Common Medical Problems | The National Family Medicine Board Review Course

my name is craig boss i'm your host for this section the common problem section uh the neurology section as well as pulmonology my background i was just talking to a couple of folks here i'm from northern michigan everybody knows in michigan you have to use your hand i'm from northern michigan up here the northwest component the gold coast if you will in a place called charlevoix my daughter is dating a fellow from france and he said charlevoix instead of charlevoix but uh it's a pleasure to be here my background i'm board certified in family medicine sleep medicine i'm also a clinical instructor for msu the college of human medicine i'm also a lavender farmer so if you want to talk about lavender we can do that too but it's a pleasure to be here we're going to talk about common problems you guys i love the common problem section because when i last took my boards now four years ago it was amazing the number of questions that really applied in some fashion to the common problem section okay i look at this as a new foundation that you made you put paper stones on and the common problem section is where you're putting all that sand on the top and you're using the broom to swish everything in to make everything solid so no doubt you all know a lot of this stuff but our goal is to give you more pearls more things that will hopefully help clinical practice but of course if you're taking your boards this will help too so first of all fifty percent of all visits that we have are what they're related to pain to upper respiratory symptoms or other somatic related issues how many times has it happened to you that you come into the office it's a friday afternoon or friday morning you look at your schedule and you see a person connie jim joe whoever with a lot of somatic complaints right fibromyalgia headaches abdominal pain fatigue all of those things can be so wearing but the thing that we have to remember that if the patient comes in with somatic complaints oftentimes those are self limited the wide majority of them will get better over time and indeed we are the best suited to take care of those patients because we know them we've established a rapport with these folks and we know how to maybe approach them maybe five percent have severe sequelae in the long run okay so bmi now i'm going to do that as it comes along into the course with things that you're going to have to know this was one of the first questions on my last board exam about bmi it seems so simple but you have to know it kilograms per meter squared so if your bmi is less than 25 you have an ideal body weight good for you and if you have a bmi of 25 to 29.9 it's overweight 30 to 39.9 obese and then over that is morbidly obese or extreme obesity now how many times has this happened to y'all so you're in the office a patient comes in dr boss i'm gaining weight and i'm not eating a thing we have to do something about this right it's very frustrating for patients because they feel as if they're doing all the right things but it's difficult a good study was done in stanford two years ago looking at various types of diets looking at low fat and low carbohydrate diet and interestingly over two year period of time the weight loss was roughly the same at about 13 pounds this was also controlled for insulin levels and it was also controlled for genetic factors they didn't control from microbiome which is kind of an important thing because it thought that perhaps some microbiome may synthesize carbohydrate differently okay but the key is calories in indeed and calories out do play a role okay so it's interesting to note that if patients decrease their caloric intake by 500 to a thousand calories a day they can lose weight now you think well sugar bear that's a lot of calories but interestingly just like i said oftentimes caloric intake is different or they perceive their caloric intake is different than what it actually is but if there's consistency that can really help but unfortunately oftentimes that wagon is slippery and people fall off the wagon and so that's an important thing to realize so the classes of drugs that can be used as an understanding of what can be used in this case understanding too that most of these drugs are used in the setting of a bmi of 30 or greater with some sort of comorbid medical issues 35 or greater without corbidities so sympathomimetica means so this stimulates the release of norepinephrine norepinephrine helps bring down appetite but of course these medications like phantaramine are what they can actually cause anxiety increased blood pressure palpitations and what else over time tolerability okay so patients should use them really no more than 12 weeks and if it is then you have to really have an understanding why and oftentimes when it's discontinued weight gain can occur the serotonin receptor agonists such as balbique it can have some relative improvement a little more specific who in the audience remembers meridia anybody yep all of us i have no hair most of you have here but with meridia it was a non-specific drug this is a little bit more specific but guys look at the weight loss it's three to four kilograms okay so it's not a huge weight loss it may have some other beneficial effect quizmia is that combination drug aphenteramine and toprimate we know how phonteramine works as we just discussed topra mate we're not really sure how it works but of course as we've seen it in patients people can lose weight it's a little bit more synergistic and the weight loss can be about five to ten percent it is a category x drug and so we have to remember that okay contrave is really unique actually that's where there's bupropion as well as natraxone now bupropion can actually increase what dopamine and norepinephrine natraxone has an opioid antagonistic approach and so with that it can actually help bring down the desire of food and maybe impact appetite a little bit okay xenecol we've seen this forever it's a lipase inhibitor and so it decreases the absorption of fats down the gi tract and as a result you have some weight loss again the weight loss is not huge side effects can occur and then some of the diabetes drug sexinda which in essence is what victoza lower dose it helps delay gastric emptying and it may have an impact on the hypothalamus as well so surgical treatments are important to know about and of course now these days a lot of folks are having bariatric surgery so we'll start with the old one that is ruined y so roon y is indicated for a bmi that's greater than 35 with comorbid medical issues or over 40. okay now as you can see with the diagram you make a small little pouch as a stomach you bypass the rest of the stomach the duodenum and the first part of the jejunum and then you bring up that other connector to that stomach that you just made and the contents of the stomach the liver so forth go in lower below okay so you have food limiting and then you have malabsorption okay so the expected weight loss is pretty substantial 70 percent hokey smokes that's pretty good okay the operative risk is pretty low and of course these things that we're going to