Objectives to direct the training of emergency medicine residents on off-service rotations: Internal medicine III

The Journal

of Emergency

Pergamon

Medicine, Vol 12, No 2, pp 237-248, 1994 Copyright 0 1994 Elsevier Science Ltd Printed in the USA. All rights reserved 0736-4679/94 M.00 + .oo

0736-4679(93)EOO21-9

Education

OBJECTIVES TO DIRECT THE TRAINING OF EMERGENCY MEDICINE RESIDENTS ON OFF-SERVICE ROTATIONS: INTERNAL MEDICINE Ill Marla Markham,

MD,’

and Glenn C. Hamilton,

MD,

MSM,

FACEM,

FAcPt

*Fellow in Curriculum Design and Education and tDepartment of Emergency Medicine, Wright State University School of Medicine, Dayton, Ohio Rep&Address: Glenn C. Hamilton, MD, MSM, FACEM, FACP, Department of Emergency Medicine, Wright State University School of Medicine, Post Office Box 927, Dayton, OH 45401

0 Abstract-Internal medicine is an essential but diverse fleld. This is the third in a three-part set of objectives for an off-service rotation ln general internal medicine for emergency medlclne residents. This series may be used to gulde the resident daring the rotation or to serve as part of a teaching program integrated wltb didactic training and emergency department experience. Cl Keywords-objectives; training; emergency medicine; residents

internal

The structure of this training may be a formal off-service rotation or a didactic series integrated with an emergency medicine experience. The objectives are a critical part of guiding any educational format and the resident’s path of learning. This is the 26th article in a continuing series of objectives to direct the training of emergency medicine residents on off-service rotations. The numbering system is derived from the core content listing developed by the Wright State University Department of Emergency Medicine.

medicine;

INTRODUCTION CONTENTS

Internal medicine covers a broad field of knowledge so large that it is often itself subspecialized. This is the last section of a three-part set of objectives for an off-service rotation in general internal medicine. These objectives include hormonal, metabolic, nutritional, musculoskeletal, nervous system, psychobehavioral, urogenital, and physician-patient skills. These objectives are not meant to be an exhaustive listing of all the possible problems that could present to the emergency department (ED). Rather, this represents the core material that can be used to guide the studies of the emergency medicine residents during the course of their training.

w

9.0 Hormonal, Metabolic, Nutritional 9.1 Presentation 9.1.1 Weakness 9.2 Acid Base 9.3 Adrenals 9.4 Electrolytes 9.5 Glucose Metabolism 9.5.1 Diabetes Mellitus 9.5.2 Hypoglycemic Syndromes 9.7 Pituitary 9.8 Thyroid

Medicine

Education-Features articles focusing on the training of emergency physicians and the administration of residency programs. This section of JEM is coordinated by Mary Ann Cooper, MD, Mercy Hospital and Medical Center, Division of Emergency Medicine, University of Illinois, Chicago. 237

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9.9 Miscellaneous 12.0 Musculoskeletal 12.2 Considerations-General 12.2.2 Infectious/Inflammatory 12.2.4 Osteopenia Bone Disease 12.2.6 Soft Tissue/Muscle Injury 13.0 Nervous System (see also Neurology and Neurosurgery Objectives) 13.1 Presentations/Considerations 13.1.1-13.1.3 Altered Mental Status 13.1.12 Seizures 13.1.14 Vomiting 13.2 Infectious/Inflammatory 13.2.2 Encephalitis 13.2.3 Meningitis 13.4 Cerebrovascular Disorders 13.4.1 Stroke Syndrome 13.45 Metabolic Injury 14.0 Psychobehavioral (see Psychiatry Objectives) 14.1 Presentation 14.3 Organic Mental Disorders 14.3.1 Dementia 14.3.2 Delirium 16.0 Urogenital 16.1.2 Anuria/Oliguria 16.1.6 Dysuria 16.1.7 Edema 16.1.9 Hematuria 16.1.11 Incontinence 16.2 Urinary Tract 16.2.1 Urinary Tract Infection 16.2.2 Renal Calculi 16.2.3 Renal Failure 16.25 Glomerulonephritis 19.0 Physician-Patient Skills 19.2 Skills 19.2.1 Communication 19.2.6 Pain Management

2. List four of the six steps in the approach to evaluating metabolic acid-base disorders (Hamilton, pp 522-524). 3. In a patient with a widened anion-gap acidosis, list four possible endogenous causes and four possible exogenous causes (Hamilton, p 527). 4. In a patient with hyperchloremic non-anion gap acidosis, list three possible endogenous causes and three possible exogenous causes (Hamilton, p 526). 5. Given four patient scenarious with ABGs and electrolytes results, write whether the COz compensation is correct for the HC03, and whether the underlying primary metabolic abnormality is due to the addition or loss of H + ion or the addition or loss of HCO, (Rosen, pp 2120-2129; Hamilton, p 523). 6. Given a patient with lactic acidosis, including a lactate level, identify it as type A or B, list four possible causes and select a treatment regimen for the next 12 hours (Hamilton, p 528). 7. Give two causes each for proximal and distal RTA, and explain how to differentiate between the two (Harrison’s, pp 1199-1200).

