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MSKAP Extravaganza:
The Eye, the Ear, and Randoms!
November 2013
Alison Landrey
Richard Pinckney
Halle 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 eye
B. Oral antihistamine
C. Topical antibiotics
D. 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.
• Which of the following is the most appropriate management
of this patient?
A. Cool compresses to the affected eye
B. Oral antihistamine
C. Topical antibiotics
D. 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 glaucoma
B. Central retinal artery occlusion
C. Ocular migraine
D. 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 glaucoma
B. Central retinal artery occlusion
C. Ocular migraine
D. 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. Amlodipine
B. Dorzolamide
C. Latanoprost
D. Lisinopril
E. 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. Amlodipine
B. Dorzolamide
C. Latanoprost
D. Lisinopril
E. 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 degeneration
B. Cataracts
C. Primary open angle glaucoma
D. 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 degeneration
B. Cataracts
C. Primary open angle glaucoma
D. 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 occlusion
B. Central retinal vein occlusion
C. Ocular migraine
D. Retinal detachment
E. 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 occlusion
B. Central retinal vein occlusion
C. Ocular migraine
D. Retinal detachment
E. 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.
• Which of the following is the most appropriate management of this
patient?
A. Biofeedback therapy
B. Immediate treatment with oral corticosteroids
C. MRI of the posterior fossa and internal auditory canal
D. 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
*if hearing loss with pain or drainage -> more likely conductive
*If hearing loss with vertigo or tinnitus -> more likely sensorineural
• 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)
• Conductive
–
–
–
–
Cholesteatoma
Foreign body, cerumen
Infection
otosclerosis
B
A
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.
• Which of the following is the most appropriate management of this
patient?
A. Biofeedback therapy
B. Immediate treatment with oral corticosteroids
C. 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.
• Which of the following is the most appropriate management
of this patient?
A. Acyclovir
B. Neomycin, polymyxin B, and hydrocortisone ear drops
C. Triethanolamine ear drops
D. 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.
• Which of the following is the most appropriate management
of this patient?
A. Acyclovir
B. Neomycin, polymyxin B, and hydrocortisone ear drops
C. Triethanolamine ear drops
D. 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. Audiometry
B. Auscultation over the right ear, eye, and neck
C. Trial of a sound-masking device
D. 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. Audiometry
B. Auscultation over the right ear, eye, and neck
C. Trial of a sound-masking device
D. 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 12hour 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 contrast
B. MRI with angiography of the brain
C. Otolith repositioning
D. 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
• Central (<1% of vertigo)
– Acoustic neuroma (esp if
– BPPV (transient with head
hearing loss concurrent)
movement)
– Migraine
– Vestibular neuronitis
(postviral inflammation with – Posterior circulation
cerebrovascular disease
nausea, persistant severe sx)
(infarct or ischemia) (consider
– Acute labyrinthitis (with
if risk factors)
hearing loss)
-> MRA if vascular
cause
– Menieres
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 12hour 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 contrast
B. MRI with angiography of the brain
C. Otolith repositioning
D. 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 vertigo
B. Cerebellar infarction
C. Meniere disease
D. 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 vertigo
B. Cerebellar infarction
C. Meniere disease
D. 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 MRI
B. Hydrochlorothiazide
C. Meclizine
D. 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 MRI
B. Hydrochlorothiazide
C. Meclizine
D. Vestibular rehabilitation
General Medicine MKSAPS Q2
•
•
•
A.
B.
C.
D.
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?
Local corticosteroid injection
Oral ibuprofen
Surgical intervention
Wrist splinting
General Medicine MKSAPS Q2
•
•
•
A.
B.
C.
D.
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?
Local corticosteroid injection
Oral ibuprofen
Surgical intervention
Wrist splinting
Correct answer
•
•
•
A.
B.
C.
D.
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?
Local corticosteroid injection
Oral ibuprofen
Surgical intervention
Wrist splinting
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
C7
C8
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.
B.
C.
D.
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?
Banding of hemorrhoids
Colonoscopy
Fiber supplementation without further evaluation
Home fecal occult blood testing
Q48
•
•
•
A.
B.
C.
D.
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?
