Gen Med Board Review – Part I
Screening/Vaccines, Common Symptoms, Musculoskeletal complaints,
Red Eye, Perioperative Medicine
April 18, 2013
A 62-year-old woman is evaluated during a follow-up visit for hypertension. She has no
complaints and is monogamous with her husband of 35 years. Her only current medication is
hydrochlorothiazide. On physical examination, blood pressure is 136/72 mm Hg and weight is 62
kg (136 lb). Physical examination is normal. Total cholesterol is 188 mg/dL and HDL cholesterol is
54 mg/dL.. She received an influenza vaccination 3 months ago and a herpes zoster vaccination 1
year ago. Her last Pap smear was 14 months ago and it was normal, as were the previous three
annual Pap smears.
Which of the following is the most appropriate health maintenance option for this patient?
Abdominal ultrasonography
Dual-energy x-ray absorptiometry
Pap smear
Pneumococcal vaccine
A 57-year-old man is evaluated during a routine examination. He has hypertension, which is well
controlled on hydrochlorothiazide. He asks if he should get a prostate-specific antigen (PSA) test.
Medical history is otherwise unremarkable. There is no family history of cancer. Blood pressure is
132/86 mm Hg, and results of the physical examination are unremarkable.
Which of the following is the best prostate cancer screening option for this patient?
1.
2.
3.
4.
Discuss the risks/benefits of screening for prostate CA
Order PSA testing
Order PSA testing and perform DRE
Perform DRE
Screening Recommendations
•
Blood Pressure:
–
•
DM2:
–
–
•
abdominal ultrasound once in men >65 and smoking hx
Colon CA:
–
–
•
DXA at 65yo then q2y
or <65 if RF (wt <70, FHx, smoking, EtOH, steroids/RA, previous fx) q5y
AAA:
–
•
Male >35 or anyone >20 with RFs
Then every 5 years for low risk people
Osteoporosis:
–
–
•
Start >45y or <45 with RFs
Screen yearly if RFs or q3y if no RFs
Hyperlipidemia:
–
–
•
Every 2 yrs if wnl; yearly if pre-HTN
Start age 50, unless AA then start at 45
Colonoscopy q10y, FOBT q1y, or flex sig q5 + FOBT q3
Routine screening for the following:
–
–
–
EtOH/tobacco dependence
Depression
Obesity
USPSTF vs ACS
Cervical
Cancer
Age 21-29: screen with
cytology q3 years
Age 30-65: cytology q3y
or cytology + HPV q5y
Stop screening at age 65
if adequate prior
screenings and not high
risk
Breast
Cancer
Biannual mammograms
age 50-74
No clinical breast exams
(CBEs)
Mammograms yearly
starting age 40
CBEs q3 yrs starting age
20, then yearly at age 40
Prostate
Cancer
Does not recommend
PSA testing
Men should make
informed decision with
their doctor about
whether to check PSA
A 68-year-old woman is evaluated during a routine examination. She states that last year she had
a painful rash on the right side of her back that was self-limited. She does not recall a history of
childhood chickenpox. She takes no medications and has no allergies.
Vital signs are normal and the physical examination is unremarkable. Complete blood count, liver
enzymes, and serum chemistry studies are all normal. She is scheduled to receive her annual
influenza vaccination today.
Which of the following is the most appropriate vaccine administration strategy to prevent herpes
zoster in this patient?
1.
2.
3.
4.
5.
Zoster vaccination if negative for varicella antibodies
Zoster vaccination if positive for varicella antibodies
Zoster vaccination now
Zoster vaccination now and in 6 months
Zoster vaccination not indicated
Live Vaccine
Dead Vaccine
Immunizations
Hepatitis A
Hepatitis B
• MSM, illicit drug
users, chronic liver
disease, food
handlers, travelers
• 2 doses
• all patients – esp
those in HepA
group, healthcare
workers, HIV, CKD,
inmates
• 3 doses
MMR
•
•
all patients
2 doses
HPV
Influenza - IM
• Females 11-26
• Males 11-21 (unless
MSM, HIV,
immunocomp, then until
age 26)
• 3 doses
Pneumococcal
Meningococcal
• All pts 65 and older
• younger if: Alaskan,
SNF residents,
immunocomp, chronic
disease, asplenic
• one time booster if 1st
vaccine >5yr ago and
given before age 65
• young adults in closed
quarters, asplenia,
complement deficiency,
travelers
• MCV4 – one dose (ages
11-55)
• MPSV4 – 2 doses (ages
<11 or >55)
Tetanus and Wounds:
• all adults – esp if >50yo,
health care workers,
chronic disease
• contraind: GBS, egg allergy
Intranasal
Tetanus
• Td – all patients
• 3 doses, then
booster every 10 yr
• sub one booster for
Tdap (age 19-64) –
or can give 2y after
last Td
Zoster
• 60 or older
regardless of
shinges hx
(most benefit 60-69)
• Vaccine Status Unknown or <3 total doses: Vaccinate now
• Clean minor wound and 3+ known vaccines – Revaccinate if last was >10yr ago
• Other wounds and 3+ known vaccines – Revaccinate if last vaccine 5+ yr ago
A 52-year-old woman is evaluated at a routine appointment and seeks advice on smoking
cessation. She smokes one and one half packs of cigarettes daily and wants help to stop. She has
tried to stop smoking on three previous occasions, each time using nicotine replacement therapy,
and she would like to try something different. She has a seizure disorder that is well controlled on
valproate.
