Week 2 Discussion
Both. case scenario summaries are attached. From each case scenario you will answer the following questions:
case 1: Internal Medicine 08: 55-year-old male with chronic disease management
case 2: Internal Medicine 15: 50-year-old male with cough and nasal congestion
- What is the CC in the case studies? What are important questions to ask the patients to formulate the history of present illness and what did the patients tell you?
- What components of the physical exams are important to review in the cases? What are pertinent positive and negative physical exam findings to help you formulate your diagnosis?
- Which differential diagnosis is to be considered with each case study? What was your final diagnosis?
Internal Medicine 08: 55-year-old male with chronic disease management
You are working with Dr. Clay in her outpatient diabetes clinic this morning.
Your first patient, Mr. Morales, was seen by Dr. Clay once before, eight years ago, but was lost to follow-up after that time.
Based on review of the electronic medical record you are able to collect the following information prior to heading into the room to meet Mr. Morales:
Mr. Morales is a 55-year-old male, diagnosed with Type 2 diabetes mellitus thirteen years ago after experiencing a 20-pound unintentional weight loss, blurry vision, and nocturia.
He was hospitalized six weeks ago with a non-ST elevation myocardial infarction and required three vessel coronary artery bypass grafting. During his admission, he was found to have a reduced ejection fraction of 20%.
He was referred for today’s visit by the cardiologist to focus on optimizing his glycemic control and reducing his risk of the comorbidities associated with poorly controlled Type 2 diabetes mellitus.
His last hemoglobin A1c (HbA1c) was 9.5% eight years ago, and he had microalbuminuria at that time.
Before you see Mr. Morales, Dr. Clay reviews diabetes chronic disease management with you.
TEACHING POINT
Diabetes Chronic Disease Management
Evaluate for and optimize prevention of diabetic complications
Macrovascular complications:
· Cardiovascular disease
· Cerebrovascular disease
Microvascular complications:
· Retinopathy
· Nephropathy
· Neuropathy
In particular, cardiovascular disease is the No. 1 cause of mortality for people with diabetes, and one of the top causes of morbidity.
Hypoglycemia, infections, foot ulcers, and amputations are additional causes of morbidity and mortality in patients with diabetes.
The American Diabetes Association publishes annual guidelines to assist in the management of a patient with diabetes.
Remember the large role that the psychosocial aspects of a diabetes diagnosis play in management
Non-adherence with medical recommendations could be due to economic, work-related, religious, social, or linguistic barriers to care. Care must be taken to assess the psychosocial status of each person with diabetes at each clinic visit to ensure that barriers to successful diabetes care are minimized.
You enter the exam room and introduce yourself to Mr. Morales.
“What brought you to the office today?”
“I had a heart attack about a month ago and had to have open-heart surgery. The heart doctors told me that my heart is weak now. My cardiologist told me that I have to get my blood sugar under control so I don’t have another heart attack. I am here to get down to work.”
“Tell me more about that.”
“I didn’t come back to see Dr. Clay because my job at the furniture factory wouldn’t give me time off for clinic appointments, and I couldn’t risk losing my job. I wasn’t checking my blood sugar before my heart attack because the testing strips are so expensive and my supervisor wouldn’t let me off the line to check anyway. Since my surgery, I haven’t gone back to work, and I’ve been checking my sugar before each meal and before bed. The hospital social worker got me two months’ worth of testing strips and lancets before I went home, but I’m going to run out in a couple of weeks. I’m worried that I won’t be able to check anymore.”
He also tells you that while he was in the hospital, they had to use insulin through his vein to keep his blood sugar controlled, and that was very upsetting to him.
You review Mr. Morales’ medications with him:
Medications
· metformin 1000 mg twice daily
· pioglitazone 15 mg daily
· glipizide 5 mg daily
· aspirin 81 mg daily
· clopidogrel 75 mg daily
· long-acting metoprolol 100 mg daily
· furosemide 80 mg twice daily
· lisinopril 20 mg daily
· amlodipine 10 mg daily
· ranitidine 150 mg twice daily
· gabapentin 300 mg twice daily
· potassium chloride 10 mEq twice daily
· atorvastatin 80 mg daily
Mr. Morales says, “The hospital doctors sent me home on an insulin shot – 40 units in my belly every night before I go to bed. I don’t like giving myself the shot, so sometimes I just don’t, but I take all the rest of my medicines like they told me to.”
