Harrison’s Book Club

1. Harrison’s Book Club Session One Chapters 11-15 8/16/05

2. Chapter 11 - Pain Which of the following statements about pain management medications is correct? a) patients receiving NSAID´s on a chronic basis should not be monitored for the development of nephrotoxicity, unless fenoprofen is the case. In addition to this, there is currently no indication to monitor BP. b) fixed-ratio combination of acetaminophen-opioids carry the risk of hepatotoxicity because of increasing the dose to relieve an escalating pain and/or because of the appearance of tolerance to the opioid component.

3. Chapter 11 – Pain (Cont.) c) sensory impairment, sensitive skin, atrophy and lost of DTR´s are all indicators of sympathetic involvement, and relief achieved by sympathetic block is diagnostic. d) TCA´s are very useful for the management of cancer-related pain, in which they potentiate opioids. On the other hand, they are almost absolutely ineffective for pain of neuropathic origin (post-herpetic neuralgia, DM neuropathy). e) opioids should be used as a last resource in the management of acute pain, since there is a great risk of addiction.

4. Chapter 12 – Chest Pain A 63 year old male presents to the emergency room with 5 minutes of retrosternal, nonradiating chest pain and progressive dyspnea. The pain developed while he was shoveling snow outside his house. This has never happened in the past. He is a 50 pk-yr smoker with a 10 year h/o hypertension. He also notes chronic arthritis of his hands/knees. Medication at home includes daily aspirin, hydrochlorothiazide, and frequent ibuprofen. His physician noted “bad cholesterol” but the patient did not want to take more medication, so he is “dieting.” Physical exam is significant for BMI of 35. BP: 156/92 HR 94 RR: 22 Temp: Afebrile. His is calm and nondiaphoretic. Exam of eyes show Grade II hypertensive retinopathy. Cardiac and Pulmonary exam are unremarkable except for noted strong PMI. EKG was performed and it shows LVH. The first troponin is negative: however, you are concerned about coronary artery disease.

5. Chapter 12 – Chest Pain (cont.) • According to the AHA, under what condition is ordering an exercise stress test without nuclear or echocardiographic imaging appropriate? • Two sets of negative troponins taken at least 4 hours apart from each other, even if patient has mild pain. • EKG changes from baseline to 4 hours. • Absence of EKG characteristics, such as LBBB or LVH. • A and C • All of the above

6. Chapter 12 – Chest Pain 2 (Cont.) A 27 year old male without prior medical history complains of one week of worsening retrosternal, achy discomfort. He is an electrician who finds his job more difficult to perform due to this pain. The pain is worse when changing positions, especially when lying down. He denies dyspnea, orthopnea or PND. He denies history of fever, cough or weight loss. When asked about family history, he remarks that his uncle has TB. Physical exam: BP: 115/76 HR: 96 Temp: Afebrile. RR: 16. In general, he was in no acute distress. There is a three component rub on cardiac exam. Pulmonary exam is unremarkable. After EKG is performed, what is the most appropriate management? A) Prednisone 40 mg PO B) GI consult for EGD C) Echocardiogram D) CT scan of the thorax E) PET scan

7. Chapter 13 – Abdominal Pain You are called to the ED to see a 45 y/o AAF with no significant PMH who comes in c/o abdominal pain. The pain started 2 hrs before as a dull ache in the epigastric area that got progressively worse; at this time the patient describes the pain as constant, 8/10, no radiation, aggravated when the patient lies down and relieved if the patient sits up, pt says she’s been nauseous but has not vomited and she’s not sure if the pain gets better or worse with food since she hasn’t eating anything in the last 4 hrs, denies SOB, CP, diarrhea, or dysuria. On PE you find an overweight female in distress lying in the fetal position BP: 144/90 P: 100 R: 20 SPO2: 98% RA; the rest is relevant for: dry mucous membranes, soft abdomen BS + in all quadrants tender to deep palpation in RUQ and LUQ and tender to superficial and deep palpation in the epigastrium no organomegaly appreciated no rigidity no rebound. What should you do next for this patient?

8. Chapter 13 – Abdominal Pain (Cont.) What should you do next for this patient? A) Order belly labs (AST, ALT, Alk phos, amylase, lipase, T Bili, D Bili). B) Order abdominal CT with contrast. C) Order abdominal ultrasound. D) Do pelvic and rectal exam.

9. Chapter 14 – Headache RG, a 27 year-old apparently healthy male, presents to your primary clinic complaining of recent onset, moderately severe headaches. They are bilateral, band-like; usually reach maximal intensity slowly after 30 minutes to an hour and have no accompanying symptoms. Episodes seem to have started in association to work, but also occur while at home. OTC NSAIDS have provided intermediate relief. Over the last month, he has had approximately 6 episodes. Your examination reveals no neurological abnormalities. He is very worried, as his father died of GBM at the age of 57.

10. Chapter 14 – Headache (Cont.) What should be your approach to this patient? A: You need to be referred to neurosurgery right now, because of genetic GBM. B: My hunch is you have a Berry aneurysm; I’ll talk to my neuroradiologist colleague, he should be able to clip it in a heartbeat. C: Your symptoms are likely to be related to tension headache, my neighbor has a great massage center; I’ll give you her number. In the meantime, here’s a script for Motrin 400mg PO q4h. D: I think you have cluster headaches. Verapamil should avoid your headaches from returning.

11. Chapter 14 – Headache 2 You’re being called by the Supreme Court to act as medical advisor on this case; A 78 year-old female with recent onset of unilateral legal blindness is suing your former co-resident. The evidence suggests she went to your colleague’s office complaining of a unilateral headache that had bothered her for approximately a week. She also had some trouble chewing her food and felt “just plain not herself lately” with asthenia, achy joints and some non-quantified weight loss. Initially the pain was tolerable, however, the day she visited the office it had explosively increased to a very severe level and felt like someone was jabbing pins over her right side.

12. Chapter 14 – Headache 2 (Cont.) Your colleague suggested she should see her psychiatrist; he felt she was starting to have somatic findings due to the recent passing of her husband. She didn’t see the psychiatrist and progressively lost her vision over the following 3 weeks. Which of the following is true regarding this lady’s condition? A: Most common age of appearance is mid-40’s. B: ESR is invariably elevated. C: Her condition definitely required immediate psychiatric evaluation. D: Prompt initiation of glucocorticoids would have avoided her blindness.

13. Chapter 15 – Back and Neck Pain A 36 year old male presents with slow-onset low back pain and buttock pain.  He notes morning stiffness and pain unrelieved by rest.  He has no neurological symptoms.  Physical exam is notable for loss of lumbar lordosis.  Straight leg test is negative. X-ray is performed and shows "bamboo" architecture of the spine. Which of the following is the most likely diagnosis? A.  L4 disk herniation B.  Osteoporosis with fracture C.  Testicular carcinoma with metastasis to the spine D.  Ankylosing spondylitis E.  Rheumatoid arthritis

14. Answers Chapter 11 - B Lucio Minces Chapter 12.1 - C Howard Blank 12.2 - C Howard Blank Chapter 13 - D Ilonka Molano Chapter 14.1 - C Leandro Perez 14.2 - D Leandro Perez Chapter 15 - D Howard Blank