic invasive disease In men, asymptomatic bacteriuria should be investigated to exclude complicating factors such as residual urine, calculi, or tumors Antibiotics can interact with multiple medications TMP-SMZ for 3 days is considered the current standard therapy for bacterial cystitis May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; coadministration with sulfonylureas may increase hypoglycemic response to sulfonylureas

46 A164: Manage urinary tract infection in a patient on multiple medications Older people have higher rates of chronic illness and are more likely to be taking multiple medications Polypharmacy increases the risk of adverse drug events such as falls, confusion and functional decline In the elderly patient taking multiple medications, avoid polypharmacy by: monitoring side effects periodically reviewing medication (e.g., is the medication still indicated, is the dosage appropriate) monitoring for interactions

47 B3: Diagnose pityriasis rosea in a patient with pruitic skin lesions PR has often been considered to be a viral exanthem Pityriasis denotes fine scales, and rosea translates as rose colored or pink PR can have a number of clinical variations. Its diagnosis is important because it may resemble secondary syphilis. PR commonly develops in children and young adults, although any age group can be affected. Most patients are aged years. Pruritus is common, usually of mild-to-moderate severity, and it occurs in 75% of patients

48 B3: Diagnose pityriasis rosea in a patient with pruitic skin lesions The herald patch is usually a single pink patch, 2-10 cm in diameter, on the neck or the trunk with a fine collarette scale About 1-2 weeks after the herald patch is seen, the generalized eruption appears One must be careful to rule out syphilis Relief of pruritus is helpful and can be accomplished by using topical steroids, oral antihistamines, topical menthol-phenol lotions, and oatmeal baths High-dose acyclovir (800 mg qid) may help shorten disease, especially if instituted early in the disease course

49 B8: Diagnose chronic fatigue syndrome Chronic fatigue syndrome (CFS) is a disorder of unknown etiology, which probably has an infectious basis Exists without other explanation, for a year or more, and is accompanied by cognitive difficulties Often give a history of an antecedent infection that precipitated the prolonged state of fatigue and followed the initial illness Patients usually are cardiac "A" intensive people from a personality standpoint Patients with CFS may be depressed secondarily because of their inability to perform normal duties at home and at work, but they are not depressive individuals per se

50 B8: Diagnose chronic fatigue syndrome Problems with short-term memory but not long-term memory Should be diagnosed only after other causes of fatigue are excluded and the fatigue has lasted for at least 1 year Usually is easily differentiated from other causes of CFS by the presence of cognitive dysfunction, which is absent in almost all other fatigue-producing disorders The most consistent laboratory abnormality in patients with CFS is an extremely low erythrocyte sedimentation rate (ESR), which approaches zero CFS laboratory abnormalities are not specific, but taken together, the abnormalities provide a pattern of normalities consistent with CFS in those patients who have a cognitive dysfunction, if other diseases with fatigue are excluded

51 B25: Diagnose vitamin C deficiency (scurvy) Scurvy is caused by a dietary deficiency of vitamin C. The body's pool of vitamin C can be depleted in 1-3 months Babies who are fed only cow's milk during the first year of life are at risk Alcoholism and conforming to food fads are risk factors Elderly individuals who eat a tea-and-toast diet are at risk Economically disadvantaged persons tend to not purchase foods high in vitamin C

52 B25: Diagnose vitamin C deficiency (scurvy) Obtaining a plasma or leukocyte vitamin C level can confirm clinical diagnosis Scurvy occurs at levels generally less than 0.1 mg/dL Symptoms occur at levels below 2.5 mg/L, which is considered deficiency Radiography may show any of the following: Subperiosteal elevation Fractures and dislocation Alveolar bone reabsorption Ground-glass appearance of cortex

53 B26: Manage diabetes-associated foot ulcers Among persons diagnosed as having diabetes mellitus, the lifetime risk of developing a foot ulcer is estimated to be 15% The most costly and feared consequence of a foot ulcer is limb amputation, which occurs 10 to 30 times more often in diabetic persons than in the general population Mortality following amputation ranges from 13% to 40% at 1 year, 35% to 65% at 3 years, and 39% to 80% at 5 years Screening allows the clinician to assign the patient to a risk category that dictates both the type and frequency of foot interventions needed This includes reviewing relevant past history, identifying any current foot deformities, and especially assessing for loss of protective sensation with a monofilament

54 B26: Manage diabetes-associated foot ulcers Other helpful screening methods include assessing for peripheral vascular disease by measuring ABIs, ensuring that the patient is wearing appropriate footwear, and checking for high plantar pressure when possible Possibly effective interventions include optimizing glycemic control, smoking cessation, intensive podiatric care, and debridement of calluses The value of prescription footwear for ulcer prevention is unclear In selected cases, evaluation for surgical procedures may be indicated

