752 Pt 1 Quiz PDF

Diagnostic Workup w/ Breast - Clinical imaging purposes: eval for mass, look for additional breast abnormalities, and to guide biopsy - Ultrasound is MORE SENSITIVE than mammogram, but LESS SPECIFIC, more EXPENSIVE, and HIGH FALSE POSITIVE rate - Perform tissue sampling if suspiciou...

Diagnostic Workup w/ Breast - Clinical imaging purposes: eval for mass, look for additional breast abnormalities, and to guide biopsy - Ultrasound is MORE SENSITIVE than mammogram, but LESS SPECIFIC, more EXPENSIVE, and HIGH FALSE POSITIVE rate - Perform tissue sampling if suspicious findings noted at any stage of eval regardless of findings at other stages dt imperfect sensitivity and specificity of clinical breast exam (CBE) and imaging - OLDER THAN 40 (30-39 should err on side of 40+) - \[Diagnostic\] MAMMOGRAM then ultrasound - 30-39 \[Sharpe Slides\]: Ultrasound and Mammogram - YOUNGER THAN 30 - ULTRASOUND or MRI (family history) - MRI indications: not recommended unless f/u on biopsy proven cancer or some other indications - GAIL model is calculator tool to assess 5-yr breast cancer risk (uses PMH, reproductive hx, hx of breast cancer among 1st degree relatives) -   - **Fibroadenoma**: firm, mobile, painless, smooth borders - **Breast cyst**: fluid-filled sacs, benign, more common in 40s, painless or tender - **Fibrocystic changes**: benign, typically bilateral - **Lipoma or other benign soft tissue mass**: soft, mobile, not too defined - - Palpable breast exam in woman 30 yr or older: CBE & diagnostic mammogram - Palpable breast exam in woman \ respiratory s/s) - Testing - TSH: thyroid fxn - CXR: masses, infiltrate, s/s of HF - CBC: check s/s of infection or anemia - BMP: assess overall health - CT scan of chest: eval for lung nodules or masses - Pulmonary function tests (PFTs): assess for COPD or restrictive lung disease - Echocardiogram (ECHO): eval heart fxn if cardiac etiology suspected Stroke - 1st line imaging: Non-contrast head CT - CT Angiography follow-up to identify intracranial large vessel occlusions and cervical carotid or vertebral artery disease - BEFAST: Balance, Eyesight, Facial drooping, Arm weakness, Speech difficulty, Time (call 911)  Headache Primary Headaches Secondary Headaches  Emergent secondary causes of headache - Thunderclap (e.g. SAH, carotid & vertebral artery dissections, HTN emergencies, acute angle-closure glaucoma) - Migraine: mild-mod pain gradually inc. over 1-2h - Cluster: can reach full intensity in mins, but it's transient (last \ - - - - - Seizures - Provoked Seizures - Unprovoked (Idiopathic) seizures - Psychogenic nonepileptic seizures (PNES) - Evaluation - History \-- aura, "deja vu," mood changes, hallucinations, confusion, post-event amnesia, presyncopal symptoms, palpitations, chest pain, nausea, dyspnea, dizziness, lightheadedness, tunnel vision - Medication use (e.g. bupropion, benadryl, tramadol, alcohol, opioids, stimulants, cocaine) - Physical exam: neuro exam, GCS - Lab Eval: EEG, epilepsy-specific MRI - Lumbar puncture: fever, stiff neck, immunocompromised, altered mental status (AMS) - EEG: Ideally perform within 24h of unprovoked seizure to capture epileptic form activity; only do in pts w/ clinical presentation consistent w/ possible seizure, like witnessed tonic-clonic movements, postictal period, evidence of tongue biting or other indicative phys exam finding - Neuroimaging - Immediate CT: w/ focal seizure, fever, persistent HA, neuro deficit, acute head trauma, anticoag use, malignancy, or immunocompromised Dizziness - TiTrATE: Timing of symptom, Triggers that provoke symptom, Targeted Exam - 3 scenarios - Episodic triggered - Spontaneous episodic - Continuous vestibular - HINTS - Head impulse - Nystagmus - Test of Skew - Differential Diagnosis of Dizziness and Vertigo: Common Causes - Peripheral v Central v Other -  -  - Assessment of Dizziness - EPISODIC - Triggered → Dix-Hallpike maneuver → Positive \[benign paroxysmal positional vertigo\] or Negative \[assess orthostatic hypotension\] - Spontaneous - Hearing loss (Meniere's) - Migraine (vestibular) - Psychiatric s/s (panic attack, psych condition) - CONTINUOUS - Trauma or Toxin → Barotrauma or meds - Spontaneous → HINTS exam - Peripheral etiology \[vestibular neuritis\] - Saccade +, unidirectional horizontal nystagmus, normal test of skew - Central etiology \[stroke or TIA\] - Saccade -, dominantly vertical nystagmus, torsional or gaze-evoked bidirectional, abnormal test of skew Cardiovascular - KEY LABS - Potassium: 3.5-5.1 - Hypokalemia: prolonged QT - Hyperkalemia: peaked T waves, widened QT interval, bradycardia, asystole, sudden death - Magnesium: 1.7-2.2 - Hypomagnesemia: cardiac arrhythmias - Brain Natriuretic Peptide - BNP \< 100 - Peripheral swelling is late sign - Informs you if body is retaining fluid - Ask if ladies have gone up in bra size (sign) - Meds can skew BNP, like spironolactone - Total Bilirubin: 0.1-1.3 - Inc CVP -\ passive hepatic congestion; pump failure - TSH: 0.5-5.0 - Hyperthyroidism v hypothyroidism - OSA Orthopedics OTTAWA ANKLE RULES - OR - Bone tenderness at the posterior edge or tip of the medial malleolus (B) OR - An inability to bear weight both immediately and in the clinic for four steps - A foot X-Ray series is only required if there is any pain in the midfoot zone and\... - Bone tenderness at the base of the fifth metatarsal OR - Bone tenderness at the navicular (D) OR - And inability to bear weight both immediately and in the emergency department - When to Image: - Based on Ottowa ankle rules, the patient meets several criteria for pursuing weightbearing XRs of the injured ankle: - Point tenderness along the distal third of the lateral malleolus - Inability to bear weight more than 4 steps both immediately following the injury and several days later in the clinic - Lab studies - To evaluate for systemic etiology of acute pain and limping the following lab studies are recommended: - CBC with Differential, ESR, CRP, Blood cultures, Lyme titer if living in an area where Lyme disease is endemic - Imaging - Plain radiography - Ottawa Ankle and Foot Rules recommended for acute ankle injuries - Standard trauma views include AP, mortise, and lateral views - Ultrasound - Used for fx ankle ligamentous injuries - High diagnostic accuracy for ATFL & CFL injuries - Less precise and sensitive than MRI for acute lateral ligament injury detection - MRI - Reliable for revealing acute tears of ATFL and CFL - GOLD standard for imaging ankle ligamentous and intra-articular injuries - Beneficial for suspected concomitant injuries or persistent symptoms - Good accuracy for detecting osteochondral lesions and syndesmotic injuries - Shoulder Impingement Syndrome - Methods to eval: Hawkins test, Neer sign, Jobe test, Painful arch - X-ray, CT, MRI (soft tissues; muscular atrophy & fatty infiltration), Ultrasound (impingement-associated conditions like bursitis and tendon changes) - ACL Tear - MRI is gold standard - Other clinical diagnostic tests: Lachman test, anterior drawer test, pivot shift test - Clinical tests were as superior to MRI in sensitivity, specificity, predictive value, accuracy, more timely, less expensive Spinal Emergency - X-Ray: initial screening for suspected fractures and/or dislocations - CT scan of spine - more detailed imaging of injury and assess extent of dmg to spinal cord - MRI: further eval of spinal cord and surrounding structures - Spinal compression - Etiologies: intervertebral disc herniation, traumatic fracture of vertebrae, epidural abscess (fever), epidural hematoma, neoplasm - Injury to C1-C4 can affect the diaphragm and other respiratory muscles - Injury to T6-T7 can result in lower extremities weakness and/or paralysis - Injury to L-L4 can result in sciatica, and/or bladder/bowel dysfunction - Spinal epidural abscess: fever, axial pain, neuro deficit, risk factors: prev infection, diabetes, IV drug use, renal disease; Dx: MRI w/ contrast - Cauda Equina syndrome: