CAPS III E1.5 Extra Questions
A 34-year-old female real estate agent presents to your oice with low back pain that began 6 days ago when she slipped in the foyer of a new condominium building. She fell onto her buttocks and experienced immediate pain over her tailbone. She was able to get up independently, but the following day, she awakened with increased pain and stiness. She states that she is barely able to move and has spent the last 5 days either in bed or lying on her couch. Her pain is located across her low back and radiates into her buttock bilaterally. It is described as constant sharp pain of variable intensity. She states that every movement aggravates it and nothing seems to help. What is your leading diagnosis? A Nonspecific low back pain (LBP) B Compression fracture C Spinal stenosis D Abdominal aortic aneurysm E Disk herniation
A. This patient has nonspecific LBP. Her young age and ability to move immediately after.. impact of the fall, and the fact that stiness was not apparent until the following day all go against a diagnosis of fracture. The localized distribution of her pain and lack of symptoms suggesting radiculopathy are also reassuring. Of utmost concern for this woman is the lack of activity over the past week and her high avoidance of movement for fear of causing greater symptoms. These are both worrisome predictors for developing a chronic condition. She would benefit from close follow-up, reassurance, and possibly early physical therapy.
A 66-year-old man with history of 2 prior myocardial infarctions, coronary artery bypass graing, hypertension, and congestive heart failure suddenly turns pale and slumps over in his chair and onto the floor while eating breakfast with his wife. He appears cold, sweaty, clammy, and unconscious. She phones 911. By the time the emergency medical technicians arrive 15 minutes later, he is groggy but awake. His pulse and blood pressure are normal, and he refuses to go with them to the hospital because he feels fine. Which of the following most suggests that he has a serious condition? A History of heart disease B Loss of consciousness C Sweating D Pallor
A. History of heart disease Explanation: Loss of consciousness defines syncope. Sweating and pallor are common symptoms of vasovagal or neural reflex syncope. This patient has a history of significant structural heart disease, which is an alarm feature. The presence of heart disease is a strong independent risk factor for a cardiac cause of -syncope with sensitivity approaching 95% in some studies (which means the absence of heart disease may be helpful in excluding a cardiac cause).
A 24-year-old man with no past medical or surgical history presents to the emergency department with abdominal pain and fever of 101°F. Six hours ago, he felt nauseated and began to notice a vague periumbilical pain that is now severe (10/10), constant, and sharp, and has migrated to the right lower quadrant. On physical examination, he is febrile and restless, and he is tender in the right lower quadrant. What is the most likely diagnosis? A Testicular torsion B Appendicitis C Ischemic colitis D Pancreatitis E Small bowel obstruction
Appendicitis Explanation: This patient is presenting with classic symptoms of appendicitis, which include anorexia, nausea, vomiting, fever, and right lower quadrant (RLQ) pain. The pain of appendicitis classically starts in the periumbilical region and then becomes localized to RLQ. Testicular torsion predominantly occurs in neonates and postpubertal boys, although up to 40% of patients are older than 21 years; the absence of testicular pain makes this diagnosis unlikely. Ischemic colitis most commonly occurs in older patients with history of smoking or atherosclerotic disease. The pain occurs after meals and lessens after emesis. Pancreatitis causes abrupt onset of epigastric pain radiating to the back; RLQ tenderness would be unusual. Approximately 50% of patients with small bowel obstruction have had prior abdominal surgeries. The typical pain of small bowel obstruction is crampy and periumbilical and occurs in paroxysms every few minutes.
A 72-year-old male smoker with chronic obstructive pulmonary disease presents to your clinic with severe low back pain. The pain began acutely yesterday after moving furniture in his living room. It is located in the central aspect of the upper lumbar spine and is described as sharp and intermittent. It is aggravated by walking, standing, and moving from a sitting to a standing position. It is relieved with rest. He used the clinic wheelchair to come to your office because the pain is limiting ambulation. On examination, he is a thin male having sharp bursts of pain with movement, although he is comfortable while sitting still between these episodes. He has severe tenderness to palpation over the L1 spinal process with milder pain to palpation over the paraspinous muscles. What is your leading diagnosis? A Nonspecific low back pain (LBP) B Compression fracture C Spinal stenosis D Abdominal aortic aneurysm E Disk herniation
B. compression fracture Explanation: The acute onset, localized distribution, and intermittent nature of the pain strongly suggest a vertebral compression fracture. Patients with chronic obstructive pulmonary disease often require intermittent treatment with corticosteroids, which increases his likelihood of compression fracture. One must also consider abdominal aortic aneurysm in a male patient older than 65 with a smoking history, but the lack of abdominal symptoms and localized mechanical nature make this diagnosis less likely. The next diagnostic step would be plain radiographic imaging with a lumbar posterior-anterior view and lateral xray.
A 65-year-old non-smoking female presents with progressive cough over a one year period. Her cough is productive of voluminous amounts of tenacious grey sputum. She says she could fill a small coffee can in a day She denies fevers, chills, pleurisy and hemoptysis_ She notes no history of frequent pneumonias, pertussis or Immunosuppression_ She has experienced a 25 pound weight loss over the last year. What is the most likely etiology of this patient's cough? A: Broncho-alveolar lung cancer B. Lung abscess C: Tuberculosis D: Pneumonia
Broncho-alveolar cancer
You receive a telephone call from a 32-year-old woman who complains of burning with urination over the past 12 hours. She also feels an intense need to urinate but reports difficulty voiding more than a small amount. She has experienced similar symptoms in the past and requests that you call in a prescription for antibiotics to her pharmacy. Additional History Your patient states that she had similar symptoms 6 months ago, which were diagnosed as a urinary tract infection. Her symptoms at that time resolved completely with antibiotic treatment. She denies any current vaginal irritation or discharge. She has had one male sexual partner for the past 2 years, does not use condoms, and has not had any sexually transmitted diseases. She denies fever, chills, nausea, vomiting, and back, pelvic, or abdominal pain. She does not have diabetes and is not pregnant. Question: What Is the Most Likely Diagnosis? A. Pyelonephritis B. Urethrocystitis due to herpes simplex virus C. Lower urinary tract infection D. Vaginal candidiasis
C. Lower UTI Your patient reports dysuria and urgency, suggesting a lower UTI. Given the prior UTI history, her pretest probability of an acute UTI is 85% to 90%. The absence of vaginal irritation or discharge makes vulvovaginitis less likely and increases the pretest probability of UTI to over 90%. Her sexual history indicates a relatively low risk for STIs, such as herpes or chlamydia urethritis. She does not endorse alarm symptoms suggesting pyelonephritis or pelvic inflammatory disease. Her high pretest probability of UTI and lack of risk factors for a complicated UTI suggest that urine culture is unnecessary. Thus she may be safely managed with telephone advice and empiric antibiotic treatment.
