Category Archives: Ambulatory

VA Ambulatory Report 8.16.17 – Falls in the Elderly and Urinary Retention in Women

Thanks Beth for the awesome case of a 90 yo F with pmhx of HTN, CKD presenting after multiple falls who developed urinary retention and fecal incontinence found to have cervical spine myelopathy from spinal stenosis.

Key Learning Points

  • Approach to a patient with falls:  Consider a physiologic approach thinking about the systems that need to be functioning properly to walk: cognition, motor strength, sensation, musculoskeletal apparatus, cardiovascular fitness, navigable environment
  • Use the CHIP rule for determining which patients presenting to urgent care or the ambulatory setting need a head CT.  The Canadian head CT rule is for patients with loss of consciousness
  • The Timed Get-Up and Go test is helpful for assessing falls risk

 

Falls in the elderly

Step 1– Assess if the fall is consistent with syncope or pre-syncope vs. mechanical cause.

Step 2 – Assess the patient for injuries related to the fall.

  • When to get a head CT?
  • Decision rules to help us decide who needs a head CT after a fall.  The Canadian CT Head Rule is often applied in the Emergency setting and only applies to patients with loss of consciousness.  The Canadian head CT rules are the most widely validated.
  • For the ambulatory and urgent care setting you could consider using the CHIP rule because it applies to patients without loss of consciousness. Note that the CHIP rule recommends head CT in patients over 60 years of age.  This is a nice reminder that our older patients are at a much higher risk of subdural hematomas due to cerebral atrophy even with minor head trauma.

 

Step 3 – Evaluate for the etiology of the fall

Falls in the elderly are multifactorial and each fall could have a different etiology so needs to be evaluated separately.

You can use a physiologic approach to falls.  Think about all the systems you need to walk (which is actually a very complex task!):

  • Cognition
    • Dementia from any cause
    • Dementias associated with decreased physical functioning: parkinsons, spinal muscle atrophy
    • Normal pressure hydrocephalus
    • Drugs and toxins: alcohol, medications (see below)
  • Motor strength
    • Primary muscle disease
    • Stroke
    • Myelopathy
    • Neuromuscular junction disorder
  • Sensation
    • Peripheral neuropathy
    • Poor vision
    • Vestibular dysfunction
  • Musculoskeletal apparatus
    • Osteoporosis
    • Fracture
    • Ligamentous Injury
  • Cardiovascular fitness
    • Orthostatic hypotension
    • Arrythmias
  • Navigable environment
    • Lighting, irregular floor surfaces, unsafe stairs, cords and carpets
  • Medications (always include as a category of your differential in the elderly!)
    • Sedative-hypnotics, TCAs, antihypertensives, cardiac medications, corticosteroids, NSAIDs, anticholinergic meds, hypoglycemic agents

 

Timed Up and Go Test

  • Can be used to help with the global gait assessment
  • How to perform: Instruct the patient to get out of the chair (without using armrests), stand up, walk forward 10 feet, turn around and walk back to chair, sit down.
  • Normal is < 10 seconds and indicates the patient is mobile.  > 20 seconds indicates the patient is variably mobile.  > 30 seconds indicates impairments in mobility
  • Aside from timing, observing the patient’s ability to perform each maneuver of the test can help you determine what area the patient is deficient .

Interventions for abnormal results of the Timed Up and Go test (Table copied from Preventing Falls in the Geriatric Population reference below)

Observation Significance Intervention
Difficulty rising from chair Proximal muscle weakness PT referral for lower extremity strengthening
Staggering or reported dizziness upon rising Possible orthostasis Check orthostatic vital signs; review medications that may contribute to orthostasis
Pill-rolling tremor, stooped posture, shuffling/festinating gait Possible parkinsonism Consider neurology referral
Increased sway, magnetic gait Possible normal pressure hydrocephalus Ask about urinary incontinence and memory issues. If these are highly suspected, consider head CT
Path deviation Possible peripheral neuropathy, cerebrovascular disease Consider neuropathy workup, examination of feet, PT referral for assistive device
Slow, antalgic gait Pain from osteoarthritis, peripheral neuropathy, podiatric disorders Pain control, examination of feet

 

Differential for Urinary Retention in Women

  • Detrusor underactivity: aging, DM, neurologic disease (stroke, spinal cord compression),
  • Outflow obstruction: pelvic organ prolapse, pelvic masses
  • Functional: Dysfunctional voiding, Detrusor sphincter dyssynergia, bladder neck obstruction
  • Meds: Most common: anticholinergic and sympathomimetic
  • Infection – UTI, genital herpes

 

Smits M, et al. Predicting intracranial traumatic findings on computed tomography in patients with minor head injury: the CHIP prediction rule. Ann Intern Med. March 20, 2007;146(6):397–405.

