· Web viewImprove understanding of pathophysiology of disease Integrate basic science into the clinical years with microbiology, pathology, and/or pharmacology Integrate radiologic

Write up cases

All students must complete one of the following cases and send to Dr. Colford and Dr. Shaheen by the Friday after the dayback session.

To complete a case, you must consider the facts given. If you are seeking other clinical information about the case, consider what clinical information might be helpful in your discussion and then say how knowing that information might affect your clinical decision making. It is expected that you use search strategies in pubmed and at least one other data base (Up to Date, EMedicine, and Wikipedia are not library data bases) to find appropriate original data. You should write an assessment and plan using a persuasive style to convince the reader of your diagnostic or therapeutic strategy and include your references from at least 2 of the sources used. You must include the planned discussion with the fictional patient in your essay.

Overall Learning Objectives:

1. Improve understanding of pathophysiology of disease2. Integrate basic science into the clinical years with microbiology, pathology, and/or

pharmacology3. Integrate radiologic findings into history where appropriate4. Create asynchronous learning opportunities with on-line learning tools5. Learn clinical reasoning by creating clinical questions and using resources such as pub-

med, google scholar, and Cochrane data base to find primary data that address the clinical scenario

6. Learn how to use and fill out a PICO worksheet in the context of a clinical case-see Page 2

7. If you would prefer, a student can use his/her own case from his/her own clinical experiences. However, the case and clinical question must be approved by the course director.

PICO Worksheet

Name: Date:

__________________________________________________________________

Clinical Question:

Study category: therapy diagnosis harm prognosis

PICO:

Patient, population, or problem being addressed

What are the characteristics of the patient or population?

What is the condition or disease?

Intervention being considered which could include:

exposure, diagnostic test, prognostic factor, therapy, patient perception

What do you want to do with this patient? Treat, diagnose, observe?

Comparison intervention or exposure

Relevant most often when looking at therapy questions.

What is the alternative to the intervention? Placebo, different drug, surgery?

Outcomes of interest

What are the relevant clinical outcomes of interest to you and your patient?

Morbidity, death, complications?

Focused, Well-Built Question:

Thanks to Texas Tech for use of their PICO worksheet

Case 1

58 year old Caucasian female with asthma has been on and off prednisone over the last year and on a moderate dose of an inhaled corticosteroid. She comes for an annual exam. Her mom had osteoporosis and she asks you about her risk for it. She has never broken a bone.

Physical exam: Height unchanged from last year. BMI 24.

Meds- Fluticasone/salmeterol 250/50 1 puff bid

Singulair 10 mg daily

Fluticasone nasal spray daily

Omeprazole 20 mg daily

Prednisone currently tapering from 40 mg daily to off.

Labs: TSH, PTH, Calcium, phosphorus, alk phos, and Vitamin D are normal

What will you recommend to this patient and why? Discuss you search strategies and your clinical question. Write about your discussion with the patient.

Case 2

66 year old female with history of hypertension and hypercholesterolemia presents with shortness of breath and dizziness. She reports the gradual onset of these symptoms over the last 3-4 weeks. She has no history of Coronary artery disease or diabetes and denies chest pain. She has noticed significant palpitations. She denies other medical problems but does feel a little sweaty today. Denies diarrhea, chest pain, pedal edema, rheumatic heart disease.

PMH: Hypertension on HCTZ 25mg po QD and lisinopril 40mg QD

Hypercholesterolemia for which she takes simvastatin 40mg daily

Allerg: none

SH: She is married, drinks 2 glasses of wine/night, no drugs, no tobacco. She exercises regularly on the hills at Governor’s Club by walking.

FH: Dad had palpitations too. Mom is 90 and lives alone still. Sister has “thyroid problems’

ROS: NC

Physical exam;

BP: 105/75 HR nurse notes it is irregular and gets 110, Temp is 99, RR 20, pulse ox 99%, weight 190# and 5ft 7” tall

HEENT: normal

Neck; Normal

Cor: Irregular irregular rhythm, tachycardic rate

Lungs: CTAB

Abd: soft non-tender, non distended

Rectal: Heme Negative

Ext: no edema, no clubbing

EKG shows:

http://www.ecglibrary.com/af_fast.html

PS please ignore the “76 yo man with breathlessness”

Chest xray looked something like this:

http://www.healthcare.uiowa.edu/InternalMedicine/////Education/Clerkship/Inpatient/documents/ReadingCXRs.pdf

Note: this xray is for a much thinner male patient than our plump hypertensive woman but gets at the point (left atrial enlargement)

If you can’t see this and would like a on-line tutorial that is awesome on reading chest xrays I would go to http://www.med-ed.virginia.edu/courses/rad/cxr/

Since the patient is hemodynamically stable, you elect to manage her as an outpatient.