talk about there are the risks there is the risk of malabsorption so we have to replace vitamins and other things in the diet dumping syndrome of course we'll talk about in just a little bit the sleeve is the most popular uh bariatric surgery today and the same thing that you saw with roux and y interestingly the sleeve was developed as um the first part of a roux and y and then they would come back and then do the re-anastomosis but it was found that over time well gosh you know what there's a pretty good weight loss with the sleeve and so it became its own standalone procedure thankfully there isn't a lot of change in anatomy other than that one component but again you're limiting how much can actually be taken in as well as some element of malabsorption the weight loss about 60 percent gastric banding really now for historical purposes there are a few centers that are doing this still but it has really kind of fallen by the wayside because of some of the complications associated with the ring perforation of the stomach slippage and so forth the weight loss was not really robust and then billio pancreatic duodenal switch is the most robust bariatric surgery that there is out there and look again at the diagram so in essence you have a roux and y but you're taking away a large portion of that small bowel and reanastomosing okay and then you're having another common uh portion way down low in the gastrointestinal tract and so the absorption issues or i should say malabsorption issues are much more pronounced as we alluded to here are some of the things that are deficient in the diet if you will or absorption and those who have bariatric surgery look at the highs you're going to hear me later on always talk about the hypers and the hype pose always know them okay so the high risk things include iron b12 calcium for example that makes sense and we want to replenish those components in the diet you know a long time ago in a land far away you know gastric surgery has been going on for a long time and oftentimes the general surgeons would do this and then what they're gone i mean that okay you're good you're healed up go to your family doctor right you know we're always getting the the results of a surgery or whatever and so it's important to realize that this is important to screen after these procedures have been done thankfully our new bariatric approaches are much more uh focused on making sure that these things are checked afterwards this goes back to what we alluded to before and again with the biliopancreatic duodenal switch that malabsorption can be more vomiting is not uncommon and that makes intuitive sense primarily why this is new eating standards right these people are eating much lower amounts compared to what they were previously and if they do overeat the risk of vomiting is there the key to remember is that if the vomiting is continuing over a six-month frame then we have to say wait is there a stenotic lesion here that's actually causing that the dumping syndrome is due to increased sugars or increased carbohydrates associated with increased fluid so if you have increased carbohydrates there's this transfer of fluid into the lumen leading to this rush leading to distension leading to symptoms in addition to getting that if you add a lot of fluids along with the food that may do the same thing gallstones why do gallstones happen well oftentimes before bariatric surgery an ultrasound is done to ensure that gallstones aren't present but when you lose a significant amount of weight the liver will do what it will dump a bunch of cholesterol into the system and as a result gallstones may occur we know of course that if you have a really significant surgery again going back to biblio pancreatic duodenal switch absorption is less and that also pays some attention to drugs so you maybe have to use something that's dissolvable instead of something else that's just taken into the stomach and some of the side effects with extra skin so what is it it's behavior modification surgery and it makes sense you can't eat as much you can't eat as much you have less calories coming in and as a result you lose weight and those rules eating slow everything mom told us right eating slow small portions to your food well and of course we have to watch out for other drugs that could actually hurt the stomach especially when you've changed the gastric mucosa so much so on the other hand weight loss that's unexplained any weight loss of greater than five percent over a six to twelve month period of time is concerning and so we want to know right if it's not identifiable okay wait this person has been dieting or maybe a new medication that could actually be doing this we have to understand why because of the risk of malignancy infection chronic disease that could be going on it's really common in the elderly and think about it too you guys when our patients come in or you're seeing a patient for the first time time a long laundry risk list of medications oh and there's this other thing called the donut hole and then these people have to pay for medications and they're making decisions and so dollars is an important thing to add to this all of these d's but this can all happen if they forget to take a medication if they forget to eat if they don't have the finances like we alluded to all of that can actually lead to weight loss so it's important to watch that and to discuss with your patients what's going on first question i wanted to be a game show host but it didn't work so you are working the first aid booth at the finish line of the 10 kilometer race it's a hot summer day suddenly the winner who is being interviewed by the local newspaper collapses the most likely explanation is a heat syncope b heat cramps c heat edema d heat exhaustion survey says a heat syncope so we're going to start from lesser degree to more severe degree heat related illnesses so heat edema you've probably all experienced that so a northern michigan boy coming to las vegas sometimes here when we get here it's 100 degrees it's 30 below where i'm at and you know suddenly i feel like i have jimmy dean sausages for fingers right because you have increased peripheral heat and then you get vasodilation okay that can actually lead to it generally it's just short-lived heat syncope as the question talked about is most likely due to a transient loss of fluid and especially with pooling think about it if y'all have been at track meets uh or watching on the infield people will finish a very demanding race let's say a three mile or two mile race or a mile race and they're just running so fast and they finished they go to the infield and what do they do they lay down and then they sit down for a long period of time they talk with their colleagues and then they get up and then they have pooling and that can result in an orthostatic condition leading to lightheadedness and potentially syncope so the key of of course is keep people moving if they sit down not for too long adding fluids cooling people off heat cramps can happen again due to lack of fluid due to salt loss potentially as well oftentimes people say oh i got a side stitch or something like that it can happen