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Clinical Problem SolvingClinical Problem SolvingSeptember 2007September 2007
Presenter: Gustavo R. HeudebertPresenter: Gustavo R. Heudebert
Discussant: Robert (DB) CentorDiscussant: Robert (DB) Centor
Division of General Internal MedicineDivision of General Internal Medicine
Knowledge
Context
Experience
HPI
Data Acquisition
“Problem Representation”
Generation of Hypothesis
Search/selection of illness scripts
Diagnosis
Bowen, JL. N Eng J Med 2006;355:2217-25.
Caso Numero UnoCaso Numero Uno
49 yo male with a three month 49 yo male with a three month history of weakness and shortness of history of weakness and shortness of breathbreath
Detail HPIDetail HPI
WeaknessWeakness– Generalized fatigueGeneralized fatigue– No muscle weaknessNo muscle weakness
Shortness of breathShortness of breath– From normal activities to DOE with From normal activities to DOE with
minimal exertionminimal exertion– No PND, orthopnea, LE edema, or chest No PND, orthopnea, LE edema, or chest
painpain
Knowledge
Context
Experience
HPI
Data Acquisition
“Problem Representation”
Generation of Hypothesis
Search/selection of illness scripts
Diagnosis
Bowen, JL. N Eng J Med 2006;355:2217-25.
More HPIMore HPI
Weight loss: 15 poundsWeight loss: 15 pounds
Decreased appetiteDecreased appetite
Pertinent ROSPertinent ROS– No fever or chills; night sweatsNo fever or chills; night sweats– No nausea or vomitingNo nausea or vomiting– No early satietyNo early satiety– No melenaNo melena
CMS ComplianceCMS Compliance
Family History: non contributoryFamily History: non contributory
Ten organ system ROS: as per HPI Ten organ system ROS: as per HPI
Social HistorySocial History– NO tobacco / EtOH / illicit drugsNO tobacco / EtOH / illicit drugs– Employed / marriedEmployed / married
MedicationsMedications– nonenone
Knowledge
Context
Experience
HPI
Data Acquisition
“Problem Representation”
Generation of Hypothesis
Search/selection of illness scripts
Diagnosis
Bowen, JL. N Eng J Med 2006;355:2217-25.
Physical ExaminationPhysical Examination136/75; RR: 16x’; HR: 103x’; 99.3◦F136/75; RR: 16x’; HR: 103x’; 99.3◦FPale and anictericPale and anictericLungs: CTA bilaterallyLungs: CTA bilaterallyCV: regular tachycardia but no m/r/gCV: regular tachycardia but no m/r/gAbdomen: no HSMAbdomen: no HSMSkin: no rash or petechiaeSkin: no rash or petechiaeNeurological: no sensory or motor Neurological: no sensory or motor deficitsdeficits
Laboratory DataLaboratory DataCBCCBC– WBC: 3.4K (normal differential)WBC: 3.4K (normal differential)– H/H: 5.1 gm/dl and 15%H/H: 5.1 gm/dl and 15%– Platelets: 53KPlatelets: 53K– MCV: 126MCV: 126
C-7: normalC-7: normalLDH: 6510; Total Bilirubin 2.6 mg/dl LDH: 6510; Total Bilirubin 2.6 mg/dl (Indirect 2.4 mg/dl)(Indirect 2.4 mg/dl)Reticulocyte count: 1.5%Reticulocyte count: 1.5%
Knowledge
Context
Experience
HPI
Data Acquisition
“Problem Representation”
Generation of Hypothesis
Search/selection of illness scripts
Diagnosis
Bowen, JL. N Eng J Med 2006;355:2217-25.
