Case 10 – A 47-year-old man with suicidal ideation

A 47-year-old man was diagnosed with AIDS 3 years ago. Shortly after his diagnosis, he informed his partner of 8 years over the phone; she subsequently hung up on him and refused to speak with him again. Since then he had become progressively more socially isolated from his friends and family and had started drinking heavily. The pain from his peripheral neuropathy is a source of constant agony. On several occasions he has expressed a desire to die to his physician, and against the doctor’s pleas he has stopped taking his antiretroviral medications. He refuses to seek help from a psychiatrist who could treat his depression and help him to cope with his illness. He views his illness as a punishment and sees no good in trying to delay the inevitable. He feels useless and beyond help.

What is the epidemiology of suicide in the United States?

The annual death rate from suicide is higher than the annual death rate from homicide. Suicide is the eighth leading cause of death for adults and the second leading cause of death for college students. Nearly 30,000 suicides occur each year; roughly 1% of the U.S. population commits suicide. For every completed suicide, there are 18 failed attempts. For men, suicides occur more frequently as they age, with a peak at age 75 years; for women, the suicide rate peaks at 40-50 years. Men who commit suicide are most likely to be >45 years old, white, and either separated, divorced, or widowed. Women are more likely to attempt suicide; men are more likely to complete the act. Most people who commit suicide communicate their suicidal intentions to their physician and see their physicians before they die. Research indicates that more than 90% of those who commit suicide have a major psychiatric illness and half are clinically depressed at the time of the act.

What is the relationship between illness and suicide?

Nearly 5% of people who commit suicide have been diagnosed with a serious physical illness. Suicide rates are high among those diagnosed with AIDS, amyotrophic lateral sclerosis, Huntington’s disease, traumatic brain injuries, epilepsy, multiple sclerosis, Parkinson’s disease, and cancer. The suicide rate in patients with AIDS is nearly seven times greater than that in the general population. In many of these medical conditions, pain is often a mitigating factor.

What assessment tools are helpful in identifying suicide risk?

The following mnemonic SAD PERSONS is helpful to remember when assessing patients for suicide risk:

1. Sex (male gender)
2. Age (older)
3. Depression
4. Previous suicide attempt
5. Ethanol abuse
6. Rational thinking loss
7. Social support lacking
8. Organized plan
9. No spouse or partner
10. Sickness

Specific questions that should be asked of a person at risk for committing suicide ought to be direct and give the patient an opportunity to discuss his or her intentions. They include:

1. Have you been feeling like life is not worth living?
2. Have you been having thoughts of harming yourself?
3. Have you developed a plan for taking your life?
4. Do you have access to a weapon or means to commit the act?

By Kristen Vierregger, University of Pennsylvania School of Medicine, Class of 2008; in association with Le TT, Schabelman E, Shivaram A, and Klein J, eds: First Aid Cases for the USMLE Step 2 CK. New York: McGraw-Hill, 2007.

Case 9 – A 35-year-old woman with vaginal discharge

A 35-year-old G1P1 woman presents to her gynecologist complaining of white vaginal discharge with a “cheesy” consistency, itching, and discomfort. Her last menstrual period was 3 weeks ago, and she does not report any new sexual partners. She uses an intrauterine device (IUD) for contraception. Her temperature is 37°C (98.6°F), heart rate is 80/min, and blood pressure is 125/80 mm Hg. Speculum examination reveals erythematous and slightly edematous external genitalia. The vaginal walls are coated with a thick, white discharge, but the cervix appears normal, and the IUD string is visible from the os. A sample is taken, two slides are made, and the pH is determined to be 4.0. The saline-prepared slide shows only epithelial and inflammatory cells, while the potassium hydroxide-treated slide shows pseudohyphae and budding yeasts. There was no odor noted upon treatment with potassium hydroxide.

What is the most likely diagnosis?

Vulvovaginal candidiasis. Classic symptoms are the white, odorless, “cheesy” discharge and vulval swelling, itching, and discomfort. The wet mount, showing the presence of budding yeasts and pseudohyphae, confirms the diagnosis.

