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General lnternal Medicine Depression and Anxiety It is difficult to distinguish grief from depression. Helplessness, hopelessness, worthlessness, guilt, and anhedonia are signs of depression rather than normal grief. Depression will respond to typical pharmacologic and nonpharmacologic therapy. Ilprognosis is Iess than 6 weeks, use a psy- chostimulant with a faster onset, such as methylphenidate. Benzodiazepines can help reduce anxiety in a palliative care setting. Anorexia Artificial nutrition in cachexia of advanced disease does not improve morbidity or mortali0i, nor does it reduce aspiration pneu monia risk. Medications used to stimulate appetite (progesterones, dronabinol, glucocorticoids) do not improve morbidity or mortality. Musculoskeletal Pain Elbow Olecranon bursitis is inflammation of a bursa that lies in the posterior aspect of the elbow and presents as a fluid filled mass. This condition may result from repetitive trauma, infection, or systemic inflammatory conditions. Olecranon bursitis does not cause restricted movement with range of motion of the elbow, whereas joint pathology causes pain and restricted movement. Aspirate a bursa if tender or warm to analyze fluid for crystals and infection. NSAIDs, elbow protection pads, and rest (if non- infectious) are first line treatments. In all cases, avoid glucocorticoid injections (no benefit but risk of harm). Epicondylitis involves pain and tenderness at either the insertion of the extensor radii tendons (lateral epicondylitis) or the flexor carpi radialis tendons (medial epicondylitis). First-line treatment is stretching and strengthening exercises and avoidance of activities that cause pain. Braces may be useful when exacerbating activities cannot be avoided. Oral and topical NSAIDS provide short term relief. Do not inject glucocorticoids. DON'T BE TRICKED o Do not obtain imaging studies in patients with flndings compatible with epicondylitis Back Patients with low back pain can be grouped into one ofthree broad categories: . nonspeciflc pain (-90'1,) . radiculopathy or spinal stenosis (-5'7,) . speciflc spine disorder, such as cancer, fracture, infection, or ankylosing spondylitis (-5'7,) Look for the "red flags," which suggest the need for early imaging:

Back Patients with low back pain can be grouped into one ofthree broad categories: . nonspeciflc pain (-90'1,) . radiculopathy or spinal stenosis (-5'7,) . speciflc spine disorder, such as cancer, fracture, infection, or ankylosing spondylitis (-5'7,) Look for the "red flags," which suggest the need for early imaging: . malignancy (history of cancer, weight loss) . spinal infection (localized pain, fever, injection drug use, UTI) o fracture (trauma) . cauda equina syndrome (bilateral leg weakness, urinary retention, saddle anesthesia) 125

General lnternal Medicine Also perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present and the patient is a candidate for surgery. Look for a herniated disk when acute back pain radiates down the leg and is associated with: r positive straight leg raise test o weakness ofthe ankle and great toe dorsiflexion (L5) . loss ofankle reflexes (S1) o less commonly, Ioss of knee reflex (L4) Spinal stenosis usually occurs in older adults and is characterized by neurogenic claudication radiating back pain and lower extremity numbness-that is exacerbated by walking and spinal extension but improved by sitting and leaning forward. A wide-based gait and/or abnormal Romberg test is >90% specific for spinal stenosis. MRI establishes the diagnosis. Recovery is generally 1-2 months for acute, nonspecific low back pain regardless ofthe intervention used. The first step is self-care (remain active, apply superficial heat). Other common interventions include: . massage . spinal manipulation . NSAIDs (first-line pharmacologic treatment as adjunct to nonpharmacologic management) Muscle relaxants may be modestly beneficial for acute pain relief, but long-term use should be avoided. Systemic glucocorticoids or epidural injections have not been shown to be ellective in the treatment of low back pain. Nonurgent surgery may be considered in patients with neurologic deficits, progressively worsening spinal stenosis, or chronic pain with corresponding abnormalities on imaging Collapsed Vertebrat Body: Unenhanced that has been refractory to conservative measures and has the potential to respond to T2-weighted MRI o{ the thoracic spine shows col- surgery. lapse of the vertebral body and compression of the spinal cord irom posteriorly displaced bony frag- Neoplastic epidural spinal cord compression, including cauda equina syndrome, is a ments in a patient with metastatic breast cancer. surgical emergency. Begin management by administering dexamethasone and obtaining immediate MRI of the entire spine.

Nonurgent surgery may be considered in patients with neurologic deficits, progressively worsening spinal stenosis, or chronic pain with corresponding abnormalities on imaging Collapsed Vertebrat Body: Unenhanced that has been refractory to conservative measures and has the potential to respond to T2-weighted MRI o{ the thoracic spine shows col- surgery. lapse of the vertebral body and compression of the spinal cord irom posteriorly displaced bony frag- Neoplastic epidural spinal cord compression, including cauda equina syndrome, is a ments in a patient with metastatic breast cancer. surgical emergency. Begin management by administering dexamethasone and obtaining immediate MRI of the entire spine. DOil'T BE TRICKED . Do not obtain imaging for patients with nonspecific low back pain. . Opioids have not been shown to be more effective than NSAIDs in chronic low back pain, and they are not recommended. Neck Pain Musculoskeletal pain is the most common reason for neck pain, causing: . pain and stiffness with neck movement . decreased cervical range ofmotion . no neurologic abnormalities Cervical radiculopathy is caused by spinal nerve root compression, causing: . neck pain with radiating arm pain o dermatomalparesthesias 127