Transcript Cases from a General Internal Medicine Consultation Clinic Eric I. Rosenberg, MD, MSPH, FACP Assistant Professor University of Florida College of Medicine March 23, 2006 Objectives •

Cases from a General Internal
Medicine Consultation Clinic
Eric I. Rosenberg, MD, MSPH, FACP
Assistant Professor
University of Florida College of Medicine
March 23, 2006
Objectives
• Present three cases from a General
Internal Medicine Consultation Clinic
• Review guidelines for meaningful medical
consultation
General “Consultation Clinic”?
• Preoperative assessment
• Questionable unifying diagnosis
• Multiple complaints but non-diagnostic
work-up
• “Gateway” to tertiary medical center
subspecialties
“Why not just hospitalize?”
• The days of most elective admissions are over
– Patients do not objectively meet physicians’ criteria
for hospitalization or E.D. referral
– Tertiary hospital beds in short supply
– Telling patients to go to tertiary hospital E.D. is
inappropriate, may not result in admission, and
creates a poor quality work-up
– Underinsured are a challenge
• Inpatient teams focus on unstable patients
– Pressure to rapidly discharge
– Multiple “hand offs” during hospitalization
– “Hand off” at discharge often flawed
“Why not refer to subspecialists?”
• Poly referrals make it harder to make a
unifying diagnosis
• Sometimes appropriate if:
– Invasive procedure logical next step
– Records review reveals no point in repeating
work-up
– Diagnosis requires subspecialty expertise to
confirm/refute
Case #1
“My neck is
swollen”
“Idiopathic Lymphadenopathy”
• 45 y/o man
• Occipital lumps noted
6 mos. ago
• Non-diagnostic
evaluation by Primary
Care, Oncologist,
Infectious Disease,
General Surgeon
History
PMHx:
Ø
Meds:
Ø
Allergies: Ø
FH:
Father died of “cancer”
SH:
Brickmason, lawn maintenance.
Divorced x 2 yrs. 3 healthy daughters.
Ø STD’s. Lives with his mother. Drinks
beer and smokes marijuana.
ROS:
Night sweats? 10lb loss. Tired.
Headaches.
Examination
• BP 140/85, P 76, T 98.4
• Not ill appearing
• Fluctuant, non-tender,
6 x 6 cm occipital
masses
• Preauricular, cervical,
supraclavicular,
trochanteric, right
inguinal masses
Prior Studies
CT scan
Ø adenopathy, Ø mass
WBC: 4,700; [9% N, 81% L, 9% M, 1% E]
Plts:
70-85,000
Hct:
43%
MCV:
ESR:
LDH:
HIV:
96
9
366
Ø
Prior Studies
ANA:
(1:80) speckled
RPR:
Beta-HCG:
Non-reactive
1
TSH:
Bone Marrow:
1.4
58,000 platelets
Flow cytometry normal
Excisional LN biopsy
(axillary)
Ø malignancy, Ø AFB,
Ø bacteria, Ø fungus
Differential Dx
• Lymphoma
• Liposarcoma
• Other neoplasm
• Abnormal exam
• LN biopsy likely nondiagnostic
• Highly questionable
“normal” CT scan
report
What would you do next?
“The patient does not have
lymphadenopathy. There is abnormal
accumulation of fat throughout the head and
neck region consistent with the clinical
diagnosis of _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.
“This is an unusual tendency for collection of
fat usually seen in middle-aged males who
are chronic alcoholics.”
Madelung’s Disease
(Multiple Symmetric Lipomatosis)
• 1st report: Brodie (1846)
• 1st series: Madelung, 33 patients (1887)
• Symmetric, Fatty, Benign tumors
– Neck, head, upper trunk (80-100%)
• Soft, painless, enlargement
• Some patients develop peripheral
neuropathy
J Oral Maxillofac Surg 2005;63.
Annals Plastic Surg 2001;46(1).