What other conditions should be included in the differential diagnosis?

The two other common causes of vaginitis are bacterial vaginosis and trichomoniasis.
Bacterial vaginosis is caused by Gardnerella vaginalis and other anaerobes that are usually suppressed by the dominance of Lactobacillus spp. The most common symptom is a discharge with an unpleasant, “fishy” odor. Wet mount in G. vaginalis infection shows epithelial cells with adherent bacteria (“clue cells”), without the presence of inflammatory cells. Preparation with potassium hydroxide reveals the characteristic amine odor (the “whiff test”).

Trichomoniasis is a sexually transmitted disease caused by the Trichomonas protozoa. The classic presentation is a frothy green discharge. Diagnosis is made by visualizing the motile protozoa on saline wet mount

Less common causes of vaginitis include atopic and contact dermatitis.

What are the common risk factors for this condition?

Associated risk factors of vulvovaginal candidiasis include”

1. Antibiotic use
2. Diabetes mellitus
3. Immunosuppression (steroids, HIV)
4. Oral or barrier contraceptive use
5. Pregnancy

What is the pathophysiology of this condition?

Like Gardnerella, Candida spp. (most commonly C. albicans) are part of the normal vaginal flora. However, when the vaginal pH changes or normal vaginal flora are eradicated by antibiotics, Candida rapidly replaces normal flora and symptoms arise. It can be transmitted sexually, but is not considered a sexually transmitted disease

What is the most appropriate management for this patient?< /span>

This patient has an uncomplicated infection, and her options include 3-7 days of topical azole treatment or single-dose oral fluconazole. A complicated infection is one in a diabetic, immunosuppressed, or pregnant patient; in a patient with a history of recurrence (?4/year) or severe symptoms; or disease caused by a Candida species other than C. albicans. Treatment of complicated infection requires 14 days of a topical azole or 2 days of fluconazole. Fluconazole is contraindicated in pregnancy, and 7 days of topical therapy is recommended.

By Melissa Rosenstein, MD, Resident in Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco Medical Center; in association with Le TT, Schabelman E, Shivaram A, and Klein J, eds: First Aid Cases for the USMLE Step 2 CK. New York: McGraw-Hill, 2007.

Case 8 – A 30-year-old man with double vision

A 30-year-old man presents to the ophthalmology clinic with a complaint of double vision. He states that when he gazes laterally to the right, he sees two images side by side. He does not have this problem when he looks to the left. Past medical history is significant for depression, for which he takes amitriptyline. He denies any ocular pain or recent viral illness. He also denies any history of tick bite and does not smoke cigarettes, drink alcohol, or use intravenous drugs. On physical examination the patient is a well-appearing, well-nourished man. Visual field testing reveals an adduction deficit in the left eye and horizontal nystagmus in the right eye during extreme right lateral gaze. Extreme right lateral gaze also recreates the painless horizontal diplopia that the patient has been experiencing. Conjugate eye movements are observed in all other directions. Accommodation and convergence are normal.

What is the most likely diagnosis?

Internuclear opthalmoplegia (INO). INO results from lesions of the medial longitudinal fasciculus (MLF), a fiber pathway that normally connects the abducens nerve nucleus (cranial nerve VI) located at the pontomedullary junction to the contralateral oculomotor nucleus (cranial nerve III) in the midbrain. Without coordination of these two nuclei, the medial rectus of the adducting eye cannot coordinate with the lateral rectus of the abducting eye. This leads to the characteristic disconjugate lateral gaze that is a hallmark of INO. In addition, the abducting eye also has end-gaze nystagmus. INO can either be unilateral (as in this patient) or bilateral, in which lateral gaze in either direction will produce diplopia.

What other condition should be considered in the differential diagnosis?