He takes out the vial of insulin, and you see that it is insulin glargine.
You continue your interview with Mr. Morales and ask him:
“Have you brought your blood sugar log with you today?”
He hands you his blood sugar log proudly. Over the last four weeks, you see that his morning fasting readings are ranging 130-169 mg/dL, including before-lunch readings of 151-247 mg/dL, before-supper readings of 184-211 mg/dL, and before-bed readings of 158-305 mg/dL. There are no recorded readings under 70 mg/dL (3.9 mmol/L).
“Some days you have many readings over 200 mg/dL. Is there anything different going on on those days that you can think of such as eating larger meals?”
“Oh, those are the days after I didn’t take my insulin shot. The readings are always higher on those days.”
“Have you had any low blood sugars?”
“I feel like I have low blood sugar several times a week, and I eat a Snickers bar because I’m afraid of passing out and going into a coma. I feel like I’m going to die — shaky, sweaty, jittery! I don’t check when I feel this way, I just eat as fast as I can – I can tell when my sugar is low.”
See the associated reference ranges in conventional and SI units.
TEACHING POINT
Hypoglycemia
It is important at each visit to ask diabetic patients if they have experienced any hypoglycemic symptoms or events that required the assistance of another person.
Often times, when a patient is hypoglycemic, he does not write it down because he is preoccupied treating the hypoglycemia.
TEACHING POINT
When to Refer Patients with Diabetes to an Endocrinologist
If a patient is having recurrent or severe hypoglycemia (seizure, coma, or impairment that requires the aid of another person), an endocrinologist should be consulted. Hypoglycemia is defined as a blood glucose <70 mg/dL.
Primary care physicians’ threshold for referral varies across providers. Other conditions that would warrant referral are when a patient’s A1c is 8% more than twice in a 12-month period, despite intensive treatment; for initiation of a complex multiple daily injection insulin regimen; or for initiation of continuous infusion insulin pump therapy.
You ask Mr. Morales about diet and physical activity.
“Can you tell me what you typically eat in a day?”
“I usually eat breakfast and lunch at McDonald’s or Denny’s. For breakfast, I usually have a bacon egg and cheese biscuit with hash browns and black coffee. For lunch, I have a sandwich, fries, and soda. If I’m really hungry, I get the “value” size of the fries and soda.”
“What drinks and snacks do you typically eat during the day?”
“I drink Coke with lunch, whole milk with supper, and usually have a big bowl of fudge ripple ice cream before I go to bed. If I’m hungry in the afternoon, I’ll grab a pack of cookies from a vending machine.”
“And what do you have for dinner?”
“My wife and I eat supper at home. We share the cooking. Usually, we have fried or stewed meat with gravy, rice, or pasta along with rolls. Sometimes we have vegetables cooked with side meat.”
“Are you able to do any exercise during the week?”
“Except for moving around at work, I didn’t get much exercise before. Since my heart surgery, I feel short of breath just walking to the mailbox at the end of the driveway!”
“Do you have any chest pain or sweating?”
“Not really.”
You now decide to focus your history on screening for complications of diabetes:
“Are you having any trouble with your vision?”
“I haven’t been to the eye doctor in years, but everything is blurry most of the time. Last time I went, the doc said that my eyes looked good, so I figured that I didn’t need to go back.”
“How about numbness or tingling in your hands or feet?”
“Both my feet are numb most of the time, and they feel like they are on fire when I stand for a long time. Before my heart attack, it was getting really hard to stand on the line for my whole shift. In the hospital, they gave me a nerve medicine, gaba-something, and it helps a lot! They told me to look at the bottom of my feet every day to check for sores or blisters, and I remember to do it once or twice a week. So far, so good.”
You leave the room so that Mr. Morales can disrobe for your exam. Dr. Clay asks what you have learned so far.