Laboratory dataLaboratory data
RBC Folate: normalRBC Folate: normal
B12 level: < 100 pg/mlB12 level: < 100 pg/ml
Intrinsic Factor: positiveIntrinsic Factor: positive
Vitamin B12 DeficiencyVitamin B12 Deficiency
Nutritional megaloblastic anemiaNutritional megaloblastic anemia
PhysiologyPhysiology– Dietary Intake of Cobalamin (Cbl)Dietary Intake of Cobalamin (Cbl)– Acid and pepsinAcid and pepsin– Pancreatic proteasesPancreatic proteases– Secretion of intrinsic factor (IF)Secretion of intrinsic factor (IF)– Ileum with receptors for Cbl-IFIleum with receptors for Cbl-IF
CausesCausesPernicious AnemiaPernicious Anemia– Anti-IF or antibodies against parietal Anti-IF or antibodies against parietal
cellscells
Intestinal DisorderIntestinal Disorder– Pancreatic insufficiency / ileitis / SB Pancreatic insufficiency / ileitis / SB
malabsorption / amyloidosismalabsorption / amyloidosis
Age relatedAge relatedMedicationsMedications– PPI , metforminPPI , metformin
FindingsFindings
HematologicalHematological– Anemia (occasionally pancytopenia), Anemia (occasionally pancytopenia),
increased LDH, low haptoglobin, increased LDH, low haptoglobin, increased indirect bilirubin, increased indirect bilirubin, macrocytosis, peripheral smearmacrocytosis, peripheral smear
NeurologicalNeurological– Subacute combined degeneration Subacute combined degeneration
(posterior and lateral columns) and CNS (posterior and lateral columns) and CNS disease (mood to dementia)disease (mood to dementia)
DiagnosisDiagnosis
Vitamin B12 levelVitamin B12 level– Methylmalonic acid and homocysteine Methylmalonic acid and homocysteine
(only in folate deficiency)(only in folate deficiency)
Intrinsic FactorIntrinsic Factor– 70% sensitive and >95% specific70% sensitive and >95% specific
Caso Numero DosCaso Numero Dos
43 yo WF with diarrhea43 yo WF with diarrhea– One year durationOne year duration– 10-12 BM/day; no blood or mucus; small 10-12 BM/day; no blood or mucus; small
volume and wateryvolume and wateryBlood in toilet paperBlood in toilet paper
– Pain with BM (crampy)Pain with BM (crampy)– 20 pounds of weight loss20 pounds of weight loss– Wakes her up at nightWakes her up at night
CMS StuffCMS Stuff
Social HistorySocial History– Municipal water; no travel or campingMunicipal water; no travel or camping– Married; no EtOH but 45 pack-year Married; no EtOH but 45 pack-year
(current); no illicit drug use(current); no illicit drug use– Former nurse; retired because of Former nurse; retired because of
diarrheadiarrhea
More CMSMore CMS
MedicationsMedications– Imodium prn; metabolite; prn ibuprofenImodium prn; metabolite; prn ibuprofen
Family History: no CRCFamily History: no CRC
Past Medical HistoryPast Medical History– Two uncomplicated pregnanciesTwo uncomplicated pregnancies
ROS:ROS:– Knee pain last two to three yearsKnee pain last two to three years– Gas in vaginaGas in vagina
Physical ExaminationPhysical Examination
AF; 73x’; 16x’; 121/64AF; 73x’; 16x’; 121/64
Skin: no rashSkin: no rash
MS: no erythema or deformitiesMS: no erythema or deformities
Pelvic:Pelvic:– Stool noted in vaginal vaultStool noted in vaginal vault
Fistula 2 cm from perineumFistula 2 cm from perineum
– Rectal: fistula palpatedRectal: fistula palpated
Laboratory DataLaboratory Data
CBCCBC– WBC: 14K with normal differentialWBC: 14K with normal differential
ESR: 33 mm/hourESR: 33 mm/hour
C-7 normalC-7 normal
Albumin 2.5 mg/dlAlbumin 2.5 mg/dl
UA: normalUA: normal
ImagingImaging
ACBE: normalACBE: normal
MRI pelvis: normalMRI pelvis: normal
ColonoscopyColonoscopy– Cobble stone appearance of colonic Cobble stone appearance of colonic
mucosamucosa– Patchy involvementPatchy involvement
BiopsyBiopsy– Consistent with Crohn’s diseaseConsistent with Crohn’s disease
Crohn’s DiseaseCrohn’s DiseaseBimodal age distributionBimodal age distribution– Second to third decade of life and then Second to third decade of life and then