Develop your clinical questions and search the literature. State what you will discuss and how with the patient.

Case 3

46 year old African American female with history of sarcoid on daily prednisone presents with a 4 day history of headache that she rates as 8/10.

Medications: Prednisone 20mg daily for the last three weeks but has been on chronic prednisone for the last one year at doses from 5-40mg

Omeprazole 20mg daily

fluticasone 220mcg 2 puffs BID

PEX: VS; 155/80, 100, 20, Temp 100.5

No papillaedema. No meningeal signs.

Lungs: Bibasilar crackles, no wheezing

Abd: Soft NT ND, No spleen palpated but liver is 2 cm below costal margin and soft

Ext: Slight peripheral edema that patient feels is unchanged.

The characteristic pathologic finding of sarcoid is:

A chest x-ray of stage I disease can be shown showing hilar adenopathy. Note the loss of the normal A-P window and the widening of the mediastinum at the area of the SVC entering into the right atrium. This is characteristic of hilar adenopathy. (note: This patient has more than stage 1 disease or she wouldn’t be on steroids)http://images.google.com/imgres?imgurl=http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/1613.jpg&imgrefurl=http://www.nlm.nih.gov/medlineplus/ency/imagepages/1613.htm&usg=___VM4IBDAobCQcVjbWlLhEC8kAYc=&h=306&w=226&sz=8&hl=en&start=2&um=1&itbs=1&tbnid=pP4CIOwz_gu15M:&tbnh=117&tbnw=86&prev=/images%3Fq%3Dchest%2Bxray%2Bsarcoid%26um%3D1%26hl%3Den%26rls%3Dcom.microsoft:en-us%26tbs%3Disch:1

This is known as a non-caseating granuloma

Devise an appropriate clinical question and search for answers. Write about any discussions you will have with your patient.

Case 4: 57 year old male smoker with stage 1 HTN presents with painless hematuria. He has no history of flank pain and no dysuria. He has a history of DVT and takes Coumadin. His INR is 2.0.

Meds: 1) warfarin 5mg alternating with 7.5mg 2) HCTZ 25mg po QD

Labs: 1+ protein and 3+ blood on urine dip. Microscopy below

Creatinine is 1.1 and other labs are normal.

PEX: VSS afebrile; No abnormalities found on exam

Devise a clinical question and search for the answers. Write about any discussion that you will have with the patient.

Case 5

68 year old white female presents with bilateral peripheral edema, mild shortness of breath worse with exertion. She has also noticed that she feels better sleeping in her recliner because she was waking with shortness of breath. She has longstanding hypertension that has not been ideally controlled.

Meds: Atenolol 50mg po QD

Asa 81m g QD

HCTZ 25mg po QD

omeprazole 20mg QD

VS: 155/85, 112, 98.6, pulse ox 90% on RA

Neck: JVP estimated at 10cm H20

COR: RRR normal S1 and S2 with an S3 heard at the apex. No S4 is heard. No murmurs

Lungs: Bibasilar crackles

Ext 2+ edema

An Echo shows an EF of 30%. Nuclear stress testing shows no reversible changes with stress.

Devise a clinical question and search for the answers.

Case 6

75 year old woman with poorly controlled diabetes and hypertension presents with fever, pleuritic chest pain, and cough productive of yellowish-green sputum and occasionally blood tinged sputum. She has some shortness of breath. She is a non-smoker but occasionally drinks alcohol.

Meds:

Metformin 500mg po BID

Glipizide ER 2.5mg QD

Lisinopril 20mg QD

HCTZ 25mg QD

Metoprolol XL 50mg QD

ASA 81mg QD

Simvistatin 20mg QD

PEX: VS 100/75, RR 28, pulse ox 91%, HR 111, T= 38.6

HEENT: rhinnorhea

NECK: Supple NT No JVD

Cor: RRR no murmurs or rubs, S4 is present

Lungs: Bibasilar crackles worse on the left and half way up with bronchial breath sounds and scattered wheezes. There is egophany present on the left

Chest xray shows:

This x-ray shows that the heart border is well visualized on the left but that there is a clear left sided infiltrate. Since the heart border is well defined, it is likely a left lower lobe pneumonia and this is confirmed by the posterior location of the pneumonia on the lateral film and the loss of the second diaphragmatic border on the lateral film.

Devise a clinical question and search for the answers

Case 7

Ms. Smith is a 59 year old Caucasian female who presents for alcohol abuse. Her husband brings her in and reports that she is drinking heavily. The patients confirms this and is reticent to quit drinking but acquiesces to an outpatient alcohol treatment program. She reports significant swelling in her abdomen, shaking, leg swelling, and has noticed brown urine and yellow eyes.

