Internal medicine Board Review:
ENT, Orthopedics, and Psychiatry
Jimmy Stewart, MD
ENT
► Common
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conditions/high yield topics for the boards:
Hearing Loss
Tinnitus
Otitis
Cerumen Impaction
Epistaxis
Sinusitis
Oral Ulcers/Cancers
Pharyngitis
Hoarseness
Hearing Loss
► Acute
vs. Chronic
► Acute
(< 2 wks)
• Steroids
• Referral to ENT
► Causes:
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Acoustic Neuroma
Meningioma
Trauma
Meningitis
Viral or Suppurative Labyrinthitis
Drugs
Hearing Loss
► Unilateral
► Interpret
vs. Bilateral
the Weber Test:
Sound should be heard equally in both ears
If the sound is heard best on the side of the hearing
loss—conductive.
If the sound is heard best in the unaffected ear—
sensorineural.
Hearing Loss
► Sensorineural
hearing loss
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brain,
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internal auditory canal
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VIII Nerve or cochlea
► Presbycusis
is most common—symmetric,
high-frequency, hard to hear in noisy
settings, 50-70 yo
Hearing Loss
► Presbycusis
Screening
►Whispered
Voice Test
►Hearing Handicap Inventory for the Elderly
►Objective Audioscopy
► Current
recs: screen with questionnaire and
audioscopy every 1-3 years >55-60yo
Hearing Loss
► Conductive
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Hearing Loss:
Otitis
cerumen impaction
cholesteatoma
otosclerosis
► Otitis
- most common
► Cholesteatoma
► Otosclerosis
- Surgery
- Surgery
Tinnitus
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Causes:
• Medications (NSAID/ASA),
• Labyrinthitis
• Noise exposure
• presbycusis
• Meniere’s disease
• otitis
• Otosclerosis
• Abnormal vascular flow
• Muscular
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Unilateral or pulsating tinnitus - intracranial or vascular imaging
• acoustic neuroma
• jugular bulb
• carotid artery abnormalities
Otitis
► Otitis
externa – water exposure (lake)
► Otalgia,
aural d/c, decreased hearing and itching.
Erythematous canal, tender with manipulation of outer ear.
► Treatment
– reestablish acidic environment (acetic acid
drops), topical antibiotics—neomycin plus polymyxin.
► Necrotizing
otitis externa — hospitalization, iv
fluoroquinolones in severe cases. Diabetics - Pseudomonas.
Otitis
► Otitis
► Rx:
media—much more common in children.
Reserve antibiotics for purulent otitis media
(opacification of TM or drainage) or refractory
cases. Amoxicillin is first line, Macrolide or Clinda
for PCN allergic pts.
Cerumen Impaction
► Symptoms
– ear fullness, conductive hearing loss, tinnitus,
ear pain, pruritis.
► Mechanical
or Chemical removal
► Contraindications
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for cerumen removal:
otitis externa,
history of severe otic infections
history of ear surgery
myringotomy tubes/perforated TM.
Epistaxis
► Anterior
► Rx
nose – most common
–administer phenylephrine or
oxymetazoline spray for vasoconstriction.
Nasal packing in refractory cases.
Sinusitis
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Acute (under 4 wks),
Sub acute (4-12 wks)
Chronic (over 12 wks)
Most cases viral
Sinusitis
► Signs
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of bacterial infection:
> 7 days of symptoms
Purulent nasal discharge
Maxillary tooth or facial pain
Abnormal transillumination
Ineffectiveness of decongestants
Pts improve then worsen
Sinusitis
► CT
Sinuses > sinus radiography.
► Treatment
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antihistamines
analgesics
systemic or topical decongestants
Topical steroids
Saline wash
► Moderate
evidence for antibiotics (Amoxicillin or
Bactrim) for bacterial rhinosinusitis.
Oral Cancer
► Men,
ETOH, Tobacco
► Biopsy any ulcers that do not resolve in 4
weeks.
Oral Cancer
► Leukoplakia
and erythroplakia precede
squamous cell carcinoma.