55 B27: Diagnose Candida albicans infefection The diagnosis usually is made based on physical examination Can appear as thrush, erythematous candidosis, chronic hyperplastic candidosis, chronic multifocal oral candidosis, denture- related stomatitis, angular stomatitis, median rhomboid glossitis and exfoliative chelitis Gram-stained smear (hyphae) or oral rinse may aid in the diagnosis Differentiate erythematous candidosis from other inflammatory stomatitides, lichen planus, and erythroplakia Differentiate pseudomembranous candidosis from lichen planus

56 B27: Diagnose Candida albicans infefection Factors predisposing individuals to oral candidal infections are as follows: Broad-spectrum antimicrobial therapy may predispose individuals to stomatitis or glossitis caused by C albicans. Topical, systemic, and aerosolized corticosteroid use may result in oral yeast infection. Smoking predisposes individuals to chronic atrophic candidosis and other forms of candidosis. Drugs with xerostomic adverse effects (eg, psychopharmaceuticals) are associated with oral candidosis. Xerostomia (as in Sjögren syndrome and after radiotherapy) predisposes individuals to candidosis. Immunologic disorders: Candidosis is common in patients with HIV infection and other secondary immunodeficiencies, including blood dyscrasias, diabetes, and malignant disease. CMC can be a feature of primary immune defects such as severe combined immune deficiency syndrome. Diabetes may predispose individuals to candidosis

57 B28: Recommend appropriate preventive measures for a young adult without recent health care Explain that discussions need to be confidential Screening/counseling on sexually transmitted diseases (STDs), HIV/AIDS, condom use, and birth control Discuss sexual health issues Counsel on importance of diet and exercise Counsel on use and dangers of smoking

58 B28: Recommend appropriate preventive measures for a young adult without recent health care Counsel on use of alcohol and drug use Counsel on dangers of drinking and driving Obtain an accurate family history and determine any risk factors Screen for lipid disorders if there are risk factors present Screen for depression

59 B32: Diagnose and treat depression in an adolescent Major depression affects 3 to 5 percent of children and adolescents The USPSTF concludes the evidence is insufficient to recommend for or against routine screening of children or adolescents for depression Physicians who choose to screen may use the Childrens Depression Inventory (CDI), a reliable and valid self-rating scale for boys and girls seven to 17 years of age Diagnosis of primary depressive mood disorders requires that physicians rule out depression from medical causes, such as endocrinopathies, malignancies, chronic diseases, infectious mononucleosis, anemia, and vitamin deficiency (especially folic acid),10 and from medications, such as isotretinoin (Accutane) Lack of improvement following treatment or medication discontinuation warrants further evaluation and treatment

60 B32: Diagnose and treat depression in an adolescent

61 B:34 Diagnose herpes zoster infection Zoster most commonly manifests in 1 or more posterior spinal ganglia or cranial sensory ganglia This results in pain and characteristic cutaneous findings along the corresponding sensory dermatomes of the involved ganglia Rarely, myelitis, meningitis, encephalitis, or visceral involvement may occur Symptoms typically include prodromal sensory phenomena along 1 or more skin dermatomes lasting 1-10 days (averaging 48 h), which usually are noted as pain or, rarely, paresthesias. Approximately 10% of patients report onset of pain and rash simultaneously

62 B:34 Diagnose herpes zoster infection After the onset of prodromal symptoms, the following signs and symptoms occur: Patchy erythema, occasionally accompanied by induration, appears in the dermatomal area of involvement. Regional lymphadenopathy may appear at this stage or subsequently. The classic finding of grouped herpetiform vesicles develops upon the erythematous base Dissemination occurs in approximately 2% of zoster cases in the general population, but it has been observed in as many as 35% of patients who are hospitalized and/or immunocompromised

63 B38: Diagnose serotonin syndrome caused by drug-drug interactions The serotonin syndrome is a potentially life-threatening adverse drug reaction that results from therapeutic drug use, intentional self- poisoning, or inadvertent interactions between drugs Triad of mental-status changes, autonomic hyperactivity, and neuromuscular abnormalities Tremor and diarrhea in mild cases to delirium, neuromuscular rigidity, and hyperthermia in life-threatening cases The neurologic examination may reveal intermittent tremor or myoclonus, as well as hyperreflexia

64 B38: Diagnose serotonin syndrome caused by drug-drug interactions A number of drugs can cause serotonin syndrome No laboratory tests confirm the diagnosis of the serotonin syndrome Hyperthermia and hypertonicity occur in lifethreatening cases, but muscle rigidity may mask the highly distinguishing findings of clonus and hyperreflexia and therefore cloud the diagnosis

