Family Medicine

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Family Medicine

• Arapahoe Peak Family Medicine
• Evergreen, CO
• Sean Ronnekleiv-Kelly

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Introduction

• Arapahoe Peak Family Medicine
• 3 Physicians
• 2 Physician Assistants
• 2 x-ray Techs
• 6 Nurses
• 5 Office Staff
• 9 Exam Rooms

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Introduction

• Clinic is open 7am 7pm M-F, 8am 1pm Saturday
• One doctor is on call per week
• The facility is also an Urgent Care facility
• All of the staff get along well, until . . .

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Introduction

• Hey docs, there is a LAC in the procedure room
• Two of the doctors and one of the PAs are
  actually surgeons at heart
• When there is a laceration, or procedure
  requiring suturing, things get intense

Its my turn to suture!!!!
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Introduction

• Other Interesting Facts
• Dr. Gonzales used to work in Idaho Springs and
  was the preceptor of Suzanne Clayton
• Dr. Hutchinson loves to ski and will occasionally
  be sick on big powder days . . .
• Dr. Sclar (PA) is an avid mountain biker, so he
  usually only gets sick during the summer
• Dr. Buchwald (my preceptor) plays in a band, his
  instrument is the electric washboard

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Introduction

• More interesting facts
• Evergreen tends to accumulate quite a bit of
  snow, and sometimes it turns into ice . . .

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Introduction

• Most patients with back pain presenting to the
  clinic had chronic problems
• After the snow, most patients presented with
  acute problems
• So doc, I was out walking my dog when . . .

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Introduction

• Another interesting case
• 76 yr old male who presents with a chief
  complaint of? (Nursing staff warned me about
  this gentleman, stating he was not very pleasant
  to speak with)
• High blood pressure
• Vague abdominal complaints
• Chronic pain

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Introduction

• Answer
• None of the above. The patients chief complaint
  consisted of
• I cant masterbate anymore and I cant have sex

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Introduction

• Description of the Practice
• Patient Population
• General
• Income
• Education
• Ages
• Common Presentations

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Introduction

• Interesting Case Presentation
• Past Medical History
• Development of the Case
• Chronic Care
• Treatment
• Outcome

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Arapahoe Peak

• Patient Population
• Most of the patients are from Evergreen and the
  surrounding area (Idaho Springs, Golden, Lookout
  Mountain, etc.)
• Many of the patients have been treated by the
  same physician for years . . . and so have their
  family members (not uncommon for the docs to know
  and treat 3 generations of family members)

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Arapahoe Peak

• Patients of all Income levels
• Very poor patient in which free samples are a
  saving grace (one woman oftentimes made a choice
  between purchasing BP meds vs. diabetic meds each
  month) and lab work is a rarity
• Middle class (most patients)
• Wealthy population that could take many of the
  more expensive medications and request extraneous
  labs

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Arapahoe Peak

• Patients of all education levels
• Low education and lack of understanding resulting
  in decreased compliance
• Fairly well educated that understand underlying
  disease and importance of treatment (majority
  here)
• Very highly educated that are intent on proving
  the physician wrong

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Arapahoe Peak

• Patients of all ages
• Young Kids (2-12)
• Adolescent (13-18
• Young Adults (19-35)
• Adults (36-65)
• Elderly Population (66 - )

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Arapahoe Peak

• Common Presentations

• Kids Young Johnny here has been sick for 3
  days . . .
• Mostly URI, Rash or Allergy
• Adolescent/Young Adult I was rippin through
  some great powder and fell . . .
• Mostly Strains/Sprains or URI

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Arapahoe Peak
Common Presentations

• Adult There is absolutely nothing wrong with
  my blood pressure . . .
• Mostly HTN, Hyperlipidemia
• Elderly Okay, maybe there is something wrong
  with my blood pressure . . .
• Mostly HTN, Diabetes

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Arapahoe Peak

• Overall, the majority of patients seen presented
  with strains/sprains and HTN
• Patient population was fairly healthy, not too
  many overweight/obese individuals
• Patients often had multiple complaints, but not
  too many extremely complicated cases

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• BM is a 54 year old overweight woman (Ht 65,
  Weight 210, BMI 35) who initially presented
  years ago (gt10) with a chief complaint of
  decreased energy, loss of interest, weight gain
  and frustration from pain in her hands.
• History, physical exam and ROS led to a diagnosis
  of depression
• Chronic care model used to determine best course
  of action, with initial failure of therapy

