Clinical Problem Solving

1
Clinical Problem Solving

• May S. Jennings, MD
• 4/17/07
• Discussant Deborah Levine, MD

2
Ms. L

• CC breast pain

3
Ms. L

• 57yo WF with bilateral breast pain which started
  one month ago
• Constant
• Pain is worse around the nipples and in the upper
  outer quadrants bilaterally
• Increasing in severity
• No breast masses, nipple discharge, breast
  warmth, fever
• No history of abnormal mammogram

4
Ms. L

• PMHx HIV (CD4 count 650), HTN
• Meds HCTZ, Premarin, ASA
• SocHx Divorced, stopped smoking last year after
  a 50 pack year history, no illicit substances

5
Ms. L

• Exam AF, VSS
• Gen thin, NAD
• Breast exquisitely tender to nipple palpation
  bilaterally with moderate tenderness in all 4
  quadrants, no discharge, no discrete masses, no
  skin abnormalities, no axillary or
  supraclavicular LAD

6
Ms. L

• Pt was taken off the Premarin and returns to your
  office 2 weeks later for follow-up
• Her right breast pain is gone but her L breast
  pain has gotten worse
• On repeat examination, she has severe tenderness
  to palpation over the nipple but no nipple
  tenderness when you squeeze her nipple to look
  for discharge

7
(No Transcript)
8
Breast Pain Differential Diagnosis
9
Cyclical Breast Pain

• Normal menstruation
• OCP use
• Cyclic mastalgia
• Fibrocystic disease

10
Non-cyclical Breast PainIntramammary

• Mastitis/Breast abscess
• Inflammatory Breast Cancer
• Breast Masses
• Hormone Replacement Therapy/Drugs
• Caffeine and Nicotine
• Large Pendulous Breasts
• Ductal ectasia
• Hydroadenitis suppurativa
• Pregnancy

11
Non-cyclical Breast PainExtramammary

• Chest wall pain
• Costochondritis
• Pectoralis Major strain
• Spinal/Paraspinal disorders
• Postthoracotomy syndrome

12
Breast Pain Diagnostics

• Some experts recommend mammogram for all women
  over age 35
• Basically, no data so base your evaluation on the
  history and exam

13
Follow-up on Ms. L

• Bx showed adenocarcinoma of the lung
• Due to extensive local metastases, the pt
  underwent palliative radiation only
• She moved to another state to live with her
  daughter and died with Hospice care several
  months later

14
Ms. L Take Home Points

• 1. Establish an organized differential diagnosis
  for breast pain.
• 2. Breast cancer is not likely without physical
  findings.

15
Ms. J

• 63yo Thai female who comes to see you to
  establish primary care because her friends think
  that she is depressed
• Why do they think youre depressed?
• She is not sure if she is depressed and she
  denies suicidal ideations

16
Ms. J

• PMHx
• CAD s/p CABG
• Hypercholesterolemia
• HTN
• Arthritis
• GERD

17
Ms. J

• Medications
• Zocor
• Pepcid
• Lasix
• KCl
• Lopressor
• ASA

18
Ms. J

• SocHx Husband died 9 months ago, homemaker, no
  tobacco or illicit drugs, one bottle of wine
  every week
• ROS positive for several ER visits over the past
  2 years for various illnesses

19
Ms. J History per the computer

• 3 visits to the ER in the past 2 years, each exam
  is significant for confusion and somnolence upon
  arrival

20
Ms. J History per the computer

• Summary of the 3 ER visits
• 1. Gastroenteritis glucose 21
• 2. New diet for weight loss glucose lt 30
• 3. Depression after husbands death glucose lt 30

21
Differential Diagnosis for Hypoglycemia

• Hypoglycemia due to treatment of diabetes
• Reactive (postprandial) hypoglycemia
• Fasting hypoglycemia
• Factitious hypoglycemia
• Drugs
• Insulinoma
• In well-appearing patients

22
Differential diagnosis of hypoglycemia in Mrs. J?

• Factitious hypoglycemia
• Insulinoma

23
Ms. J

• AF, VSS, O2 sats 97 on room air
• NAD, not ill-appearing
• Remainder of exam WNL

24
Making the Diagnosis

• Tests for the following should be done
  simultaneously when the patient is hypoglycemic
  and symptomatic
• Insulin level
• C peptide level
• Sulfonylurea levels
• If necessary, perform 72 hour fasting protocol to
  induce symptomatic hypoglycemia

25
Interpretation of Lab Data

• 1. Proinsulin Insulin C peptide
• 2. Commercial insulin products only contain the
  insulin portion of this equation

26
Interpretation of Lab Data
27
Follow-up on Ms. J

• 72 hour fast was terminated in 8 hours due to
  symptomatic hypoglycemia
• Lab data met criteria for insulinoma
• After a lengthy search, the insulinoma was
  eventually located
• Resection of pancreatic insulinoma was curative

28
(No Transcript)
29
(No Transcript)
30
(No Transcript)
31
Ms. J Take Home Points

• 1. Symptomatic hypoglycemia in a non-diabetic
  patient is uncommon.
• 2. Symptomatic hypoglycemia in a non-diabetic
  patient is most likely due to use of diabetic
  medications.
• 3. Appropriate lab tests done while the patient
  is symptomatic and hypoglycemic are sufficient to
  make the diagnosis.

