Cervical spinal cord compression produces lower motor weakness in the arms or hands (atrophy, suppressed reflexes) and upper motor weakness in the legs (increased muscle tone, hyperreflexia, clonus, upgoing extensor reflexes in the toes).
This patient most likely has cervical myelopathy (Option A), a condition most commonly caused by degenerative cervical spondylosis. Combined upper and lower motor neuron findings indicate disease in the spinal cord, the only anatomic location in the body where both segments are found together and can be affected simultaneously. Lower motor neuron weakness originates at the level of compression, and upper motor neuron weakness occurs below it. Cervical spinal cord compression produces lower motor weakness in the arms or hands (atrophy, suppressed reflexes) and upper motor weakness in the legs (increased muscle tone, hyperreflexia, clonus, upgoing extensor reflexes in the toes). Lhermitte sign, an electric shock–like pain radiating from the neck to the spine or the arms, can be produced by forward flexion of the neck, but it is insensitive for the presence of cervical cord disease. Clinical diagnosis of cervical myelopathy should be confirmed with MRI. Treatment is surgical decompression.
Cervical radiculopathy (Option B) is caused by spinal nerve root compression resulting from degenerative spinal changes or disk herniation. It manifests as neck pain radiating to the arm, paresthesia in a dermatomal distribution, decreased deep tendon reflexes, and diminished strength in the affected extremity. This patient's examination findings are not consistent with cervical radiculopathy.
Cervical sprain (Option C) is a common musculoskeletal cause of neck pain. Typical symptoms include pain and stiffness with movement and decreased cervical range of motion. This patient's abnormal neurologic findings rule out cervical sprain.
Myofascial neck pain (Option D) may be differentiated from other musculoskeletal causes by localized tenderness and pain with palpation of “trigger points” on the neck and shoulder. The neurologic examination is normal in patients with myofascial neck pain.
Whiplash injury (Option E) develops after trauma involving abrupt acceleration and deceleration, leading to sudden neck flexion and extension. The physical examination reveals pain and stiffness of the neck with decreased range of motion due to pain. The neurologic examination in patients with whiplash injury is normal as long as concussion was not a feature of the injury. Without a history of acceleration-deceleration trauma, whiplash injury is unlikely in this patient.
Spinal imaging for acute back pain should be limited to patients with “red flags” suggesting an underlying process that requires intervention, such as a personal history of cancer or symptoms concerning for cancer (fever, persistent pain, vertebral tenderness, or weight loss) or cauda equina syndrome (bowel or bladder dysfunction, persistent or increasing lower motor neuron weakness, or saddle anesthesia). In this case, the patient's injection drug use and focal vertebral tenderness should heighten suspicion for an acute infection of the spine, such as epidural abscess, diskitis, or osteomyelitis. MRI is considered the gold standard in patients with suspected spinal infection, cancer, cord compression, or cauda equina syndrome.
Neurogenic thoracic outlet syndrome typically presents with nonradicular and anatomically widespread symptoms (weakness, numbness, paresthesia, and pain) affecting the arm, neck, and shoulder; symptoms worsen with repetitive overhead activities
Superior labrum anterior and posterior (SLAP) lesions are often caused by repetitive overhead stress; patients present with deep anterolateral shoulder pain that worsens with abduction and external rotation
Acute-onset urinary incontinence may indicate the presence of a transient, reversible cause.
Common causes of acute, transient urinary incontinence include medications and urinary tract infection
Prevention of pressure injuries in hospitalized patients requires regular risk assessment and pressure redistribution through proper patient positioning and an advanced static mattress or overlay
Degenerative meniscal tears are associated with diffuse or medial knee pain; catching, locking, or inability to extend the knee; and pain with flexion activities, such as squatting.
Degenerative meniscal tears can be managed conservatively with such strategies as physical therapy and strengthening exercises
Calcaneal stress fracture
Stress fractures located at the base of the second metatarsal, fifth metatarsal diaphysis, and medial malleolus are associated with a high risk for nonunion, and orthopedic referral is recommended.
Calcaneal fractures pose a low risk for nonunion and can be managed with rest, crutches, a walking boot, and/or footwear padding to achieve pain-free ambulation.
