Image of the Week 12/16/2014

What common incidental finding can be seen on this CT scan performed as part of an evaluation for abdominal pain and diarrhea on a 57-year old man?

Primary Hypertension

Our talk this evening was given by Jake Decker, PGY2 in Primary Care on a specific facet of hypertension discussed the previous week: Primary Hypertension.

Case:

A 58 y/o M with no significant PMH comes in with an elevated BP of 148/88 today.

HTN Definition and Goals:

• Elevated BP: a reading of elevation or not.
• HTN: a diagnosis, disease state. The average of 2+ properly measured reading at each of two or more visits after initial screen.
• Clinically we use these guidelines of whether patients are at these goals:
• ages 18-59: <140/<90
• ages >60: <150/<90

• DM (all ages): 
• <140/<90 because of comorbidities
• Cutoff still controversial because not sure if want to be aggressive with older patients' BP because it might be harmful.
• Kidney disease (all ages): <140/<90

HPI:

• Diet, obesity
• Episodic/constant
• Associated with other conditions?
• Recent caffeine intake
• Kidney problems
• What meds patients is on (NSAIDs, steroids, SSRIs, TCAs, OCPs)
• Smoking, alcohol, and cocaine use (raises BP)
• HA, dizziness
• Vision change
• chest pain, palpitations
• snoring, daytime tiredness
• Sweating, tremors

Physical exam: 

• General impressions
• Take vitals at least twice
• Eye exam (retinal hemorrhages)
• Vascular exam (asymmetric or diminished pulses)
• Cardiac (stenosis, dilated heart muscle)
• Lungs (crackles)
• Basic metabolic panel; creatnine reading to assess end organ damage.
• Urinalysis; CKD can cause HTN, chronic HTN causes CKD.
• EKG: conduction abnormalities, previous/current ischemia or infarction, LV hypertrophy.

Treatment:

• 1) Lifestyle modification 
• Diet/exercise, quitting smoking/drinking. 
• Dash and Mediterranean diets are most largely studied for HTN. 
• Limit sodium to <2400 mg/daily.  
• If end organ damage and reading of 160/90, skip to step 2.

• 2) Pharmacotherapy
• Thiazide diuretics
• Calcium channel blockers
• ACE inhibitors
• ARBs
• For non-black patients: all equal choices
• For black patients: thiazide or CCB
• For CKD patients: ACEi or ARB because they reduce pressure in glomerulus.
• For women of childbearing age: CCB

Hypertension: Another Way to Look at It

Tonight's talk was delivered by Tomi Jun, MS IV on the hypertension areas we can pay attention to specifically in the CCC clinic.

Hypertension cutoffs:

• Stage 1: >140/90
• Stage 2: >160/100

Method:

• 3 measurements, each 1 week apart.
• Consistent pattern.
• Be mindful of activity and white coat measurements.

Primary HTN: treating HTN directly

Secondary HTN: Blood pressure elevated because of secondary causes like a tumor that secretes epinephrine (rare case). The treatment is not to manage the BP but to remove the tumor.

When BP is >180/120:

• Hypertensive urgency: Regular checkup finding asymptomatic HTN. 
• Emergency: when people are showing symptoms like chest pain, altered mental status. If people have a high BP but asymptomatic we still want to send them to the ER.

What we are worried about

•  End organ damage
• Brain
• Heart
• Kidneys
• Vasculature
• Long term damage

________________________________________________________________________
Atherosclerosis: 

• injury to vasculature. 
• plays role in other areas of HTN. 
•  Buildup over time leading to lack of oxygen or rupture
• Achemia and strokes occur. 
• Coronary artery disease occurs, which leads to...

Heart disease: 

• Heart attack leads to heart failure
• Left ventricular hypervole: thickening of left ventricle. The muscle gets bigger and stiffer as it pumps against high systemic resistance.

Kidney disease:

• HTN big risk factor for end stage renal disease --> dialysis. 
• HTN makes substances squeeze through kidney vessels, damaging them.

________________________________________________________________________

Case 1:

• 50 yo F African American with obesity, HTN, DM.
• BP 150/90
• BMI 45.1
• 3 HTN meds: metropolol, losartan, chlotalidone
• Worried about: risk factors such as smoking and DM for kidney disease, heart failure, athero, and stroke.
• Think about changing metropolol to a medication that acts upon calcium channels.

JNC8 Guidelines:

• For people <60, goal is >150/90
• Previously 140/90 from JNC7
• Recently found that there is no additional benefit from goal of 140/90, which takes more meds to achieve.

