MSKAP Extravaganza: The Eye, the Ear, and Randoms! November 2013 Alison Landrey Richard Pinckney Halle Sobel

MSKAP Extravaganza:The Eye, the Ear, and Randoms!

November 2013Alison Landrey

Richard PinckneyHalle Sobel

• A 23-year-old man is evaluated for a 3-day history of redness and itchiness of the right eye. He had an upper respiratory tract infection 3 days before the eye symptoms began. Each morning he has awoken with crusting over the lids. He is otherwise healthy, with no ocular trauma or recent medical problems.

• On physical examination, he is afebrile, blood pressure is 122/72 mm Hg, pulse rate is 66/min, and respiration rate is 16/min. Right eye conjunctival injection is present, with some crusting at the lids. Bilateral vision is 20/20. Pupils are equally round and reactive to light.

• Which of the following is the most appropriate management of this patient?

A. Cool compresses to the affected eyeB. Oral antihistamineC. Topical antibioticsD. Topical corticosteroids

• A 23-year-old man is evaluated for a 3-day history of redness and itchiness of the right eye. He had an upper respiratory tract infection 3 days before the eye symptoms began. Each morning he has awoken with crusting over the lids. He is otherwise healthy, with no ocular trauma or recent medical problems.

• On physical examination, he is afebrile, blood pressure is 122/72 mm Hg, pulse rate is 66/min, and respiration rate is 16/min. Right eye conjunctival injection is present, with some crusting at the lids. Bilateral vision is 20/20. Pupils are equally round and reactive to light.


A. Cool compresses to the affected eyeB. Oral antihistamineC. Topical antibioticsD. Topical corticosteroids

The Red Eye

• How long are people with conjunctivitis contagious?

• What is the treatment for viral conjunctivitis?

• Typically no pain, cornea is clear, pupil is normal. IOP is normal.

The Red Eye

• Why should you care?

• Most common eye condition seen in primary care.

• What should the history and physical focus on?

The Red Eye

• What are other causes of the red eye?

• Who needs referred emergently to an ophthalmologist?

The Red Eye• Glaucoma• Orbital Disease• Scleritis• Uveitis• Conjuncitivitis• Keratitis (HSV)• Subconjuctival Hematoma• Corneal Conditions• Chalazion, stye

The Red Eye

• Uveitis: urgent referral

• The presence of ciliary flush

• Presents with pain, photophobia and blurred vision

The Red Eye

The Red Eye

• Episcleritis

• Superficial inflammation of the superficial vessels of the episclera

• Typically no pain, no visual changes, no tearing, resolves without treatment

The Red Eye

• Scleritis: emergent referal

• Inflammation of the fibrous layer of the eye underlying the conjunctiva and episclera

Severe, dull pain, may have awoken a patient from sleep; may be visual loss

• A 76-year-old woman is evaluated for a 1-day history of headache, left eye pain, nausea and vomiting, seeing halos around lights, and decreased visual acuity of the left eye. She has type 2 diabetes mellitus, hypertension, and atrial fibrillation. Medications are metformin, digoxin, metoprolol, hydrochlorothiazide, and warfarin.

• On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 148/88 mm Hg, pulse rate is 104/min, and respiration rate is 16/min. Visual acuity wearing glasses is 20/40 (right eye) and 20/100 (left eye). The left eye has conjunctival erythema. The right pupil is reactive to light, the left pupil is sluggish and constricts in response to light from 6 mm to 4 mm. On palpation of the ocular globe, the left globe feels firm as compared with the right.

• Which of the following is the most likely diagnosis?A. Acute angle-closure glaucomaB. Central retinal artery occlusionC. Ocular migraineD. Temporal arteritis

• A 76-year-old woman is evaluated for a 1-day history of headache, left eye pain, nausea and vomiting, seeing halos around lights, and decreased visual acuity of the left eye. She has type 2 diabetes mellitus, hypertension, and atrial fibrillation. Medications are metformin, digoxin, metoprolol, hydrochlorothiazide, and warfarin.

• On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 148/88 mm Hg, pulse rate is 104/min, and respiration rate is 16/min. Visual acuity wearing glasses is 20/40 (right eye) and 20/100 (left eye). The left eye has conjunctival erythema. The right pupil is reactive to light, the left pupil is sluggish and constricts in response to light from 6 mm to 4 mm. On palpation of the ocular globe, the left globe feels firm as compared with the right.

• Which of the following is the most likely diagnosis?A. Acute angle-closure glaucomaB. Central retinal artery occlusionC. Ocular migraineD. Temporal arteritis

Acute-Angle Glaucoma

• What is the pathophysiology?

