General Internal Medicine Noon Conference

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General Internal Medicine Noon Conference

• Overview of 2006-2007
• Stanford Massie M.D.
• Director, GIM Noon Conference

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GIM Conference Background

• Somewhat different from Monday and Friday
  conferences
• Target the practicing internist
• Emphasis on ambulatory topics
• Often case based, interactive
• All talks given by GIM faculty
• Also one of the core conferences for medicine
  residents

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Series Overview (1)

• Clinical Problem Solving (CPS)
• Clinical Pathology Conference (CPC)
• Updates
• Common Ambulatory Topics (CAT)

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Series Overview (2)

• Medicine Consultation Series
• Evidence Based Medicine Series
• Ethics case discussions

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Division of GIM Web Site

• Address http//gim.dom.uab.edu
• Calendar of upcoming conferences
• Slides for all previous talks
• AMR schedule
• Russell Intern Ambulatory Talks
• Many other useful links

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What we need from you

• Sign in to get credit for attendance
• Conference evaluations
• Feedback

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Now on to the cases.
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Clinical Problem Solving

• GIM Noon Conference
• Discussant Carlos Estrada M.D.
• Presenter Stanford Massie M.D.
• July 18, 2006

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Carlos Estrada
http//www.imdb.com/name/nm1900091/photogallery
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Carlos Estrada
movies.yahoo.com/ shop?dhvcfinfoid1808645852
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Carlos Estrada
The Bad News Bears
www.cinemovies.fr/ perso-BillyBobThornton-4-...
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Case 1 HPI

• 29 y.o. female c/o cessation of menses
• Reports last period was 5 months ago, prior to
  that they were always regular
• Home pregnancy test negative
• Has noted some fatigue and intolerance to cold
  temperatures
• Notes intentional 30 lb. weight loss X 8 mos.

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Case 1 HPI

• Denies visual changes, H/A, galactorrhea or hair
  loss.
• Weight loss achieved by cutting calories, denies
  excessive exercise, laxative or diuretic use

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Case 1 PFSH

• PMH Schizophrenia, Tonsillectomy
• Meds Ziprasidone (Geodon), Neurontin,
  Clozapine, Cogentin
• Social History
• Lives alone, unemployed
• Denies tobacco, Etoh or drugs
• Family History Unremarkable

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Case 1 Physical Exam

• Vital Signs 60 134 lbs. (BMI 18.5)
• Rest of examination was unremarkable

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Case 1 Data

• Labs
• HCG negative
• TSH normal
• Prolactin 57.1 (2-25)
• LH/FSH normal
• Dx Medication related hyperprolactinemia
• No further workup done (imaging etc.)

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Amenorrhea

• Primary vs. Secondary
• Transient, intermittent or permanent
• Results from dysfunction of
• Hypothalamus
• Pituitary
• Ovaries
• Uterus
• Vagina
• Definition (2) absence of menses for more than
  three cycles or six months in women who
  previously had menses

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Amenorrhea

• After excluding pregnancy, the most common causes
  of secondary amenorrhea
• Ovarian disease 40 percent
• Hypothalamic dysfunction 35 percent
• Pituitary disease 19 percent
• Uterine disease 5 percent
• Other 1 percent

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Hyperprolactinemia

• Secreted by pituitary (lactotroph cells)
• Regulated by tonic inhibition by dopamine from
  hypothalamus
• Physiologic causes include pregnancy, nipple
  stimulation and stress
• Major pathologic causes of hyperprolactinemia
• Pituitary adenomas (hypersecretion)
• Damage to pituitary or stalk
• Dopamine antagonism
• Decreased clearance of prolactin

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MRI of the head should be performed in a patient
with any degree of hyperprolactinemia to look for
a mass lesion in the hypothalamic-pituitary
region, except if the patient is taking a
medication known to cause hyperprolactinemia,
such as an antipsychotic drug, and that drug
typically causes the magnitude of the prolactin
elevation.
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Newer Generation Anti-Psychotics
"large geodon 9"
homepage.mac.com/imarsian/PhotoAlbum6.html
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Case2 HPI

• 48 y.o. AAF c/o weakness
• Insidious onset 2-3 weeks ago, symptoms
  progressive
• She notes the following
• Her joints and muscles ache
• Shes had subjective fevers (low grade), but no
  chills or sweats
• Poor appetite with diminished oral intake
• She denies
• N/V, diarrhea/constipation or weight loss
• Rash or morning stiffness
• Focal weakness or other neurologic symptoms