9.0 Hormonal,

2. Laboratory findings are nonspecific in early adrenal insufficiency but may later show changes; match findings (Harrison’s, p 1730).

Metabolic, Nutritional

Medicine

9.1 Presentation 9.1.1 Weakness 1. Discuss some possible causes of a patient presenting with complaint of “weakness” (Rosen, pp 1815-1823). 9.2 Acid Base 1. Given four sets of ABGs and electrolytes, correctly classify them as respiratory or metabolic acidotic and alkalotic processes from a list of five possibilities.

9.3 Adrenals 1. Adrenal insufficiency caused by gradual adrenal destruction is characterized by an insidious onset of slowly progressive symptoms. List two signs and symptoms for these organ systems (Harrison’s, p 1730). a. b. c. d. e.

a. b. c. d. e. f. g.

General Neurologic Cardiac Gastrointestinal Skin

Sodium Chloride Bicarbonate Potassium Glucose Red cells Eosinophils

1. reduced 2. elevated 3. no change

3. List which four signs and symptoms mandate ACTH stimulation testing to rule out adrenal insufficiency (Harrison’s, p 1730). 4. For a patient taking replacement hormones, list

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Medicine Ill

three situations that would necessitate increased hormone replacements (Harrison’s, p 1731). 9.4 Electrolytes 1. Given a patient with a sodium of 118 mEq/L,

list:

a. The three possible etiologic classifications of hyponatremia. b. The recommended treatment for each of these classifications (Hamilton, p 492). 2. Given a renal failure patient with a serum K+ of 7.8 mEq/L (Hamilton, pp 501,505-506): a. Describe immediate response modalities that will antagonize potassium and produce intracellular shifts. b. List delayed response methods that will reduce total body potassium. 3. Given a patient with multiple myeloma, and a serum Calcium of 14mg%, select the correct principles of management (Hamilton, p 513). 4. Match which correlates best with hypocalcemia vs. hypercalcemia, and which fits both (Hamilton, p 510; Harrison’s, p 1916): 1. irritability, depression a. hypocalcemia 2. muscle spasms, carpopedal b. hypercalcemia spasm, facial grimacing, la- c. both ryngeal spasms, and convulsions 3. QT prolonged 4. QT shortened 5. cardiac dysrhythmias 6. often associated hypomagnesemia 7. constipation, anorexia, vomiting 8. polyuria, nocturia, flank pain, hematuria 9. bone pain 5. Match signs and symptoms that best fit hypomagnesemia, hypermagnesemia, or both (Harrison’s, pp 1936-38). 1. anorexia, vomiting, lethargy 2. paresthesias, muscular cramps 3. irritability, confusion 4. muscle fasciculations 5. associated hypokalemia

a. hypomagnesemia b. hypermagnesemia c. both

6. assocated hypocalcemia 7. cardiac dysrhythmias 8. torsade de pointes 9. alcoholic withdrawal 10. diuretics 11. pre-eclamptic or eclamptic patient undergoing treatment 12. central nervous system depressant 6. Match common intravenous fluids with electrolytes, pH, and osmolarity (Barsan, pp 47-48).

sodium pH

&q/L

osmolarity mOsm/L

Other

DSW (5 g dextrose ineach 1OOmL) 0.45% Saline 0.9% Saline Ringer’s lactate

9.5 Glucose Metabolism 9.5.1 Diabetes Mellitus 1. List 4 signs and symptoms that would support the diagnosis of the active diabetes mellitus in a patient with a family history of diabetes (Harrison’s, p 1743). 2. Specify how serum glucose is used to establish the diagnosis of diabetes (Rosen, p 2170). 3. Write orders for appropriate laboratory tests and initial stabilization (including fluids [type/rate], medications, other interventions) in a patient with known diabetes mellitus presenting with signs/ symptoms consistent with DKA (Hamilton, pp 481-482; Rosen, pp 2184-2186). 4. Perform at least four of the five following calculations with 10% accuracy when given a set of laboratory results in a patient with DKA (Hamilton, pp 479-480,521,531). a. b. c. d.

