Cases from a General Internal Medicine Consultation Clinic

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

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Objectives

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

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General Consultation Clinic?

• Preoperative assessment
• Questionable unifying diagnosis
• Multiple complaints but non-diagnostic work-up
• Gateway to tertiary medical center
  subspecialties

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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

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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

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Case 1

• My neck is
• swollen

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Idiopathic Lymphadenopathy

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

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History
PMHx Ø
Meds Allergies Ø Ø
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.
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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

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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
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Prior Studies
ANA (180) 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
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Differential Dx

• Lymphoma
• Liposarcoma
• Other neoplasm
• Abnormal exam
• LN biopsy likely non-diagnostic
• Highly questionable normal CT scan report

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What would you do next?
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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.
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Madelungs 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 200563. Annals Plastic
Surg 200146(1).
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Epidemiology

• Adults
• Men gt Women (151 to 301)
• Mediterranean ethnicity (1/25,000 Italian men)
• Chronic, heavy alcohol consumption
• 60-90 of these patients are alcoholics

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Similar Conditions

• HIV Lipodystrophy
• patients on protease inhibitors
• Dercums Disease (Adiposis dolorosa)
• Diffuse, painful, multiple fatty tumors
• Women gt Men

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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 198463(1). J Clin Endo Met 200186(6).
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Sequelae

• Tracheal / laryngeal / esophageal compression
• Dysphagia, dyspnea, dysphonia
• Respiratory arrest

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Diagnosis

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

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Treatment

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

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Prognosis

• Disfiguring and progressive
• Dietary and lifestyle changes usually
  unsuccessful in shrinking tumors

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Acta Oto-Laryngologica 2005125.
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J Oral Maxillofac Surg 200563.
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Acta Oto-Laryngologica 2005125.
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Follow-Up

• Referred to university general surgeon
• Referral still pending to plastic surgeon
  (underinsured)
• 6 months later, hospitalized for severe pneumonia
  still awaiting excision

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Case 2

• I get short of breath

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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

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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.
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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 lt 30 minutes) Frequent sinus infections chronic post-nasal drip, gagging/nausea in AM 2 pillow orthopnea
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Eagles 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 193725.
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Styloid Process Elongation

• normal length lt 2.5 cm
• 2 - 4 of pop. gt 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

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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 199515.
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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)

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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

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Prior Studies
CXR Normal
Hct Creatinine Glucose 34 0.7 mg/dL 73 mg/dL
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Differential Dx Dyspnea

• Eagles Syndrome
• Deconditioning
• Myocardial Ischemia
• COPD

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What would you do next?
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Dobutamine Stress Echocardiogram

• Resting echocardiogram
• EF 25-30
• Hypokinetic anterolateral and septal walls
• Angiogram
• 50 distal LM
• 100 occluded pLAD
• CABG

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Issues for Preoperative Evaluation

• Risk of perioperative cardiopulmonary
  complications?
• What do evidence-based guidelines suggest?
• Explanation for dyspnea on exertion and abnormal
  ECG?

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Predictors of Increased Perioperative
Cardiovascular Risk
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Risk of Cardiac Death or Nonfatal MI by
Noncardiac Procedure Type
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ACC/AHA Guidelines
MINOR PREDICTORS
Poor Functional Capacity (lt4 METs)
Moderate/Excellent Functional Capacity (gt4METs)
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. 2002.
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Take-Home Points

• How would you have evaluated the patients
  symptoms if he wasnt going to have surgery?
• Individualize guidelines
• Skepticism about patients labelled with
  unfamiliar diagnoses

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Follow-Up

• Dyspnea resolved
• Headaches, jaw and neck pain persist
• Intervention still pending with Facial Pain
  Center

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Case 3

• I keep losing weight

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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

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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).
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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.
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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

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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
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Prior Serologies
Na 133
K 4.6
Cl- 101
CO2 23
BUN 9
Cr 0.9
ALP 341
ALT 611
AST 524
Eosinophils 7
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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
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What would you do next?
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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

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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

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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

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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

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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

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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

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Something still doesnt quite fit

• During 1 year f/u visits, Endocrinologists note
  ACTH level consistently too low for Addisons
  Disease
• Usually gt200 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

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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

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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.

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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