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• Through assessment of accompanying symptoms,
  patient was found to have Bi-Polar disorder
  instead of MDD
• Multiple treatment modalities attempted, but each
  one failed.
• Patient referred to local mental health clinic
  for management of BPD
• Comorbid medical conditions managed by Family
  Physician

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• In 2004, pt noticed weight gain, fatigue and
  chills, but no other symptoms of depression
• Lab values to evaluate underlying medical
  condition
• Elevated TSH, Low T4
• Patient diagnosed with Hypothyroidism and
  initiated on Levothyroxin

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• Since being diagnosed with BPD and hypothyroid,
  the patient had gained approximately 15 lbs,
  leading to a BMI of 37.8.
• Pt began to notice achiness in some of her joints

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Weight Loss Strategy 1 - Dietary

• According to the NIH clinical guidelines, how
  much should someone decrease their caloric intake
  in order to achieve 10 weight loss (with BMI
  gt35)?
• Decreased caloric intake by 500-1000 kcal / day
  will lead to 1-2 lb weight loss / week
• What other dietary guidelines are there in terms
  of fat and caloric intake?
• Fat lt 25 of calories and sat fat lt 7-8

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Weight Loss Strategy 1 - Dietary

• BM and her physician discussed various strategies
  and utilized many options
• Calorie Counting
• Weight watchers
• Ultraslim
• These were not very effective
• Patient utilized local nutritionist to optimize
  diet
• Failed this treatment as well

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Weight Loss Strategy 2 - Exercise

• According to the NIH guidelines, most weight loss
  occurs because of decrease caloric intake, but
  physical activity will complement dietary changes
• Initiate walking/swimming 30 minutes 3x/week
• Build up to 45 minutes 4-5x/week
• Long term goal of at least 30 minutes moderate
  intensity most days of the week

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Weight Loss Strategy 2 - Exercise

• BM attempted various exercise regiments but
  failed each time
• Shoulders hurt during swimming
• Unable to walk due to joint pain
• Similar complaints with other exercises

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• April 2006, pt began to have shoulder joint pain
  and muscle aches
• Tentative diagnosis of polymyalgia rheumatica
• Responded to prednisone, sxs improved
• Ecchymosis developed and prednisone was stopped
• Sxs returned

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Weight Loss Strategy 3 - Pharmacotherapy

• Used as an adjunct to diet/exercise
• Reserved for those with BMIgt30 or those with
  BMIgt27 and associated risk factors (HTN,
  Dyslipidemia, CHD, DMII)

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Weight Loss Strategy 3 - Pharmacotherapy

• BM used multiple trials of pharmacotherapy
• Most medications ineffective
• Achieved weight loss with Xenical, but this
  exacerbated her BPD

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• Aug 2006 to Nov 2006
• Diagnosed with Restrictive Lung Disease 2/2
  obesity
• Diagnosed with OA of both hip joints and knee
  joints
• Pt unable to perform even minimal exercise
• Patient presented in February
• Nothing seems to work. I eat because I am
  unhappy and Im unhappy because I eat

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• As each strategy failed, another one was added in
  conjunction with, not instead of, the previous
  strategy.
• At this point in time, the patients BMI had
  increased to 41.
• The patient felt dejected, whatever she tried
  resulted in failure
• What other options do we have?

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Weight Loss Option 4 - Surgery

• Indications for bariatric surgery
• BMI gt 40 or gt35 with comorbid conditions
• Reserved for patients who have failed medical
  therapy
• Patient currently preparing for gastric
  laparoscopic banding (excited by the prospect of
  success she feels this will be an effective
  treatment)

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Resources

• In a community / rural environment, pt able to
  utilize local resources
• Mental Health Clinic
• Local Nutritionist
• Local Recreation Center
• Family Physician utilized chronic care
• Mood Disorder
• Obesity

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Chronic Care Model

• Diet
• Decrease intake by 500-1000 kcal
• Fat to 25, sat fat to 7-8
• Exercise
• 30 minutes 3x/week to start
• Build to 30 minutes medium intensity most days of
  the week
• Medication
• Orlistat
• Xenical
• Surgery

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• Questions?