Tag Archives: Ambulatory

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!)


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.



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




Thanks to Ashley Stein-Merlob for presenting an yet to be solved case of a 63 yo female with worsening cognitive impairment, chronic diarrhea and weight loss undergoing a work-up for malabsorption.

The dirty scoop on STOOL STUDIES

  • Fecal fat
    • Sudan Ill Stain: Qualitative assessment, less sensitive, often used as a first pass test
    • Quantitative 72-96 hour collection. Gold standard. More sensitive but difficult to get.
  • Bacterial culture
    • Not necessary in chronic diarrhea
    • Indications in acute diarrhea: severe illness, inflammatory diarrhea, high risk hosts, symptoms lasting > 7d days, public health concerns
  • Osms and Electrolytes
    • Order if suspect surreptitious diarrhea from laxative abuse
  • Biofire PCR
    • Available at the VA, tests for 22 pathogens including C. dif, e. coli, shigella, giardia, and more. May be helpful for acute diarrhea but more costly than targeted testing

Approach to UNEXPLAINED WEIGHT LOSS in Older Adults

  • The differential is broad and includes almost every organ system.
    • Most common categories: malignancy, psychiatric, gastrointestinal disease, endocrine.
    • In the elderly consider the 9 D’s of weight loss: Dementia, Dentition, Depression, Diarrhea, Disease (acute and chronic), Drugs, Dysfunction, Dysgeusia, and D
  • First pass work-up
    • Basic labs: CBC, BMP, LFTs, TSH
    • CRP, ESR
      • ** Pearl from Meg Pearson – Although non-specific an elevated test result may prompt you to do a more thorough work-up.***
    • LDH, UA, CXR, FOBT
    • Consider: 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.
    • When to get colonoscopy?
      • Primarily to look for microscopic colitis, IBD, malignancy
      • Should be considered if there are persistent symptoms, inconclusive diagnosis, or failure to respond to therapy.
      • Probably best to refer to GI prior to colo to ensure biopsies are taken
    • Resource: AAFP Practice guidelines for Unexplained Weight Loss in Older Adults



Ambulatory Report – 5.17.17 – Shin Nodules…Erythema Nodosum!

Thanks to Grant Smith for presenting a case of a 62 yo M h/o questionable SLE presenting with subcutaneous nodules on the shins thought to be Erythema Nodosum with unclear etiology!
  • Turns out this isn’t LT’s first deep dive into EN!  He was already ahead of the curve in 1984.
    • DDC6576B-C1A7-4A62-AE17-199E0C7D8E72
  • As promised, here’s the document to get a FREE version of Visual Dx!  (It’s great for dermatology and more!)
    • Note: you have to be physically present at the VA when doing this, or on the VA VPN.
    • Getting VisualDx
  • We talked a bunch about the Common etiologies of EN vs. the More Uncommon.  Here’s a list of a bunch of those dx’s (Missing from the list below – Pregnancy!)
    • 173C44D6-960C-4DA6-A6C5-0F8FC74233DF
  • When you find a diagnosis of EN, you should send an initial work up (per UpToDate)
    • CBC (to assess for infxn & malig)
    • ESR +/- CRP (elevation sign of systemic dz & widespread inflam)
    • Antistreptolysin O (ASO) titers (repeated 2-4 wks later)
    • CXR (assess for sarcoid, TB, pulm infxn, lymphoma)
    • PPD or Quantiferon

Evernote Link: https://www.evernote.com/l/ADWRkMKZe3xCCaISL1vIWweJR_Flkg-O-_U

Ambulatory Report – Syncope, Stress, Cath OH MY!