• Halos, severe pain (may present as a headache), decreased visual acuity, elevated IOP, pupil mid-dilated

• A 70-year-old man is evaluated for a 6-month history of low energy and decreased libido. He is not in a depressed mood and is still interested in daily activities. He has glaucoma and hypertension. Over the past year his vision has decreased and his ophthalmologist has adjusted his medications repeatedly. His current medications are timolol drops, latanoprost drops (a prostaglandin analogue), dorzolamide drops (a topical carbonic anhydrase inhibitor), lisinopril, and amlodipine.

• On physical examination, temperature is 37.6 °C (99.7 °F), blood pressure is 138/84 mm Hg, pulse rate is 48/min and regular, and respiration rate is 12/min. BMI is 28. Other than bradycardia, the results of the physical examination are normal. An electrocardiogram shows only sinus bradycardia.

• Which of this patient's medications should be discontinued?A. AmlodipineB. DorzolamideC. LatanoprostD. LisinoprilE. Timolol

• A 70-year-old man is evaluated for a 6-month history of low energy and decreased libido. He is not in a depressed mood and is still interested in daily activities. He has glaucoma and hypertension. Over the past year his vision has decreased and his ophthalmologist has adjusted his medications repeatedly. His current medications are timolol drops, latanoprost drops (a prostaglandin analogue), dorzolamide drops (a topical carbonic anhydrase inhibitor), lisinopril, and amlodipine.

• On physical examination, temperature is 37.6 °C (99.7 °F), blood pressure is 138/84 mm Hg, pulse rate is 48/min and regular, and respiration rate is 12/min. BMI is 28. Other than bradycardia, the results of the physical examination are normal. An electrocardiogram shows only sinus bradycardia.

• Which of this patient's medications should be discontinued?A. AmlodipineB. DorzolamideC. LatanoprostD. LisinoprilE. Timolol

Glaucoma Treatment

• How does timolol work?

• Local drugs can have systemic effects.

• How do carbonic anydrase inhibitors work for glaucoma?

• A 70-year-old woman is evaluated for a 3-month history of vision problems. She reports that objects may appear blurry or distorted, particularly in the central field. She has difficulty reading and recognizing faces. She has no eye pain or recent eye trauma. She is a smoker. She is on no medications.

• On physical examination, vital signs are normal. Funduscopic findings are shown :shown . The remainder of the eye examination is normal.

• Which of the following is the most likely diagnosis?A. Age-related macular degenerationB. CataractsC. Primary open angle glaucomaD. Retinal detachment

• A 70-year-old woman is evaluated for a 3-month history of vision problems. She reports that objects may appear blurry or distorted, particularly in the central field. She has difficulty reading and recognizing faces. She has no eye pain or recent eye trauma. She is a smoker. She is on no medications.

• On physical examination, vital signs are normal. Funduscopic findings are shown :shown . The remainder of the eye examination is normal.

• Which of the following is the most likely diagnosis?A. Age-related macular degenerationB. CataractsC. Primary open angle glaucomaD. Retinal detachment

Q 29• A 55-year-old man is evaluated for a 1-day history of seeing flashing lights,

“squiggly” lines, and floating objects in his left eye followed by loss of vision at the outer periphery of the eye shortly after having breakfast this morning. He now describes seeing what looks like a curtain coming down in that location. He has myopia requiring prescription glasses.

• On physical examination, vital signs are normal. Vision in the right eye is 20/100 uncorrected and 20/40 with glasses. Vision in the left eye is 20/100 uncorrected and 20/40 with glasses. Pupils are equally reactive to light and accommodation. There is no conjunctival injection. Findings on funduscopic examination are shown :shown .

• Which of the following is the most likely diagnosis?A. Central retinal artery occlusionB. Central retinal vein occlusionC. Ocular migraineD. Retinal detachmentE. Temporal arteritis

Q 29• A 55-year-old man is evaluated for a 1-day history of seeing flashing lights,

“squiggly” lines, and floating objects in his left eye followed by loss of vision at the outer periphery of the eye shortly after having breakfast this morning. He now describes seeing what looks like a curtain coming down in that location. He has myopia requiring prescription glasses.

• On physical examination, vital signs are normal. Vision in the right eye is 20/100 uncorrected and 20/40 with glasses. Vision in the left eye is 20/100 uncorrected and 20/40 with glasses. Pupils are equally reactive to light and accommodation. There is no conjunctival injection. Findings on funduscopic examination are shown :shown .

• Which of the following is the most likely diagnosis?A. Central retinal artery occlusionB. Central retinal vein occlusionC. Ocular migraineD. Retinal detachmentE. Temporal arteritis

• A 19-year-old woman is evaluated for a 1-week history of left ear canal pruritus, redness, and pain. She swims 1 mile each day and has recently started wearing plastic ear plugs to keep water out of her ears while swimming.