A 25-year-old graduate student complains of a burning sensation in her throat and upper abdomen. She drinks 3 to 4 cups of coffee per day and often skips meals. Symptoms are often worse at bedtime. Which of the following symptoms would be most consistent with a diagnosis of gastroesophageal reflux? A Weight loss B Flatulence C Chronic cough D Vomiting
Chronic cough Explanation: Gastroesophageal reflux is a common condition that is often precipitated by ingestion of spicy foods or alcohol and classically causes a burning sensation in the epigastrium and radiating into the chest. Symptoms are worse upon lying down, and patients often complain of a bitter taste in their mouth. Chronic cough is a common complaint due to reflux of gastric contents. Nausea may occur, but vomiting is rare. Weight loss and flatulence are not features of GERD.
Case Scenario | Resolution A 56-year-old man presents to the emergency department (ED) with a complaint of chest pain that began 60 minutes earlier and has not resolved. He states he has never had a heart attack before. He is a current smoker and has smoked 1 pack per day for 30 years. He has been having intermittent episodes of chest pain off and on for the last 4 months, but today was the first time that the chest pain persisted prompting him to visit the ED. Additional History The patient initially noticed the chest pain a few months ago while walking or climbing stairs. These episodes would resolve a few minutes aer stopping and resting. In the last month, he has noticed that less eort would bring on the pain and has even noticed it while sitting watching television. Today, he awoke from sleep with chest pain that did not go away and so he came to the ED. Today's pain is a diuse precordial burning and pressure that radiates to both shoulders and arms. Prior episodes have been felt in his lower jaw. Right now he feels nauseous and as if he cannot quite catch his breath; this is something he has never felt previously. On further questioning, some time ago, he was told his cholesterol was high but he never sought further followup. He has been under a great deal of stress at work during the last few months. Question: What Is the Most Likely Diagnosis? A. Acute coronary syndrome B. Pericarditis C. Pulmonary embolism D. Gastroesophageal reflux
Correct answer: A The patient presents with acute coronary syndrome. He describes a prodrome of typical exertional angina that has progressed to rest symptoms over the last month (unstable angina). On presentation, the pain is prolonged and exhibits several features consistent with acute myocardial ischemia including an oppressive nature, radiation to the arms and shoulders, and associated dyspnea. These alarm symptoms are occurring on the backdrop of a high probability for coronary artery disease (CAD)—a 56-year-old man with typical angina and risk factors of smoking and high cholesterol has an estimated CAD prevalence of greater than 90%. An electrocardiogram and cardiac biomarkers should be obtained without delay in this patient.
A 67-year-old man comes to your clinic for his annual appointment concerned about increasing shortness of breath. A year ago he was able to walk up the stairs to his apartment without diiculty, but now he has a hard time walking one block. He has a 70 pack-year smoking history, and several previous attempts to stop smoking have been unsuccessful. Additional History This patient has had slowly progressive dyspnea with exercise but no symptoms at rest. The chronicity of the patient's symptoms and his ability to engage in conversation reassure you that he does not require urgent intervention. He expresses frustration that he is unable to get a full breath when simply walking around his home. The dyspnea often worsens when he has a "cold," but he denies an acute increase in symptoms. There are no other triggers. When you ask about related symptoms, he describes a persistent cough productive of thick green sputum. The cough has been an irritating presence for the past several months. He denies fevers, chest pain, chest tightness, or orthopnea. Question: What Is the Most Likely Diagnosis? A. Asthma B. Chronic obstructive pulmonary disease C. Congestive heart failure D. Pneumonia
Correct answer: B The most common causes of dyspnea are primary cardiac and pulmonary causes, anemia, deconditioning, and functional dyspnea. The patient describes a productive cough for greater than 3 months and an impressive smoking history; both have high likelihood ratios for chronic obstructive pulmonary disease (COPD). The patient's presentation is highly suggestive of the chronic bronchitis variant of COPD. However, congestive heart failure and COPD frequently occur together; thus a diagnosis of one does not exclude the other. Further evaluation for cardiac causes should be pursued because the patient has several coronary artery disease risk factors (smoking, male sex, and age over 60) and CHF may be contributing to the patient's dyspnea. The classic symptoms of asthma are dyspnea, wheezing, and cough, which overlap with those of COPD, making diagnostic distinction diicult. In this case, the patient's older age of onset makes asthma less likely. Pneumonia is unlikely based on the chronicity of symptoms and lack of systemic symptoms or signs of infection.
A 27-year-old woman comes to your oice to discuss her "sick headaches," which started during high school. Her mother nudged her to see you. The headaches do not awaken her from sleep but can be disabling and occasionally require her to miss work. Sometimes she vomits during an attack. Over the past 6 months, her headaches have become more severe and frequent, prompting her visit today. Additional History Her headaches are similar in quality to the ones she has had since adolescence. They are now more severe and frequent, but the location, character, and associated symptoms have not changed. They are unilateral, throbbing, and associated with nausea and photophobia. They are usually worse during the first 2 to 3 days of her menses. You determine that this is an "old" headache. She has no alarm symptoms such as fever, dysequilibrium, focal weakness, or neck stiness. The detail with which she can provide a careful history suggests that her mental status is normal. On some occasions, her headaches are preceded by unusual zigzag flashing lights o to the right side of her visual field lasting 20 minutes or so. On further questioning, she has been under a great deal of stress, and her sleep schedule has been erratic. She has also been drinking up to 5 to 6 cups of coffee per day. Question: What Is the Most Likely Diagnosis? A. Tension-type headache B. Migraine C. Brain tumor D. Cervicogenic headache
Correct answer: B The patient has old headaches (ie, they are the same in character as her usual headaches, albeit more severe). Therefore, the diagnosis for her headaches remains the same. Cervicogenic headache is generally a disease of middle-aged or older patients and is uncommon in young women. Occasionally, it can occur in younger patients aer whiplash-type neck injuries. It is most commonly a burning or dull pain in the occiput and forehead. Brain tumor is a new headache. The character and description of her pain have not changed, as one would expect if a new source, such as brain tumor, were the cause of the headache. The unilateral, throbbing nature of the headaches is typical of migraine. The occasional visual aura and associated nausea confidently establish the diagnosis of migraine with great certainty. These 2 features most accurately distinguish migraine from tension-type headache. She has no alarm symptoms. The challenge is to determine why the headaches are more severe and frequent now. Her headaches are likely worse due to a change in her lifestyle including triggers of irregular sleep and excessive caeine.