here but it can also happen in the lower extremities and all the extremities and so again fluid and cool down heat tetany i threw this in i just think it's interesting because when people are overheated what are they doing they're potentially hyperventilating if you hyperventilate you go into a respiratory alkalosis and that can actually cause some of the circumoral paresthesias as well as tightening heat exhaustion now we want to spend some time with this this is really important to understand and especially as we go to heat stroke okay so it's the inability for the cardiac output to be maintained so there's a lack of fluid fluid levels have gone down perhaps through exercise sweating so forth and then you get these symptoms so look at these you have sweating you have a temperature that's less than 104 you may have agitation just feeling out of sorts fatigue so in this case the same thing that you would normally do you replace fluids you have them rest you cool them off generally they'll do fine in some cases if it's quite significant then iv fluids may be necessary now heat stroke is really important to understand okay because compared to what a lot of people think it's not just due to heat related sweating loss of fluid the classic form of heat stroke is what it's in the elderly okay and it's not necessarily associated with exertion so in this case the hypothalamus is not responding appropriately to cool the patient off and then think about it too in new york city somebody's up in a high-rise apartment it's 100 degrees outside oops my fan isn't working the poor thing can't open the window they don't want to go outside they don't know anybody you see where that's going right anticholinergic medications can do it beta blockers so they're not responding appropriately with a sympathetic response and as a result you can have overheating so this is important to differentiate exertional is what we all think about um i was talking with a colleague just before this who is from fayetteville north carolina and that's where fort bragg is that's where i did my training i was in the army during the first desert storm a long time ago and you know guys coming in parachuting into a miserable hot sandy field they come in in a body bag of ice okay because they are overheated they don't have the fluid support and then they're dinging their hypothalamus so it's important to differentiate the two so in heat stroke you come in you're hot and you're flushed and you're dry temperature is greater than 104 rectal is the best of course and there's mild moderate and severe but quite frankly in any form of heat stroke it's all severe okay it's all severe so look at the mortality what so a mortality of roughly 40 percent when that hypothalamus has been dinged one time it can be that way for a long time and the level of dysfunction is based on how long this has lasted okay so we think of frequently what with heat stroke we think of rhabdo which is true so you can go into acute renal failure but remember too it can be all the cardiovascular manifestations low blood pressure you can have dic you can have bleeding in the gastrointestinal tract and of course neurological sequela including coma so we want to cool these folks just like i said with a soldier coming in from the field we pack them in ice but remember the elderly probably not so much of a good idea and so novel techniques of cooling off the palms the face and the soles of the feet may actually help in that situation but this is an intensive care situation and we want to monitor for all those things so we want to take them into the hospital and cool them off and watch for risk factors now hypothermia on the other hand is as you can see here a temperature less than 95. again remember hypers and hypos so the worst form is less than 82 so if you're less than 82 you are blue okay less than 82 you are blue if you're over 90 or if you're less than 95 to 90 you're mild and so the symptoms that can be noted are just gradually getting worse as the temperature the core temperature is less so typically with mild these patients you know they're having a hard time talking they're shivering they may have cold diuresis cold induced diuresis because in the periphery there's vasoconstriction you have a higher mean arterial pressure in the core that's god talking to you okay i'm going to try to save you and so when that happens then you have increased filtration in the kidneys and increase excretion of urine but in severe levels then you go into the potential risk of coma and cardiovascular disease so initially we take off all the cold clothing the wet clothing and we want to warm them up and so in mild cases that's typically okie doke you can get a bear hugger going on warm blankets and that will help but in more severe cases active rewarming is necessary so that we can go ahead and get that temperature up to avoid those risks okay again like i alluded to watch out for that core after drop because again if that if you're warming the outside or the legs too much then you're not really warming up the core too much then you can get that core after drop too so you can use warm saline warm oxygen we're going to use external heating as well if it's really severe you can use peritoneal avage or hemodialysis you can use pleural irrigation primarily on the left side why because that's where the heart is and so you can actually help warm up the heart too and that's a good segue ventricular arrhythmias are not uncommon in severe hypothermia why well think about it so that causes ventricular arrhythmias the electrical component isn't working well and you get one shot with electricity you get one shot with drugs think about it too if somebody's kind of cold-hearted you go up to them you talk to them hey how are you today you get a stone face so you walk away and then you're going to come back later you want to warm up to them and hopefully that will warm them up so you actually get a response and that's what's true with the heart as well and so if you keep giving drugs in the face of a heart that that's not working well then when it does warm up you're going to have a problem if you've loaded them with a bunch of epi or other stimulants for the heart frostbite is just as we all know it's that depth of that superficial layer of epithelium as a result you get that cold pale firm numb sensation on the extremities okay generally in mild cases just rewarming is fine but of course with deeper burns if you will the reverse burn you can get blistering and if that happens you don't burst them you cover them and if they do then we want to cover them maybe with an antibiotic ointment and then sometimes a tetanus shot is necessary who likes vertigo i just realized that my voice echoed so vertigo is fun vertigo is fun and you're saying you're so crazy so at the end of a friday you're wanting to get home right and so when the patient comes in with vertigo don't get caught up with dizziness versus vertigo if they're dizzy they're having britishness symptoms that's what's important two different types peripheral and central we're going to talk about um all of these in the peripheral case but remember this that's abrupt onset and