INO can easily be confused with a medial rectus palsy since the affected eye appears to have lost its ability to adduct. However, most patients with INO still have the ability to converge, as this ocular movement pattern (bilateral ocular adduction in response to focusing on an object moving closer to the eyes) does not require an intact MLF. Additionally, INO is often the presenting sign of multiple sclerosis (MS). Most (92%) patients who develop INO because of demyelination will progress to full-blown MS. Such patients require close follow-up so that the diagnosis of MS can be made at an early and more easily managed stage. Another important consideration is that myasthenia gravis (MG), which can be life threatening if left untreated, can also initially mimic the findings of INO. Half of patients with MG present initially with extraocular muscle weakness. As such, patients in whom there is any question of the diagnosis should undergo testing for anti-acetylcholine receptor antibody.

What test(s) should be used to determine the etiology of this condition?

The presence of INO suggests that the patient has a brain stem lesion involving the MLF. There are many disease processes that can create such a lesion, including:

1. Brain stem and fourth ventricular tumor
2. Brain stem infarction
3. Drug intoxication (eg, phenothiazines, tricyclic antidepressants, toluene, tacrolimus)
4. Lyme disease
5. Multiple sclerosis (the most common cause of bilateral INO in young adults)
6. Trauma
7. Subdural hematoma
8. Syphilis
9. Viral infection

In this patient, a history of tricyclic antidepressant use may explain his symptoms, as this medication is known to cause INO. Other tests to determine an etiology would include a toxin screen, MRI of the brain, FTA-ABS/VDRL (test for syphilis), Lyme titer, fasting blood glucose, complete blood count with differential, and blood pressure measurement.

What is the most appropriate management for this patient?

Treatment is focused on the etiology of the brain stem lesion associated with INO.

By Daniel Osei, MD, Resident in Orthopedic Surgery, Hospital for Special Surgery; in association with Le TT, Schabelman E, Shivaram A, and Klein J, eds: First Aid Cases for the USMLE Step 2 CK. New York: McGraw-Hill, 2007.

Case 7 – An 18-year-old woman with vaginal discharge and vulvar pain

An 18-year-old woman presents to the health clinic complaining of a fever and malaise. Upon further questioning she also admits to a foul vaginal discharge and vulvar pain. She denies having sexual intercourse recently, but she does admit to “blacking out” at a party 1 week ago and is worried that she may have unknowingly and unwillingly had unprotected sexual intercourse then. Her temperature is 38.6°C (101.5°F). There is significant tender lymphadenopathy in the inguinal region. Examination of the external genitalia reveals three painful, well-demarcated soft ulcers with necrotic bases in the vestibule of the vagina. Pelvic examination reveals a foul-smelling purulent discharge.

What is the most likely diagnosis?

Chancroid. Chancroid is a sexually transmitted infection caused by the gram-negative bacillus Haemophilus ducreyi. The infection is spread by direct sexual contact when the organism comes in contact with an open lesion; the organism cannot invade intact tissue.

How is the diagnosis made?

Chancroid is generally diagnosed clinically as it is difficult to isolate the causative organism, H. ducreyi. The best material for culturing and isolating the organism is aspirated pus from a bubo, but the organism can be isolated in less than a third of cases. Polymerase chain reaction of genital samples is becoming a more widely available form of testing. Importantly, syphilis should be ruled out before making the diagnosis of chancroid.

What other infections should be considered in a patient with genital ulcers?

Patients presenting with genital ulcers should be screened for other sexually transmitted infections such as chlamydia, gonorrhea, HIV, hepatitis B virus, and hepatitis C virus.
Genital ulcers are an important factor in the spread of HIV, as HIV-negative persons with genital ulcers have higher rates of acquisition, and HIV-positive persons with genital ulcers transmit HIV more effectively.

How do the genital lesions in this condition compare to those in other sexually transmitted diseases?

The best treatment option is one dose of azithromycin (1 g by mouth) or ceftriaxone (250 mg intramuscuarly). Ciprofloxacin (500 mg by mouth twice a day for 3 days) is another option, but less desirable give the multidose requirement.By Cynthia L. Bartus, MD, Resident in Dermatology, Emory University School of Medicine; in association with Le TT, Schabelman E, Shivaram A, and Klein J, eds: First Aid Cases for the USMLE Step 2 CK. New York: McGraw-Hill, 2007.