Meds: None

Allerg: None

PMH: G3P3, One is physically disabled in a group home. The other 2 live locally and she reports occasionally strained relationships.

SH: No tobacco, Drinks 1 bottle of vodka daily. No drugs. Married, was a homemaker.

FH: No alcohol or drug problems but she says that they don’t discuss health issues in her family. She denies domestic violence in the family.

ROS: negative.

PE: Thin white female in NAD, weight is 104#, down 8 pounds from previous annual exam 1 year ago. HR is 110 RR is 18 and she is afebrile. She seems irritable, impatient, and speech seems slightly pressured.

HEENT: PERRLA, Conj pink, Slight jaundice to sclera, OP clear, no lesions

Neck: Supple, No LAN, No TM

Cor: RRR s1 s2 no murmurs

Lungs: CTA and Percussion

Abd: Mildly distended, NT, ND +BS, Liver is palpated 4 cm below costal margin. Probable ascites, and prominent venous markings on her abdomen.

Ext: No CC, 1+edema both feet.

Neuro: Intention tremor. Is shaky with gait and it is slightly wide based. More difficulty with turning. Finger to nose testing reveals dysmetria (passing object and then readjusting and coming back to object when trying to touch it). No asterixis Motor is 5/5. Sensory is intact to light touch. Reflexes: patient is diffusely hyperreflexic.

Labs: White cells 11.1 normal diff, HCT is 34 with MCV of 101, Platlets are 88.

GGTP is 388, Alkaline phosphatase is 250, AST is 440 and ALT is 250. Albumin is 2.2 and PT is 13.9 (up to 11.5 is normal) . Total Bili is 3.0.

Alcohol screen is positive with a level of 323mg/dL with common parlance 0.3.

Drug screen is negative.

You send her first for an ultrasound of her liver. It shows:

Portal hypertension and macronodular cirrhosis. There is also an enlarged spleen and moderate amounts of ascites.

She then underwent a liver biopsy that shows significant fatty infiltrate and periportal fibrosis consistent with cirrhosis

Images from www.md.huji.ac.il/mirror/webpath/LIVER.html

Devise a clinical question:

Case 8

55 year old male with complaints of severe knee pain and swelling that came on acutely

PMH: Hypertension, Pseudogout, asthma, recurrent tooth abscesses for which he is on penicillin

Meds: Enalapril, HCTZ, ASA, albuterol prn, and PCN VK and ibuprofen for a recent tooth abscess

Allerg: NKDA

SH: Occasional EtOh, no drugs, Married for 35years.

FH: Mother died of CAD, father of prostate cancer.

PEX: 140/80, 100, 37.1, 20 In significant pain

HEENT: normal

NECK: supple No LAN, No thyoidmegaly

COR: RRR s1s2 normal

Lungs: CTA

Knee: Swollen, warm, tender to touch, does not let MD flex/extend knee

To diagnose this you do a tap of the fluid in the knee which shows:

Develop a clinical question and research the answer.

Case 9-EXAMPLE-Thanks to Nate Montgomery

Mr. S is 59 year old Med/Surg nurse who comes to clinic asking if he should have a PPD placed for routine TB screening. He grew up in Korea and did receive the BCG vaccine as a child. He thought he should not have to have a PPD and could just have chest xrays if he started to cough. He has never been treated with antibiotics for TB and cannot remember whether he has had a positive PPD in the past or not. He has chronic medical problems of GERD, BPH and high cholesterol. He take omeprazole, simvastatin and tamsulosin daily.

The patient has a PPD placed and returns in 48 hrs. You measure the distance between the dots and it is 15 mm.

Ask a specific clinical question and search for the answer and discuss below.

Case 9

Clinical question 1: “Amongst patients with a history of BCG vaccination, what are the senstivity and

specificity of PPD testing in evaluating TB infection?”

Pubmed search strategy:

MESH terms : “BCG vaccine”, “PPD/tuberculin test”, and “specificity”

Limits: humans, English.

Results: 29 articles, including two studies specifically addressed the clinical question.

o Bugiani M et al. “Tuberculin reactivity in adult BCG-vaccinated subjects: a cross-

sectional study.” Int. J. Tuberc. Lung Dis. 2003; 7: 320-6.

