COMMON SYMPTOMS

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COMMON SYMPTOMSCOMMON SYMPTOMS

What do they mean?What do they mean?ACUTE- < 3 weeks. ACUTE- < 3 weeks.

PERSISTENT/ CHRONIC- > 3 weeksPERSISTENT/ CHRONIC- > 3 weeksCHAPTER 2CHAPTER 2

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COUGHCOUGHACUTEACUTE

In healthy adults, most cases of acute cough are In healthy adults, most cases of acute cough are due to viral respiratory infections.due to viral respiratory infections.

Chronic medical conditions can cause acute Chronic medical conditions can cause acute cough during exacerbations: asthma, CHF, cough during exacerbations: asthma, CHF, allergic rhinitis.allergic rhinitis.

Cough from a viral respiratory infection CAN Cough from a viral respiratory infection CAN persist beyond 3 weeks.persist beyond 3 weeks.

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COUGHCOUGH

ACUTEACUTE Dyspnea does not typically accompany acute Dyspnea does not typically accompany acute

cough in a viral resp infection, and cough in a viral resp infection, and Cough + Dyspnea- requires a work-up: CXR, Cough + Dyspnea- requires a work-up: CXR,

ABGs, PFTs, Cardiovascular eval.ABGs, PFTs, Cardiovascular eval.

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COUGHCOUGH

PERSISTENTPERSISTENT In the absence of respiratory infections, therapy In the absence of respiratory infections, therapy

w/ ACE inhibitors, or abnormalities on CXR, 90% w/ ACE inhibitors, or abnormalities on CXR, 90% of cases of persistent cough are due to:of cases of persistent cough are due to:

1) Postnasal drip (allergies).1) Postnasal drip (allergies). 2) Asthma.2) Asthma. 3) GERD.3) GERD.

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COUGHCOUGHPERSISTENTPERSISTENT

OTHER CAUSES:OTHER CAUSES: Lung cancer, TB - both can present w/ fever, Lung cancer, TB - both can present w/ fever,

night sweats, weight loss.night sweats, weight loss. Chronic bronchitis / COPD.Chronic bronchitis / COPD. Other chronic infections (crypto, coccy, etc.)Other chronic infections (crypto, coccy, etc.) Interstitial lung disease- pulmonary fibrosis, Interstitial lung disease- pulmonary fibrosis,

sarcoidosis, etc.sarcoidosis, etc. Psychogenic.Psychogenic.

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COUGHCOUGHDIAGNOSTIC STUDIESDIAGNOSTIC STUDIES

ACUTE COUGH- CXR should be done in the ACUTE COUGH- CXR should be done in the patient with: abnormal vital signs (tachycardia, patient with: abnormal vital signs (tachycardia, tachypnea); physical exam findings suggestive of tachypnea); physical exam findings suggestive of pneumonia (rales, consolidation), decreased pneumonia (rales, consolidation), decreased pulse-ox.pulse-ox.

PERSISTENT COUGH- CXR, empiric Rx for PERSISTENT COUGH- CXR, empiric Rx for postnasal drip, GERD, asthma for 2-4 weeks; if postnasal drip, GERD, asthma for 2-4 weeks; if no better, PFTs, referral.no better, PFTs, referral.

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DYSPNEADYSPNEA The perception of uncomfortable breathing.The perception of uncomfortable breathing.

3 BROAD CATEGORIES:3 BROAD CATEGORIES: 1) MECHANICAL- COPD, myasthenia gravis1) MECHANICAL- COPD, myasthenia gravis 2) COMPENSATORY- hypoxemia, acidosis.2) COMPENSATORY- hypoxemia, acidosis. 3) PSYCHOGENIC- anxiety / panic attack.3) PSYCHOGENIC- anxiety / panic attack. Dyspnea commonly accompanies a multitude of Dyspnea commonly accompanies a multitude of

acute and chronic medical conditions.acute and chronic medical conditions.

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DYSPNEADYSPNEA Acute dyspneaAcute dyspnea as the chief complaint warrants as the chief complaint warrants

urgent evaluation, looking for:urgent evaluation, looking for: P.E., pneumothorax, asthma, COPD.P.E., pneumothorax, asthma, COPD. Pneumonia, cardiac disease such as MI, CHF, Pneumonia, cardiac disease such as MI, CHF,

valvular dysfunction (rupture of chordae valvular dysfunction (rupture of chordae tendonae), arrhythmias.tendonae), arrhythmias.