Case 6 – A 29-year-old pregnant woman seeking nutritional advice

A 29-year-old G2P1 woman presents to her obstetrician’s office at 10 weeks’ gestation for her screening visit. She reports no complaints and states that she has been feeling well. Her past medical history is significant for a seizure disorder that began when she was a teenager. Her seizures have been well controlled with phenytoin, and she was able to discontinue her medication during her previous pregnancy without incident. Since discovering she was pregnant again, she self-discontinued her medication and has been feeling well with no reported seizure activity. She is concerned about maintain an adequate nutritional intake during her current pregnancy.

What is the most important vitamin for this patient to take?

All women of child-bearing age are advised to consume a daily intake of 400 µg of folic acid throughout the periconceptional period to help prevent congenital neural tube defects. This patient’s history of anti-epileptic medication puts her fetus at greater risk for neural tube malformations, and so this patient is advised to ingest at least 4 mg of folic acid daily.

What is the mechanism of action of this vitamin?

Folic acid, a biochemically inactive compound, is the precursor for tetrahydrofolic acid and methyltetrahydrofolate, compounds that are essential for the maintenance of normal erythropoiesis and required cofactors for the synthesis of purine and thymidylate nucleic acids.

What vitamin should be avoided during pregnancy?

Vitamin A, also known as retinoic acid, is frequently used to treat severe cystic acne. Vitamin A should be avoided during pregnancy because of its association with spontaneous abortion and neural tube defects. Although vitamin A is most teratogenic when taken at 5-7 weeks’ gestation, it should be avoided at all gestational ages.

When is iron supplementation required in pregnancy?

Pregnancy causes a physiologic anemia. This is the result of the physiologic increase in plasma volume, which results in an effective decrease in hemoglobin and hematocrit. All pregnant women should take a daily prenatal vitamin that contains iron in order to avoid worsening anemia. Additional iron supplementation at higher doses should be given to any woman with a superimposed cardiac or hematologic condition, such as sickle cell disease.

What vitamin supplements must be given with iron?

When iron is given in large doses, as in the treatment for anemia, copper and zinc should also be prescribed, since large doses of iron inhibit the absorption of these minerals.

By Hindi Stohl Posy, MD, Resident in Obstetrics and Gynecology, Johns Hopkins University; in association with Le TT, Schabelman E, Shivaram A, and Klein J, eds: First Aid Cases for the USMLE Step 2 CK. New York: McGraw-Hill, 2007.

Case 5 – A 35-year-old woman considering abortion

A 35-year-old G3P3 woman presents to the office complaining of breast tenderness, bloating, and mild nausea. Her last menstrual period was 6 weeks ago. She is married and has three children under 5 years of age. She uses oral contraceptive pills for birth control. On physical examination she is afebrile, with a heart rate of 90/min and blood pressure of 140/80 mm Hg. Pelvic examination reveals a normal cervix with a bluish tint. Results of a urine pregnancy test are positive. Transvaginal ultrasound reveals a 6-week-sized gestational sac with detectable fetal heartbeat. The patient is visibly distressed upon hearing about the pregnancy, which she says was unplanned. She says she is overwhelmed with taking care of her three children and does not think she can support another child, financially or emotionally. She says she has considered working with an adoption center, but she was on bed rest for 6 weeks during her last pregnancy and is afraid of the risks and difficulties of carrying this pregnancy to term. She asks for information about abortion.

What types of abortion are available for this patient?

There are two types of abortion available to this patient: medical and surgical. Medical abortion is available for patients with unwanted pregnancies up to 10 weeks’ gestation. Medical abortion uses a combination of mifepristone (formerly known as RU-486) and misoprostol. Mifepristone is a progesterone antagonist administered orally at the provider’s office. Two days later misoprostol, a prostaglandin, is taken orally or vaginally, either at the provider’s office or at home. Most patients will pass the products of conception at home in the next 4-24 hours.