• On physical examination, she is afebrile, blood pressure is 98/66 mm Hg, pulse rate is 62/min, and respiration rate is 16/min. She appears healthy and in no distress. There is pain with tugging on the pinna and compression or movement of the tragus. The left ear canal is shown :shown . With irrigation, the left tympanic membrane appears normal. There is no preauricular or cervical lymphadenopathy.

• Which of the following is the most likely diagnosis?• A Acute otitis externa• B Delayed-type hypersensitivity reaction to ear plugs• C Malignant otitis externa• D Otitis media

• A 19-year-old woman is evaluated for a 1-week history of left ear canal pruritus, redness, and pain. She swims 1 mile each day and has recently started wearing plastic ear plugs to keep water out of her ears while swimming.

• On physical examination, she is afebrile, blood pressure is 98/66 mm Hg, pulse rate is 62/min, and respiration rate is 16/min. She appears healthy and in no distress. There is pain with tugging on the pinna and compression or movement of the tragus. The left ear canal is shown :shown . With irrigation, the left tympanic membrane appears normal. There is no preauricular or cervical lymphadenopathy.

• Which of the following is the most likely diagnosis?• A Acute otitis externa• B Delayed-type hypersensitivity reaction to ear plugs• C Malignant otitis externa• D Otitis media

Otitis Externa• Symptoms:– ear fullness– Exacerbated by jaw motion

• Exam Findings– Canal erythema and edema, purulent debris– TM may be erythematous as well (but not bulging)– Pain with movement of tragus or pinna

• Treatment– Polymyxin/cortisporin drops OR topical

fluoroquinolones (e.g. ofloxacin)

• A 29-year-old man is evaluated for the gradual onset of right-sided hearing loss. He reports a continuous high-pitched ringing in his right ear that has been present for 3 to 4 months.

• On physical examination, vital signs are normal. When a vibrating 512 Hz tuning fork is placed on the top of his head, it is louder in the left ear. When placed adjacent to his right ear, it is heard better when outside the ear canal than when touching the mastoid bone. Otoscopic examination is normal bilaterally. Neurologic examination is normal other than right-sided hearing loss.


A. Biofeedback therapyB. Immediate treatment with oral corticosteroidsC. MRI of the posterior fossa and internal auditory canalD. Otolith repositioning maneuver

Weber and Rinne

• Weber: fork on forehead– Lateralizes to unaffected side in sensorineural

hearing loss, affected side in conductive

• Rinne: fork on mastoid then held over ear canal– If heard better on mastoid: suggests conductive

loss

• Sensorineural– acoustic neuroma/schwannoma

(unilateral, sometimes with tinnitus and vertigo)

– Menieres (unilateral with vertigo, tinnitus)

– SSNHL (unilateral, <3 days, often idiopathic

– Presbycusis (bilat, gradual)– Drug induced (bilat: loop

diuretics, AGs, chemo)– Autoimmune (bilateral

progressive)– Noise induced

• Conductive– Cholesteatoma– Foreign body, cerumen– Infection– otosclerosis

*if hearing loss with pain or drainage -> more likely conductive*If hearing loss with vertigo or tinnitus -> more likely sensorineural

A

B

C

Acoustic Neuroma Visual

• A 29-year-old man is evaluated for the gradual onset of right-sided hearing loss. He reports a continuous high-pitched ringing in his right ear that has been present for 3 to 4 months.

• On physical examination, vital signs are normal. When a vibrating 512 Hz tuning fork is placed on the top of his head, it is louder in the left ear. When placed adjacent to his right ear, it is heard better when outside the ear canal than when touching the mastoid bone. Otoscopic examination is normal bilaterally. Neurologic examination is normal other than right-sided hearing loss.


A. Biofeedback therapyB. Immediate treatment with oral corticosteroidsC. MRI of the posterior fossa and internal auditory canal D. Otolith repositioning maneuver

Asymmetric Sensorineural hearing loss not clearly due to menieres should be evaluated with MRI to exclude acoustic neuroma, meningioma

• A 72-year-old woman is evaluated for sudden hearing loss in the left ear with moderate ringing that started yesterday. She has no vertigo or dizziness.

• On physical examination, vital signs are normal. Otoscopic examination is initially obscured by cerumen bilaterally. Once cerumen is removed, the tympanic membranes appear normal and there is some redness in the canals bilaterally. When a 512 Hz tuning fork is placed on top of the head, it is louder in the right ear. When placed adjacent to the left ear, it is heard better when outside the ear canal than when touching the mastoid bone. Neurologic examination is normal other than left-sided hearing loss.