offset central we're thinking about a brainstem tumor we're thinking about the posterior circulation okay nystagmus is your friend because nystagmus gives us a sense of what's going on with vertigo oftentimes it's peripheral okay so it's horizontal i should say so horizontal nystagmus it's looking to the periphery ding okay but that is also the most common form in central forms of vertigo okay but if you have central or um rotatory uh nystagmus that's more specific for a central lesion we want to differentiate things too of course light headness presyncope so if somebody's been hyperventilating if they're anxious that may actually cause a pre-syncable-like symptom disequilibrium is more common with a neurological problem a neurodegenerative problem sensory ataxia parkinson's proximal weakness and peripheral neuropathy and then of course too if a patient has non-specific dizziness if they say gosh they just feel dizzy but they can get up fine and they can walk in a straight line without difficulty we want to look at psychosomatic related issues dizziness in the elderly is very common and again like we talked about previously just with medication lists and other comorbid medical issues there's a lot of things that could actually contribute to this if they fall they can break a hip if they have a fall and they're alone that could lead to scary things but medications conditioning and all these other things that we're going to talk about in regards to dizziness remembering too in the elderly their pre-test probability of a central event goes up and again remembering tias so in the final analysis peripheral issues are the most common when it comes to vertigo and then we have the pre-sinkable we have cardiac related issues we have psychiatric and again brain stem lesions in the elderly if you have a concern an mri is reasonable again because we want to look at the posterior functions so here's the question a 56 year old male presents with episodic spontaneous vertigo hearing loss oral fullness and tinnitus what would be the most appropriate treatment a physical therapy b caffeine supplementation c diuretics d vitamin b supplementation survey says c in this particular case so we're talking about many years i would like to suggest to you to remember something when it comes to many years always think of i'm going to turn up the heat when it comes to meniere's that's kind of random but heat hearing loss episodic vertigo oral fullness and tinnitus okay and we want to differentiate this for the reasons that we'll describe in a little bit but these are the classic symptoms associated with meniere's and in this case the question is talking about many years so we don't really understand why it may be due to endolymphatic high drops so increased pressure within the inner ear that's doing this if it's due to another reason if the patient had a stroke and now is displaying these types of symptoms that's meniere's syndrome so testing is not specific the symptoms as we all know within clinical practice can sometimes be variable but it is a clinical diagnosis we do an mri because we want to differentiate this versus something else again that we're going to talk about in another slide or two okay because we want to rule out a lesion that could actually be contributing to this so salt restriction not really well proven diuretic therapy may actually have some improvement some of the other classic medicines that we use for dizziness are really symptomatic treatments anti-medics anxiolytics and in the very rare case destructive therapy will be done so like i said previously why would we do an mri this is what i was talking about okay acoustic neuroma so this is of the eighth cranial nerve and they arise from schwann cells so it's a schwannoma it's like guacamole so schwannoma is the tumor that arises on the eighth cranial nerve that can lead to these symptoms but look at the symptoms unilateral hearing loss and tinnitus okay so that's one similar to many years gradual onset persistent vertigo versus episodic vertigo of many years trigeminal neuralgia and then again headache so that's a little bit different but because like we know in clinical practice i wish everybody would read google i wish everybody would look at webmd to present to me all the symptoms that are classic but they don't and so that's why we do an mri because we want to ensure that there is not a tumor of that eighth cranial nerve okay bppv so in the semicircular canals you have this uh cilia moving back and forth back and forth so when you turn your head fluid moves cilia moves and it tells you where you are in space and time but if an auto lip drops into that mix then you're having something else tickle those cilia and then you get dizziness okay so it's positional triggered by the onset change in position looking down turning that brings it on okay nausea and vomiting is very common no tinnitus no hearing loss and again nystagmus is your friend okay so nystagmus with that positional change so in the hall pipe maneuver a patient is sitting you have them look to the side and then you have them lay down and we're looking for nystagmus as that procedure is completed and then you repeat it you know what happens right these patients when they're sitting there they'll say okay i'm going to lay you down no no no no no no and then they'll have onset of symptoms and we hope to see nystagmus okay now treatment the epley maneuvers are very helpful there's some other ones out there too but i would just ask you to always remember the eppley maneuver instead of just giving somebody antivert because antivert is what it's a symptomatic therapy it's not getting at the cause of that underlying what we perceive to be an otolith that's causing the disruption labyrinthitis is an inflammation of that same structural component it's onset but it's persistent vertigo often associated with nausea and vomiting there's the viral prodrome then the symptoms and thankfully it gets better over time so we already talked about this medications that are used are used as a symptom control measure while we get at the underlying cause lastly with syncope and presyncope it's a sudden loss of consciousness so if you have a patient come in and they didn't really lose consciousness it may have been a pre-sinkable episode it may have been somewhat of a basal bagel episode but loss of consciousness denotes true syncope look at the etiologies there's four different ones so neurally mediated orthostatic arrhythmias as well as structural okay so that's what's going through your mind when you have a patient coming in with these symptoms so like we talked about vasovagal think you can see the frequency as we go through these things and we want to look at the underlying causes so we're looking at an ekg is there a concern of ischemia is there other chemistry or hematologic reasons for this so we're going to go through the exam we're going to see if there's provocative factors get that history and do appropriate diagnostic testing finally of course tilt table testing can be done in the case of syncope echocardiogram to look again for structural abnormalities that could be leading to this okay well we're going to go ahead