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Why Is This Important? Phone Triage) and Physical Exam Goals Diagnostic Dilemmas Learn which features of the history and 1. What is the cause of this patient’s red eye? physical examination are most useful 2. Does this patient have a pathologic headache? Use risk scores and clinical decision tools 3. Does this patient have endocarditis? Distinguish benign from potentially serious 4. What is the cause of this patient’s back pain? conditions Identify clinical pearls and pitfalls What is the Cause of this Patient’s Mr. Ira Tatedi Red Eye? 32 year old man with one day h/o mild redness of OD, pain, and photophobia. Physical exam shows circumcorneal injection, and visual acuity is 20/80. Key Elements of History (including Why is this Important? Phone Triage) and Physical Exam Most cases of red eye are caused by viral History and Triage Physical Examination conjunctivitis, which does not generally Is vision affected? Visual acuity require any treatment Is there a foreign Pupil size/reactivity Some cases are caused by bacterial or allergic body sensation? Discharge conjunctivitis, for which specific treatment is Is there Pattern of redness indicated photophobia? Foreign body A minority of cases are caused by other Was there trauma? Hypopyon/hyphema conditions, which require urgent or emergent Are patient a contact referral to an ophthalmologist lens wearer? It is essential to be able to distinguish them Is there discharge from one another throughout the day? Anatomy/Differential Diagnosis Conjunctivitis Viral Conjunctivitis – Erythema with co-existing URI – Watery, serous discharge Episcleritis – Normal vision Scleritis Bacterial Keratitis – Staph > pneumococcus or H. flu – Eyelid edema Iritis/uveitis – Mucopurulent discharge Corneal abrasion – Eyes “glued shut” upon awakening Subconjunctival hemorrhage Chlamydial – Sexually active individual with Acute closed angle glaucoma “bacterial conjunctivitis” not responding to treatment Episcleritis and Scleritis Keratitis Episcleritis Inflammation of the superficial vessels Localized or diffuse erythema Inflammation of the cornea Discomfort/irritation, not pain Due to infection, dry eyes, medications, Dilated vessels contact lens irritation No vision changes Tearing, erythema, pain, decreased vision Scleritis Cloudiness, irregular surface, loss of Inflammation of the fibrous layer of the eye epithelial cells Intense pain and tenderness Photophobia Uptake of fluorescein dye Change in visual acuity Refer urgently to ophthalmology Iritis/Uveitis Other Causes of Red Eye Young, middle-aged patients Subconjunctival hemorrhage –Pain – Well circumscribed hyperemia on sclera – Normal vision, painless –Photophobia – 2-3 weeks for reabsorption of blood – Blurred vision Corneal abrasion 35% have severe impairment Direct injury from object, contact lenses – Circumcorneal (peri-limbic) injection “ciliary flush” – Foreign body sensation – Constricted pupil – Watery eyes –Photophobia Inflammatory cells in the anterior chamber Acute closed-angle glaucoma – Usually seen with slit lamp – Eye pain, nausea/vomiting – If severe, can settle to form a hypopyon –Cloudy cornea Urgent ophthalmology referral – Fixed mid-dilated pupil Adapted from UpToDate Key Elements of Assessment of the Red Eye Acuity Foreign Photo- Discharge Cardinal Red Eye: Pearls and Pitfalls Body phobia Features Sensation Conjunctivitis Normal No No Yes Discharge Diagnosis of the cause of red eye is made mostly Episcleritis and Normal or No No None Dull ache on the basis of history with physical exam findings Scleritis decreased being confirmatory for some conditions Keratitis Normal or Yes Yes Sometimes Corneal decreased opacities If the vision is unaffected, the pupil reacts, and Iritis/Uveitis Normal or No Yes None or Miotic pupil there is no foreign body sensation, photophobia, or decreased watery corneal opacity, red eye can be managed by the Subconjunctival Normal No No None Extravasated Hemorrhage blood primary care practitioner Corneal Normal or Yes Yes Watery Contact Most of these cases are related to conjunctivitis Abrasion decreased lenses Other clinical situations require urgent or emergent Acute Normal or No Sometimes None or Eye pain referral to an ophthalmologist for consultation Closed-Angle decreased watery Glaucoma Does this Patient Have a Pathologic Headache? Ms. Cephalalgia 29 year old woman Several year history of migraines Pain becoming worse over 2-3 months Bifrontal and non- throbbing She asks: “Do I have a brain tumor?” Why is this Important? There are Two Types of Headache 1. Old headaches Headache is one of the top five reasons that patients see primary care providers and also 2. New headaches top five for ER visits All pathologic headaches are new headaches Most headaches