Clinical Problem Solving

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Clinical Problem Solving

• Presenter J. R. Hartig, MD
• Discussant Jason L. Morris, MD
• January 23rd, 2007

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Common Clinical Problems
3
Not the Rare Breeds
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Objectives

• Review 3 common internal medicine clinical
  complaints and problems
• Learn from our expert clinician thought
  processes, questions he asks, testing
• 2-3 Take Home points for each case
• History and Physical
• Lab / Testing
• Treatment

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Case 1 kNot in My Throat

• 33 yo WF c/o 3 day history dysphagia
• Ive got a knot in my throat.

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Case 1 kNot in My Throat

• 33 yo WF c/o 3 day history dysphagia
• Ive got a knot in my throat.
• Noted difficulty swallowing solids liquids.
  Food gets stuck. Unable to swallow pills. No
  odynophagia.

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Case 1 kNot in My Throat

• 33 yo WF c/o 3 day history dysphagia
• Ive got a knot in my throat.
• Noted difficulty swallowing solids liquids.
  Food gets stuck. Unable to swallow pills. No
  odynophagia.
• Awoke in the morning feeling mildly SOB as if
  I couldnt get the air into my lungs. Notices
  positional dyspnea harder to breathe when I
  lay a certain way.

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Case 1 kNot in My Throat

• 33 yo WF c/o 3 day history dysphagia
• Ive got a knot in my throat.
• Noted difficulty swallowing solids liquids.
  Food gets stuck. Unable to swallow pills. No
  odynophagia.
• Awoke in the morning feeling mildly SOB as if
  I couldnt get the air into my lungs. Notices
  positional dyspnea harder to breathe when I
  lay a certain way.
• Panic feelings while she eats.

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Case 1 More HPI/ROS

• No trouble chewing, or initiating swallow
  feels deeper. Not painful at all.
• Never had before.

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Case 1 More HPI/ROS

• No trouble chewing, or initiating swallow
  feels deeper. Not painful at all.
• Never had before.
• No F/C, URI sx.
• No rash or changes visible to her.

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Case 1 More HPI/ROS

• No trouble chewing, or initiating swallow
  feels deeper. Not painful at all.
• Never had before.
• No F/C, URI sx.
• No rash or changes visible to her.
• No abdominal pain. Mild heartburn in the past
  OTC meds this seems different.
• No CP, DOE, or other cardiac symptoms

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Case 1 History

• PMHx IBS-colonoscopy 2004 normal
• LBP L4-L5 disc herniation
• GDM last A1C 5.4
• Migraine Headaches

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Case 1 History

• PMHx IBS-colonoscopy 2004 normal
• LBP L4-L5 disc herniation
• GDM last A1C 5.4
• Migraine Headaches
• PSHx TAH without oophorectomy 2000
• Meds Prozac 20mg day
• Allg Morphine, Lortab, Darvocet, Percocet

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Case 1 History

• PMHx IBS-colonoscopy 2004 normal
• LBP L4-L5 disc herniation
• GDM last A1C 5.4
• Migraine Headaches
• PSHx TAH without oophorectomy 2000
• Meds Prozac 20mg day
• Allg Morphine, Lortab, Darvocet, Percocet
• FHx Mom- hypothyroidism. MGM Graves Disease
• Dad- HTN, cirrhosis, melanoma
• SHx married, 3 kids, smoker 1ppd x5y, no Etoh

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Case 1 Physical Exam

• VS AF P 74 R 16 BP 106/65 Wt 208lbs (no ?)

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Case 1 Physical Exam

• VS AF P 74 R 16 BP 106/65 Wt 208lbs (no ?)
• HEENT no visible abnormalities in OP
• Neck No LAD, No mass ? but ? Abn thyroid gland
  estimated 4cm in size on R

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Case 1 Physical Exam

• VS AF P 74 R 16 BP 106/65 Wt 208lbs (no ?)
• HEENT no visible abnormalities in OP
• Neck No LAD, No mass ? but ? Abn thyroid gland
  estimated 4cm in size on R
• CV RRR
• Chest CTA
• Abd BS, S, NTND, No mass or HSM
• Reflexes normal

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What next?
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What next?

• Lab
• CBC, FBP, Ca2, LFTs nl
• TSH, FT4, FT3 nl

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CXR and Soft Tissue Films
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Barium Swallow
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Thyroid Ultrasound
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Thyroid Ultrasound

• Yeah, right

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What next?