AAFP article on falls in the elderly: http://www.aafp.org/afp/2000/0401/p2159.html

 

 

VA Ambulatory Report 8.2.17 – Weight loss and artificial valve endocarditis

Thanks Tim for presenting the case of a 76 yo M with a pmhx of AS s/p valve replacement presenting to clinic with subacute fatigue, fevers, and weight loss found to have endocarditis likely from one of the HACEK organisms with final culture results still pending.

Key Learning Points

  • If your baseline work-up (see details below) of weight loss in the elderly is normal, the likelihood of malignancy is very low.  There is no need for further testing, but you should continue with close follow-up.
  • TAVR is indicated for severe AS with symptoms and prohibitive surgical risk but also been shown to be non-inferior for high and intermediate surgical risk patients
  • Complications of artificial heart valves include: infection, thromboembolism, obstruction, regurgitation, and hemolytic anemia
  • HACEK organisms most often will grow in blood cultures but can take longer than our more common strep and staph species.

 

Weight loss in the elderly (flash back to report pearls from 6.7.17!)

  • Work-up is directed by history and physical but at a minimum should include: CBC, BMP, LFTs, TSH, CRP, ESR, LDH, UA, CXR, FOBT, maybe abdominal ultrasound
  • A prospective study demonstrated that if this baseline work-up is normal none of the patients went on to have malignancy demonstrated on additional testing. Therefore if the baseline work-up is normal, no further testing is necessary but continue with close follow-up.
  • AAFP Practice guidelines for Unexplained Weight Loss in Older Adults

 

Artifical Heart Valves

  • Types of artifical valves
    • When choosing between bioprosthesis vs. mechanical valves it should be a shared decision with the patient. Things to consider:
      • Longevity of the valve: Mechanical heart valves last 20-30 years vs. 10-15 years with bioprosthetic valves. Consider mechanical heart valves most often in patients < 60 years and bioprosthetic valves in patients > 70 years
      • Anticoagulation: Required in mechanical valves
    • Ball and cage valves: Phased out ~ 20 years ago, very durable but more complications including thromboembolism, migration of the whole valve, and the ball getting stuck in the cage
  • Methods for valve replacement: Surgical vs. TAVR
    • The PARTNER trial demonstrated non-inferiority of TAVR vs. SAVR for high surgical risk patients
    • Indications for TAVR:
      • Severe AS with symptoms and prohibitive risk for surgical replacement
      • Severe AS with symptoms and high surgical risk
        • Patients could also undergo SAVR
        • The PARTNER trial demonstrated non-inferiority of TAVR vs. SAVR for high surgical risk patients
      • TAVR is a reasonable alternative for patients at intermediate surgical risk depending on patient specific variables
        • PARTNER II trial demonstrated non-inferiority for TAVR vs. SAVR in intermediate risk patients
      • Contraindicated for bicuspid aortic valves
      • TAVR has not been studied in asymptomatic patients and therefore is not recommended.  Patients should be monitored clinically for development of symptoms.
  • Complications of artificial valves
    • Infection
    • Thrombus
      • Prosthetic valve thrombus leading to obstructive symptoms
      • Thromboembolism
    • Valve obstruction
      • Can be due to: leaflet fibrosis, Calcification, pannus formation, or thrombus
        • LT taught us about a patient he had with pannus formation which is fibrous tissue ingrowth around the valve.  This is much less common than other causes of obstruction
      • For dx: get echo to determine valve gradient and consider CT to better characterize the mass on the valve.  The patient may need surgery for diagnosis and treatment.
    • Valve regurgitation
      • Can occur both through the valve itself and paravalvular
      • Due to leaflet degeneration, calcification, endocarditis, thrombus, or pannus formation
    • Hemolytic Anemia