The metatarsals, tarsals, and calcaneus are the most common sites of stress fracture in the foot. Physical examination may reveal bony tenderness, pain with percussion, or pain with hopping on a single leg. The calcaneal squeeze test may elicit pain in patients with calcaneal fracture. Management of foot and ankle stress fractures depends on the risk for nonunion, predominantly defined by the location of the fracture. Evaluation by an orthopedic surgeon is warranted in fractures at high risk for nonunion. Such risk factors include fracture at the base of the second metatarsal, fifth metatarsal diaphysis, and medial malleolus. Calcaneal fractures pose a low risk for nonunion and can be managed with rest, crutches, a walking boot, and/or footwear padding to achieve pain-free ambulation. Follow-up radiography at 4 weeks can help document healing. Once the patient can ambulate without pain and has no pain with provocative maneuvers on examination, activity can be gradually reintroduced. Most patients with low-risk injuries can resume running by 8 to 12 weeks.
In all cases of stress fracture, forces on the fracture site must be reduced to permit pain-free ambulation and to facilitate healing. Common examples of protective devices include a walking boot, leg splint, and hard-soled shoe. Casting (Option A) is not required in the management of most stress fractures.
Several treatment modalities of unproved benefit have been suggested for patients with stress fracture, including electrical stimulation (Option B), therapeutic ultrasonography, prostacyclin analogs (such as iloprost), and extracorporeal shockwave therapy. Clinical trials have demonstrated that electrical stimulation is no more effective than placebo in the healing of stress fracture and cannot be recommended.
MRI (Option C) is more sensitive than radiography for detection of stress fracture and can provide prognostic information about the risk for nonunion; it should be performed when plain radiographs are unrevealing but clinical probability is high. Because this patient's radiograph reveals a visible fracture in a low-risk location, MRI would not alter management at this point.
The bleeding risk from aspirin (ASA) is likely worse than benefit of ASA in primary prevention of major adverse cardiac events “MACE” – (ARRIVE, ASCEND, ASPREE trials).
For elderly patients on long term aspirin for primary prevention, it is safe (and encouraged) to discontinue aspirin therapy. (ASPREE NEJM 2018)
7 metrics for ideal cardiovascular health
Lipid, Blood pressure, glucose, healthy diet, appropriate energy intake, physical activity, avoid tobacco
Lifelong low dose aspirin (usually 81 mg daily in the US) is recommended for secondary prevention, unless there is a contraindication (e.g. significant bleed). (Antithrombotic Trialists’ Collaboration – BMJ 2002 PMID: 11786451).
If a patient has had coronary or peripheral revascularization (stent or arterial bypass), MI or stroke, then ASA use is considered secondary prevention.
PCI for stable CAD – DAPT for 6 months, then discontinue p2y12; continue aspirin lifelong
PCI for ACS - Continue DAPT (i.e. ASA plus clopidogrel) for one year. Then, calculate a DAPT score (from DAPT study). If the DAPT score is 2 or higher and no bleeding stigmata, then continue DAPT for 30 months before stepping down to aspirin monotherapy
IMPROVE-IT Trial: Ezetimibe plus statin versus statin plus placebo. Cardiovascular events lowered in ezetimibe plus statin group (average LDL of 53) versus high dose statin alone.
FOURIER Trial: Statins alone (median LDL in 92) versus statins plus PCSK9 inhibitor (median LDL 30). No decrease in CV death over 2.2 years, but 1.5% absolute risk reduction in composite CV events (acute coronary syndrome, stroke, revascularization).
CAC scores detect atherosclerosis, NOT stenosis.
CAC score of zero gives most patients a 10 year warranty
Check CAC score if risk between 5-20% risk (low to intermediate risk) on Framingham, or the ASCVD Pooled cohort equation
Certain insurers now covering CAC scoring e.g. Aetna, Medicare in Cali, United Healthcare. If not covered, then costs $200.
Absolute score (does not account for age, gender, race, etc.). Score 0 = very low risk, score 1-100 = low risk, score 101-299 = intermediate risk, scores >300 = coronary heart disease (CHD) risk equivalent
Relative score considers percentile of plaque burden based on age, and gender. If >75th percentile, then considered high risk. If >90th percentile, then CHD risk equivalent
If CAC score is zero, then consider omitting or de-escalating cardioprotective medications (e.g. aspirin, statin)
Treatment is as easy as ABCDE (Aspirin, blood pressure, cholesterol, diet, and exercise)
New SCCT 2017 CAC Guidelines recommend rough estimate of CAC scores and plaque burden (mild, moderate, severe) on all chest CTs even if not gated.