65 B44: Respect patient autonomy in health care decision making Medical care in the United States has rapidly moved away from a paternalistic approach to patients and toward an emphasis on patient autonomy Respect for patient autonomy is one of the cornerstones of contemporary medical ethics, and an important principle for medical practitioners Respect for patient autonomy is not the only significant ethical obligation; preventing harm, acting for the good of the patient and issues of justice (resource allocation) are also important The decision-making process, through which respect for the patient's autonomy may be demonstrated, is complex in general practice Theres duty to respect the patient's rights to self-determination and confidentiality

66 B44: Respect patient autonomy in health care decision making The patient should feel involved in the decision making process If a patient is lucid and has capacity to make their own decisions, then we have to respect the decisions that they make about their own lives As doctors, its our job to make the patient fully aware of the likely outcome of their decision and to treat them the best we can whilst respecting their beliefs, no matter how bizarre they may seem to us Recommendations are offered that promote an intense collaboration between patient and physician so that patients can autonomously make choices that are informed by both the medical facts and the physician's experience

67 B53: Recommend prophylactic therapy for mountain sickness Management of AMS follows three axioms: Further ascent should be avoided until the symptoms have resolved patients with no response to medical treatment should descend to a lower altitude If and when cerebral edema is suspected, patients should urgently descend to a lower altitude Drug treatment for prophylaxis is recommended if rapid ascent is unavoidable. Acetazolamide is the preferred drug Prophylactic aspirin can be used for prevention of headache

68 B63: Confirm a suspected diagnosis of hereditary angioedema Patients with HAE develop recurrent episodes of localized subcutaneous or submucosal edema The angioedema may involve any part of the body, but most frequently affects the skin, upper respiratory tract, oropharynx, and gastrointestinal tract In HAE, an erythematous rash may develop, but unlike urticaria, it is not warm or pruritic laryngeal edema is a common and ominous symptom as it is a major cause of death in these patients due to asphyxiation Swelling of the intestine may cause severe crampy abdominal pain and even vomiting secondary to obstruction

69 B63: Confirm a suspected diagnosis of hereditary angioedema Less common presentations of HAE include migraine and transient ischemic attacks Detailed history and physical examination are the first steps in evaluation of a patient presenting with angioedema Other causes of urticaria and angioedema are physical agents (eg, cold), allergy to food, drugs (eg, ACE inhibitors, NSAIDS), and insect stings; angioedema secondary to serum sickness, blood product reaction, and contrast dyes should also be excluded

70 B67: Confirm a suspected diagnosis of hemolytic anemia in a patient with jaundice Hemolysis presents as acute or chronic anemia, reticulocytosis, or jaundice Intravascular hemolysis is the destruction of red blood cells in the circulation with the release of cell contents into the plasma. The more common extravascular hemolysis is the removal and destruction of red blood cells with membrane alterations by the macrophages of the spleen and liver Anemia most often is discovered through laboratory tests, but the history and physical examination can provide important clues about the presence of hemolysis and its underlying cause Along with anemia, a characteristic laboratory feature of hemolysis is reticulocytosis, the normal response of the bone marrow to the peripheral loss of red blood cells

71 B67: Confirm a suspected diagnosis of hemolytic anemia in a patient with jaundice The anemia of hemolysis usually is normocytic, although a marked reticulocytosis can lead to an elevated measurement of mean corpuscular volume Destruction of red blood cells is characterized by increased unconjugated bilirubin, increased lactate dehydrogenase, and decreased haptoglobin levels Hemoglobinuria, which causes red-brown urine, is indicated by a positive urine dipstick reaction for heme in the absence of red blood cells The direct antiglobulin test (DAT), also known as the direct Coombs' test, demonstrates the presence of antibodies or complement on the surface of red blood cells and is the hallmark of autoimmune hemolysis

72 B67: Confirm a suspected diagnosis of hemolytic anemia in a patient with jaundice Spherocytes (arrows), characterized by a lack of central pallor, occur in both autoimmune hemolytic anemia and hereditary spherocytosis.

73 B69: Manage pharyngitis according to the guidelines This misuse of antibiotics has led to the development of antibiotic-resistant bacteria Symptoms of sore throat, fever, headache Physical findings include fever, tonsillopharyngeal erythema and exudates, palatal petechiae, tender and enlarged anterior cervical lymph nodes, and absence of cough Confirm diagnosis with throat culture or rapid antigen testing before using antibiotics Negative rapid antigen test results may be confirmed with throat culture

74 B69: Manage pharyngitis according to the guidelines Most pharyngitis cases are viral in origin The presence of the following is uncommon with group A streptococcal infection and points away from using antibiotics: conjunctivitis, cough, rhinorrhea, diarrhea, and absence of fever. First-line therapy: Penicillin V (Veetids), penicillin G benzathine (Bicillin LA) Alternative therapy:Amoxicillin, macrolides (erythromycin preferred in patients allergic to penicillin), oral cephalosporins, clindamycin (Cleocin)

