Common Problems in Ambulatory Internal Medicine (Case 2: A Problem Set of Five Common Cases)

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Common Problems in Ambulatory Internal Medicine (Case 2: A Problem Set of Five Common Cases)

Madelaine R. Saldivar MD, MPH and M. Susan Burke MD

CASE 1

A 35-Year-Old Woman with Headache

The patient is a 35-year-old healthy woman who comes to the office with daily headache and dizziness for 6 weeks. Her only medication is an oral contraceptive. Her exam is unremarkable except for a blood pressure of 130/90 mm Hg and body mass index of 30.

Differential Diagnosis

Primary Headache	Secondary Headache
Migraine	Medication side effect
Tension	Inflammatory: systemic lupus erythematosus (SLE), temporal arteritis
	Infectious: meningitis, sinusitis
	Intracranial mass or hemorrhage

Speaking Intelligently

When we see this patient in the office, our first task is to determine whether she is well enough to continue her evaluation in the office. Signs and symptoms that warrant consideration for immediate transfer to the emergency department (ED) for emergent evaluation include sudden-onset severe headache, focal neurologic complaints, projectile vomiting, and severe hypertension. Headaches are common, and 90% of the time there will be a benign cause. A gradual onset of symptoms and a precipitating event, such as increased stress or a recent viral illness, make us consider benign causes.

PATIENT CARE

Clinical Thinking

• A careful history is the best tool to narrow the differential diagnosis.

• Migraine and tension-type headaches are the most common causes of cephalgia, but don’t forget to look for warning signs that point to a more ominous cause.

• If there are no warning signs to serious disease, initial empirical treatment for one of these disorders is recommended.

• Radiologic studies are reserved for persistent or changed symptoms.

• Counseling on modifying environmental and lifestyle triggers is important.

History

Making sure there are no concerning symptoms is important. These are:

• Age over 50 years

• Accompanying systemic symptoms

• Headache brought on by exertion

• Visual changes or focal neurologic deficits

• Sudden onset of the worst headache of one’s life

• Severe hypertension

• Change in the pattern of chronic headache

• Projectile vomiting

Physical Examination

• Concentrate on vital signs (fever, hypertension, or hypotension) and the neurologic exam, including a funduscopic exam, looking for papilledema and/or hemorrhages. Any abnormality should prompt immediate transfer to the ED for acute management and workup.

Tests for Consideration

• Computed tomography (CT) head	$334
• Magnetic resonance imaging (MRI) brain	$534
• Complete blood count (CBC)	$11
• Basic metabolic profile (BMP)	$12
• Serum human chorionic gonadotropin (hCG)	$21
• Lumbar puncture	$272
• Urinalysis	$4
• Antinuclear antibody (ANA)	$16
• Erythrocyte sedimentation rate (ESR)	$4

Clinical Entities

Medical Knowledge

Migraine Headache
Pφ	The pathophysiology of headaches is not well understood. However, experts agree that there are multiple factors that contribute to development of a headache: 1. Increased neuroexcitation with cortical spreading depression 2. Vascular dilation
TP	Migraine can be distinguished from other types of primary headaches by its characteristics.

Dx	Making the diagnosis is based on history and physical. Secondary causes and warning signs of more serious causes should not be present.
Tx	All of the headaches described above respond to acute management with analgesics. Acetaminophen and ibuprofen have been shown to be effective as first-line medications for tension and migraine headaches. Remove headache triggers—alcohol, chocolate, sweeteners, caffeine, nitrites, hormonal medications, stress, and schedule changes or sleep deprivation. If migraine headaches persist, consideration should be given to headache prophylaxis with daily suppressive therapy (e.g., amitriptyline, β-blocker, or topiramate). See Cecil Essentials 119.

Secondary headaches are discussed in Chapter 64, Headache.

a. Temporal arteritis: It is a large-vessel vasculitis that affects the temporal artery, usually bilaterally. Associated symptoms include temporal headache, jaw claudication, and vision changes. It should be considered in any patient presenting with typical complaints, especially in patients over the age of 50 years. It is a medical emergency that requires treatment with immediate steroids. Diagnosis is made by temporal artery biopsy.

b. Subarachnoid hemorrhage: This is usually due to trauma or rupture of a cerebral artery aneurysm. Typical symptoms include sudden onset of an excruciating headache with no history of headache in the past. The diagnosis should not be delayed. Emergent CT scan is warranted. Treatment is usually expectant management and blood pressure control in an intensive-care setting.