A 62-year-old man with a history of hyperlipidemia, hypertension, and coronary artery disease presents to your primary care practice with abdominal pain for 6 months. His pain gets worse aer eating meals. Additional History The patient characterizes his pain as dull and crampy and rates it as a 5 on a 10-point pain scale. His pain is nonradiating and is localized to the epigastric and periumbilical areas. The pain worsens about an hour aer each meal and gets better aer vomiting. All foods tend to trigger his pain. He denies blood or bile in his emesis. Since the onset of his pain, he has lost 20 lbs. He denies fever, chills, or blood, mucus, or fat in his stool. He denies heartburn or previous abdominal surgeries. He is a school teacher who stopped smoking 10 years ago and drinks alcohol socially. He does not use illicit drugs, and he has no family history of heart disease, diabetes, or malignancy. His medications include aspirin, simvastatin, hydrochlorothiazide, and metoprolol. On physical examination, he is well appearing with mild abdominal tenderness in the periumbilical region without guarding or rebound. Question: What Is the Most Likely Diagnosis? A. Peptic ulcer disease B. Pancreatitis C. Cholecystitis D. Chronic mesenteric ischemia
Correct answer: D The patient presents with abdominal pain for 6 months, which puts it into the chronic abdominal pain category. Furthermore, he is a former smoker and has history of hyperlipidemia and coronary artery disease, which raises the suspicion of generalized atherosclerotic disease. Nearly 50% of patients with chronic intestinal ischemia have either peripheral vascular disease or coronary artery disease. His symptoms of nausea, vomiting, weight loss, and pain starting an hour aer eating and resolving aer emesis are all characteristic of chronic bowel ischemia. About 80% of patients with intestinal -ischemia present with weight loss, often ascribed to food aversion because patients associate their pain with meals. Peptic ulcer disease could be chronic and present with epigastric pain, but a 20-lbs weight loss would be unusual for this condition. Pancreatitis and cholecystitis cause nausea and vomiting, but patients with these disorders typically are more acutely ill and often have fever.
A 58-year-old woman comes to you complaining of diiculty sleeping. She reports that her sleep problems began about 2 months ago, and since that time, she has felt "drained, weak, and not like my usual self." Over the past 2 months, she also acknowledges having gained 12 lbs. The patient appears visibly lethargic to you, as evidenced by her slumped posture, sluggish movement, delayed replies to your questions, and diiculty sustaining attention. Additional History Upon further questioning, you discover that the patient has developed similar symptoms during previous periods in her life. These periods have lasted from 2 months to 2 years, with the patient eventually getting back to her "old self." You also find out that she has typically consumed 1 to 2 alcoholic beverages each night since her mid-20s. She denies having constipation, sensitivity to cold, or dry skin. However, she feels sad nearly all the time lately and no longer is interested in doing things that she used to enjoy. When questioned about her family history, the patient reports that periods of sadness sometimes aected her mother, who died 16 months ago. Question: What Is the Most Likely Diagnosis? A. Bereavement B. Substance-induced mood disorder C. Dysthymic disorder D. Mood disorder due to a general medical condition E. Major depressive disorder
Correct answer: E The patient has major depressive disorder. She has symptoms of depressed mood, anhedonia, weight gain, insomnia, psychomotor retardation, fatigue, and diminished ability to concentrate. From the available history, it is unclear whether the patient has feelings of guilt/worthlessness or suicidal ideation. If a major depressive episode is suspected, the clinician should always assess for suicidal ideation and take appropriate steps if the patient has a plan or intent to commit suicide. Although the patient lost her mother 16 months ago, bereavement should be considered in place of major depressive disorder only if the patient has experienced the loss of a loved one in the past 2 months. Although the patient uses alcohol, her relatively low consumption level and the lack of correlation between alcohol intake and her mood go against a diagnosis of substance-induced mood disorder. Dysthymic disorder does not fit because she has experienced periods of interepisode recovery aer prior depressive episodes. Mood disorder due to a general medical condition is not suggested by the data; in particular, the patient denied a number of symptoms suggestive of hypothyroidism.
You have just diagnosed bacterial urinary tract infection (UTI) in a 56-year-old woman. She reports 3 UTIs in the past year and is concerned about why they keep recurring. She has multiple sclerosis and was diagnosed with type 2 diabetes 1 year ago. She has chronic, intermittent urinary incontinence, which is large volume and occurs without warning in both the daytime and at night. She denies vaginal dryness, dyspareunia, hematuria, or unilateral back pain but had a kidney stone 10 years earlier. What is the most likely explanation for her recurrent urinary tract infections? A Retained kidney stone B Diabetes C Atrophic vaginitis D Chronic incontinence
D. Explanation: This patient has several risk factors for recurrent UTI. Chronic incontinence increases the risk of recurrent UTI in postmenopausal women. Her symptoms of incontinence also suggest neurogenic bladder, due to multiple sclerosis. With neurogenic bladder, incomplete bladder emptying and retained urine can lead to recurrent UTIs. Although atrophic vaginitis is also a risk factor for UTI in postmenopausal women, this patient does not have symptoms of vaginal dryness or pain with intercourse, making it a less likely explanation. Although a retained kidney stone could serve as a nidus for recurrent infections, her lack of hematuria, flank pain, or symptoms of nephrolithiasis make this an unlikely explanation for her recurrent UTIs.
A 20-year-old college wrestler comes to your oice with his mother because she is concerned that he has "passed out" in church. While attending Sunday services during the summer, he has twice become dizzy while standing and slumped to the floor. He was briefly "out of it" but revived quickly when taken outside. On each occasion, he insisted on completing the religious service. Additional History On both occasions, the church was crowded and hot, and the congregation had been standing for a prolonged period. He initially felt a graying out of his vision, then his hearing began to fade, and finally, he felt suddenly very hot and sweaty. The next thing he remembers was being surrounded by people fanning him as he came to consciousness. His mother reported that he slumped down to the floor very suddenly and looked "pale and clammy." He spontaneously recovered and was only momentarily confused. The other episode occurred the previous summer under similar circumstances. He is taking no medications, has no history of cardiac disease, and denies palpitations. There is no history of seizures. He keeps himself fit and exercises regularly to keep in shape for the wrestling season. There is no family history of sudden death, although a paternal grandfather died in his seventies of "heart attack." His mother and father are healthy. Question: What Is the Most Likely Diagnosis? A. Sinus node dysfunction B. Long QT syndrome C. Seizure D. Vasovagal syncope E. Orthostatic hypotension
D. Vasovagal syncope Loss of consciousness is the sine qua non of syncope. The rapid onset with spontaneous, complete recovery excludes other forms of loss of consciousness such as coma, drug intoxication, and seizure. This is true syncope. The circumstances of a hot, crowded environment with prolonged standing and a previous history are characteristic of vasovagal syncope, as are the premonitory symptoms. The negative family and medical history and absence of palpitations also support that diagnosis. Orthostatic hypotension typically occurs with standing and has an underlying autonomic disorder or history compatible with volume loss.
A 21-year-old man arrives in clinic for his annual physical and complains of generalized weakness for several months. He used to be a track star, but recently quit the team. He has been sleeping more and has a hard time rousing himself from bed in the morning. Since quitting the track team, he has had decreased appetite and the inability to focus in class. He is tired all the time and doesn't seem to enjoy activities that he used to. What is the likely diagnosis? A Duchenne muscular dystrophy B Deconditioning C Depression D Myasthenia gravis E Hyperthyroidism
Depression A careful physical examination should be conducted to confirm that the patient does not have true neuromuscular weakness; however, this patient's history is most consistent with functional weakness resulting from depression. Deconditioning causes easy fatigability, not asthenia. Although patients with hyperthyroidism typically have increased appetite, hyperthyroidism is possible, and so thyroid-stimulating hormone level should be measured. Duchenne muscular dystrophy presents with proximal weakness, so is unlikely.
