Patients should be evaluated for -unhealthy alcohol use- if they have:
. -Excessive intake- (men>14 drinks /week or > 4 drinks /day ; woman: > 7 drinks/week or > 3 drinks /day) . -Impairment- in social or occupational function . Legal or social -consequences- (eg , low of job , arrest for driving while intoxicated) . -Adverse health effects- (eg, liver toxicity, resistant hypertension)
The evaluation of alcohol use disorders should address -current alcohol intake- , personal and family history of alcohol -abuse and treatment- , and medical any psychological -complications- of alcohol intake . Patients should also be screened for abuse of -other substances- ( eg, tobacco , illicit drugs , prescription medications) and for comorbid -psychiatric illness-.
Different diagnosis
The differential diagnosis for alcohol use disorders is usually straightforward . however , patient amy have additional problems that need to be identified and addressed . the following disorders should be considered when evaluating a patient with alcohol abuse:
The initial screen for unhealthy use can utilize single-item screen , or the AUDIT or AUDIT-C test. the CAGE questions are helpful in further characterizing alcohol use un patients who are positive on the initial screen.
Alcohol use (abuse) screening
1 Single-item screening
. How many times in the past year have you had (5 for men) ( 4 for women) or more drinks in a day?
2 AUDIT-C
. How often do you drink alcohol ? . How many drinks do you have on a typical day when you are drinking? . How offend do you have (6 for men) (4 for women) or more drinks on 1 occasion?
3 AUDIT
. 10-items screen assessing frequency , number of drinks &psychosocial consequences
CAGE
. Have you felt you should -Cut down- on your drinking? . Have others -Annoying - you by criticizing your drinking? . Have you ever felt bad or -Guilty - about your drinking? . Have you ever taken a drink first thing in the morning (Eye-opener) to steady your nerves?
The following section include additional items hat may be useful in evaluation of a patient with alcohol abuse.
History
History of present illness
. At what age did you start drinking alcohol? . On average , how many drinks do you have in a day? in a week? . How many days a week do you drink? . Have you had any mood changes? . Do you get anxious over small changes ? . Do you get anxious over small things? . If you don’t drink for 2-3 days do you get any shakes (tremors)? . Has you drinking veer gotten you in trouble?
Past medical history
. Have you had any seizures? . have you had liver problems? . Do you have high blood pressure ?
Family history
. Do you have any family members with alcohol or drug problems?
Social history
. Are you facing any stressful situations in your home? . Do you have any financial or occupational problems? . Do you smoke? . Do you use recreational drugs?
. Signs of cirrhosis : telangiectasia, jaundice, gynecomastia
Heart
. Tachycardia, ectopy /arrhythmia
Abdomen
. Signs of cirrhosis, ascites , spider angioma , caput medusae . Hepatomegaly , splenomegaly
Neurologic
. Tremor . Ataxia /cerebellar dysfunction
Psychiatric
. Impaired level of consciousness . Anxious or depressed affect . Increased or decreased psychomotor activity
Closing the encounter Patient with alcohol abuse have frequently interpersonal conflicts and criticism form family , friends and coworkers . For this reason , it os assertional to convey empathy and use nonjudgemental language when conducting the interview . Adverse findings(eg , signs of cirrhosis ) should be noted and discussed in a straightforward manner , but “lectures “ are rarely helpful . Although treatment and disposition (eg ,admit to alcohol treatment facility) are beyond the scope of the USMLE Step 2 CS exam , you should inquire about patient’s desire for treatment and provide assurance that you will continue to work with them to address their medical problems.
Diagnostic studies
The diagnosis of alcohol use disorder is based on clinical findings . Additional testing is ordered only as necessary to evaluate potential medical complications ( , eg , alcoholic liver disease ) and comorbidities . The following studies should be considered as the individual case warrants:
most patient with acute (<4-6 weeks) , uncomplicated low back pain have etiology and will have spontaneous resolution . However , patients with chronic or atypical symptoms are more likely have to require diagnostic and therapeutic intervention. For this reason , the evaluation of patients with back pain should give careful attention to duration of symptoms and other features that might suggest a poor prognosis.