Practice-Based Learning and Improvement: Evidence-Based Medicine

Title
Practice parameter: evidence-based guidelines for migraine headache; report of the Quality Standards Subcommittee of the American Academy of Neurology

Authors
Silberstein SD

Problem
What are evidence-based approaches to treating migraine headache?

Intervention
Analgesic medications and prophylactic medications

Quality of evidence
Systematic review of class I studies for treatment, class I, II, and III studies for diagnosis and neuroimaging utility

Outcome/effect
Migraine is a chronic condition with episodic attacks that affects 18% of women and 6% of men. Treat acute attacks rapidly. Consider prophylactic medications to reduce disability, frequency, and severity associated with attacks.

Historical significance
Migraine headaches are common and are disabling at a significant cost to society due to lost work productivity.

CASE 2

A 43-Year-Old Man with Back Pain

The patient is a 43-year-old truck driver who presents with right lower back pain (LBP) that started about a week ago when he lifted a heavy load at work. He stopped working and has been resting ever since. He tried acetaminophen, which did not help; however, his brother’s oxycodone with acetaminophen does provide him with relief.

Differential Diagnosis

Mechanical/nonspecific	Disk herniation	Compression fracture
Degenerative spine disorders	Spinal stenosis

Speaking Intelligently

Back pain is the second most common symptom-related reason for which patients present to the doctor. The vast majority of low back pain is due to mechanical or nonspecific causes and does not require imaging. The goal of evaluation is to identify those patients needing urgent attention by looking for signs and symptoms (red flags) suggesting an underlying condition that may be more serious and by determining who may need urgent surgical evaluation. We also evaluate for psychosocial factors (yellow flags), because they are stronger predictors of LBP outcomes than either physical examination findings or severity and duration of pain.

PATIENT CARE

Medical Knowledge

Mechanical Low Back Pain/Nonspecific
Pφ	Complex and multifactorial; can involve any lumbar spine elements including bones, ligaments, tendons, disks, muscle, and nerve. Onset may be from an acute event or cumulative trauma. Most common presentation of back pain. May be divided into acute (<4 weeks), subacute (4–12 weeks), or chronic (>12 weeks).
TP	Pain can be hard for patient to localize because of the small cortical region dedicated to the back.
Dx	Clinical diagnosis; imaging is indicated only if red flags are present or symptoms persist. More than 90% of symptomatic lumbar disk herniations occur at the L4/L5 and L5/S1 levels.
Tx	Most mechanical LBP resolves within 6 weeks. If it persists or worsens (or both), consider imaging. For acute pain use heat, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and/or spinal manipulation. For chronic pain, use exercise, heat, NSAIDs, tricyclic antidepressants, and/or spinal manipulation. May also consider acupuncture or cognitive behavioral therapy. See Cecil Essentials 119.

Disk Herniation
Pφ	Herniation is thought to result from a defect in the annulus fibrosus, most likely due to excessive stress applied to the disk, with extrusion of material from the nucleus pulposus. Herniation most often occurs on the posterior or posterolateral aspect of the disk.
TP	Dermatomal distribution of sensory deficit, motor weakness, or hyporeflexia.
Dx	Clinical exam including SLR test. MRI is indicated only if weakness or incontinence is present.
Tx	Initial treatment is with analgesics and/or steroids. Surgery is reserved for patients with refractory pain or with evidence of motor deficits. Outcomes are similar at 5 years for patients treated either way.

a. Inflammatory spondyloarthropathies: This condition usually presents before age 40 years, has an insidious onset, and is associated with morning stiffness. It may also have systemic features (e.g., eye, skin).

b. Spinal stenosis: This is a degenerative disorder resulting from hypertrophy of facet joints and ligamentum flavum; it can be congenital. Pain is worsened with walking, improved by rest—“neurogenic claudication.” Surgery is only for severe symptoms.

c. Epidural abscess: Usually there is sudden onset of severe pain that can progress rapidly to radicular symptoms, spinal cord dysfunction, and paralysis.

d. Compression fracture: This is associated with decreased bone density due to osteoporosis, bone tumors, or metastatic cancer. Low-level trauma can produce symptoms.

e. Referred pain: This may come from organs such as lung (pleuritis, pulmonary embolism), kidney (pyelonephritis, stone), aorta (aneurysm), or uterus (fibroids).

