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Internal medicine Board Review: ENT, Orthopedics, and Psychiatry

Internal medicine Board Review: ENT, Orthopedics, and Psychiatry . Jimmy Stewart, MD. ENT. Common conditions/high yield topics for the boards: Hearing Loss Tinnitus Otitis Cerumen Impaction Epistaxis Sinusitis Oral Ulcers/Cancers Pharyngitis Hoarseness. Hearing Loss.

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Internal medicine Board Review: ENT, Orthopedics, and Psychiatry

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  1. Internal medicine Board Review: ENT, Orthopedics, and Psychiatry Jimmy Stewart, MD

  2. ENT • Common conditions/high yield topics for the boards: • Hearing Loss • Tinnitus • Otitis • Cerumen Impaction • Epistaxis • Sinusitis • Oral Ulcers/Cancers • Pharyngitis • Hoarseness

  3. Hearing Loss • Acute vs. Chronic • Acute (< 2 wks) • Steroids • Referral to ENT • Causes: • Acoustic Neuroma • Meningioma • Trauma • Meningitis • Viral or SuppurativeLabyrinthitis • Drugs

  4. Hearing Loss • Unilateral vs. Bilateral • Interpret the Weber Test: Sound should be heard equally in both ears If the sound is heard best on the side of the hearing loss—conductive. If the sound is heard best in the unaffected ear—sensorineural.

  5. Hearing Loss • Sensorineural hearing loss • brain, • internal auditory canal • VIII Nerve or cochlea • Presbycusis is most common—symmetric, high-frequency, hard to hear in noisy settings, 50-70 yo

  6. Hearing Loss • Presbycusis Screening • Whispered Voice Test • Hearing Handicap Inventory for the Elderly • Objective Audioscopy • Current recs: screen with questionnaire and audioscopy every 1-3 years >55-60yo

  7. Hearing Loss • Conductive Hearing Loss: • Otitis • cerumen impaction • cholesteatoma • otosclerosis • Otitis - most common • Cholesteatoma-Surgery • Otosclerosis- Surgery

  8. Tinnitus • Causes: • Medications (NSAID/ASA), • Labyrinthitis • Noise exposure • presbycusis • Meniere’s disease • otitis • Otosclerosis • Abnormal vascular flow • Muscular • Unilateral or pulsating tinnitus - intracranial or vascular imaging • acoustic neuroma • jugular bulb • carotid artery abnormalities

  9. Otitis • Otitis externa– water exposure (lake) • Otalgia, aural d/c, decreased hearing and itching. Erythematous canal, tender with manipulation of outer ear. • Treatment – reestablish acidic environment (acetic acid drops), topical antibiotics—neomycin plus polymyxin. • Necrotizing otitis externa—hospitalization, iv fluoroquinolones in severe cases. Diabetics - Pseudomonas.

  10. Otitis • Otitis media—much more common in children. • Rx: Reserve antibiotics for purulent otitis media (opacification of TM or drainage) or refractory cases. Amoxicillin is first line, Macrolide or Clindafor PCN allergic pts.

  11. Cerumen Impaction • Symptoms – ear fullness, conductive hearing loss, tinnitus, ear pain, pruritis. • Mechanical or Chemical removal • Contraindications for cerumenremoval: • otitis externa, • history of severe oticinfections • history of ear surgery • myringotomytubes/perforated TM.

  12. Epistaxis • Anterior nose – most common • Rx –administer phenylephrine or oxymetazoline spray for vasoconstriction. Nasal packing in refractory cases.

  13. Sinusitis • Acute (under 4 wks), • Sub acute (4-12 wks) • Chronic (over 12 wks) • Most cases viral

  14. Sinusitis • Signs of bacterial infection: • > 7 days of symptoms • Purulent nasal discharge • Maxillary tooth or facial pain • Abnormal transillumination • Ineffectiveness of decongestants • Pts improve then worsen

  15. Sinusitis • CT Sinuses > sinus radiography. • Treatment • antihistamines • analgesics • systemic or topical decongestants • Topical steroids • Saline wash • Moderate evidence for antibiotics (Amoxicillin or Bactrim) for bacterial rhinosinusitis.

  16. Oral Cancer • Men, ETOH, Tobacco • Biopsy any ulcers that do not resolve in 4 weeks.

  17. Oral Cancer • Leukoplakia and erythroplakia precede squamous cell carcinoma.

  18. Oral Ulcers • Aphthous stomatitis - most common • Recurrent aphthous stomatitis – • HIV • IBD • celiac sprue • Behcet’s • SLE • HSV (extremely painful)

  19. Acute Pharyngitis • 90% infectious: • 50% Viral • 30% Idiopathic • 20 % Bacterial—most Group A Strep. • Only use antibiotics when group A step is highly likely: • Fever • Tonsillar exudate • Tender Anterior cervical lymphadenopathy • Absence of cough • Throat cultures in pts with 3-4 criteria and a negative rapid test. • PCN x 10 days, Erythromycin in PCN allergic pts—Azithromycin or cefuroxime are similarly effective but more expensive.