You present the history to Dr. Clay and tell her that you are particularly concerned about Mr. Morales’ diet. You and Dr. Clay look at the triage sheet and see that Mr. Morales’ height is 176.5 cm (69.5 inches) and his weight is 123 kg (272 lbs). You calculate his BMI: it is 39.6 kg/m2.
TEACHING POINT
Body Weight Management in Patients with Diabetes
Classification BMI in kg/m2 Normal 19-24 Overweight 25-29 Obese 30-39 Morbidly obese 40+ Maintenance of a healthy body weight is essential in the management of patients with diabetes. However, for some patients, attainment of an ideal body weight is too large a goal, especially if they are morbidly obese. Studies have shown that a modest weight loss of approximately 5-10% of the current weight can lead to significant improvement in glycemic control, blood pressure control, and lipid parameters.
You look at the rest of Mr. Morales’ vital signs:
Vital signs:
· Temperature is 36.3 C (97.9 F)
· Pulse is 74 beats/minute
· Respiratory rate is 12 breaths/minute
· Blood pressure is 152/86 mmHg today (148/92 mmHg at the cardiologist’s office two weeks ago)
· Fingerstick blood glucose is 158 mg/dL (8.8 mmol/L)
You retake his blood pressure manually and read 150/90 mmHg.
You proceed with Mr. Morales’ exam, paying special attention to the fundoscopic exam.
Physical Exam
General: Obese, older male in no apparent distress.
HEENT: Normocephalic, atraumatic. Oropharynx clear and moist. Dentition and dental hygiene good. Pupils equal and reactive to light and accommodation. Extraocular movements intact. No icterus.
Fundoscopic exam: Several microaneurysms bilaterally and hard exudates on the left.
Neck: Supple and thick. No increased JVD. No carotid bruits. Carotid pulses 2+ bilaterally with normal upstroke. No thyromegaly or masses.
Lungs: Clear to auscultation bilaterally. No wheeze, rales, or rhonchi.
Cardiac: PMI diffuse and laterally displaced. Regular rate and rhythm. Normal S1, S2, no S3, no S4, no murmurs.
Abdomen: Soft, nontender, nondistended, no hepatosplenomegaly.
You are glad you will have the opportunity to practice the diabetic foot exam you reviewed last night.
You proceed with Mr. Morales’ exam:
Physical Exam
· Extremities: Full range of motion without clubbing or cyanosis. No peripheral edema.
· Diabetic foot exam: 1+ dorsal pedis and posterior tibialis pulses bilaterally with decreased sensation to monofilament and vibration to the mid-shin. No ulcers. + diffuse onychomycosis.
· Neurologic: Awake, alert and oriented times four. Cranial nerves II-XII are grossly intact. Muscle strength is 5/5 throughout with normal tone and bulk. Deep tendon reflexes are trace throughout. Gait normal. No tremor.
· You and Dr. Clay return to speak with Mr. Morales. Dr. Clay spends time catching up with him, clarifying some parts of the history and performing her own physical exam.
· She then asks, “How’s the smoking going?”
· He responds, “I know I need to stop smoking, Dr. Clay. I’ve cut down to less than half a pack a day, but I just can’t quite seem to do it.”
· She encourages him, “We’ll help you come up with a plan for stopping completely. We know that you can do it!”
· Dr. Clay asks Mr. Morales to get redressed and go to the lab to have some blood drawn. She directs him to return to the exam room when he is finished so you can discuss the next steps for his care together.
· You and Dr. Clay return to the exam room to talk to Mr. Morales about your recommendations for his diabetic care.
· Dr. Clay starts, “We’d like you to stop taking the metformin and pioglitazone because those medications are not the best or safest in patients who have heart failure like you do.”
· “But won’t that make my blood sugars go up with two less medicines everyday? I thought we were going to get my blood sugars lower,” Mr. Morales wants to know.