A. AcyclovirB. Neomycin, polymyxin B, and hydrocortisone ear dropsC. Triethanolamine ear dropsD. Urgent audiometry and referral

• A 72-year-old woman is evaluated for sudden hearing loss in the left ear with moderate ringing that started yesterday. She has no vertigo or dizziness.

• On physical examination, vital signs are normal. Otoscopic examination is initially obscured by cerumen bilaterally. Once cerumen is removed, the tympanic membranes appear normal and there is some redness in the canals bilaterally. When a 512 Hz tuning fork is placed on top of the head, it is louder in the right ear. When placed adjacent to the left ear, it is heard better when outside the ear canal than when touching the mastoid bone. Neurologic examination is normal other than left-sided hearing loss.


A. AcyclovirB. Neomycin, polymyxin B, and hydrocortisone ear dropsC. Triethanolamine ear dropsD. Urgent audiometry and referral

Sudden sensorineural hearing loss

• If no obvious cause on exam (infection, cerumen), urgent referral to ENT

• Prednisone may have some benefit in reversing hearing loss

• A 66-year-old woman is evaluated for several months of a “whistling” or “swishing” sound in her right ear. She notes that it gets faster and louder when she exercises and thinks it is timed to her heartbeat. She does not notice any hearing loss, dizziness, or vertigo.

• On physical examination, temperature is 37.4 °C (99.3 °F), blood pressure is 138/84 mm Hg, and pulse rate is 84/min. Auditory acuity to normal conversation appears normal, and otoscopic examination is unremarkable bilaterally. Neurologic examination is normal.

• Which of the following is the most appropriate next step in the management of this patient?

A. AudiometryB. Auscultation over the right ear, eye, and neckC. Trial of a sound-masking deviceD. Trial of a nasal corticosteroid spray

• A 66-year-old woman is evaluated for several months of a “whistling” or “swishing” sound in her right ear. She notes that it gets faster and louder when she exercises and thinks it is timed to her heartbeat. She does not notice any hearing loss, dizziness, or vertigo.

• On physical examination, temperature is 37.4 °C (99.3 °F), blood pressure is 138/84 mm Hg, and pulse rate is 84/min. Auditory acuity to normal conversation appears normal, and otoscopic examination is unremarkable bilaterally. Neurologic examination is normal.

• Which of the following is the most appropriate next step in the management of this patient?

A. AudiometryB. Auscultation over the right ear, eye, and neckC. Trial of a sound-masking deviceD. Trial of a nasal corticosteroid spray

Pulsatile Tinnitus

• Concern for vascular etiology– Stenosis or AVM

• Eustachian Tube Dysfunction can also uncommonly cause pulsatile tinnitus– Look for middle ear effusion on exam, ask about

significant nasal congestion, evidence of conductive hearing loss

• Of note: nonpulsatile tinnitus Is most commonly due to sensorineural hearing loss ->audiometry appropriate

• A 72-year-old man is evaluated in the emergency department for a 12-hour episode of dizziness, described as a “spinning sensation” when he opens his eyes. He has nausea without vomiting, has had no loss of consciousness, no palpitations, and no other neurologic symptoms. He requires assistance to walk. He prefers to keep his eyes closed but has no diplopia. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus. He had an upper respiratory tract infection 2 weeks ago. Medications are hydrochlorothiazide, lisinopril, simvastatin, and metformin.

• On physical examination, vital signs are normal. There are no orthostatic changes. Results of a cardiovascular examination are normal. He has no focal weakness. He cannot stand without assistance. Vertical nystagmus occurs immediately with the Dix-Hallpike maneuver. It persists for 90 seconds and does not fatigue. Electrocardiogram is consistent with left ventricular hypertrophy and shows no acute changes.

• Which of the following is the most appropriate next step in management?A. CT scan of the head without contrastB. MRI with angiography of the brainC. Otolith repositioningD. Trial of vestibular suppressant medication

Vertigo:1) What features distinguish vertigo from other causes of dizziness? 2) What are two general categories of vertigo?

the Dix Hallpike helps distinguish Peripheral (horizontal nystagmus) vs. Central (vertical)

• Peripheral– BPPV (transient with head

movement)– Vestibular neuronitis

(postviral inflammation with nausea, persistant severe sx)

– Acute labyrinthitis (with hearing loss)

– Menieres

• Central (<1% of vertigo)– Acoustic neuroma (esp if

hearing loss concurrent)– Migraine– Posterior circulation

cerebrovascular disease (infarct or ischemia) (consider if risk factors)-> MRA if vascular cause suspected

- Head trauma (get hx of coagulopathy

- Brain lesion (mets, toxoplasmosis, CNS lymphoma – hx of cancer, HIV)

• A 72-year-old man is evaluated in the emergency department for a 12-hour episode of dizziness, described as a “spinning sensation” when he opens his eyes. He has nausea without vomiting, has had no loss of consciousness, no palpitations, and no other neurologic symptoms. He requires assistance to walk. He prefers to keep his eyes closed but has no diplopia. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus. He had an upper respiratory tract infection 2 weeks ago. Medications are hydrochlorothiazide, lisinopril, simvastatin, and metformin.

