History: onset, duration, chronology, description of events. Have the patient’s episodes been witnessed? Does the patient lose consciousness, are there warning signs of post-ictal symptoms, can the patient prevent an episode by sitting down or other means. If dizziness is a feature, is this light-headedness or true vertigo (vertigo means that the patient senses actual movement of either the room or themselves). What is the patient doing when these episodes occur? Are muscle jerks a feature? Associated fatigue, weakness,
nausea/vomiting, chest pain, shortness of breath, palpitations, focal neurological symptoms. Past medical history (e.g. diabetes, heart disease), medications, drug use, alcohol, smoking, allergies, family history, review of systems.
Differential diagnosis: Medication induced bradycardia (Digoxin), hypovolemia (Lasix). Cardiovascular arrhythmia, valvular disease, subclavian steal. Metabolic: hypoglycemia. Central nervous system: seizures (e.g. narcolepsy, tumor), stroke/TIA, cervical spondylosis, anxiety with hyperventilation, middle ear (benign positional vertigo, acoustic neuroma, Meniere’s disease). Autonomic: vagal, orthostatic hypotension. Infection in elderly can present in many ways: UTI etc.
Digoxin overdose: anorexia, nausea, vomiting, bradycardia, visual effects: yellow, green or white halo around objects, decreased level of consciousness, abdominal pain and diarrhea. ECG shows junctional tachycardia, PVC’s, AV block, and sometimes PSVT.
Physical exam should include: vitals, orthostatic BP, check for signs of dehydration (thirst, mucous membrane moistness, HR, urine output, skin turgor, BP), cardiopulmonary exam (see question #13), neurologic exam (see question #5) and mini-mental status exam (see question #4).
Investigations: Digoxin level, CBC, lytes, urea, creatinine, INR/PTT, glucose, ECG, 24 hour Holter monitor, echocardiogram, EEG, CT head, carotid Doppler.
64. 30 year old male, married with 2 children. Brought in by police for violent and dangerous behavior. Take a history. Q: Would you admit this patient? What are the criteria for a Form 1?
History: Attempt to determine whether patient is sad (depressed), bad (antisocial, reaction to stressful or frustrating events, poor anger management), or mad (mania, schizophrenia). Is the episode related to drugs of abuse or organic (brain tumor, metabolic disturbance)? Cover history for depression (see question #4), mania (see question #4) and schizophrenia (see question #57) with mental status exam (see question #4) and mini mental (see question #4).
Criteria for admission: patient requires observation or medication in a controlled, safe setting for diagnosis, patient appears to be a danger to himself or others, environment at home unsuitable for the patient at this time, patient requires medical work up for organic causes, patient in need of detoxification.
Criteria for a Form 1: Forcible admission for assessment without right to appeal, maximum 72 hours, can be administered by any licensed physician who has seen the patient within a week, both criteria must be met:
1. Patient appears to be danger to himself/herself or others. 2. Patient appears to be currently suffering from a mental illness.
65. 65 year old male with dysphagia. Take a history. Q: Differential diagnosis and investigations. History: see question #10.
Investigations: Barium swallow (liquid and with marshmallow for transfer), endoscopy with biopsy, CT chest, esophageal manometry, 24 hour pH reflux study.
66. 65 year old male outpatient with shortness of breath, cough, sputum. Take a history and perform a physical exam. Findings: Lobar consolidation with yellow-green sputum. Q: Given a diagnosis of pneumonia, recommend treatment.
History: Name, age, occupation, travel history, pets. Cough (acute, chronic, worse in any position/season/night, anything relieve), sputum (what color, quantity, frequency, quality), hemoptysis (quantity, frequency, quality e.g. blood tinged/clots), dyspnea (constant, duration, onset, frequency, severity, exercise tolerance, triggers, alleviating), fever, chills, malaise, fatigue, increase in asthmatic symptoms (wheeze, cough), preceding viral illness. Onset, chronology of symptoms, positional factors (orthopnea), chest pain, ankle swelling. History of COPD? Medications, compliance with meds (observe use of puffers), drugs of abuse (alcohol), smoking, allergies, past medical history, family history, review of systems.
Physical Exam: Cardiopulmonary exam as in question #13 and #24.
Treatment: for diagnosis of community-acquired pneumonia, admit if patient is systemically ill (may have septicemia), if the patient is debilitated or hypoxia is a feature (send blood cultures and give oxygen). Start IV cefuroxime 750 mg IV q8h. Switch to a more specific oral antibiotic when culture results become available. For outpatient therapy: Clavulin (amoxicillin + clavulanate) 500/125 mg PO BID. Follow up in 1 week. Discontinue therapy after 3 afebrile days.
Note: this therapy does not cover atypicals. Practices vary according to the treatment population: Antibiotic therapy for pneumonia
Presentation Likely Organisms
Community acquired, no COPD Streptococcus pneumonia (typical) or Mycoplasma pneumoniae & chlamydia (atypical) Community acquired with COPD add Haemophilus influenza
Alcoholics & debilitated patients add Gram negatives, Legionella and anaerobes (in aspiration)
Diabetics or hospital acquired add Staphylococcus aureus and in very ill patients: Pseudomonas aeruginosa Therapies:
1. IV cefuroxime 750mg IV q8h covers: Strep, Staph (unless it is MRSA…), gram negatives, anaerobes. Change to more specific oral agent when organism known.
2. Clavulin (amoxicillin + clavulanate) 500/125mg PO BID. Covers Strep, Staph, gram negatives and anaerobes. 3. Septra (trimethoprim + sulphamethoxizole) 2 tabs PO BID (or 1 DS tab BID) covers Strep, Staph and gram negatives. 4. Erythromycin 500mg PO/IV QID covers Strep and atypicals.
5. Penicillin G 1-2 million units IV q4h effectively covers Streptococcus only. Oral version is penicillin V 250-500mg PO q6h.
6. Piperacillin 3g IV q6h + Tobramycin 2mg/kg IV q8h is a standard therapy for Pseudomonas aeruginosa. Piperacillin also covers Strep, gram negatives and anaerobes, while Tobramycin adds further gram negative coverage with synergy.
7. Clindamycin 300mg IV q8h or PO q6h covers Strep, Staph and anaerobes.
8. Vancomycin 1g IV q12h or 125mg PO q6h for MRSA also covers Strep and anaerobes. Sanford Guide: Rx influenced by local prevalences.
Presumed viral pneumonia in adults: cought, no sputum, dyspnea/hypoxia, interstitial infiltrates Influenza, parainfluenza, adenovirus, RSV, hantavirsu For influenza A or B: zanamivir 10mg inhaled BID x 5d or oseltamivir 75mg PO BID x 5d. Start within 48 hours of symptoms onset.
For influenza A: rimantadine 100mg PO 2x/d or amantadine 100mg PO 2x/d. Adults over age 18:
Community acquired; non-hospitalized.
Smokers: S. pneumo, H. influenzae, Moraxella catarhalis. Post-viral bronchitis: S. pneumo, rarely S. aureus. No co-morbidity: Mycoplasma, Chlamydia
pneumoniae, viral, rarely S. pneumo. Alcoholic stupor: S. pneumo, anaerobes, coliforms. Epidemic: Legionaire’s. Birds: Psittacosis. Rabbits: Tularemia. Parturient livestock or cats: Coxiella burnetii. Airway obstruction: Anaerobes.
Azithro 0.5gm PO x1 then