A cross-sectional study performed in Italy, which compared PPD results in

4987subjects who had close contact with individuals with infectious TB 2-6

months prior to the study (TB exposure group), 4962 BCG-vaccinated subjects

without known TB exposure (BCG vaccine group), and 5000 subjects who were

not BCG-vaccinated and had no known TB exposure (control group). Whereas

the median diameter of induration was 13 mm in the TB exposure group, it was

only 4 mm in the BCG vaccine group and 0 mm in the control group. Using 12

mm of induration as a cutoff, this study found that the PPD tests had a sensitivity

of 74.6% and a specificity of 98.8%. These values would correspond to a

positive likelihood ratio of 62.2. Hence, this study supports interpreting the

patient’s 15mm of induration as a positive result.

o Wang L et al. “A meta-analysis of the effect of Bacille Calmette Guerin vaccination on

tuberculin skin test measurements.” Thorax. 2002; 57: 804-9.

A meta-analysis of 26 articles evaluating the effect of BCG vaccination on PPD

results in patients without TB. This study found that subjects previously

vaccinated with BCG were initially more likely to have positive PPD results,

even when 15 mm of induration was set as the cut off for a positive result.

However, this increased reactivity was lost if more than 15 years had elapsed

since vaccination (37.6% of subjects vaccinated with BCG had 10 mm of

induration, compared to 47.8% of subjects not vaccinated).

Given that treatment of TB is dictated by public health algorithms, I next performed a search to review

these protocols.

Clinical question 2: “Amongst asymptomatic patients with a positive PPD, what are recommended

treatment guidelines?”

MESH terms: “Practice guidelines”, “PPD”, “asymptomatic”

Limits: humans, English

Results: 1 article- Sharmu et al. J. Fam. Pract. 2006; 55: 163-5.

Assessment and Plan

The patient is a 59 year old healthcare worker who received BCG vaccination as a child and is

now presenting to discuss PPD testing. His most recent PPD had 15 mm of induration.

BCG-induced enhancement of PPD skin testing is limited to the first 15 years after vaccination

(Thorax. 2002; 57: 804-9). Moreover, cross-sectional studies have demonstrated that patients with a

remote history of BCG vaccination have a median diameter of induration of just 4 mm. When a 12 mm

cutoff is used for positive results, the specificity of PPD testing is high, with only very rare false positive

from BCG vaccination (Int. J. Tuberc. Lung Dis. 2003; 7: 320-6.). Given that had 15 mm of induration

and given that he was vaccinated more than 50 years ago, the patient’s PPD result should be interpreted as

positive. It should be noted that as a healthcare worker, he is at increased risk of acquiring TB, meaning

that his pretest probably of infection was higher, as well.

Accordingly, the next step in the patient’s management is to enter the TB management algorithm

(J. Fam. Prac. 2006; 55: 163).. First, he will have a chest x-ray. If it is normal, the patient will INH for

9 months. If the chest x-ray shows evidence of an active TB infection, we will need to collect sputum

samples for culture. While those results were pending, he would need to take a four-drug combination

with isoniazid, ethambutol, rifampin, and pyrazinamide. On the other hand, if the chest x-ray shows

evidence of an old TB infection, the next step is sputum culture. If negative, the patient would likewise

be treated like patients with a normal chest x-ray, receiving one drug, INH, for 9 months. On the other

hand, if sputum culture is positive, the patient would be treated like patients with active TB, receiving

four drug therapy.

Conversation with patient

In speaking to the patient, I would validate the reasoning behind his skepticism and acknowledge

that a history of BCG vaccination can influence PPD test interpretation. However, I would explain that

this increased PPD reactivity decreases with time. After 15 years, patients who have received BCG

vaccination are no more likely than unvaccinated patients to have a false positive PPD result. As a result,

the size of the response he experienced would be atypical without a history of TB infection. I would also

emphasize that, as a healthcare worker, he is at increased risk of acquiring TB. As a result, the only safe

approach is to interpet his PPD should as positive. I would emphasize that this interpretation promotes

his own safety and the safety of his patients and contacts.

Next I would explain to the patient that public health agencies have determined a series of next

steps that should be taken with any patient who has a positive PPD. Since he has had a positive test, he

should start taking these steps, the first of which is a chest x-ray. I would explain that the results of chest

x-ray, may or may not require that he provide a sputum sample for culture. Either way, there are

basically two possible final outcomes. Either, he will take on pill, INH, for nine months, or he will take

four drug combination. I would emphasize that I will keep him updated as results become available, and

should he have any questions, I am available.

Works Cited

(1) Bugiani M et al. “Tuberculin reactivity in adult BCG-vaccinated subjects: a cross-sectional

study.” Int. J. Tuberc. Lung Dis. 2003; 7: 320-6.

(2) Wang L et al. “A meta-analysis of the effect of Bacille Calmette Guerin vaccination on

tuberculin skin test measurements.” Thorax. 2002; 57: 804-9.

(3) Sharma U et al. “What is the recommended approach to asymptomatic patients who develop a

reactive PPD?” The Journal of Family Practice. 2006; 55: 163.