• On physical examination, vital signs are normal. There are no orthostatic changes. Results of a cardiovascular examination are normal. He has no focal weakness. He cannot stand without assistance. Vertical nystagmus occurs immediately with the Dix-Hallpike maneuver. It persists for 90 seconds and does not fatigue. Electrocardiogram is consistent with left ventricular hypertrophy and shows no acute changes.

• Which of the following is the most appropriate next step in management?A. CT scan of the head without contrastB. MRI with angiography of the brainC. Otolith repositioningD. Trial of vestibular suppressant medication

• A 48-year-old man is evaluated for a 2-day history of episodic dizziness with nausea. He noted the onset abruptly and compares the feeling to “being on a roller coaster.” His most severe episodes occurred while arising from bed and when parallel parking his car. The symptoms lasted 30 to 40 seconds and were followed by two episodes of emesis. He has no recent fever, headache, tinnitus, hearing loss, double vision, dysarthria, weakness, or difficulty walking. He had a similar episode 5 years ago. Medical history is significant for depression. His only medication is citalopram.

• On physical examination, vital signs are normal. Results of cardiac and neurologic examinations are normal. The Dix-Hallpike maneuver precipitates severe horizontal nystagmus after about 20 seconds. With repeated maneuvers, the nystagmus is less severe.

• Which of the following is the most likely diagnosis?A. Benign paroxysmal positional vertigoB. Cerebellar infarctionC. Meniere diseaseD. Vestibular neuronitis

• A 48-year-old man is evaluated for a 2-day history of episodic dizziness with nausea. He noted the onset abruptly and compares the feeling to “being on a roller coaster.” His most severe episodes occurred while arising from bed and when parallel parking his car. The symptoms lasted 30 to 40 seconds and were followed by two episodes of emesis. He has no recent fever, headache, tinnitus, hearing loss, double vision, dysarthria, weakness, or difficulty walking. He had a similar episode 5 years ago. Medical history is significant for depression. His only medication is citalopram.

• On physical examination, vital signs are normal. Results of cardiac and neurologic examinations are normal. The Dix-Hallpike maneuver precipitates severe horizontal nystagmus after about 20 seconds. With repeated maneuvers, the nystagmus is less severe.

• Which of the following is the most likely diagnosis?A. Benign paroxysmal positional vertigoB. Cerebellar infarctionC. Meniere diseaseD. Vestibular neuronitis

• A 49-year-old woman is evaluated for vertigo of 1 week's duration. She was seen 1 week ago in the emergency department. During that visit, she described severe vertigo that predictably occurred while abruptly turning her head to the right and lasted less than 1 minute. She had no antecedent viral illness, headache, hearing loss, tinnitus, diplopia, dysarthria, dysphagia, or weakness. She was diagnosed with benign paroxysmal positional vertigo and given instructions for head tilting exercises (Epley maneuver). Her symptoms improved but have not abated. She is afraid to drive because of the symptoms. She has no history of hypertension, diabetes mellitus, hyperlipidemia, or tobacco use.

• On physical examination, vital signs are normal. With the Dix-Hallpike maneuver, she develops horizontal nystagmus and nausea after 15 seconds. The nystagmus lasts approximately 1 minute. The Epley maneuver is unsuccessful in relieving symptoms. The remainder of the examination is normal, including the neurologic examination.

• Which of the following is the most appropriate management?A. Brain MRIB. HydrochlorothiazideC. MeclizineD. Vestibular rehabilitation

• A 49-year-old woman is evaluated for vertigo of 1 week's duration. She was seen 1 week ago in the emergency department. During that visit, she described severe vertigo that predictably occurred while abruptly turning her head to the right and lasted less than 1 minute. She had no antecedent viral illness, headache, hearing loss, tinnitus, diplopia, dysarthria, dysphagia, or weakness. She was diagnosed with benign paroxysmal positional vertigo and given instructions for head tilting exercises (Epley maneuver). Her symptoms improved but have not abated. She is afraid to drive because of the symptoms. She has no history of hypertension, diabetes mellitus, hyperlipidemia, or tobacco use.

• On physical examination, vital signs are normal. With the Dix-Hallpike maneuver, she develops horizontal nystagmus and nausea after 15 seconds. The nystagmus lasts approximately 1 minute. The Epley maneuver is unsuccessful in relieving symptoms. The remainder of the examination is normal, including the neurologic examination.