In addition to brief smoking cessation counseling, which of the following is the most appropriate
pharmacologic therapy to offer?
1.
2.
3.
4.
Bupriopion
Nortriptyline
Sertraline
Varenicline
Smoking Cessation
Agent
Success
SEs, contraind
Pregnancy
Nicotine replacement
(gum, patch, spray, inhaler,
lozenge)
Increases cessation 1.5x
over control
Avoid in recent MI,
arrhythmia, unstable
angina
Safety unclear
Bupropion
Increases cessation 2x over
control
Avoid in seizure disorder
and eating disorder;
associated with HTN
Safety unclear
Varenicline (Chantix)
Increases cessation 3.5x
control and 2x over
bupropion
Associated with
drowsiness, fatigue, sleep
disturbance, depressed
mood, suicidal thoughts,
constipation
Safety unclear
A 52-year-old man is evaluated for a daily cough for the past 6 months. It occurs throughout the
day and occasionally at night, but he does not notice any specific triggers. There is occasional
production of small amounts of white sputum but no hemoptysis. He does not have any known
allergies, has no new pets or exposures, and does not smoke. He does have nasal discharge. He
has not noticed any wheezing and has no history of asthma. He has no symptoms of heartburn.
He has had no fever, weight loss, or foreign travel, and takes no medications.
Vital signs are normal. There is no cobblestone appearance of the oropharyngeal mucosa. Lungs
are clear to auscultation. A chest radiograph is normal.
Which of the following is the most appropriate management for this patient?
1.
2.
3.
4.
5.
Antihistamine/decongestant combination
CT scan of chest
Inhaled fluticasone
Proton-pump inhibitor
Pulmonary function testing
Chronic cough
•
•
•
•
3-8 weeks = subacute
>8 weeks = chronic
Etiologies (often multifactorial):
1.
Upper Airway Cough Syndrome (post-nasal drip)
• Exam may show “cobblestoning” or mucous down oropharynx
• Tx: 1st generation antihistamine + decongestant (if not due to sinusitis)
• If allergic rhinitis, add daily nasal steroid
2.
Asthma (cough-variant)
• May present with cough associated with exercise or exposure to cold
• If dx uncertain, do methacholine challenge
3.
GERD
• Consider trial of PPI
4.
Other:
• Nonasthmatic Eosinophilic bronchitis
– Normal CXR, spirometry, and negative methacholine challenge
– Dx: Bronch
– Tx: avoid occupational exposure; Inhaled steroids
• Chronic bronchitis
• Bronchiectasis – voluminous purulent sputum production
• Smoking
• Meds (ACEI, NSAIDs, bblockers, macrobid, cellcept)
Approach to workup:
– History to try and identify cause
– Medication review
– CXR
(99% due to UACS, Asthma, or GERD in nonsmokers with normal CXR and not on ACEI)
An 89-year-old woman is evaluated for dizziness that she has had for the past year, mainly while
standing and ambulating. The dizziness is described as a sense of unsteadiness. The symptoms
can last for minutes to hours, and she has at least 4 to 5 episodes per day. There are no
reproducible activities that cause the dizziness. She does not describe hearing loss, headache,
diplopia, or other motor or sensory symptoms. Medical history includes type 2 diabetes mellitus,
hypertension, hyperlipidemia, osteoporosis, and mild dementia. Current medications are
hydrochlorothiazide, ramipril, simvastatin, metformin, insulin glargine, low-dose aspirin, and
donepezil.
Exam reveals no orthostasis. Cardiopulmonary exam is normal. The patient has a positive
Romberg sign and is unsteady on tandem gait. Rapid alternating movements are slowed. The
patient has a corrected visual acuity of 20/50 in the right eye and 20/70 in the left eye. Vibratory
sense and light touch are diminished in a stocking pattern in the lower extremities, and ankle jerk
reflexes are 1+. She has no motor abnormalities and no cranial nerve abnormalities. A DixHallpike maneuver does not elicit vertigo or nystagmus. Labs are wnl.