and get going then we're going to go ahead and start up with this second component of the common problem section we're going to keep sweeping sand into those cobblestones okay so when it comes to visual testing the important thing to know is as we get older our eyes get worse we kind of know that so we have these things in pockets and so forth but just remember this when you hit age 50 every two years is typically pretty appropriate just for a visual exam and then refractive testing for example a dilated exam if necessary or if there's other medical issues uh that need to be looked at okay obviously if there's acute change we want to address that now acute visual loss is what it's an emergency because i read the newspaper we only get two okay so if we have visual loss we have to be very proactive and this is always a test question you guys okay amarosis fugax fleeting loss of sight is typically due to an embolic phenomenon okay and it's very brief just minutes perhaps not too long at all but that's due to an embolic phenomenon generally now there's some other things can do this too but embolic is probably the test answer when it comes to anterior ischemic optic neuropathy there are two different types there's arteritic and non-arteritic arteritic is what you think about with temporal arteritis okay so elevated sed rate discomfort change in vision but non-arteritic is due to a change in blood pressure and especially in those who have hypertension and diabetes okay so think about this at night time what happens your blood pressure goes down as parasympathetic tone increases blood pressure goes down and we call that the dipping effect so if there's a pre-existing problem associated with flow and there's a significant drop in blood pressure the most common time for this to happen is in the early morning hours optic neuritis as we all know is very a very typical finding associated with demyelinating disease and specifically ms and then retinal detachment is the flashing lights the lightning strikes so forth that can occur when we think about that think about a previous history of trauma think about viral infections diabetes so forth that can actually increase the risk of retinal detachment dry eyes again a real common finding and again as time goes on that can actually occur with the lacrimal ducts in those who are elderly but again we want to look at what's going on underneath meaning are they taking medications that can do this are they having difficulty sleeping and they're taking 50 to 75 milligrams of benadryl at night are they on an antidepressant and anticholinergic do they have sojourn syndrome okay so we want to attack the underlying cause and then make those changes if necessary if everything else looks okay then using topical supplements is way okay diagnosis of dry eyes this is a good thing to remember shermer's test so you put filter paper on the eye and if you have less than 10 millimeters of wetness after five minutes that's a diagnosis and again like i mentioned you can use substitutes and other more expensive substitutes as well to help with those dry eye symptoms so the major causes of excessive tearing are indeed a problem with the lacrimal duct you have stenosis that leads to excess tearing then of course if you have an exposure so those are the common causes for excessive tearing here's a question a 26 year old female presents with right eye pain for two hours fluorescein dye shows a one by two millimeter defect not involving the pupil treatment includes checking intraocular pressure patching atomic antibiotic ointment or re-evaluation in one week survey says c okay now that's somewhat debatable people say well wait do we really need to do that but still on recommendations antibiotic ointment is still recommended in this case now when it comes to corn liberation of course that's what we're talking about it's the super denuding superficial denuding of the cornea leading to these symptoms of discomfort pain watering watering of the eye we want to take a look with visual acuity because we want to make sure there isn't maybe keratitis or another underlying problem that's actually causing the problem with vision and we want to really take a good look topical tetra can be used so that we can actually numb up the eye so that we can take a look good irrigation and then fluorescein staining fluorescein staining will actually uptake and then we can see this lesion then after that optomic ointment as we've already discussed and patching doesn't need to be used unless you use a topical anesthetic because remember if you do do that then they can't feel things so just protecting the eye for an hour or two is the reasonable thing to do until that wears off conjunctivitis very common we see it all the time the key etiology for this is adenovirus okay one eye commonly may spread to the other it is contagious up to two weeks and just symptomatic therapy is fine but of course oftentimes the parent or the patient comes in hey i need antibiotics for this and so a lot of education has to go into it so bacterial conjuncted conjunctivitis is very common associated with these agents and again a good thing to remember strep pneumos staph aureus as well as h flu again erythromycin is very reasonable but if you have a patient with an increased potential risk of complications including those who wear a contacts think about a higher level of treatment including a fluoroquinolone because of pseudomonas we'll touch on that in a little bit if you have a very hyperactive discharge think of gonorrhea and don't forget chlamydia okay allergic of course that almost goes without saying somebody goes out mows the lawn they come in they're tearing their red eyes so it's an allergic response or a contact response and we're going to treat that symptomatically subconjunctival hemorrhage you know how many people come into the office they say oh my gosh i think i have a terrible problem going on with my eye and this is just a low level of bleeding in that subconjunctival area which generally is reassuring we reassure the patients and typically in about two weeks this will resolve remember though check out that blood pressure are they on an anticoagulant it can happen with a valsalva it can happen with heavy work they wake up with this episcleritis is as the name implies it's above the sclera and it's not associated with visual loss pain redness two different types diffuse and nodular okay diffuse and nodular more common in females than males and it's often associated with connected tissue disease okay scleritis on the other hand is much more painful associated with visual loss and again you have this red eye that's uncomfortable again the same thing diffuse nodular but also necrotizing okay a way to distinguish the two can be neo-synephrine drops you put a drop or two of neo-synephrine in the eye and if there's blanching that's more likely to be episcleritis uveitis is where there's an inflammatory condition of the ciliary body the iris and the choroid okay one of the first test questions too it just i can just remember all the first initial questions on my last boards that i took the question was this a patient comes in or comes in complaining