Metabolic acidosis (DKA eg), Metabolic acidosis (DKA eg), methemoglobinemia, carbon monoxide methemoglobinemia, carbon monoxide poisoning, cyanide toxicity (such as from smoke poisoning, cyanide toxicity (such as from smoke inhalation).inhalation).

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DYSPNEADYSPNEA Can distinguish mechanical from compensatory Can distinguish mechanical from compensatory

from psychogenic with arterial blood gas (ABG) from psychogenic with arterial blood gas (ABG) evaluation. EXCEPT for: cyanide toxicity and evaluation. EXCEPT for: cyanide toxicity and carbon monoxide poisoning.carbon monoxide poisoning.

MECHANICAL- respiratory acidosis, w/ or w/out MECHANICAL- respiratory acidosis, w/ or w/out hypoxemia.hypoxemia.

COMPENSATORY- respiratory alkalosis w/ or COMPENSATORY- respiratory alkalosis w/ or w/out hypoxemia or metabolic acidosis.w/out hypoxemia or metabolic acidosis.

PSYCHOGENIC- respiratory alkalosis.PSYCHOGENIC- respiratory alkalosis.

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ACID-BASE REVIEWACID-BASE REVIEWCO2 + H20 ↔ H2CO3 ↔ H+ + HCO3‾CO2 + H20 ↔ H2CO3 ↔ H+ + HCO3‾

(H2CO3 = CARBONIC ACID, HCO3‾ = “BICARB”)(H2CO3 = CARBONIC ACID, HCO3‾ = “BICARB”)

HENDERSON HASSELBACH EQUATIONHENDERSON HASSELBACH EQUATION

pH = pKa + log([HCO3‾] / 0.03[CO2])pH = pKa + log([HCO3‾] / 0.03[CO2])

OR, SIMPLIFIEDOR, SIMPLIFIED

pH = -log10(H+)pH = -log10(H+)

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ACID-BASE REVIEWACID-BASE REVIEW Remember to consider what is the disease and what is the Remember to consider what is the disease and what is the

compensatory responsecompensatory response The disease:The disease: RESPIRATORY ACIDOSIS: CO2 IS RESPIRATORY ACIDOSIS: CO2 IS RETAINEDRETAINED, pH , pH goesgoes

downdown RESPIRATORY ALKALOSIS: CO2 IS RESPIRATORY ALKALOSIS: CO2 IS EXHALEDEXHALED, , pH pH goes goes

upup METABOLIC ACIDOSIS: METABOLIC ACIDOSIS: DECREASEDECREASE IN HCO3 IN HCO3, pH , pH goes goes

downdown METABOLIC ALKALOSIS: METABOLIC ALKALOSIS: INCREASEINCREASE IN HCO3-, IN HCO3-, pH pH goes goes

upup

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ACID-BASE REVIEWACID-BASE REVIEW

The compensation:The compensation: SHORT TERM: respiratory, by altering amount of SHORT TERM: respiratory, by altering amount of

CO2 exhaled.CO2 exhaled. LONG TERM: by the kidney, by altering amount LONG TERM: by the kidney, by altering amount

of H+ excreted, thereby changing HCO3-.of H+ excreted, thereby changing HCO3-.

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ACID-BASE REVIEWACID-BASE REVIEW

For review of Acid-Base Metabolism:For review of Acid-Base Metabolism: http://www.nda.ox.ac.uk/wfsa/html/u13/u1312_01.htmhttp://www.nda.ox.ac.uk/wfsa/html/u13/u1312_01.htm http://www.acid-base.com/index.phphttp://www.acid-base.com/index.php For interpretation of ABGsFor interpretation of ABGs http://www.health.adelaide.edu.au/paed-anaes/javamahttp://www.health.adelaide.edu.au/paed-anaes/javama

n/Respiratory/a-b/AcidBase.htmln/Respiratory/a-b/AcidBase.html

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DYSPNEA – DYSPNEA – THE DDx BASED ON SxsTHE DDx BASED ON Sxs

If dyspnea is If dyspnea is sudden in onsetsudden in onset and and severesevere, and , and absence absence of of other Sxs, think: P.E., pneumothorax, increased LVEDP (as in other Sxs, think: P.E., pneumothorax, increased LVEDP (as in CHF, silent MICHF, silent MI).).