Which of the following management options is the best choice for this patient?
1.
2.
3.
4.
Brain MRI
Meclizine
Physical therapy
Replace aspirin with aspirin/extended-release dipyridamole
A 79-year-old man is evaluated in the emergency department for vertigo that began suddenly
about 1 hour ago, associated with severe nausea and vomiting. He noticed that he could not
seem to sit up straight and could not walk without assistance. The patient denies confusion,
motor weakness, hearing loss, dysarthria, diplopia, fever, or paresthesias. Medical history is
remarkable for hypertension, hyperlipidemia, and type 2 diabetes mellitus. Current medications
are lisinopril, atorvastatin, low-dose aspirin, insulin glargine, metformin, and atenolol. There are
no allergies.
The patient demonstrates unsteadiness on finger-to-nose testing in the right upper extremity and
is unable to walk more than a few steps or stand without assistance. Motor strength and reflexes
are normal. Visual acuity and visual fields are normal. Otoscopic and hearing exams normal.
Cardiopulmonary examination is normal.
Which of the following in the most appropriate management option for this patient?
1. Admit for telemetry
2. Brain MRI
3. Intravenous methylprednisolone
4. Oral meclizine
A 61-year-old man is evaluated for dizziness that started about 2 days ago while he was looking
over his shoulder. He describes the symptoms as “room spinning” dizziness and mild nausea. The
symptoms resolved within several minutes when he lay back on the couch and was perfectly still.
They recurred several hours later while turning in bed and the next day while backing out of his
driveway. He denies diplopia, slurred speech, confusion, motor weakness, paresthesias, tinnitus,
antecedent infection, or hearing loss. He has no other medical problems and takes no
medications.
Vital signs are normal. The cardiopulmonary examination is normal. Peripheral nystagmus and
reproduction of symptoms on the Dix-Hallpike maneuver when the head is turned right are
demonstrated. There are no focal neurologic defects. Visual acuity and hearing are normal.
Which of the following management options is the beset choice for this patient?
1. Audiometry
2. Brain MRI with magnetic resonance angiography
3. Cardiac event monitor recording
4. Epley canalith repositioning maneuver
5. Methylprednisolone
Vertigo
1. VERTIGO – “room spinning”
2. PRESYNCOPE – nearly losing
consciousness
3. DISEQUILIBRIUM – unsteady while
Nonspecific
DIZZINESS
Disequilibrium
Presyncope
walking
• Usually multifactorial/in elderly
• DDx: deconditioning, peripheral
neuropathy, poor hearing or
eyesight, polypharmacy
4. NONSPECIFIC – none of the above
• DDx: hypoglycemia, medications,
thyroid dz, anemia, stress,
psychiatric
Vertigo – “room is spinning”
1. Nystagmus – vertical vs horizontal
2. Episodic or Persistent
3. How long does it last?
4. Associated with hearing loss? Tinnitus? Nausea?
– Central Cause:
• Nystagmus vertical or changes direction with different head positions; no
latent period; longer duration; non-fatiguing
• Etiologies:
– Tumors (<1%) – Acoustic Neuromas
» Unilateral hearing loss/tinnitus
– Posterior circulation CVA
» Persistent vertigo; other symptoms (neurologic, nausea/vomiting)
– Migraine headaches
– Peripheral (vestibular) Cause:
• Nystagmus horizontal or rotary; delayed onset; lasts seconds; fatigues with
repetition
• Vertigo symptoms more pronounced than central causes
• Often associated with recent URI, hearing loss, tinnitus, or head trauma
• 3 major etiologies:
– BPPV
– Vestibular Neuronitis
– Meniere Disease
Vestibular Vertigo
Cause
Nature
Duration
Hearing loss?
Tinnitus?
Nausea?
Treatment
BPPV
Otolith
debris in
semicircular
canals
Episodic
Minutes
No
No
No
Eply maneuver
+/- vestibular
suppressants
Vestibular
Neuronitis
Post-viral
inflammation of
vestibular
portion of
CN VIII
Persistent Days
No
No
Yes
Can add
steroids;
meclizine if it
persists
Meniere’s
Endolymphatic
hydrops (too
much fluid in
canals)
Episodic
Yes
(unilateral)
Yes
(typically
unilateral)
Yes
Avoid triggers
(salt, caffeine,
EtOH), rehab,
vestibular
suppressants
Minuteshours
Vestibular suppressants: anticholinergics, antihistamines, benzos
A 36-year-old woman is evaluated in the emergency department after collapsing suddenly while
waiting in line at a county fair on a hot summer day. The patient states she felt nauseated and
became diaphoretic and lightheaded. She sat on the ground and then lost consciousness.