Practice-Based Learning and Improvement: Evidence-Based Medicine

Title
Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society

Authors
Chou R, Qaseem A, Snow V, et al., for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel

Institution
American College of Physicians

Reference
Ann Intern Med 2007;147:478–491

Problem
Back pain is common, but there is little consensus among the different specialties as to the appropriate clinical evaluation and management.

Intervention
To present the available evidence for evaluation and management of acute and chronic back pain

Quality of evidence
The literature search for this guideline included studies from Medline (1966 through November 2006), Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and EMBASE.

Outcome/effect
Seven recommendations guide the clinician through the optimal approach to low back pain.

Historical significance/comments
The article provides joint recommendations from the ACP and APS.

Interpersonal and Communication Skills

Explore Underlying Reasons for Somatic Complaints

When a patient presents with multiple complaints, there are usually underlying social and psychological factors that should be explored. It is important to determine the patient’s insight regarding how these factors might be contributing to his or her problems. Express empathy and validate the decision to seek medical care. Reassure the patient that he or she does not have any life-threatening cause for the symptoms. Offering a patient a good balance of appropriate pharmacologic treatment and lifestyle modification is the best approach. Be clear that you will be following up with him or her in the near future.

Professionalism

The Impaired Physician

Working in a busy outpatient clinic, physicians share the care of patients with many colleagues. There are times when the care that another physician provides raises concerns that the physician might be impaired. The American Medical Association defines an impaired physician as being unable to fulfill professional and personal responsibilities because of an alcohol or drug dependency, or a psychiatric illness. It is estimated that up to 15% of working physicians meet this criteria at some point during their careers, so it is reasonable to estimate that a considerable number of doctors have seen, or know firsthand, a colleague who may be impaired. Sometimes the impairment is clear: emotional lability, frequent absences, medical errors, and patient complaints. However, because doctors are high-performing individuals who are accustomed to masking stress and emotional issues while at work, impairment may be less obvious.

Physicians have an ethical obligation to report their suspicions of an impaired colleague who might be practicing under the influence of alcohol or drugs, or has a significant psychiatric impairment that is affecting patient safety. Such concerns should be reported to either the chief of service in the hospital or the state’s program for impaired physicians. Many physicians have difficulty following through on such reports, particularly when reporting involves a personal colleague. It is important to note, however, that many physicians, once reported, are able to keep their medical license and safely practice medicine again with proper counseling and rehabilitation.

Systems-Based Practice

Health Care Information Technology Can Enhance Patient Care

You have just seen your partner’s patient, who is complaining of neck pain, in the ED. You know that she has been treated for this before, but when she arrives in the ED on a Saturday, her file is in a cabinet in your locked office miles away. Paper-based medical records increase costs as a result of repeating laboratory tests and imaging studies, and increase the chance for errors. There is an enormous potential for information technology to impact the way in which we practice medicine. The ideal situation is to access this patient’s electronic health record (EHR) on a personal digital assistant (PDA), write inpatient orders wirelessly through the hospital’s computerized physician order entry (CPOE) system, and wirelessly transmit outpatient prescriptions to the patient’s pharmacy. Widespread adoption of these resources in the future will reduce unnecessary costs, decrease the likelihood of medical errors, and improve physician and patient satisfaction. As part of the American Recovery and Reinvestment Act, the Centers for Medicare and Medicaid Services (CMS) has released the final rule defining the term “meaningful use” of EHRs, which is a requirement that hospitals and medical professionals must meet to qualify for the Medicare and Medicaid incentives.

CASE 3

A 40-Year-Old Woman with Fatigue

The patient is a 40-year-old Greek woman who presents for lab results from a recent annual physical exam. Her only complaint was mild fatigue. Her lab tests were as follows:

Hemoglobin (Hgb) 10.0 (normal range 12.0–16.0 g/dL)

Hematocrit (Hct) 30.0% (normal range 35.0–47.0%)

Mean corpuscular volume (MCV) 69 fL (normal range 83–92 fL)

Red blood cell distribution width (RDW) 14% to 16% (normal range 11.1–14.5%)

Differential Diagnosis

Microcytic Anemia	Normocytic Anemia	Macrocytic Anemia
Iron deficiency	Chronic disease	Vitamin B12 deficiency
Chronic disease	Chronic kidney disease	Folate deficiency
Thalassemia	Acute blood loss	Myelodysplasia
Sideroblastic anemia	Sickle cell anemia	Bone marrow failure
	Hemolysis	Hypothyroidism