Lifestyle modification:

• Weight reduction: every 10 kg lost can bring down diastolic BP by 20. 
• Cut dietary salt, reduce alcohol intake, exercise.

________________________________________________________________________

What to ask:

• Meds adherence
• PMH
• Lifestyle (smoking, exercise, diet, alcohol)
• Symptoms (cardiac, neuro)

What to examine:

• Signs of heart failure
• Fundoscopy
• Labs
• basic metabolic panel
• kidney function
• electrolytes
• lipid profile
• urinalysis
• screen/eval DM
• Look for evidence of end-organ damage or other relevant risk factors.

Image of the Week 12/02/2014

Which genetic disorder would this X-ray of the lungs be associated with?

Image of the Week 11/25/2014

What condition is shown here? 

Interprofessional Education

Today's installment of the Inter-Professional Education series was delivered by Kristi Larned, pharmacist, on situational awareness in the clinic between our IPE members. Our clinic consists of attending physicians, med students, nursing students, pharmacists, and other related healthcare professionals such as administrative assistants and patient recruiters.

Situational awareness: 

• Understanding of, or knowledge about, a situation or process that is shared among team members through communication.
• Being attentive to the environment.
• Technique used in decision-making in settings that need quick action.
• A skill that can be improved over time.

Situational monitoring:

• Pay attention to the status of the patient
• Cross-monitor team members
• Survey environment
• Preventing errors that may be caused
• Fosters mutual respect and communication for team members
• Ensures everyone on the team has an idea of what it should look like
• Enables team members to predict and anticipate better
• Creates commonality between members
• Progress toward goal

Barriers:

• Distraction
• Workload
• Fatigue
• Misinterpretation
• Failure to share information (forgot, distracted)

Shared mental model: 

• Perception
• Understanding of or knowledge about a situation or process that is shared among team members through communication.
• Increased accountability

Situation Monitoring Prescribed to:

• Rounds, which are quick
• When more attention is given to patients with more acute conditions.
• People are talking over the team so it's easy to miss information

Strategies to overcome this:

• Checklists
• Engage the patient when discussing regimen
• Helping others with a heavy workload
• Cosigner making sure you're doing everything complete
• Huddles, debriefs, more communication
• Cross-monitoring

Clinical encounter:

• 47 year old female
• History of coronary artery disease, diabetes, mild hypertension
• Status post CABG (Coronary Artery Bypass Grafting) and NSTEMI (Non-ST segment elevation myocardial infarction).
• Chief complaint: shortness of breath and intermittent substernal discomfort.

Our plan to address patient:

• Getting a set of vitals to figure out tests to run
• Approaching the pt directly to identify the cause of SOB
• Survey the scene for any helpful people around
• Notifying the appropriate personnel
• Start triaging

Image of the Week 11/18/2014

What physical examination finding is displayed on this nail? Why does this condition develop?

Image of the Week 11/11/2014

What is notable about this patient’s hands? What diseases contribute to this condition?

Infectious Disease Case

Our talk this evening was on an infectious disease (ID) case by Sarah Housman, Primary Care Resident at BIDMC.

Case:
A 21M patient who is otherwise healthy complains of a sore throat, fevers, and chest pain. He had a fever 3 days prior. A nurse told him he had strep throat and started him on penicillin. The patient says it feels like someone is sitting on his chest.

In clinic:

• Has strep throat, no remarkable physical exam
• WBC 12
• 70% Neutrophils
• Trop 0.32
• CRP 91
• EKG: ST elevation everywhere
• Day 2 Labs showed Trop 1.09
• Echocardigram shows focal myocarditis and myoregional systolic dysfunction.

Differential Diagnosis:

• Myocarditis (inflammation of muscle tissue, enzyme count increases)
• Pericarditis (inflammation of lining of heart, ST and PR elevation on EKG)
• Myopericardits (heart tissue inflammtion and damage --> CRP elevation)

Diagnosis:
The patient has myopericarditis. Diagnose for both pericarditis and myocarditis conditions by EKG changes, auscultation, pleuric chest pain, cardiac enzymes elevated, depressed injection fraction certain areas are hypokinetic, and look at the MRI.

Treatment:

• NSAIDs (for 2 weeks)
• Cholchicine to prevent recurrence by inhibiting microtubule formation (for 3 months).
• The most common side effect is diarrhea.
• Patients who are at risk of peptic ulcer disease, kidney disease don’t tolerate NSAIDs.

What about the Strep Throat?