• Which of the following is the most appropriate management?A. Brain MRIB. HydrochlorothiazideC. MeclizineD. Vestibular rehabilitation

General Medicine MKSAPS Q2• A 58-year-old woman is evaluated for a 7-week history of tingling pain involving

the first, second, and third digits of the right hand. The pain is worse at night and radiates into the thenar eminence. The pain does not radiate into the proximal forearm. She has hypothyroidism and her only current medication is levothyroxine.

• On physical examination, the patient reports pain with palmar flexion at the wrist with the elbow extended. She also reports pain with percussion over the median nerve at the level of the wrist. There is no thenar or hypothenar eminence atrophy. Strength is 5/5 with thumb opposition. A hand diagram is completed shown demonstrating the location of the patient's paresthesia.

• In addition to avoidance of repetitive wrist motions, which of the following is the most appropriate initial treatment?

A. Local corticosteroid injectionB. Oral ibuprofenC. Surgical interventionD. Wrist splinting

General Medicine MKSAPS Q2• A 58-year-old woman is evaluated for a 7-week history of tingling pain involving





Correct answer• A 58-year-old woman is evaluated for a 7-week history of tingling pain involving





CTS:Risk factors/etiology

• Compression of the median nerve related to space issues in carpal tunnel

• More likely in women – size of tunnel?• Obesity – fatty compression?• Pregnancy - increased fluid• Diabetes and hypothyroidism• RA and Connective tissue disease –inflammatory fluids?• Aromatase inhibitors - due to tendon thickening• Genetics• Workplace factors - all theoretical, and not born out by

research

What is wrong with this photo?

Median nerve also includes sensation for radial side of ring finger

How can you be sure this is not radiculopathy?

Just ask Spock

C8

C7

C6

Sleep posture of wrists

• May be causal or contribute

Consensus on order of treatment

• Splints followed (in refractory cases) by injections or oral steroid therapy for patients with mild to moderate symptoms

• Reasons to go consider going to surgery– Severe symptoms (as measured by standardized tools)

– Failure of injections/splint– Evidence of motor involvement

Q48• A 46-year-old man is evaluated for a 3-week history of occasional painless bright

red rectal bleeding. He has no fatigue, lightheadedness, weight loss, or abdominal pain. His stools are frequently firm, occasionally hard, and there is no change in the frequency or consistency of his bowel movements. He has never been screened for colorectal cancer.

• On physical examination, temperature is 37.2 °C (98.9 °F), blood pressure is 132/78 mm Hg, and pulse rate is 84/min. Digital rectal examination yields a stool sample that is positive for occult blood; the examination is otherwise normal. Anoscopy reveals a few internal hemorrhoids without active bleeding. Laboratory studies show a blood hemoglobin level of 14 g/dL (140 g/L).

• Which of the following is the most appropriate management of this patient?A. Banding of hemorrhoidsB. ColonoscopyC. Fiber supplementation without further evaluationD. Home fecal occult blood testing

Q48• A 46-year-old man is evaluated for a 3-week history of occasional painless bright

red rectal bleeding. He has no fatigue, lightheadedness, weight loss, or abdominal pain. His stools are frequently firm, occasionally hard, and there is no change in the frequency or consistency of his bowel movements. He has never been screened for colorectal cancer.

• On physical examination, temperature is 37.2 °C (98.9 °F), blood pressure is 132/78 mm Hg, and pulse rate is 84/min. Digital rectal examination yields a stool sample that is positive for occult blood; the examination is otherwise normal. Anoscopy reveals a few internal hemorrhoids without active bleeding. Laboratory studies show a blood hemoglobin level of 14 g/dL (140 g/L).

• Which of the following is the most appropriate management of this patient?A. Banding of hemorrhoidsB. ColonoscopyC. Fiber supplementation without further evaluationD. Home fecal occult blood testing

Causes of rectal bleeding (BRBPR)

• All causes of lower GI bleed• Anorectal lesions– Fissures– Hemorrhoids– Ulcers– Proctitis

Usual work-up• History and physical exam• Add anoscopy if the above is not diagnostic• Add sigmoidoscopy in patients with ALL these criteria

– Age 40-49– No family history colon cancer– No evidence of IBD– You do see an obvious local sources of bleeding – i.e. hemorrhoids

• Skip sigmoidoscopy and go right to colo with ANY of the following:– Age >=50– IBD symptoms– No hemorrhoids seen or other local cause of bleeding– Family history of CRC

Q79• A 38-year-old woman is evaluated for left knee pain. The pain has been

present for the past 3 weeks. Before onset, she had been preparing for a 5-kilometer race by running approximately 2 miles per day, 6 days per week, for the past 6 months. Walking up steps makes the pain worse; she also notes pain at night. She has never had this pain before.