Calcification of breast arteries on mammography is correlated with CAC and should be treated as a risk factor
Okay to exercise without further testing if low to intermediate CAC score. If score >300, then consider functional test or CCTA prior to exercise.
Omega 3 fatty acids at 1,000 mg daily or more is useful for prevention of sudden death in post ACS patients.
Omega 3 fatty acids at dose of 4,000 mg per day is needed to lower triglycerides. Indicated if TG remain above 500 on first line therapy.
Hypertriglyceridemia with level above 500 on optimal statin dose, then consider addition of fibrate and/or omega-3 fatty acids. Uncertain clinical benefit in patient with moderate elevation (200-300) of triglycerides.
Statin intolerance can be overcome in most patients using the following methods:
Same statin at lower dose
Different statin
Use of rosuvastatin or atorvastatin 3 times weekly
Statins are safe to take for at least 20 years and probably longer (this data is still being collected, but will be available in the future)
Withdrawal of statins at the end of life is not harmful and may be beneficial.
Vitiligo, an autoimmune skin condition characterized by depigmented patches, is associated with autoimmune thyroid disease; thyroid-stimulating hormone measurement should be performed at time of diagnosis
In patients undergoing major surgery, warfarin should be withheld a minimum of 5 days before surgery to normalize the INR.
In patients on chronic warfarin therapy, warfarin should be restarted within 12 to 24 hours of surgery, pending adequate hemostasis
Nonbullous impetigo, characterized by eroded erythematous papules or plaques with honey-colored crust, can be treated with topical antibiotics, such as mupirocin or retapamulin
In patients with active cancer, annual vaccination with the standard-dose inactivated influenza vaccine should be administered at least 2 weeks before initiation of chemotherapy or 1 week after administration of chemotherapy if between cycles.
The live attenuated influenza vaccine is contraindicated in immunocompromised patients, including those with active cancer or who are undergoing chemotherapy
Oral ulipristal acetate is an effective oral emergency contraception option for women with a BMI greater than 26.
The copper intrauterine device is the most effective form of emergency contraception option and can reduce the risk for pregnancy by 99% if placed within 5 days of unprotected sexual intercourse
Menopause is a clinical diagnosis made retrospectively when a woman has not experienced a menstrual period for 12 months, and routine laboratory testing for the diagnosis is not recommended.
Patients with possible early menopause (age <40 years) should have pregnancy excluded and undergo measurement of follicle-stimulating hormone, thyroid-stimulating hormone, and prolactin
Melasma is a hyperpigmentation disorder that occurs mostly on the sun-exposed areas on the face; it most commonly affects women of childbearing age.
The first-line treatment for melasma is strict sun protection with sun avoidance, sunscreen, and sun-protective clothing
Patients at the highest risk for perioperative stroke include those with a history of prior stroke or transient ischemic attack.
Elective surgery should ideally be delayed at least 6 months after a prior stroke, and possibly as long as 9 months following stroke or transient ischemic attack.
A progressive increase in perioperative mortality for all procedures is observed as Model for End-stage Liver Disease scores rise.
Patients with compensated cirrhosis who have Model for End-stage Liver Disease (MELD) scores below 8 to 10 may proceed with most surgeries with optimal medical management; a MELD score greater than 20 precludes all but the most urgent surgeries for life-threatening illness.
Chest radiography and spirometry (Options A, C) are not indicated for a preparticipation physical examination in a patient with either well-controlled asthma or exercise-induced bronchospasm, as is the case for this patient.
In patients with coronary stents, guidelines recommend that dual antiplatelet therapy should be continued uninterrupted for 14 to 30 days after bare metal stent placement and a minimum of 3 to 6 months after drug-eluting stent placement.
In patients with an urgent need for surgery, discontinuation of a P2Y12 inhibitor can be considered after a minimum of 3 months in patients with a drug-eluting stent; aspirin should be continued if at all possible
Hormone therapy is the most effective treatment for vasomotor symptoms associated with menopause.