66thth to 7 to 7thth decade of life decade of life
Common manifestationsCommon manifestations– Chronic diarrheaChronic diarrhea– Crampy abdominal painCrampy abdominal pain– Weight lossWeight loss– Gross blood loss is uncommonGross blood loss is uncommon
Clinical presentation is variableClinical presentation is variable
Fistulae and sinus tractsFistulae and sinus tractsInitiates and terminates in epithelia-Initiates and terminates in epithelia-lined organslined organs– Related to transmural inflammationRelated to transmural inflammation
33% to 50% risk (at 10 and 20 years)33% to 50% risk (at 10 and 20 years)– Enteroenteric Enteroenteric – EnterovesicalEnterovesical– Enterovaginal: gas and stool in vaginaEnterovaginal: gas and stool in vagina– EnterocutaneousEnterocutaneous
Rectovaginal fistulaeRectovaginal fistulae
Most commonly related to obstetric Most commonly related to obstetric traumatrauma– Prolonged laborProlonged labor
Other causesOther causes– Malignancies: colon and pelvicMalignancies: colon and pelvic– IBD, particularly Crohn’sIBD, particularly Crohn’s
Complex managementComplex management
Caso Numero 3Caso Numero 3
57 yo WM “seeing funny”57 yo WM “seeing funny”– Blurry and double visionBlurry and double vision– Eight days durationEight days duration– Heralded by sudden onset of eye painHeralded by sudden onset of eye pain
Retro-orbitalRetro-orbital
– No traumaNo trauma– No fever or chillsNo fever or chills– No prior similar episodeNo prior similar episode
Other InformationOther InformationPast Medical HistoryPast Medical History– T2DM, gout, hypertension, CKD, and T2DM, gout, hypertension, CKD, and
hyperlipidemiahyperlipidemia
Social HistorySocial History– Former tobacco, no EtOH or illicit drug Former tobacco, no EtOH or illicit drug
useuse– Married, employed (clerical work)Married, employed (clerical work)
Medications: ASA, HCTZ, metformin, Medications: ASA, HCTZ, metformin, enalapril, and simvastatinenalapril, and simvastatin
Physical ExaminationPhysical Examination97.9 F; BP: 153/111; 87x’; 14x’97.9 F; BP: 153/111; 87x’; 14x’WD, WN, NAD. Diplopia resolves WD, WN, NAD. Diplopia resolves when covering one eyewhen covering one eyePupillary reflexes: normal. Esotropia Pupillary reflexes: normal. Esotropia of left eyeof left eyeCN examination: inability to abduct CN examination: inability to abduct left eye pass midline. Rest of CN left eye pass midline. Rest of CN normalnormalDecrease pinprick and discrimination Decrease pinprick and discrimination of both feet of both feet
DiplopiaDiplopiaDue to muscular or neurological Due to muscular or neurological problemproblemImportant issuesImportant issues– PainPain
Sudden (?); preceded diplopia (?)Sudden (?); preceded diplopia (?)
– Direction of maximal diplopiaDirection of maximal diplopia– Horizontal Vs. VerticalHorizontal Vs. Vertical– Associated findingsAssociated findings
Exophthalmos (?)Exophthalmos (?)
Diabetic MononeuropathiesDiabetic Mononeuropathies
Two formsTwo forms– CranialCranial
Sudden onsetSudden onset
Pain precedes diplopiaPain precedes diplopia
Resolves spontaneouslyResolves spontaneously
III, IV, and VI nerve palsiesIII, IV, and VI nerve palsies
– PeripheralPeripheralMedian and ulnar most commonMedian and ulnar most common
Also peronela and femoral (very rare)Also peronela and femoral (very rare)
VI Nerve PalsyVI Nerve Palsy
UnilateralUnilateral– Most likely cause in adults is either Most likely cause in adults is either
idiopathic or related to diabetesidiopathic or related to diabetes– Sudden onset of ocular pain followed by Sudden onset of ocular pain followed by
diplopiadiplopiaPain usually resolves before diplopiaPain usually resolves before diplopia
– Pupillary sparingPupillary sparing– Esotropia and inability to abduct the eyeEsotropia and inability to abduct the eye
VI Nerve PalsyVI Nerve Palsy