32
Ms. A

• 57yo AAF here for increased frequency of falls
• R hand clumsiness and weakness which has
  progressively worsened over the past 9 months
• Weakness then spread to my R leg and now she
  has difficulty keeping her balance and is falling
  2-3 times per day

33
Ms. A

• Pertinent ROS
• Dysesthesias in her fingertips and the soles of
  her feet bilaterally
• Constant burning pain from her thoracic spine
  around to her abdomen and down into her vagina
• R arm feels cold all the time
• No bowel or bladder incontinence

34
Ms. A

• She comes to see you for a second opinion because
  her previous PCP tells her that all of her
  symptoms are related to her diabetes

35
Patterns of Diabetic Neuropathy

• Distal symmetric polyneuropathy
• Focal mononeuropathy (CN III, median)
• Autonomic neuropathy
• Polyradiculopathy due to thoracic and lumbar root
  disease (amyotrophy)
• Mononeuropathy multiplex

36
Distal Symmetric Polyneuropathy

• Classic diabetic neuropathy
• Sensory loss in a stocking-glove distribution
• In severe cases, it progresses to include motor
  loss distally as well

37
Polyradiculopathy

• Lumbar (diabetic amyotrophy)
• Thigh pain
• Painful proximal weakness in one leg
• Inflammation of nerve (vasculitis?)
• Thoracic
• Severe abdominal pain in a band-like distribution

38
Mononeuropathy Multiplex

• Asymmetric involvement of multiple peripheral
  nerves

39
Ms. A

• PMHx DM, HTN, GERD, asthma, OSA
• Medications Protonix, Cozaar, 70/30 insulin,
  Advair
• SocHx Single, 5 adult children, lives alone with
  a male friend who checks in on her, discharged 2
  weeks ago from inpatient drug rehab (6 pack of
  beer daily and cocaine use qod for the past 37
  years)

40
Differential Diagnosis

• Diabetic neuropathy
• Alcohol-related neuropathy
• HIV-related neuropathy
• Progressive Multifocal Leukoencephalopathy
• Vasculitis
• Cryoglobulinemia

41
Ms. A

• AF, VSS including BP 126/69
• Gen obese, normal mental status
• Back no point tenderness
• Rectal normal sphinctor tone

42
Ms. A Neuro Exam

• AO x 3, Cranial nerves intact
• Strength 4/5 throughout except 4-/5 R hip
  flexion and 3/5 R wrist/grip, no atrophy, normal
  tone
• Sensation dysesthesias thoughout all 4 ext and
  back but light touch intact, proprioception and
  vibration diminished, Romberg equivocal
• Reflexes 3 and symmetric, unable to elicit
  ankle jerks bilaterally, Hoffmans, -
  Babinski, clonus R gt L (continuous on R)
• Cerebellar finger-to-nose and heel-to-shin
  normal
• Gait ataxic wide-based gait with some spasticity

43
Motor Neurons

• Upper
• Spasticity
• Clonus
• Hyperreflexia
• Babinski positive
• Hoffman positive

• Lower
• Atrophy
• Fasiculations
• Fibrillations
• Decreased muscle tone
• Loss of reflexes

44
Ms. A Labs

• HgA1C 6.5

45
Differential Diagnosis

• Amyotrophic Lateral Sclerosis
• Neoplasia (Intrinsic or Extrinsic)
• Heriditary Spastic Paraplegia
• Multiple Sclerosis
• Normal Pressure Hydrocephalus
• Spinal Cord Infarctions
• Syringomyelia
• Vitamin B12 Deficiency
• Cervical Spondylotic Myelopathy

46
(No Transcript)
47
Cervical Spondylotic Myelopathy

• Stenosis and eventual ischemia of the spinal cord
  due to progression of cervical DJD
• Cervical DJD is very common, so
• Why do some people get myelopathy while other are
  asymptomatic?
• Repetitive subclinical trauma
• Work that places an increased load on the head
• Posture
• Down syndrome

48
(No Transcript)
49
Common Symptoms

• Clumsy or weak hands
• Leg weakness or stiffness
• Neck stiffness or pain
• Pain in shoulders and arms
• Unsteady gait

50
Common Signs

• Atrophy of the hand musculature
• Hyperreflexia
• Lhermittes sign
• Sensory loss

51
Interesting Facts

• Clinical presentation is highly variable
• Can start with a stocking-glove sensory loss
• Usually associated with neck pain or stiffness

52
Patterns of Cervical Spondylotic Myelopathy

• Transverse affects corticospinal tract,
  spinothalamic tract and posterior columns
• Motor syndrome
• Central cord syndrome upper extremities mostly
  affected, cape distribution
• Brown-Sequard syndrome unilateral cord lesion,
  ipsilateral corticospinal tract, contralateral
  analgesia
• Brachialgia

53
Follow-up on Ms. A

• Admitted to NS service at UAB for successful
  C4-C6 anterior cervical decompression and fusion
• Marked improvement in symptoms and exam 24 hours
  after procedure
• Component of diabetic neuropathy yet to be
  determined, but all symptoms and signs can be
  explained by CSM

54
Ms. A Take Home Points

• 1. Remember that diabetic neuropathy has many
  patterns.
• 2. Be familiar with the differential diagnosis in
  patients with mixed upper and lower motor neuron
  findings.