General Internal Medicine Noon Conference

1. General Internal Medicine Noon Conference Overview of 2006-2007 Stanford Massie M.D. Director, GIM Noon Conference

2. GIM Conference: Background Somewhat different from Monday and Friday conferences Target the practicing internist Emphasis on ambulatory topics Often case based, interactive All talks given by GIM faculty Also one of the core conferences for medicine residents

3. Series Overview (1) Clinical Problem Solving (CPS) Clinical Pathology Conference (CPC) Updates Common Ambulatory Topics (CAT)

4. Series Overview (2) Medicine Consultation Series Evidence Based Medicine Series Ethics case discussions

5. Division of GIM Web Site Address: http://gim.dom.uab.edu Calendar of upcoming conferences Slides for all previous talks AMR schedule Russell Intern Ambulatory Talks Many other useful links

6. What we need from you� Sign in to get credit for attendance Conference evaluations Feedback

7. Now on to the cases�.

8. Clinical Problem Solving GIM Noon Conference Discussant: Carlos Estrada M.D. Presenter: Stanford Massie M.D. July 18, 2006 Dr. Estrada graduated from Cayetano Heredia University Medical School in Lima, Peru, and completed an internal medicine internship, residency, and chief residency at Henry Ford Hospital in Detroit, Michigan, where he also completed a general internal medicine fellowship. During his fellowship, he completed a master in science degree at the University of Michigan in Ann Arbor. He is certified by the American Board of Internal Medicine. He joins UAB faculty from The Brody School of Medicine at East Carolina University in Greenville, North Carolina, where he served as chief of the Division of General Internal Medicine and associate professor of medicine. Dr. Estrada graduated from Cayetano Heredia University Medical School in Lima, Peru, and completed an internal medicine internship, residency, and chief residency at Henry Ford Hospital in Detroit, Michigan, where he also completed a general internal medicine fellowship. During his fellowship, he completed a master in science degree at the University of Michigan in Ann Arbor. He is certified by the American Board of Internal Medicine. He joins UAB faculty from The Brody School of Medicine at East Carolina University in Greenville, North Carolina, where he served as chief of the Division of General Internal Medicine and associate professor of medicine.

9. Carlos Estrada

10. Carlos Estrada

11. Carlos Estrada

12. Case #1: HPI 29 y.o. female c/o cessation of menses Reports last period was 5 months ago, prior to that they were always regular Home pregnancy test negative Has noted some fatigue and intolerance to cold temperatures Notes intentional 30 lb. weight loss X 8 mos. Patient�s gait noted to be unsteady, and has had some urinary incontinence (discovered later)Patient�s gait noted to be unsteady, and has had some urinary incontinence (discovered later)

13. Case #1: HPI Denies visual changes, H/A, galactorrhea or hair loss. Weight loss achieved by cutting calories, denies excessive exercise, laxative or diuretic use Patient�s gait noted to be unsteady, and has had some urinary incontinence (discovered later)Patient�s gait noted to be unsteady, and has had some urinary incontinence (discovered later)

14. Case #1: PFSH PMH: Schizophrenia, Tonsillectomy Meds: Ziprasidone (Geodon), Neurontin, Clozapine, Cogentin Social History: Lives alone, unemployed Denies tobacco, Etoh or drugs Family History: Unremarkable

15. Case #1: Physical Exam Vital Signs: 6�0� 134 lbs. (BMI 18.5) Rest of examination was unremarkable

16. Case #1: Data Labs: HCG negative TSH normal Prolactin 57.1 (2-25) LH/FSH normal Dx: Medication related hyperprolactinemia No further workup done (imaging etc.)

17. Amenorrhea Primary vs. Secondary Transient, intermittent or permanent Results from dysfunction of: Hypothalamus Pituitary Ovaries Uterus Vagina Definition (2�): absence of menses for more than three cycles or six months in women who previously had menses

18. Amenorrhea After excluding pregnancy, the most common causes of secondary amenorrhea: Ovarian disease � 40 percent Hypothalamic dysfunction � 35 percent Pituitary disease � 19 percent Uterine disease � 5 percent Other � 1 percent

19. Hyperprolactinemia Secreted by pituitary (lactotroph cells) Regulated by tonic inhibition by dopamine from hypothalamus Physiologic causes include pregnancy, nipple stimulation and stress Major pathologic causes of hyperprolactinemia: Pituitary adenomas (hypersecretion) Damage to pituitary or stalk Dopamine antagonism Decreased clearance of prolactin Pathologic causes include lactotroph adenomas, other hypothalamic and pituitary disorders, estrogen, drug use, hypothyroidism, chest wall injury, and chronic renal failure. Pathologic causes include lactotroph adenomas, other hypothalamic and pituitary disorders, estrogen, drug use, hypothyroidism, chest wall injury, and chronic renal failure.

