Presentation on theme: "Cases from a General Internal Medicine Consultation Clinic"— Presentation transcript:
1 Cases from a General Internal Medicine Consultation Clinic Eric I. Rosenberg, MD, MSPH, FACPAssistant ProfessorUniversity of Florida College of MedicineMarch 23, 2006
2 ObjectivesPresent three cases from a General Internal Medicine Consultation ClinicReview guidelines for meaningful medical consultation
3 General “Consultation Clinic”? Preoperative assessmentQuestionable unifying diagnosisMultiple complaints but non-diagnostic work-up“Gateway” to tertiary medical center subspecialties
4 “Why not just hospitalize?” The days of most elective admissions are overPatients do not objectively meet physicians’ criteria for hospitalization or E.D. referralTertiary hospital beds in short supplyTelling patients to go to tertiary hospital E.D. is inappropriate, may not result in admission, and creates a poor quality work-upUnderinsured are a challengeInpatient teams focus on unstable patientsPressure to rapidly dischargeMultiple “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 diagnosisSometimes appropriate if:Invasive procedure logical next stepRecords review reveals no point in repeating work-upDiagnosis requires subspecialty expertise to confirm/refute
7 “Idiopathic Lymphadenopathy” 45 y/o manOccipital lumps noted 6 mos. agoNon-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 massesPreauricular, 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:70-85,000Hct:43%MCV:96ESR:9LDH:366HIV:Ø
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.”
29 Pre-Operative Evaluation 55 y/o man with chronic neck and ear pain, worse with head motionDiagnosed with “Eagles Syndrome” by Facial Pain ClinicSurgical intervention recommendedDyspnea on exertion and abnormal ECG noted by Anesthesiologist
30 History PMHx: No cardiopulmonary disease Multiple back surgeries Hemicolectomy for “stricture”Meds:Topiramate, OxycodoneAllergies:NoneFH:Non-contributorySH: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
33 Styloid Process Elongation “normal” length < 2.5 cm2% - 4% of pop. > 3 cm (palpable)Ossification key featureTrauma (tonsillectomy)AgingControversiesOnly ~ 5% symptomaticVariable length (up to 4cm) in asymptomatic patientsSometimes diagnosed despite normal length
34 Carotid Artery Syndrome Compression of internal/external carotid artery parietal or eye painNeck pain worsened by head rotationDizzinessTransient loss of visionSyncopeCephalalgia 1995;15.
35 Treatment Transpharyngeal steroid/anesthetic injection Transpharyngeal manipulation and fracturing of styoid processStyloid process removalExtraoral (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 palpationNo JVD, No S3Clear LungsNo peripheral edema
49 “Idiopathic hypercalcemia” 48 y/o AA man with 40 lb wt. loss x 6 monthsLethargy, weakness, fatigue, anorexiaPrimary care diagnosed flu-like syndrome2nd 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-contributorySH: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, pleasantNo adenopathyClear lungs, Normal heartNo organomegalyClubbingDifficulty raising arms above headHemoccult positive brown stoolNormal prostateNormal skin lesions
57 Serologies WBC 5,200 ( 0.2% eosinophils) Hct 31%, Plts 217,000 Ca 10.6, Albumin 4ESR 73ANA negativeC-ANCA negative, P-ANCA negative
58 Imaging CT Chest/Abdomen/Pelvis MRI Abdomen 5.7mm spiculated mass RUL 1.6 cm mass L kidneyMRI Abdomen1.7 cm solid enhancing lesion L kidney
59 ImpressionRenal Cell Carcinoma with possible early pulmonary metastasesReferred to UrologistChronic active Hepatitis B infectionFailed lamivudine, likely not a good candidate for further treatment at present
60 “Something still doesn’t quite fit…” UrologistLikely has early renal cell CA, but lesion too small to explain symptomsSuspect other, underlying metastatic processNeeds repeat colonoscopy prior to nephrectomy; referred to hepatology for pre-op liver evalHepatologistHepatitis 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/dLRx: Hydrocortisone and FludrocortisoneResolution of hypotensionDramatic improvement in functional statusDischarged home
62 Addison’s Disease (Adrenocortical Insufficiency) Autoimmune mediatedAtrophic, non-functional adrenal glands(rarely) Neoplastic, infectious causesLymphoma, Metastatic carcinomaHistoplasmosis, TuberculosisTreat with lifelong glucocorticoid and mineralocorticoid replacementEvaluate 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 DiseaseUsually >200 pg/ml if Addison’sOnly 4 – 12 pg/ml on repeated testing of patientNegative anti-adrenal antibodiesMRI Brain negative for pituitary tumorTestosterone, estradiol levels normalFatigue recurs if hydrocortisone stopped
64 “Idiopathic Isolated ACTH Deficiency” Extremely rare disorderDiagnosed 1 year after hospitalizationInsulin “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 activeNormal life expectancyLeft 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 ComplexityAwareness of syndrome clustersCommunication & Interviewing Skills (Time)Obtaining medical records (HIPAA)Focus the question(s)Avoid unnecessary/perfunctory duplicationAvailability for Co-ManagementOrder/Prescribe vs. RecommendCoordinationExpedite referrals and follow-up