Speaking Intelligently

Anemia is a common finding in asymptomatic or minimally symptomatic patients in the primary-care office. We always try to identify an underlying cause. In the United States iron deficiency is the predominant cause of anemia. We use the MCV (a measure of the average size of red blood cells) to categorize the anemia as microcytic, macrocytic, or normocytic. Based on this woman’s low MCV, concentrate on microcytic causes of anemia. Since she is only mildly symptomatic, she can be evaluated in the office. Symptoms that might prompt admission to the hospital would be hypotension, tachycardia, active bleeding, or decompensation of other comorbid illnesses, such as congestive heart failure or unstable angina.

PATIENT CARE

Clinical Thinking

• Iron deficiency is the most common cause of microcytic anemia.

• It can be due to poor iron intake or chronic blood loss.

• The most sensitive test for iron deficiency is the serum ferritin, a measure of stored iron.

• In the United States, blood loss causes most cases of iron deficiency anemia; looking for a source of blood loss is imperative.

History

• With iron deficiency anemia, sources of blood loss can be identified with a good history.

• Menstrual history is imperative, including pad count, presence of clotted blood, and any menstrual irregularities.

• Gastrointestinal blood loss is the next consideration. Symptoms related to upper and lower gastrointestinal bleeding should be explored, including melena or hematochezia, hematemesis, epigastric pain, and changes in bowel habits. A history of weight loss should make one think of gastrointestinal malignancy.

• A careful family history is essential in making the diagnosis of thalassemia, an inherited disorder common in patients of Mediterranean, Asian, or African descent.

Physical Examination

• More acute blood loss can also be associated with hemodynamic instability, including orthostatic hypotension and tachycardia.

• Mild anemia (Hgb < 10 g/dL) usually is not associated with any physical findings.

• More severe anemia (Hgb < 7 g/dL) is usually associated with signs, including pale conjunctivae, slow capillary refill, and new cardiac systolic murmur (“flow murmur”).

• “Koilonychia,” or spooning of the nails, may also be present.

• Chronic blood loss is usually compensated even if the Hgb level is severely low.

Tests for Consideration

• Iron studies (serum iron, total iron-binding capacity [TIBC], and ferritin)	$40
• Reticulocyte count	$6
• Hgb electrophoresis, if family history present	$19
• Fecal occult blood testing	$5

Clinical Entities

Medical Knowledge

Iron Deficiency Anemia
Pφ	Iron deficiency anemia is caused by either decreased intake or absorption of iron, or loss of iron-containing red blood cells through hemolysis or bleeding. Gastrointestinal hemorrhage is a frequent pathologic cause of iron deficiency anemia; other causes are malabsorption syndromes and gastric bypass.
TP	In mild anemia, patients usually complain of fatigue, decreased exercise tolerance, and headaches. In more severe anemia, patients may have pica (a persistent desire to eat nonfood substances).
Dx	Low serum ferritin is the most sensitive marker for iron deficiency anemia. Since ferritin can be falsely elevated or normal due to acute inflammation, also measure the transferrin ratio, serum iron, or TIBC. In iron deficiency states, this ratio is low. Serum iron alone is a poor measure of iron stores.
Tx	Iron sulfate 325 mg three times a day is the treatment of choice. In patients with malabsorption problems, parenteral iron can be used. Hemoglobin levels should respond within several weeks. See Cecil Essentials 49.

Anemia of Chronic Disease
Pφ	Patients with chronic inflammatory diseases have decreased secretion of erythropoietin and decreased responsiveness of erythroid precursors to erythropoietin.
TP	This is usually a laboratory finding seen in patients with chronic diseases, such as SLE, malignancy, congestive heart failure, and diabetes mellitus.
Dx	The typical iron study profile shows normal serum ferritin, low or normal serum iron, and low TIBC, resulting in normal transferrin saturation.
Tx	Treat the underlying inflammatory disorder. Since iron stores are normal, iron supplementation is not necessary. Erythropoietin may be used if erythropoietin levels are low for the degree of anemia found. See Cecil Essentials 49.

a. Thalassemia: Hemoglobin is made of heme linked to protein chains, 2α and 2β. Thalassemia results from abnormalities of one or more of these chains, resulting in abnormal erythropoiesis and hemolysis. Depending on the type and number of gene mutations, these disorders can be mild, with asymptomatic anemia, or severe, resulting in fetal death (hydrops fetalis). Hgb electrophoresis is used to make the diagnosis.

b. Sideroblastic anemia: Sideroblastic anemia results from impaired heme synthesis due to either hereditary gene mutation or acquired states such as alcoholism, copper deficiency, zinc or lead toxicity, and drug toxicity (e.g., isoniazid, chloramphenicol). These mutated heme proteins are unable to utilize ferritin, leading to iron overload. Diagnosis is made by high serum iron level and bone marrow examination showing ringed sideroblasts.

