Cases from a General Internal Medicine Consultation Clinic

Eric I. Rosenberg, MD, MSPH, FACPAssistant 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 isswollen”

“Idiopathic Lymphadenopathy”

• 45 y/o man• Occipital lumps noted

6 mos. ago• Non-diagnostic

evaluation by Primary Care, Oncologist, Infectious Disease, General Surgeon

History

PMHx: Ø

Meds: Allergies:

Ø

Ø

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.

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

Prior Studies

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

CT scan Ø adenopathy, Ø mass

Prior Studies

ANA: (1:80) 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

Differential Dx

• Lymphoma• Liposarcoma• Other neoplasm

• Abnormal exam• LN biopsy likely non-

diagnostic• Highly questionable

“normal” CT scan report

What would you do next?

“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

neuropathyJ 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

Acta Oto-Laryngologica 2005;125.

J Oral Maxillofac Surg 2005;63.

Acta Oto-Laryngologica 2005;125.

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

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.

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

Eagle’s Syndrome(Elongated Styloid Process Syndrome)

• 1st described: Marchetti (1652)• 1st series: Eagle (1937)• Sub-Types

1. Dysphagia, Odynophagia, Otalgia

2. 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

Prior Studies

CXR: Normal

Hct:

Creatinine:

Glucose:

34%

0.7 mg/dL

73 mg/dL

Differential Dx: Dyspnea

• Eagle’s Syndrome• Deconditioning• Myocardial Ischemia• COPD

What would you do next?

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?

Predictors of Increased Perioperative Cardiovascular Risk

Major Unstable Coronary Syndrome Recent MI (7-30 days) “Stable” angina if “unusually sedentary” Decompensated CHF High-grade AVB Symptomatic ventricular dysrhythmias Severe valvular disease

Intermed “Mild” angina Old MI, CHF, DM, CKD

Minor Age >70 Baseline LVH/LBB/ST abnormality Atrial fibrillation Old CVA Uncontrolled HTN Poor functional capacity

Risk of Cardiac Death or Nonfatal MI by Noncardiac Procedure Type

High (>5%)

Emergent major operations, Vascular; prolonged cases with large fluid shifts/blood loss

Intermed (<5%) Carotid endarterectomy; head & neck; intraperitoneal/intrathoracic; orthopaedic; prostate

Low (<1%) Endoscopic/superficial procedures; cataracts; breast surgery

ACC/AHA Guidelines

MINOR PREDICTORS

Poor Functional Capacity

(<4 METs)

Moderate/Excellent Functional Capacity

(>4METs)

High Risk Procedure

IntermediateOr

Low Risk Procedure

Noninvasive Testing O.R.

Postop Risk Stratification and Risk Factor

Reduction

Eagle KA, et al. ACC/AHA Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery. 2002.

• 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

Take-Home Points

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

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).

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.

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

Prior SerologiesCa+ 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

Prior SerologiesNa+ 133

K+ 4.6

Cl- 101

CO2 23

BUN 9

Cr 0.9

ALP 341

ALT 611

AST 524

Eosinophils 7%

Prior Studies

EGD Duodenal ulcer (no cancer)

Colonoscopy Non-diagnostic (poor prep)

Bone Marrow Normochromic, normocytic anemia, hypocellular

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

What would you do next?

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

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

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

“Something still doesn’t 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

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

Addison’s 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

“Something still doesn’t quite fit…”

• During 1 year f/u visits, Endocrinologists note ACTH level consistently too low for Addison’s Disease– Usually >200 pg/ml if Addison’s– 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

“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

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.”

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