W/ chest painW/ chest pain, think: , think: M.I., P.E., pneumo, pleurisy, M.I., P.E., pneumo, pleurisy, pericarditispericarditis. Need to dig deeper into the pain- was it acute in . Need to dig deeper into the pain- was it acute in onset, chronic, pleuritic, exertional.onset, chronic, pleuritic, exertional.

W/ W/ fever and coughfever and cough think infection. think infection. Dyspnea w/ Dyspnea w/ no other Sxsno other Sxs, think non-cardiopulmonary causes , think non-cardiopulmonary causes

of impaired O2 delivery: anemia, carbon monoxide, of impaired O2 delivery: anemia, carbon monoxide, methemoglobinemia, PE, metabolic acidosis.methemoglobinemia, PE, metabolic acidosis.

W/ W/ wheezingwheezing, think: asthma, COPD, foreign body., think: asthma, COPD, foreign body.

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DYSPNEA – DYSPNEA – THE PHYSICAL EXAMTHE PHYSICAL EXAM

Inspect- breathing pattern, resp rate, pursed lips Inspect- breathing pattern, resp rate, pursed lips (emphysema), barrel chest (chronic bronchitis), use of (emphysema), barrel chest (chronic bronchitis), use of accessory muscles (asthma), asymmetrical excursion of accessory muscles (asthma), asymmetrical excursion of the chest and/or diaphragm (pneumo).the chest and/or diaphragm (pneumo).Head & Neck- JVD (CHF).Head & Neck- JVD (CHF).Lungs- the usual- breath sounds, crackles Lungs- the usual- breath sounds, crackles and wheezesand wheezesHeart- the usual- murmurs, rubs, location of Heart- the usual- murmurs, rubs, location of PMI, etc.PMI, etc.Extremities- edema (CHF), evidence of DVT Extremities- edema (CHF), evidence of DVT (P.E.).(P.E.).

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DYSPNEA – DIAGNOSTIC STUDIESDYSPNEA – DIAGNOSTIC STUDIES ““Causes of dyspnea that can be managed without a chest X-Causes of dyspnea that can be managed without a chest X-

ray are few: ingestions causing lactic acidosis, ray are few: ingestions causing lactic acidosis, methemoglobinemia, and carbon monoxide poisoning.” methemoglobinemia, and carbon monoxide poisoning.”

““In the absence of physical examination evidence of In the absence of physical examination evidence of COPD or CHF, the major remaining causes of dyspnea COPD or CHF, the major remaining causes of dyspnea include P.E., upper airway obstruction, foreign body, include P.E., upper airway obstruction, foreign body, and metabolic acidosisand metabolic acidosis.”.”

CXR, ABG’s, EKG.CXR, ABG’s, EKG. V / Q SCAN – to r/o P.E. V / Q SCAN – to r/o P.E. (Ventilation/Perfusion Scan =V/Q)(Ventilation/Perfusion Scan =V/Q)

Blood tests- CBC, carboxyhemoglobin & methemoglobin Blood tests- CBC, carboxyhemoglobin & methemoglobin levels.levels.

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EDEMAEDEMADIFFERENTIAL DxDIFFERENTIAL Dx

CHRONIC VENOUS INSUFFICIENCY.CHRONIC VENOUS INSUFFICIENCY. VENOUS THROMBOSIS.VENOUS THROMBOSIS. CELLULITIS.CELLULITIS. MUSCULOSKELETAL DISORDERS. (ruptured MUSCULOSKELETAL DISORDERS. (ruptured

Baker’s cyst).Baker’s cyst). LYMPHEDEMA.LYMPHEDEMA. SYSTEMIC DISEASE- CHF, cirrhosis, renal failure, SYSTEMIC DISEASE- CHF, cirrhosis, renal failure,

nephrotic syndrome.nephrotic syndrome. MEDICATION- Ca channel blockers.MEDICATION- Ca channel blockers.