Surgical abortion is available until 22-24 weeks’ gestation (depending on state law), with procedures available in the third trimester to protect the life or health of the mother. The most common surgical abortion procedure is the vacuum aspiration, also called the dilation and suction curettage (D&C). The cervix is dilated and the uterine contents are evacuated with electric suction. Up to 10 weeks’ gestation, a hand-held syringe can be used instead of the electric suction in a procedure called manual vacuum aspiration.

What is the epidemiology of abortion?

Half of all pregnancies every year in America are unplanned, and half of those end in abortion. If current rates continue, 35% of American women will have had an abortion by the time they are 45 years old. Eight-eight percent of abortions are performed in the first trimester, while only 2% are done after 21 weeks’ gestation. Fifty percent of women having an abortion report that they were using birth control at the time of conception.

What are the complications of abortion?

Legal abortion is a very safe procedure with a complication rate of <1%. The most common complications of medical abortion are incomplete abortion or prolonged bleeding, both of which are treated with a suction procedure. The passage of the uterine contents is often uncomfortable, with heavy cramping similar to that experienced during a spontaneous miscarriage. Complications of surgical abortions are rare, but include perforation, infection, and reactions to anesthesia. There is no evidence linking abortion and increased breast cancer risk.

What is the recommended follow-up after an abortion?

Medical abortion requires a follow-up visit 7-14 days after administration of the mifepristone to ensure that the abortion was completed. Surgical abortion follow-up is usually 2-3 weeks after the procedure. Contraception counseling should be started on the day of the procedure and continued at the follow-up visit.

By Melissa Rosenstein, MD, Resident in Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco Medical Center; in association with Le TT, Schabelman E, Shivaram A, and Klein J, eds: First Aid Cases for the USMLE Step 2 CK. New York: McGraw-Hill, 2007.

Case 4 – An 18-year-old woman after a motor vehicle accident

An 18-year-old woman is brought to the emergency department by ambulance after suffering a motor vehicle accident. The patient had been alert when the paramedics arrived at the scene of the accident, but her level of consciousness declined en route to the hospital. The patient told the paramedics she had been unrestrained and had hit her windshield during the collision. On presentation the patient appears drowsy but is responsive to verbal commands. She complains of back and neck pain and a headache. The patient has a contusion and abrasion over her right temporal region; the remainder of her head, ear, eye, nose, and throat examination is normal. Neurological examination reveals no focal deficits, and cranial nerves II-XII are intact. Vital signs, a complete blood count, and blood chemistry test results are within normal limits. A lateral x-ray of the cervical spine reveals no abnormalities. Noncontrast CT scan of the head shows a small fracture of the skull in the temporal region and an underlying extra-axial lenticular hyperdensity.

What is the most likely diagnosis?

Epidural hematoma (EDH). EDH is an accumulation of blood between the inner table of the skull and the dural membrane. In a patient with a history of blunt head trauma, radiographic evidence of a temporal bone fracture, and an underlying lens-shaped collection of blood, EDH is the most likely diagnosis. Because the underlying brain has usually been spared from injury, prognosis is excellent if treated quickly and aggressively.

What are the typical clinical findings associated with this condition?

EDH is sometimes (approximately 20% of cases) characterized by a patient experiencing a lucid interval prior to experiencing a decline in consciousness. Many patients are comatose by the time they receive medical attention. Other common presenting signs and symptoms include headache, seizure, and vomiting.

What other symptoms can occur with this condition?

As in all expanding space-occupying lesions, increasing intracranial pressure can lead to brain herniation and possible death. Signs of increasing intracranial pressure that may signal imminent herniation include:

1. A triad of bradycardia, respiratory depression, and hypertension (Cushing’s triad)
2. Cranial nerve VI palsy
3. Dilated, sluggish, or fixed pupils
4. Papilledema secondary to impaired axonal transport and congestion of the optic nerve
5. Spontaneous periorbital bruising

What risk factors are associated with a worse prognosis?

