Differential diagnosis 1 weeks 5 6
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Differential Diagnosis 1 Weeks 5-6. Lower Leg Swelling. Two forms of pressure: onconic (i.e. protein) and hydrostatic (i.e. gravity or obstruction) onconic - decrease in albumin due to decreased production (liver) or loss (kidney); differentiate with urinarlysis and/or liver enzymes

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Differential Diagnosis 1 Weeks 5-6

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Differential diagnosis 1 weeks 5 6

Differential Diagnosis 1Weeks 5-6


Lower leg swelling

Lower Leg Swelling

Two forms of pressure: onconic (i.e. protein) and hydrostatic (i.e. gravity or obstruction)

onconic - decrease in albumin due to decreased production (liver) or loss (kidney); differentiate with urinarlysis and/or liver enzymes

determine if acute and unilateral suggestive of deep vein thrombosis or bilateral suggestive of a body-wide process

differentiate pitting from non-pitting edema


Fever

Fever

  • Fever is caused by the release of endogenous pyrogens

  • This occurs with many disorders other than infection including:

    • Collagen vascular disease

    • Hypersensitivity reactions

    • Neoplastic diseases

    • Hemorrhage

    • Crystalline arthritis

    • Thromboembolic events

  • Children often have an over-reactive febrile response

  • Seniors often feel normal, however, have a temperature

  • If the cause is not evident within 1 week consider the above list for FUO


Lymphadenopathy

Lymphadenopathy

Distinguish between recent onset or chronic

Determine whether painful or tender and associated with other systemic findings

Determine whether single, regional, or generalized

Determine whether hard and fixed or mobile


Lymphadenopathy1

Lymphadenopathy

Children have more lymph tissue per body weight and tend to react to infection with more lymph node swelling

Persisten lymphadenopathy greater than 3 weeks should be biopsied (2 biopsies if 1st is negative)

Adenopathy that is either supraclavicular and/or singular, non-tender, rubbery, or non-mobile should be biopsied

Inguinal adenopathy is almost always benign


Obesity

Obesity

  • The prevalence of overweight has increased from the 1988-1994 NHAMES III report to the 1999-2000 report as follows (Ogden ref):

    • 12-19 year olds from 10.5% to 15-5%

    • in 6-11 year olds from 11.3% to 5.3%, and

    • for 2-5 year olds from 7.2% to 10.4%

  • The prevalence of class 3 obesity(BMI > 40) is increasing rapidly in the years 1990-2000 from 0.78% in 1990 to 2.2% in 2000 with the highest increase among black women, individuals who have not completed high school and short persons (Freedman ref).

  • The age-adjusted prevalence of obesity was 30.5% in 1999-2000 compared to 22.9% in 1994 (Flegal ref). The prevalence of overweight increased from 55.9% to 64.5%. Extreme obesity increased from 2.9% to 4.7%.

  • These statistics become important in the context of one study which found that white men aged 20 y/o with BMIs >45 are predicted to have 13 years of life lost (YLL); 8 YLL for women in same range.


Obesity references

Obesity References

Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA 2002;288:1728-1732.

Freedman DS, Kettel-Khan L, Serdula MK, et al. Treads and correlates of class 3 obesity in the United States from 1990-2000. JAMA 2002;288:1758-1770.

Flegal KM, Carroll MD, Ogeden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999-2000. JAMA 2002;288:1723-1727.

Fontaine KR, Redden DT, Wang C, et al. Years of life lost due to obesity. JAMA 2003;289(2):187-193.


Weight loss

Weight Loss

> 5% of total body weight within 6 months or > 10% in 1 year

7%-36% have cancer; 9%-18% are depressed, 14%-17% have a GI disorder 25%-35% have no identifiable cause

Only 1/3 of patients with significant weight loss report it as a chief complaint

50% of patients who do complain are unsupported by past medical records or family members


General questions for weight loss

General Questions for Weight Loss

  • Intentional? (temporary diet vs. anorexia nervosa)

  • Unintentional?

    • Normal or increased intake?

      • signs/symptoms of metabolic disorder?

    • Decreased intake?

      • lack of appetite?

      • pain with eating or swallowing?


Anorexia characteristics

Anorexia Characteristics

Bizarre body-image distortion

Refusal to increase weight to at least 15% below normal

Life centers around avoiding fat; emphasis on protein intake

Hyperactivity manifested as excessive exercise or busyness

Associated in some instances with bulimia


Bulimia

Bulimia

Characterized by purging activities such as vomiting and use of laxatives

Non-purging activities include excessive exercise and fasting

Occurs when individual feels bored, lonely, anxious, or angry

Food is usually high carbo and fat

Patient not necessarily thin


Signs symptoms of bulimia

Signs/Symptoms of Bulimia

Swelling of hands and feet

Abdominal fullness and general bloating

Headaches, fatigue, and weakness

Puffy cheeks due to parotid gland irritation

Dental problems associated with corrosive effect of vomiting

Finger calluses (back of hand) due to vomiting

Chronic hoarseness


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