You evaluate a patient with insomnia and determine that he has obstructive sleep apnea (based on polysomnography), for which you institute therapy. What condition is he at risk for developing over the next 6 months? A Heart failure B Depression C Advanced sleep phase disorder D Addiction to benzodiazepines used as a sleep aid
Depressoion Insomnia is a significant risk factor for the future development of depression. Heart failure is unlikely to develop in just 6 months if the patient complies with therapy for sleep apnea. Benzodiazepines would be a poor choice of therapy in patients with sleep-disordered breathing or sleep apnea. Advanced sleep phase disorder is an uncommon circadian rhythm disorder and would have no relation to this patient's sleep apnea or insomnia.
A 21-year-old man presents with a history of headaches every other day for the last 5 days. Each headache lasted for about 1 hour with sharp pain surrounding one eye accompanied by tearing of his eye and discharge from his nose Which one of the following possible diagnoses is most likely? A: Rebound headache B. Transformed migraine headache C: Subarachnoid hemorrhage D: Tension type headache E: Cluster headache
Feedback Question #1 CORRECT Close Cluster headache features include: Severe, unilateral, temporal, orbital, or supraorbital pan lasting 15 min - 3 hours and at least one of the following injectionJlacrimatlon, nasal congestion/rhinorrhea, eyelid edema, forehead and facial sweating, mosis/ptosis, restlessness or agitation frequency 1 every other to 8 per day.
A 60-year-old man with a history of diabetes mellitus presents to clinic complaining of three months of low back pain. The pain is mostly in his back, and radiates to his buttocks and thighs when he walks. The pain improves when he sits down, and he also reports improvement while he IS grocery shopping and bends to push the cart He denies pain while in bed He denies numbness, fever or weight loss Over-the-counter naproxen helps, but he feels limited In his daily activities On exam, there is no back tenderness. Straight leg raise test is negative bilaterally; reflexes are symmetric, strength is normal; and sensation IS normal -Dorsalis pedis and posterior tibialis pulses are easily palpable. His gait is normal. What is the most likely etiology of his back pain? A: Peripheral vascular disease B. Spinal stenosis C: Epidural abscess D: Spinal osteomyelitis E Herniated disk
Feedback Question #3 CORRECT Close The classic presentation of spinal stenosis includes persistent back and leg discomfort brought on by walking or standing that IS relieved by Sitting or bending forward. Lack of fever or systemic symptoms makes infectious etiologies unlikely. His reflexes and neurologic exam are also unremarkable and pulses are easily palpable, making peripheral vascular disease and herniated disk less likely
A 25-year-old female presents to clinic with crusted lips and an acute onset diffuse painful eruption that is starting to demonstrate blistering, accompanied by fever. You are MOST suspicious that this eruption represents? A: Atopic dermatitis B. Basal cell carcinoma C: Psoriasis vulgaris D: Drug eruption
Feedback Question #4 CORRECT Close The differential diagnosis for an eruption accompanied by fever includes an infection, drug eruption, or a rheumatologic condition. Given the pain of this eruption and incipient blistering, a diagnosis of Stevens-Johnson syndrome/ toxic epidermal necrolysis should be entertained and a medication exposure elicited. This eruption is acute making atoplc dermatitis and psoriasis vulgaris unlikely Scabetic infestation would be pruritic as opposed to painful, and not be associated With fever.
A 27-year-old female presents to your office complaining of headaches. She has about 3-5 episodes each month. The headaches usually start with seeing flashing lights, then develop into a severe, throbbing headache on the side of her head Any noises or bright lights make the pain worse, so she usually lays down In a dark room until it goes away. It can last for an entire day. What is the most likely diagnosis? A: Sub-Arachnoid Hemorrhage B. Migraine Headaches C: Cluster Headaches D: Tension Headaches E Secondary Headaches
Feedback Question #5 CORRECT Close The description of migraine headaches adopted by the International Headache Society (HIS) is, "Recurring headache disorder manifesting in attacks lasting 4-72 hours Typical characteristics of migraine headaches are unilateral location, pulsating quality, moderate or severe intensity aggravation by routine physical activity and association with nausea, andJor photophobia and phonophoba "
Which one of the following is most true about migraines? A: Migraines are a rare cause of headaches B: Migraines are caused by cold fluids stimulating the trigeminal nerve C: There is no definitive diagnostic test D: They frequently result in strokes and permanent disability
Feedback Question #6 CORRECT The diagnosis of migraine is clinical (based on clinical features). No tests directly reveal the condition. Headache lecture - slide 45.
Which one of the following variables is most directly responsible for cardiovascular syncope? A: Blood pressure B: Stroke volume C: Peripheral vascular resistance D: Cardiovascular reflex E: Heart rate
Feedback Question #7 CORRECT Close Feedback: Understand syncope as a decrease in cerebral blood flow due to an acute, transient decrease in blood pressure.
A 63-year-old man presents for evaluation of exertional dyspnea that also occurs whenever he moves from a lying to a standing position. Social history is significant for a 30 year history of heavy alcohol use. He is a nonsmoker. On exam his respiratory rate = 28/min_ Chest is clear to auscultation. Heart is normal. Skin exam reveals multiple small dilated blood vessels (telangiectasias) over his chest. Extremities have no edema. Based on this Information which one of the following statements is most correct? A: He has tachypnea secondary to congestive heart failure. B. He has orthopnea secondary to alcoholic liver disease. C: He has hyperpnea as the cause of his dyspnea_ D: He has bradypnea secondary to heavy alcohol use. E He has platypnea secondary to alcoholic liver disease.
Feedback Question #9 CORRECT Close Understand the key elements of the history and physical examination critical to the diagnosis of cough
28-year-old man who recently emigrated from Mexico visits your clinic with a history of 4 months of cough. He has lost 15 to 20 lbs unintentionally and has occasional fevers and night sweats. The cough is dry, and he has coughed up a moderate amount of blood on 3 occasions. He has been a smoker for 2 years. There is no history of wheezing, rhinitis, or reflux symptoms. He currently works as a security guard in a chemical plant. What are the alarm features in this patient? A History of smoking B Duration of the cough C Hemoptysis and weight loss D Type of job
Hemoptysis and weight loss Explanation: The alarm features in this case are hemoptysis, weight loss, and fever. Although serious causes of cough are not common, the alarm features require immediate action and often additional testing. The duration of the cough provides a guideline for the dierential diagnosis, but it is not an alarm feature. Although smoking and his occupation provide additional information, they are not alarm features.
