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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 March 23, 2006. Objectives. Present three cases from a General Internal Medicine Consultation Clinic
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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 March 23, 2006
Objectives • Present three cases from a General Internal Medicine Consultation Clinic • Review guidelines for meaningful medical consultation
General “Consultation Clinic”? • Preoperative assessment • Questionable unifying diagnosis • Multiple complaints but non-diagnostic work-up • “Gateway” to tertiary medical center subspecialties
“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
“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
Case #1 “My neck is swollen”
“Idiopathic Lymphadenopathy” • 45 y/o man • Occipital lumps noted 6 mos. ago • Non-diagnostic evaluation by Primary Care, Oncologist, Infectious Disease, General Surgeon
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
Differential Dx • Lymphoma • Liposarcoma • Other neoplasm • Abnormal exam • LN biopsy likely non-diagnostic • Highly questionable “normal” CT scan report
“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.”
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).
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
Similar Conditions • HIV Lipodystrophy • patients on protease inhibitors • Dercum’s Disease (Adiposis dolorosa) • Diffuse, painful, multiple fatty tumors • Women > Men
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).
Sequelae • Tracheal / laryngeal / esophageal compression • Dysphagia, dyspnea, dysphonia • Respiratory arrest
Diagnosis • Typical visual pattern of distribution • CT/MRI if looking for airway/esophageal compromise • Excision to exclude malignancy
Treatment • Cease alcohol, tobacco • Low calorie diet, weight loss • Cosmesis via excision (technically difficult) • Liposuction • Medical therapies unproven • Salbutamol (stimulate lipolysis) • Thyroid extract
Prognosis • Disfiguring and progressive • Dietary and lifestyle changes usually unsuccessful in shrinking tumors
Follow-Up • Referred to university general surgeon • Referral still pending to plastic surgeon (underinsured) • 6 months later, hospitalized for severe pneumonia & still awaiting excision
Case #2 “I get short of breath”
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
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.
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
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.
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)
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
Differential Dx: Dyspnea • Eagle’s Syndrome • Deconditioning • Myocardial Ischemia • COPD
Dobutamine Stress Echocardiogram • Resting echocardiogram: • EF 25-30% • Hypokinetic anterolateral and septal walls • Angiogram: • 50% distal LM • 100% occluded pLAD • CABG
Issues for Preoperative Evaluation • Risk of perioperative cardiopulmonary complications? • What do evidence-based guidelines suggest? • Explanation for dyspnea on exertion and abnormal ECG?
Risk of Cardiac Death or Nonfatal MI by Noncardiac Procedure Type
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. 2002.
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
Follow-Up • Dyspnea: resolved • Headaches, jaw and neck pain: persist • Intervention still pending with Facial Pain Center
Case #3 “I keep losing weight”
“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