Determine Anion Gap Adjust Na + level for osmolar effect of glucose Adjust K + level for pH Determine if the respiratory compensation reflected in the pcoz is adequate e. Calculate the number of mEq of NaHco3 that may be needed in the first 24 hours

5. Given a list of historical points, physical findings,

Marla Markham and Glenn C. Hamilton

240

laboratory results and treatment regimen; match which are appropriate for DKA vs. hyperosmolar coma (narrison’s, pp 1749-1753). a. Usually a complication in insulin dependent diabetes b. Usually a complication in non-insulin-dependent diabetes May be polyuric i. Usually cannot take care of water needs on own secondary to stroke, tube feeding,

1. DKA 2. Hyperos-

molar coma

etc.

e. May present in coma f. Fluid deficit usually 5-10 L Fluid deficit usually 10 L ii: Ketones present i. Ketones absent j. Hyperosmolar k. Needs fluids and insulin m. Mortality = 10% n. Mortality > 50% 6. Given five organs, match the diabetic complica-

tion with the organ (Harrison’s, pp 1753-1755). 7. From the three forms of Insulin below, match onset and duration of action of each (EZurrison’s, pp 1746-1747). (all answers in hours) 1, 2.5,4, 8,24, 36 Onset

Duration

Regular NPH Lente

9.5.2 Hypoglycemic

a. insulin b. oral hypoglycemic agent c. unknown (Hamilton,

Syndromes

a. b. c. d. e. f. g. h. i.

abnormal behavior anxiety clouding of vision confusion convulsions dizziness headache hunger loss of fine motor skill j. sweating k. tachycardia 1. tremor

p 484; Harrison’s, p 1763).

9.7 Pituitary 1. Using the lateral radiography of the skull, identify an enlarged sella, and give three possible causes (Harrison’s pp 1675-1678). 2. Match the pituitary hormones with the disease state caused by over or under production or altered release (Harrison’s, pp 1655-1668). 1. Acromegaly 2. Addison’s 3. Adults deficit-fine

facial wrinkling 4. Amenorrhea, 5. 6. 7. 8. 9.

10. 11. 12.

1. Match the signs and symptoms representing autonomic (adrenergic) manifestations and those representing the neuroglycopenic manifestations of hypoglycemia (Harrison 3, p 1759). 1. Autonomic 2. Neuroglycopenic

2. Given a short clinical history, write a prioritized list of four causes of hypoglycemia (Harrison’s, pp 1760-1763). 3. A patient presents with altered mental status from hypoglycemia. Discuss appropriate treatment and make the correct disposition if episode caused by:

infertility Children deficit short stature Cushing’s syndrome Galactorrhea Gigantism Hyperthyroidism Hypogonadotropism Hypothyroidism Unable to lactate

a. Adrenocorticotropin (ACTH) b. Gonadotropins Follicle-stimulating hormone (FSH) Luteinizing hormone (LH) c. Growth hormone W-U d . Prolactin e. Thyrotropin (TW

3. A patient presents with severe headache and visual

field deficits in the postpartum period. Possibilities include eclampsia and ischemic necrosis of the pituitary. Outline their respective clinical courses and treatments (Hurrison’s, pp 1673, 1788; Rosen, pp 1984-1985). 4. Select the correct explanation of how assessment of plasma to urine osmolality can help to differentiate central and nephrogenic diabetes insipidus (Harrisods, pp 1686- 1687). 9.8 Thyroid 1. Choose four signs and symptoms consistent with a patient in thyroid storm (Hurrison’s, p 1709; Rosen, p 2243). 2. List three differential diagnostic possibilities of thyroid storm and how to differentiate between them (Harrison’s, p 1709; Rosen, p 2243).