According to her son, she was unconscious for less than a minute, exhibited some twitching
movements when she first lost consciousness, but had no incontinence or symptoms of confusion
upon awakening. She had no further symptoms upon regaining consciousness.
She has a history of hypertension and hyperlipidemia. On exam, temperature is normal, blood
pressure is 142/80 mm Hg (supine) and 138/78 mm Hg (standing), pulse rate is 84/min (supine)
and 92/min (standing). Cardiac and neurologic examinations are normal. An ECG is normal.
Which of the following is the most appropriate management option for this patient?
1.
2.
3.
4.
5.
Echocardiogram
Electroencephalogram
Exercise stress test
Tilt-table testing
No further testing
20%
1
20%
20%
2
3
20%
4
20%
5
Syncope
Cardiac
Neurogenic
Outflow
obstruction
Neurocardiogenic
(Vasovagal)
Seizure
Ischemia
(rare)
Severe AS
CVA (very
rare)
HOCM
PE
Orthostasis
Arrhythmias
Meds
Non-neurogenic
Neurogenic
MS
Venous
pooling
ALS
• Vasovagal:
•
•
•
Volume
depletion
Polyneuropathy
Adrenal
insufficiency
Specific trigger leads to increased parasympathetic (vagal) tone (decreased HR and increased BP)
Prodrome of nausea, lightheadeness, dizziness, diaphoresis
Dx: clinical or tilt-table test
Tx: trigger avoidance; supine with legs up when it occurs; compression stockings, tilt training, bblockers if
frequent episodes
A 42-year-old man is seen in the office for low back pain that began after lifting a box 5 days ago.
The pain is moderately severe, and almost any movement makes it worse. He tried lying down
and experienced some, but not complete, relief. He reports that he has had no trouble urinating.
He has no other symptoms and is otherwise healthy.
Physical examination reveals tenderness over the L4 paravertebral musculature bilaterally. His
gait is slow owing to the pain. Results of a straight-leg-raising test are normal. There are no signs
of motor weakness or sensory loss, including perineal sensation. Deep tendon reflexes are
normal bilaterally.
Which of the following is the best initial management option?
1.
2.
3.
4.
5.
Acetaminophen
Epidural corticosteroid injection
MRI of lumbar spine
Plain radiographs of the lumbar spine
Strict bed rest
20%
1
20%
20%
2
3
20%
4
20%
5
Acute Back Pain
•
Decide which type:
1.
Nonspecific (90%)
•
•
•
2.
Associated with radiculopathy/spinal
stenosis (6%)
•
•
3.
•
Will resolve on their own
Tx conservatively with Tylenol or NSAIDs
No imaging needed
Radiating pain down leg(s), + straight leg raise
If pain >1 month, then get MRI
Due to spinal pathology – need further
imaging
Red flags = need further imaging
– Cancer – Hx of malignancy and new onset low
back pain; unexplained weight loss – MRI
– Infection – Hx of IVDU, fever, recent infxn – MRI
– Cord Compression – Hx of malignancy, new
neuro deficits – MRI of all spinal levels
– Cauda Equina Syndrome (L1-S5 nerve roots) –
Urinary retention, fecal incont, saddle anesth,
motor deficits at multiple levels - MRI
– Compression Fx – Hx of osteoporosis or steroid
use + fall – plain xray
A 47-year-old man is evaluated in the office for right lateral shoulder pain. He has been pitching
during batting practice for his son’s baseball team for the past 2 months. He has shoulder pain
when lifting his right arm overhead and also when lying on the shoulder while sleeping.
Acetaminophen does not relieve the pain.
On physical examination, he has no shoulder deformities or swelling. Range of motion is normal.
He has subacromial tenderness to palpation, with shoulder pain elicited at 60 degrees of passive
abduction. He also has pain with resisted mid-arc abduction but no pain with resisted elbow
flexion or forearm supination. He is able to lower his right arm smoothly from a fully abducted
position, and his arm strength for abduction and external rotation against resistance is normal.
Which of the following is the most likely diagnosis
1.
2.
3.
4.
5.