75 B70: Diagnose and treat methanol ingestion Methanol, also known as wood alcohol, is a commonly used organic solvent Upon ingestion, methanol is quickly absorbed in the gastrointestinal tract and metabolized in the liver Initial symptoms generally occur hours after ingestion Initially, the symptoms from methanol intoxication are similar to those of ethanol intoxication, often with disinhibition and ataxia. Following a latent period, patients may develop headache, nausea, vomiting, or epigastric pain. In later stages, drowsiness may rapidly progress to obtundation and coma. Formic acid accumulates within the optic nerve resulting in vision loss

76 B70: Diagnose and treat methanol ingestion Significant methanol ingestion leads to anion gap metabolic acidosis and in an elevated osmolar gap To find the osmolar gap, take the measured plasma osmolality and subtract the calculated osmolality. Definitive diagnosis of methanol toxicity requires a confirmed increase in the serum methanol level with gas chromatography Supportive therapy is aimed at initiating airway management, correcting electrolyte disturbances, and providing adequate hydration Antidote therapy is directed towards delaying methanol metabolism until the methanol is eliminated from the system either naturally or via dialysis. This is often accomplished in 2 ways: ethanol or fomepizole Hemodialysis can easily remove methanol and formic acid

77 B73: Diagnose statin-induced myopathy Many patients treated with statins have muscle symptoms, and some patients develop severe muscle toxicity The most serious risk of these drugs is myositis with rhabdomyolysis Randomized trials and community surveillance have demonstrated an extremely low incidence of serious muscle toxicity in patients receiving statins: 1 case per Skeletal muscle weakness is frequent in association with clinically important myositis and rhabdomyolysis but can also occur in patients with no or little CK elevation.

78 B73: Diagnose statin-induced myopathy Patients complaining of myalgias without elevated CK levels can continue the medication if their symptoms are tolerable If the symptoms are not tolerable or are progressive, the offending agent should be stopped There are rare clinical anecdotes that patients complain of persistent muscle discomfort while taking statins, occasionally associated with CK elevations, both of which persist after withdrawal of the medication. Such patients should be evaluated for other conditions, such as polymyalgia rheumatica and temporal arteritis, which may have been unmasked by statin therapy, as well as hypothyroidism, which can elevate CK concentrations

79 B75: Confirm a diagnosis of Marfans syndrome suggested by cardiovascular complications The diagnosis of Marfan syndrome remains mainly clinical Cardiovascular involvement is the most serious problem associated with Marfan syndrome Major criteria include the following: Aortic root dilatation involving the sinuses of Valsalva: The prevalence of aortic dilatation in Marfan syndrome is 70-80%. It manifests at an early age and tends to be more common in men than women. A diastolic murmur over the aortic valve may be present. Aortic dissections involving the ascending aorta

80 B75: confirm a diagnosis of Marfans syndrome suggested by cardiovascular complications Minor criteria are listed as follows: Mitral valve prolapse (55-69%): Midsystolic clicks may be followed by a high-pitched late-systolic murmur and, in severe cases, a holosystolic murmur. Dilatation of proximal main pulmonary artery in the absence of peripheral pulmonic stenosis or other cause. Calcification of mitral annulus (patients <40 y) Dilatation of abdominal or descending thoracic aorta (patients <50 y) For the cardiovascular system to be involved, a minor criterion must be present

81 B80: Provide preconception counseling to a patient with previous gestational diabetes mellitus Approximately 4% of all pregnant women develop GDM, making it about 100 times more common than pregestational diabetes Groups at increased risk are African Americans, obese women, women of advanced maternal age, those with a prior history of GDM or family history of DM, and women who have had previous large for gestational age (LGA) babies Screening in the high-risk populations is essential. There is some evidence that early screening, before 24 weeks gestation, identifies a significant percentage of women with GDM -- 40% in one study Women with risk factors be screened at one of the early prenatal visits (between 12 and 24 weeks gestation); if the test result is negative, they should be screened again per standard protocol at 24 to 28 weeks

82 B80: Provide preconception counseling to a patient with previous gestational diabetes mellitus Close monitoring is essential, including multiple daily finger-stick blood sugar measurements (FSBS), careful dietary management, and, possibly, insulin injections Frequent, often weekly, visits with the physician and sometimes biweekly visits with a diabetic nurse-educator are recommended Women with diagnosed GDM measure blood glucose levels before breakfast and then 2 hours postprandially The target FSBS for the 2-hour postprandial values is 120mg/dL For the fasting test, the acceptable maximal value can range from 95 to 105mg/dL Exercise is the second component of initial therapy

83 B83: Diagnose and treat impetigo Infection caused by group A beta-hemolytic streptococci (GABHS) or S aureus Begins with a single 2- to 4-mm erythematous macule that rapidly evolves into a vesicle or a pustule This vesicle is very fragile and ruptures early, leaving a crusted exudate of a honey or yellow color over the superficial erosion The infection spreads to contiguous and distal areas through inoculation of other wounds from scratching

