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July 2, 2013 Issue

Clinical Practice Points

Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement

This guideline recommends screening for HIV infection in all adolescents and adults aged 15 to 65 years, younger adolescents and older adults who have risk factors for HIV infection, and all pregnant women.

Use this guideline to:

  • Review which patient groups are at increased risk for HIV infection.
  • Discuss why the USPSTF made this recommendation even in the absence of controlled trials to establish the benefit of such screening.
  • Ask your residents how often they think screening should be performed. The Task Force discusses the lack of clear evidence to answer the question but offers some advice according to an individual patient’s risks.
  • Discuss how these recommendations might affect public health. An accompanying editorial notes that consensus on broad screening policies together with a growing belief in universal treatment and the goal of universal health care access might halt this epidemic.
  • Get some CME for yourself! You’ve reviewed the guideline to help prepare a teaching session—why not log on and complete the quick CME question?

Focus on Pressure Ulcers:

Pressure Ulcer Risk Assessment and Prevention. A Systematic Comparative Effectiveness Review

Pressure Ulcer Treatment Strategies. A Systematic Comparative Effectiveness Review

These reviews evaluate evidence regarding the prevention of, screening for, and treatments of pressure ulcers.

Use these studies to:

  • Ask whether your residents pay attention to pressure ulcers. Why or why not? Who gets them? Why might they prove a devastating problem?
  • Review the staging of ulcers. You may use the Powerpoint slide available from the second systematic review addressing treatment (Figure 1).
  • Invite a member of your hospital’s wound care team (often an RN) to be a guest expert at resident report. Ask her/him to discuss the prevention, staging, and treatment of ulcers. When are those special, expensive beds really needed? When is surgical debridement necessary?

In the Clinic: Care of Returning Military Personnel

This concise and eminently practical review asks—and provides answers to—questions about the care of patients who have served in the military. It includes questions—structure an interactive teaching session around them.

Use this review to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below—there are more at the end of this In The Clinic.
  • Ask your residents what are the common medical problems in returning military personnel? What should a health assessment of these patients include?
  • Review the possible symptoms of traumatic brain injury.
  • Get more CME for yourself—you’re answering the questions with your residents, so log on and enter them to claim your CME.

Humanism and Professionalism

Once Upon a July (Saved)

Play an audio recording of this issue’s On Being a Doctor in which Dr. Nickas recalls her first night on call as a newly minted physician (translated—intern!) and how a wise, calm, and helpful nurse got her (and her patient) through it.

Use this opportunity to discuss:

  • The anxiety your interns, and their residents, are facing as they start a new year.
  • How your interns and residents feel about taking advice from their nursing colleagues. Does it hurt their egos? Have we moved beyond an era when doctors felt "insulted" at the notion that s/he could be taught by a nurse?

mksap16

A 28-year-old man is evaluated for a constant, global, bandlike headache of mild intensity and for slight photophobia without phonophobia or nausea. He recently completed 10 years of military service with recent tours of duty in a combat zone. During combat, he experienced loss of consciousness and transient hearing loss a tank he was riding in struck an explosive device. Since that event, he has had intermittent vertigo, tinnitus, minor difficulties with concentration, and increased irritability. He has had no nightmares, and he has no ongoing concerns about the trauma or any “reliving” of the event.

Physical and neurologic examination findings are normal, as are results of laboratory studies.

Which of the following is the most likely diagnosis?

A. Meniere disease
B. Migraine headache
C. Traumatic brain injury (TBI)
D. Posttraumatic stress disorder
E. Tension-type headache

Answer: C. Traumatic brain injury (TBI)

Key Point: Common symptoms of traumatic brain injury include headache, fatigue, sleep disturbances, difficulties with concentration and memory, and emotional lability with an increased tendency for depression, anxiety, and irritability.

Educational Objective: Diagnose traumatic brain injury in a patient returning from military service.

This patient most likely has traumatic brain injury, which is characterized by a complex of somatic, neurologic, and psychiatric symptoms after a concussive head injury. Common symptoms include headache, fatigue, sleep disturbances, difficulties with concentration and memory, and emotional lability with an increased tendency for depression, anxiety, and irritability. Dizziness and tinnitus also are frequently reported. Approximately 10% to 20% of military personnel returning from combat deployment have had a reported concussion, and 5% of them have some evidence of traumatic brain injury. Studies have shown that patients with this disorder score lower than control patients on neuropsychological tests that measure attention, verbal learning, reasoning, and information processing. Additionally, abnormalities on functional neuroimaging, such as PET or single-photon emission CT, have been reported. The precise pathophysiologic basis for the constellation of complaints remains unknown.

Meniere disease does cause vertigo, tinnitus, and sensorineural hearing loss in affected patients but does not explain the neuropsychiatric symptoms reported by this patient.

Despite the presence of photophobia, this patient's headache does not meet criteria for migraine in that it is bilateral, bandlike, and mild in intensity.

Posttraumatic stress disorder can cause cognitive and emotional symptoms, such as memory loss and irritability, and may provoke headaches, but the absence of persistent memories, dreams, or flashbacks of the traumatic event favors an alternative explanation for this patient's presentation.

Although the pain described is typical of chronic tension-type headache, the other neuropsychiatric symptoms reported are not and suggest that another diagnosis is more likely.

Bibliography
Evans RW. Persistent post-traumatic headache, postconcussion syndrome, and whiplash injuries: the evidence for a non-traumatic basis with an historical review. Headache. 2010;50(4):716-724. PMID: 20456159

This question was derived from MKSAP® 16, the latest edition of the Medical Knowledge Self-Assessment Program.


From the Editors of Annals of Internal Medicine and Education Guest Editor, Erin Ney, MD, FACP Assistant Residency Program Director, Department of Internal Medicine, Thomas Jefferson University.

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