• On physical examination, vital signs are normal. There is tenderness to palpation located near the anteromedial aspect of the proximal tibia. A small amount of swelling is present at the insertion of the medial hamstring muscle. There is no medial or lateral joint line tenderness.

• Which of the following is the most likely diagnosis?A. Iliotibial band syndromeB. Patellofemoral pain syndromeC. Pes anserine bursitisD. Prepatellar bursitis

Q79• A 38-year-old woman is evaluated for left knee pain. The pain has been




Work-up of anterior knee pain

• Referred pain – hip pathology (especially in elderly)

• Radicular/neuropathy pain – L4 goes over anterior knee, can be first presentation of peripheral neuropathy

• Systemic illness – should see effusion• Local disease

Local diseases causing anterior knee pain

• Knee extensor apparatus– Patellofemoral Pain Syndrome (PFPS)– Patellar tendonopathy– OA of the knee cap (chondromalacia) – Osgood Schlatter disease

• OA of femoral-tibial joint• Plica syndrome• Bursitis

– Prepetellar bursitis– Infrapatellar bursitis– Pes anserine bursitis

Patellofemoral Pain Syndrome (PFPS)

– The most common cause of knee pain– This pain presents under or around knee cap– Repetitive force across knee cap combined with poor

tracking of patella in the trochlear groove.• Things associated with repetitive force

– Running down hill– Jumping sports– Stairs– Biking in to hard a gear (especially early season)– Weight gain

• Things associated with angle– Increase Q angle (knock kneed)– Fallen arches (over pronation)

Patellar tendonopathy

• Pain at the inferior pole of patella – insertion point of patella tendon

• Seen in jumpers (Jumpers knee)

OA

of the

knee cap (chondromalacia)

• Aching pain under knee cap

• May result from prolonged PFPS

Osgood

Schlatter

disease

• This is an avulsion injury seen in athletes under the age of 19

• Occurs at the tibial attachment of patellar tendon

Common causes of knee pain in runners

• Petallofemoral pain syndrome• IT band syndrome• Pes anserine bursitis

Review• A 38-year-old woman is evaluated for left knee pain. The pain has been




Q141• A 55-year-old woman is evaluated during a follow-up appointment. She has

hypertension and hyperlipidemia. She does not use alcohol. Review of systems is notable for fatigue and occasional constipation. She is menopausal. Her family history is noncontributory. Her medications are simvastatin (40 mg/d), aspirin, and lisinopril.

• On physical examination, she is afebrile, blood pressure is 140/82 mm Hg, pulse rate is 66/min, and respiration rate is 12/min. BMI is 25. She has mildly dry skin. There is no evidence of xanthomas and no hepatomegaly.

• In addition to recommending diet and exercise therapy, which of the following is the most appropriate management?

A. Add gemfibrozilB. Increase simvastatin to 80 mg/dC. Measure hemoglobin A1c levelD. Measure thyroid-stimulating hormone level

Total Cholesterol 284 mg/dlHDL cholesterol 55 mg/dlLDL Cholesterol 231 mg/dltriglycerides 113 mg/dlGlucose 100 mg/dl

Q141• A 55-year-old woman is evaluated during a follow-up appointment. She has

hypertension and hyperlipidemia. She does not use alcohol. Review of systems is notable for fatigue and occasional constipation. She is menopausal. Her family history is noncontributory. Her medications are simvastatin (40 mg/d), aspirin, and lisinopril.

• On physical examination, she is afebrile, blood pressure is 140/82 mm Hg, pulse rate is 66/min, and respiration rate is 12/min. BMI is 25. She has mildly dry skin. There is no evidence of xanthomas and no hepatomegaly.

• In addition to recommending diet and exercise therapy, which of the following is the most appropriate management?

A. Add gemfibrozilB. Increase simvastatin to 80 mg/dC. Measure hemoglobin A1c levelD. Measure thyroid-stimulating hormone level

Total Cholesterol 284 mg/dlHDL cholesterol 55 mg/dlLDL Cholesterol 231 mg/dltriglycerides 113 mg/dlGlucose 100 mg/dl

Q52• A 75-year-old woman is evaluated during a follow-up examination for recently diagnosed

symptomatic peripheral arterial disease. The patient has hypothyroidism, hypertension, atrial fibrillation, and smokes cigarettes (30-pack-year history). Her current medications are diltiazem, warfarin, hydrochlorothiazide, levothyroxine, calcium, and vitamin D.

• On physical examination, she is afebrile, blood pressure is 140/82 mm Hg, pulse rate is 66/min, and respiration rate is 12/min. BMI is 21. Posterior tibialis and dorsalis pedis pulses are diminished bilaterally (1+); the skin on the anterior aspect of the lower legs is shiny and hairless. Heart rhythm is irregularly irregular and without murmurs. Neurologic and musculoskeletal examinations are normal.