Thanks to James Anstey for presenting a great case of a 69 yo M from Ukiah h/o HTN, COPD, CKD, MI in 2010 p/w and episode of LH which evolved to syncope who got a cath and had Critical L Main dz (w/o > 50% stenosis in any of the other vessels) and got PCI to the vessel.
Stress Testing is a Popular Topic!  Here are some previous posts with great pearls:
Stress Testing in a NUTSHELL (if you want more stuff, here’s my Evernote on Cardiac Stress Testing)
  • There are STRESSORS and there are IMAGING Modalities – A “Stress Test” requires BOTH (you can mix & match like picking your cone type AND your ice cream flavor!)
    • Stressors
      • Treadmill or Bicycle
      • Pharmacologic = “Lexiscan” (which is Regadenoson) or Dobutamine
    •  Imaging
      • EKG
      • Echo
      • Nuclear Perfusion (within Nuclear you then have to choose between Tracers and the Imaging Modality)
        • Tracers = Technetium (aka Myoview) and Rubidium
        • Nuclear Imaging Options = SPECT and PET
          • PET is more sensitive & specific and has lower radiation (but yes, it’s more $$$)
    • The most common Stressor & Imaging combinations in the US are:
      • Treadmill ECG
      • Treadmill Echo
      • Treadmill Nuclear MPI
      • Supine Bike Echo
      • Regadenoson Nuclear MPI
      • Dobutamine Echo
Here are a couple two cents that I’ve gathered along the way about picking the right test:  The Luke Zier Approach
  • Step 1 = Is pt sxmatic
    • do NOT stress if asxmatic
  • Step 2 = Can pt exercise?
    • If yes —> treadmill or bike (which can be assessed with ECG/echo/nuclear)
    • If no —> chemical stress (most commonly assessed with echo/nuclear
    • In terms of sensitivity:
      • If want low-moderate —> ECG alone
      • If want high-moderate —> Echo/Nuclear
  • Step 3 = Does pt have normal ECG?
    • LVH (hard to interpret the ST segment) OR known obstructive CAD w/ or w/o revise —> echo or nuclear imaging
    • Resting LV WMA, paced rhythm or LBBB —> nuclear MPI should be performed over dobutamine echo
  • Step 4 = Is pt high risk (should they go straight to cath?)
  • Step 5 = Any contraindications?

Evernote Link: https://www.evernote.com/l/ADWn11N_2VJCNoce_ucanTrRQACtDNv_EjU

Ambulatory Report – 5.3.17 – Abd Pain and Endometrial Carcinoma

Thanks to Dave Anderson for presenting a case of a 68 yo F h/o HTN presenting with subacute onset of abdominal pain and diarrhea, ultimately found to have likely Endometrial Carcinoma vs. Leiomyosarcoma.
  • First some Pearls from LT & the Attendings:
    • Cope (of Cope’s Early Dx of the Acute Abdomen) notes that “localized rigidity” as a physical exam is far more significant than “rebound”
    • Is the diarrhea from malabsorption?  Look for the greasy ring around the toilet! (LT says things like “floating stools” are not as useful)
    • If you’re wondering about what imaging study to order —> CALL RADS!
    • If you’re in the outpatient setting, and have a serious case but doesn’t need admission, and you’re not 100% sure what to do —> CALL THE INPATIENT SPECIALTY CONSULT PAGERS!
    • Old people with new abdominal pain —> dig deeper than you normally would to find a cause!
  • Quick Dive in Endometrial Carcinoma:
    • Abnormal Uterine Bleeding in 75-90% (though our pt had no AUB)
    • Can see cervical cytologic changes in those with endometrial carcinoma
    • Risk Factors for Endometrial Cancer (and the RR of each)
      • Increasing Age (1.4% prevalence in women 50-70yo)
      • Unopposed Estrogen Tx (RR 2-10)
      • Tamoxifen Tx (RR 2)
      • Late Menopause after 55yo (RR 2)
      • Nulliparity (RR2)
      • Chronic Anovulation (RR 3)
      • Obesity (RR 2-4)
      • Diabetes (RR 2)
    • Work Up for those Suspected of having Endometrial Neoplasia
      • Pelvic Exam (do bimanual to assess uterus size)
      • Labs
        • rule out pregnancy
        • consider a CBC and INR depending on heaviness of bleed
      • Pelvic u/s is first line to assess for AUB
      • Endometrial sampling (get Gyn involved to decide btw EMB, curettage, surgical bx)

Evernote Link: https://www.evernote.com/l/ADVud9IRNFdEnps4qVquepa0_mUis24EiKA

Ambulatory Report – Sinus Tach, Blue Feet, and POTS!