• Group A strep can cause myocarditis.
• This patient could have rheumatic fever.
• Use JONES Criteria to help diagnose.

JONES Criteria:

• J- joint pain and migratory polyarthritis
• O- (represents a heart) carditis
• N- painless nodules on achilles tendon
• E- erythema
• S- Sydenham's chorea

For diagnosis: one major criterion (chorea, carditis, migratory arthritis) PLUS two minor criteria (fever, arthralgias, elevated ESR and CRP, prolonged PR). Our patient has 1 major and 2 minor criteria.

Why not Rheumatic Fever?

• 2-4 weeks after developing strep throat, rheumatic fever develops.
• This patient's timing is 2 days, making rheumatic fever an unlikely case.

Conclusion:

• Because he met the criteria, the patient should go to the ID clinic and be treated for rheumatic fever. 
• Patient is on long term penicillin (5 yrs while he’s in college since he’s at the risk of getting strep again). 
• Also treated for myopericarditis with NSAIDs for 2 weeks and Colchicine for 3 months.

Image of the Week 11/04/2014

What injury of the ear is shown in this image? What causes this condition?

Interprofessional Education Using TeamSTEPPS

Today’s talk and interactive session were delivered by Amy Weinstein on IPE Teams in Primary Care.

TeamSTEPPS 

• The program our clinic uses for inter-professional education.
• Provides an opportunity to learn about them to enhance patient care. 
• Created by the AHRQ that provides skills in 4 areas for us to work in teams. 
• Performance
• knowledge
• skills
• attitudes
•  This nationally studied program works. 
• We can see a 50% reduction in weight adverse outcome score which describes the adverse event score per delivery. 
• We also see significant improvement in teamwork outcomes, communication, supportive behavior, reductions in turnover rate, increases in employee satisfaction, and better continuity of care.

IPE teams consist of attending physicians, med students, nurses, pharmacists, social workers, case managers, admins, medical assistants, front desk. The physician and nurse workflows sometimes do not line up. Some of them, such as the phone scheduling staff, are never seen when working with patients yet they are all part of patient care. How do we interact with all of these team members? TeamSTEPPS is designed to break down the barriers and come together as a team.

Barriers to teamwork:

• people: workload, distraction, conflict 
• systems: hiearchy, lack of coordination, miscommunication, lack of role clarity.

Case— Background: 
The patient is a 49 y/o F with Type 2 diabetes and depression comes in for follow up care. She takes Lantus and Humalog. The patient also takes insulin morning and evening, but rarely at lunch. She's been getting increasingly depressed.

MD: Biggest concern is depression
PharmD: Wants to review medication regimen and discuss action plan for hypoglycemia

Case— Clinical encounter: It’s a busy IPE night and the team rushes off to see the patient before huddling. The attending goes in with her own agenda about depression and the PharmD doesn’t get to talk to the patient about hypoglycemia and changes to the medication regimen. The MD thought the visit went well but not the PharmD.


Strategies for addressing breakdowns: 

1.  Leadership: 
• Process of motivating people to work together
• Anyone can be a leader
• They are role models who shape teamwork through open sharing of info
• Give constructive and timely feedback
• Faciliates briefs, huddles, debriefs, and conflict resolution. 
• Organize ppl to achieve common goal.
• Involves planning, processing, and improvement.
2. Planning: 
• form the team and huddle
• designate team roles and responsibilities
• establish climate and goals
• engage in short and long term planning
3. Problem solving: 
• touch base
• discuss critical issues and emerging events
• anticipate outcomes and likely contingencies
• assign resources
• express concerns.
4. Debrief:
• brief and information information exchange and feedback session
• occurs after event or shift
• designed to improve teamwork skills
• designed to improve outcomes
• recognize what good teamwork is

Case— Solutions: deal with pt chief complaint, pt centered; have a plan in advance, finding time to debrief after; knowing what the pt thinks about the plan, making sure pt understands regimen and offer perspective on big picture. have pts repeat directions back to ensure understanding, checking in mid visit. debriefing afterward. otherwise it wont be a good set up for teamwork. keep in mind that we’re all here for the pt.

Take home points: 

• Everyone can be a leader
• Hold huddling sessions
• Hold debriefs to bring the team together

Image of the Week 10/28/2014

A patient presents with the lesion on his back. What factors should the provider keep in mind in evaluating this lesion for melanoma?

Image of the Week 10/21/2014

A patient with a history of alcoholism presents with these lesions on her face and chest. What is a likely etiology of this presentation? 