Oral Ulcers
► Aphthous
stomatitis - most common
► Recurrent
aphthous stomatitis –
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HIV
IBD
celiac sprue
Behcet’s
SLE
HSV (extremely painful)
Acute Pharyngitis
► 90%
infectious:
• 50% Viral
• 30% Idiopathic
• 20 % Bacterial—most Group A Strep.
► Only
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use antibiotics when group A step is highly likely:
Fever
Tonsillar exudate
Tender Anterior cervical lymphadenopathy
Absence of cough
► Throat
► PCN
cultures in pts with 3-4 criteria and a negative rapid test.
x 10 days, Erythromycin in PCN allergic pts—Azithromycin or
cefuroxime are similarly effective but more expensive.
Acute Pharyngitis
► Infectious
mononucleosis—presents with
fever, LA, and exudative pharyngitis.
► How
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is that different from group A Strep?
Prolonged symptoms
Splenomegaly—50% of cases
Hepatomegaly—10% of cases
Lymphocytosis
Thrombocyopenia
Hoarseness
► Acute—overuse
vs. infection—resolves in less than 2
wks without AntiBx.
► Chronic
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(>2 weeks)
PND,
Cancer,
inhaled corticosteroids/asthma,
acid reflux.
Referral for direct laryngoscopy.
► Smokers
or former smokers with hoarseness persisting
beyond 3 weeks - direct laryngoscopy.
Orthopedics
► Common
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Conditions/High Yield Topics:
Low Back Pain
Shoulder Pain
Hand and Wrist Pain
Hip Pain
Knee Pain
Foot and Ankle Pain
Low Back Pain
► 95%
of pts with disc herniation have sciatica.
► Positive
► Wasting
crossed straight leg raise test.
of calf muscle, weak ankle dorsiflexion are
generally predictive—weak plantar flexion is highly
predictive of S1 radiculopathy.
Low Back Pain
► Long-term
outcome - good
► In
pts older than 50 yrs, an initial spine radiograph series
and ESR to r/o cancer.
► Systemic
Dx or history of cancer or trauma, an abnormal
neuro exam, or no improvement after 2-4 wks of
conservative therapy need additional evaluation.
► Cauda
Equina Syndrome
Low Back Pain
► Red
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Flags
Major Trauma
Corticosteroid Use
Age >50 yrs
Unexplained Wgt Loss
Fever, immunosuppression, injection drug use
Saddle anesthesia, bowel/bladder incontinence
Severe/Progressive neuro deficit
Low Back Pain
► Imaging
studies are OVERUSED!.
► MRI
and electromyography are the tests of
choice when the diagnosis is unclear.
► MRI
tends to over-diagnose anatomic
abnormalities.
Low Back Pain
► NSAIDS,
Acetaminophen, Muscle Relaxants.
► Tricyclic
antidepressants/gabapentin/cymbalta
► GET
OUT OF BED!
► Surgery
may relieve symptoms in pts with an
identifiable spondylolisthesis or disk herniation—pain
and neurologic symptoms are similar at 1 and 5
years
Shoulder Pain
► Most
common
• subacromial bursa
• impingement.
► Other
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sources of pain
adhesive capsulitis
rupture of the rotator cuff tendon
OA
cervical radiculopathy
► Don’t
forget about referred pain
Shoulder Pain
► NSAID
and rest for 2 wks.
► Subacromial
corticosteroid injection
► PT
► Surgical
referral when conservative measures fail.
Elbow Pain
► Epicondylitis—inflammation
at the extensor radii
tendon on the lateral or medial epicondyle of the
humerus.
► Rx:
immobilization (sling) and NSAIDS for 2-3 weeks.
Corticosteroid injection for recalcitrant symptoms.
► Olecranon
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bursitis
repetitive trauma
RA
gout
infection
Wrist and Hand Pain
► Bilateral
Pain
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degenerative
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inflammatory
► Unilateral
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overuse
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trauma
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crystal-induced synovitis
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reactive process
Wrist and Hand Pain
► Psoriatic
arthritis - skin findings
► Rheumatoid
- PIP, MCP and wrist.
