Clinical Problem Solving

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Clinical Problem Solving

• Presenter Deborah A. Levine, MD, MPH
• Assistant Professor of Medicine
• Discussant Alan Stamm, MD
• Professor of Medicine
• March 20, 2007

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• After his examination, his doctor took Dan into
  the room and said, Dan, I have some good news
  and some bad news.
• Dan said, Give me the good news first.
• The doctor replied, Theyre going to name a
  disease after you.

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Case 1

• A 62 year-old white woman with
• metastatic breast cancer presents
• with bilateral wrist pain x 3 months

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Medical Narrative

• The history of present illness in her own words

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Medical History

• PMH
• Metastatic breast cancer
• -1/01 IIIA (T2N20) ER/PR
• -4/05 Lung/pleura
• -8/05 remission with SERM change
• -10/06 L5 met s/p XRT
• L4 and L5 disc herniation with right sciatica
• Hyperlipidemia
• OA

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Medical History

• PMH
• Metastatic breast cancer
• -1/01 IIIA (T2N20) ER/PR
• -4/05 Lung/pleura
• -8/05 remission with SERM change
• -10/06 L5 met s/p XRT
• L4 and L5 disc herniation with right sciatica
• Hyperlipidemia
• OA

• Medications
• Fulvestrant (Faslodex) IM Zoledronic acid IV QMO
• QMO
• Neurontin
• Naprosyn BID-gt TID
• Pravachol
• Aspirin

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Physical Exam
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Physical Exam
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De Quervains Stenosing Tenosynovitis

• Washer Womans Sprain
• Fritz de Quervain, a Swiss surgeon, published 5
  case reports of patients with tender thickened
  first dorsal compartments of the wrist in 1895.

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De Quervains Stenosing Tenosynovitis

• Commonly seen in mothers/caregivers of infants
  aged 6-12 months
• Often bilateral
• Repetitive lifting of the baby as it grows
  heavier? friction tendinitis
• Direct trauma
• Second most common entrapment tendinitis in hand
  wrist (1/20th as frequent as trigger digit)

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Pain develops over the styloid process of the
radius, radiating up the forearm and down the
thumb. Pain can occur suddenly following a
strain of the wrist. The aching pain,
aggravated by use of the hand, gradually
intensifies and may cause considerable weakness
and disability.
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Tender thickening of the first dorsal compartment
over the radial styloid. Thickening may be bone
hard and seem like a mass.
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Treatment

• Splinting of thumb and wrist
• NSAIDS
• Corticosteroid injection of sheath of the first
  dorsal compartment
• One injection permanently relieves symptoms (50)
• Second injection given 1 month later permanently
  relieves symptoms in another 40-45
• Surgical release of the tendons
• Relief is usually permanent.

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Key Points

• De Quervains Stenosing Tenosynovitis is common
• Involves tendons in first dorsal compartment of
  wrist
• Due to acute or repetitive trauma
• Diagnose by exam (Finkelsteins test, tender
  radial stylus)
• Treated by
• Rest/NSAIDS Corticosteroid injection Surgery
• Prognosis is excellent but can recur

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I do not know why they call it tendernitis as
there is nothing tender about this affliction.
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Case 2

• 81 year-old white male veteran with h/o HTN
  and prostate cancer 1995 presents for evaluation
  of creatinine rise.
• Creatinine 0.9 (6/06) ? 1.5 (12/06)

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Medical History

• Prostate cancer T3cN0M0 (1995)
• poorly differentiated adenocarcinoma
• High grade Gleason 9/10
• Extended into seminal vesicles
• Smaller focus Gleason 2/5 left lateral LN
• s/p radical retropubic prostatectomy (PIVOT)
• PSA 15?1.06 (postop)?2 range (2002)
• ?19 (12/05)?45 (2006) begun on hormonal therapy
• HTN, OA

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Evaluation

• Repeat creatinine 1.4
• Urinalysis normal
• Urine eosinophils
• PSA 45
• Hgb 10, MCV 88 RDW 14

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Evaluation

• Normal post-void residual test

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Evaluation

• Ultrasound shows moderate left hydronephrosis
  with dilatation of the visualized proximal left
  ureter
• Left kidney 12.6 cm, Right kidney 11.6 cm
• Large right kidney cyst

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U/S in UTO
Normal
UTO
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Urology Consult

• Same day
• Bicalutamide (Casodex)
• androgen R agonsit
• Goserelin (Zoladex)
• GRH analog
• Schedule procedure

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Diagnostic cystoscopy with retrograde pyelogram I

• Proximal bulbar urethral stricture
• 1 cm bladder tumor right lateral wall
• Both ureteral orifices patent with output of
  urine
• Procedure terminated to defer for operative
  procedure

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Diagnostic cystoscopy with retrograde pyelogram II

• Urethral dilatation
• 1 cm bladder tumor right lateral wall invasive
• Minimal efflux from left ureteral orifice
• Normal mid and distal left ureter
• Moderate hydronephrosis of the left kidney with
  narrowing to an area 1 cm below the left UPJ
  (?stricture)
• Stent placed