• Lab
• CBC, FBP, Ca2, LFTs nl
• TSH, FT4, FT3 nl
• Imaging
• CXR no cardiopulmonary disease
• Barium swallow moderate narrowing of the
  cervical esophagus thought 2o to the thyroid
• Thyroid U/S multiple nodules largest on R 3.5cm
  No LAD

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The Results

• Sent to ENT for thyroidectomy
• Pathology demonstrated nodular hyperplasia in a
  background of lymphocytic thyroiditis and Hurthle
  cell change

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The Results

• Sent to ENT for thyroidectomy
• Pathology demonstrated nodular hyperplasia in a
  background of lymphocytic thyroiditis and Hurthle
  cell change Hashimotos thyroiditis

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Pathology
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Hashimotos Thyroiditis

• Chronic Autoimmune Thyroiditis
• Most common cause of hypothyroidism

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Hashimotos Thyroiditis

• Chronic Autoimmune Thyroiditis
• Most common cause of hypothyroidism
• Cause
• Combination of genetics and environment
• Close familial association with Graves Disease

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Hashimotos Thyroiditis

• Chronic Autoimmune Thyroiditis
• Most common cause of hypothyroidism
• Cause
• Combination of genetics and environment
• Close familial association with Graves Disease
• Epidemiology
• WomenMen 71
• Can occur in children

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Hashimotos Thyroiditis

• Clinical Features
• Goiter
• Hypothyroidism
• Post-partum thyroiditis
• Labs
• Thyroid peroxidase and thyroglobulin antibodies
• Thyroid function tests ? / ? /
• Treatment

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Dysphagia Evaluation
UpToDate v14.2 2006
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Dysphagia Evaluation
UpToDate v14.2 2006
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Case 1 Take Homes

• History sets the stage for dysphagia
• Where does the food get stuck?

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Case 1 Take Homes

• History sets the stage for dysphagia
• Where does the food get stuck?
• Dysphagia evaluations start with a swallow!
• OK to proceed directly to endoscopy if unlikely
  to have upper esophageal disease

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Case 1 Take Homes

• History sets the stage for dysphagia
• Where does the food get stuck?
• Dysphagia evaluations start with a swallow!
• OK to proceed directly to endoscopy if unlikely
  to have upper esophageal disease
• Hashimotos is the most common cause of
  hypothyroidism and goiter

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(No Transcript)
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Case 2

• 36 yo WM c/o L arm progressive weakness for 9-12
  months

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Case 2

• 36 yo WM c/o L arm progressive weakness for 9-12
  months
• Has noticed progressive difficulty with job
  duties on L arm
• Pulling and pushing objects became impossible.
• Since the onset, it now involves loss of grip
  strength also.

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Case 2

• 36 yo WM c/o L arm progressive weakness for 9-12
  months
• Has noticed progressive difficulty with job
  duties on L arm
• Pulling and pushing objects became impossible.
• Since the onset, it now involves loss of grip
  strength also.
• Can no longer hold his children with that arm (2y
  4y)
• Cannot hold coffee or do buttons.

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Case 2 More History

• Over time noted changes other places
• R sided fine motor problems buttons
  twitching.
• Can actually see muscle spasms happening at night

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Case 2 More History

• Over time noted changes other places
• R sided fine motor problems buttons
  twitching.
• Can actually see muscle spasms happening at night
• Not really fatigue-related
• Cut back on his job slightly better not going
  away

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Case 2 More History

• Over time noted changes other places
• R sided fine motor problems buttons
  twitching.
• Can actually see muscle spasms happening at night
• Not really fatigue-related
• Cut back on his job slightly better not going
  away
• Never any pain or loss of sensation
• Also reports problems swallowing especially in
  the AM with liquids solids. Something catches

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Case 2 History

• PMHx Chronic Neck and Back pain
• Eczema
• Bells Palsy with recovery as a child

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Case 2 History

• PMHx Chronic Neck and Back pain
• Eczema
• Bells Palsy with recovery as a child
• Meds Centrum
• Potassium gluconate (muscle cramps)
• Allg Codeine bad dreams, hallucinations

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Case 2 History

• PMHx Chronic Neck and Back pain
• Eczema
• Bells Palsy with recovery as a child
• Meds Centrum
• Potassium gluconate (muscle cramps)
• Allg Codeine bad dreams, hallucinations
• FHx Mom- chol
• Dad- CAD, s/p CABG, HTN, DM
• SHx works as a die finisher (labor) 60-70h now
  40/wk. Married, 2 kids, smoker 40-50 pk/yr, rare
  Etoh, chew