Wrist and Hand Pain
► Thumb
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1st Carpometacarpal deg arthritis
women 30-60
Thumb splint
NSAIDS
► Radius
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De Quervains tenosynovitis
Finkelstein test
NSAIDS, Steroid injection
Hand and Wrist Pain
► Carpal
Tunnel Syndrome:
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Tinel’s
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Phalen’s
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diabetes
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hypothyroidism
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Pregnancy
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Splinting
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NSAIDS
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Referral for surgery
Hip Pain
► OA,
bursitis, and myofascial syndromes
► OA:
Pain progresses gradually, felt in the groin,
except in severe case is present when walking but
not at rest.
► Internal
► Initial
rotation is usually limited.
therapy with NSAIDS, joint replacement
Hip Pain
► Trochanteric
bursitis—tender on lateral palpation, pain with
walking or lying on affected side.
► Iliopsoas—pain
in thigh, pelvis and groin that decreases when
the hip is flexed.
► Ischial—pain
► Heat,
with sitting.
Massage and NSAIDS—local injection in refractory cases.
Hip Pain
► Most
common myofascial: ileotibial band syndrome.
► Dull
ache over the lateral hip and thigh. Pain is
reproduced by stretching the fascia.
► Treat
► DD:
with stretching, heat, NSAIDS and +/-PT.
osteonecrosis of femoral head
Knee Pain
► Inflammatory
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gout
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pseudogout
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RA
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Reiter’s
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infection
► Arthrocentesis
essential for diagnosis.
Knee Pain
► Prepatellar
bursitis
• frequent kneeling
• Aspirate the bursa
► Patellar
tendonitis
• jumping sports, stair climbing
• tenderness over tendinous attachment to the patella.
► Chondromalacia
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patellae
running
descending stairs
lateral tracking of patella
displacement and pain with extension, crepitus
► Anserine
bursitis—medial tibial plateau
Knee Pain
► Osteoarthritis
• >55 unless there is a Hx of obesity, trauma or
infection
• physical therapy
• NSAID
• corticosteroid injection
• hyaluronic acid
• Joint replacement
Knee Pain
► Trauma—When
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to get x-rays? Ottawa rules:
55 yrs or older
Isolated tenderness of the patella
Tenderness at the head of the fibula
Inability to flex to 90 degrees
Inability to bear weight.
Knee Pain
► Anterior
Cruciate Ligament Tear: twisting injuries, large
effusion, Lachman test/anterior drawer test.
► Collateral
twisting.
ligament tears occur with valgus or varus without
► Posterior
cruciate tears occur with falls onto a flexed knee or
force onto the anterior knee—usually associated with injury to
other ligaments.
► Meniscal
tears—pain, stiffness, locking, popping, need MRI to
diagnose.
Foot and Ankle Pain
► Ankle radiographs
• Non-weight bearing
• Point tenderness distal posterior medial/ lateral malleolus.
► Foot radiographs
• Non-weight bearing
• Point tenderness navicular or the base of the fifth metatarsal.
► Sprain
treatment
• RICE
• wt bearing as tolerated
• PT
Foot and Ankle Pain
► Achilles
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rest
NSAIDS
stretching
Do not inject!
► Plantar
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tendonitis
Fasciitis
Worse in the morning and after long periods of
rest
stretching
orthotics
NSAIDS
Ankle and Foot Pain
► Hallus
Valgus (bunion)—lateral deviation of the great toe,
painful swollen bump over the head of the first metatarsal.
Causes--Genetics, narrow shoe boxes, and hyperpronation.
Rx: surgery for severe pain, difficulty in fitting footwear,
impaired function.
► Morton’s
Neuroma—fibrosis of the nerve passing between the
third and fourth distal metatarsals—burning, cramping
forefoot pain. Rx: broad toed shoes, pronatory insoles, and
corticosteroid injections.
► Stress
fractures of the metatarsals occur with a sudden
increase in activity—may initially have negative radiographs
and require bone scans.
Psychiatry
► Common
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Conditions/High Yield Topics:
Depression
Bipolar Disorder
Generalized Anxiety Disorder
Panic Disorder and Panic Attacks
Somatization Disorders
Obsessive Compulsive Disorder
Alcohol Withdrawal
Eating Disorders
Depression
► Criteria
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►5
for Major Depressive Episode:
Depressed mood most of the day almost every day
Diminished interest or pleasure
Wgt loss or wgt gain
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue
Feelings of worthlessness or excessive guilt
Diminished ability to concentrate
Recurrent thoughts of death, suicidal ideation, or suicide attempt
– One of which must be depressed mood or diminished
interest. Sx = 2 wks.