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Post-stent CT

• Non-contrast CT
• Minimal residual left renal pelvicaliceal
  dilatation post left ureteral stenting suggests
  the presence of small obstructing secondary
  mass/stricture not visualized
• Asymmetric bladder wall thickening of superior
  posterolateral mucosa 1.4 cm superior to the
  right ureter worrisome for TCC
• No abnormal resection bed soft tissue
• No regional lymphadenopathy

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Pathology

• Bladder tumor
• Adenocarcinoma
• Extension into muscle layer bladder wall
• PSA, Racemase, Gleason 6

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Obstructive Uropathy
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Urinary tract obstruction (UTO)

• Common
• 400,000 hospital discharges (1993)
• Prevalence of hydronephrosis 3 autopsy
• Acute or chronic
• Partial or complete
• Unilateral or bilateral
• May occur at any site in the urinary tract

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Etiology Varies by Age

• Children Anatomic abnormalities (including
  urethral valves or stricture, and stenosis at the
  ureterovesical or ureteropelvic junction)
• Young adults calculi
• Older adults prostatic hypertrophy or carcinoma,
  retroperitoneal or pelvic neoplasms, and calculi

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Sequelae

• Altered urodynamics
• Increased risk of superimposed infection
• Renal calculi

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Presentation of UTO Varies by Site, Severity and
Acuity

• Acute
• Pain
• Azotemia

• Chronic
• May be silent
• Infection
• Acute urinary retention
• Azotemia

Urinary symptoms??? Anuria
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UTO

• UTO should be considered in all patients with
  otherwise unexplained renal insufficiency.
• The history may be helpful in some cases
• e.g., BPH symptoms, prior malignancy, renal
  calculi.
• Early diagnosis of UTO is important
• Most cases can be corrected
• A delay in therapy can lead to irreversible renal
  injury

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Approach

• Bladder catheterization
• possible clues suprapubic pain, a palpable
  bladder, or an older man with unexplained renal
  failure.

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Key Points

• Consider UTO in all patients with unexplained
  (acute or chronic) renal insufficiency
• Ultrasound is test of choice
• Rapid diagnosis and treatment saves nephrons

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• As the X-ray tech walked down the aisle
• to say the marriage vows with
• her former patient, a coworker nurse whispered
  to a doctor seated next
• to her, Wonder what she saw in him.

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Case 1

• A 60 year-old Ecuadoran man with
• history of NHL presents
• with left leg weakness x 5 days

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HPI A bad month

• Low back pain
• Subjective fever
• 5-10 lb weight loss
• Urinary frequency

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Medical History

• PMH
• NHL IIIB 2 years PTA
• -s/p CHOP
• -Remission
• Gout
• Hypertension
• Meds Allopurinol, lisinopril, aspirin

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Cryptococcus neoformans in an india ink
preparation
India ink preparation of cerebrospinal fluid
(x400) shows a prominent clear zone around
individual yeasts, consistent with the capsule of
Cryptococcus neoformans. The yeast in the center
of the slide is budding.
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Cryptococcosis
Photomicrograph of a silver stained slide shows
multiple organisms of Cryptococcus neoformans.
Many of the organisms are surrounded by a pale
halo reflecting the presence of a polysaccharide
capsule (arrow). The yeast forms themselves tend
to be variable in size and shape and reproduce by
a process of narrow neck budding, in contrast to
broad-based budding in blastomycosis.
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Cryptococcus neoformans
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Cryptococcus neoformans

• Rare if normal immunity
• Immunosuppressed at risk
• HIV, transplant, heme malignancies, steroids,
  sarcoid
• Practically all adults have serum antibodies to
  C. neoformans antigen
• Sera analysis of NYC kids suggest that
  seroconversion for most is lt age 10
• Active surveillance in AL (1992-1993) 0.84
  cases/100,000 annual incidence non-HIV

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Source

• Pigeon and other avian excreta, fruit and
  eucalyptus trees

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Pathogenesis

• Initial acquisition
• Clearance of infection
• Latent infection
• Acute infection disseminated disease
• Reactivation (Baker 1950s)
• Most infections are asymptomatic
• Depends on inoculum, immunologic state of host,
  virulence of strain

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Clinical Sites of Disease

• Lung
• CNS
• Skin
• Eye
• Prostate (reservoir for relapse less well
  studied)
• Others Bone, blood, joint, peritoneum

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Lymphatic Drainage of the Prostate
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Laboratory Diagnosis

• Direct microscopic exam (India Ink)
• Cultures
• Serology
• Detection of cryptococcal polysaccharide and
  diagnosis of invasive cryptococcosis sensitivity
  and specficity 90

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Treatment

• Induction
• Amphotericin B Flucytosine X 2 weeks
• Complete
• Fluconazole PO x 8 weeks

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Key Points

• Consider all causes of osteolytic lesions
  (oncologic and non-oncologic)
• Its not cancer until its proven to be cancer.
  George Bosl, MD, Chairman of Medicine, Memorial
  Sloan-Kettering Cancer Center

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• On the natural history side, medicine is a
  science on the curative side, medicine is an
  art. This is implied in Hufelands aphorism
• The physician must generalize the disease and
  individualize the patient.
• From Medical Essays 1842-1882
• by Oliver Wendell Holmes, 1892

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