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Case 2 PFSH

• PMH
• Depression
• H/O Breast Abscess
• Low Back Pain
• Meds Seroquel, Zoloft, Flexeril, Capsaicin,
  NSAID
• SH
• Habits drinks ETOH, smokes cigarrettes
  (?quantity), occ. marijuana, cocaine in past. No
  IVDU.
• Sexual history Sexually active with friend
  monogamous, does not use protection
• FH noncontributory

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Case2 Physical Exam

• Vital Signs 121/80, P-96, R-20, Wt 132 lbs.,
  62
• HEENT anicteric, O/P clear.
• Neck no LAN
• Cardiac/Pulm unremarkable
• Abdomen normal except tender liver edge, spleen
  not palpable
• Musculoskeletal no edema or muscle tenderness,
  good ROM of joints without synovitis

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Case2 Lab Data

• Data
• CBC and Chemistries were normal
• UA and UDS were normal
• CRP 0.8
• AST 409, ALT 556, AP 108, TB 0.4
• Hepatitis serologies
• HAV IgM, HCV Ab, HBsAb all negative
• HBsAg positive
• HBcAb not done

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Case2 Lab Data

• 1 week later
• AST 565, ALT 905, TB 0.6
• Hepatitis Serologies
• HBcAb (IgM) positive
• HBeAg positive
• HBeAb negative
• 2 weeks later
• AST 1700, ALT 2000, TB 4.0, INR normal
• 3 months later
• AST/ALT normal

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Acute Hepatitis B Infection

• 70 of patients have subclinical or anicteric
  hepatitis
• 30 develop icteric hepatitis
• Fulminant hepatitis occurs in 0.1-0.5
• Method of acquisition varies by location
• SE Asia/China perinatal transmission
• US/Western Europe/Canada sexual contact and IVDU

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Acute Hepatitis B Infection

• Incubation period is 1-4 months
• Serum sickness like syndrome during prodrome
• Key symptoms after prodrome Anorexia, nausea,
  jaundice, RUQ discomfort, and fatigue
• Only 5 of adults progress to chronic infection

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Causes of Polyarticular Pain Polyarthritis (show
figure 1) Viral arthritis (show figure 2)
Postinfectious or reactive arthritis
Fibromyalgia Multiple sites of bursitis or
tendinitis Soft tissue abnormalities
Hypothyroidism Neuropathic pain Metabolic bone
disease Depression
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(No Transcript)
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http//www.cdc.gov/ncidod/diseases/hepatitis/slide
set/hep_b/slide_3.htm
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Case 3 HPI

• 25 y.o. female c/o rash and fever
• Reports rash started 3 days ago
• Rash started on hands, now also on back, elbows,
  legs and feet, rash is not pruritic
• Notes fatigue for 1 week, subjective fevers for
  3d
• Denies new soaps/detergents or new meds
• Has 8 month old child, still nursing
• Denies joint swelling or arthralgias, eye
  complaints, genital or urinary complaints

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Case 3 PFSH

• PMH Mild Asthma
• Meds None
• Social Hx
• Home married, monogamous, one child.
• Habits No camping/hikes but takes walks
  outdoors. Volunteers in church nursery. No
  tobacco/ETOH/drugs.
• Family Hx noncontributory

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Case 3 Physical Exam

• Vital Signs unremarkable
• Neck 2.5 cm Ant. Cervical LN, tender and mobile
• Skin Palmar blisters, not intensely
  erythematous, some on fingers as well

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www.lib.uiowa.edu/.../handfootmouth.html
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Case 3 More history

• Rash started on palms started as red circles
  and blisters which then became nodular
• Other areas involved include back, elbows and
  feet but hands are most noticeable
• Baby had cold symptoms/fever 1 week ago

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Case 3 Diagnosis

• Hand, Foot and Mouth Disease

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Hand, Foot and Mouth Disease

• A common acute illness caused by an enterovirus
• The only clinically distinguishable skin eruption
  caused by enterovirus
• Mostly seen in children
• Characterized by
• Fever
• Vesicular lesions on tongue/buccal mucosa
• Small, tender nodular lesions on palms, feet,
  buttocks and genitalia
• Resolution in several days

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Hand, Foot and Mouth Disease

• Coxsackie A viruses most commonly isolated
• Enterovirus 71 serotype associated with more
  serious illness (CNS)

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http//www.accesskent.com/Health/HealthDepartment/
CD_Epid/images/Hand_Foot_Mouth.jpg
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www.lib.uiowa.edu/.../handfootmouth.html
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Great Job Dr. Estrada!!!