Inanition , patients with possible infection , malignancy , or bony injury (eg , compression fracture 0 may require more aggressive evaluation . These -red flag- features include:
. Age > 50 . History of cancer . Constitutional symptoms(eg,fever, weight loss) . Nocturnal pain . No response to appropriate treatment . Significant neurologic deficits
Different diagnosis
Causes of low back pain
Musculoskeletal
1 Mechanical (eg, muscle strain)
. Normal neurologic examination . Paraspinal tenderness
. Age>50 . Worse at night . Not relieved with rest
Infectious
Osteomyelitis, discitis , abscess
. Recent infection of intravenous drug use . Fever ,m spine tenderness
The differential diagnosis os heavily dependent on age , comorbid and historical conditions (eg, history of malignancy) , and risk factors ( eg , intravenous drug use for infectious causes, menopausal status for osteoporosis) . the most common cause son back pain and the major clinical clues are listed in the table.
HISTORY AND PHYSICAL EXAMINATION
Inanition to the standard medical history and physical examination , the following sections , include most common items should be included in the evaluation of a patient with back pain.
History
History of present illness
. When did the pain start? . Can you show me where the pain is ? . What were you doing when the pain began? . On a scale 1 to 10 , how severe is the pain? . Please describe the pain (eg , sharp , burning , aching) . Have you had pain like this before ? . Dose this pain wake you up at night? . Dose anything make the pain worse ? Is it better or worse with resting? . Have you tried any medications of other treatments for your pain?
. Nerve root compression / radicular pain: 1 Can you feel the pain down your legs or in your feet? 2 Do you have any weakness , numbness s, or tingling in your legs? 3 Have you control of your bowel or bladder?
. Have you had any injuries to your back?
Past medical history
. Do you have a history of cancer ? Any recent infections? . Have you used nay glucocorticoid medications , such as prednisone?
Social history
. Do you smoke ? . Do you drink alcohol ? how much ? How often ? . Do you use recreational drugs?
Review of systems
. General : weight loss , fever , night sweats . Musculoskeletal : other joints pain/swelling , joint stiffness . Neurologic L Weakness , loss of sensation . Genitourinary : Menopausal state, dysuria / frequency / urgency
Physical examination
General
. Posture , body habits , pain behaviors
neurologic
. Lower extremity strength . Lower extremity sensory function . Lower extremity reflexes . Straight 0leg raise test . Gait 1 walk normally 2 walk on toes 3 walk on heels with toes dorsiflexed
Musculoskeletal
. Visible deformity of spine (scoliosis, loss of lumber lordosis) . Spinal or paraspinal tenderness . Range of motion of lumbar spine
Genitourinary
. Costoverterbral od suprapubic tenderness
Extremities
. Lower extremity pulses
Closing the encounter
Treatment is not tested as part of Step2 CS , but diagnostic testing for a patients with back pain is oriented toward identifying which patients can be managed conservatively with simple analgesics and which will need more aggressive treatment. In light of this , discuss the factors in the history and physical examinations that are most relevant in guiding subsequent testing and treatment:
. Patients with acute, -uncomplicated back pain- are manage conservatively , without additional testing, Advise the patient to maintain moderate activity. . Patient with -prolonged or recalcitrant pain- may require more complex interventions(eg, physical therapy). . Patients with -“red flag” features”- warrant specific imaging test. . Patients with severe or worsening -neurologic deficits- may require surgical intervention and will need and imaging and /or electrodiagnositc studies.
Diagnostic studies
Imaging for uncomplicated low back pain is not recommended . If no additional testing is required , write “ No studies indicated “ in the Diagnostic Studies section of the patient notes.
Diagnostic tests that can be considered for patients with back pain include:
Patients with a variety of disorders raining form being musculoskeletal pain to myocardial ischemia may report chest pain . Most causes have a distinct -profile of historical features- (eg, location , quality , aggravating / relieving factors ) but clinical characteristics car rarely specific enough for a firm diagnosis (eg, pain that is worse with meals is usually due to a gastroesophageal source but can occasionally be due to cardiac angina). In addition , some causes of chest pain are notoriously difficult to identify based on clinical characteristics alone (eg, pulmonary embolism).