• In addition to strongly recommending smoking cessation, which of the following is the safest treatment for this patient?

A. AtorvastatinB. PravastatinC. RosuvastatinD. Simvastatin

Total Cholesterol 238 mg/dlHDL cholesterol 36 mg/dlLDL Cholesterol 165 mg/dltriglycerides 205 mg/dlCreatinine .9 mg/dl

Q52• A 75-year-old woman is evaluated during a follow-up examination for recently diagnosed

symptomatic peripheral arterial disease. The patient has hypothyroidism, hypertension, atrial fibrillation, and smokes cigarettes (30-pack-year history). Her current medications are diltiazem, warfarin, hydrochlorothiazide, levothyroxine, calcium, and vitamin D.

• On physical examination, she is afebrile, blood pressure is 140/82 mm Hg, pulse rate is 66/min, and respiration rate is 12/min. BMI is 21. Posterior tibialis and dorsalis pedis pulses are diminished bilaterally (1+); the skin on the anterior aspect of the lower legs is shiny and hairless. Heart rhythm is irregularly irregular and without murmurs. Neurologic and musculoskeletal examinations are normal.

• In addition to strongly recommending smoking cessation, which of the following is the safest treatment for this patient?

A. AtorvastatinB. PravastatinC. RosuvastatinD. Simvastatin

Total Cholesterol 238 mg/dlHDL cholesterol 36 mg/dlLDL Cholesterol 165 mg/dltriglycerides 205 mg/dlCreatinine .9 mg/dl

Metabolization of statins

• Pravastatin – renally cleared – makes it a preferred agent for patients who are on meds metabolized by cytochrome p450

• atorvastatin, lovastatin, and simvastatin are primarily metabolized through the cytochrome P-450 3A4 (when taken with diltiazem the statin level increases)

• Rosuvastatin and fluvastatin are metabolized through the cytochrome P-450 CYP2C9 isoenzyme – warfarin interaction

Q41• A 67-year-old man is evaluated during a routine examination. He has hypertension

and obesity. He also has a history of gout, but has not had an attack in more than 1 year. His current medications are lisinopril and a daily aspirin.

• On physical examination, blood pressure is 140/82 mm Hg; vital signs are otherwise normal. BMI is 32. His waist circumference is 107 cm (42 in). There is no hepatomegaly.

• In addition to recommending weight loss and exercise, which of the following is the most appropriate treatment for his lipid abnormalities?

A. ColesevelamB. Extended-release nicotinic acidC. FenofibrateD. Omega-3 fatty acids

Total Cholesterol 192 mg/dlHDL cholesterol 27 mg/dlLDL Cholesterol 68 mg/dltriglycerides 554 mg/dlGlucose 100mg/dlCreatinine 1.1 mg/dl

Treating hypertriglyceridemia

• High triglycerides appears to be an independent risk factor for CAD

• There has been debate whether this is causal or high triglycerides is confounded by low HDL, insulin resistance, or other factors

• Management is based on whether level is over 1000

Management of triglycerides <=1000

• Lifestyle interventions = more impact in men (33% reduction expected)– Weight loss– Exercise– Reduce refined carbohydrate intake (lower GI

diet)– Reduce fat intake in people with triglycerides

above 500 ( no impact when triglycerides are low)

Fish oil

• 3-15gms/day drops triglycerides by up to 50%• There is no data showing reduction in clinical

outcomes with fish oil supplements

Fibrates

• Helsinki heart trial – patients with triglycerides >200 and TC:HDL >5 had reduced cardiac outcomes with gemfibrozil (secondary analysis-primary prevention)

• VA HIT trial – patients with low HDL, triglycerides <=300 had reduction in cardiac events with gemfibrozil (secondary prevention trial, primary analysis)

• Accord lipid trial – diabetic patients with triglycerides >204 mg/dl and HDL <=34 had reduction in events with fenofibrate when added to statin as compared to statin alone. (Primary prevention – primary analysis)

Statins

• In heart protection study – average LDL was 131 only while average trigycerides was 354– treatment with simvastatin reduced cardiac events

• This study was not designed to evaluate the effect of statins for high triglycerides- interpret with caution





A. ColesevelamB. Extended-release nicotinic acidC. FenofibrateD. Omega-3 fatty acids






A. Colesevelam – not a treatment for high triglycerides (raises them)B. Extended-release nicotinic acid – contraindicated in patients with gout, no dataC. Fenofibrate – data showing benefitD. Omega-3 fatty acids – no data showing impact on outcomes


Documents

MSKAP Extravaganza: The Eye, the Ear, and Randoms! November 2013 Alison Landrey Richard Pinckney Halle Sobel