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  Recent dental or surgical procedure  Cough  Roth spots  Pleuritic chest pain  Osler’s nodes  Back pain  Janeway lesions

Cutaneous and Ocular Manifestations of Complications of Bacterial Endocarditis Endocarditis

 Cardiac (50%): Valvular insufficiency, heart failure  Neurologic (40%): Embolic stroke, hemorrhage, brain abscess  Septic emboli (25%): Pneumonia/lung abscess, infarction of kidneys and other organs  Other metastatic infection: Vertebral osteomyelitis, septic arthritis, psoas abscess  Systemic immune reaction: Acute glomerulonephritis http://www.slideshare.net/jbearth/micro-quiz-4th-yr

Diagnosis and Differential Diagnosis of Bacterial Endocarditis

 Symptoms often nonspecific, and differential diagnosis is broad  Consider in all patients with a protracted febrile illness, particularly if risk factors  Diagnosis suspected by symptoms and/or signs but is confirmed with blood cultures and echocardiography  Additional tests depending on clinical features  Use modified Duke criteria Blood Cultures and Echocardiography Bacteriology of Endocarditis

 Positive blood cultures are necessary for microbiologic • Most common pathogens include diagnosis of endocarditis Staphylococcus aureus, viridans  Three sets detect 96-98% of organisms; separate streptococci, Streptococcus venipuncture sites gallolyticus (bovis), HACEK organisms, and enterococci  Most pathogens detected within 48 hours; fastidious ones may take up to 5 days • Less commonly Coxiella burnetii, Bartonella, Chlamydia, Legionella,  Echocardiography whenever suspected Mycoplasma, and Brucella  TTE initially; sensitivity/specificity of 75%/100% for • Diagnosis by serology or PCR detecting vegetations testing  TEE is better for diagnosing complications (e.g., • Culture-negative endocarditis abscess, leaflet perforation); sensitivity of >90% for rarely detecting vegetations http://emedicine.medscape.com/article/1954887-overview#a7

Diagnosis of Bacterial Endocarditis Modified Duke Criteria Using Modified Duke Criteria

Major Minor Definite Possible  Positive BC x 2 with  Risk factors Endocarditis Endocarditis typical organism  Fever Pathologic • Vegetation or • Not applicable  Persistent positive BCs  Vascular: emboli, intracardiac abscess  Coxiella burnetti infarcts, mycotic  Echo: vegetations, aneurysm, Janeway Clinical • 2 major criteria • 1 major and 1 abscess, partial lesions minor criteria dehiscence of  Immune features: GN, • 1 major criterion • 3 minor criteria prosthetic valve, new Osler nodes, Roth and 3 minor criteria regurgitation spots  Other positive BC • 5 minor criteria

Bacterial Endocarditis: What is the Cause of this Patient’s Back Pain? Pearls and Pitfalls

 Consider in patients with a protracted febrile illness, particularly those with risk factors  Symptoms are generally nonspecific; fever and a murmur are the most common physical findings  May occasionally present with cardiac, neurologic, embolic, or metastatic infectious complications  Diagnosis by blood cultures and echocardiography using the modified Duke criteria  Prompt diagnosis and treatment are essential for optimal clinical outcome Case: Cy Attica Why is this Important?

 74 y.o. man with leg • Low back pain is the most common heaviness and pain on walking three blocks musculoskeletal complaint among adult relieved with rest and patients seen in primary care practice sitting. Gradual onset. • Specific diagnosis established in only 15-20% History of intermittent LBP. PMH: HTN, DM. • Produces at least short-term impairment in 70-  PE: reduced ROM lower 80% of general population over lifetime spine, no focal neurologic • A small percentage of cases are not self- findings, preserved pulses. limited, reflect a more serious underlying  What is his diagnosis? disease, and may require specific interventions

Common Patho-Anatomical Conditions

Demographics/Epidemiology

• Most cases ages 30-60 years • Leading cause of disability in persons < 45 • Comparable rates among men and women • Incidence greater among women than men in