Smoking Cessation Pharmacotherapy Options

Dr. Jake Decker delivered this evening's talk on smoking cessation with an emphasis on pharmacotherapy options.

Many of our chronic disease patients smoke. Smoking is a learned behavior and a physical addiction to nicotine. Combining counseling with pharmacologic therapy is most effective.

Nicotine Withdrawal Syndrome:

• Depressed mood
• Insomnia
• Irritability, frustration, anger
• Anxiety
• Difficulty concentrating
• Restlessness
• Increased appetite
• Weight gain

Options

Nicotine Replacement Therapy:

• Provides nicotine without using tobacco 
• Reduce withdrawal allowing breaking of behavior
• Dependence to NRT is rare
• In general NRT use is recommended for 2-3 months
• longer use is ok if risk for relapse
• Combinations of different NRTs are more effective than either alone.

Transdermal Patch:

• Dose the strength of patch by how much the patient smokes
• Use patch on nonhairy part of body as it's changed each morning. 
• They should quit smoking while on the patch because patients can't self regulate their own nicotine toxicity, results in symptoms of nausea.
• There can be irritation at the skin site so don't put it in the same spot each day.

Gum:

• Dosed based on how much patients smoke, use as needed to keep a basal level of craving. 
• A certain amount of nicotine is released when chewed, "park" it in your gums until nicotine is absorbed via buccal mucosa and taste goes away, chew again. 
• Acidic beverages should be avoided before and during.

Lozenge:

• Like the gum, dosed based on how many cigarettes in a day. 
• More user-friendly but chalky and not palatable.

Inhaler:

• Different than the e-cigarette, used as an inhaler puff as needed
• Delivers vapor to oropharynx and absorbed into buccal mucosa
• Fights craving and addresses behavioral addiction. 
• Patients love this method but is costly and not covered by insurance.
• Must be prescribed and not available OTC
• Helpful to patients with pulmonary disease.

Nasal Spray:

• puffs in nose
• not as well tolerated by patients as it causes runny nose, sneezing, and tearing.

Comparing Methods of NRT:

• The NRT patch high dose is twice better than placebo. The gum is a little less effective, followed by inhaler. 
• Combining patch and gum/spray is much more effective.
• The patch will give continuous nicotine but people will have cravings so the gum counters that. 
• Chantix has abstinence rate of 33.2% and can be used in combination with NRT but the safety is not yet clear.

Image of the Week 10/14/2014

A 37-year-old man comes in for a physical examination. After taking the patient’s blood pressure, the physician performs a dilated funduscopic exam and observes this image of the week. What do you think the patient’s blood pressure findings were? 

Image of the Week 10/07/2014

An elderly woman with a history of alcoholism presents to the clinic with the engorged abdominal veins pictured. What is this presentation called and what is the most likely etiology?

Image of the Week 09/23/2014

Which is the healthiest cereal choice? How do you know?

Surgery in the Clinic

Tonight's presentation was by Kyle Checchi, MSIV, on surgery in the clinic. We see a lot of surgery in the OB/GYN setting but there are other instances in which surgery is done.

Case Study #1:
A 37 year old female with a BMI of 30 has abdominal pain with the following:

• RUQ
• steady and severe
• nausea/vomiting
• diminished appetite, worse with fatty food
• 1+ hr after meal, prolonged > 4-6 hrs). 
• Unremarkable medical history.  

 Based on this information, we think it is obstruction of the cystic duct.

Cholecystitis:

• RUQ pain with contraction of gallbladder against stone in the cystic duct
• colicky pain after fatty intake
• no signs of obstruction or infection
• fear of perforation of gallbladder

Reasons to send in to be seen:

• Cannot maintain PO intake
• Pain not adequately controlled
• Charcot's triad (fever, jaundice, RUQ pain)
• Reynolds pentad (triad plus shock and altered mental status)

Case Study #2:

A 25 year old male complains of discomfort and bulge in the abdominal wall.

• Heaviness and dull discomfort
• History of open appendectomy
• Located at scar
• Cosmetic concern
• Appearance and discomfort worsened with coughing or straining
• Distinguish hernia from ischemic pain

Rational clinical abdominal exam:

• Murphy's signs: cessation of inspiration when pressure applied over gallbladder
• Rovsing's signs: pain in RLQ with deep palpation of LLQ
• Psoas sign: pain with passive/ active extension and flexion at hip, lie on side and grab leg, flex/extend at hip joint and check for discomfort. Bring leg in and kick out to move core muscles, see if anything on the peritoneal muscles inflamed.
• Obturator sign: pain with adduction and external rotation at hip
• Peritoneal signs:
• rebound: increase in pain with quick withdrawal of hand from deep palpation
• guarding: tensing of the abdominal muscles at initiation of palpation
• tap tenderness: pt reacts when percussing

Other Surgery in Clinic:

• Scratch test (hepatomegaly)
• Assessing size of liver, for hepatitis
• Used instead of percussing.