are benign New headache is either: A small percentage of patients will have a serious condition that could cause permanent – New onset headache in person without chronic neurological harm if not diagnosed headache history or – A change in the character of headache in a Clues in history provide the correct diagnosis person with old headaches Need to minimize unnecessary neuroimaging A change in severity or frequency is not a new headache Differential Diagnosis Which Historical Features are Most Helpful in the Diagnosis of Migraine? Benign Pathologic Feature Positive LR Negative LR Primary headaches Brain tumor Migraine AVM Nausea 19.2 0.20 Tension-type Subarachnoid Photophobia 5.8 0.25 Cluster hemorrhage Phonophobia 5.2 0.38 Brain abscess Secondary headaches Exacerbation by activity 3.7 0.24 TMJ Meningitis Unilateral pain 3.7 0.43 Cervicogenic Temporal arteritis Throbbing pain 2.9 0.36 Sinusitis Subdural hematoma Flu-like illness Smetana GW. Arch Intern Med. 2000;160:2729. Clinical Prediction Rule: Does this Patient Have a Migraine? Always Examine Fundi for Papilledema Number of LR+ (CI) Features 1. Pounding? ≥ 4 24 (1.5-388) 2. 4-72 hours? 3 3.5 (1.3-9.2) 3. Unilateral? 4. Nausea? 2 0.41 (0.32-0.52) 5. Disabling? For definite or possible migraine by IHS criteria Rational Clinical Exam Series. JAMA. 2006;296:1274. Meta-Analysis: Which Clinical Features Best Mnemonic for Pathologic Predict Abnormal Neuroimaging? Headaches Red Flags “SNOOP” American Headache Society Feature LR+ LR- Feature Examples Cluster-type headache 11 0.95 Systemic symptoms or Fever, weight loss Abnormal neuro exam 5.3 0.71 HIV, known malignancy secondary risk factors “Undefined” headache 3.8 0.66 Eye pain, visual loss, mental Aura 3.2 0.51 Neurologic symptoms or signs status changes, hemiparesis Focal symptoms 3.1 0.79 Onset “Thunderclap” Increased by Valsalva 2.3 0.70 Older > 50 years old, especially new Vomiting 1.8 0.47 and progressive New headache 1.2 0.89 Previous headache Change in clinical features of Migraine type headache 0.55 1.2 history old headache Rational Clinical Exam Series. JAMA. 2006;296:1274. American Headache Society Worrisome Features: When To Image? Choosing Wisely 2014 Change in pattern of old headache • Don’t perform neuroimaging studies in patients with stable 1 headaches that meet criteria for migraine. Migraine variants – New migraine headache >40 y.o. (r/o AVM) • Don’t perform computed tomography (CT) imaging for headache when magnetic resonance imaging (MRI) is – Side-locked migraine headache (r/o AVM) 2 available, except in emergency settings. – Prolonged aura Focal neurologic exam • Don’t recommend surgical deactivation of migraine trigger points outside of a clinical trial. “Thunderclap” headache (r/o SAH) 3 New progressive headache over months in person without chronic headache history • Don’t prescribe opioid or butalbital-containing medications 4 as first-line treatment for recurrent headache disorders. New persisting headache after age 50 Exertional or sexual headache • Don’t recommend prolonged or frequent use of over-the- 5 counter (OTC) pain medications for headache. Headache: Pearls and Pitfalls Does this Patient Have Endocarditis? Do not be fooled by old headache history: consider pathologic headache if change in pain character Brain tumor headaches typically worsen over 1-2 months before neurologic impairment Always examine fundi for evidence of papilledema Remember features of migrainous headache that may indicate AVM: side-locked, prolonged aura, older age at onset “Thunderclap” headache should prompt imaging to rule out SAH Consider temporal arteritis if patient > 50 years old regardless of pain character https://en.wikipedia.org/wiki/Infective_endocarditis The urgent care clinic said that I just have a virus… Why is this Important? Mr. Lee Quivalve is a 56 y.o. man with 3 weeks of fever, decreased Most subacute bacterial endocarditis is appetite, and fatigue. nonspecific in presentation and often initially He denies chest pain and misdiagnosed dyspnea. It is important to maintain an index of PMH: rheumatic heart disease. suspicion for this diagnosis in patients with PE: T=100.2 F. COR: II/VI protracted illnesses of unclear etiology holesystolic murmur at apex, no Early diagnosis and initiation of antibiotic gallops. Lungs: clear. Abdomen: therapy are associated with better clinical soft, nontender, without outcomes organomegaly. Skin: no rash or lesions. Risk Factors for Endocarditis Clinical Findings in Endocarditis Symptoms Signs Valvular or congenital heart disease Fever (90%) Murmur (85%) Prosthetic value Headache Splenomegaly Prior endocarditis Myalgias/arthralgia Petechiae Injection drug use Abdominal pain Nail splinter Immunosuppression Dyspnea hemorrhages
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