 

Endocarditis

  • HACEK organisms: Although historically classified as culture negative endocarditis, our current culture methods can grow these organisms but they take longer to grow (Median time is ~ 3 days).
  • Most common cause of culture negative endocarditis: fastidious organisms and strep species in patients already on antibiotics.
    • Diagnosing Q fever endocarditis
      • Phase I IgG antibody titer should be > 800
        • Duke’s criteria include microbiological evidence of infection. Major criteria: IgG Phase I titer > 6400. Minor criteria is a titer > 800
  • Shout out to Rabih’s prior morning report pearls on endocarditis breaking the differential down between culture positive and culture negative endocarditis.

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References:

PARTNER Trial: Smith, Craig R., et al. “Transcatheter versus surgical aortic-valve replacement in high-risk patients.” New England Journal of Medicine 364.23 (2011): 2187-2198. http://www.nejm.org/doi/full/10.1056/NEJMoa1103510#t=article

PARTNER II Trial: Leon, Martin B., et al. “Transcatheter or surgical aortic-valve replacement in intermediate-risk patients.” N Engl J Med 2016.374 (2016): 1609-1620.  http://www.nejm.org/doi/full/10.1056/NEJMoa1514616

AHA/ACC Guidelines for management of Valvular Heart Disease: http://circ.ahajournals.org/content/early/2017/03/14/CIR.0000000000000503

Ambulatory Report 7.26.17 – Charles Bonnet Syndrome, Alice-in-Wonderland syndrome, and high output heart failure!

Double Ambulatory Report Cases!
Case 1: LT presented a case of his primary care patient of 30 years!  The case was an elderly male pmhx of CAD, Afib, macular degeneration presenting with left visual field hallucinations found to have Charles Bonnet syndrome.
Case 2: Thanks Lily for presenting this interesting and yet to be solved case of a young male with a history of severe eczema on topical steroids, bloody bowel movements, who presents with subacute lower extremity edema and anemia.
Takeaways:
  1. Charles Bonnet syndrome: visual hallucinations that occur in people with vision loss due to disinhibition of the visual cortex
  2. Divide your differential for lower extremity edema into unilateral or bilateral causes.
  3. High output heart failure can be seen in many disease states including anemia, obesity, beriberi, and hyperthyroidism.
Charles Bonnet syndrome: 
  • Visual hallucinations in individuals with vision loss
  • Pathophysiology is theorized to be due to visual sensory deafferentation leading to disinhibition of the visual cortex which then fires spontaneously
  • Can occur in visual loss due to any cause including macular degeneration, optic nerve pathology, stroke, etc
  • The hallucinations can be non-formed (lines, flashes, shapes) or formed (people, scenes)
  • May be more common than we realize due to patients underreporting and clinicians mis-diagnosing as psychosis or dementia

 

Alice-in-Wonderland Syndrome
  • Episodes of visual hallucinations, bizarre perceptual distortions (usually body size distortion), or impairments in sense of time
  • Can be seen in migraines, temporal lobe epilepsy, brain tumors, psychoactive drugs,  or EBV infections
Differential diagnosis of lower extremity edema
  • Unilateral
    • Cellulitis
    • Clot
    • Lymphedema
    • Asymmetric venous stasis
  • Bilateral
    • Nephrotic Syndrome
    • Cirrhosis
    • Heart Failure
    • Low albumin state or protein loss
      • protein-losing enteropathy
      • Malnutrition
    • Refeeding syndrome
    • Pregnancy
    • Hypothyroidism
    • Venous stasis
    • Increased capillary permeability due to sepsis, burns, trauma, allergic reaction
    • Drugs: vasodilators, CCB, alpha-blockers, NSAIDs, steroids, androgens, estrogen, gabapentin, ropinirole, pramipexole, docetaxel, cisplatin
High Output Heart Failure
  • Hemodynamic characteristics: Elevated cardiac output, low SVR, increased oxygen consumption
  • Leads to neurohormonal activation —> reduced renal blood flow — > chronic volume overload due to retention of salt and water (See diagram below)
  • Patients will have symptoms of volume overload similar to low output heart failure
    • However, they will have warm extremities due to low SVR and vasodilatation
  • Causes:
    • Physiologic: excitement, anxiety, stress, exercise, pregnancy, fever
    • Pathologic
      • Obesity
      • AV shunts
      • Liver disease
      • Lung disease
      • Myeloproliferative disorders
      • Sepsis
      • Hyperthyroidism
      • Anemia
      • Beriberi
      • Dermatologic disorders (psoriasis)
      • Certain renal disorders (AV fistula)
      • Carcinoid syndrome
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Ambulatory Report 7.19.17 – Secondary Hypertension and a Hemorrhagic Stroke in a young patient

