M3 M4: Interested in improving physical exam skills 4th Year Elective MASTER PHYS DIAGNOSIS Block IV

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M3 / M4Interested in improvingphysical exam
skills?4th Year ElectiveMASTER PHYS
DIAGNOSISBlock IV b (Jan 28-Feb 24 2008, 09)
Clubbing Profile sign (Lovibond) gt 180 º

• Goals
• Master / improve physical exam skills
• Be proficient in interpreting phys diagn
  literature
• Use the physical exam as a diagnostic test
• If interested, contact Carlos Estrada, MD, MS
  cestrada_at_uab.edu

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Common Ambulatory Topics (CAT)
ChallengingUlcers and Headaches
Carlos Estrada, MD, MS Associate Professor of
Medicine Division of General Internal Medicine
2007
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Objectives

• Go deeper in differential diagnosis and physical
  exam of ulcers and headaches
• Interest 2 additional people to submit a clinical
  vignette to a regional meeting

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A Non-Healing Ulcer

• Sagar U Nigwekar, MD
• Rochester General Hospital, Rochester, NY
• Discussant
• Gustavo Heudebert, MD
•    The University of Alabama at Birmingham

(adapted with permission)
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History

• 49-year-old Caucasian woman
• Left calf ulcer
• Duration 8 weeks
• Began as skin redness
• Progressive slow enlargement
• Associated with itching
• Intermittent purulent discharge
• Pain at and around ulcer site

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History (cont' d)

• Left leg pain
• Duration 8 weeks, progressive
• Throbbing, sharp, moderate
• At and around the ulcer site
• Non-radiating
• Not controlled on naproxen

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Review of Systems

• No trauma
• No fever, chills
• No nausea, vomiting, diarrhea
• No claudication, weakness, paresthesias
• No animal/insect bites

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PMH - Medications - SH - FH

• PMH
• Diabetes mellitus, type 2
• Hypertension
• Medications Metformin, HCTZ
• SH Full time, office. No tobacco, alcohol,
  drugs. No travel
• FH noncontributory

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Physical Examination

• T 37.8ºC, BP 128/78 mmHg
• HR 99/min, RR 16/min
• Moderate distress due to leg pain
• Pulmonary, cardiac, abdomen normal
• Vascular no bruits, normal peripheral pulses and
  capillary refill, no retinopathy
• Musculoskeletal no joint deformities

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Examination (cont' d)

• Reduced vibratory and proprioceptive sensations
  distal to ankles bilaterally
• Normal motor strength
• Normal deep tendon reflexes
• Plantar reflexes downgoing bilaterally

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Left Leg

• Left calf ulcer
• Oval violaceous
• 10 x 5 cm
• ?? tender
• Thick black crust
• Erythema
• ROM knee, ankle - Ok

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Questions

• Differential diagnosis?
• Next steps in management?
• Thoughts?

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Initial Evaluation (07/2006)

• WBC 16,000 cells/µL 92 PMN
• Hgb 13 g/dl
• Na 140 mEq/L
• K 3.7 mEq/L
• Cl 104 mEq/L
• CO2 29 mEq/L
• BUN 15 mg/dl
• Cr 1.2 mg/dl
• eGFR 60 ml/min

• Calcium 10.4 mg/dl
• Albumin 3.0 g/dl
• AST 10 U/L
• ALT 43 U/L
• Alk Phos 73 U/L
• CK 200 U/L
• (96-140 U/L)
• HgbA1C 9.5
• (4.6-6.0)

Corrected Ca Ca 0.8 (4 -Albumin) 11.2
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Imaging

• X-ray left leg
• Soft tissue swelling
• No bony destruction
• MRI left leg
• Cellulitis
• No osteomyelitis

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Thoughts?
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Hospital Course
Wound care treatment
IV antibiotics
day 1 day 2 day
6 day 9
Debridement
Admission
Multiple negative blood cultures
MRI leg
? Ca- PO4, iPTH, Vit D levels ordered
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Laboratory Results

• PO4 2.1mg/dL (2.2-4.5 mg/dL)
• iPTH 82 pg/mL (14-72 pg/mL)
• 25-OH D 25 ng/mL (15-50 ng/mL)
• 1,25-OH2D 20 pg/mL (10-65 pg/mL)
• Previous Ca levels

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Hospital Course
Wound care program
IV antibiotics
day 1 day 2 day 9
day 21
Debridement
Admission
MRI leg
? Calcium w/u- ?PO4, ? PTH, normal Vit D