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3. De Quervain’sthryoiditis may simply presentasa patient complainingof ear pain and “sorethroat” that may havecomeon acutelyor havesmoldered for weeks. Outline its diagnosis and treatment (Harrison’s,p 1711). 4. The differential diagnosisfor coma is lengthy;list four signsor symptomsthat could help you suspecthypothyroidismasa causeof coma (Rosen,p 2248). 5. Given four thyroid teststhat might be orderedin the emergencydepartmentby an endocrineconsultant, be ableto match them with a descriptionof their usefulness(Harrison’s,p 1697).

g. Vitamin B6 (pyridoxine) h. Vitamin C

9.9 Miscellaneous 1. Match the variouscausesof alterationsin the uric acid level (Bakerman,p 427). Uric acid 1. Allopurinol 2. Chronic renalfailure a. Elevated 3. Diuretics 4. Gout b. Low 5. Hematologicproblems,leukemia, especiallyafter chemotherapy,etc. 6. Hemochromatosis 7. LargeSalicylates 8. Malnutrition 9. Renaltubular defects 10. Severealcoholismwith liver failure 11. Wilson’sdisease 2. Match the diseaseprocessinducedcausedby too little or too much of the listed group of vitamins (Harrison’s,pp 436-442,18%). a. Vitamin A 1. Acute: abdominalpain, b. Vitamin D nausea,vomiting, headc. Vitamin E ache 2. Beriberi d. Thiamine (vitamin Bl) 3. Causesuricosuriaand e. Riboflavin (vipredisposesto oxalate tamin B2) kidney stones f. Niacin 4. Hypercalcemia

Color Normal Noninflammatory Inflammatory Gout Pseudogout u Septic-infectious

clarity

5. Impaired dark adaptation 6. Oralanticoagulants+ this leadsto potentiation 7. Pellagra 8. Rickets 9. scurvy 10. Seizures,EEG abnormalities 11. Severeflushing, pruritus, gastrointestinalupset 12. Sorethroat, hyperemia, edemaof the pharyngeal andoral mucousmembranes

3. Identify salientclinical and psychopathologicfactors in anorexianervosaand bulimia (Harrison’s, p 417). 12.0Musculoskeletal 12.2Considerations-General 1. A patient presentswith a single hot joint; list a differential diagnosisof four possiblecausesfor this condition (Hamilton, pp 687-690). 2. List the descriptorsof direction of the rangeof motion measurementsfor the wrist, hand, and digits (Rosen,p 547). 3. List specific radiographicabnormalitiesthat can be found in assessingjoints using the mnemonic SECONDS(Hamilton, p 691). 4. Identify the correctsite for diagnosticarthrocentesis in a patient with a suspectedseptic knee, ankle, elbow, wrist, or interphalangealjoint. List appropriate laboratory studiesfor the fluid obtained (Hedges,pp 849-859). 5. Choosethe correct indications for diagnosticarthrocentesisof the hip joint (Rosen,p 678). 12.2.2Infectious/Inflammatory 1. Fill in the boxesregardingsynovial fluid characteristics(Rosen,p 814,Table 39-4).

Viscosity

WBC

PMN

Glucose

crystals

Marla Markham and Glenn C. Hamilton

242

2. A patient presents with a known history of gout. Describe appropriate evaluation and therapy (Rosen, p 816). 3. Given the following radiographic and laboratory findings, mark as most consistent with gout or pseudogout (Hamilton, p 691; Rosen, pp 816-817; Hedges, p 858). Gout

Pseudogout

Asymmetric lesions with an overlying rim of bony overgrowth Stippling Urate crystals Calcium pyrophosphate crystals Negative biiefringence. needlelike crystals Positive birefringence, rhomboid crystals Great toe MTP joint most common Knee most common joint Occasionally associated with hypercalcemia

4. Match the most common organisms and appropriate therapy for septic arthritis (Rosen, p 815). 5. Given a patient with radiographic findings of osteoarthritis, choose the typical radiographic findings and appropriate therapeutic interventions (Hamilton, pp 697,700). 6. Describe the three mechanisms that may produce osteomyelitis (Rosen, p 831). 7. List the three most common organisms causing osteomyelitis and their appropriate therapy (Rosen, pp 832,840). 12.2.4 Osteopenia Bone Disease 1. List four risk factors for osteopenic bone disease (Harrison’s, p 1922). 2. List the differential diagnosis of osteopenic bone disease (Harrison’s, p 1923). 12.2.6 Soft Tissue/Muscle

13.0 Nervous System (See also Neurology and Neurosurgery Objectives) 13.1 Presentations/Considerations 13.1.1-13.1.3

Altered Mental Status

1. Match the following five clinical conditions characterized by altered mental status with their definitions (Hamilton, pp 808-809). a. Coma b. Acute confusion with depressed consciousness c. Delirium d. Amnesic states e. Dementia

1. X-linked recessive, onset by age 5, kyphoscoliosis, respiratory failure in second to third decade 2. Autosomal dominant, onset in adolescence. Prophylactic acetazolamide prevents attacks.