Thanks John for presenting this great case!  We discussed the case of a 31 yo male with a pmhx of hypertension and hemorrhagic stroke who was presenting for primary care now undergoing a work-up for secondary hypertension.

High-yield pearls

  • The most common causes of a hemorrhagic stroke in a young person are vascular malformations and hypertension
  • Consider an age-based approach to secondary hypertension work-up
  • LT pearl: If you are concerned about pheo, check orthostatics.  Untreated pheo patients will have positive orthostatics because they are chronically vasoconstricted and cannot adjust adequately to postural changes
  • Recognize lots of medications and dietary sodium will affect your renin/aldosterone ratio.  If your patient is on an ACEi or ARB, you do not need to stop the medication in your first pass you evaluation but know that a normal result does not exclude primary hyperaldosteronism.

 

Hemorrhagic CVA in the young:

  • Most frequent RISK FACTOR: tobacco use, HYPOcholesterolemia, HTN, alcohol use
  • Most frequent ETIOLOGY: vascular malformation and HTN
  • The final neurologic outcome was favorable in 60%
  • Causes overall:
    • Aneurysm/vascular malformation
    • Trauma
    • Severe HTN
    • Tumor
    • Septic/mycotic aneurysm
    • Bleeding d/o
    • CNS infection (eg HSV encephalitis)
    • Vasculitis
    • Drugs (cocaine, meth)
    • Secondary transformation from central venous thrombosis

 

Secondary Hypertension

Who should I work-up a patient for secondary hypertension?

  • 5-10% of all adults with HTN will have a secondary cause of HTN
  • Consider evaluation in patients with:
    • Resistant HTN: Defined as inadequately controlled BP when on three anti-hypertensives one of which must be a diuretic
    • Early or late onset HTN
    • Severe or accelerated course of HTN
    • Antihypertensive drug intolerance
    • Suggestive features on history or physical

When thinking about secondary hypertension consider an age-based approach to focus your differential. (Thanks for sharing Abbi and Jackie!)

afp20101215p1471-t3

Secondary Hypertension Differential and Suggestive Clues on history, physical, and basic labs

  • Renal Vascular Disease: Renal artery stenosis or fibromuscular dysplasia
    • Look for creatinine increases by >30% after starting ACEi or ARB, asymmetric size of kidneys, recurrent flash pulm edema, bruit on exam (not very sensitive)
  • Primary renal disease
    • Will see abnormal creatinine and UA
  • Endocrine causes
    • Pheochromocytoma
      • Triad; headache, palpitations, sweating,
      • LT pearl: check orthostatics!  Untreated pheo patients are chronically vasoconstricted so cannot adjust blood pressure with positional changes
    • Hyperaldosteronism
      • Unexplained hypokalemia, urine potassium wasting
      • One half of patients will have normal serum potassium
      • Typically mild HTN presenting in middle age
    • Cushing’s
      • Cushinoid features on physical exam
      • History of steroid use
    • Hypothyroid
    • Primary hyperparathyroidism
      • Hypercalcemia
  • Coarctation of the Aorta
    • Diminished or delayed femoral pulses
    • Asymetric BPs: BP in right arm > left arm or HTN in arms and low BP in legs
  • OSA
    • Obesity, daytime somnolence, snoring
  • Drugs
    • Cocaine, amphetamines
  • Medications
    • NSAIDs, OCPs, antidepressants, calcineurin inhibitors, decongestants, steroids,

 

Things that affect renin/aldo ratio: 