Although the evaluation of chest pain in clinical settings is oriented to first rule out life-threatening disorders , the differential diagnosis in the USMLE Step 2 CS exam should formulated based only on liked , without regard to seriousness ., Also , some scenarios in Step 2 Camay incorporate images , such as ECG or chest-x-ray ; you should review common abnormalities on these tests prior to the exam.
Differential diagnosis
Differential diagnosis & features of chest pain
Coronary artery disease
1 Substernal 2 Radiation to arm , shoulder , or jaw 3 Precipitated by exertion 4 Relieved by rest or nitroglycerin
1 Sudden , severe “tearing” pain 2 Radiates to back 3 Elderly men 4 Hypertension &risk factors for atherosclerosis
Gastrointestinal / esophageal
1 Nonexertional , relieved by antacids 2 Upper abdominal & substernal 3 Associated with regurgitation, nausea, dysphagia 4 Nocturnal pain
Chest wall / musculoskeletal
1 Persistant &/or prolonged pain 2 Worse with movement or change in position 3 Often follows repetitive activity
the most common causes of chest pain are listed in the table , alone with clinical features that are characteristic of each other , In addition , be aware of disorders in adjacent structures 9eg, neck/thyroid, liver , gall bladder , shoulder) that may cause pain in the chest. Also , herpes zoster (shingles) is a very common and frequently overlooked cause of chest pain
HISTORY AND PHYSICAL EXAMINATION
The following sections include the most common items to address in the evaluation of chest pain.
History
History of present illness
. Have you had pain like this before? If so , what was the outcome? . Do you still have pain or has it resolved ?
. For active chest pain 1 What were you doing when the pain begin? 2 Can you think of anything that may have caused the pain?
. For resolved or intermittent chest pain? 1 How long ago did the chest pain episodes begin? 2 How often do the episodes occur? 3 How long do the episodes last? 4 What brings on the pain (eg, walking , exercising)? 5 How far can you walk before you develop chest pain or shortness of breath?
. Point to where the pain is . Do you feel it anywhere else? . On a scale of 1 to 10 , how severe is it? . Describe the point (eg, sharp , burning , crushing , heavy). . Dose anything make the pain better/worse? . Do you have other symptoms associated with the pain (eg ,shortness of breath , palpations , nausea , sweating , lightheadedness )? . Have you had a fever? . Have you had a cough? . Do you have swelling in the leg? . Do you have leg pain while walking? . Risk factors for pulmonary embolism; Unilateral leg pain/ swelling , immobilization , recent surgery, clotting disorders
Past medical history
. Have you been diagnosed with any other medical conditions (eg , high blood pressure , diabetes , heart problems , high cholesterol)?
Family history
. Is there anyone in your immediate family with heart disease?(Note : Cornily artery disease is very common & is usually relevant to family members only of it occurs early in life.)
Social history
. Do you smoke ? At what age did you start & how much do you smoke? . Do you drink alcohol? How much & how often? . Do you use recreational drugs(especially cocaine or amphetamine)?
Patients with chest pain are frequently concerned about potentially serious causes. They may also have ha previous similar (diagnosed or undiagnosed ) episodes . Asking the patient what they think may be the cause of the pain (eg “What do you think your pain is due to , or what are you concerned may be the cause of it?”) is often helpful in evaluating chest pain , both to improve patient communication and to clarify the differential diagnosis.
In most cases , the diagnostic test will be simple and familiar to the patient (eg , chest-x-ray , ECG ), but you should explain more complex tests (eg , echocardiogram , ventilation /perfusion scan) and get the patient;s permission before proceeding . Reassure the patient that the result should be available quickly and you will explain the results as soon as possible.
Diagnostic studies
Common diagnostic studies that should be considered for patients with chest pain include:
. ECG . Chest-x-ray . Pulse oximetry (if not provided) or arterial blood gas analysis . High-sensitivity D-dimer . CT pulmonary angiogram or ventilation/ perfusion scan . Echocardiogram . CT scan of the chest . Barium esophagram or upper GI endoscopy . Liver / gall bladder ultrasound
Subacute ( 3-8 weeks) and chronic(>8weeks) cough is common reason for physician visits. Whereas patients with acute cough(<3 weeks) often present with a characteristic constellation of symptoms (eg , influenza presenting with subbed -onset fever, myalgia , headache , and cough) those with only a nonproductive cough may avoid coming to the clinic until the symptoms have been present for an extended period.