Banding of hemorrhoids
Colonoscopy
Fiber supplementation without further evaluation
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.
•
A.
B.
C.
D.
Which of the following is the most likely diagnosis?
Iliotibial band syndrome
Patellofemoral pain syndrome
Pes anserine bursitis
Prepatellar bursitis
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.
•
A.
B.
C.
D.
Which of the following is the most likely diagnosis?
Iliotibial band syndrome
Patellofemoral pain syndrome
Pes anserine bursitis
Prepatellar bursitis
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)
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
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.
•
A.
B.
C.
D.
Which of the following is the most likely diagnosis?
Iliotibial band syndrome
Patellofemoral pain syndrome
Pes anserine bursitis
Prepatellar bursitis
Q141
•
•
•
A.
B.
C.
D.
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.
Total Cholesterol
HDL cholesterol
LDL Cholesterol
triglycerides
Glucose
284 mg/dl
55 mg/dl
231 mg/dl
113 mg/dl
100 mg/dl
In addition to recommending diet and exercise therapy, which of the following is
the most appropriate management?
Add gemfibrozil
Increase simvastatin to 80 mg/d
Measure hemoglobin A1c level
Measure thyroid-stimulating hormone level
Q141
•
•
•
A.
B.
C.
D.
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.
Total Cholesterol
HDL cholesterol
LDL Cholesterol
triglycerides
Glucose
284 mg/dl
55 mg/dl
231 mg/dl
113 mg/dl
100 mg/dl
In addition to recommending diet and exercise therapy, which of the following is
the most appropriate management?
Add gemfibrozil
Increase simvastatin to 80 mg/d
Measure hemoglobin A1c level
Measure thyroid-stimulating hormone level
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.
Total Cholesterol
HDL cholesterol
LDL Cholesterol
triglycerides
Creatinine
238 mg/dl
36 mg/dl
165 mg/dl
205 mg/dl
.9 mg/dl
In addition to strongly recommending smoking cessation, which of the following is the safest
treatment for this patient?
A. Atorvastatin
B. Pravastatin
C. Rosuvastatin
D. Simvastatin
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.
Total Cholesterol
HDL cholesterol
LDL Cholesterol
triglycerides
Creatinine
238 mg/dl
36 mg/dl
165 mg/dl
205 mg/dl
.9 mg/dl
In addition to strongly recommending smoking cessation, which of the following is the safest
treatment for this patient?
A. Atorvastatin
B. Pravastatin
C. Rosuvastatin
D. Simvastatin
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.
B.
C.
D.
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.
Total Cholesterol
HDL cholesterol
LDL Cholesterol
triglycerides
Glucose
Creatinine
192 mg/dl
27 mg/dl
68 mg/dl
554 mg/dl
100mg/dl
1.1 mg/dl
In addition to recommending weight loss and exercise, which of the following is
the most appropriate treatment for his lipid abnormalities?
Colesevelam
Extended-release nicotinic acid
Fenofibrate
Omega-3 fatty acids
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 triglyceridesinterpret with caution
Q41
•
•
•
A.
B.
C.
D.
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.
Total Cholesterol
HDL cholesterol
LDL Cholesterol
triglycerides
Glucose
Creatinine
192 mg/dl
27 mg/dl
68 mg/dl
554 mg/dl
100mg/dl
1.1 mg/dl
In addition to recommending weight loss and exercise, which of the following is
the most appropriate treatment for his lipid abnormalities?
Colesevelam
Extended-release nicotinic acid
Fenofibrate
Omega-3 fatty acids
Q41
•
•
•
A.
B.
C.
D.
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.
Total Cholesterol
HDL cholesterol
LDL Cholesterol
triglycerides
Glucose
Creatinine
192 mg/dl
27 mg/dl
68 mg/dl
554 mg/dl
100mg/dl
1.1 mg/dl
In addition to recommending weight loss and exercise, which of the following is
the most appropriate treatment for his lipid abnormalities?
Colesevelam – not a treatment for high triglycerides (raises them)
Extended-release nicotinic acid – contraindicated in patients with gout, no data
Fenofibrate – data showing benefit
Omega-3 fatty acids – no data showing impact on outcomes