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EDEMAEDEMACHRONIC VENOUS INSUFFICIENCYCHRONIC VENOUS INSUFFICIENCY

By far the most common cause of edema.By far the most common cause of edema. 2% of the population.2% of the population. Due to incompetence of the valves in the Due to incompetence of the valves in the veins of the veins of the

leg; also a complication of DVT.leg; also a complication of DVT. Results in leakage of not only fluid but leukocytes and Results in leakage of not only fluid but leukocytes and

other inflammatory components, resulting in lymphatic other inflammatory components, resulting in lymphatic obstruction and worsening edema.obstruction and worsening edema.

PRESSURE IS A DISEASE- ultimately results in impaired PRESSURE IS A DISEASE- ultimately results in impaired arterial supply, tissue necrosis, ulceration.arterial supply, tissue necrosis, ulceration.

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EDEMAEDEMACHRONIC VENOUS INSUFFICIENCYCHRONIC VENOUS INSUFFICIENCY

PHYSICAL FINDINGS: shiny, atrophic skin, lack PHYSICAL FINDINGS: shiny, atrophic skin, lack of hair, increased pigmentation; pitting; redness of hair, increased pigmentation; pitting; redness & warmth when inflamed; stasis ulcer most & warmth when inflamed; stasis ulcer most commonly over the medial malleolus; commonly over the medial malleolus;

Can be unilateral or bilateralCan be unilateral or bilateral..

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EDEMAEDEMAD.V.TD.V.T

The most life-threatening cause of edema.The most life-threatening cause of edema. Unilateral.Unilateral. Risk factors: recent immobilization from surgery; Risk factors: recent immobilization from surgery;

bed-rest, air travel; OCP / estrogen use; bed-rest, air travel; OCP / estrogen use; pregnancy and the puerperium; obesity; pregnancy and the puerperium; obesity; malignancy; less commonly malignancy; less commonly genetic deficienciesgenetic deficiencies of Protein S, Protein C, or Anti-thrombin III; of Protein S, Protein C, or Anti-thrombin III; Mutant Factor V (the “Leiden” mutation).Mutant Factor V (the “Leiden” mutation).

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EDEMAEDEMAD.V.TD.V.T

MANIFESTATIONS:MANIFESTATIONS: Pain, swelling, muscle tenderness (calf/gastrocs)Pain, swelling, muscle tenderness (calf/gastrocs) Many cases of DVT are asymptomatic.Many cases of DVT are asymptomatic. Most common sites: venous sinuses in the soleus Most common sites: venous sinuses in the soleus

muscle, and in the posterior tibial and peroneal muscle, and in the posterior tibial and peroneal veins.veins.

HOMAN’S SIGN: pain in the calf on dorsiflexion HOMAN’S SIGN: pain in the calf on dorsiflexion of the foot.of the foot.

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EDEMAEDEMAWHEN EDEMA IS BILATERALWHEN EDEMA IS BILATERAL

THINK SYSTEMIC DISEASE.THINK SYSTEMIC DISEASE. CHF.CHF. NEHROTIC SYNDROME & CIRRHOSIS, DUE TO NEHROTIC SYNDROME & CIRRHOSIS, DUE TO

DECREASED INTRAVASCULAR OSMOTIC DECREASED INTRAVASCULAR OSMOTIC PRESSURE FROM PRESSURE FROM HYPOALBUMINEMIA.HYPOALBUMINEMIA.

THESE PATIENTS WILL ALSO HAVE THE THESE PATIENTS WILL ALSO HAVE THE OTHER FEATURES OF THOSE OTHER FEATURES OF THOSE CONDITIONS.CONDITIONS.

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EDEMAEDEMADIAGNOSIS / DIAGNOSTIC STUDIESDIAGNOSIS / DIAGNOSTIC STUDIES

History, physical exam.History, physical exam. Assess for risk factors for DVT.Assess for risk factors for DVT. Unilateral or bilateral.Unilateral or bilateral. Other physical findings to suggest systemic Other physical findings to suggest systemic

disease?disease? Color duplex ultrasonography. The “Doppler” Color duplex ultrasonography. The “Doppler”

study. Use liberally to R/O DVT as DVT is hard to study. Use liberally to R/O DVT as DVT is hard to exclude on clinical grounds.exclude on clinical grounds.