  • Meds
    • Mineralocorticoid receptor antagonist
    • Diuretics
    • ACEi or ARB
      • You do not need to take your patient off their ACEi or ARB in your first pass work-up because many with primary hyperaldosteronism will have an abnormal result.  However, if the result is normal you cannot exclude primary hyperaldosteronism and may need to recheck it off the medication.
    • Beta blockers
    • Clonidine
    • NSAIDs
    • SSRIs
    • OCPs
  • Hypokalemia/Hyperkalemia
  • Na restricted diet/Na loaded diet
  • Pregnancy
  • Renovascular HTN
  • Malignant HTN
  • Liddle syndrome: Liddle syndrome is a genetic disorder characterized by early, and frequently severe HTN with low plasma renin activity, metabolic alkalosis, hypokalemia, and normal to low aldosterone.

At the VA, endocrine clinic helps with obtaining this test and providing your patient with the appropriate instructions to avoid spurious results.

 

References:

Intracranial hemorrhage in Young People: http://stroke.ahajournals.org/content/30/3/537

Age Based Approach to Secondary Hypertension from the AAFP: http://www.aafp.org/afp/2010/1215/p1471.html

 

SFPC Ambulatory Report 7.13.17 Post-pancreatectomy diabetes

Thanks to Alicia for presenting a challenging management case of a patient with ESRD s/p transplant and traumatic pancreatectomy resulting in brittle diabetes.
Learning Pearls
  • Post-pancreatectomy considerations
    • Reasons people lose pancreatic function
      • Diseases: CF, chronic pancreatitis
      • Surgical resection due to malignancy, trauma, chronic pancreatitis
    • Endocrine replacement
      • Insulin: Patients should be treated similar to those with Type 1 Diabetes
      • Patients also lose their endogenous glucagon production
    • Exocrine replacement
      • Pancreatic enzymes
      • Vitamin supplementation: Should also supplement with the fat soluble vitamins (Vitamins A, D, E, K) due to fat malabsorption
  • Insulin pump Criteria
    • American Association of Clinical Endocrinologist recommendations for the Ideal candidates in adult patients:
      • DM type 1 or DM type 2 who is insulin dependent and intensively managed
      • Performing >= 4 insulin injections and >=4 glucose checks daily
      • Motivated
      • Willing and able to carry out the necessary tasks to manage the pump
      • Willing to maintain frequent contact with the healthcare team
        • Multidisciplinary team follow-up including pump trainer, educator, and endocrinologist
        • Monthly specialist f/u until on stable regimen
  • Islet cell/pancreas transplant
    • Can isolate islet cells from a resected pancreas or transplant full pancreas
    • ~30% of patients are insulin free after islet cell transplant.  Success depends on the mass and quantity of islet cells transplanted
    • Require lifelong immunosuppression therefore you will need to balance the risk of immunosuppressive medications with the benefits
    • ADA criteria for transplant:
      • Patients with ESRD who have had or will have a kidney transplant.  Most often perform simultaneous pancreas-kidney transplant
      • Patients without renal disease who have a history of severe metabolic complications from DM and consistent failure of insulin therapy to prevent acute complications
  • New Onset Diabetes after Transplant (NODAT)
    • Incidence is not known due to varying study methodology
    • Risk factors
      • Patient factors: Older age, obesity, African American race, hispanic ethnicity, family hx of DM, hx of gestational DM
      • Transplant factors: Meds (steroids, calcineurin inhibitors, mTOR inhibitors)
      • Other: HCV, preoperative hyperglycemia, hypomagnesemia
    • All patients should have post-op glucose checks weekly for first four weeks, then at 3 and 6 months and then yearly. A1c should be checked 3 months post-op

Evernote link to Ambulatory Report Pearls: https://www.evernote.com/l/AMqtLjXrppRJlr5wKbWTwz5rPF6NDejyCC4