84 B83: Diagnose and treat impetigo Antibiotics are the mainstay of therapy. The drug chosen must provide coverage against coagulase-positive S aureus and GABHS. In areas with high percentage of CA- MRSA, the empiric antibiotic choice should provide coverage for this possibility. Topical antibiotics pose fewer potential problems than systemic antibiotics, but their use is reserved only for cases involving lesions that are small or few in number Systemic therapy must cover all likely pathogens in the context of the clinical setting

85 B84: Diagnose brain death Initially, for an accurate diagnosis of brain death, there must be clear evidence of an acute, catastrophic, irreversible brain injury, and any reversible conditions that may obfuscate the clinical assessment Subsequently, the physical examination must show coma, absent motor responses, absent brain stem reflexes, and apnea Some protocols call for a second examination, performed after a variable interval Further confirmatory studies (e.g., electroencephalography [EEG] or cerebral blood flow studies) may be ordered if there is any ambiguity in the clinical evaluation If the cause of death cannot be determined with absolute accuracy, consider cerebral angiography. The absence of intracranial arterial circulation, as demonstrated by four-vessel angiography, confirms brain death

86 B84: Diagnose brain death Perform the apnea test. This test should be the last test and should be conducted after two clinical examinations (separated by the mandatory observation period) have confirmed the absence of brain stem functions. The patient is disconnected from the ventilator while oxygenation of the lungs is continued passively. On the basis of calculation (whereby PaCO2 is assumed to rise 4 mm Hg in the first minute and 3 mm Hg every minute thereafter), the patient is allowed to build up to a PaCO2 of 60 mm Hg or more without becoming hypoxic. If there is no respiratory effort, the apnea test is considered confirmatory.

87 B88: Diagnose erythema multiforme In addition to characterizing skin and mucous membrane lesions of EM, a complete history should document recent constitutional symptoms, prior history of herpes simplex infection, and use of prescription and over-the-counter medications Sudden onset of rapidly progressive, symmetrical, and cutaneous and/or mucocutaneous lesions, with concentric color changes in some or all lesions Centripetal spread Burning sensation in affected areas Pruritus generally absent Nonspecific prodromal symptoms suggestive of a viral syndrome in at least 50% of case

88 B88: Diagnose erythema multiforme Symmetrically distributed, erythematous, expanding macules or papules evolve into classic iris or target lesions, with bright red borders and central petechiae, vesicles, or purpura. Lesions may coalesce and become generalized. Vesiculobullous lesions develop within preexisting macules, papules, or wheals. Rash favors palms and soles, dorsum of the hands, and extensor surfaces of extremities and face. Postinflammatory hyperpigmentation or hypopigmentation may occur. Eye involvement occurs in 10% of EM cases, mostly bilateral purulent conjunctivitis with increased lacrimation. Mucous membrane blistering occurs in about 25% of cases of EM, is usually mild, and typically involves the oral cavity.

89 B93: Treat polyarticular gout in the immediate postoperative period The goals of therapy are early resolution of inflammation, prevention of recurrent attacks, and reversal of complications arising from deposition of urate crystals in joints, kidneys, and tophi Glucocorticoid therapy, either oral or parenteral, is effective in patients who are unable to take or tolerate NSAIDs and colchicine initial dosage of prednisone is 0.5 to 0.75 mg/kg a day rapid tapering over the next 7 to 10 days Intra-articular steroids are useful in patients with multiple medical problems, involvement of only a few joints, or contraindications to other therapies

90 B93: Treat polyarticular gout in the immediate postoperative period Corticotropin (ACTH) is still an option for treating gout An intramuscular dose of 100 IU produces 100 mg of cortisol over 16 hours Although this agent has been shown to be as effective as indomethacin, it carries a higher risk of rebound attacks, and multiple injections may be required Some investigators have reported efficacy in acute attacks

91 B99: Diagnose Menieres disease Recurrent, spontaneous episodic vertigo; hearing loss; aural fullness; and tinnitus Either tinnitus or aural fullness (or both) must be present on the affected side to make the diagnosis At least 2 definitive episodes of vertigo of at least 20 minutes duration must occur to make the diagnosis Sensorineural hearing loss must be documented audiometrically in the affected ear at least once during the course of the disease Tinnitus is often nonpulsatile and may be described as whistling or roaring

92 B99: Diagnose Menieres disease A complete neurologic examination is necessary to differentiate Ménière disease from other conditions Nystagmus and vertigo associated with peripheral causes such as Ménière disease should be fatigable and exhibit habituation following dix-hallpike The Romberg test reveals significant instability during acute attacks Laboratory tests should be directed at differentiating Ménière disease from other causes based on associated symptoms A patient with a history classic for Ménière disease does not normally need imaging studies performed