Practice-Based Learning and Improvement: Evidence-Based Medicine

Title
Anemia in adults: a contemporary approach to diagnosis

Author
Tefferi A

Historical significance
Provides a stepwise approach to the adult patient with anemia

Reference
Mayo Clin Proc 2003;78:1274–1280

CASE 4

A 29-Year-Old Man with a Rash

A 29-year-old man comes in with a rash on his wrist and elbow. He is healthy except for exercise-induced asthma and mild seasonal allergies. He says the rash is pruritic and started gradually. On exam, the rash is seen to be an erythematous and slightly raised plaque, and is located on the palmar surface of the wrist and the antecubital folds of the elbow. There are no satellite lesions.

Differential Diagnosis

Eczema/atopic dermatitis	Seborrheic dermatitis	Contact dermatitis
Nummular dermatitis	Psoriasis	Lichen simplex chronicus

Speaking Intelligently

The first step is to determine if the rash is due to a primary dermatologic problem or is a sign of a systemic illness. Dermatitis is a rash related to a defect in the protective epidermal layer of the skin, characterized by pruritus and erythema, and lichenification in chronic cases. There are multiple forms of dermatitis, and these can be distinguished from one another by history and physical exam. It is important to distinguish between dermatitis and psoriasis, since psoriasis is more of a systemic inflammatory process that can have nonepidermal manifestations.

PATIENT CARE

Clinical Thinking

• Dermatitis can be divided into various categories based on its history, appearance, and location.

• Take note of these characteristics and any treatments that have been used in the past, with or without success.

• Recent exposures, change in diet or medications, and family or personal history of dermatitis or allergies are useful.

• Psoriasis has a very strong hereditary component.

History

• Detailed personal history of exposures, medications, diet, diet changes

• Over-the-counter creams that have been used and failed

• Family history of atopy, asthma, psoriasis, inflammatory disorders

• History of psoriatic involvement of joints, gastrointestinal tract

• History of HIV risk factors or infection

Physical Examination

• Characterize size, shape, distribution (check to be sure palms/soles and mucous membranes are not involved), and borders

• Identify associated papules, pustules, or vesicles

• Note evidence of arthritis or nail changes (pitting) on exam

• Note if lymphadenopathy is present

Tests for Consideration

• Skin scraping with potassium hydroxide (KOH) prep	$6
• Biopsy	$105
• HIV test	$13

Clinical Entities

Medical Knowledge

Atopic Dermatitis
Pφ	Usually starts in childhood but can persist into adulthood; a result of genetic predisposition and environmental factors.
TP	Pruritic, eczematous, poorly demarcated papulovesicular lesions located on wrists and on antecubital and popliteal fossae (flexor surfaces). Skin can become lichenified from chronic scratching. Excoriations are generally present. There is a general association with personal or family history of allergies, asthma, and allergic rhinitis. The history often includes sensitivity to certain products.
Dx	Clinical presentation is usually typical. IgE levels and peripheral eosinophilia are usually present.
Tx	Avoid exposure to irritating materials. Use emollients, such as hypoallergenic soap and lotion, daily. Mild- to moderate-potency steroids are effective. Antihistamines can help with pruritus.

Seborrheic Dermatitis
Pφ	The cause is unclear, but the yeast Malassezia is implicated. Overgrowth causes a skin inflammatory response, resulting in seborrhea.
TP	Erythematous scaly plaques in areas with sebaceous glands such as the scalp, nasolabial folds, eyebrows, and upper trunk. These plaques are not intensely pruritic. Commonly associated with HIV.
Dx	Physical exam revealing the above distribution of plaques is enough to establish the diagnosis.
Tx	For scalp lesions, shampoos containing tar, selenium sulfide, and zinc pyrithione are usually effective. Since Malassezia fungal infection is implicated in the inflammatory response, use of antifungal shampoo may also be useful. For face and skin lesions, topical low-potency steroids and antifungal creams have been used with success. See Cecil Essentials 108.