20%
20%
20%
2
3
20%
20%
Adhesive capsulitis
Bicipital tendinitis
Glenohumeral arthritis
Rotator cuff tear (complete)
Rotator cuff tendinitis
1
4
5
Shoulder
• Rotator Cuff Tendonitis – most common
shoulder complaint
– Subacromial pain on exam and impingement when
reaching overhead
– No need to image
– Treatment:
• first 2 weeks – subacromial injection, NSAIDs, ROM
exercises
• >2 weeks - add PT
• Rotator Cuff Tear
– Weakness, loss of function, + drop arm test
• Bicipital tendonitis
– Pain with forced supination of hand when elbow
flexed 90 degrees
• Adhesive Capsulitis (Frozen Shoulder)
– Progressive decreased ROM (due to stiffness and not
so much limited from pain) – loss of rotation and
abduction
• GH osteoarthritis
– Gradual anterior pain and stiffness
– Crepitus and anterior joint line tenderness on exam
A 72-year-old woman is evaluated for a 8-month history of aching in her left wrist that keeps her
awake at night. She is in a knitting group and has found it increasingly difficult to perform fine
hand movements. Using the Katz hand diagram, the patient indicates the presence of sensory
changes in the first through third digits. She also reports wrist pain with sparing of the palm and
some pain into the forearm. Her only medication is acetaminophen.
On physical examination, there is weakness of thumb abduction, hypalgesia in a median nerve
distribution, and thenar atrophy. Vascular assessment in the hand is normal. A nerve conduction
study and electromyogram demonstrate medial neuropathy.
Which of the following is the most appropriate management option for this patient?
1.
2.
3.
4.
5.
Corticosteroid injection
NSAIDs
Surgery
Ultrasound treatment
Wrist splint
20%
1
20%
20%
2
3
20%
4
20%
5
Carpal Tunnel
• Predisposing Factors:
– Pregnancy, RA, OA,
Hypothyroidism, Obesity,
carpal fracture
• Treatment:
– Conservative measures
(none has been proven
superior or first line)
• Splinting, NSAIDs, US, PT
• Short-term prednisone vs
steroid injections
– Surgery – first line if
evidence of severe
neuromuscular
compromise
A 48-year-old overweight woman is evaluated for buttock pain. She began jogging 1 week ago to
lose weight. Over the last 2 days, pain has developed deep in the left gluteal area. The pain is an
ache that she first noticed while lying in bed on her left side. It was somewhat relieved by lying
on her right side. The pain has become severe enough that she avoids putting weight her left leg
while climbing stairs. The pain does not radiate. Ibuprofen has helped the pain somewhat. She is
on no other medications.
On physical examination, there is tenderness elicited over the left sciatic notch when pressure is
applied with the thumb. When lying on the right side, abduction of the leg is painful. The hip joint
has no pain with full range of motion. There is no tenderness in the groin or over the lateral
thigh, and FABER (Flexion, ABduction, and External Rotation of the hip) test results are normal.
Reflexes and the straight-leg-raising test are normal.
25%
25%
25%
2
3
25%
Which of the following is the most likely diagnosis?
1.
2.
3.
4.
Left hip osteoarthritis
Left trochanteric bursitis
L4-L5 disk herniation (Sciatica)
Piriformis syndrome
1
4
Hip
•
•
•
•
•
Osteoarthritis = true hip pain (groin, worse with weight bearing)
Trochanteric Bursitis = bursal pain (lateral, worse with lying on that side)
Piriformis Syndrome = compression of sciatic nerve by piriformis muscle
– Seen in prolonged sitting or carrying large wallet in back pocket
– Tx: Stretching/NSAIDs
Osteonecrosis
– RFs: steroids, sickle cell disease
– Dx: MRI (if early disease); xray (if late disease)
Meralgia Paresthetica = entrapment of lateral cutaneous nerve under inguinal ligament
– Decreased sensation over lateral thigh
– clues: obesity, belt, tight clothes
A 35-year-old woman is evaluated in the office for a 5-day history of acute right knee pain that
began when she hopped down from the bed of a truck, twisting her knee. She experienced a
popping sensation and a gradual onset of knee joint swelling over the next several hours. Since
then, she has continued to have moderate pain, particularly when walking up or down stairs. She
reports no locking or giving way of the knee or any previous knee injury.
On physical examination, the right knee has a minimal effusion with full range of motion. The
medial aspect of the joint line is tender to palpation. Maximally flexing the hip and knee and
applying abduction (valgus) force to the knee while externally rotating the foot and passively
extending the knee (McMurray test) result in a palpable snap but no crepitus.
Which of the following is the most likely diagnosis?
1.
2.
3.
4.