93 B104: Suspect insulin resistance on the dermatologic evidence of acanthosis nigricans Acanthosis nigricans is characterized by a dark, slightly raised, velvetlike eruption of the flexural areas Most often seen in the axillae, it can also occur in the inguinal area, on the sides of the neck, in the abdominal area, and even in the mouth The most common scenario is the development of lesions in obese persons, those with adult-onset diabetes mellitus, or those with a strong family history of diabetes mellitus The acanthosis is thought to be representative of insulin resistance Some cases may follow a hereditable pattern, with or without diabetes Acanthosis Nigricans Mayo Clin Proc. 2004;79:1571

94 B104: Suspect insulin resistance on the dermatologic evidence of acanthosis nigricans Acanthosis nigricans may be a manifestation of internal malignancy, including solid tumors and lymphoma, or it can develop as the result of drug ingestion The diagnosis is most often clinical, but a skin biopsy can be performed when the diagnosis is unclear At times superficial fungal or yeast infections can imitate acanthosis nigricans Treatment is difficult unless the underlying condition is removed

95 B105: Diagnose and manage pubertal gynecomastia Gynecomastia is a benign enlargement of the male breast resulting from a proliferation of the glandular component of the breast Defined clinically by the presence of a rubbery or firm mass extending concentrically from the nipples Fat deposition without glandular proliferation is termed pseudogynecomastia Gynecomastia is usually bilateral, it can be unilateral It is common in infancy, adolescence, and in middle- aged to older adult males

96 B105: Diagnose and manage pubertal gynecomastia Pubertal gynecomastia resolves spontaneously within several weeks to 3 years in approximately 90% of patients. Breasts greater than 4 cm in diameter may not completely regress Patients with physiologic gynecomastia do not require further evaluation. Further evaluation is necessary in patients with the following: Breast size greater than 5 cm (macromastia) A lump that is tender, of recent onset, progressive, or of unknown duration Signs of malignancy

97 B108: Confirm a suspected diagnosis of hypophosphatemia Since parathyroid hormone stimulates the kidneys to excrete phosphate, hypophosphatemia is a common sequela of primary and secondary hyperparathyroidism Respiratory alkalosis moves phosphate into cells Administering carbohydrate lowers serum phosphate by stimulating the release of insulin (refeeding syndrome) Catecholamines and beta-receptor agonists also stimulate phosphate uptake into cells Phosphate may be lost via the gut, as in chronic diarrhea, malabsorption syndromes, severe vomiting, or NG suctioning

98 B108: Confirm a suspected diagnosis of hypophosphatemia Weakness of skeletal or smooth muscle is the most common clinical manifestation of phosphate deficiency It can involve any muscle group, alone or in combination, ranging from ophthalmoplegia to proximal myopathy to dysphagia or ileus Respiratory insufficiency may occur in some patients with severe hypophosphatemia, particularly when the underlying cause is malnourishment Impaired cardiac contractility occurs, leading to generalized signs of myocardial depression Commonly impairs neurologic function, which may be manifested by confusion, seizures, and coma

99 B112: Recognize a potential conflict of interest A conflict of interest exists when physicians' primary duty to their patients conflicts or appears to conflict with a secondary interest, which may consist of another important professional responsibility, a contractual obligation, or personal gain In providing counsel to their patients, physicians should be motivated by the desire to serve their patients' best interests and not by the financial incentives inherent in the practice environment Examples: overusing in the fee-for-service setting under using in the managed-care setting accepting drug-industry gifts participating in business arrangements involving referrals MKSAP 14

100 B112: Recognize a potential conflict of interest Even small gifts may affect clinical judgment and heighten the perception (or the reality) of a conflict of interest Acceptance of gifts, hospitality, trips, and subsidies of all types from those in the health care industry is strongly discouraged Small gifts from patients that express appreciation or cultural tradition may be acceptable if they do not distort the physician–patient relationship by raising expectations of preferential treatment Larger gifts, physicians may either respectfully decline or redirect them to suggested charities

101 B124: Recommend the most appropriate medical care, regardless of the patients insurance coverage or ability to pay Clinicians often play a central role in determining patients adherence to treatment plan Patients level of trust in their physician may be especially important in shaping their medication adherence decisions in the face of high out-of-pocket medication costs Physician trust has been found to be even more important than treatment satisfaction in predicting subsequent adherence to recommendations and overall satisfaction with care. Physicians must not take into account ability to pay or insurance (or lack of) when recommending a treatment plan. Plans must be the most efficacious for the particular patient.