• Drains from surgery such as a mastectomy. If red, swollen, warm, tender skin, it could be fluid or an infection.

Image of the Week 09/16/2014

A 63-year-old white female presents to the ER confused. The patient’s history is positive for alcoholism. A pathology resident diagnoses megaloblastic anemia given the history information and the peripheral blood evaluation below. About which vitamin deficiencies should the medical student caring for the patient be concerned?

Image of the Week 09/09/2014

A missionary returning from Africa is brought to the emergency room one evening for high fever, vomiting, headache, confusion, and bloody diarrhea. The patient is found to be febrile, slightly hypotensive, has a nonpruritic rash on the neck and arms, and a nosebleed. What sort of precautions should the ER physicians take if this patient is infected with the virus shown below?

Live Blog: Diabetes Examination

This week we welcomed back Dr. Paige Comstock, PGY3, for a talk on the diabetic examination. 

At the start of a diabetic exam, the vital signs-- specifically blood pressure targeted at 130/80-- are the most important.

Skin findings in diabetics:

• Velvety, hyperpigmented areas called Acanthosis Nigracans
• Diabetic dermopathy found in 50% of diabetics. They have microvascular complications like neuropathy.

Eye complications of diabetes:

• diabetic retinopathy
• cataract
• glaucoma.

The foot examination:

• Necessary because there is a 25% lifetime risk to develop ulcers due to neuropathy, deformity, and trauma.
• Look for 
• sweating
• ABI (Ankle Brachial Index) if indicated
• callouses because of neuropathy
• nail dystrophy
• paronychia
• areas of abnormal erythema
• check interdigitally.
• Deformities (rigidity, claw toe, hammer toe, charcot foot) lead to increased pressure in some points of the foot which leads to more trauma. 
• For the neurologic exam, perform the microfilament test on various pressure points on the foot. 
• Other neurologic tests include ankle reflexes, pin prinks, and tuning fork on the foot.
• Vascular exam includes palpating the distal pulses to check whether there is poor blood supply. This is a risk factor for recurrent ulcerations.

Image of the Week 09/02/2014

A 25-year old white male presents with the pruritic, rapidly evolving rash below. What type of hypersensitivity reaction is this?

Live Blog: Anorectal Malformations

Today's talk was given by chief medical resident Rebecca Glassman on anorectal malformations.

At times in clinic we can be presented with a patient complaining of rectal pain. As a clinician, you perform a rectal exam to  feel the prostate and rectal muscles when there's a suspected GI bleed, complaints of prostate enlargement symptoms, concern about prostatitis, and also when patients have  lower back pain to test for tone of cord compression.

Some common anorectal complaints are itching and bleeding. To do a rectal exam, Dr. Glassman recommends having patients lying on the bed in a fetal position with draping, using lubricant when necessary. Looking for nodules and elevated PSA levels.

Case Study:

A 34 y/o M with a history of painless bleeding from hemorrhoids in the past presents with severe anal itching. You would think hemorrhoids, incontinence, fungal infections.

This is Pruritus ani, the differential of which is very large. There are systemic illnesses (diabetes, thyroid disease), mechanical factors (chronic dirarrhea, anal fissure), dermatologic factors (psoriasis), skin sensitivity from food (tomatoes, beer, milk products), infections (scabies, syphilis), and medications (bacitracin).

Take Home Points:

Anorectal pain: 

• The patient history tells you a lot about the condition. 
• Among the possible variations of anorectal pain are fissures, constipation, hernia, internal hemorrhoids, prolapse, thrombosed external hemorrhoids, fistulas, and proctalgia fugax.
• It's important to stop the itch cycle by identifying the underlying cause and then soothing the area with the appropriate medication.

Anal fissure 

• The stretching of the anal mucosa beyond capacity
• The internal sphincter muscle is exposed causing spasm
• Spams pulls apart the edge of fissure causing pain and impairing healing. 
• Goals are to relax the interal sphincter, maintaining bowel movements, relief the pain. 
• Medical therapy includes topical nitroglycerin, topical nifedipine (less side effects), injected botulinum toxin (decreases spasm), or surgical therapy (sphincterotomy).
• Management includes either stool softeners (Miralax) or contractile agents (senna).