Epidemiology
•
•
•
•
Adults
Men > Women (15:1 to 30:1)
Mediterranean ethnicity (1/25,000 Italian men)
Chronic, heavy alcohol consumption
– 60-90% of these patients are alcoholics
Similar Conditions
• HIV Lipodystrophy
– patients on protease inhibitors
• Dercum’s Disease (Adiposis dolorosa)
– Diffuse, painful, multiple fatty tumors
– Women > Men
Etiology
• Unknown
•
Lipoprotein lipase activity
– HDL usually elevated
– Our patient: HDL 94, LDL 52, Trigly 81
• Alcohol  Lipogenic effects
• Defective lipolysis
– Mitochondrial defect in brown fat
• Familial (but inheritable?)
Medicine 1984;63(1).
J Clin Endo & Met 2001;86(6).
Sequelae
• Tracheal / laryngeal / esophageal
compression
• Dysphagia, dyspnea, dysphonia
• Respiratory arrest
Diagnosis
• Typical visual pattern of distribution
• CT/MRI if looking for airway/esophageal
compromise
• Excision to exclude malignancy
Treatment
•
•
•
•
•
Cease alcohol, tobacco
Low calorie diet, weight loss
Cosmesis via excision (technically difficult)
Liposuction
Medical therapies unproven
– Salbutamol (stimulate lipolysis)
– Thyroid extract
Prognosis
• Disfiguring and progressive
• Dietary and lifestyle changes usually
unsuccessful in shrinking tumors
Acta Oto-Laryngologica 2005;125.
J Oral Maxillofac Surg 2005;63.
Acta Oto-Laryngologica 2005;125.
Follow-Up
• Referred to university general surgeon
• Referral still pending to plastic surgeon
(underinsured)
• 6 months later, hospitalized for severe
pneumonia & still awaiting excision
Case #2
“I get short of
breath”
Pre-Operative Evaluation
• 55 y/o man with chronic neck and ear
pain, worse with head motion
• Diagnosed with “Eagles Syndrome” by
Facial Pain Clinic
• Surgical intervention recommended
• Dyspnea on exertion and abnormal ECG
noted by Anesthesiologist
History
PMHx:
Meds:
Allergies:
FH:
SH:
No cardiopulmonary disease
Multiple back surgeries
Hemicolectomy for “stricture”
Topiramate, Oxycodone
None
Non-contributory
30-pack-years tobacco. Occasional
marijuana, alcohol.
History
ROS: Jaw pain, back pain and LE numbness
Lightheaded, dizzy x 2 yrs.
Chronic Fatigue
“Equilibrium off when go uphill”
“Breathing is fine” (walk 2.5 miles q AM in < 30
minutes)
Frequent sinus infections; chronic post-nasal
drip, gagging/nausea in AM; 2 pillow orthopnea
Eagle’s Syndrome
(Elongated Styloid Process Syndrome)
•
•
•
1st described: Marchetti (1652)
1st series: Eagle (1937)
Sub-Types
1. Dysphagia, Odynophagia,
Otalgia
2. Carotid Artery Syndrome
Eagle W. Arch Otolaryngol 1937;25.
Styloid Process Elongation
• “normal” length < 2.5 cm
• 2% - 4% of pop. > 3 cm
(palpable)
• Ossification key feature
– Trauma (tonsillectomy)
– Aging
• Controversies
– Only ~ 5% symptomatic
– Variable length (up to 4cm)
in asymptomatic patients
– Sometimes diagnosed
despite normal length
Carotid Artery Syndrome
• Compression of internal/external carotid
artery  parietal or eye pain
• Neck pain worsened by head rotation
• Dizziness
• Transient loss of vision
• Syncope
Cephalalgia 1995;15.
Treatment
• Transpharyngeal steroid/anesthetic injection
• Transpharyngeal manipulation and fracturing of
styoid process
• Styloid process removal
– Extraoral (better visualization but lengthy, complicated
by internal carotid thrombisis, cervical emphysema)
– Intraoral (risk of glossopharyngeal nerve damage,
difficult to control bleeding if vessels damaged)
Examination
• BP 112/74, P 78, T 98
• Appears well
• Neck tightness, restricted movement, painful
to palpation
• No JVD, No S3
• Clear Lungs
• No peripheral edema
Prior Studies
CXR:
Hct:
Creatinine:
Glucose:
Normal
34%
0.7 mg/dL
73 mg/dL
Differential Dx: Dyspnea
•
•
•
•
Eagle’s Syndrome
Deconditioning
Myocardial Ischemia
COPD
What would you do next?