NEJM 2007;356:2239-2243. occupations requiring heavy exertion • Men generally present at younger age • Precipitating event in only 6-28% of cases • Recurrence of occupational low back pain in 33-60% of patients within 3 years

Causes of Acute Low Back Pain Mechanical Low Back Pain

 History • Pain in back, buttock +/- thigh, often severe • Onset hours to days after new/unusual exertion • No history of major trauma, infection or malignancy • Relief of pain in supine position +/- legs flexed  Physical examination • Paravertebral tenderness/spasm • Scoliosis or loss of lumbar lordosis • No demonstrable neurologic deficits  Supporting studies Ann Intern Med. 2002;137:586-97. • None necessary Herniated Intervertebral Disc

 History • Acute onset, severe, lancinating • Often antecedent flexion strain injury or trauma • Sciatica • Relief of pain with hip in partial flexion  Physical examination • Striking paravertebral tenderness/spasm, with splinting in awkward postures • Evidence of radiculopathy  Supporting studies • Usually none early; later, MRI, EMG/NCV Dermatomes

Accuracy of Exam for Disc Herniation When to Suspect Malignancy or Infection? Finding Sensitivity Specificity Physical examination Ipsilateral SLR 0.80 0.40 • Tender spinous process(es) Crossed SLR 0.25 0.90 • Variable neurologic findings Ankle dorsiflexors weak 0.35 0.70 • Evidence of systemic cancer/infection EHL weak 0.50 0.70 Supporting studies Plantar flexion weak 0.06 0.95 • Epidural process best delineated by MRI, CT +/- Quadriceps weak 0.01 0.99 myelogram Sensory loss 0.50 0.50 • LS x-rays may reveal destructive bony lesions Decreased ankle reflex 0.50 0.60 • Bone scan sensitive for metastatic carcinoma Decreased knee reflex 0.50 -- (but not for myeloma) • ESR/CRP usually elevated JAMA. 1992;268:760.

Red Flags Cancer or infection Spinal fracture Cauda equina Prior CA or recent Hx of significant Acute onset urinary infection trauma retention Prolonged use of Loss of anal sphincter Imaging in a Fever > 100 F Patient corticosteroids tone Age > 70 +/- limited Unexplained weight loss Saddle anesthesia with a “Red trauma Global/progressive LE Flag” Diagnosis Immunosuppression weakness

Intravenous drug use

Corticosteroid use No change or worse with rest Age > 50

N Engl J Med. 2006;355:2012. Persistence > 1 month Systematic Review of “Red Flags” Spinal Stenosis • Included 14 studies evaluating 53 red flags History • Many red flags provide virtually no change in • Back pain may vary from absent to severe probability of fracture or malignancy or have • Pseudoclaudication often prominent • Pain worsens during the day, aggravated by untested diagnostic accuracy standing, relieved by rest and trunk flexion • Red flag with highest post-test probability for • Weakness, bladder and bowel dysfunction malignancy is history of malignancy (33%) • Age > 50 • Red flags with highest post-test probability for Physical examination spinal fracture: 1) older age (9%); 2) prolonged • Neurologic findings vary, often multiple levels use of corticosteroids (33%); 3) severe trauma • Findings of osteoarthritis may be prominent (11%; and 4) presence of contusion/abrasion Supporting studies (62%) • Standard radiographs; MRI or CT +/- myelography; Brit Med J. 2013;347:f7095. NCV/EMG

Low Back Pain: Pearls and Pitfalls ACP Clinical Practice Guidelines

• Conduct focused history and exam to distinguish: – Nonspecific low back pain – Back pain potentially associated with radiculopathy and/or spinal stenosis – Back pain associated with another potential spinal cause • Do not obtain imaging routinely in patients with nonspecific low back pain • Image for severe or progressive neurological deficits or when serious underlying conditions are suspected • Also image for potential candidates for surgery or epidural injection Ann Intern Med. 2007;147:478.