· “You’re right, Mr. Morales. Without those two medicines, your readings will likely increase, so we’d like to increase your glipizide to 10 mg daily to help. Taking glipizide with glargine insulin every day will also help. We’d like to have you call the office in a few days with your readings so we can see how it’s going. We will be working closely in the coming weeks and months to keep your glucose well controlled, and we’d like you to see a diabetes educator and a nutritionist for help with your food choices and portions.”
· You tell him that you’d like to better control his blood pressure, and he agrees to take the increased lisinopril dose.
· “The good thing, Mr. Morales, is that getting your glucose and blood pressure under control will help your kidneys function better. And stopping smoking will help too. Have you thought about whether you are ready to quit now? Would you consider setting a quit date?”
· He responds, “Maybe we can talk about that when I come back the next time.”
· You remind him to check his blood sugar with his glucose meter when he feels “low” so that he doesn’t eat when he doesn’t need to. You reiterate the proper treatment of blood glucose to achieve a reading of >70 mg/dL (>3.9 mmol/L).
· You make him an appointment for a dilated eye exam and advise him to check his feet daily.
· You are able to give him two more weeks of testing strips and the toll-free number to the patient assistance line for glargine insulin so that he can request samples. You ask him to see the clinic’s social worker for further help with patient assistance and hand him a note for work explaining his need to be allowed off the line to check his blood sugar regularly, as well as his need to be seen in close follow up with Dr. Clay.
· As he leaves, Mr. Morales says, “I’ll see you in two weeks, and thank you for taking the time to really talk to me and find out how to help. I feel like I am really going to be able to take care of myself this time, and I’ll have my tobacco quit date when I see you again!”
·
· It is two weeks later and Mr. Morales is back in Dr. Clay’s diabetes clinic.
· You take a look at the electronic medical record, and the lab results from Mr. Morales’ initial clinic visit reveal:
Lab Values: Conventional: SI: Potassium 4.8 mEq/L 4.8 mmol/L BUN 29 mg/dL 10.4 mmol/L Creatinine 1.8 mg/dL 159 μmol/L Hemoglobin A1c 8.3% Total cholesterol 213 mg/dL 5.52 mmol/L Triglycerides 385 mg/dL 4.35 mmol/L HDL 38 mg/dL 0.98 mmol/L LDL 117 mg/dL 3.03 mmol/L · Liver function panel: normal
· Spot urine albumin to creatinine ratio: 120 mcg/mg creatinine
· You realize that the spot urine albumin to creatinine ratio confirms Mr. Morales’ prior history of increased urinary albumin excretion. Prior to seeing Mr. Morales, you decide to look up some information about diabetic nephropathy.
· You are glad that you increased Mr. Morales’ lisinopril dose during the last visit since it will hopefully slow progression of his diabetic nephropathy.
· You highlight that his A1c is above goal, but you tell Dr. Clay that it may not be necessary to make adjustments to his diabetic regimen since that was done at the last visit.
· See the associated reference ranges in conventional and SI units.
· TEACHING POINT
· Diabetic Nephropathy
· Epidemiology
· Diabetic nephropathy occurs in 20% to 40% of diabetic patients and is the most common etiology of end-stage renal disease in the U.S.
· Risk factors associated with the progression of diabetic nephropathy include: obesity, increasing age, African American race, and tobacco abuse.
· Pathogenesis
· Kidney insult appears to originate with glomerular hypertension and hyperfiltration. Chronic hyperglycemia leads to mesangial expansion, deposition of matrix, increased amount of VEG-F and other cytokines, local inflammation, and activation of protein kinase C.
· Prevention / Treatment
· Two large prospective trials (DCCT with type 1 diabetics and UKPDS with Type 2 diabetics) revealed that intensive glucose management resulted in prevention or delayed onset and progression of diabetic nephropathy.
· Aggressive blood pressure lowering is critical for treatment of increased urinary albumin excretion. In patients with hypertension with increased urinary albumin excretion, an ACE inhibitor or ARB therapy is recommended to delay the onset and decrease progression of diabetic nephropathy.