Depression
► Criteria
for Dysthymic Disorder
• Depressed mood for most of the day, more days than not
for two years.
• Presence of two or more:
►Poor
appetite
►Insomnia
►Fatigue
►Low self-esteem
►Poor concentration
►Feelings of Hopelessness
During the two year period the person has never been
without these Sx for more than 2 months.
Depression
► Treatment:
• SSRI.
• Tricyclics
► Frequent
► 6-9
follow up
months of treatment
► Cognitive
behavioral, interpersonal and problemfocused therapies are also effective with medication.
Bipolar Disorder
► Screen
all pts with depressive Sx for bipolar
disorder.
► Bipolar
► Bipolar
I—extreme swings in mood
II—shorter, less severe high periods
and depressive episodes.
Bipolar Disorder
►Li
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Monitor renal function
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Sick sinus syndrome
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Thyroid
►Divalproex
Generalized Anxiety Disorder
► Worry
or concern disproportionate to the likelihood
of the feared event. DSM IV:
• Excessive worry x6 months
• Worry is pervasive and difficult to control
• Three of these Sx:
►“On edge”
►Easily tired
►Concentration difficulty
►Irritability
►Muscle tension
►Sleep disturbance
Generalized Anxiety Disorder
► Limit
caffeine use
► relaxation
► treat
techniques
coexisting psychiatric diagnoses.
► SSRI/norepinephrine
reuptake inhibitors
► Tricyclics
► Benzodiazepines—preferably
long acting.
Panic Attacks/Panic Disorder
► Intense,
unexpected episodes of terror and
fear accompanied by somatic symptoms.
► Pts
with prolonged apprehension and/or
avoidance behavior have panic disorder.
► Very
often associated with major
depression—when associated has a much
higher rate of suicide.
Panic Attacks/Panic Disorder
► For
pts with infrequent attacks and no avoidance—
education and relaxation techniques.
► Phobic
avoidance—cognitive behavioral therapy or
medication.
► Medications—SSRI
reuptake inhibitors
► Benzodiazepines
or selective norepinephrine
in severe cases.
Somatization Disorder
► Almost
never the right answer on the test!
Obsessive Compulsive Disorder
►High
dose SSRI
Alcohol Withdrawal
► Minor
withdrawal symptoms—insomnia,
tachycardia, tremor, headache, and GI
upset.
► Major
withdrawal symptoms—seizures,
hallucinations, and delirium tremens.
Alcohol Withdrawal
► Minor
symptoms begin within 6-12 hours of
alcohol cessation and usually resolve within
48 hours.
► Delirium
tremens—disorientation,
hallucinations, hypertension, agitation and
tremor. Usually begins several days after
last alcohol use and persists for up to 5
days.
Alcohol Withdrawal
► Risk
factors for severe withdrawal—Hx of severe
withdrawal, chronic alcohol use, age over 30 yrs,
and presence of a significant concurrent illness.
► Treatment—supportive:
Thiamine/Folate,
electrolyte supplementation.
► Benzodiazepines
improve withdrawal symptoms
and decrease the incidence of seizure and DTs.
Lorazepam in pts with known hepatic disease.
Symptom triggered dosing reduces duration and
total amount of medication.
Eating Disorders
► Bulimia—pattern
of binge eating with
associated purging—self induced vomiting,
laxative and diuretic abuse. Dysmorphic
body image.
► Anorexia—Refusal
to maintain normal body
weight, fear of wgt gain, severe body image
disturbance, amenorrhea.
Eating Disorders
► Treatment
involves interdisciplinary teams—
internist, psychiatrist, and nutritionist.
► Cognitive
behavioral therapy is helpful—more
so for bulimia.
► Pharmacotherapy
is less helpful—be sure to
treat underlying co morbid conditions (OCD
and depression)
The End!
Good Luck.