Measure D-dimers of fibrin degradation products Measure D-dimers of fibrin degradation products in the serumin the serum

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EDEMAEDEMATREATMENT OF VENOUS INSUFFICIENCYTREATMENT OF VENOUS INSUFFICIENCY

1) ELEVATION.1) ELEVATION. 2) COMPRESSION.2) COMPRESSION.

Consider referral to a vascular surgeon, as Consider referral to a vascular surgeon, as some patients w/ chronic venous some patients w/ chronic venous insufficiency will also have peripheral artery insufficiency will also have peripheral artery disease, which can be worsened with disease, which can be worsened with compression.compression.

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FEVERFEVER

Most commonly due to infections.Most commonly due to infections. In adults: 25-40% infections, 25-40% In adults: 25-40% infections, 25-40%

malignancy.malignancy. In children: infection 30-50% of the time.In children: infection 30-50% of the time.

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FEVERFEVERFUO - fever of unknown originFUO - fever of unknown origin – –

““unexplained cases of fever exceeding 38.3° C. on several unexplained cases of fever exceeding 38.3° C. on several occasions occasions for at least 3 weeks in patients without neutropenia or for at least 3 weeks in patients without neutropenia or immunosuppression.”immunosuppression.”CAUSES OF FUO:CAUSES OF FUO:

1) INFECTION1) INFECTION

2) NEOPLASMS2) NEOPLASMS

3) AUTOIMMUNE DISORDERS3) AUTOIMMUNE DISORDERS

4) MISCELLANEOUS4) MISCELLANEOUS

5) 10-15% UNDIAGNOSED CAUSES5) 10-15% UNDIAGNOSED CAUSES

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FEVERFEVERCAUSES OF FUOCAUSES OF FUO

1) INFECTION- TB, endocarditis, fungi, occult abscesses, 1) INFECTION- TB, endocarditis, fungi, occult abscesses, osteomyelitis, UTI, and other “exotic” infections osteomyelitis, UTI, and other “exotic” infections

such as such as malaria, toxoplasmosis, CMV, etc.malaria, toxoplasmosis, CMV, etc. 2) NEOPLASMS- most commonly lymphomas and 2) NEOPLASMS- most commonly lymphomas and

leukemias.leukemias. 3) AUTOIMMUNE DISORDERS- most common are Juvenile 3) AUTOIMMUNE DISORDERS- most common are Juvenile

RA (Still’s Disease), Lupus, Polyarteritis Nodosa.RA (Still’s Disease), Lupus, Polyarteritis Nodosa.

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FEVERFEVERCAUSES OF FUOCAUSES OF FUO

4) MISCELLANEOUS-4) MISCELLANEOUS- thyroiditis, thyroiditis, sarcoidosis, recurrent PE, alcoholic sarcoidosis, recurrent PE, alcoholic hepatitis, Crohn’s, drug fever, etc.hepatitis, Crohn’s, drug fever, etc.

5) 10-15% UNDIAGNOSED CAUSES-5) 10-15% UNDIAGNOSED CAUSES- of of these, 75% will abate without treatment, the these, 75% will abate without treatment, the rest will eventually manifest their rest will eventually manifest their underlying disease.underlying disease.

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FEVERFEVEREVALUATIONEVALUATION

““Uncommon presentations of common Uncommon presentations of common diseases are more common than common diseases are more common than common presentations of uncommon diseases.”presentations of uncommon diseases.”

So look for the common stuff, most commonly So look for the common stuff, most commonly infection.infection.

History & physical. Lab as appropriate.History & physical. Lab as appropriate. Ask about travel, diet, drugs.Ask about travel, diet, drugs. For FUO, I would refer the patient to an For FUO, I would refer the patient to an internal internal

medicine medicine specialist, who may refer the patient to an specialist, who may refer the patient to an infectious disease infectious disease specialist, who may refer the patient specialist, who may refer the patient to a rheumatologist, who to a rheumatologist, who may……may……

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INVOLUNTARY INVOLUNTARY WEIGHT LOSSWEIGHT LOSS

Loss of 5% or more of usual body weight over 6-12 Loss of 5% or more of usual body weight over 6-12 months.months. Often indicates serious physical or Often indicates serious physical or psychological psychological illness.illness. MOST COMMON CAUSES:MOST COMMON CAUSES:

1) CANCER- 30%1) CANCER- 30%

2) GI DISORDERS- 15%2) GI DISORDERS- 15%

3) DEMENTIA, DEPRESSION, ANOREXIA- 3) DEMENTIA, DEPRESSION, ANOREXIA- 15%.15%.