Transdermal estrogen is recommended for patients with moderate risk for coronary artery disease, increased risk for venous thromboembolism, hypertriglyceridemia, or high or intermediate risk for breast cancer.
Erythrasma, a superficial skin infection, manifests as thin, atrophic, finely wrinkled pink-brown plaques in the intertriginous areas; Wood lamp evaluation reveals a soft coral-red or pink fluorescence.
Symptoms of erythrasma are limited to mild pruritus, and treatment for localized disease is topical erythromycin
Topical tacrolimus and pimecrolimus are immunomodulators (calcineurin inhibitors) that can be effective in treating atopic dermatitis without the risk for skin atrophy, striae, and telangiectasias that can occur with topical glucocorticoid use.
Lynch syndrome is caused by germline mutations in the mismatch repair genes MLH1, MSH2, MSH6, and PMS2 or the epithelial cell adhesion molecule gene (EPCAM).
Patients with Lynch syndrome should be screened for colon cancer with colonoscopy beginning at ages 20 to 25 years (or 2-5 years before the earliest cancer diagnosis in the family) and screened for stomach and small-bowel cancers with upper endoscopy beginning at age 30 to 35 years.
Features of hepatopulmonary syndrome include orthodeoxia (worsening oxygen saturation while upright) and platypnea (worsening sense of dyspnea when upright); echocardiography with contrast can confirm the diagnosis.
Patients with cirrhosis and portal hypertension who present with dyspnea on exertion should be suspected of having portopulmonary hypertension; echocardiography is the initial screening test.
Weight loss and tobacco smoking cessation should be recommended to patients with gastroesophageal reflux disease who are obese and smoke, respectively.
Patients with nocturnal gastroesophageal reflux disease should avoid late-evening meals by eating at least 3 hours before bedtime and should elevate the head of the bed.
Gallbladder polyp size greater than 1 cm is a risk factor for malignancy; treatment for such polyps should be cholecystectomy.
Gallbladder polyps associated with gallbladder stones or primary sclerosing cholangitis are more likely to be neoplastic regardless of the polyp size.
Spectrum of arousal
agitation, combative, hyperactive to drowsy, lethargic, stupor, coma
Issues with cognition
confusion, amnesia, hallucinations, and detachment
Must carefully distinguish between delirium, dementia, and psychosis
Delirium – acute, fluctuating decline in attention and cognition
Dementia –chronic cognitive impairment
Psychosis –loss of contact with reality defined by delusions, hallucinations, catatonia or thought disorganization
Common Causes of AMS – HE STOPS 4 TIPS on VOWELS (AEIOU)
Hepatic Encephalopathy
Stroke (brainstem)
Temp
Alcohol
Endocrine (thyroid, Addison’s)
Trauma
Infection
Electrolytes (Na/K/Ca/glc)
O2
Porphyria
Intoxication (illicits, antichol)
Psych
Shock
Opiates
Seizure
Uremia
EVALUATION
Detailed History (usually from surrogate)
What is specifically different about the patient? When did it start? Do you have any suspicions for the cause? What medications does the patient take? Does he/she handle their medications?
Detailed Physical Exam
Vital Signs
Thorough neuro exam in addition to full exam. Even consider pulling out the fundoscope.
Studies
CBC, CMP, accucheck, abg, thyroid function tests, troponin, UDS, BAL, serum osm, U/A, blood cultures, ammonia
Depending on history consider –anticonvulsant levels, TCA levels, digoxin, theophylline, acetaminophen, salicylate levels
CXR, CT head non-contrast
Consider MRI
EKG assesses MI
If clinical suspicion is high for such things as meningitis -> LP
If there is ANY concern for increased ICP (papilledema, seizure, hx of metastatic cancer, focal neuro deficits) à CT HEAD PRIOR TO LP to avoid herniation! Always err on the side of imaging.
GCS (Glasgow Coma Scale)
Initially formulated to assess outcomes in patients with head trauma
Sometimes used as a tool to gauge consciousness and research purposes of brain injury but is not validated for metabolic encephalopathy.