Dobutamine Stress
Echocardiogram
• Resting echocardiogram:
– EF 25-30%
– Hypokinetic anterolateral and septal walls
• Angiogram:
– 50% distal LM
– 100% occluded pLAD
• CABG
Issues for Preoperative Evaluation
• Risk of perioperative cardiopulmonary
complications?
• What do evidence-based guidelines
suggest?
• Explanation for dyspnea on exertion and
abnormal ECG?
Predictors of Increased Perioperative
Cardiovascular Risk
Major
Unstable Coronary Syndrome
Recent MI (7-30 days)
“Stable” angina if “unusually sedentary”
Decompensated CHF
High-grade AVB
Symptomatic ventricular dysrhythmias
Severe valvular disease
Intermed “Mild” angina
Old MI, CHF, DM, CKD
Minor
Age >70
Baseline LVH/LBB/ST abnormality
Atrial fibrillation
Old CVA
Uncontrolled HTN
Poor functional capacity
Risk of Cardiac Death or Nonfatal MI by
Noncardiac Procedure Type
High (>5%)
Emergent major operations, Vascular;
prolonged cases with large fluid
shifts/blood loss
Intermed (<5%)
Carotid endarterectomy; head & neck;
intraperitoneal/intrathoracic;
orthopaedic; prostate
Low (<1%)
Endoscopic/superficial procedures;
cataracts; breast surgery
ACC/AHA Guidelines
MINOR PREDICTORS
Poor
Functional Capacity
(<4 METs)
Intermediate
Or
Low Risk Procedure
Moderate/Excellent
Functional Capacity
(>4METs)
High Risk Procedure
Noninvasive Testing
O.R.
Postop
Risk Stratification
and Risk Factor
Reduction
Eagle KA, et al. ACC/AHA Guideline Update on Perioperative
Cardiovascular Evaluation for Noncardiac Surgery. 2002.
Take-Home Points
• How would you have evaluated the
patient’s symptoms if he wasn’t going to
have surgery?
• Individualize guidelines
• Skepticism about patients labelled with
unfamiliar diagnoses
Follow-Up
• Dyspnea: resolved
• Headaches, jaw and neck pain: persist
• Intervention still pending with Facial Pain
Center
Case #3
“I keep losing
weight”
“Idiopathic hypercalcemia”
•
•
•
•
48 y/o AA man with 40 lb wt. loss x 6 months
Lethargy, weakness, fatigue, anorexia
Primary care diagnosed flu-like syndrome
2nd Primary Care Physician found HBsAg(+)
– Hepatologist attempted treatment with lamivudine (not
tolerated)
• Oncologist diagnosed idiopathic hypercalcemia
History
PMHx:
Meds:
Ø
Pantoprazole, Acetaminophen
Allergies: Ø
FH:
Non-contributory
SH:
Home remodeler and sheet rock
worker. Very physically active. 1 ppd
tobacco and 1-2 beers/day plus liquor
daily x 28 years (has quit).
History
ROS:
Tinnitus
Fevers, night sweats, myalgias, arthralgias
“Food doesn’t have any taste”
No tattoos, blood transfusions, travel outside
U.S.
No known occupational exposures to asbestos,
lead, mold.
No dyspnea, hemoptysis, orthopnea, PND.
No memory loss, depression, neurological
problems.
No skin lesions.