• Severe pain
• Non-healing ulcer
• Hyperparathyroidism

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Skin Biopsy
Septal panniculitis
Adventitial calcification
Luminal narrowing
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Putting it All Together?
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Final Diagnosis
Non-healing ulcer Calciphylaxis Primary
hyperparathyroidism
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Clinical Course

• Parathyroidectomy- adenoma (0.6 g)
• Serum calcium normalized
• Patient discharged on insulin, HCTZ
• Outpatient wound care continued
• Leg ulcer resolved over 4 months

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• Non-Healing Ulcers
• Differential Diagnosis

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Primary Cutaneous Disorders

• Peripheral vascular dis (venous, art)
• Livedoid vasculitis
• Sq cell carcinoma
• Factitious

• Infections
• Anthrax
• Tularemia
• Bubonic plague
• Buruli ulcer
• Leprosy
• Cutaneous TB
• Chancroid
• Primary syphilis

Harrison's Internal Medicine, 2007
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Systemic Diseases

• Legs
• Leukocytoclastic vasculitis
• Hemoglobinopathies
• Cryoglobulinemia
• Cholesterol emboli
• Necrobiosis lipoidica
• Antiphospholipid syndrome
• Neuropathic
• Panniculitis

• Hands and feet
• Raynaud's phenomenon
• Generalized
• Pyoderma gangrenosum
• Calciphylaxis
• Infections (fungi, chronic herpes
  varicellazoster)
• Lymphoma
• Mucosal

Harrison's Internal Medicine, 2007
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Calciphylaxis

• Rare but serious disorder
• 4 in ESRD population
• Reported in breast carcinoma treated with
  chemotherapy, liver cirrhosis, Crohn's disease,
  RA and SLE
• Primary hyperparathyroidism very rare cause of
  calciphylaxis

Am J Clin Pathol 2000 113280287 Surgery
19971221083-9
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Calciphylaxis

• Pathophysiology
• Tissue ischemia- small vessel mural and extra
  vascular calcification with thrombosis
• Local skin trauma
• Clinical findings
• Violaceous, painful nodules, necrotic ulcers,
  superinfection
• Trunk, buttocks or extremity

J Cutan Med Surg 1998 2245248 Kidney Int
2002612210-7
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Calciphylaxis

• Treatment
• Aggressive wound care program
• Lowering Ca x P product
• Parathyroidectomy ?
• Hyperbaric O2, Na thiosulfate, steroids ?
• Prognosis poor, 60 mortality

Surgery 2001130645-50 South Med J 1994
87278-81
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Non- Healing UlcerTake Home Points

• In patients with painful non-healing skin ulcers
• Review differential diagnosis
• Consider calciphylaxis

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Lilac festival
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2007 SSGIM, New Orleans UAB. Oral Presentations

• NA Dbouk, M Arguedas. Suicidal tendencies
  screening for underlying depression amongst
  hepatitis C patients.
• N Van Wagoner, M Patel, F S Massie. When Mac
  Attacks.
• J Townsend, L Willett. When Young Ears Hang Low
  But Wont Wobble To And Fro.
• B Corliss, S Cohen Missing the Diagnosis Could
  Drive You Mad.
• P Depuy, C Estrada. Rash And Fever A Syndrome
  Not Just For Kids.

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2007 SSGIM, New Orleans UAB. Poster Presentations

• K Ward, Jason Hartig. You Cant Get Blood From A
  StoneOr This Guy.
• J Jennings, G Luy, G Heudebert. Nausea, Vomiting
  And Diarrhea Sometimes A Gut-Check Is In Order
  Before Making A Diagnosis.
• S Mehta, R Centor. All Seizures Are Not Epilepsy.
  
• G Luy, C Logan, G Heudebert. An Old Enemy Strikes
  Back Again.
• P Bravo, W Chatham. A Case of Giant Cell
  Arteritis With A Normal ESR Presenting As Stroke
  And Transient Ischemic Attack.

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Is It All In His Head?