A 67-year-old hospitalized man complains of shortness of breath for the past hour. Although lying in the bed, he is breathing quickly and appears nervous. He was admitted 4 days earlier aer being hit by a car and was found to have a displaced tibial fracture, which required immediate operative intervention. Chest radiograph at admission showed a 5-cm lung mass suspicious for cancer. The patient has a 60 pack-year smoking history. He has had a persistent nonproductive cough for the past several months but denies any other symptoms. what is the most likely diagnosis? A Bronchitis B Bronchiectasis C Lung cancer D Tuberculosis
Lung Cancer Explanation: Weight loss, tobacco exposure, advanced age, and hemoptysis make lung cancer a likely diagnosis.
The captain of the high school cheerleading team presents to clinic with a chief complaint of several months of shortness of breath upon exertion. She is unable to identify any triggering symptoms. She denies hormonal contraceptive use. Which of the following is the most important aspect of the history to elicit? A Recent bee sting B Menorrhagia C Recent immobilization D Exposure to asbestos
Menorrhagia Aer cardiac and pulmonary causes, anemia is the most common cause of shortness in breath. In young women, menorrhagia is a common cause of anemia and should be considered in this case. The prolonged nature of the patient's symptoms is inconsistent with anaphylaxis. Chronic pulmonary embolism is unlikely in this otherwise healthy teenager. Although exposure to asbestos can cause infiltrative lung disease, pleural disease, or malignancy, it typically does not develop for decades.
A 48-year-old healthy obese woman comes to your clinic with a 1-day history of nonradiating epigastric burning pain that started 2 hours aer eating lunch, which she rates as a 4 on 10-point pain scale. She describes similar pains in the past few months but never as severe. The pain is worse when lying flat in bed at night and has been relieved in the past by antacids. She denies fevers, weight loss, changes in her bowel movements, or radiation to her back. Physical examination demonstrates normal vital signs and is only notable for mild epigastric tenderness. A Cholecystitis B Pancreatitis C Peptic ulcer disease D Aortic dissection E Celiac sprue
PUD Explanation: Peptic ulcer disease (PUD) is very common; symptoms may include epigastric "burning" or pain, epigastric fullness, postprandial belching, or bloating. As in this patient, duodenal ulcer pain classically occurs hours aer eating on an empty stomach. Gastric ulcer pain classically occurs soon aer eating. Pancreatitis and cholecystitis are important considerations in the dierential diagnosis of acute epigastric pain. Patients with these disorders are typically more ill-appearing, with fevers and nausea or vomiting. In addition, pancreatitis pain is often severe and may radiate to the back. Aortic dissection most commonly presents with tearing chest pain that radiates to the back and is seen in patients who have severe hypertension, abuse cocaine, or have a connective tissue disorder such as Marfan syndrome. Celiac sprue usually presents with diarrhea, flatulence, weight loss, and bloating; acute pain is unusual in this condition.
A 65-year-old man with a prior myocardial infarction presents to your office with intermittent chest pain for the last 10 days. The pain is diffuse and precordial, increases with inspiration or lying down, and is relieved by sitting up and leaning forward. Sometimes the pain can last for hours at a time. It is somewhat different from his prior heart attack pain, but bothers him nonetheless and can bring on a sensation of shortness of breath when it is severe. Three weeks ago, he had what felt like the flu, but this resolved after a few days. The pain is not clearly related to exertion. What is the most likely diagnosis? A Pericarditis B Unstable angina C Musculoskeletal chest pain D Pulmonary embolism
Pericarditis The correct answer is A. You answered A. Explanation: Although the patient has had a prior myocardial infarction, the features of his current chest pain (nonexertional, pleuritic, and positional) do not suggest myocardial ischemia. The recent flu-like illness and relief of the pain upon sitting up and leaning forward suggest pericarditis.
A 30-year-old man complains of recurrent, self-limited episodes of "bloody" urine and abdominal pain. He has a 10-year history of smoking one-half pack of cigarettes per day. His grandfather died of kidney disease, and his paternal aunt and father are currently treated on the "kidney machine." What is the most likely diagnosis? A Polycystic kidney disease B Bladder cancer C Ureteral calculus D IgA nephropathy E Urinary tract infection
Polycystic kidney disease Explanation: This patient's family history is positive for kidney disease in his grandfather, father, and paternal aunt, which suggests a familial form of kidney disease. Autosomal dominant polycystic kidney disease (PCKD) is common, occurring in approximately 1 in 500 births. Patients with PCKD can present with recurrent gross hematuria and abdominal pain of one of the multiple cysts found in the grossly enlarged, often football-sized kidneys. Although smoking is an alarm feature for bladder cancer, this disease rarely occurs in patients less than 40 years old. A ureteral calculus would be expected to cause intense flank or abdominal pain, and unlike PCKD, there is not a clear genetic predisposition. Likewise, there is no clear genetic cause for IgA nephropathy. The self-limited nature of the patient's symptoms (without treatment) does not support the diagnosis of urinary tract infection.
A 48-year-old female presents with a a-week history of persistent cough that was preceded by an episode of low-grade fever, sore throat and rhinitis that lasted 5 days. She describes the cough as persistent, hacking and non-productive She IS a non- smoker and denies hemoptysis. The most likely etiology of her cough is. A: Asthma B. Bacterial sinusitis C: Pertussis D: Post infectious
Post infections
A 30-year-old man comes to the emergency room complaining of mild dyspnea and diuse chest pain that started suddenly 3 hours ago and worsens with inspiration. While sitting in the waiting room, he has an episode of prolonged coughing that produces small amounts of bright red blood. The physical examination reveals tachycardia and a testicular mass. He has no other medical problems and takes no medications. He just returned from a 12-hour drive to visit his family. What is the most likely diagnosis? A Bronchitis B Pulmonary embolism C Pneumonia D Tuberculosis
Pulmonary Embolism Explanation: The most likely diagnosis is pulmonary embolism, which typically presents with acute chest pain and dyspnea. Prolonged immobility and hypercoagulability are risk factors for pulmonary embolism. The patient was immobile for a prolonged period of time during his recent travel. Furthermore, his testicular mass most likely represents a malignancy, which increases his risk for hypercoagulability. Bronchitis and pneumonia are less likely as he did not complain of fevers or increased sputum production. He does not have risk factors for tuberculosis.
A 67-year-old hospitalized man complains of shortness of breath for the past hour. Although lying in the bed, he is breathing quickly and appears nervous. He was admitted 4 days earlier aer being hit by a car and was found to have a displaced tibial fracture, which required immediate operative intervention. Chest radiograph at admission showed a 5-cm lung mass suspicious for cancer. The patient has a 60 pack-year smoking history. He has had a persistent nonproductive cough for the past several months but denies any other symptoms. What is the most likely cause of his dyspnea? A Lung mass B Pulmonary embolism C Rib fracture D Anxiety E Deconditioning
Pulmonary Embolism Pulmonary embolism (PE) is the most likely cause of dyspnea in this patient. The significant smoking history and suspicious mass on chest radiograph are very concerning for lung cancer. The patient's acute dyspnea is most likely due to a venous thromboembolism (deep venous thrombosis) originating in the leg. The modified Wells criteria are clinical prediction rules that can be used to classify the patient as likely (score > 4) or unlikely (score ≤ 4) to have a PE (see van Belle et al reference in Suggested Reading section of Chapter 25). This patient has a Wells score of 4.5, placing him in the category of likely to have a PE because he has had recent surgery (1.5 points) and does not have an alternative diagnosis that is more likely than PE to explain his symptoms (3 points). If the patient also has lung cancer, leading to a hypercoagulable state, this would further increase his Wells score (1 point). Smoking has also been associated with an increased risk of PE. Rib fractures are generally highly painful and lead to shallow, hesitant respirations and, if displaced, can cause pneumothorax. In this case, rib fracture is unlikely given the delay between the patient's accident and the onset of dyspnea. Anxiety should not be diagnosed until other causes have been ruled out. Deconditioning will be a concern for this patient during his recovery but is unlikely to present acutely.