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INVOLUNTARY INVOLUNTARY WEIGHT LOSSWEIGHT LOSS

THE WORK-UPTHE WORK-UP History and physical. Psychological eval.History and physical. Psychological eval. LAB- CBC, Chem profile, TSH, UA, Hemoccult.LAB- CBC, Chem profile, TSH, UA, Hemoccult. RADIOGRAPHS- CXR, UGI.RADIOGRAPHS- CXR, UGI. These usually reveal the cause.These usually reveal the cause. If not, Phase II- GI endoscopy, tests for If not, Phase II- GI endoscopy, tests for

malabsorption, Mammogram, PSA.malabsorption, Mammogram, PSA. In 15-25%, no cause is found. F/U req. In 15-25%, no cause is found. F/U req.

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FATIGUEFATIGUE1-3% of visits to generalists.1-3% of visits to generalists. “ “Fatigue of unknown cause or related to Fatigue of unknown cause or related to

psychiatric illness exceeds that due to psychiatric illness exceeds that due to physical physical illness, injury, medications, drugs, illness, injury, medications, drugs, or alcoholor alcohol.”.”My take on “unknown cause” is it’s due My take on “unknown cause” is it’s due to an to an interplay of interplay of life-style and emotional factors.life-style and emotional factors.IMPORTANT CAUSES:IMPORTANT CAUSES: thyroid disease, CHF, thyroid disease, CHF, infection (endocarditis, hepatitis), infection (endocarditis, hepatitis), COPD, sleep COPD, sleep apnea, anemia, apnea, anemia, autoimmune disease, cancer.autoimmune disease, cancer.

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FATIGUEFATIGUE OTHER CAUSES:OTHER CAUSES: Alcoholism, recreational drugs, side effects from Alcoholism, recreational drugs, side effects from

medication (sedatives, beta blockers).medication (sedatives, beta blockers). PSYCHOLOGICAL- depression, insomnia, PSYCHOLOGICAL- depression, insomnia,

somatization disorders.somatization disorders. PSYCHIATRIC- depression, dysthymia, PSYCHIATRIC- depression, dysthymia,

somatoform disorders, anxiety disorders, panic somatoform disorders, anxiety disorders, panic attack.attack.

Irritable bowel syndrome.Irritable bowel syndrome.

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CHRONIC FATIGUE SYNDROMECHRONIC FATIGUE SYNDROME

Diagnosis of exclusion.Diagnosis of exclusion.No confirmatory physical finding or lab tests.No confirmatory physical finding or lab tests.Etiology unknown, no single pathogenic mechanism, Etiology unknown, no single pathogenic mechanism, likely a heterogeneous abnormality.likely a heterogeneous abnormality.There is a greater prevalence of past and current There is a greater prevalence of past and current psychiatric diagnoses in patients w/ this syndrome, psychiatric diagnoses in patients w/ this syndrome, esp. affective esp. affective disorders.disorders.

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CHRONIC FATIGUE SYNDROMECHRONIC FATIGUE SYNDROMEDIAGNOSTIC CRITERIADIAGNOSTIC CRITERIA

Work-up/lab is/are normal/negative.Work-up/lab is/are normal/negative. Criteria for severity of fatigue are met.Criteria for severity of fatigue are met. 4 or more of the following are present for > 6 4 or more of the following are present for > 6

months:months:1.1. Impaired memory or concentration.Impaired memory or concentration.2.2. Sore throat.Sore throat.3.3. Tender cervical or axillary lymph nodes.Tender cervical or axillary lymph nodes.4.4. Muscle pain.Muscle pain.5.5. Multijoint pain.- Unrefreshing sleep.Multijoint pain.- Unrefreshing sleep.6.6. New headaches.- PostexertionalNew headaches.- Postexertional

malaise. malaise.

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THE WORK-UPTHE WORK-UP

1) History and physical.1) History and physical.

2) Mental status exam.2) Mental status exam.

3) Lab- CBC, Chem profile, ESR, TSH, UA.3) Lab- CBC, Chem profile, ESR, TSH, UA.

4) Other tests as indicated by the Hx and PE.4) Other tests as indicated by the Hx and PE.