a. Allergic contact dermatitis: This is a delayed, type IV cell-mediated hypersensitivity reaction requiring previous exposure. Common types are poison ivy, nickel jewelry, leather, and latex allergies. Treatment is with topical steroids and calamine lotion. Diffuse cases might require oral steroids.

b. Nummular dermatitis: This is characterized by round lesions that can occur on any part of the body. There may be a single lesion or there may be as many as 50 lesions. The cause is unknown. Patients complain of intense pruritus, oozing, and scaling. This condition is often confused with tinea corporis. Treatment is a moderate- to high-strength topical steroid and daily skin moisturizer.

c. Psoriasis: Psoriasis is an immune-mediated inflammatory disease that results in hyperproliferation of the epidermis. It can be distinguished from other causes of dermatitis, because it is not generally pruritic and often has associated systemic findings, such as nail pitting, distal interphalangeal joint deformity, symmetrical large-joint arthritis, and seronegative spondyloarthropathy. Treatment depends on the extent and severity of illness, and includes topical steroids, tar, ultraviolet radiation, oral steroids, retinoids, methotrexate, and other immunomodulatory drugs.

Practice-Based Learning and Improvement: Evidence-Based Medicine

Title
Atopic and non-atopic eczema

Authors
Brown S, Reynolds NJ

Historical significance: clinical review
Discussion of the pathophysiology and genetic factors important in the development of eczema. Also discusses common treatments for eczema.

Reference
BMJ 2006;332:584–588

CASE 5

A 57-Year-Old Man with a Cough

A 57-year-old man with hypertension, coronary artery disease, and obesity presents with dry cough for 4 weeks. He notes the cough is worse at night but also occurs during the day. He still smokes cigarettes (¼ pack per day). He denies chest pain. He is compliant with his medications, including lisinopril, simvastatin, loratadine, and aspirin. On exam he has a few scattered wheezes but no rales or rhonchi. He is obese. His cardiac exam is normal.

Differential Diagnosis

Bronchopulmonary infection	Congestive heart failure	Allergic rhinitis/postnasal drip
Asthma exacerbation	Gastroesophageal reflux disease (GERD)	Head and neck cancer
Asthma exacerbation	Gastroesophageal reflux disease (GERD)	Lung cancer

Speaking Intelligently

Take a detailed history, paying extra attention to the time frame of the cough. Acute infectious causes tend to resolve within 2 to 6 weeks, while more chronic causes will persist for months. Associated symptoms are very important, especially in the case of cardiac causes. Since this patient has a history of heart disease and ongoing risk factors, make sure to include an angina and heart failure history in questioning.

PATIENT CARE

Clinical Thinking

• The chronicity of the cough and the associated symptoms will help in narrowing the differential to just a few diseases.

• Keep in mind the patient’s risk factors and age.

• Consider the most morbid conditions first, and try to eliminate them as possibilities based on history. If you cannot, initiate a workup on this initial visit.

• If the pretest probability of lung cancer or congestive heart failure is low based on the history, further testing can be delayed until the more common and benign diagnoses have been empirically treated.

History

Important red flags that should prompt early testing include:

• Cardiac: dyspnea on exertion, history of heart disease, chest pain, worsening orthopnea, paroxysmal nocturnal dyspnea

• Cancer: weight loss, hemoptysis, voice changes, worsening dyspnea, dysphagia

• Once these have been addressed, the history should include asking about other symptoms associated with each of your most likely causes: GERD, postnasal drip, and asthma.

Physical Examination

• Concentrate on the lung and head and neck exams.

• Are there any signs of allergic rhinitis (dark circles under the eyes, nasal crease, turbinate congestion)?

• Do you hear wheezing, stridor?

• Is there cervical lymphadenopathy?

Tests for Consideration

• Chest radiography if infection is a concern or red flags are present	$45
• Pulmonary function tests (PFTs)	$52
• CT of the chest and/or neck	$334
• Esophagogastroduodenoscopy (EGD)	$600

Clinical Entities

Medical Knowledge

Asthma
Pφ	Immediate IgE-mediated bronchospasm followed by cell-mediated inflammatory response in prolonged symptoms and in chronic asthma.
TP	Presents with acute onset of shortness of breath and dyspnea; may be audibly wheezing. Tachypnea and difficulty completing sentences may precede respiratory failure. Clinical exam will reveal wheezing.
Dx	Chest radiograph is usually normal; peak expiratory flow rate and FEV1 are decreased.
Tx	Bronchodilators (albuterol, salmeterol); corticosteroids (inhaled and/or oral); immunomodulators (montelukast); other (theophylline). See Cecil Essentials 17.