of low back pain it's always in the morning it's in the mid-20s to early 30s and then x-ray examination reveals what a bamboo spine what is that ankylosing that will always be on the test you guys it's just always but uveitis can be part of that hlab27 okay so always remember those coordination of those questions too so uveitis is part of this you can see a sluggish pupil and that makes sense right because all those structures associated with pupil dilation may be associated with this but we want to get these folks to the ophthalmologist quickly because if not treated they can have significant change in sight carrots and corn go together so keratitis goes with the cornea okay so those two vegetables go together so keratitis and the cornea so keratitis can happen for a lot of different reasons so is it a foreign body is it a contact lens is it a significant light exposure has the person been arc welding is there a new chemical new drops that the patient has been using that's actually causing this so we want to differentiate what's going on there it can be very uncomfortable there may be a change in vision as well remember herpes zoster so on florestein staining if there's a dendritic appearance that's herpes we always think about that and if there's a lesion on the nose in the setting of what looks like zoster think of hutchinson's sign because the nasal ciliary branch of the trigeminal nerve also has innervation to the tip of the nose and also of the cornea and so if you see that that could be the sign of herpes zoster related keratitis as we've already alluded to with contact lens wears they're at increased risk for keratitis if there's an injury or if they've been using poor hygiene or if they've been keeping their lens in for too long soft lenses are associated with pseudomonas pseudomonas is soft when it comes to contact lens wears and because of that we want the contact lens to be out good irrigation and then we want to follow these folks very closely topical fluoroquinolones is probably the drug of choice again because of that risk of pseudomonas and they should be followed closely trigium or surfer's eye is associated with that fibrovascular change in the middle portion or the medial portion of the eye which can actually um detract not only from looks but it can also lead to an astigmatism too so generally if there isn't any problem with vision you can leave that alone but if it is overly cosmetic concerning for the patient or if there's a change in vision that could be taken care of generally due to uv light exposure therefore surfer's eye cataracts is what good board question number one leading uh reason for the loss of sight in the world okay so our friends in medical school had it right who decided to go into ophthalmology they said well sugar bear there's 300 million multiply that times two take a subsection of those folks yeah that's going to work out okay all right and so when it comes to cataracts that can be due to aging it can also be due to chronic disease it can be due to injury a lot of uv light exposure can actually predispose a patient to cataract formation now when that comes down to cataracts that are significantly impacting vision you can have this treated with fake emulsification and lens implant the lenses have gotten much better and fake emulsification is a very brief process a small slit this ultrasound goes in there takes that out you put in a new lens and away we go risk factors for glaucoma include hyperopia african american descent age greater than 30 or cataracts survey says be okay so glaucoma is interesting so what do we typically think of what do we think of when it comes to glaucoma that's an increase in pressure right generally greater than 21 but please know and we're going to talk about this too is that it doesn't have to be an increase in pressure really it's probably best denoted as a change in the optic nerve optic nerve atrophy or neuropathy that happens over time which could be multifactorial including metabolic change microcirculation as well as maybe sympathetic tone all right but classically we think of this this is the second leading loss of sight in the world as that pressure goes up because as the pressure goes up there's loss of visual field in the periphery and as it continues then it can actually impact central vision if you hear cupping on your exam that's talking about glaucoma okay two types open which is most common closed which is least common age factors as we've alluded to here and this goes back to our question in african-made african-american populations myopia not hyperopia so nearsightedness and so it's important to screen these folks over time and especially with a family history i've already alluded to this so it's thought that it's due to a problem of increased production of aqueous humor or difficulty getting that out okay but it may be normal pressure glaucoma and it can be a significant level of patience in your practice so that's where uh follow-up and looking for other underlying reasons for that has to be determined but when it comes to treatment again we're looking at options that will decrease production and help facilitate flow which you can see here the common ones that we see zalatan alphagen pilocarpine timolol all of these can be used in some combination agents as well to help facilitate flow to decrease pressure and of course surgery can be done but generally this is the last resort so acute rise in intraocular pressure is due to a closure of that angle typically generally in those who are predisposed so the lens is further forward and it closes down that angle and they could be doing fine but let's say then they have a dilated exam and then it closes okay then they have an acute onset of symptoms which can include pain change in vision and then they have what they have a shallower anterior uh chamber right because that pressure comes out and you have a flattening okay you can also have an oculocardiac reflex for example if there's a lot of pressure on the eye you can also develop other problems as this happens so as the pressure goes up you may actually kick in vehicle tone which leads to significant bradycardia and even a sister i've seen that once okay so when we see that acute onset this is an emergency because this could lead to visual loss our ophthalmology friends may go ahead and place them on iv acetazolamide or they'll do emergency iridotomy which is in essence boring a hole to allow that aqueous humor to come out to minimize that pressure effect okay now on to age-related macular degeneration so this is a degeneration of the macula resulting in a loss of central vision two different types dry and wet dry is druzanoid druzanoid is dry and druzanoid is a waste product in essence between the retina and the choroid as that builds up and especially in that area of the macula that can affect site wet is associated with a more pronounced loss of vision and generally due to neovascular growth okay because that happens you may have small hemorrhages again leading to the loss of sight really don't know what happens here but it can happen with age it can happen with smoking so that gradual loss of sight if you see on the exam amsler