Patients with a prolonged cough should be queried for risk factors (eg, smoking) , chronic medical conditions (eg,seasonal allergies ), or subtle symptoms (eg , night sweats, weight change) that may suggest the likely causes.
. Asthma . Post-respiratory tract infection . Chronic bronchitis . Bronchiectasis . Lung cancer . Non asthmatic eosinophilic bronchitis
Other causes
. Gastroesophageal reflux . ACE inhibitors
-Postnasal drip- (upper -away cough syndrome) , - Gastroesophageal reflux disease-(GERD) , and -asthma- causes > 90% of chronic cough in nonsmokers without known pulmonary disease . Wheezing or atopic history (eg , seasonal allergies , eczema) suggest asthma . Increased sputum production is nonspecific but suggests postnasal drip or lower airway disease (eg, chronic bronchitis, bronchiectasis). In smokers , an early-morning cough suggests chronic bronchitis.
Adult pertussis and post infectious cough often begin with unremarkable upper respiratory symptoms . Systemic symptoms (eg , fever , weight loss) may indicated malignancy or chronic infection (eg, tuberculosis) . note that the dry cough caused by- ACE inhibitors- can begin up to a year or more after initiation of therapy.
HISTORY AND PHYSICAL EXAMINATION
In addition to the standard general medical history and physical examination , the following sections include the most common items in the evaluation of a patient with chronic cough.
History
history of present illness
. When did the cough start? . Is it a day cough or dose it bring up sputum ? What color is the sputum? Has there been blood in the sputum? . Is there anything that makes your cough worse ? better? . Have you noticed drainage in the back of your throat? . Do you get short of breath? . Have you noticed wheezing? . Do you have frequent heartburn or acid reflux? . Do you have chest pain? . Have you had a fever? chills? Night seats ? Weight loss? . Features of heart failure - prior heart problems ? - Swelling in your feet ? - How many pillow do you sleep on ? Do you get out of breath if you lie flat?
Past medical history
. Have you had heart or uno problems in the past? . Do you have trouble with allergies or eczema9recently or as a child)? . If history of hypertension m review medications for ACE inhibitors.
Family history
. Is there anyone in your family with asthma?
Social history
. What kind of work do you do?(Ask industrial workers about asbestos exposure) . Do or did you smoke? . Have you traveled outside the US recently?
Following the history and physical examination , the diagnosis may be apparent . However , diagnostic testing may be needed before the cause can be confirmed . In such cases , explain the most likely causes and the goal of the specific tests. in addition, ion the patient smokes , inquire about readiness to quit and offer to provide support to help them quit.
Diagnostic studies
Diagnostic testing in pulmonary dies can be subdivided into -structural tests-(eg , chest X-ray, CT scan) and -functional tests- (eg , pulmonary function tests, arterial blood gas analysis). The tests chosen will be influenced by the mist likely cause; patient with undifferentiated symptoms often require both structural and functional tests.
Tests to consider for patients with chronic cough include:
. Plain film chest x-ray (most patients with a chronic cough should receive a chest x-ray) . Pulmonary function tests : Asthma, wheezing , suspected chronic bronchitis . Arterial blood gas analysis : Tachycardia , tachypnea , or abnormal pulse oximetry . ECG, echocardiogram; Heart failure or valvular heart disease . Chest CT: Risk of malignancy , interstitial lung disease . Esophagram : Dysphagia , obstructive symptoms
Although chronic cough may have an allergic etiology, allergy tests are rarely helpful in the initial assessment. Bronchoscopy and nasal endoscopy are also not usually part of the initial workup
JuanFe
發表於： 2018/06/05 10:46pm
CHRONIC DIARRHEA
Doorway information about patient
The patient is a 34-year-old man who comes to the clinic due to 4 weeks of diarrhea.
Acute diarrhea is usually a self-limited illness . Unless bloody stools , systemic symptoms (eg , fever), or signs of dehydration are present, most cases are manages conservatively and do not need an extensive investigation.
