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Cases from a General Internal Medicine Consultation Clinic

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

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  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

  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

  11. Prior Studies

  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. “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.”

  15. 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).

  16. 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

  17. Similar Conditions • HIV Lipodystrophy • patients on protease inhibitors • Dercum’s Disease (Adiposis dolorosa) • Diffuse, painful, multiple fatty tumors • Women > Men

  18. 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).

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

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

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

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

  23. Acta Oto-Laryngologica 2005;125.

  24. J Oral Maxillofac Surg 2005;63.

  25. Acta Oto-Laryngologica 2005;125.

  26. Follow-Up • Referred to university general surgeon • Referral still pending to plastic surgeon (underinsured) • 6 months later, hospitalized for severe pneumonia & still awaiting excision

  27. Case #2 “I get short of breath”

  28. 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

  29. History

  30. History

  31. 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.

  32. 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

  33. 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.

  34. 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)

  35. 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

  36. Prior Studies

  37. Differential Dx: Dyspnea • Eagle’s Syndrome • Deconditioning • Myocardial Ischemia • COPD

  38. What would you do next?

  39. Dobutamine Stress Echocardiogram • Resting echocardiogram: • EF 25-30% • Hypokinetic anterolateral and septal walls • Angiogram: • 50% distal LM • 100% occluded pLAD • CABG

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

  41. Predictors of Increased Perioperative Cardiovascular Risk

  42. Risk of Cardiac Death or Nonfatal MI by Noncardiac Procedure Type

  43. 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.

  44. 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

  45. Follow-Up • Dyspnea: resolved • Headaches, jaw and neck pain: persist • Intervention still pending with Facial Pain Center

  46. Case #3 “I keep losing weight”

  47. “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

  48. History

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