25%
25%
25%
2
3
25%
Anserine bursitis
Anterior cruciate ligament tear
Meniscal tear
Patellofemoral pain syndrome
1
4
Knee
• Acute Trauma – “popping”, effusion
– ACL – sudden twist + hyperextension
• Anterior drawer or Lachman test
– PCL – trauma to flexed knee
– LCL/MCL – medial/lateral force without twisting
– Meniscus – McMurray test = 97% specific
• Patellofemoral Syndrome
– Females <45yo
– Reproducing the pain by firmly moving the patella
along the femur confirms the diagnosis
• Iliotibial Band Syndrome = inflammation of distal
part of iliotibial ligament
– “Knife-like” lateral pain that occurs with repetitive
flexion/extension
• Bursitis
– Pes anserine, prepatellar, suprapatellar
A 25-year-old woman presents for evaluation of recurrent, bilateral eye pain and redness.
Symptoms began several months ago without a specific inciting event. With each episode, she
has deep or boring pain that is constant and has awakened her from sleep. She has had
photophobia, tearing, and decreased vision during the episodes.
Vital signs are normal. Visual acuity is 20/40 bilaterally. There is photophobia. The pupils are
equal, round, and reactive to light. Extraocular movements are intact but painful. The corneas
appear clear. On the lateral aspect of both eyes, there is a localized area of raised erythema, with
superficial blood vessels coursing over top of erythema but no white sclera visible between the
blood vessels. There is no discharge or crusting of the lids.
Which of the following is the most likely diagnosis regarding her eyes?
20%
1.
2.
3.
4.
5.
20%
20%
2
3
20%
20%
Episcleritis
Scleritis
Subconjunctival hematoma
Uveitis
Viral conjunctivitis
1
4
5
•
Red eye
Conjunctivitis = most common cause
– Allergic
• Recurrent, seasonal
• Itchy eyes with watery discharge;
diffuse redness (bilateral)
• Tx: topical antihistamine, cool
compress, topical NSAIDs (3 days)
– Viral
• Typically starts in one eye along with
URI, then moves to the other side
• Tearing, foreign body sensation, can
have LAD
• Very contagious; Adenovirus = most
common
• Tx: supportive, cold compress PRN
– Bacterial
• Diffuse unilateral redness with AM
mucopurulent discharge
• Pneumococcus = most common
(followed by Staph, Hemophilus)
– Tx: topical Abx
• If suspect GC or Chlamydia as cause,
need referral to ophtho + Abx
Red Eye
•
Urgent call to Ophtho if:
–
•
Scleritis
–
–
–
–
•
Pain, Decreased vision, seeing “halos”, photophobia
**urgent ophtho referral
Iritis (or Iridocyclitis or Uveitis)
–
–
•
Spontaneous, PAINLESS; associated with recent straining/coughing
Self-limiting in 2 weeks
Keratitis = Corneal inflammation
–
–
•
Still able to see white sclera between prominent vascular markings
Self-limited; not associated with underlying disease
Subconjunctival Hemorrhage
–
–
•
Cannot see white sclera between prominent vascular markings
Severe constant ocular pain worse with EOM, photophobia
**associated with CVD and rheum disease
**urgent referral as can lead to orbital rupture!!
Episcleritis
–
–
•
Vision changes, Photophobia, Pupillary changes, pain, trauma, anytime cornea involved (“kerato”)
Intense pain, photophobia, ciliary injection, irregularly shaped pupil
May indicate infection or underlying CVD/Rheum disease
Acute Angle-Closure Glaucoma
–
Pain, seeing “halos”, HA, n/v, dilated pupil
68-year-old woman is evaluated in the emergency department for difficulty seeing out of her left
eye. The symptoms were first present upon awakening 45 minutes earlier. She describes her
vision as “looking through a dark veil.” Her right eye is unaffected. There is no associated pain,
head-ache, muscle aching, or difficulty chewing, and no trauma or history of a similar episode.
She has hypertension, hypercholesterolemia, and chronic open-angle glaucoma. Current
medications are ramipril, hydrochlorothiazide, atorvastatin, aspirin, and timolol ophthalmic
solution.
20%
20%
20%
2
3
20%
20%
Vital signs are normal. Visual acuity in the right eye is 20/30, corrected for glasses; in the left eye,
visual acuity is restricted to finger counting. Both globes are nontender to palpation. There is no
conjunctival injection. Ophthalmoscopic examination of the right eye is normal. Findings in the
left eye are shown. Venous pulsations are noted. Pupils are equal. The right pupil reacts to direct
and consensual light stimulus. The left pupil has sluggish response to direct light, but normal
consensual response. Cardiac and neurologic examinations and electrocardiogram are normal.
Which of the following is the most likely diagnosis?
