Harrisons Book Club

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Harrisons Book Club
Session One Chapters 11-15 8/16/05
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Chapter 11 - Pain
Which of the following statements about pain
management medications is correct?   a) patients
receiving NSAIDs 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.
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Chapter 11 Pain (Cont.)
c) sensory impairment, sensitive skin, atrophy
and lost of DTRs are all indicators of
sympathetic involvement, and relief achieved by
sympathetic block is diagnostic.   d) TCAs 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.
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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.
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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

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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
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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
shes been nauseous but has not vomited and shes
not sure if the pain gets better or worse with
food since she hasnt 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?
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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.
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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.
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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
Ill 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 Ill give you her number. In the
meantime, heres a script for Motrin 400mg PO
q4h. D I think you have cluster headaches.
Verapamil should avoid your headaches from
returning.
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Chapter 14 Headache 2
Youre 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 colleagues
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.
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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 didnt see the psychiatrist and
progressively lost her vision over the following
3 weeks. Which of the following is true
regarding this ladys condition? A Most common
age of appearance is mid-40s. B ESR is
invariably elevated. C Her condition definitely
required immediate psychiatric evaluation. D
Prompt initiation of glucocorticoids would have
avoided her blindness.
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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    
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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