5) Possibly- HIV; ANA, Rheumatoid factor, if joint 5) Possibly- HIV; ANA, Rheumatoid factor, if joint symptoms present.symptoms present.

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TREATMENTTREATMENTNo single drug helpful. No cure, but recovery is No single drug helpful. No cure, but recovery is possible.possible.Comprehensive, multidimensional Comprehensive, multidimensional approach.approach.Current treatment of choice: Cognitive-Current treatment of choice: Cognitive-behavioral therapy combined with behavioral therapy combined with graded graded exercise.exercise.Sympathetic ear.Sympathetic ear.

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DYSURIADYSURIA Painful urination. Painful urination. Common. Common. Common.Common. Common. Common.

DIFFERENTIAL DxDIFFERENTIAL Dx Acute cystitis – Dx’d 50-60% of the time.Acute cystitis – Dx’d 50-60% of the time. Acute pyelonephritis.Acute pyelonephritis. Vaginitis (Candida, trichomonas). Vaginitis (Candida, trichomonas).

See next slide.See next slide. Urethritis. Cervicitis.Urethritis. Cervicitis.

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DYSURIADYSURIASYMPTOMS AND THE DxSYMPTOMS AND THE Dx

Dysuria, frequency, urgency WITHOUT Dysuria, frequency, urgency WITHOUT vaginal discharge or itching → increased vaginal discharge or itching → increased likelihood of cystitis.likelihood of cystitis.

Dysuria, frequency, urgency WITH vaginal Dysuria, frequency, urgency WITH vaginal discharge or itching → decreased likelihood discharge or itching → decreased likelihood of cystitis.of cystitis.

W/ fever, back/flank pain, N/V → think W/ fever, back/flank pain, N/V → think pyelopyelo..

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If the patient has dysuria, frequency, and urgency, If the patient has dysuria, frequency, and urgency, w/out vaginal discharge, itching, fever, or flank pain, w/out vaginal discharge, itching, fever, or flank pain, you can treat for cystitis w/ out a fancy-schmancy you can treat for cystitis w/ out a fancy-schmancy evaluation or even a UA.evaluation or even a UA.

If any of the other Sxs are present, need to evaluate If any of the other Sxs are present, need to evaluate w/ PE including vaginal exam, wet prep, KOH, UA.w/ PE including vaginal exam, wet prep, KOH, UA.

Always need to R/O upper tract infection / Always need to R/O upper tract infection / pyelopyelo as as this can progress to sepsis and septic shock, esp in this can progress to sepsis and septic shock, esp in the older patient.the older patient.

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HEMATURIAHEMATURIA Can be consistent w/ the Dx of cystitis (hemorrhagic Can be consistent w/ the Dx of cystitis (hemorrhagic

cystitis), but need to also consider urolithiasis and cystitis), but need to also consider urolithiasis and malignancymalignancy

If upper tract disease is suspected, especially stones, If upper tract disease is suspected, especially stones, consider imaging studies- IVP, ultrasound, helical CT.consider imaging studies- IVP, ultrasound, helical CT.

Remember: children and the elderly do not always Remember: children and the elderly do not always have “typical” presentations, esp fever in the elderly.have “typical” presentations, esp fever in the elderly.

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DYSURIADYSURIATREATMENTTREATMENT

Acute, uncomplicated cystitis in the otherwise Acute, uncomplicated cystitis in the otherwise healthy patient (not immunosuppressed, not healthy patient (not immunosuppressed, not pregnant, etc) can be treated by a 1-3 day course pregnant, etc) can be treated by a 1-3 day course of antibiotics- macrodantin, trim-sulfa.of antibiotics- macrodantin, trim-sulfa.

Phenazopyridine- an OTC drug for symptomatic Phenazopyridine- an OTC drug for symptomatic relief.relief.

If fever, tachycardia, and hypotension are If fever, tachycardia, and hypotension are present, hospitalization should be considered.present, hospitalization should be considered.

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RED FLAGSRED FLAGS

HemoptyisHemoptyis HematemesisHematemesis Central chest pain lasting >20 minsCentral chest pain lasting >20 mins ShockShock ConvulsionsConvulsions Headaches requiring emergent neuro-Headaches requiring emergent neuro-

imaging imaging

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COMMON SYMPTOMS