Examination
•
•
•
•
•
•
•
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T 97.4 P93, BP 90/63, 103 lbs [142 lbs]
Cachectic, alert, pleasant
No adenopathy
Clear lungs, Normal heart
No organomegaly
Clubbing
Difficulty raising arms above head
Hemoccult positive brown stool
Normal prostate
Normal skin lesions
Prior Serologies
Ca+
Albumin
Hct
MCV
Ferritin
TSH
B-12
HBsAg
HIV
SPEP
ESR
12.3
3
35%
94
181
3.8
487
(+)
(-)
Normal
75
PTH
8
Retic
1.4
HBsAb (-)
PSA
0.5
Prior Serologies
Na+
K+
ClCO2
BUN
Cr
ALP
ALT
AST
Eosinophils
133
4.6
101
23
9
0.9
341
611
524
7%
Prior Studies
CXR
CT Chest
Abd U/S
ECG
RUL scar
Small lesion RUL, apical scarring
Thickened gallbladder wall
HR 95, sinus, inverted T-waves
inferolateral leads
EGD
Colonoscopy
Bone Marrow
Duodenal ulcer (no cancer)
Non-diagnostic (poor prep)
Normochromic, normocytic
anemia, hypocellular
What would you do next?
Serologies
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WBC 5,200 ( 0.2% eosinophils)
Hct 31%, Plts 217,000
Ca 10.6, Albumin 4
ESR 73
ANA negative
C-ANCA negative, P-ANCA negative
Imaging
• CT Chest/Abdomen/Pelvis
– 5.7mm spiculated mass RUL
– 1.6 cm mass L kidney
• MRI Abdomen
– 1.7 cm solid enhancing lesion L kidney
Impression
• Renal Cell Carcinoma with possible early
pulmonary metastases
– Referred to Urologist
• Chronic active Hepatitis B infection
– Failed lamivudine, likely not a good candidate
for further treatment at present
“Something still doesn’t quite fit…”
• Urologist
– Likely has early renal cell CA, but lesion too small to
explain symptoms
– Suspect other, underlying metastatic process
– Needs repeat colonoscopy prior to nephrectomy;
referred to hepatology for pre-op liver eval
• Hepatologist
– Hepatitis B viremia (can treat perioperatively to lower
risk of infection to surgical team)
– Orthostatic in clinic  admitted to hospital
ACTH Stimulation Test
• AM Cortisol: 3.1 mcg/dL
• 30 minutes After Cosyntropin: 5 mcg/dL
• Rx: Hydrocortisone and Fludrocortisone
– Resolution of hypotension
– Dramatic improvement in functional status
• Discharged home
Addison’s Disease
(Adrenocortical Insufficiency)
• Autoimmune mediated
• Atrophic, non-functional adrenal glands
• (rarely) Neoplastic, infectious causes
– Lymphoma, Metastatic carcinoma
– Histoplasmosis, Tuberculosis
• Treat with lifelong glucocorticoid and
mineralocorticoid replacement
• Evaluate for possible secondary causes
“Something still doesn’t quite fit…”
• During 1 year f/u visits, Endocrinologists note
ACTH level consistently too low for Addison’s
Disease
– Usually >200 pg/ml if Addison’s
– Only 4 – 12 pg/ml on repeated testing of patient
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•
•
•
Negative anti-adrenal antibodies
MRI Brain negative for pituitary tumor
Testosterone, estradiol levels normal
Fatigue recurs if hydrocortisone stopped
“Idiopathic Isolated ACTH
Deficiency”
• Extremely rare disorder
• Diagnosed 1 year after hospitalization
• Insulin “Stress Test”
– If isolated pituitary ACTH deficiency, then
stress of hypoglycemia will fail to induce rise
in ACTH levels
Follow-Up
•
•
•
•
•
Healthy on 20mg Hydrocortisone daily
Weight 154 pounds
Very physically active
Normal life expectancy
Left nephrectomy revealed no evidence renal
cell cancer
– “extraordinarily unusual lesion.. Fibrosis with plasma
cells, lymphoid tissue, granulomas… no insights into
possible histiogenesis of this nodule.”
Challenges to Effective
Consultation by Generalists
• Comfort with Complexity
– Awareness of syndrome clusters
• Communication & Interviewing Skills (Time)
– Obtaining medical records (HIPAA)
– Focus the question(s)
– Avoid unnecessary/perfunctory duplication
• Availability for Co-Management
– Order/Prescribe vs. Recommend
• Coordination
– Expedite referrals and follow-up