1. Acute confusional state associated with an increased alertness 2. Decrease in alertness and inability to think clearly 3. Impaired ability to recall events before an illness and to form new memories 4. Neither arousal nor awareness is present 5. Gradual deterioration of all intellectual functions

2. In a patient who presents with altered mental status, list six interventions to be considered or performed while gathering information (Hamilton, pp 810-811). 3. Fill in the chart distinguishing between functional and organic illness (Hamilton, p 8 18).

Injury

1. Match the clinical picture with the most likely diagnostic possibilities for the following patients: a. Duchenne Muscular Dystrophy (Harrison’s, p 2112). b. Familial Periodic Paralysis (Harrison’s, p 2121).

2. List 5 causes of rhabdomyolysis (Rosen, p 2233). 3. Select the correct findings on urinalysis in a patient with rhabdomyolysis (Rosen, p 2236). 4. Describe appropriate therapy aimed at protecting the kidneys in a patient experiencing rhabdomyolysis (Rosen, p 2240).

Functional

Organic

Onset vs Orientation Sensorium Mentation Hallucinations Involuntary movement disorders Focal neurologic signs Incontinence

4. Select when a lumbar puncture is indicated in altered mental status (Hamilton, p 820). 5. List the most common treatable causes of altered

Objectives-Internal

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Medicine III

mental status referred to in the mnemonic AEIOU-TIPPS (Hamilton, p 822). 13.1.2 Ataxia 1. Describe an appropriate history and physical examination used to evaluate ataxia, disorders of equilibrium and gait (Harrison’s, p 171). 2. List four general categories in the differential diagnosis of gait disorders (Harrison’s, pp 171-172). 13.1.12 Seizures 1. List the important aspects of the history and physical examination that are important for evaluating a patient presenting with seizures (Hamilton, pp 866-867). 2. List six life-threatening causes of seizure that can be immediately addressed (Hamilton, p 865). 3. Choose the correctly prioritized treatment for status epilepticus (Hamilton, p 873). 13.1.14 Vomiting 1. List two specific disorders that may cause vomiting in each general category (Harrison’s,p 252). Specific Disorders Acute abdomen Disorders of alimentary tract Central nervous system Metabolic disorders Drugs and chemicals

13.2 Infectious/Inflammatory 13.2.2 Encephalitis 1. List the expected findings in suspected encephalitis of viral origin (Harrison’s,p 2032): a. clinical examination b. LP c. CT scan 2. Describe a brief differential diagnosis and general treatment guidelines in a patient with suspected encephalitis of viral origin (Harrison’s, p 2033). 13.2.3 Meningitis 1. Match the pathogens with descriptions. (More than one may match each number.) (Hamilton, p 849.)

1. Most common pathogens 2. Less than 1 month old 3. Most common in infancy and early childhood 4. Most common in older children and young adults 5. Most common in elderly

a. Hemophilusin-

jluenzae b . Neisseriameningit-

idis c. Streptococcuspneumoniae d. group B streptococcus

e. Escherichiacoli f. Listeria g. Enterococci

2. List four high-yield findings during a history and physical examination that would lead you to suspect meningitis (Hamilton, pp 851-853). 3. List other diseases that present with fever, headache, altered mental status, vomiting, malaise, and meningismus (Hamilton, pp 854-855). 4. Match CSF findings with normal, viral, or bacterial syndromes (Hamilton, pp 856-858). a. WBC > 50,008 mm3; low glucase, high protein, no organisms on Gram’s stain b. Clear, cell count 65 mm3, 90% lymphocytes, glucose 60 mg%, protein 40 mg%, no organisms on Gram’s stain c. wbc 4 mm3, clear, glucose 70 mg%, protein 40 mg%

1. normal 2. bacterial 3. viral

5. List three pathogens commonly seen in immunocompromised patients that aren’t usually seen in the general patient (Hamilton, p 860). 6. Select the patient who can be safely discharged home with nonbacterial meningitis (Hamilton, p 860). 13.4 Cerebrovascular Disorders 13.4.1 Stroke Syndrome 1. Match the disease process to the type of stroke (Hamilton, p 878). a. Atherosclerotic stroke b. Atheromatous embolic c. Hemorrhagic

1. Localized narrowing and thrombus formation, silent until a critical narrowing occurs in one or more vessels 2. Emboli most often from the bifurcation of the carotid arteries 3. Usually from cerebral emboli that first cause ische-