acute disc herniation, severe low back pain, sciatica, saddle anesthesia, bowel/bladder dysfunction; Dx: MRI, needs urgent surgical decompression - Spinal epidural hematoma: spont or secondary to trauma, procedures, or anticoag use; affects cervicothoracic region; severe spinal pain -\> progressive neuro deficits; Dx: MRI **RED FLAGS FOR BACK PAIN** (red = s/s of malignancy) - Hx of cancer - Age \>50 - Unexplained weight loss - Pain \>1 month - Night pain - Pain unresponsive to prev therapies - Lower extremity weakness and/or paresthesia - Bowel/bladder incontinence - Saddle anesthesia - Significant motor deficits not localized to a single unilateral nerve root - Recent trauma especially in elderly, MVC, or sports injury - Progressive or severe neuro deficit - Persistent neuromotor after 4-6 weeks of conservative tmnt - Suspected cord compression IMAGING & TESTS for LOW BACK PAIN - X-rays - AP and lateral - see intervertebral disc height loss - CBC, ESR, CRP \-- eval infectious, malignant, or rheumatologic causes - MRI: eval for cord compression, cauda equina, infection, malignancy, distinguish degenerative disc disease and/or spinal stenosis - CT scan: rarely used except emergent traumatic situations to eval fractures and instability **Red Flag Findings in Pts w/ Low Back Pain \-- Possible Etiologies** - Cauda Equina Syndrome - Subjective - Progressive motor or sensory loss - New urinary retention or overflow incontinence - New fecal incontinence - Objective - Saddle anesthesia - Loss of anal sphincter tone - Significant motor deficits encompassing mult. Nerve roots - Fracture - Subjective - Significant trauma relative to age - Prolonged corticosteroid use - Age \> 70, osteoporosis - Objectives: contusions or abrasions - Infection - Subjective - Spinal procedure in past 12 mos - IV drug use, immunosuppression, distant lumbar spine surgery - Objective - Fever, wound in spinal region - Localized pain and tenderness - Malignancy - Subjective: Hx of metastatic cancer, Unexplained weight loss - Objective - Focal tenderness and localized pain in setting of risk factors Differential Diagnosis of Mechanical Low Back Pain - **Lumbosacral muscle strains/sprains**: often following isolated traumatic incidents or overuse, pain worse w/ movements, relieved w/ rest; restricted ROM, muscle tenderness, or trigger points - **Lumbar spondylosis:** pain present in or radiate from hips, worse w/ activity - **Disk herniation:** L5 or S1. L4-L5 or L5-S1; pain, paresthesia, sensory change, loss of strength or reflexes depending on affected nerve root - **Spondylolysis**: pain with activities involving lumbar extension; insidious - **Vertebral compression fracture**: fracture may occur slowly overtime or acutely w/ mild trauma; localized back pain worse w/ flexion often point tenderness on palpation; risks: inc age, hx trauma, chronic steroids, osteoporosis - **Spondylolisthesis**: pain radiates into the buttocks or posterior thigh; leg pain may be worse than back pain - **Spinal stenosis:** back pain sometimes w/ sensory loss or weakness in legs +-----------+-----------+-----------+-----------+-----------+-----------+ | Different | | | | | | | ial | | | | | | | Dx of Hip | | | | | | | Pain in | | | | | | | Children | | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | Disease | Hx | Fever | Phys Exam | X-rays | Labs | +-----------+-----------+-----------+-----------+-----------+-----------+ | Septic | Acute | Fever \> | Inability | Normal | WBC \> | | arthritis | onset of | 101.5 F | to bear | early | 12k | | | pain and | | weight, | | | | | fever | | child | | ESR \> 40 | | | | | rests in | | | | | | | external | | Aspiratio | | | | | rotation | | n | | | | | & refuses | | of joint | | | | | to move | | shows WBC | | | | | joints; | | \>50k | | | | | appears | | | | | | | ill | | \*emergen | | | | | | | cy\* | +-----------+-----------+-----------+-----------+-----------+-----------+ | Transient | Hx of | Mild or | Able to | Normal | CRP \