Eye Opening
Spontaneous
4
To speech
3
To pain
2
No response
1
Verbal Response
Oriented x 3
5
Confused/disoriented
4
Inappropriate words
3
Incomprehensible sounds
2
No response
1
Best Motor Response
Obeys commands
6
Moves to localized pain
5
Flexion withdrawal to pain
4
Abnormal flexion
3
Abnormal extension
2
No response
1
BEST
15
COMATOSE
<8
UNRESPONSIVE
3
In patients with functional dyspepsia who do not respond to an initial trial of a proton pump inhibitor, therapy with a tricyclic antidepressant should be initiated.
Antimotility drugs, such as loperamide, can be used in patients with mild or moderate traveler's nondysenteric diarrhea and as adjuvant therapy in patients treated with antibiotics.
Antibiotics are not recommended for mild traveler's diarrhea.
Salvage therapy for Helicobacter pylori infection should not include antibiotics that have been previously taken.
The combination of bismuth subcitrate or bismuth subsalicylate along with metronidazole, tetracycline, and a proton pump inhibitor is the preferred salvage regimen for Helicobacter pylori infection.
Patients with ulcers at high risk for rebleeding (active bleeding, nonbleeding visible vessel, or adherent clot) should receive intravenous proton pump inhibitor (PPI) therapy for 72 hours, followed by an oral PPI twice daily for 8 weeks.
Because of the higher costs associated with continuous infusion, twice-daily intravenous PPI therapy is preferable given the similar clinical efficacy for upper gastrointestinal bleeding.
The diagnostic criteria for gastroparesis include a combination of compatible symptoms, absence of gastric outlet obstruction or ulceration, and an objectively measured delay in gastric emptying.
Tests to document delayed gastric emptying include scintigraphy, wireless motility capsule, and breath testing; scintigraphy of a solid-phase meal is preferred.
Microscopic colitis can be idiopathic, but medications, including NSAIDs, proton pump inhibitors, and selective serotonin reuptake inhibitors, have been associated with its development.
Treatment of microscopic colitis starts with discontinuation of potentially causative medications, symptomatic treatment with loperamide, and possibly progression to oral budesonide.
Dermatitis herpetiformis typically presents with intensely pruritic papules and fragile vesicles that rapidly break, leaving tiny erosions, and is commonly associated with histologic and serologic evidence of celiac disease.
Dermatitis herpetiformis responds rapidly to dapsone; testing for glucose-6-phosphate dehydrogenase deficiency is required before initiation of therapy.
Alcohol and tobacco avoidance are strongly recommended for patients with chronic pancreatitis.
After an episode of gastrointestinal bleeding, aspirin for primary prevention of atherosclerotic cardiovascular disease should be discontinued.
After an episode of gastrointestinal bleeding, aspirin for secondary prevention of atherosclerotic cardiovascular disease should not be routinely stopped; if aspirin is stopped, then it should be restarted as soon as hemostasis is achieved.
Serologic testing for celiac disease must occur while the patient is on a gluten-containing diet.
Genetic testing for celiac disease with HLA-DQ2 or HLA-DQ8 can rule out celiac disease but not confirm it.
Acute pancreatitis is most commonly caused by biliary disorders, and patients should undergo transabdominal ultrasonography for the detection of gallstones.
For patients with mild gallstone pancreatitis, same-admission cholecystectomy can reduce rates of gallstone-related complications compared with cholecystectomy 25 to 30 days after hospital discharge.
Testing for molecular alterations (epidermal growth factor receptor, ALK, ROS1) is a routine component of the evaluation of any patient with metastatic non–small cell lung cancer.
For metastatic non–small cell lung cancer with an ALK translocation, initial treatment should be with alectinib.
Aromatase inhibitors are associated with an increased risk of osteoporosis and fracture.
Calcium and vitamin D supplements are recommended for patients taking aromatase inhibitors, as is screening for osteoporosis with dual-energy x-ray absorptiometry.
Gastroesophageal tumors should be evaluated for human epidermal growth factor 2 overexpression.
Adding trastuzumab to chemotherapy regimens for patients with metastatic gastroesophageal tumors and human epidermal growth factor 2 overexpression provides a modest survival benefit.
Surgery is the standard treatment for stage I and most stage II non–small cell lung cancers.
For patients with non–small cell lung cancer who are not candidates for surgery, stereotactic radiation therapy can be used to treat stage I cancers.