Marla Markham and Glenn C. Hamilton

244

mic damage to blood vessels, which bleed when reperfused 2. Match the following patient descriptions with the corresponding neurovascular syndrome (Harrison’s, pp 1981-1998): a. Carotid ar1. Contralateral hemiplegia and hemianesthesia. If tery dominant hemisphere is insyndrome b. Middle cerevolved, global aphasia. bral artery Nondominant hemisphere affected, apractoagnosia syndrome and anosognosia, dysarc. Posterior cerebral artery thria. 2. Faintness on arising from syndrome horizontal position, recurd. Anterior cerebral artery rent loss of consciousness, e. Vertebral baheadache, neck pain, transient blindness, dim vision silar artery with exercise, premature syndrome cataract, claudication of jaw muscles. Transient monocular blindness. 3. Homonymous hemianopsia, memory defect, topographic disorientation, complex hallucinations 4. Paralysis of opposite foot and leg, urinary incontinence, gait apraxia, slowness, delay. 5. Combination of bilateral long tract signs (sensory and motor) with signs of cranial nerve and cerebellar dysfunction such as “locked in” state of quadriplegia. 3. Choose from the following list what can be included in the differential diagnosis of stroke (Rosen, p 1837). a. b. c. d. e. f. g. h. i. j. k. 1.

Subdural hematomas Traumatic carotid dissection Air embolism Gaint cell arteritis Hypoglycemia Wernicke’s encephalopathy Migraine Todd’s paralysis Meniere’s disease Meningitis Encephalitis Labyrinthitis

m. Dementia n. Acute glaucoma 4. List risk factors common to all stroke patientsTIA, stroke in evolution, completed stroke, and embolic stroke (Hamilton, p 884). 5. Match the acute interventions used in the treatment of specific stroke syndrome (Hamilton, p 890). 1. Transient ischemic attacks 2. Stroke in evolution 3. Completed stroke 4. Embolic stroke 5. Subarachnoid hemorrhage 6. Intracerebral hemorrhage

a. Heparinization after CT scan. May be deferred if the stroke is massive. b. Intravenous heparin therapy is instituted following CT scan. c. Mass effect may cause associated cerebral edema, which is treated with selected use of hyper-ventilation, diurectics, and positional maneuvers . d. Monitor blood pressure and observe for signs of developing cerebral edema. e. No acute intervention is needed other than starting aspirin. f. Reduce cerebral stimulation and vasospasm, maintain adequate arterial blood pressure, and treat cerebral edema appropriately. Early neurosurgical consultation.

13.4.5 Metabolic Injury 1. List three strategies essential to support the postischemic brain (Rosen, p 178). 2. List four metabolic causes of altered mental status (Hamilton, p 821). 14.0 Psychobehavioral

(see Psychiatry Objectives)

14.1 Presentation 1. List five of the components of an accurate Mental Status Examination (Harrison’s, p 18 1). 2. Match the following symptoms with the 4 major classifications of psychiatric disease (Hamilton, p 945).

Objectives-Internal

Medicine Ill

1. Affective Depression 2. Affective Mania 3. Schizophrenia 4. Personality Disorder Borderline Personality 5. Anxiety

a. Apprehensive, jittery, worries, ruminates, hypervigilant, poor concentration b. Disturbance of thought content and form, hallucinations or delusions, inappropriate and blunted affect, disturbed sense of self, unusual relation to environment c. Feels sad or worthless, poor concentration, depressed affect, thoughts of suicide d. Signs of self-damaging acts such as suicidal gestures, self-multilation, recurrent accidents or fights e. Talkative, hyperactive, flight of ideas, grandiosity, short attention span, irritable, lack of judgment, impulsive, and mood lability, hallucinations or delusions

14.3 Organic Mental Disorders 14.3.1 Dementia 1. Outline a reasonable course of investigation in evaluating dementia in the elderly (Harrison’s, p 192). 2. List four possible reversible medical causes of dementia in the elderly (Narrison’s, pp 191-192). 3. List two irreversible causes of dementia (Harrison’s, pp 191-192). 16.0 Urogenital

245

physical examination in the patient presenting with dysuria (Hamilton, pp 1045-1046). 2. Select three steps in evaluation of the sexually active woman with dysuria that includes evaluation for vaginitis and mucopurulent cervicitis (narrison’s, p 528). 3. List four nonurinary causes of dysuria (Hamilton, p 1046). 16.1.7 Edema 1. List two causes of localized edema (Harrison’s, p 232). 2. Discuss evaluation of generalized edema in terms of serum albumin levels and urine output (Harrison’s, p 232). 16.1.9 Hematuria 1. Describe some aspects of the medical history that may help in the approach to evaluate hematuria (Rosen, p 1899). 2. Match the two most frequent causes of hematuria by age and sex (Rosen, p 1900). 1. Age O-20 years 2. Age 20-40 years 3. Age 40-60 years (females) 4. Age40-60years (males) 5. Age 60 years and older (females) 6. Age 60 years and older (males)

a. acute glomerulonephritis b. acute urinary tract infection c. congenital urinary tract abnormalities with obstruction d. bladder cancer e. urolithiasis f. benign prostatic hyperplasia

