clinical problem solving

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