Most cases of superior vena cava syndrome are caused by malignancies with large mediastinal masses, and most patients do not require emergency intervention.
For superior vena cava syndrome, a tissue biopsy should be obtained to determine the underlying malignancy and guide further management
Well-differentiated neuroendocrine tumors are indolent, frequently discovered incidentally, and often initially only require observation and serial imaging.
Somatostatin analogues are highly effective in controlling hormonal manifestations of gastrointestinal neuroendocrine tumors and should be given if hormone-related symptoms are present.
Fine-needle aspiration is the initial step in evaluating a neck mass suspicious for head and neck cancer.
Immunotherapy with an anti–CTLA-4 antibody plus an anti-programmed death antibody improves response rates compared with either agent alone and is the preferred treatment for patients with metastatic melanoma without a BRAF mutation.
In a patient with metastatic melanoma with a BRAFmutation, treatment with either immunotherapy or BRAF-targeted therapy is appropriate
Prophylactic cranial irradiation reduces the incidence of brain metastases in patients with either limited or extensive-stage small cell lung cancer who have responded to their initial therapy.
Prophylactic cranial irradiation improves overall survival in patients with limited-stage small cell lung cancer who have responded to their initial therapy.
In patients with recently diagnosed atrial fibrillation and concomitant cardiovascular conditions, early rhythm control (antiarrhythmic drugs or ablation) reduces the primary composite end point of cardiovascular death, stroke, or hospitalization for heart failure or acute coronary syndrome compared with usual care.
Cardiac angiosarcomas are rare malignant cardiac tumors that typically arise within the right atrium and are commonly associated with sanguinous pericardial effusion.
In patients with peripheral artery disease, antithrombotic therapy with very low-dose rivaroxaban plus aspirin reduces the occurrence of cardiovascular death, myocardial infarction, or stroke by 2% and increases the risk for major bleeding by 1%.
No study has demonstrated the benefit of intensifying lipid management when the LDL cholesterol level is below 70 mg/dL (1.81 mmol/L).
The murmur of hypertrophic cardiomyopathy is typically a rapidly peaking crescendo-decrescendo murmur heard best along the left lower sternal border.
Dynamic maneuvers, such as Valsalva maneuver or squatting and standing, may be useful in diagnosing hypertrophic cardiomyopathy.
In women with typical angina symptoms, nonobstructive coronary stenoses are present on coronary angiography in more than 50% of cases, and microvascular dysfunction is thought to be a predominant cause of symptoms in these patients.
Left ventricular systolic dysfunction is the most common cause of chronic secondary mitral regurgitation.
Guideline-directed medical therapy is recommended as first-line therapy for patients with heart failure and secondary mitral regurgitation because it can reduce left ventricular volumes in many patients and, in so doing, reduces severity of secondary mitral regurgitation
The typical murmur of a patent ductus arteriosus is a continuous “machinery” murmur that envelops the S2, making it inaudible; the murmur is heard beneath the left clavicle.
Patent ductus arteriosus closure is indicated in patients with left-sided cardiac chamber enlargement even in the absence of symptoms, as long as pulmonary artery systolic pressure is less than 50% systemic
The preferred method of treating ST-elevation myocardial infarction is primary percutaneous coronary intervention.
Approximately 50% of patients with ST-elevation myocardial infarction (STEMI) have other obstructive lesions remote from the area of infarction (“nonculprit” lesions); studies have shown the benefit of nonculprit lesion revascularization within 4 to 6 weeks following STEMI
Catheter ablation is an appropriate treatment for patients with atrial flutter
Management of bicuspid aortic valve disease follows the recommendations for the predominant valve lesion type (aortic stenosis or regurgitation) and its severity.
In patients with a bicuspid aortic valve and aortic sinuses or an ascending aorta 4.0 cm or larger in diameter, lifelong serial imaging is reasonable
Tolvaptan can slow kidney function decline in adults at risk for progressive autosomal dominant polycystic kidney disease.
Blockade of the renin-aldosterone system is a staple of treating patients with autosomal dominant polycystic kidney disease, including those on tolvaptan
Back pain:
https://www.physio-pedia.com/STarT_Back_Screening_Tool
https://pain-calculator.com/calculators/low-back-pain/