16.1.11 Incontinence 1. Discuss four causes of urinary incontinence their treatment (Harrison’s, p 277).

and

16.1.2 Anuria/Oliguria 16.2 Urinary tract 1. Define anuria and oliguria (Harrison’s, p 273). 2. Approach to azotemia (or oliguria) is differentiated by whether it is long-standing and stable, or recent and increasing. If recent, what are the most discriminating additional measurements? (Hurrison’s, pp 273, 1147). 16.1.6 Dysuria 1. List four high yield findings during a history and

16.2.1 Urinary Tract Infection 1. Describe at least three antibiotic regimens commonly used in simple urinary tract infection and when they are appropriate (Harrison’s, p 542). 2. Match signs, symptoms, and urinary analysis to the correct patient (Hamilton, pp 1049, 1054). a. Cystitis b. Pyelonephritis

1. Fever, rigors, nausea, vomiting, flank pain, costover-

Marla Markham and Glenn C. Hamilton

246

c. Prostatitis d. Urethritis

tebral angle tenderness 2. Irritative voiding, perineal aching, genital or perigenital pain, sexual dysfunction, and low back pain may all be symptoms 3. Stuttering onset of symptoms, absence of hematuria, mucopurulent cervical discharge with edematous exocervix, new sexual partners, pyuria without bacteriuria 4. Frequency, dysuria with pyuria and bacteriuria

1. Discuss four major categories to be considered in the differential diagnosis of acute renal failure (Harrison%, p 1145). 2. Match each of the following scenarios to the type of renal failure it most likely describes (Rosen, pp 1924, 1930). a. b. c. d.

3. Describe three predisposing factors in the development of urinary tract infection (Hamilton, p 1045). 4. Identify four gram-negative pathogens that may cause urinary tract infections; indicate the most common agent (Hamilton, p 1050). 5. Select who should be admitted for treatment of upper urinary tract involvement (suspected pyelonephritis) (Hamilton, p 1056). 6. List clinical and urinalysis findings in a male patient with suspected prostatitis. Discuss treatment and why follow-up with urology is often indicated (Hamilton, p 1054). 7. Discuss clinical findings, evaluation, and treatment in suspected perinephric or renal abscess (Harrison%, p 518). 16.2.2 Renal Calculi 1. List four important historical features in urolithiasis (Rosen, p 1903). 2. Outline various diseases that simulate urolithiasis (Rosen, p 1905). 3. List three diagnostic studies used to evaluate for urolithiasis (Rosen, p 1904). 4. List the indications, contraindications, and complications of intravenous pyelogram in suspected renal calculi (Rosen, p 1906; Hedges, pp 898-902). 5. Describe three radiographic changes that could be seen on KUB and IVP in a patient with suspected renal calculi (Rosen, p 1907; Hedges, p 892) (see also Radiology Objectives). 6. Given a patient with documented renal calculi, choose the indications for hospitalization (Rosen, p 1907). 16.2.3 Renal Failure

Chronic Prerenal Postrenal Renal

1. Suspect in setting of volume loss, volume redistribution, or decreased effective renal perfusion. Typically associated with a normal urinalysis, high BUN/Cr ratio, increased urine osmolality, urine sodium concentration less than 20 mEq/ L, and FENa less than 1%. A rapid response to volume repletion is also characteristic. 2. Urine volume may vary from zero to several liters per day. Urine indices and BUN/Cr ratio tend not to be helpful, although an increase in the latter is common. 3. Often diagnosed by its manifestation on microscopic urinalysis or by associated extrarenal manifestation or clinical setting. 4. Often presents with nonspecific complaints, often of insidious onset, such as generalized weakness, poor appetite, or deterioration of mental functioning. Initial laboratory tests may show a reasonably well-tolerated but rather severe anemia with elevated BUN and serum creatinine levels.

