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Cases from a General Internal Medicine Consultation Clinic Eric I. Rosenberg, MD, MSPH, FACP Assistant Professor University of Florida College of Medicine.

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Presentation on theme: "Cases from a General Internal Medicine Consultation Clinic Eric I. Rosenberg, MD, MSPH, FACP Assistant Professor University of Florida College of Medicine."— Presentation transcript:

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: ØØØØ FH:Father died of cancer SH:Brickmason, lawn maintenance. Divorced x 2 yrs. 3 healthy daughters. Ø STDs. 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 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 CT scanØ adenopathy, Ø mass

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?

14

15 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 Madelungs Disease (Multiple Symmetric Lipomatosis) 1 st report: Brodie (1846) 1 st 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 Dercums Disease (Adiposis dolorosa) –Diffuse, painful, multiple fatty tumors –Women > Men

19 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).

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 Eagles Syndrome (Elongated Styloid Process Syndrome) 1 st described: Marchetti (1652) 1 st series: Eagle (1937) Sub-Types 1.Dysphagia, Odynophagia, Otalgia 2.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 73 mg/dL

38

39 Differential Dx: Dyspnea Eagles 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) High Risk Procedure Intermediate Or Low 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

46 How would you have evaluated the patients symptoms if he wasnt going to have surgery? Individualize guidelines Skepticism about patients labelled with unfamiliar diagnoses Take-Home Points

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 2 nd Primary Care Physician found HBsAg(+) –Hepatologist attempted treatment with lamivudine (not tolerated) Oncologist diagnosed idiopathic hypercalcemia

50 History PMHx:Ø Meds: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).

51 History ROS:Tinnitus Fevers, night sweats, myalgias, arthralgias Food doesnt 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+12.3PTH8 Albumin3 Hct35% MCV94Retic1.4 Ferritin181 TSH3.8 B HBsAg(+)HBsAb(-) HIV(-)PSA0.5 SPEPNormal ESR75

54 Prior Serologies Na K+K+ 4.6 Cl CO223 BUN9 Cr0.9 ALP341 ALT611 AST524 Eosinophils7%

55 Prior Studies EGDDuodenal ulcer (no cancer) ColonoscopyNon-diagnostic (poor prep) Bone MarrowNormochromic, normocytic anemia, hypocellular CXRRUL scar CT ChestSmall lesion RUL, apical scarring Abd U/SThickened gallbladder wall ECGHR 95, sinus, inverted T-waves inferolateral leads

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 –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 doesnt 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 Addisons 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 doesnt quite fit… During 1 year f/u visits, Endocrinologists note ACTH level consistently too low for Addisons Disease –Usually >200 pg/ml if Addisons –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


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