However , patient with chronic(> 4 weeks) diarrhea are less likely to have spontaneous resolution and warrant additional workup . Patient with usually soft but otherwise normal stools may use the term ”diarrhea” so the interview should begin by clarifying the frequency , volume , and consistency of stools.
Different diagnosis
Most patients who comes for evaluation of chronic diarrhea have one of the following:
. Functional diarrhea: loose stools without additional symptoms . Irritable bowel syndrome: loose stools , altered bowel habits , sensation of incomplete . Inflammatory bowel disease: 1, Crohn disease : watery diarrhea , fever m weight loss , abdominal pain 2, Ulcerative colitis : cramps , tenesmus (sensation of needing to strain to pass stool), visible blood
. Malabsorption : Increased stool volume , weight loss, steatorrhea , flatulence , possible association with foods(dairy products , gluten) . Paradoxic diarrhea: impacted stool with diarrhea due to passage of watery stool around the impaction(especially in frail or elderly patient)
Patient with chronic diarrhea should be queried for foreign travel and risk factors for -HIV-, which would broaden the differential diagnosis significantly . Waterlyt diarrhea following exposure to rural or wildness water resource suggests -giardiasis- ; parasitic causes of chronic diarrhea are otherwise uncommon in the United States.
HISTORY AND PHYSICAL EXAMINATION
The following section include the most common items that should be included in the evaluation of a patient with diarrhea . In patients with chronic diarrhea , the history is usually more helpful than the physical examination.
History
History of [resent illness
. Please explain what you mean by “ diarrhea” . When did the diarrhea start? . How many times a day are you going? . Do you have large or small volume? . What is the pattern ? Are symptoms continuous m or do you have normal bowel movements in between? . Do you see blood or pus? . Do you pass mucus in the stool? . Is the diarrhea greasy or oily? . Do you have abdominal pain or cramps? . Have you had fever , chills or weight loss? . Is the diarrhea associated with any particular foods? . Have you started any new medications, include over-the-counter medications? . Are you taking weight loss pills (eg, orlistat) or artificial sweeteners(eg sorbitol)? . Have you been traveling or camping recently? . Dose anyone around you have similar symptoms?
Past medical history
. Have you had abdominal surgeries?
Social history
. Are you sexually attire ? Have you been active with men , women , or both? . Do you use illicit drugs?
. Inspect for scars & distension. . Auscultate for bowel sounds . Percuss for bowel gas pattern. . Palpate for tenderness , especially along the course of colon.
Closing the encounter
The closing conversation should review the most likely diagnosis and any clinical features that suggest serious illness . Discuss whether an aggressive evaluation is warranted or whether you should order tests in a stepwise fashion, If endoscopy is considered , provide basic education about the procedure and obtain the patient’s consent before proceeding.
Diagnostic studies
Virtually all patients with diarrhea should have a rectal examination ; this is not allowed in the USMLE Step 2 CS exam but should be listed in the Diagnostic studies section. Also , most patients warrant basic laboratory studies (eg, electrolytes , urea nitrogen, creatinine , blood counts , fecal occult blood) to assess serious and identify dehydration or other potential complications of the diarrhea.
Patient with bloody diarrhea or fever need an expedited evaluation with early colonoscopy . in contrast , patient with non bloody diarrhea and no systemic symptoms may warrant only a few basic laboratory tests and a trial of dietary modification before invasive studies.
Diagnostic tests to consider in chronic diarrhea include:
. Total protein , albumin(possible malabsorption) . TSH . Inflammatory markers (eg, erythrocytes , sedimentation rate, C-reactive protein) . Quantitative stool fat . Stool Guardia antigen . Anti-tissue transglutaminase antibody assay(suspicion for celiac disease , comorbid type 1 diabetes) . HIV serology . Colonoscopy
JuanFe
發表於： 2018/06/05 10:45pm
CONFUSION
Doorway information about the patient
The patient is a 65-year-old man who is brought to the clinic by his wife for 2-3 months of confusion.
Changes in mental status are most noticeable when they have an abrupt onset : patient with a slow progressive decline in function may not be brought for medical attention until the problem is far advanced and is noticed by a family member or friend who has not seen the patient for a long time.