grid right the grid that you look at look at that spot see if there's wavy lines that's what we're checking for we're checking for macular degeneration okay so we take a look at the eye ophthalmology takes a peek we confirm the diagnosis this is important to denote when it comes to dry macular degeneration treating immediately even the setting of mild chains is not necessarily helpful only if you have moderately severe change to severe are supplements helpful okay it seems as if the antioxidant therapy vitamins you know eye vitamins so forth may be helpful but only in those moderately severe to severe cases beta carotene is linked to lung cancer in those who are smokers so we want to use alternative anti-oxidant therapy when it comes to wet treatment you can use laser therapy but what's common now it's lucentis it's sebastin injections are put in because these medications are endothelial growth inhibitors so that makes sense it decreases that neovascular growth decreases the risk of this developing so dental anatomy there's primary teeth and secondary okay primary teeth typically come on starting at age six months up to two years there's 20 during this period of time they're shed starting at six years going to 12. it's important to note there is some gender race changes there but here's the key thing remember if you're not getting those teeth completed in 30 months there's an issue what's going on is there something that's going on underneath that could affect things permanent teeth just like i started to talk about six years of age going forward and there's 32. visual structure is includes the crown then the enamel and the pulp okay the root is non-visible and around the root is the cementum so carries prevention we want to start getting children into their dentist by one year of age but it's also important for us to be aware of water supplies do they need fluoride supplementation as well as fluoride varnishes who's doing fluoride varnishes anybody yep some are doing that it's not something that most family docs are doing but interestingly it is recommended that family docs be trained in doing this primarily in those sites that are pro possibly more rural but even in metropolitan areas this can be done we used to suggest we'll just wipe the teeth off maybe use the soft toothbrush without toothpaste but even now when teeth are present just using a small smear if you will of toothpaste is fine dental caries i think we all know that happens as there are sugars carbohydrates and then microorganisms break up these sugars leading to acid leading to pitting leading to cavities that will actually wear into the teeth we're always aware of babies with bottles in their mouth this still happens it just seems like wait does that still happen a baby's being put into a crib with a bottle but it does so it's very important to be aware of that pulpitis is what well when a patient comes in with significant pain significant change to temperature gradients we're talking about a problem with the root okay and so when people need a root canal this is what we're talking about so there's wearing of the enamel into the pulp due to a cavity leading to infection and inflammation our dental colleagues take that out they fill it in and then they put a cap on top of that or a new crown um you know i always say too when it comes to oral hygiene whether it be periodontitis as i mentioned or or that you saw there or gingivitis just floss the teeth you want to keep you know that's probably the best thing to do this is always going to be on the boards you guys always going to be on the boards and that is tetracycline so six months of gestation to seven years increase the risk of tetracycline affecting the teeth okay so always be aware of that modeled enamel associated with fluoride that's in excess and hyperbolarum anemia that blue black discoloration delayed tooth eruption we alluded to this previous if it's extending past when we normally expect think of a nutritional underlying problem is there a genetic problem is there another metabolic disease process and when babies come out smiling after birth you know we want to be careful about that with natal teeth because they can be loose we want to minimize the risk of aspiration dry mouth and the elderly is super common and again thinking back to polypharmacy thinking about the fact that salivary glands aren't working as well and so we know that by people saying gosh i'm getting more cavities i have problems with my dentures they have problems talking so we look at underlying causes maybe get off some of those anticholinergics do they have sojourns and then we treat symptomatically hiccups it's a reflex arc generally it's vagal or phrenic nerve issue and it can just happen spontaneously sometimes through medications sometimes through surgery even just a post-operative change if someone has swallowed a lot of air if they've eaten very quickly that could actually sponsor that reflex arc so if somebody has hiccups we tell them to do what we try to really increase that bagel tone so or cough and that might actually get rid of that because we're resetting that vagal tone glossitis anything that can be a chemical irritant to the tongue is or if there's a heat exposure something very hot hot pizza with a lot of cheese is there a new medicine that's being used is there tobacco use significant alcohol usage so any of those could potentially cause glossitis but of course we want to be aware of the fact too that is this a cancer do they have lichen planus do they have other reasons that could actually lead to this iron deficiency anemia are they chewing on a lot of ice are they b12 deficient as well so burping belching we normally swallow air some may swallow more than others typically associated with just swallowing too much air with food maybe eating too quickly but remembering medicine remembering beta blockers they lower the lower esophageal tone caffeine alcohol they can do the same things spicy foods depending and so we want to rule those things out you've been waiting haven't you so the average production of flatus is about 500 to 1500 cc's a day this was years ago now we were actually in vegas and a person came up to me and he was actually part of the study and this was done i think it was in minnesota and they literally wore suits and that was measured and so i'm i was amazed i said and of course i talked too much i had my microphone still on and i said oh my gosh this is great about passing gas and everybody heard so when it comes to gas we know that we're swallowing air we know that methane is being produced as food goes along the gi tract and this leads to some of that offensive odor so many different things each person is different right it depends on each person what may actually do this and we know that we can avoid food things like bino for some people may actually work what is that that's alpha carboxyl it's a it's a enzyme system that actually decreases complex carbohydrates into more simple carbohydrates and as a result that decreases that production of gas now as we've already alluded to and i think ed covered this in one of his talks when it comes to bacterial overgrowth that can be an