4. List three actions used to evaluate the patient with

acute renal failure (Harrison’s, p 1149). 5. Define acute renal failure (Harrison%, p 1144). 6. Select the four clinical settings or situations in

which the question of acute renal failure most commonly occurs (Harrison’s, p 1145). 7. Match the major complications with the following organ systems in a patient with acute renal failure (Harrison’s, pp 1147-l 148). a. b. c. d.

Cardiopulmonary Gastrointestinal Hematologic Metabolic

1. Volume overload, hypertension, dysrhythmias, pericarditis, pulmonary edema

Objectives-Internal

e. Neurologic f. Renal

2. Normocytic normochromic anemia,mild leukocytosis,and thrombocytopenia 3. Lethargy,somnolence, confusion,disorientation, asterixis,agitation, myoclonic muscle twitching, andgeneralizedseizures 4. Decreaseurine output 5. Hyperkalemia,hyperphosphatemia,hypocalcemia,hypermagnesemia,metabolic acidosis 6. Anorexia, nausea, vomiting, ileus, poorly definedabdominal complaints,intestinal hemorrhage

8. List at least four major causesof chronic renal failure and identify which are potentially reversible if treatedearly (war&on%, p 1151). 9. Discuss the clinical and laboratory findings in chronic renal failure in eachof the following categories(Hurrison-Ts, p 1153): fluid and electrolyteabnormalities F. cardiovascularand pulmonary hematologicprofiles i. skeletalabnormalities e. neuromusculardisturbances f. hematologicdisturbances 16.2.5Glomerulonephritis 1. In suspectedglomerular disease,outline the five major clinical syndromesby describingtheir clinical findings, course,andactualcharacteristicmorphologiclesion(Hartsion‘s, pp 1170-1180). a. b. c. d. e.

Acute glomerulonephritis Rapidly progressiveglomerulonephritis Chronic glomerulonephritis Nephroticsyndrome Asymptomatic.urinary abnormalities

19.0Physician-PatientSkills 19.2Skills

247

Medicine III

19.2.1Communication

a.

Outline an approachto the manipulative patient that helpsto ensuregood patient care(Hamilton, pp 1134-l135). List the steps an emergencyphysician can take both to preventand to addressthe dissatisfiedpatient (Hamilton, p 1136). Summarize how emergencyphysicianscan deal with the hostile alcoholic or substanceabuser (Hamilton, p 1137). Discussthe major principle of dealingwith violent patients(Hamilton, p 1137). List somedangersignsto look for in a potentially hostilepatientand stepsthat emergencyphysicians can take to preventor deal with them (Hamilton, pp 1137-l138).

19.2.6Pain Management 1. Match possibledrug choicesin the management of the following patients(Barsan,pp 107-l 11). 1. Short procedures a. nitrous oxide 2. Severepain of longer b. midazolam c. meperidine duration 3. Acute myocardialin- d. fentanyl e. morphine farction f. nitroglycerin 4. Abdominal pain 5. Migraine headaches g. butorphanol h. dihydroergotamine 6. Renalcolic 7. Vaso-occlusivecrisis of sicklecell anemia 2. Givenfive analgesicmedications,beableto match them with their common complications (Barsan, pp 92-101). 1. Codeine a. Respiratorydepres2. Morphine sulfate sion 3. Meperidine(Deb. Sedation merol) C. Nausea/vomiting 4. Buprenorphine d. Narcotic withdrawal symptoms (Buprenex) e. Musclerigidity 5. Fentanyl(Sublif. Hallucinations maze) 8. Miosis h. Vasodilatationand hypotension i. Urinary retention and urgency j. MAO inhibitor crisis

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Marla Markham and Glenn C. Hamilton

Bakerman, S. ABC’s of interpretive laboratory data, 2nd ed. Greenville, NC: Interpretive Laboratory Data, Inc.; 1984. Barsan, WG, Jastremski, MS, Syverud, SA. Emergency drug therapy. Philadelphia: WB Saunders Company; 1991. Hamilton G, Sanders A, Strange G, Trott A. Emergency medicine: an approach to clinical problem-solving. Philadelphia: WB Saunders Company; 1991.

*Indicates briefcase.

references

that are in the Internal

Medicine

*Harrison’+Wilson J, Braunwal E, Isselback K, et al. Harrison’s principles of internal medicine, 12th ed. Philadelphia: WB Saunders Company; 1991. Hedges J, Roberts J. Clinical procedures in emergency medicine, 2nd ed. Philadelphia, WB Saunders Company; 1991. Rosen P, Barker FJ II, Barkin RM, et al. Emergency medicine: concepts and clinical practice, 3rd ed. St. Louis: Mosby; 1992.