· Referral
· Referral to nephrology is appropriate if the cause of kidney disease is not certain, and or there are challenging management issues present, such as resistant hypertension or electrolyte derangement. The threshold for referral to nephrology varies across providers; however, nephrology should be consulted if Stage 4 or greater chronic kidney disease (GFR < 30 ml/min per 1.73 m2) develops since this has been found to reduce cost, improve quality of care, and keep people off dialysis longer.
Internal Medicine 15: 50-year-old male with cough and nasal congestion
It is September and you are working with Dr. Erin Griffin in her outpatient general medicine clinic. She asks you to see Mr. Fadil Taleb, a 50-year-old male with respiratory symptoms. Dr. Griffin tells you he is relatively new to the practice and has been seen only once in the past for a general physical.
You enter the room and introduce yourself. You then begin taking a history.
“What brings you to the office today?”
“I have been sick for the past three or four days. It started with my throat being scratchy and lots of sneezing. Now my nose is all stopped up, and I’m blowing it constantly. I’m also coughing a lot.”
“Have you had a fever?”
“I felt warm the first day but now I just have the chills occasionally. I am also really tired.”
“Is anyone else you know ill?”
“My kids were sick at the end of last week. One of them is still coughing but the others seem better. My kids are in school right now, and during the school year it seems like one of them picks up something at school almost every other week. I ride the bus to and from work, and there are always people coughing there.”
“Do you smoke?”
“Yeah, doc, I know it’s not good for my health, but I do smoke. Usually it’s about a half pack per day, but since I have been sick, I have been smoking only one or two cigarettes a day.”
“Tell me more about your cough. Do you bring anything up?”
“No, it’s a dry cough, but it wakes me up at night several times.”
“Do you feel short of breath?”
“No, not really.”
“Does your chest hurt?”
“No. Can’t say that it does.”
“Have you tried any medicine to help?”
“My face has felt full, so I took some Actifed Cold and Allergy tablets, but they didn’t seem to do much. I’ve also taken some Cold-EEZE, vitamin C, and Waltussin DM, but nothing is helping.”
“Have you had problems like this before?”
“I had this same thing last fall and it lasted a couple of weeks. I hate to bother you doctors with this, but I don’t want to get any worse.”
You review Mr. Taleb’s chart and confirm the following:
Past Medical History:
Hyperlipidemia (6 months ago)
Lab Values: Conventional: SI: Total cholesterol 220 mg/dL 5.70 mmol/L HDL 41 mg/dL 1.06 mmol/L LDL 145 mg/dL 3.76 mmol/L Medications:
· None except over-the-counter medications
· Actifed Cold and Allergy (phenylephrine and chlorpheniramine)
· Cold-EEZE (zinc gluconate)
· Vitamin C
· Waltussin DM (guaifenesin and dextromethorphan).
Allergies:
None
Family History:
· Mother: Alive and well.
· Father: High cholesterol, HTN.
· Paternal uncle: Coronary artery disease, hx of MI.
· Three sisters: Well.
Social History:
Married and monogamous. Works as a computer specialist for the help desk at the hospital. Three children ages 12, 15, and 18 years old. Has smoked half pack per day for the past 25 years. Quit with each of his wife’s pregnancies, then resumed a year or so later. He rarely drinks alcohol and has never used IV drugs.
Review of Systems:
No headache, myalgias, hemoptysis, weight loss, or night sweats.
Most Likely / Important Diagnoses
The following are the most likely / important diagnoses at this point:
· allergic rhinitis (A)
· acute bronchitis (C)
· viral upper respiratory infection (URI) (I)
At this point, URI, allergic rhinitis, and acute bronchitis seem to be the most likely diagnoses. You are anxious to gather more information from Mr. Taleb.
TEACHING POINT
Differential of Acute Respiratory Symptoms in Middle-Aged Male with Smoking History
Viral URI · Sore throat is often the first symptom.
· Sneezing and stuffy nose are classic symptoms, particularly in its first stage.
Allergic rhinitis · The cardinal symptom is the seasonal occurrence of sneezing, watery rhinorrhea, nasal congestion, and itchy, watery eyes.
· Causes symptoms that last for weeks during exposure to environmental allergens; thus, a short duration of symptoms would argue against this diagnosis.