The mortality rate for EDH is 5%-40% depending on the presence of the following risk factors:

1. Advanced age
2. Increased hematoma volume
3. Increased intracranial pressure
4. Intradural lesions
5. Lower Glasgow Coma Scale rating
6. Papillary abnormalities
7. Rapid clinical progression
8. Temporal location

What is the most appropriate management for this patient?

Treatment for EDH is the same as for all head trauma. Initial management focuses on hemodynamic stabilization and management of life-threatening issues. Burr holes are indicated if brain herniation appears imminent and definitive surgery cannot take place in the emergent setting. Definitive surgical treatment involves craniotomy and excavation of the underlying hematoma.

By Daniel Osei, MD, Resident in Orthopedic Surgery, Hospital for Special Surgery; in association with Le TT, Schabelman E, Shivaram A, and Klein J, eds: First Aid Cases for the USMLE Step 2 CK. New York: McGraw-Hill, 2007.

Case 3 – A 28-year-old pregnant woman with postpartum bleeding

A 28-year-old G1P1 woman at 39 weeks’ gestation presents to the emergency department complaining of severe, regular uterine contractions. On cervical examination she is 5 cm dilated and is promptly admitted to the labor and delivery unit. The patient reports no complications with her pregnancy and has no medical problems. After almost 22 hours of active laboring, the patient delivers a 3.6-kg (8-lb) healthy baby girl. The placenta is delivered without difficulty, but the patient continues to bleed postpartum. Vaginal examination reveals the patient has extensive perineal lacerations.

How is this condition classified?

First-degree perineal laceration due to birth trauma are a common obstetric complication caused by stretching of the birth canal by the infant. First-degree lacerations are limited to the vaginal mucosa, skin, and superficial subcutaneous and submucosal tissues. Perineal lacerations due to birth trauma are categorized into four groups. First-degree lacerations are explained above. Second-degree lacerations penetrate into the superficial fascia and transverse perineal musculature, while third-degree lacerations extend further, tearing the anal sphincter. Fourth-degree lacerations extend beyond the anal sphincter and into the rectal lumen.

What are the risk factors for this condition?

Risk factors associated with lower genital tract trauma in the obstetric setting include nulliparity, a large infant, precipitous birth, operative delivery, and/or episiotomy.

What is the most appropriate management for this patient?

First-degree lacerations of the perineum or vagina not involving underlying tissues rarely require repair, as they tend to heal quickly and neatly. Sutures are needed only for such injuries in the event of active bleeding. Second-, third-, and fourth-degree lacerations, however, always require surgical repair. In these lacerations the tissues may be frayed and in some cases macerated, making identification of the tissue ends and suture lines more difficult. In the event of a fourth-degree laceration, the torn rectal mucosa must be repaired separately from the rest of the tissue and with specific attention and care to avoid fistula formation.

By Hindi Stohl Posy, MD, Resident in Obstetrics and Gynecology, Johns Hopkins University; in association with Le TT, Schabelman E, Shivaram A, and Klein J, eds: First Aid Cases for the USMLE Step 2 CK. New York: McGraw-Hill, 2007.

Case 2 — A 43-year-old woman with malaise and myalgia

A 43-year-old woman presents to her primary care physician complaining of general malaise and widespread myalgia. She has not had a good night’s sleep for years and always wakes up exhausted. The fatigue that she feels in the mornings lasts all day, which she says is greatly affecting her ability to work. She used to be active but now even her 5-block walk to work leaves her tired and short of breath. On the weekends, she spends all day in bed because she is unable to motivate herself to do anything but rest. In addition to her lack of energy, the patient also is suffering from muscle and joint pain, which is particularly bad in the mornings. The pain is mostly concentrated around her neck, shoulders, and back. The pain is sometimes so bad that even her clothing causes extreme discomfort. On examination has no inflammation or swelling of any joints but is tender to palpation over her shoulders bilaterally and her neck. Other than this, the patient’s entire neuromuscular examination is unremarkable. An extensive laboratory work-up, including red blood cell count, white blood cell count, erythrocyte sedimentation rate, antinuclear antibody, thyroid function testing, and muscle enzymes, is negative.