A 60-year-old male smoker was brought to the ED aer passing out while standing up. He regained consciousness a few minutes later but offered complaints of chest pain and dyspnea. The chest pain is rightsided and sharp and worsens with inspiration and cough. His cough is mildly productive and at times bloodtinged. On further questioning, he had felt generally well prior to this episode, although he had knee surgery 6 weeks ago. What is the most important diagnostic consideration? a. pericarditis b. myocardial infarction c. pneumothorax d. pulmonary embolism
Pulmonary embolism Explanation: Chest pain and dyspnea with syncope should raise consideration for conditions that disrupt global cardiac output including acute myocardial infarction, other serious cardiovascular causes (eg, arrhythmia, valvular heart disease), and large pulmonary embolism that obstructs right ventricular flow. Here, the patient has had recent lower extremity surgery that increases the likelihood of deep venous thrombosis that can lead to pulmonary embolism. The pleuritic nature of chest pain and associated hemoptysis also suggest pulmonary embolism. Pleuritic chest pain can also be a feature of pericarditis, pneumonia, and pneumothorax, although the presentation usually does not include acute chest pain with syncope. The overall constellation points most strongly to pulmonary embolism.
A 25-year-old medical student agrees to have 75 mL of blood drawn for a scientific study. While the phlebotomist is attempting to draw the blood, she encounters difficulty and begins manipulating the needle and probing. The medical student becomes pale, cold, and clammy. A few seconds later, he slumps over in the chair and has several brief jerking movements of the arms and legs. He is helped down to the floor and promptly regains consciousness. After a few brief moments of confusion, he appears normal and is quite embarrassed. What is the most likely diagnosis? A Seizure B Orthostatic hypotension C Carotid sinus syncope D Vasovagal syncope
Removal of 75 mL of blood is insufficient to cause orthostatic hypotension. Finally, there is no antecedent, reproducible history of neck turning or a tight collar to suggest carotid sinus syncope. Answer: D- Vasovagal syncope
A 55-year-old overweight woman presents to clinic with nausea, vomiting, and abdominal pain. She had no prior gastrointestinal symptoms until about 16 hours ago when she developed increasingly severe upper abdominal discomfort, followed by nausea and nonbloody emesis and subjective fever and chills, but no jaundice. Which of the following can best establish or exclude a diagnosis of acute cholecystitis? A Physical examination showing right upper quadrant tenderness with inspiratory arrest (Murphy sign) B Liver chemistry panel (aspartate aminotransferase [AST], alanine aminotransferase [ALT], alkaline phosphatase, total and direct bilirubin, albumin) C Complete blood count D Right upper abdominal ultrasonography E No further testing needed
Right upper abdominal ultrasonography Explanation: No single clinical finding has sufficient diagnostic power to establish or exclude a diagnosis of acute cholecystitis in a patient with upper abdominal pain without further testing. With this patient's clinical presentation, ultrasonographic findings of cholelithiasis, a thickened gallbladder wall, and a gallbladder that is tender when pressed with the ultrasound transducer (sonographic Murphy sign) confirm a diagnosis of cholecystitis. The dierential diagnosis in this case includes acute cholecystitis, acute pancreatitis, and acute cholangitis. The Murphy sign has an LR+ of 2.8 but is subject to examiner bias.
Your patient, a 22-year-old woman with a presumptive diagnosis of migraine headaches, comes to see you for a routine periodic health examination. Which of the following locations of head pain would be most consistent with the diagnosis of migraine? A Occipital B Frontal C Temporal D Periorbital E Vertex
TEmporal we didn't learn this but remember UNILATERAL for Migraine. and Periorbital would be CLUSTER Explanation: While there is some variation of pain location among patients with migraine, most patients will report unilateral pain that is most intense in the temporal area. Occipital and vertex pain raise the possibility of a cervicogenic headache. Periorbital pain can occur with cluster headache and with trigeminal neuralgia. Frontal pain is nonspecific.
A 67-year-old man with a 40 pack-year smoking history complains of shortness of breath for the past 6 months and swelling in his legs. He often wakes up at night gasping for breath and feels most comfortable sleeping on 3 pillows. He has no past history of COPD or CHF, but he has diabetes and hypertension. What is the most likely diagnosis? A Congestive heart failure B Chronic obstructive pulmonary C Asthma D Lung cancer E Pulmonary embolism
The correct answer is A. CHF Explanation: The patient has several coronary artery disease risk factors (male sex, age > 55 years, smoking history, diabetes, and hypertension) and describes paroxysmal nocturnal dyspnea, 3-pillow orthopnea, and lower extremity edema, the classic symptoms of congestive heart failure (CHF). The patient's significant smoking history also raises suspicion for chronic obstructive pulmonary disease. Asthma is less likely given the patient's age of onset. The patient's smoking history puts him at increased risk of lung cancer. Pulmonary embolism can be diicult to diagnose. Although the other diagnoses cannot be definitively excluded, the clinical picture is most consistent with CHF.
Which of the following is not a cause of syncope? A Carotid distribution transient ischemic attack B Severe aortic stenosis C Pulmonary embolism D Paroxysmal supraventricular tachycardia E Left atrial myxoma
The correct answer is A. You answered A. Explanation: Transient ischemic attacks (TIAs) are transient and, like syncope, self-limited. However, carotid artery distribution TIAs typically last longer and are associated with localizing neurologic signs and symptoms. Vertebrobasilar TIAs may cause loss of consciousness but are accompanied by hemianopsia or other focal neurologic features such as vertigo, dysarthria, and diplopia. In general, cerebrovascular disease is an unusual cause of syncope and should not be considered unless there are focal neurologic symptoms or signs. Only subclavian steal causes loss of consciousness compatible with syncope, often triggered by arm exercise. All other options are known causes of syncope. Severe aortic stenosis causes exercise-induced syncope via decreased cerebral perfusion due to obstruction of le ventricular outflow and cardiac output in the face of peripheral vascular dilatation in exercising muscles. Pulmonary embolism raises pulmonary arterial pressures causing functional obstruction to right ventricular outflow, which leads to "underfilling" of the le ventricle and decreased cardiac output. Le atrial myxoma causes transient obstruction of inflow to the le ventricle and thus decreased cardiac output, leading to decreased cerebral perfusion that is often positional
In one of your acute care openings, you see a 72-year-old man with hypertension, diabetes mellitus, and chronic tobacco use. He awakened without any problems but developed the acute onset of dizziness during breakfast. He can barely walk. He notes double vision. What would be the most reasonable next step in caring for this patient? A Return home and monitor symptoms of vestibular neuronitis B Send him to the emergency department for urgent evaluation of acute vertebrobasilar infarct C Perform maneuvers in the office to realign inner ear otoliths for BPPV D Hold all blood pressure medications to prevent syncope
The correct answer is B. Explanation: This patient is having an acute vertebrobasilar infarct and has numerous red flags. He has multiple stroke risk factors, including diabetes mellitus, hypertension, and tobacco use. The sudden onset of dizziness, severe ataxia, and double vision are all alarm symptoms. He requires an urgent evaluation for a serious neurologic cause.