Ambulatory Report 7.5.17: Hyponatremia in Clinic

Thanks to Jesse for presenting a great case of a 95 yo M in clinic in the process of being evaluated for hyponatremia and for sharing this excellent review article on the diagnosis and treatment of hyponatremia: http://www.eje-online.org/content/170/3/G1.full.pdf
We reviewed that our approach to hyponatremia can be lab based or volume exam based
  • Lab based: first pass work-up check Serum Osms, Urine Osms, Urine Sodium (See schematic below)
  • Volume-exam based: Likely easier in the outpatient setting given lab results will not be immediately available
Medications that cause hyponatremia: antiepileptics, antidepressants, antipsychotics, diuretics
Non-hypotonic causes of hyponatremia
  • Pseudohyponatremia: Normal serum osmolality without shifts of water, artifact of lab measurement
    • Elevated lipids or proteins (MM)
  • True hyponatremia due to attracting water from intracellular compartment
    • Mannitol, glucose
Other Pearls
  • To do a cort stim at the VA can send the patient to endocrine clinic
  • Salt tabs?  Consider just having the patient eat their favorite salty food
  • Serum Uric acid is often low in SIADH (not part of the lab algorithm, but fun to think about)
Lab-based approach to Hyponatremia
 Screen Shot 2017-07-05 at 10.36.43 AM
 Volume Exam Based Approach 
  • Hypovolemic
    • Extra-renal loses
      • GI losses
      • Skin losses
    • Renal losses
      • Diuretics
      • Primary Adrenal insufficiency
      • Cerebral salt wasting
    • Third spacing
      • Pancreatitis, sepsis, bowel obstruction
  • Euvolemic
    • SIADH
      • Malignancy: carcinoma, sarcomas, lymphomas
      • Lung disease: pneumonia, small cell lung cancer
      • CNS: subarachnoid hemorrhage, infection
      • Non-specific causes: general anesthesia, nausea, pain, stress
      • Meds/Drugs: antiepileptics, antidepressants, antipsychotics, diuretics, chemo, ecstasy
    • Endocrinopathies
      • Hypothyroid
      • Secondary adrenal insufficiency
  • High water, low salt
    • Psychogenic polydipsia
    • Beer Potomania
  • Hypervolemic
    • Heart Failure
    • Cirrhosis
    • Nephrotic Syndrome
    • Renal Failure

Ambulatory Report Pearls 6.28.17

Thank you Julia Janssen for presenting your first week of intern year!  We had the case of a 56 yo F pmhx of HTN, alcohol use disorder presenting with chronic facial and sinus pain found to have homonymous hemianopsia from an old stroke. 
Diagnostic Criteria for Chronic Sinusitis
  • To meet the definition of sinusitis you need both symptoms AND documented radiographic or nasoscopic inflammation
    • Symptoms for >12 weeks
    • Two or more of the following symptoms:
      • Mucopurulent discharge (anterior, posterior, both)
      • Nasal obstruction (congestion)
      • Facial pain, pressure, or fullness
      • Decreased sense of smell
    • AND inflammation documented on one of the following:
      • Purulent mucus or edema in middle meatus or ethmoid region
      • Polyps in nasal cavity or middle meatus
      • Radiographic imaging with inflammation in the paranasal sinuses
Localizing the lesion in homonymous hemianopsia
  • Optic tracts
    • Lesions here can also produce a relative afferent pupillary defect called Wernicke’s pupil
      • Test: Shine light on intact hemifield and have normal pupillary constriction. Shine light on blind hemifield and pupillary constriction will be absent or diminished
      • Can be difficult to test due to light scattering across the iris
  • Lateral geniculate nucleus
  • Optic Radiations
    • Internal Capsule
      • Lesion often also affects corticospinal tract and corticobulbar tract —> Contralateral hemiparesis and and hemianesthesia
    • Temporal lobe
      • More often presents as “pie-in-the-sky” visual loss in addition to aphasia, memory deficits, auditory and visual hallucinations
    • Parietal lobe
      • More often has incomplete homonymous hemianopsia and contralateral hemineglect
  • Occipital lobe 
    • Most common cause
    • Most commonly due to vascular lesions 
    • Often have macular sparing due to bilateral representation of the macula in the occipital lobe
  • MRI is the test of choice to evaluate the optic nerve
  • Patients with complete homonymous hemianopia should not drive
  • Patients with neglect from a parietal lobe lesion can have visual field neglect instead of true visual loss but will also have sensory neglect.  Best way to rule out neglect as at the cause of the visual field findings is to do extinction testing on sensory exam.
Link to Evernote: https://www.evernote.com/l/AMr89m1D3H9En5_RleQ-Gtaw77ISuZuSU54