1. 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

2. Objectives
Present three cases from a General Internal Medicine Consultation Clinic
Review guidelines for meaningful medical consultation

3. General “Consultation Clinic”?
Preoperative assessment
Questionable unifying diagnosis
Multiple complaints but non-diagnostic work-up
“Gateway” to tertiary medical center subspecialties

4. “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

5. “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

6. Case #1
“My neck is
swollen”

7. “Idiopathic Lymphadenopathy”
45 y/o man
Occipital lumps noted 6 mos. ago
Non-diagnostic evaluation by Primary Care, Oncologist, Infectious Disease, General Surgeon

8. History PMHx: Ø Meds: Allergies: 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.

9. 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

10. 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: 96
ESR: 9
LDH:
366
HIV: Ø

11. Prior Studies ANA: (1:80) speckled RPR: Non-reactive Beta-HCG: 1 TSH:
1.4
Bone Marrow:
58,000 platelets
Flow cytometry normal
Excisional LN biopsy (axillary)
Ø malignancy, Ø AFB,
Ø bacteria, Ø fungus

12. Differential Dx Lymphoma Liposarcoma Other neoplasm Abnormal exam
LN biopsy likely non-diagnostic
Highly questionable “normal” CT scan report

13. What would you do next?

15. “The patient does not have lymphadenopathy
“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.”

16. 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).

17. 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

18. Similar Conditions HIV Lipodystrophy
patients on protease inhibitors
Dercum’s Disease (Adiposis dolorosa)
Diffuse, painful, multiple fatty tumors
Women > Men

19. Etiology Unknown Alcohol  Lipogenic effects Defective lipolysis
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).

20. Sequelae Tracheal / laryngeal / esophageal compression
Dysphagia, dyspnea, dysphonia
Respiratory arrest

21. Diagnosis Typical visual pattern of distribution
CT/MRI if looking for airway/esophageal compromise
Excision to exclude malignancy

22. Treatment Cease alcohol, tobacco Low calorie diet, weight loss
Cosmesis via excision (technically difficult)
Liposuction
Medical therapies unproven
Salbutamol (stimulate lipolysis)
Thyroid extract

23. Prognosis Disfiguring and progressive
Dietary and lifestyle changes usually unsuccessful in shrinking tumors

24. Acta Oto-Laryngologica 2005;125.

25. J Oral Maxillofac Surg 2005;63.

26. Acta Oto-Laryngologica 2005;125.

27. Follow-Up Referred to university general surgeon
Referral still pending to plastic surgeon (underinsured)
6 months later, hospitalized for severe pneumonia & still awaiting excision

28. Case #2
“I get short of breath”

29. 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

30. History PMHx: No cardiopulmonary disease Multiple back surgeries
Hemicolectomy for “stricture”
Meds:
Topiramate, Oxycodone
Allergies:
None
FH:
Non-contributory
SH:
30-pack-years tobacco. Occasional marijuana, alcohol.

31. 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

32. Eagle’s Syndrome (Elongated Styloid Process Syndrome)
1st described: Marchetti (1652)
1st series: Eagle (1937)
Sub-Types
Dysphagia, Odynophagia, Otalgia
Carotid Artery Syndrome
Eagle W. Arch Otolaryngol 1937;25.

33. 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

34. 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.

35. 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)

36. 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

37. Prior Studies CXR: Normal Hct: Creatinine: Glucose: 34% 0.7 mg/dL

39. Differential Dx: Dyspnea
Eagle’s Syndrome
Deconditioning
Myocardial Ischemia
COPD

40. What would you do next?

41. Dobutamine Stress Echocardiogram
Resting echocardiogram:
EF 25-30%
Hypokinetic anterolateral and septal walls
Angiogram:
50% distal LM
100% occluded pLAD
CABG

42. Issues for Preoperative Evaluation
Risk of perioperative cardiopulmonary complications?
What do evidence-based guidelines suggest?
Explanation for dyspnea on exertion and abnormal ECG?

43. Predictors of Increased Perioperative Cardiovascular Risk

44. Risk of Cardiac Death or Nonfatal MI by Noncardiac Procedure Type

45. ACC/AHA Guidelines
MINOR PREDICTORS
Poor
Functional Capacity
(<4 METs)
Moderate/Excellent
Functional Capacity
(>4METs)
Intermediate Or
Low Risk Procedure
High Risk Procedure
Postop
Risk Stratification
and Risk Factor
Reduction
Noninvasive Testing
O.R.
Eagle KA, et al. ACC/AHA Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery

46. 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

47. Follow-Up Dyspnea: resolved Headaches, jaw and neck pain: persist
Intervention still pending with Facial Pain Center

48. Case #3
“I keep losing weight”

49. “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

50. History PMHx: Ø Meds: Pantoprazole, Acetaminophen Allergies: 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).

51. 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.

52. Examination 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

53. Prior Serologies Ca+ 12.3 PTH 8 Albumin 3 Hct 35% MCV 94 Retic 1.4
Ferritin
181
TSH
3.8
B-12
487
HBsAg
(+)
HBsAb
(-)
HIV
PSA
0.5
SPEP
Normal
ESR 75

54. Prior Serologies Na+ 133 K+ 4.6 Cl- 101 CO2 23 BUN 9 Cr 0.9 ALP 341
ALT
611
AST
524
Eosinophils 7%

55. Prior Studies CXR RUL scar CT Chest Small lesion RUL, apical scarring
Abd U/S
Thickened gallbladder wall
ECG
HR 95, sinus, inverted T-waves inferolateral leads
EGD
Duodenal ulcer (no cancer)
Colonoscopy
Non-diagnostic (poor prep)
Bone Marrow
Normochromic, normocytic anemia, hypocellular

56. What would you do next?

57. Serologies 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

58. Imaging CT Chest/Abdomen/Pelvis MRI Abdomen 5.7mm spiculated mass RUL
1.6 cm mass L kidney
MRI Abdomen
1.7 cm solid enhancing lesion L kidney

59. 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

60. “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

61. 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

62. 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

63. “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
Negative anti-adrenal antibodies
MRI Brain negative for pituitary tumor
Testosterone, estradiol levels normal
Fatigue recurs if hydrocortisone stopped

64. “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

65. 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.”

66. 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