1. Acute angle-closure glaucoma
2. Acute occipital stroke
3. Central retinal artery occlusion
4. Central retinal vein occlusion
5. Retinal detachment
1
4
5
Eye Emergencies
•
•
•
•
•
•
Acute Angle Closure Glaucoma
Central Retinal Artery Occlusion
– Due to embolus or thrombus
– Unilateral/painless, “looking through a dark veil”
– Pale retina on exam with “cherry red spot” near fovea
– Tx: emergent surgery; optic massage x15 min
Central Retinal Vein Occlusion
– Presents similarly to CRAO but retina with “cotton wool spots” or “blood & thunder”
Giant Cell Arteritis
– Abrupt vision loss due to thrombosis of posterior ciliary or ophthalmic artery
– Associated with PMR
– Tx: emergent steroids
Retinal Detachment
– Seeing “flashes of light”, multiple floaters, decreased vision and metamorphopsia (wavy
vision)
Cellulitis (Preseptal vs Septal)
– CT to assess depth of infection
– Preseptal (not involving orbit): Usually due to contiguous spread of skin or sinus infection
– Septal (involving orbit): usually from dental, soft tissue infection
• Can be complicated by meningitis or cavernous sinus thrombosis
A 64-year-old woman is evaluated during a health maintenance examination. She has
hypertension and hypercholesterolemia. She has no symptoms to report. She is a current smoker,
with a 20 pack-year history. Current medications are atenolol and hydrochlorothiazide.
Vital signs are normal. BMI is 28. Funduscopic examination reveals bright, yellow, refractile
deposits scattered in the retina of the right eye, with approximately five deposits seen on direct
ophthalmoscopy. The left fundus appears normal. On visual acuity testing, near vision is 20/20
with reading glasses, and distance vision is 20/25 for both eyes. The remainder of the physical
examination is normal.
A lipid panel obtained prior to today’s visit reveals a total cholesterol of 190 mg/dL ; LDL
cholesterol of 120 mg/dL; HDL cholesterol of 40 mg/dL; and triglycerides of 150 mg/dL.
25%
25%
25%
25%
Which of the following is the most effective management option for this patient’s ocular findings?
1.
2.
3.
4.
Antioxidant supplements
Atorvastatin
Lower blood pressure to below 130/85 mm Hg
Smoking cessation
1
2
3
4
A 78-year-old woman is evaluated because of concerns about her ability to drive. She has trouble
seeing on bright, sunny days and also at night because of the glare from headlights of oncoming
cars. The patient has type 2 diabetes mellitus and a 55-pack-year smoking history. Her current
medications include metformin and glipizide.
This patient’s history is most suggestive of which of the following ophthalmologic disorders?
1.
2.
3.
4.
5.
Age-related macular degeneration
Cataracts
Presbyopia
Primary open-angle glaucoma
Proliferative diabetic retinopathy
20%
1
20%
20%
2
3
20%
4
20%
5
Macular Degeneration/Glaucoma/Cataracts
•
Macular Degeneration = central vision loss
– “Dry” – 80% - gradual vision loss
•
“Drusen” (amorphous deposits) form behind retina
– “Wet” – 20% - more rapid and profound
•
Neovascularization near macula
– RFs: age, smoking
– Tx: stop smoking!
•
•
For “wet”, can try photodynamic tx or laser photocoagulation
Primary Open Angle Glaucoma = peripheral vision loss
– Due to obstruction in outflow of aqueous humor from anterior chamber
– Initially asymptomatic with loss of periph vision, but can lead to progressive optic neuropathy and
elevated IOP
– Increased cup:disc ratio (>0.5)
– Treatment (often with systemic side effects)
•
•
•
•
Bblockers (timolol) -> decrease inflow
A2-agonists (brimonidine) -> decrease inflow and increase outflow
PG analogues (latanoprost) -> increase outflow
Cataracts = contrast/glare issues
–
–
–
–
Due to opacification of lens
Symptoms: glare, reduced vision, loss of contrast, decreased illumination
RFs: age, smoking, UV light, DM, steroids
Tx: surgery
Macular Degeneration
Glaucoma
Cataracts
A 60-year-old woman is evaluated before undergoing a lumpectomy for breast cancer tomorrow.
Medical history is significant for hypertension, type 2 diabetes mellitus, chronic kidney disease, a
myocardial infarction 2 years ago, and a stroke 1 year ago with residual right-sided hemiparesis.
The patient does not have chest pain or shortness of breath and is otherwise asymptomatic. She
uses a walker to ambulate. Current medications are metoprolol, simvastatin, furosemide,
losartan, nifedipine, insulin glargine, insulin aspart, and aspirin.
On physical examination, temperature is 36.8 °C, BP 160/90 mm Hg, HR 66/min, and RR is
25% and
25%
25%pedal edema.