102 B134: Evaluate suspected testicular torsion This urologic emergency requires prompt diagnosis, immediate urologic referral, and rapid definitive treatment for salvage of the testicle. Salvage rate of 100% is found in patients who undergo detorsion within 6 hours of pain; 20% viability rate if detorsion occurs after 12 hours; and 0% viability if detorsion is delayed greater than 24 hours. History includes a sudden onset of severe unilateral scrotal pain 50% of patients have a history of prior episodes of intermittent testicular pain that has resolved spontaneously (intermittent torsion and detorsion) Torsion can occur with activity, be related to trauma, or develop during sleep and includes the following Scrotal swelling,Nausea and vomiting (20-30%), Abdominal pain (20- 30%), Fever (16%), Urinary frequency

103 B134: Evaluate suspected testicular torsion Involved testicle painful to palpation; frequently elevated in position when compared with the other side Usually, no relief of pain upon elevation of scrotum (elevation may improve the pain in epididymitis [Prehn sign]) Testicular torsion is a clinical diagnosis. Imaging studies usually are not necessary; ordering them wastes valuable time when the definitive treatment is surgical. If the diagnosis is equivocal, radionuclide scan of the testicles can be helpful to assess blood flow and to differentiate torsion from other conditions. Scan is abnormal in torsion when it demonstrates decreased uptake in the affected testicle, suggesting no blood flow to that side. Radionuclide scans have a sensitivity of % accuracy in detecting testicular blood flow. Color Doppler has a sensitivity of 86%, specificity of 100%, and accuracy of 97% in the diagnosis of testicular torsion when the presence of identifiable intratesticular flow is the sole criterion for diagnosis

104 B136: Manage a breast mass in a young woman The malignancy rate for palpable breast masses in women younger than 40 years is approximately 3 percent In these women, mammography is less reliable than it is in older women and has a false-negative rate of nearly 80 percent Patients presenting with a breast mass should undergo clinical breast exam Guidelines from NCCN state that masses in women <30 undergo ultrasound (preferred), needle sampling or observation for 1-2 menstrual cycles If ultrasound is positive mammogram or biopsy is the next step depending on whether the finding is cystic, solid or not visualized

105 B136: Manage a breast mass in a young woman In women 30 or over breast mass evaluation starts with a mammogram For BiRads category 1-3 the patient should undergo ultrasound following mammogram Further recommendations depend on whether finding is cystic, solid or indeterminate For BiRads category 4-5 the patient should go directly to biopsy

106 B146: Manage epistaxis in a patient requiring posterior nasal packs with hospitalization Patients with posterior epistaxis require hospitalization Gauze, sponge packs, Foley catheter, pneumatic nasal catheters or tonsillar packing is placed to close of the choana to prevent escape of bleeding in the nasopharynx Requires a formal anterior pack for stability Indications include failed anterior packing, skull base trauma, hemorrhage from a major branch of the shenopalatine artery

107 B146: Manage epistaxis in a patient requiring posterior nasal packs with hospitalization Has risk of airway compromise Requires patient cooperation as this is painful May require intubation or general anesthesia Risk of pressure necrosis, hypoxia, sinusitis, bacteremia Requires prophylactic antibiotics to reduce risk of otitis media, sinusitis and toxic shock syndrome

108 B150: Schedule the least risky, most appropriate screening test for a patient with painless jaundice Patients in this category typically present with insidious development of jaundice and associated constitutional symptoms (weight loss, fatigue, etc.). Mechanical biliary obstruction can be confirmed by sonography. Malignant obstruction is most commonly due to pancreatic carcinoma but may be secondary to cholangiocarcinoma of either the proximal or distal duct or to periductal nodal compression A contrast-enhanced multipass CT examination with multiplanar reformation has high sensitivity to lesion detection and 70% accuracy in discrimination of resectable and unresectable disease

109 B150: Schedule the least risky, most appropriate screening test for a patient with painless jaundice In situations in which the pre-test probability of obstruction is low but concern about the possibility exists, either ultrasound or MRCP is the first-line test, because of patient convenience and low complication rates If the patient's presentation is confusing, and the imaging work-up frequently is geared to the dominant clinical symptom. Ultrasound is an inexpensive, relatively accurate method, certainly appropriate if the sole question is whether or not obstruction exists

110 B153: Prescribe a first-line pharmacologic treatment for a patient with social anxiety disorder Social phobia is an intense, irrational and persistent fear of being scrutinized or negatively evaluated by others to meet the diagnostic criteria for this disorder, the symptoms must be severe enough to cause significant distress or disability. Somatic manifestations of anxiety are common in the primary care setting; common ones include chest pain, palpitations, shortness of breath, dizziness, fatigue, insomnia, and gastrointestinal complaints If a wide variety of social or performance situations are feared, and especially if unpredictable situations are feared, patients with social anxiety disorder can feel restless, anxious, keyed-up, and on edge, constantly fearing a chance social encounter.