• Mady Slater MD, Cindy Lai MD
• University of California, San Francisco
• Discussant
• Steven Shadowitz MD MSc FRCPC
•   Sunnybrook Health Sciences Centre
•   University of Toronto

(adapted with permission)
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History

• 22-year-old man, headache x 6 m
• Episodic
• Bifrontal, crushing, constant
• Painful ! 10/10
• Initially monthly lasting 3 days
• Now bimonthly lasting 3 days
• Multiple ER visits

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HeadacheAdditional Information

• No change with position
• No prodrome- no smells, scotoma
• No nasal drainage or eye pain
• No neurologic symptoms
• No trauma
• Began 4 weeks after returning from 2nd tour to
  Iraq where he served in combat in the marines

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PMH - Medications FH - SH

• PMH none
• Meds ibuprofen
• Fam
• Mother, stroke in 40s (? etiology)
• No migraines

• Social
• Smoker ¼ ppd x 8 yrs
• No alcohol, drugs
• Married
• Lives in S Franc
• Left marines due to HA

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Review of Systems

• Fatigue causing increased sleep and decreased
  ability to exercise
• Normal appetite, unintentional 15 lb weight loss
  in 6 months

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Physical Examination

• 36.5 ºC BP 102/60 HR 70 RR 20 99 RA
• No distress, fatigued appearing
• HENT, CV, Pulm, Abd normal
• Muskuloskeletal normal bulk and strength
• Neuro normal
• Optho no papilledema, nl visual fields

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Laboratory Evaluation

• CBC
• Chem 16
• UA
• CK, Ca, Ph
• LFTs

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Further Review of Systems

• ? energy, stamina, muscle mass
• ? libido (sex 2 / day ? q o week)
• Decreased ejaculate volume
• Decreased facial hair
• Shaving q day ? q week

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Repeat Physical Exam

• Normal thyroid exam
• No galactorrhea/gynecomastia
• Normal testicular size

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Brain MRI

• 14 x 19x 23mm
• Sellar, suprasellar mass
• Midline
• Severe mass effect on pituitary gland and optic
  chiasm

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Visual Field Testing
Bitemporal hemianopsia
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Superior Compression Meningioma Rathkes Cyst
Inferior Compression Pituitary Adenoma
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Additional Testing

• Testosterone 0 (15-25 nmol/L)
• LH 4 (7-24 u/L)
• FSH 3 (2-9 mu/L)
• ACTH 15 (10-60 pg/ml)
• Cort Stim Test 6 (gt20mcg/dl)
• TSH 4.3 (2.5-13.3 mu/ml)
• Free T4 7.4 (12-31 nmol/L)
• Prolactin 34 (1.5-19 pmol/L)
• IGF-1 103 (182-780 g/L)

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Transsphenoidal Resection

• Epithelial-lined cyst
• Thickened wall
• Adjacent to benign adenohypophysis
• Rathkes Cleft Cyst

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Final Diagnosis

• Panhypopituitarism secondary to
• Rathkes Cleft Cyst

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Clinical Course

• Adrenal insufficiency steroids, fluids
• Hypothyroidism levothyroxine (Synthroid )
• Hypogonadism testosterone patch
• Symptoms have since resolved
• Medical alert bracelet, hydrocortisone amp for
  emergencies

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Pituitary Mass Diff Diagn

• Pituitary adenoma
• Pituitary hyperplasia
• Craniopharyngioma
• Meningioma
• Malignant tumors or metastatsis
• Cysts Rathkes cleft, arachnoid, dermoid cysts
• Abscess

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Rathkes Cleft Cyst

• Symptoms
• None
• HA, visual disturbance, endocrinopathies
• Treatment
• Transsphenoidal surgery
• Prognosis
• Symp improve, 70-80

J Neurosurg 1991 74 535-44
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HeadacheTake Home Points

• Go deeper !
• Perform an in-depth ROS
• Perform a detailed bedside visual field exam

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ChallengingUlcers and Headaches

• Painful non-healing skin ulcers review
  differential diagnosis (calciphylaxis)
• Headaches perform a detailed ROS and bedside
  visual field exam

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Award Winners

• Andrew Sellers. 2007 SSGIM, New Orleans
• Bud Marsteller. 2007 ACP
• Jacob Townsend. 2006 SSGIM, Atlanta
• Millie Long. 2005 SSGIM, New Orleans

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Visual Field Testing
Bitemporal hemianopsia
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Pituitary Hormones
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HeadacheImaging Recommended

• Abnormal neurologic exam
• Significant change in frequency/severity
• Worsened HA with therapy
• Onset with exertion, cough, sexual activity
• Orbital bruit
• Onset gt 40 yrs

Multispecialty consensus on diagnosis and
treatment of headache. Neurology 2000 541553