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Case 2 Physical

• VS T 97.1 P 89 R 16 BP 125/84 WT 155

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Case 2 Physical

• VS T 97.1 P 89 R 16 BP 125/84 WT 155
• Gen WDWN W? in NAD
• HEENT normal fundi and OP exam
• CV RRR no M/G/R pulses normal
• CHEST CTA
• ABD no organomegaly

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Case 2 Physical

• VS T 97.1 P 89 R 16 BP 125/84 WT 155
• Gen WDWN W? in NAD
• HEENT normal fundi and OP exam
• CV RRR no M/G/R pulses normal
• CHEST CTA
• ABD no organomegaly
• EXT obvious muscle wasting in L forearm and
  hypothenar/thenar. Nl ROM in all joints, nl
  pulses. Strength 5/5 except 4/5 in L deltoid,
  tri/biceps, and hand. Reflexes brisk (3) in LUE
  and LLE.
• Neuro as above, with CN 2-12 nl, cerebellar nl,
  MS nl.

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Now what?
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Now what?

• Labs?
• Other studies?
• Imaging?
• Refer?

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Labs

• B12, TFTs, folate, CMP, CBC all normal. RPR NR
• HIV neg
• IFE no monoclonal gammopathy
• ESR 0
• Lyme serology negative
• CK 854

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Other Studies

• NCS Decreased CMAP amplitude in the L and R
  peroneal nerves, and L median motor nerve
• EMG Increased insertional activity, 2
  fibrillation potentials
• Consistent with widespread active and chronic
  denervation in motor neuron diseases

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Imaging Studies

• MRI of C/T/L spine with degenerative changes but
  cord appears normal.
• MRI head without abnormality

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Now what?

• REFER!!!!!

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Playing Fair

• Additional Family History
• Great Aunt and Grandfather with

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Playing Fair

• Additional Family History
• Great Aunt and Grandfather with
• History of ALS

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Amyotrophic Lateral Sclerosis

• Lou Gehrigs Disease (Motor Neuron Disease)
• Classified
• Sporadic 90
• Familial 10

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Amyotrophic Lateral Sclerosis

• Lou Gehrigs Disease (Motor Neuron Disease)
• Classified
• Sporadic 90
• Familial 10
• Epidemiology
• MaleFemale 1.31
• Increases each decade after 40
• 7000 cases / year in the U.S.

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Amyotrophic Lateral Sclerosis

• Pathology
• Loss of neuronal cells with gliosis
• Cause - unknown

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Amyotrophic Lateral Sclerosis

• Pathology
• Loss of neuronal cells with gliosis
• Cause - unknown
• Clinical Presentation
• Combination of Upper and Lower MN signs
• Upper
• Weakness, hyperreflexia, spasticity
• Lower
• Atrophy, amyotrophy, fasciculations

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Upper v Lower Motor Neuron Signs
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Amyotrophic Lateral Sclerosis

• Patterns of presentation
• Asymmetric limb 80. UpperLower
• Bulbar 20 Dysarthria, dysphagia
• Respiratory and Axial

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Amyotrophic Lateral Sclerosis

• Patterns of presentation
• Asymmetric limb 80. UpperLower
• Bulbar 20 Dysarthria, dysphagia
• Respiratory and Axial
• Treatment
• Supportive, non-pharmacologic care
• Riluzole
• 155 outpatients 12 month survival 74 v 58
• 959 pts survival without tracheotomy

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Case 2 Take Homes

• Upper v Lower Motor Neuron Signs
• ALS
• Asymmetric limb weakness
• Bulbar signs

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(No Transcript)
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Case 3

• 25 yo W? presents to the office c/o spider bite
  on the L upper thigh

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Case 3

• 25 yo W? presents to the office c/o spider bite
  on the L upper thigh
• Treated for ca-MRSA with Bactrim without
  improvement.
• Began experiencing migratory arthralgias and then
  developed other painful lesions over legs, arms,
  hands, and feet. Few on torso.

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Case 3

• 25 yo W? presents to the office c/o spider bite
  on the L upper thigh
• Treated for ca-MRSA with Bactrim without
  improvement.
• Began experiencing migratory arthralgias and then
  developed other painful lesions over legs, arms,
  hands, and feet. Few on torso.
• Purple with ring of erythema and yellow margins
  with central ulceration 2mm-3cm

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Case 3

• Fever 100.9
• Nausea without V or D
• Since admission seems to have new lesions at
  sites of trauma

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Case 3

• Fever 100.9
• Nausea without V or D
• Since admission seems to have new lesions at
  sites of trauma
• Normal CXR 1 month prior to this now has a
  dramatically different appearance despite lack of
  any new symptoms.