issue too so rarely antibiotic therapy can be used to help bring down that overgrowth but generally avoidance is fine and of course there's even external devices activated charcoal and severe cases now obviously we can joke around about passing gas and things like that but if there's significant bloating significant gas significant pain we want to be aware of irritable bowel inflammatory bowel disease hernias this is important this is an important thing to know about this is a classic test question so there's protrusion of inter-abdominal contents into weak areas of the abdomen remember if you hear hasselbox triangle you're talking about a in director direct direct okay so it's medial to the inferior epigastric arteries if it's lateral to the inferior epigastric arteries it's indirect okay when we're checking via the scrotum for example in a male we're feeling that pressure coming through the inguinal canal but surgery thankfully takes care of this we want to be careful uh watch for strangulation of these hernias but also what in the female female is femoral below the inguinal ligament in the femoral canal if there's pain heaviness this has to be addressed because of the risk of incarceration but female is femoral hernia umbilical hernias are actually quite common in children nothing to do with this really except if it persists after four years of age how many people have seen a mom or dad bring a baby in with a quarter on their belly button you know yeah exactly you know we're gonna we're gonna fix that thing but generally we give our patients reassurance the parents reassurance that that's going to get better now it's different though in adults because with an adult especially with valsalva they can have incarceration we want to ensure that's taken care of incisional i think everyone knows that's after typically surgery inorectal disease most common reason for bleeding rectal bleeding is the are these the hemorrhoids the polyps the fissures don't forget about cancer though when it comes to cancer if there's a predict lesion it's not getting better with typical therapy we want to take a piece of that because it could be some sort of anal rectal carcinoma when it comes to evaluation if the patient is less than 40 we can just take a look if there's a reasonable cause for it if we see a hemorrhoid if we see a fissure we can give reassurance treat the local cause and follow up in between though 40 and 50 taking a look is reasonable you can use a flex zig or a colonoscopy but as time goes on colonoscopy is the mechanism of choice as far as taking evaluation anal fissures are very uncomfortable typically associated with straining hard stools and you get a tear literally a tear that occurs most pains in the you know where are posterior those pas are posterior okay if they're anterior start thinking of other things such as crohn's like ed talked about because in those particular situations you're transmural through the intestinal lining possibly causing fistulas that can look like this too okay generally with conservative therapy these get better if they don't topical medicines that actually lead to smooth muscle relaxation can be helpful because if there's smooth muscle relaxation that increases blood flow increases healing hemorrhoids again you're going to get a question on hemorrhoids on the examination or on your review so itchy bleeding every one of us knows about this but what are hemorrhoids hemorrhoids are a normal process that is the hemorrhoid plexus the hemorrhoid plexus in the rectum is normal and when there's a lot of straining a lot of constipation then we can get thrombosis that can lead to the four different grades of internal hemorrhoids including grade one where there's no prolapse grade two there's prolapse but they spontaneously resolve grade three prolapse you need digital or forced reduction and then four there's prolapse and they don't reduce okay measures to take care of these of course everything that we do we add fiber we want to soften the stools we treat locally but when it comes to internal hemorrhoids banding can be used but if they're really severe if we're talking about a stage four surgical treatment may be necessary when it comes to external you're always the star if the person comes in within three days they have an acutely thrombosed hemorrhoid and you take care of it don't do ind do an excisional technique because if you just take an 11 blade stick it in there and pop it out there's a high pretest probability of that healing over quickly and you're going to get another problem so do an excisional biopsy and take care of it that way lastly just a couple of slides of paritis and i it's a it's not a diagnosis it's a symptom so in this case generally associated with benign conditions again hemorrhoids other topical issues but not to forget the neoplasm okay again carcinoma can present this way and sometimes we won't find anything which statement is correct regarding the treatment of benign prostatic hyperplasia i'm going to say hyperplasia it's not hypertrophy it's hyperplasia alpha blockers help by decreasing actual size the number of prostatic cells alpha blockers are first line effective treatment saw palmetto has no proven efficacy and surgery is the first line treatment and should be tried prior to medical regimen surveys says be yup so when it comes to prostatic hyperplasia we've got two different issues obstructive symptoms of course that's where people say i have post microaction dribbling i have difficulty with my stream irritable symptoms are frequency nocturia for example it's interesting to note that there really isn't a marked association between size and symptoms you could have that with different sizes and generally renal failure does not happen unless it's been long prolonged and a very significant obstruction medications like we talked about alpha blockers are probably the best because they act right away they're smooth muscle relaxers so at the neck of the bladder there's relaxation and you get better flow when it comes to five alpha reductase inhibitors such as avadar for example it takes a while for those things to work and it works by decreasing the conversion of testosterone to dihydrotestosterone which is associated with increased hyperplasia okay saw palmetto in some cases may help a little bit surgery can be done and of course if it's not getting better after appropriate therapy that we just talked about acute urinary retention is more common in elderly 70 and above people come in with significant pain significant fullness and the most common cause is bph not to forget increased constipation themosis is there a chronic infection so we lower the bladder tone obviously we put in a catheter we empty out the bladder we keep that in for a short period of time and then we give them a trial without the catheter starting those medications early but remember those five alpha reductase inhibitors don't work right away you can use them in combination with the other medications and that can actually be helpful okay

Channel: The Center for Medical Education

Views: 37,501

Keywords: family medicine

Id: u2InL4kVQn8

Length: 66min 11sec (3971 seconds)

Published: Tue Feb 01 2022