· Fever is not common, and if present argues against this diagnosis.
Acute bronchitis · A self-limited inflammation of the large airways in the lung which is characterized by cough. It leads to excessive tracheobronchial mucus production sufficient to cause purulent sputum in half of patients. The cause is usually viral, but it can lead to a secondary bacterial infection.
· Symptoms during the first few days are hard to distinguish from those of a URI. However, the cough of acute bronchitis persists for more than five days.
You proceed with the physical examination. During your examination, you note the following:
Vital signs:
· Temperature: 37.2 C (98.9 F)
· Pulse: 76 beats/minute
· Respiratory rate: 14 breaths/minute
· Blood pressure: 125/76 mmHg
· Weight: 91 kg (200 lbs)
· Height: 178 cm (70 in)
· Body Mass Index: 28.7 kg/m2
General: Well developed, well nourished male. No acute distress.
Eyes: Clear conjunctiva, no discharge, anicteric sclera.
Ears: Canals are clear. TMs are clear. No redness or bulging.
Nose: No maxillary or frontal sinus tenderness on palpation. No dullness on transillumination.
Throat: Slightly reddened posterior pharynx but no exudates or tonsillar enlargement. There is no cobblestoning.
Neck: No cervical or supraclavicular lymphadenopathy.
Chest: Good excursion. No dullness to percussion. Rhonchi throughout all lung fields. There are no wheezes or crackles.
CV: RRR normal S1 and S2. No murmurs, rubs, or gallops.
Skin: Yellow nicotine stains on right ring and middle finger.
Dr. Griffin joins you to review what you have covered with Mr. Taleb up to this point. She asks what you found on the nasal examination. You confess you didn’t look up his nose, but will now.
You examine Mr. Taleb’s nose and find clear discharge with slight erythema of the nasal mucosa.
Question
Which findings on a nasal examination are most consistent with bacterial sinusitis? Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
· A. Mucosal edema, erythema, and purulent nasal discharge.
· B. Mild mucosal edema that is shiny or glassy-appearing, and clear nasal discharge.
· C. Mild mucosal edema that is pale or bluish in color. Clear nasal discharge.
· You tell Dr. Griffin, “I think Mr. Taleb has a viral upper respiratory infection. He does not have a fever, productive cough, or signs of consolidation – ruling out pneumonia. His throat is not very red, and there are no exudates, so I don’t think it is strep throat. Since he does not have purulent nasal discharge, sinus tenderness or tooth pain, sinus infection is unlikely. His rhonchi support the possibility of early viral bronchitis, but it is too early in his illness to say for sure. Given the constellation of nasal congestion, scratchy throat, and cough with a benign physical, I think a viral URI is the most likely diagnosis.”
· Dr. Griffin says, “I agree with you that Mr. Taleb is suffering from the common cold. How do you think we should treat him?”
· At this point, Mr. Taleb interjects, “A Z-Pack has worked for me in the past.”
· With some help from Dr. Griffin, you explain to Mr. Taleb that you believe he has a common cold. You go on to explain that colds are caused by viruses and not bacteria and that antibiotics treat bacterial infections only. You end by telling him that viral infections are self-limited, and treatment is supportive. You discuss how to prevent spreading the cold and and inform Mr. Taleb when he can expect to feel better. You then ask if he has any questions.
· “Are you sure it is not the flu? Should I get a flu shot?”
· “Yes, I am sure it is not the flu. With the flu you would have a high fever that started all of a sudden, a lot of muscle aches, a headache, as well as a bad cough. And yes, you’re right, as a smoker you should receive a flu shot. We start administering it as soon as it is available; ideally you should have it before October 1st.”
· “My last doctor always gave me antibiotics. Are you sure I don’t need them?”
· “Yes. Antibiotics will not work for your viral infection and they can cause problems, such as diarrhea. Furthermore, using antibiotics unnecessarily can cause bacteria to become resistant to them, so the antibiotic won’t work when you do need it! There is a tiny chance you could develop bacterial sinusitis, but this happens less than 2% of the time. If you develop a toothache in your upper teeth or a fever, you should give us a call.”
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