Family Medicine 7000 Final Presentation

1
Family Medicine 7000Final Presentation

• by
• Dan Brown

2
Chicago Creek ClinicIdaho Springs, CO
3
Dr. Rik Santaguida
4
Saturday Commute
5
Weekday Commute
6
The Patient Population

• Blue collar
• Workers Comp
• Uninsured
• Medicare / Medicaid
• Acute care
• Chronic care

7
Frequent Complaints

• Orthopedic complaints
• Infectious disease
• Injuries / lacerations
• Health maintenance visits
• Mood disorders

8
An Interesting Patient

• 55 yo male with painless swelling of the LLE of
  that has been present for months
• Exact duration unknown, but pt described onset as
  gradual
• Recent Doppler exam negative for DVT
• No previous hx of DVT, OSA, Pulm/Cardiac disease
• No current meds
• No complaints of dyspnea, fatigue, additional
  areas of edema

9
Physical Exam

• BMI 32, BP 136/86, P80, RR16, T 98.4
• Unilateral LLE edematous
• LLE Non-tender
• Schaumberg purpura (brown hemosiderin deposits)
  on pretibial aspect of LLE.
• Possible eczema / dermatitis on pretibial aspect
  of LLE

10
Physical Exam Continued

• No elevated JVD
• Pulm CTAB
• Cardiac RRR, no MRG
• No liver signs No ascites, spider hemangiomas,
  or jaundice

11
Key Elements of Physical Exam

• Elevated BMI
• Consistent with OSA (Pulm HTN)
• Consistent with venous insufficiency

12
Key Elements of Physical Exam

• Distribution of edema
• Unilateral is consistent with a local cause
• Bilateral / Generalized is consistent with a
  systemic etiology.

13
Key Elements of Physical Exam

• Skin
• Schaumberg purpura and dermatitis are consistent
  with venous insufficiency

14
Causes of LE Edema

• CHF
• Dyspnea
• Fatigue
• Edema
• Elevated JVD
• Basilar crackles
• Gallop rhythm

15
Causes of LE Edema

• Pulmonary HTN
• May be secondary to OSA
• Chronic lung disease
• Left Heart Failure

16
Causes of LE Edema

• Medications
• Antihypertensive drugs
• Calcium channel blockers, Beta blockers,
  Clonidine, Hydralazine, Minoxidil, Methyldopa
• Hormones
• Corticosteroids, Estrogen, Progesterone,
  Testosterone
• Other
• Nonsteroidal anti-inflammatory drugs,
  Pioglitazone, Rosiglitazone, Monoamine oxidase
  inhibitors

17
Causes of LE Edema

• Lymphedema
• Tumor (lymphoma, prostate cancer)
• Surgery involving lymphatics
• Radiation therapy
• Infection

18
Causes of LE Edema

• DVT
• Generally acute onset
• Usually painful
• Elevated D-Dimer
• Doppler used to confirm

19
Causes of LE Edema

• Venous Insufficiency
• Associated with varicose veins
• Obesity
• Dermatitis
• Schaumberg purpura

20
DDX

• DDX for chronic (gt72 hr) unilateral LE edema
• Venous insufficiency
• Lymphedema
• Tumor
• Reflex sympathetic dystrophy (vasomotor
  disturbances)
• May-Thurner Syndrome

21
May-Thurner Syndrome

• Also called Iliac Vein Compression Syndrome
• Prevalence unknown

22
May-Thurner Syndrome

• The overlying right common iliac artery
  compresses the left common iliac vein against the
  lumbar vertebral bodies.
• This has two effects on the LCIV
• Physical entrapment
• Intimal hypertrophy due to the chronic pulsatile
  force from the artery

23
(No Transcript)
24
CT
25
Venogram
26
TX

• Non-surgical measures
• Leg elevation
• Compression stockings or pneumatic compression
  pumps
• In select cases diuretics

27
Tx

• Surgical interventions
• Usually reserved for patients that develop DVT
  secondary to May-Thurner Syndrome
• Transluminal stenting
• Angioplasty
• Venous bypass surgery
• Repositioning of the artery

28
Our Patient

• No hx of DVT
• Doppler negative for DVT
• Recommended conservative therapy
• Elevation
• Compression Stockings

29
Community Resources

• Recreation Center
• BP monitoring at Safeway

30
Clear Creek Community Service Center in Idaho
Springs

• Department of Nursing Services
• Home visits
• HTN screening
• Immunizations
• Educational forums
• Pregnancy testing
• Family planning referrals
• Flu shots

31
Clear Creek Community Service Center in Idaho
Springs

• WIC
• Nutrition / breast feeding education
• Clear Creek Tobacco Prevention Coalition

32
Clear Creek Community Service Center in Idaho
Springs

• Jefferson Center for Mental Health
• Children/family issues
• Serious mental illnesses
• Suicide prevention
• Early intervention

33
Clear Creek County Human Services in Georgetown

• Human Services
• Child protection
• Adult protection
• Therapy financial assistance
• Drug/Alcohol evaluations
• Psychological evaluations
• Parenting classes

34
Dr. Santiguida Quotes

• Would you rather have an ounce of gold or a
  pound of horse crap
• Saying that being overweight runs in the family
  really means that no one runs in the family

35
References

• Cil, Barbaros, et al, Case 76 May-Thurner
  Syndrome, Radiology, November 2004 233361-365
• Ely, John W., et al, Approach to Leg Edema of
  Unclear Etiology Evidence-Based Clinical
  Medicine, JABFM, March-April 2006, 19148-160
• Kim, Jong-Youn, et al, Percutaneous Treatment of
  Deep Vein Thrombosis in May-Thurner Syndrome,
  Cardiovascular and Interventional Radiology,
  February 21, 2006, 29571-575
• Moll, Stephan, Thrombophilia Support Page,
  http//www.fvleiden.org/ask/71.html