25%
14/min. Examination is normal except for right-sided hemiparesis
mild bilateral
Pertinent laboratory results: blood urea nitrogen, 35 mg/dL; creatinine, 2.2 mg/dL; random
glucose, 180 mg/dL; hemoglobin A1c, 8.1%.
An ECG shows normal sinus rhythm, left ventricular hypertrophy, first-degree atrioventricular
block, and nonspecific ST-T wave changes.
Which of the following is the most appropriate preoperative management?
1. Postpone surgery until blood pressure is below 140/90 mm Hg
2. Postpone surgery until dobutamine stress echocardiography is obtained
3. Postpone surgery until fasting glucose is below 110 mg/dL (6.11 mmol/L)
4. Proceed with surgery
1
2
3
4
A 65-year-old man with a 2-year history of severe osteoarthritis of the right knee is evaluated
before undergoing total knee replacement surgery. Until 1 month ago, the patient was able to
walk four or more blocks and four flights of stairs but now can only walk one block because of
severe knee pain. He has a 3-year history of occasional chest pain that occurs less than once each
month and develops only after walking too quickly. There has been no change in the severity or
frequency of the chest pain and no dyspnea. Medical history is significant for a myocardial
infarction 4 years ago, type 2 diabetes mellitus, and hypertension. Current medications are
metoprolol, fosinopril, atorvastatin, insulin glargine, metformin, and aspirin.
20%
20%
20%
20%
20%
Blood pressure is 140/80 mm Hg, pulse rate is 60/min. BMI is 30. There is no jugular venous
distention. The lungs are clear. There are no murmurs or gallops. Serum creatinine is 1.5 mg/dL
(132.6 µmol/L). An electrocardiogram shows normal sinus rhythm with Q waves in leads II, III, and
aVF; nonspecific ST-T wave changes; and left ventricular hypertrophy. A chest radiograph is
normal.
Which of the following is the most appropriate preoperative cardiac testing?
1.
2.
3.
4.
5.
Coronary angiography
Dobutamine stress echocardiography
Exercise (treadmill) thallium imaging
Resting two-dimensional echocardiography
No additional testing is indicated
1
2
3
4
5
A 70-year-old man with severe disability due to claudication in his right leg and a 2-month history
of increasingly frequent chest pain undergoes preoperative cardiovascular evaluation prior to
elective right femoropopliteal bypass graft surgery. The patient can only walk one block because
of claudication and chest pain despite adequate medical treatment. Medical history is significant
for coronary artery disease, a myocardial infarction 4 years ago, hypertension, and type 2
diabetes mellitus. The patient underwent left femoropopliteal bypass graft surgery 2 years ago
under general anesthesia without complications. He has a 55 pack-year smoking history but
stopped smoking 2 years ago. Current medications are20%
metoprolol,
20%atorvastatin,
20% amlodipine,
20%
20%
fosinopril, isosorbide mononitrate, insulin glargine, insulin aspart, and aspirin.
Vital signs are normal. There is no jugular venous distention. Cardiopulmonary examination is
normal. Pulses in the right calf are decreased. There is no calf tenderness and no peripheral
edema. An electrocardiogram shows Q waves in the inferior leads.
Which of the following is the best preoperative management?
1.
2.
3.
4.
5.
Coronary angiography
Dipyridamole nuclear imaging stress testing
Dobutamine stress echocardiography
Two-dimensional echocardiography
No testing needed
1
2
3
4
5
Perioperative
Guidelines
Emergent?
Yes
Proceed with
surgery and
optimize meds
if time
No
Active cardiac
conditions?
Yes
No
Delay surgery
for further
eval/tx
Low risk
surgery?
Yes
No
Adequate
functional capacity
(4 METs) without
symptoms?
Proceed
with surgery
Yes
Proceed
with surgery
Clinical
RFs
0
Proceed
1-2
proceed; consider
periop heart rate
control and/or
noninvasive testing
Intermediate risk
Proceed; consider
periop HR control
and/or
noninvasive
testing
>3
Type of
surgery?
Vascular
Noninvasive
testing
Perioperative Guidelines - Definitions
• Active Cardiac Conditions:
– MI <30d, UA or severe angina, decompensated CHF, arrhythmias,
severe valve disease
• Low Risk Surgery:
– Endoscopic, superficial, breast, ambulatory, cataract
• 4 METs:
– Flight of stairs, walk up a hill, walk 4 mi/hr
• Clinical RFs:
– Hx of heart disease, Hx of CHF, hx of stroke, DM2, renal insufficiency
• Intermediate Risk Surgery
– Intraperitoneal, intrathoracic, endovascular aortic aneurysm, CEA,
head/neck, orthopedic, prostate
• Vascular Surgery
– Peripheral vascular, major valve surgery