Gastroesophageal Reflux Disease
Pφ	Hyperacidity in the distal esophagus due to abnormal relaxation of the lower esophageal sphincter.
TP	Heartburn symptoms; cough; association with certain foods, especially mint, spicy foods, fatty foods, alcohol.
Dx	Response to empirical treatment with antacid therapy; esophagogastroduodenoscopy can show typical inflammatory changes; probe of the lower esophageal area shows acidic pH.
Tx	Proton-pump inhibitor therapy; avoidance of foods that cause symptoms; weight loss; in severe cases, fundoplication surgery may be needed. See Cecil Essentials 36.

Allergic Rhinitis
Pφ	IgE-mediated histamine release in response to environmental exposure.
TP	Postnasal drip with nasal congestion, rhinorrhea, and cough.
Dx	Typical symptoms respond to antihistamine treatment; in severe cases allergy skin and radioallergosorbent testing (RAST) may be necessary.
Tx	Antihistamines; steroid nasal inhaler. See Cecil Essentials 98.

a. Head and neck cancer: Cough can be a presenting symptom of vocal cord polyps and cancer. A smoking history and complaint of voice change should raise suspicion of this diagnosis. Diagnostic test of choice is direct laryngoscopy by an otolaryngologist.

b. Pulmonary embolus: Cough is usually associated with hemoptysis. Be suspicious with anyone with multiple risk factors and no other diagnosis that is more likely. Test of choice is a CT angiogram of the chest.

c. Pertussis: Pertussis is characterized by paroxysms of severe cough that sounds like a whoop. The cough is often associated with post-tussive vomiting. The cough usually lasts 6 weeks. This is highly contagious and requires treatment with antibiotics. Pertussis vaccination can help to prevent disease and is now included in the tetanus and diphtheria booster (Tdap); give as a one-time dose to adults from 19 through 64 years of age.

Practice-Based Learning and Improvement: Evidence-Based Medicine

Title
The diagnosis and treatment of cough

Authors
Irwin RS, Madison JM

Problem
What is the best approach to diagnosing cough?

Intervention
This is a discussion of common causes of cough and a stepwise approach to diagnosis and management, including suggested guidelines for treatment.

Outcome/effect
Using a systematic approach can lead to appropriate diagnosis and management of cough in 88% to 100% of cases while avoiding nonspecific therapy and costly diagnostic tests.

Reference
N Engl J Med 2000;343:1715–1721

Interpersonal and Communications Skills

Prepare Patients for the Possibility of Further Testing

Before you begin the evaluation of a patient, it is important to communicate the potential need for more invasive testing depending on the results of initial studies. Prepare the patient to consider the possible need for further testing, as it is important to be sure that he or she will be willing to undergo future tests, such as colonoscopy or CT scanning, if an abnormality is identified. If patients are unsure about their willingness to comply with additional testing, empathize with their concerns, but assist them in understanding the rationale for your management plan.

Systems-Based Practice

Use Practice Guidelines in Medical Decision Making

Practice guidelines are a useful tool in helping to treat chronic diseases such as asthma and anemia. The best practice guidelines are based on evidence and are endorsed by expert panels consisting of representatives from stakeholder organizations. Guidelines can be found easily by performing a web-based search: http://www.guideline.gov. This is an excellent link to the National Guideline Warehouse assembled by the Agency for Healthcare Research and Quality. The Institute of Medicine has proposed standards for a trustworthy guideline in which a guideline should (1) follow a transparent process; (2) be developed by a multidisciplinary panel; (3) use rigorous systematic evidence; (4) review and summarize evidence (and gaps) about potential benefits and harms of each recommendation; (5) provide a rating of the level of confidence in the evidence and the strength of each recommendation; (6) undergo extensive external review; and (7) have a mechanism for revision as new evidence becomes available.

Guideline standards from Laine C, Taichman DB, Mulrow C: Trustworthy Clinical Guidelines, Annals of Internal Medicine, June 7, 2011, vol. 154, no. 11, 774–775, Table 1. Used with permission from American College of Physicians.