An 18-year-old male is brought to your clinic by his parents, who state that their son has been withdrawing from them and from his friends at school. They report that he has been especially irritable over the past months and prefers to isolate himself. You suspect that the patient may be suering from a depressive episode. Of the following symptoms, which symptom is most crucial to assess before the patient (or any patient that you suspect has depression) leaves your oice? A Fatigue B Diiculty concentrating C Anhedonia (diminished interest/pleasure) D Suicidal ideation
The correct answer is D. You answered D. Explanation: If a patient appears to be suering from depression, it is critical to assess for suicidal ideation, plan, and intent. Some clinicians fear that inquiring about suicide may inadvertently introduce the idea and thereby put the patient at higher risk, but evidence does not support this notion (Gould MS, Marrocco FA, Kleinman M, et al. Evaluating iatrogenic risk of youth suicide screening programs. JAMA. 2005;293:1635- 1643). If a patient endorses having thoughts of death or of hurting himself or herself, a clinician should then inquire as to whether the patient has a plan or method for attempting suicide, whether the patient has a history of previous attempts, and whether the patient intends to carry out the suicide plan. Positive responses to these inquiries put a patient at high risk for suicide, and emergency measures such as inpatient hospitalization should be considered.
Your next patient is a 30-year-old man with a chief complaint of abdominal pain. The pain intensifies in the absence of food and generally is relieved once he eats. He reports vomiting several times a week. Which of the following features, if present, would suggest a diagnosis of peptic ulcer disease? A Pain worsening upon lying down B Pain colicky in nature C Diiculty with swallowing D History of prolonged NSAID use
The correct answer is D. You answered D. Explanation: Peptic ulcer disease can cause significant morbidity, particularly if it is associated with bleeding or perforation. Patients with gastric ulcers generally find their symptoms worsened with food, whereas those with duodenal ulcers generally exhibit decreased symptomatology aer eating. NSAID use and Helicobacter pylori infection are 2 of the most important risk factors for peptic ulcer disease. Pain that is worse upon lying down is suggestive of reflux. Colicky pain is more suggestive of biliary disease, and diiculty with swallowing or odynophagia is typically associated with an esophageal stricture, irritation, ring, or mass.
You evaluate a 52-year-old nurse who lost consciousness while reading in bed. Her husband witnessed the episode and phoned 911. Which historical feature is most concerning for a serious cause of syncope? A Loss of consciousness B Spontaneous, prompt, and complete recovery C Sweating and nausea D Occurrence in the supine position
The correct answer is D. You answered D. Explanation: The first 3 options are typical of vasovagal syncope. Loss of consciousness in the supine position is an alarm symptom suggesting a cardiac cause such as an arrhythmia.
A 76-year-old man with history of diabetes and hypertension comes to the emergency department for evaluation of bright red blood per rectum. The patient reports 3 episodes of bright red blood per rectum with clots. There is no stool mixed with the blood. He denies dizziness, fatigue, shortness of breath, abdominal pain, nausea, vomiting, or hematemesis. He had a normal colonoscopy 1 year ago except for diverticulosis and internal hemorrhoids. Six months ago, he had one prior episode of bright red blood per rectum that resolved on its own and for which he did not seek medical care. On physical examination, he is well appearing and in no acute distress. His blood pressure is 120/70 mm Hg, and his heart rate is 80. His nasogastric lavage is negative, with bilious fluid. What is the most likely etiology of this patient's hematochezia? A Esophagitis B Gastric cancer C Hemorrhoids D Diverticulosis
The correct answer is D. You answered D. Explanation: The patient has a history of diverticulosis, with one prior episode of self-limited GI bleeding. Bleeding occurs in less than 5% of patients with diverticulosis. Most diverticular bleeds stop spontaneously but may recur in 25% of cases. Esophagitis and gastric cancer are unlikely to present with hematochezia. Hemorrhoids present with trivial amounts of bright red blood per rectum, such as blood on the toilet paper aer wiping or drops of blood in the toilet bowl aer a bowel movement. Occasionally, red blood is noted to cover the stool. Hemorrhoidal bleeding does not cause frankly bloody bowel movements with clot.
A 30-year-old alcoholic man with no past medical or surgical history is brought in by ambulance to the ED with severe (7/10) epigastric abdominal pain. The pain started 5 hours aer the ingestion of a large meal. It radiates to the back and is associated with nausea and nonbloody, nonbilious emesis. He denies any problems or pain with urinating. On physical examination, he is afebrile, tachycardic, and tender without rebound in the epigastrium and le upper quadrant. What is the most likely diagnosis? A Peptic ulcer disease B Cholecystitis C Appendicitis D Nephrolithiasis E Pancreatitis
The correct answer is E. You answered E. Explanation: After gallstones, alcohol is the second most common cause of acute pancreatitis and is the most common cause in men. This patient is presenting with many classic features of pancreatitis including epigastric pain radiating to the back associated with nausea and vomiting. Peptic ulcer disease is usually characterized by chronic epigastric burning that occurs after eating and is relieved with antacids. The pain is usually not severe and is rarely associated with nausea and vomiting. Both cholecystitis and appendicitis pains are also acute and severe and can be associated with nausea and vomiting. However, cholecystitis pain is usually localized to right upper quadrant and may radiate to the right shoulder. Appendicitis pain initially starts in the periumbilical region and then localizes to the right lower quadrant. Nephrolithiasis patients may be asymptomatic or have colicky flank pain that radiates to the groin and is often associated with urinary symptoms including dysuria and urgency.
A 78-year-old man presents to your clinic with gradual onset of perineal and scrotal pain and fever over the past 36 hours. He was recently hospitalized with pneumonia and discharged 7 days ago. With further questioning, he reports dysuria since hospital discharge, which he relates to the removal of a bladder catheter he had in place while in the hospital. Which of the following is the most likely cause of his pain? A Urolithiasis B Abdominal aortic aneurysm C Testicular torsion D Inguinal hernia E Prostatitis
The correct answer is E. You answered E. Explanation: Prostatitis or epididymitis is more likely to occur in older patients with recent instrumentation. Each has a more gradual onset and later presentation than testicular torsion and is often accompanied by dysuria and fever. Nephrolithiasis and abdominal aortic aneurysm rupture typically cause pain in the abdomen and perineal area. These entities and inguinal hernia are all less likely to present with fever.