Thanks to Rabih Geha for presenting a case of a 32 yo F without signif PMH presenting with progressive SOB and blue feet, and ultimately found to have POTS!
Wait, sorry, what’s POTS?  It’s Postural Tachycardia Syndrome!
  • Pearls
    • Orthostatics should ONLY cause a change in HEART RATE, and should have a very minimal effect on BP
    • Young Women most affected
  • Epi
    • Typically younger adults & children (14-45yo)
    • Estimated that 500,000 Americans suffer from POTS
    • Women:Men = 4-5:1
  • Clinical Manifestations
    • Sx = Dizziness, LH, weakness, blurred vision, fatigue when standing; as well as pulpit, tremulousness, anxiety
      • Can see GI sx (nausea, and cramps, early satiety, bloating, cons tip, diarrhea)
    • Signs
      • Venous pooling which may manifest as acrocyanosis (blue/purple color of hands & feet) & edema when upright
      • Syncope seen in ~40% of patient
    • Sx often appear abruptly and often after a viral illness
  • Dx
    • Sustained HR increase > 30 bpm or an increase to 120 bpm or greater within first 10 minutes of tilt
    • Usually NO orthostatic hypotension
    • This is a diagnosis of EXCLUSION
  • Tx (all meds are off-label)
    • Continue exercising (exercise training should have a central role in tx)
    • Encourage fluid repletion and salt intake
    • Meds = fludocortisone, midodrine
    • +/- B-blockers

Evernote Link: https://www.evernote.com/l/ADX_7qKpL4VAA5ezev53M24OIRwl6NYFNbs

Ambulatory Report – 3.29.17 – Peripheral Neuropathy and B12!

Thanks to Robert Hutchins for presenting a case of a 74 yo M presenting with bilateral, symmetric, upper and lower extremity peripheral neuropathy, ultimately found to be B12 deficiency (and no, he wasn’t a Vegan or Vegetarian!)
  • So what labs SHOULD I be ordering?
    • Based on an Evidenced Based Review from the Academy of Neurology in 2008, the highest yield tests are (despite what I said in report):
      • Screening for DM – A1c (and if it is not clearly abnormal, consider testing for impaired glucose tolerance with a GTT)
      • B12 (+/- MMA)
      • SPEP & Immunofixation
    • That said, many neurologists advise FIRST getting electromyography and/or nerve conduction studies (EMG/NCS) when there is no clear etiology or when Sx are severe or rapidly progressive
      • Then, based on the EMG/NCS —> order the appropriate tests
        • Axonal Etiologies
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        • Demyelinating Etiologies

          • FD46D817-F8D5-4E12-A276-4B8D9EB4A271
  • Like all things, clinical judgment in terms of severity and rapidity will certainly play into the order of your workup.  Given that, you could consider the following:
    • First Step – Take a great History & Physical
      • the Hx will really help guide if you should be sending additional tests
      • if the presentation is severe or with rapid/acute onset —> get Neuro involved & EMG/NCS ASAP
    • Second Step – Common things are Common
      • Send off 1st Pass labs = A1c, B12 +/- MMA, and SPEP + Immunofixation
    • Third Step – get the EMG/NCS
      • I would considering placing this order when you send your 1st Pass labs
    • Fourth Stepbased on Steps 1-3 —> decide what other additional testing you should send (see above)
      • In addition to the labs above, could ask Neuro’s input on getting nerve bx, skin bx, autonomic testing, and quantitative sensory testing

Evernote Link: https://www.evernote.com/l/ADWn64TECIZG_Ywh7i33AmtA6nSwn3DkPds