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Case 3 History

• PMHx Severe aphthous ulcers since childhood
• PPD with negative CXR s/p 6 months tx
• PSHx Tonsillectomy
• Meds None
• Allg IVP dye

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Case 3 History

• PMHx Severe aphthous ulcers since childhood
• PPD with negative CXR s/p 6 months tx
• PSHx Tonsillectomy
• Meds None
• Allg IVP dye
• FHx Mom, Dad, and sibling healthy
• No known chronic or unusual diseases in family
• SHx Dentist currently completing fellowship
  training in Boston. Previously native Alabamian.
• No Etoh, tobacco or drug use.
• Travel to Japan for 2 weeks approx 2 weeks prior

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Case 3 Physical

• VS T 99.0 P 105 R 18 BP 98/68 O2sat 95 on
  RA
• Gen WDWN W? in no resp. distress but in pain

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Case 3 Physical

• VS T 99.0 P 105 R 18 BP 98/68 O2sat 95 on
  RA
• Gen WDWN W? in no resp. distress but in pain
• Skin multiple discrete violaceous lesions
  ranging in size 3mm to 3.5cm. Larger lesions with
  central ulceration and purulent appearance.
• HEENT no conjunctival lesions. Small pustule
  noted at the right nares 2mm and several 2-4mm
  ulcerated lesion on buccal and gingival surfaces.

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Physical Exam
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Case 3 Physical

• VS T 99.0 P 105 R 18 BP 98/68 O2sat 95 on
  RA
• Gen WDWN W? in no resp. distress but in pain
• Skin multiple discrete violaceous lesions
  ranging in size 3mm to 1.5cm. Larger lesions with
  central ulceration and purulent appearance.
• HEENT no conjunctival lesions. Small pustule
  noted at the right nares 2mm and several 2-4mm
  ulcerated lesion on buccal and gingival surfaces.
• CV mildly tachycardic but RR with M/G/R. nl
  pulses
• CHEST CTA B
• ABD BS soft, NTND, no organomegaly or masses
• EXT no other changes except skin no arthritis

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CXR
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CT scan of chest
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Unfair question

• Where might you possibly start with this patient?

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Labs

• CMP and basic labs wnl except CBC mild anemia,
  thrombocytosis, and neutrophilia.
• HIV neg, RPR NR, hepatitis neg, all cultures neg
  including BAL/TBBx and skin.
• RF, ANA, complement studies normal
• Extensive w/u for malignancy negative as well

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General Rule for Rashes

• If you dont know
• Biopsy It!

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Histology
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Sweets Syndrome

• 1964 Sweet describes 8 female patients with
  fever, leukocytosis, and erythematous plaques
  with infiltrating neutrophils
• acute febrile neutrophilic dermatosis
• May occur on its own.
• 25 of individuals have an underlying malignancy

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Sweets Syndrome

• Malignancies particularly heme-related
• ID vaccinations
• Bacterial infections streptococcus,
  mycobacterium, Yersinia, typhus, salmonella
• Viral infections cytomegalovirus, chronic active
  hepatitis, HIV
• Drugs lithium, furosemide, hydralazine, oral
  contraceptives, minocycline, and
  trimethoprim-sulfamethoxazole.
• Autoimmune and collagen vascular diseases RA,
  SLE, mixed connective tissue disease, Hashimoto
  thyroiditis, Sjögren's syndrome, Behcet's disease
  
• Inflammatory bowel disease Crohn's disease,
  ulcerative colitis
• Other pregnancy, complement deficiency, subacute
  necrotizing Lymphadenitis, and Poem's syndrome.

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Sweets Syndrome
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Case 3 Take Homes

• Biopsy rashes if you are not sure
• Sweets Syndrome is the start of a diagnosis

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Final Summary

• Case 1
• Dysphagia evaluation swallow study or endoscopy
• Hashimotos most common cause of hypothyroidism

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Final Summary

• Case 1
• Dysphagia evaluation swallow study or endoscopy
• Hashimotos most common cause of hypothyroidism
• Case 2
• Upper v Lower Motor Neuron Signs
• ALS
• Asymmetric limb weakness
• Bulbar signs

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Final Summary

• Case 1
• Dysphagia evaluation swallow study or endoscopy
• Hashimotos most common cause of hypothyroidism
• Case 2
• Upper v Lower Motor Neuron Signs
• ALS
• Asymmetric limb weakness
• Bulbar signs
• Case 3
• Biopsy rashes if you are not sure
• Sweets Syndrome is the start of a diagnosis

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Last thought

• If you are only half as intelligent as Dr.
  Morris, youll make an outstanding physician.
• THANK YOU!!!