Family Medicine Rotation

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Family Medicine Rotation

• Michelle McBurney

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Topics

• Introduce the clinical site
• New West Physicians, Broomfield
• Present an interesting case

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The Practice

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New West Physicians

• 15 offices in the Denver metro/Frontrange Area
• 47 Physicians
• 31 Family Medicine
• 16 Internal Medicine
• Conduct Clinical Research Trials

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New West Physicians in Broomfield

• 3 MDs, 1 DO, 1 PA
• 5 MAs
• 6 Office Staff
• 1 Practice Manager
• 1 Onsite Phlebotomist

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The Clinic
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12 Exam Rooms
Ultrasound Room
Minor Procedure Room
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Acupuncture
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Onsite Phlebotomist and Lab
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James Yeash, DO
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Melissa Coomes, MD
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Office Staff MAs
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Charlottes Web
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Avista Hospital
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Demographics
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Payment Sources

• Insurance 82.27
• Secure Horizons 6.43
• Medicaid 4.04
• Self Pay 3.02
• Auto 0.10
• Workmans Comp 0.03

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Top Visit Types

• WCC
• HTN
• Hyperlipidemia
• URI
• DM
• OB Visits

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Procedures

• Skin lesion removals and biopsies
• Colposcopy
• Vasectomies
• Casting
• Trigger point and joint injections
• Flexible sigmoidoscopy
• Osteopathic manipulation

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The Case
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History of Present Illness

• 55 y.o. male presents to clinic in severe
  respiratory distress.
• Increasing SOB x5 days
• Productive cough with grey tinged sputum
• Night sweats
• Cyanosis in extremities
• Weakness and numbness in legs

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Physical Exam

• General
• Thin male in respiratory distress
• Gray and ashen color
• Lungs
• Wheezes to all lung fields
• Pursed lip breathing
• Use of accessory muscles to breathe

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O2 Saturation

• 80 on 3.0L O2
• 78 on 4.0L O2
• 97 on 5.0L O2

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Medical History

• Severe COPD
• HIV
• Tobacco Addiction

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Current Medications

• Advair 50/250, one puff BID
• Spireva QD
• Albuterol, 2 puffs Q 4 hours prn
• Oxygen 2-4L

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Plan

• 2 in-office nebulizer treatments
• Xopenex 1.25mg
• DuoNeb 45 minutes later
• Levaquin 400mg QD x7 days for Bronchitis
• Follow up in 24 hours
• Proceed to ED if symptoms worsen

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Follow Up Visit

• Still wheezing, but much improved
• No longer using accessory muscles to breathe
• O2 Sat 88 on room air
• Discussed HIV status and COPD

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HIV History

• Diagnosed in 2000 after positive result on
  insurance physical
• Married to a woman but is bisexual
• Does not wish to inform his wife
• Has not had sexual relations in over 10 years
• Reluctant to go to hospitals

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HIV Management

• Currently not on antiretroviral medication
• Periodic visits to Infectious Disease group at
  UCHSC
• CD4 count 416 -Viral load 11,776
• Start medication if CD4 count lt 350 or Viral load
  gt 55,000

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COPD History

• Diagnosed in 2002
• Significant smoking history
• gt 120 pack years
• Has attempted to quit multiple times
• Multiple exacerbations each year managed in the
  office

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COPD Management

• Advair 50/250, one puff BID
• Spireva QD
• Albuterol, 2 puffs Q 4 hours prn
• Oxygen 2-4L

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What makes this case so difficult?
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Managed solely by PCP

• Refuses to use community resources
• Refuses to go to the hospital
• No social support for HIV status

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Recommended Resources

• Quit Line
• HIV Resource and Referral Network
• Free service of CDPHE
• Counseling Legal experts
• Support Groups Nutrition information
• Education Etc
• Internet resources for COPD HIV

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Overview

• The Clinic
• Full service clinic
• Traditional and non-traditional treatment
• The Case
• 2 Chronic conditions managed solely by PCP
• Need for community resources

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