  20. Acute Pharyngitis • Infectious mononucleosis—presents with fever, LA, and exudative pharyngitis. • How is that different from group A Strep? • Prolonged symptoms • Splenomegaly—50% of cases • Hepatomegaly—10% of cases • Lymphocytosis • Thrombocyopenia

  21. Hoarseness • Acute—overuse vs. infection—resolves in less than 2 wks without AntiBx. • Chronic (>2 weeks) • PND, • Cancer, • inhaled corticosteroids/asthma, • acid reflux. • Referral for direct laryngoscopy. • Smokers or former smokers with hoarseness persisting beyond 3 weeks - direct laryngoscopy.

  22. Orthopedics • Common Conditions/High Yield Topics: • Low Back Pain • Shoulder Pain • Hand and Wrist Pain • Hip Pain • Knee Pain • Foot and Ankle Pain

  23. Low Back Pain • 95% of pts with disc herniation have sciatica. • Positive crossed straight leg raise test. • Wasting of calf muscle, weak ankle dorsiflexion are generally predictive—weak plantar flexion is highly predictive of S1 radiculopathy.

  24. Low Back Pain • Long-term outcome - good • In pts older than 50 yrs, an initial spine radiograph series and ESR to r/o cancer. • Systemic Dx or history of cancer or trauma, an abnormal neuro exam, or no improvement after 2-4 wks of conservative therapy need additional evaluation. • CaudaEquinaSyndrome

  25. Low Back Pain • Red Flags • Major Trauma • Corticosteroid Use • Age >50 yrs • Unexplained Wgt Loss • Fever, immunosuppression, injection drug use • Saddle anesthesia, bowel/bladder incontinence • Severe/Progressive neuro deficit

  26. Low Back Pain • Imaging studies are OVERUSED!. • MRI and electromyography are the tests of choice when the diagnosis is unclear. • MRI tends to over-diagnose anatomic abnormalities.

  27. Low Back Pain • NSAIDS, Acetaminophen, Muscle Relaxants. • Tricyclic antidepressants/gabapentin/cymbalta • GET OUT OF BED! • Surgery may relieve symptoms in pts with an identifiable spondylolisthesis or disk herniation—pain and neurologic symptoms are similar at 1 and 5 years

  28. Shoulder Pain • Most common • subacromial bursa • impingement. • Other sources of pain • adhesive capsulitis • rupture of the rotator cuff tendon • OA • cervical radiculopathy • Don’t forget about referred pain

  29. Shoulder Pain • NSAID and rest for 2 wks. • Subacromial corticosteroid injection • PT • Surgical referral when conservative measures fail.

  30. Elbow Pain • Epicondylitis—inflammation at the extensor radii tendon on the lateral or medial epicondyle of the humerus. • Rx: immobilization (sling) and NSAIDS for 2-3 weeks. Corticosteroid injection for recalcitrant symptoms. • Olecranon bursitis • repetitive trauma • RA • gout • infection

  31. Wrist and Hand Pain • Bilateral Pain • degenerative • inflammatory • Unilateral • overuse • trauma • crystal-induced synovitis • reactive process

  32. Wrist and Hand Pain • Psoriatic arthritis - skin findings • Rheumatoid - PIP, MCP and wrist.

  33. Wrist and Hand Pain • Thumb • 1stCarpometacarpal degarthritis • women 30-60 • Thumb splint • NSAIDS • Radius • De Quervainstenosynovitis • Finkelstein test • NSAIDS, Steroid injection

  34. Hand and Wrist Pain • Carpal Tunnel Syndrome: • Tinel’s • Phalen’s • diabetes • hypothyroidism • Pregnancy • Splinting • NSAIDS • Referral for surgery

  35. Hip Pain • OA, bursitis, and myofascial syndromes • OA: Pain progresses gradually, felt in the groin, except in severe case is present when walking but not at rest. • Internal rotation is usually limited. • Initial therapy with NSAIDS, joint replacement

  36. Hip Pain • Trochanteric bursitis—tender on lateral palpation, pain with walking or lying on affected side. • Iliopsoas—pain in thigh, pelvis and groin that decreases when the hip is flexed. • Ischial—pain with sitting. • Heat, Massage and NSAIDS—local injection in refractory cases.

  37. Hip Pain • Most common myofascial: ileotibial band syndrome. • Dull ache over the lateral hip and thigh. Pain is reproduced by stretching the fascia. • Treat with stretching, heat, NSAIDS and +/-PT. • DD: osteonecrosis of femoral head

  38. Knee Pain • Inflammatory • gout • pseudogout • RA • Reiter’s • infection • Arthrocentesis essential for diagnosis.

  39. Knee Pain • Prepatellarbursitis • frequent kneeling • Aspirate the bursa • Patellar tendonitis • jumping sports, stair climbing • tenderness over tendinous attachment to the patella. • Chondromalaciapatellae • running • descending stairs • lateral tracking of patella • displacement and pain with extension, crepitus • Anserine bursitis—medial tibial plateau

  40. Knee Pain • Osteoarthritis • >55 unless there is a Hx of obesity, trauma or infection • physical therapy • NSAID • corticosteroid injection • hyaluronic acid • Joint replacement

  41. Knee Pain • Trauma—When to get x-rays? Ottawa rules: • 55 yrs or older • Isolated tenderness of the patella • Tenderness at the head of the fibula • Inability to flex to 90 degrees • Inability to bear weight.

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