22. Newer Generation Anti-Psychotics

23. Case#2: HPI 48 y.o. AAF c/o �weakness� Insidious onset 2-3 weeks ago, symptoms progressive She notes the following: Her joints and muscles ache She�s had subjective fevers (low grade), but no chills or sweats Poor appetite with diminished oral intake She denies: N/V, diarrhea/constipation or weight loss Rash or morning stiffness Focal weakness or other neurologic symptoms

24. Case #2: PFSH PMH: Depression H/O Breast Abscess Low Back Pain Meds: Seroquel, Zoloft, Flexeril, Capsaicin, NSAID SH: Habits: drinks ETOH, smokes cigarrettes (?quantity), occ. marijuana, cocaine in past. No IVDU. Sexual history: Sexually active with �friend�� monogamous, does not use protection FH: noncontributory

25. Case#2: Physical Exam Vital Signs: 121/80, P-96, R-20, Wt 132 lbs., 62� HEENT: anicteric, O/P clear. Neck: no LAN Cardiac/Pulm: unremarkable Abdomen: normal except tender liver edge, spleen not palpable Musculoskeletal: no edema or muscle tenderness, good ROM of joints without synovitis

26. Case#2: Lab Data Data: CBC and Chemistries were normal UA and UDS were normal CRP 0.8 AST 409, ALT 556, AP 108, TB 0.4 Hepatitis serologies: HAV IgM, HCV Ab, HBsAb all negative HBsAg positive HBcAb not done

27. Case#2: Lab Data 1 week later: AST 565, ALT 905, TB 0.6 Hepatitis Serologies: HBcAb (IgM) positive HBeAg positive HBeAb negative 2 weeks later: AST 1700, ALT 2000, TB 4.0, INR normal 3 months later: AST/ALT normal

28. 70% of patients have subclinical or anicteric hepatitis 30% develop icteric hepatitis Fulminant hepatitis occurs in 0.1-0.5% Method of acquisition varies by location: SE Asia/China: perinatal transmission US/Western Europe/Canada: sexual contact and IVDU Acute Hepatitis B Infection

29. Incubation period is 1-4 months Serum sickness like syndrome during prodrome Key symptoms after prodrome: Anorexia, nausea, jaundice, RUQ discomfort, and fatigue Only 5% of adults progress to chronic infection Acute Hepatitis B Infection

33. Case #3: HPI 25 y.o. female c/o rash and fever Reports rash started 3 days ago Rash started on hands, now also on back, elbows, legs and feet, rash is not pruritic Notes fatigue for 1 week, subjective fevers for 3d Denies new soaps/detergents or new meds Has 8 month old child, still nursing Denies joint swelling or arthralgias, eye complaints, genital or urinary complaints

34. Case #3: PFSH PMH: Mild Asthma Meds: None Social Hx: Home: married, monogamous, one child. Habits: No camping/hikes but takes walks outdoors. Volunteers in church nursery. No tobacco/ETOH/drugs. Family Hx: noncontributory

35. Case #3: Physical Exam Vital Signs: unremarkable Neck: 2.5 cm Ant. Cervical LN, tender and mobile Skin: Palmar blisters, not intensely erythematous, some on fingers as well

37. Case #3: More history Rash started on palms: started as red circles and blisters which then became nodular Other areas involved include back, elbows and feet but hands are most noticeable Baby had cold symptoms/fever 1 week ago

38. Case #3: Diagnosis Hand, Foot and Mouth Disease

39. Hand, Foot and Mouth Disease A common acute illness caused by an enterovirus The only clinically distinguishable skin eruption caused by enterovirus Mostly seen in children Characterized by: Fever Vesicular lesions on tongue/buccal mucosa Small, tender nodular lesions on palms, feet, buttocks and genitalia Resolution in several days

40. Hand, Foot and Mouth Disease Coxsackie A viruses most commonly isolated Enterovirus 71 serotype associated with more serious illness (CNS)

43. Great Job Dr. Estrada!!!