Sensores

History: see question #28.

Likely diagnosis: benign prostatic hyperplasia.

Differential diagnosis: transitional cell carcinoma of bladder, UTI, nephrolithiasis, hydronephrosis, prostatitis, prostate cancer, renal cell carcinoma, essential hematuria (tends to occur in children).

Two investigations: prostate specific antigen (PSA), cystoscopy, renal, bladder and prostate ultrasound, intravenous pyelogram (IVP). 91. 20 year old female with hypertension. Perform a physical exam. Q: Give a differential diagnosis. What investigations would you order?

92. 67 year old male complains of bladder distension, inability to urinate and dribbling of urine from the urethra. Take a history. Q: What investigations would you order?

History: patient ID. Onset of symptoms, chronology, previous episodes. Associated constipation, perineal numbness, leg weakness, diabetic neuropathy. Is patient on a new medication? Suprapubic pain, pain on urination, frank blood in the urine, color of urine, difficulty initiating or maintaining urinary stream, renal pain, groin pain. Previous renal colic or diagnosis of nephrolithiasis? Known prostatic hypertrophy or cancer? Diabetes? B12 deficiency? Recent surgery? History of hypercalcemia, hypertension. Malignant symptoms: night sweats, weight

loss, fatigue. Medications, drugs/alcohol, smoking, past medical history, past surgical history, family history, review of systems. Investigations: urinalysis, urine microscopy and culture with sensitivities, cystoscopy, PSA, renal and pelvic ultrasound.

1992

93. 60 year old female feeling depressed. Complains of stomach pain. Perform focused mental status exam.

Mental status: appearance, behavior (dress, grooming, posture, gait, apparent age, physical health, body habitus, expressions, attitude - cooperative?, psychomotor activity, attention, eye contact), speech (rate, rhythm/fluency, volume, tone, quantity, spontaneity, articulation), mood (subjective emotional state in patient’s own words), affect (Quality – euthymic, depressed, elevated, anxious; Range – full, restricted; Stability – fixed, labile; Appropriateness; Intensity - flat, blunted), suicidal ideation (low, intermediate, high – poor correlation between clinical impression of suicide risk and probability of attempt), thought process (coherent, flight of ideas, tangentiality, circumstantiality, thought blocking, neologisms, clanging, perseveration, word salad, echolalia), thought content (delusions – bizarre vs. non-bizarre,

obsessions, preoccupations, phobias, recurrent themes), perceptual disturbances (illusions, hallucinations, depersonalization, derealization), insight, cognition, judgment.

94. 16 year old girl brought to the office by a classmate for weight loss over the past six months. The classmate is worried about anorexia nervosa. Take a history and counsel.

History: amount of weight lost, time frame. How did the patient lose the weight? What is the patient’s diet now? Still losing weight? How often does the patient weigh herself? Are you proud of this weight loss? Do you think you need to lose more? Are you afraid of becoming “fat”? Do you admire women who are smaller than you? Binge eating, post-prandial vomiting, laxative or diuretic abuse, excessive exercise, diet pills. Wearing baggy clothes to conceal “fatness,” unable to look at self in a mirror or to be touched by others. Ask about the home environment, is there a problem with expressing conflict openly? Signs of malnutrition, amenorrhea (> 3 consecutive menstrual cycles missed), sallow skin, rash, easy bruising, dry and sparse hair, lassitude, weakness, anemia, neurologic findings (carpal and tarsal nerve compression, confusion, emotional lability, loss of corticospinal vibration and position sense), glossitis, heart burn, teeth erosion, GI bleeding. Counsel: Determine ideal body weight using standard height/weight charts (BMI = weight (kg)/height2 _(m2_{), ideal is about 20-25 for}

females). Show patient her position on the chart. Explain that anorexia nervosa is a modern disease of highly motivated young women. These women exercise extreme control over their bodies, often as a means of sublimating their inability to express conflict at home. Warn patient that excessive weight loss has led to the deaths of many young women who were unable to correct their anorexia. Explain that proper body weight is essential for health and mental function, including learning and performing well at school/career. You understand that the patient may be proud of her weight loss. Being underweight may show a great deal of self control and will power, but being at ideal weight shows more. Invite patient to develop a healthy body image by not equating soft or fatty body areas with overweight. Emphasize that attractiveness and good health depend on a good balance of fatty tissues as well as lean. Contract with the patient to gain a certain number of pounds per week. Discuss how she will do this.

Contract for specific weight gain goals (2 lbs/week). Involve dietician. Halt diuretics, laxatives, diet pills. Close monitoring of weight, vitals, heart rhythm, potassium. Arrange follow up with patient and her family to discuss family dynamics, expression of conflict in the home.

95. 2 year old child with history of fever and 1 seizure. Counsel parents. See also question #9.

Most likely diagnosis: benign febrile seizure (febrile seizures usually occur 6 months to 6 years, associated with initial rapid rise in temperature, no neurologic abnormalities/evidence of CNS infection/inflammation before or after, no history of non-febrile seizures, most commonly generalized tonic-clonic, < 15 minutes duration, no recurrence in 24 hours, atypical may show focal origin/> 15 minutes/> 1/24 hours/transient neurologic defect).

Counsel parents regarding febrile seizure: A typical febrile seizure is a brief generalized tonic-clonic seizure related to high fever (at least 39 degrees Celsius) and occurring between the ages of 3 months and 7 years. The post-ictal stage is characterized by improvement in confusion, lethargy, limpness. The greatest risk factor for febrile seizures is a history of febrile seizures in the parents. This is the most common seizure in children (3-5% of children, M > F). Occur between the ages of 6 months and 6 years. Thought to be due to initial rapid rise in temperature. These seizures may come about as a result of fever from any cause, including post immunization. In the absence of an abnormal developmental history (CP, developmental delay), and an otherwise well child, they are usually benign. Seizures do not cause mental impairment unless they are prolonged (> 30 min) but can be a symptom of brain damage.

Prognosis after a single febrile seizure: 65% will never have another seizure, 30% will have further febrile seizures, 3% will go on to have seizures without fever, and 2% will develop lifelong epilepsy (risk factors for this are: developmental and/or neurological abnormalities of child prior to seizures, family history of non-febrile seizures and an atypical initial seizure).

Treatment of recurrence: control fever with antipyretics (Tylenol), tepid bath, fluids for comfort only and use Ativan (lorazepam) 1 mg SL/PO (or diazepam 5-10 mg PR) if a seizure occurs at home. Turn patient onto his/her side, do not force objects or fingers into mouth. Bring to ER if seizure does not stop within 10 minutes. Seizures do not cause mental impairment unless they are prolonged (> 30 min), although seizures can be a symptom of brain damage. Patient should be investigated with CT head and EEG. Prophylactic anticonvulsant therapy is a consideration with repeated seizures.