You see a 40-year-old woman with throbbing headaches. She reports that the symptoms began approximately 2 months ago and have gradually worsened. They are always on the right side. On one occasion, she had a prolonged visual aura of zigzag lines that lasted for one day and persisted aer the headache had resolved. Which of the following features is not an alarm symptom that should prompt concern for headache? A New onset of headache at age 40 B Throbbing pain C Prolonged visual aura D Worsening pain over 2 months E Pain always on the right side
Throbbing pain Migraine headaches usually begin for the first time in adolescence. Migraine-like headaches that begin for the first time at age 40 raise concern about an arteriovenous malformation (AVM). Although migraines are commonly unilateral, they should vary from one side to the other over a patient's lifetime. Pain always on the same side also suggests the possibility of AVM, although in some patients, this will prove to be an atypical manifestation of ordinary migraine. Pain that worsens over 2 to 3 months is worrisome for a brain tumor. Finally, visual aura should not last for more than 1 hour, so a prolonged aura raises concern for AVM as well. Throbbing pain is a cardinal feature of migraine and by itself is not an alarm symptom.
You are seeing an 80-year-old man with a 2-day history of dysuria and increased urinary frequency. These symptoms have worsened over the last day, and this morning, he was unable to urinate. He also developed fever, shaking chills, and lower abdominal pain. He underwent bladder catheterization during a hospitalization 1 week ago. He denies back pain, hematuria, and scrotal swelling or pain. What is the most likely diagnosis? A Prostate cancer B Bacterial epididymitis C Bladder outlet obstruction from benign prostatic hyperplasia D Acute bacterial prostatitis
acute bacterial prostatitis Explanation: This patient has new-onset dysuria and urinary frequency suggesting bladder irritation or infection. His worsening voiding symptoms are concerning for acute urinary retention. This constellation of symptoms, along with systemic symptoms suggesting acute infection, makes acute bacterial prostatitis the most likely diagnosis. Benign prostatic hyperplasia and recent bladder catheterization are the 2 most common risk factors for acute prostatitis. Although epididymitis can also cause fever and chills and may be seen in patients with bacterial prostatitis, this patient's lack of scrotal swelling and pain make epididymitis less likely. His symptoms are concerning for acute bladder outlet obstruction, which is likely due to a swollen, inflamed prostate rather than benign prostatic hyperplasia alone.
A 22-year-old woman presents to your clinic with a 1-year history of a frequent "flip-flopping" sensation in her chest. She has no personal or family history of heart disease and notices her symptoms most after her morning coffee. Two days ago, she got very light-headed during an episode and had to sit down because she thought she was very close to passing out. She was recently put on erythromycin for sinusitis. Which of the following statements is most accurate? a. she requires no further work-up b. An electrocardiogram should be performed to look for QT prolongation c. her symptoms are certain to resolve if she stops ingesting caffeine
b Many clinicians might overlook this patient's palpitations because they have been chronic. Although stopping caeine may help, the key point is that she reports a recent presyncopal episode (an alarm symptom) aer starting a new medication (erythromycin). Erythromycin is well known to cause QT prolongation, so obtaining an electrocardiogram to measure the QT interval is the most appropriate answer. Clinicians who are uncertain about a medication's eect on the QT interval should consult a pharmacist or online resource.
Each of the following women presents with dysuria and has not had a medical evaluation for over a year. Which patient does not need testing for chlamydia? A 19-year-old sexually active woman who consistently uses condoms B 32-year-old woman with a new male sexual partner C 26-year-old woman who has not been sexually active for the past year D 27-year-old married woman who had chlamydia at age 26
c. not sexually active for past yr Sexually active young women with dysuria are at relatively high risk for urethritis caused by chlamydia or other sexually transmitted infections. In addition to urinalysis, such women should be queried about their risk for sexually transmitted infections. Sexually active women who are less than 25 years old, have a new male sexual partner, or report a prior sexually transmitted infection (STI) are at high risk and should undergo pelvic examination and chlamydia testing. Because condom use reduces, but does not eliminate, the risk of STIs, women who are at high risk should undergo chlamydia screening regardless of their use of barrier contraceptive methods.
In a patient with severe right-sided flank pain, which of the following lowers your suspicion for nephrolithiasis? A Stabbing, severe pain B Intermittent nature of pain C Onset approximately 2 months ago D Hematuria
c. onset approximately 2 months ago Explanation: It is unlikely that this patient would tolerate the severe pain of nephrolithiasis for 2 months before seeking medical attention. The pain of pyelonephritis is often described by patients as intense spasm-like pain in the flank. Nephrolithiasis can be associated with gross hematuria. Finally, nephrolithiasis can recur, and a history of nephrolithiasis may prompt suspicion that another kidney stone has formed.
A 29-year-old man reports episodic palpitations for the last 2 months. He has recently taken a job as a construction worker and is working on a new high-rise building. He has the episodes whenever he is working on the roof. He reports associated diaphoresis and shortness of breath but denies personal history of cardiac disease, family history of arrhythmia, or dizziness. Which of the following points in the history would be most reassuring? A Polyuria B A personal history of panic disorder and multiple unexplained symptoms C A family history of long QT syndrome D Use of diphenhydramine for seasonal allergies
✓ B A personal history of panic disorder and multiple unexplained symptoms This patient has no identified alarm symptoms for arrhythmia. Although male gender may suggest a cardiac etiology, a history of panic disorder carries a likelihood ratio of 0.5. The other 3 answers all suggest an arrhythmic cause. Polyuria may indicate arrhythmia because of atrial stretch (causing increased release of atrial natriuretic peptide). A family history of long QT syndrome is an obvious red flag, and use of antihistamine can be associated with QT prolongation.
A 56-year-old man sees you for a long-standing cough. He has had a cough for at least 6 months. On a review of systems, he denies wheezing, nasal congestion, weight loss, fevers, or hemoptysis. He has occasional heartburn characterized by a midline retrosternal burning, especially aer heavy meals or chocolate. He has had frequent hoarseness over the past month. Another physician did a preliminary work-up that included a chest x-ray and blood and urine studies. All of these tests were normal. What should you do next? A Do additional questioning/testing for possible bronchial asthma B Do additional questioning/testing for possible GERD C Do additional questioning/testing for possible infectious causes of cough D Follow his symptoms and schedule a follow-up in 1 month
✓ B Do additional questioning/testing for possible GERD The correct answer is B. You answered D. Explanation: His symptoms suggest GERD. Heartburn characterized by a midline retrosternal burning is a characteristic feature of GERD. Hoarseness may be a sign of severe disease. The patient should be treated empirically for this diagnosis. Depending on his response to therapy, additional testing might be required to confirm the diagnosis. Although asthma remains a possibility, he had no wheezing or other features to suggest this diagnosis. Based on his symptoms, the likelihood of an infectious cause of his cough is low.