What conditions should be included in the differential diagnosis?

Numerous conditions are associated with chronic pain and fatigue:

1. Ankylosing spondylitis
2. Fibromyalgia
3. Hypothyroidism
4. Inflammatory myositis and metabolic myopathies
5. Myofascial pain syndromes
6. Polymyalgia rheumatica
7. Psychiatric disorders, sleep disturbances, and migraine
8. Systemic and rheumatic diseases (rheumatoid arthritis, Sjögren’s syndrome, systemic lupus eruthematosus)

What is the most likely diagnosis?

Fibromyalgia. While considered a diagnosis of exclusion, fibromyalgia should be diagnosed in patients who present with chronic myalgias and arthralgias but who have no evidence of joint or muscle inflammation on physical exam or laboratory testing. Fibromyalgia is ten times more common in women than in men, and it most often presents in people 30-50 years old. It is associated with depression, anxiety, sleep disorders, and irritable bowel syndrome (IBS).

How is this condition classified?

As defined by the American College of Rheumatologists, patients diagnosed with fibromyalgia will exhibit:

1. Excess tenderness in at least 11 of 18 predefined (bilateral) anatomic sites:
   1. Occiput, at the suboccipital muscle insertion
   2. Low cervical, at the anterior aspects of the intertransverse spaces (C5-7)
   3. Lateral epicondyle, 2 cm distal to the epicondyles
   4. Knee, at the medial fat pad proximal to the joint line
   5. Second rib, at the second costochondral junction
   6. Trapezius, at the midpoint of the upper border of the muscle
   7. Supraspinatus, above the spine of the scapula near the medial border
   8. Gluteus, in the upper outer quadrants of the buttocks in the anterior fold of muscle
   9. Greater trochanter, posterior to the trochanteric prominence
2. Widespread musculoskeletal pain for ?3 months

Fulfillment of both criteria is 80% sensitive for the diagnosis of fibromyalgia.

What is the most appropriate management for this patient?

Treatment focuses on utilizing multiple modalities to alleviate a patient’s symptoms. Analgesics such as tramadol are often effective in providing pain relief. Because inflammation is not a major part of this disorder, anti-inflammatory medications such as ibuprofen or glucocorticoids are not effective. Antidepressant medications are often used as initial treatment.

By Daniel Osei, MD, Resident in Orthopedic Surgery, Hospital for Special Surgery; in association with Le TT, Schabelman E, Shivaram A, and Klein J, eds: First Aid Cases for the USMLE Step 2 CK. New York: McGraw-Hill, 2007.

Case 1 – A 70-year-old man with increasing shortness of breath

A 70-year-old man presents to the emergency department complaining of increased shortness of breath with minimal exercise, cough, and fatigue. These symptoms began 2 weeks ago and have progressed gradually. He reports he used to feel this way “all the time” years ago, but that this has not happened much since he began using his inhalers and his “water pill.” He also has a history of chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), coronary artery disease (CAD), diabetes mellitus, hypertension, and 30-pack-years of smoking. He denies swelling of the extremities, fever or chills, productive cough, chest pain, or palpitations. He cannot remember the names of his medications, but says he has not missed any doses. When asked about his diet, he says he has been eating more hot soup since the weather has gotten colder. His temperature is 37.5°C (99.5°F), blood pressure is 135/90 mm Hg, heart rate is 90/min, respiratory rate is 18/min, and oxygen saturation is 94% on room air. Examination of the neck reveals mild jugular venous distension. Examination of the lungs reveals loud crackles throughout the lung fields bilaterally. Examination of the heart reveals a laterally displaced point of maximum impulse with no murmurs, rubs, or gallops. There is mild clubbing of the extremities, as well as pitting edema of the lower extremities to the knee, bilaterally. His plasma brain natriuretic peptide level on rapid bedside assay is 500 pg/mL, and an x-ray of the chest reveals perivascular haziness, interstitial edema, and an enlarged cardiac silhouette.

What conditions should be included in the differential diagnosis?