Impaired mental status can be ,infestation of visually any disease process if severe enough .Be alert for sign and symptoms that can point to the -primary body system- (eg, abdominal pain, productive cough) . Also , be aware that elderly patients who develop an acute medical illness may present with delirium but without the more characteristic symptoms of the illness(eg, urinary urgency and dysuria in acute cystitis). Although vital signs may be normal , subtle abnormalities may be an important clue too the diagnosis (eg, mild tachycardia in alcohol withdrawal)
The differential diagnosis of confusion can be subdivided into chronic/progressive (i.e., -dementia-) and acute/fluctuating (i.e.,-delirium-) causes , patients may have manifestations of both , and patients with underlying dementia are more likely to develop delirium during an acute illness.
Alcohol , illicit drugs , and perception pharmaceuticals are common precipitating factors for delirium. A history of mental illness is also helpful in identifying the cause of confusion , but it is often not known at the time of presentation.
Before formulating a differential diagnosis , male sure that the patient has a true cognitive rather than a sensory deficit(eg, hearing loss) or aphasia that may be interpreted as confusion .Also patents with affective disorders may develop alterations in behavior that are difficult to distinguish form dementia.
HISTORY AND PHYSICAL EXAMINATION
Ask questions to narrow down the primary system , than follow with more detailed questions to identify a specific cause within a system . Also , try to understand the patent’s -baseline mental status- , relying on family members if possible (eg, “When was the last time your spouse seemed normal to you ?”). If the patient becomes irritable or uncooperative , it is usually better to make your clinical determinations based on the information you are able to obtain in the available time arther than rush the patient.
History
History of present illness
. Your spouse is concerned about you being confused . Do you feel unusual? . Are there nay specific times or situations that cause this confusion? . Have you noticed any problems with your memory? . Have you had any weakness, tingling , or numbness in your arm or legs? . Have you had any dizziness? . Have you ever had any jerky hand movements or seizures? . Do you have any history of head trauma? . Have you had any fever? . Do you have headaches? . Have you ever passed out? . Assess activities of daily living: - Are you able to do regular activities , such as dressing , eating , walking & bathing? - Are you able to go shopping ? manage your household finances? - Are you able to do your regular housework? Prepare your own food? - Are you able to drive ? have you had any accidents or traffic citations recently?
Social history
. Who do you live with? . What kind of work do (did) you do? . Do you smoke? . Do you drink alcohol? How much &how often? . Have you used recreational drugs?
Physical; examination
General
.Observe hygiene, posture & psychomotor activity
HEENT
. Palpate for thyroid enlargement
Lungs
. Examine for signs of consolidation
Abdomen
. Palpate for masses & tenderness (especially suprapubic tenderness)
Neurologic
. Cognition - Memory , recent & remote (eg,recent events , recall of 3 objects) - Concentration (serial 7s , “ world ” spelled backward) - Estimate of intelligence (fund of knowledge , current events) - Abstraction (interpretation of similarities, proverbs) - Insight (awareness of illness)
. Examine cranial nerves . Test gait & reflexes . Evaluate muscle strength & sensory function
Closing the encounter
The history and physical examination for a patient with confusion amy be lengthy ; stay aware of the time and allow adequate time for warp-up . Patients9ad their family members) with declining mental function may be understandably anxious . Encourage them to express their concerns , both to enhance the physician-patient relationship and potentially to marrow the differential diagnosis
If the diagnosis is not clear by the end of the encounter , state your uncertainty honestly. Do not provide false reassurance , but assure patients that you will work with them evaluate their condition and that you will inform them of your findings in a timely manner.
Diagnostic studies
As with the medical history , diagnostic testing should begin with a broad assessments of system , with more specific tests done later to rule in or rule out individual disorders . Brain imaging should be considered if there is impaired arousal , history of trauma , focal neurologic findings , or correctable cause identified on initial assessment . Test to consider include:
. Electrolytes, glucose , renal function markers . Liver function tests . Complete blood count . TSH . Vitamin B12 . HIV serology . Urinalysis and culture . Urine drug screen . Lumbar puncture/cerebrospinal fluid analysis (especially for patient with fever or features suggesting meningitis) . MRI of the brain . CT scan of the brain . Electroencephalogram (especially of patients with prior seizures or head trauma )