111 B153: Prescribe a first-line pharmacologic treatment for a patient with social anxiety disorder It is important to distinguish between the circumscribed and generalized types of social phobia before initiating pharmacotherapy because the circumscribed type has responded to an "as-needed" schedule (typically of beta blockers) whereas the generalized type has responded better to standing dosage schedules (typically of specific antidepressants) of at least three months' duration Selective serotonin reuptake inhibitors (SSRIs) have become the most widely recommended medications for social anxiety disorder Paroxetine (Paxil) has become the best-studied agent in this class, and it is the only one to have received FDA approval for this indication at the present time

112 B158: Evaluate a patient with an abnormal Pap smear Human papillomaviruses (HPV) are thought to cause virtually all cervicaldysplasias and carcinomas The false-negative rate of the Pap smear is at least 20%. This means that biopsy is imperative for visible cervical lesions Reactive, reparative atypia (presence ofimmature cells formed in the process of healing or regrowth of the squamousepithelium) is a common finding that often follows treatment of dysplasia andother conditions such as cervical or vaginal infections. It is a benign findingthat does not warrant increased surveillance Glandular atypia must therefore be evaluated by colposcopy and biopsy and not merely followed with repeat Papsmears

113 B158: Evaluate a patient with an abnormal Pap smear Studies of series of women with AGUS Pap smears suggest the occurrence of dysplasia or carcinoma in at least 30% of patients Squamous atypia (ASCUS) can be followed by repeated Pap smears in patients who are expected to be compliant and not otherwise at high risk for dysplasia (such as HIV-infected women). If atypia (especially when favoring dysplasia) persists for 1 year, colposcopy is probably indicated. When LSIL is diagnosed by biopsy, treatment is optional in compliant patients. In young women, treatment of LSIL should consist of cryosurgery or laser and not excisional techniques such as loop excision or cone biopsy. HSIL (high-grade squamousintraepithelial neoplasia ) warrants prompt colposcopic evaluation, cervical biopsy, and treatment

114 B159: Diagnose a popliteal cyst in a patient with unilateral lower-extremity edema Popliteal cyst, results from fluid distention of the gastrocnemio-semimembranous bursa Symptoms include: Mass, swelling, Aching, Knee effusion, Thrombophlebitis, clicking of the knee, buckling of the knee, Locking of the knee DVT should be excluded in patients with Baker cyst and leg swelling Arthritis is the most common condition associated with Baker cysts

115 B159: Diagnose a popliteal cyst in a patient with unilateral lower-extremity edema Imaging evaluation of a Baker cyst begins with conventional radiography to detect a soft-tissue mass, internal calcifications, displacement of an atherosclerotic popliteal artery, and the unusual case of adjacent bony involvement from a large and/or long-standing cyst Ultrasonography determines whether the popliteal mass is a pure cystic structure or a complex cyst and/or solid mass Color Doppler imaging can confirm the absence of vascular flow within the mass to exclude a popliteal artery aneurysm Baker cysts are often detected on MRI evaluations of the knee (performed for any indication) One of the most important benefits of employing MRI is the ability to use the axial plane to establish positive identification of the high–signal intensity, fluid-filled neck of the cyst that connects the cyst to the joint space. This makes it possible to discriminate between a benign Baker cyst and one of the uncommon, but clinically important, types of cystic tumors, such myxoid liposarcoma, that can occur in the popliteal fossa

116 B163: Manage moderate hypothermia Hypothermia is classified by severity as mild (core temperature of 32 to 35 °C [90 to 95 °F]), moderate (28 to 32 °C [82 to 90 °F]), and severe (<28 °C [<82 °F]) Moderate hypothermia (28-32°C) Oxygen consumption decreases, and the CNS depresses further; hypoventilation, hyporeflexia, decreased renal flow, and paradoxical undressing may be noted. Most patients with temperatures of 32°C or lower present in stupor. As the core reaches temperatures of 31°C or below, the body loses its ability to generate heat by shivering. At 30°C, patients develop a higher risk for arrhythmias. Atrial fibrillation and other atrial and ventricular rhythms become more likely. The pulse continues to slow progressively, and cardiac output is reduced. J wave may be seen on ECG in moderate hypothermia. Between 28°C and 30°C, pupils may become markedly dilated and minimally responsive to light, a condition that can mimic brain death.

117 B163: Manage moderate hypothermia Many hypothermic patients are volume contracted because of cold diuresis. As a result, hematocrit level may be deceptively high. Hematocrit levels may increase 2% for each 1°C drop in core temperature ABG may show higher oxygen and carbon dioxide levels and a lower pH than a patient's actual values as the blood is warmed in the ABG machinery Direct treatment at maintaining or restoring cardiac perfusion; maximizing oxygenation is indicated for a prolonged period of time until the core temperature is at least 32°C. Initiate warmed, humidified oxygen; provide heated intravenous saline; and place warmed blankets or heat lamps around a hypothermic patient Optimal rewarming techniques depend upon a patient's condition

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