In a patient with a history of CAD, COPD, and CHF who presents with dyspnea on exertion and fatigue, the current condition is likely due to an exacerbation of one of those three underlying diseases. It is of primary importance to distinguish between them when evaluating the presenting symptoms. Shortness of breath as an anginal equivalent can be ruled out by ECG and response to nitrates. However, the causes of COPD and CHF exacerbations are many, and may overlap such that teasing apart the symptomatology proves difficult. Etiologies that, by themselves, can cause gradually worsening shortness of breath and fatigue can include both cardiac and pulmonary diseases, including:

1. Anemia
2. Heart failure secondary to ischemia/infarction, dysrhythmia, valvular dysfunction, infection, or volume overload
3. Lung infections (pneumonia, bronchitis, bronchiectasis)
4. Mechanical impairment of ventilation
5. Pulmonary edema
6. Pulmonary embolism
7. Sepsis

In addition, these conditions can “tip” patients with underlying COPD or CHF “over the edge.”

What is the most likely diagnosis?

CHF exacerbation leading to pulmonary edema. This patient’s dyspnea, jugular venous distension, and tachypnea in the presence of crackles, pulmonary edema, an elevated brain natriuretic peptide (BNP) level, and cardiomegaly suggest an acute exacerbation of CHF. An exacerbation of COPD is unlikely given that this patient does not have fever, productive cough, or wheezing. Additionally, the patient reported increasing intake of soup, a particularly salty food, which can significantly increase water retention, thereby worsening CHF. A mnemonic for the causes of recurrent CHF is FAILURE:

1. Forgot medication
2. Arrhythmia/anemia
3. Ischemia/infarct/infection
4. Lifestyle (increased sodium intake, decreased exercise); most common cause
5. Upregulation (increased cardiac output due to pregnancy, hyperthyroidism, etc)
6. Renal failure
7. Embolus (pulmonary)

How is this condition classified?

The American College of Cardiologists and American Heart Association developed guidelines in 2001 for the classification and treatment of CHF:

What are the typical laboratory/imaging findings in this condition?

In addition to an x-ray of the chest that may show pulmonary edema, patients with CHF exacerbations may have:

1. Decreased hematocrit (anemia may exacerbate CHF)
2. Increased potassium, creatinine, and blood urea nitrogen levels (renal failure may exacerbate CHF)
3. Increased plasma BNP level, which is usually elevated in CHF exacerbations
4. A chest radiograph showing cardiomegaly, cephalization of pulmonary vessels, and/or pleural effusion
5. ECG changes showing left ventricular hypertrophy, arrhythmias, or ischemia or low-voltage or old infarcts (in fact, a normal ECG makes systolic dysfunction highly unlikely)
6. ECG showing abnormal ventricular size (dilated, hypertrophic, or restrictive cardiomyopathy) or function (systolic or diastolic)

What is the most appropriate management for this patient?

This patient appears to have stage C heart failure as defined by the table above. His physical exam and x-ray of the chest show evidence of myocardial hypertrophy, and he is having current symptoms (recurrent). He should probably be admitted to the hospital for a trial of intravenous diuresis (which often succeeds when oral diuretics fail). Upon clinical improvement and discharge, he should be prescribed an ACE inhibitor (given his atherosclerosis, hypertension, and diabetes mellitus), a diuretic (given his evidence of fluid retention), and digitalis (for symptomatic control). He should also recieve frequent blood pressure monitoring, exercise counseling, possibly spironolactone, and/or an angiotensin receptor blocker. In addition, he should take aspirin and a statin for his CAD, and should have an echocardiogram done to evaluate his ejection fraction and any structural heart disease, namely valvular abnormalities.

By Brian Ash, MD, Resident in Anesthesia and Perioperative Care, University of California, San Francisco Medical Center; in association with Le TT, Schabelman E, Shivaram A, and Klein J, eds: First Aid Cases for the USMLE Step 2 CK. New York: McGraw-Hill, 2007.

Next Week: A 43-year-old woman with malaise and myalgia…