Fissures are hard to treat to referring the pt to surgery is really helpful for if it comes to sphincterotomy. These patients are so miserable that if they don't respond to the topical treatment, you want them to have other options.

Hemorrhoids 

• Thrombosed blood vessels
• The cushion composed of arterio-venous chall and connective tissue is swollen. 
• Complications: thrombosis (acute pain with large mass) which need surgery to open up the hemorrhoids bringing instant relief. Other complications are bleeding, prolapse, pain, abscess, incontinence.
• Management: fiber supplementation, Preparation H suppositories, analgesic creams, sitz baths (soaking hemorrhoids in warm water) for soothing and decreasing irritation.

Anorectal abscess:

• Infection starts in crypts of Morgagni --> extends along anal gland. 
• Over 50% of abscess will result in fistulas. The patients need to have abscess drain. 
• Think about other potential underlying diseases such as Crohn's and diabetes.

Proctalgia fugax: 

• Episodes can occur yearly or 4x/week. Associated with sweating, pallor, incredibly distressing to pts. Urgency to defecate but pass no stool. 
• Treatment: warm water, ice, valium, deep breathing. 
• A lot of patients have spontaneous onset.

Image of the Week 08/19/2014

What is seen on the tonsils in this image?

Image of the Week 08/12/2014

What condition is the cause of this hair loss?

Image of the Week 08/05/2014

What is responsible for these large nodules on the leg? What disease is this condition most associated with?

Image of the Week 07/29/2014

What condition is responsible for the hyperpigmentation of the axila shown here?

Image of the Week 07/22/2014

An elderly patient with history of smoking comes in with a chronic cough, shortness of breath, and fatigue. What do you see in the patient’s chest X-ray? What is the diagnosis? 

Image of the Week 07/15/2014

What is present on the patient’s lower legs and with which disease is it associated?

Live Blog: Hypertension

Our talk today was delivered by Dr. Paige Comstock of BIDMC on hypertension. Hypertension is one of the most common chronic diseases seen in non-pregnant adults in our clinic at BIDMC.

Hypertension is the most common risk factor for a myocardial infarction (heart attack) and stroke. Blood pressure should be measured two times and have at least two visits after the initial screen.

Blood Pressure Ranges

Normal: less than 120/80
Pre-hypertension: 120-139/80-89

Hypertension stage 1: 140-159/90-99

Hypertension stage 2: greater than 160/100

People get hypertension because of increased sympathetic activity (increased beta adrenergic responsiveness), genetics, increased angiotension II activity, increased cardiac output, or increased systemic vascular resistance.

Some risk factors are being of African American race, hypertension in both parents, ingesting too much salt or alcohol, inactivity, and being overweight.

The consequences of this disease are stroke, myocardial infarction, congestive heart failure, chronic kidney disease, and ventricular arrhythmia.

To diagnose, take measurements over multiple visits with the patient seated for 5 minutes, legs uncrossed, arm at level of heart. Measure both arms at first visit and be sure to have the appropriate cuff size.

Interestingly, our clinic at Healthcare Associates can set up blood pressure monitors for patients at home so patients can track measurements of their blood pressure before coming into clinic.

Some secondary causes of hypertension are onset at young age, absent family history, severe hypertension at diagnosis, resistance to antihypertensive therapy, and spontaneous hypokalemia (low potassium).

Some examples of these causes are primary renal disease, excessive NSAID use, sleep apnea, Cushings syndrome, renovascular disease, and pheochromoctyoma.

The Joint National Committee-8 reviewed all the literature and published these treatment goal recommendations:

General population age > 60, goal < 150/90

General population age <60, goal <140/90

Diabetes and age >18, goal <140/90

Chronic kidney disease and age >18, goal <140/90

For patient counseling, the healthcare professional should give specific advice, recommend lifestyle changes and gradually increase activity, suggest 1-2 changes in eating habits, and refer patients to resources such as action plans sponsored by AMA and fitness and diet apps such as My Fitness Pal.

Image of the Week 07/08/2014

(Courtesy of Maureen K. Sheehan, MD.)

A 40-year-old patient comes in stating she feels fatigue and heaviness in her legs, especially after standing for several hours. What is seen on the patient’s thigh? What is the diagnosis?

Live Blog: Low Back Pain

Our didactic was done by Dr. Kristin Remus, a clinician educator at BIDMC and one of CCC's faculty preceptors.

Low back pain (LBP) is the second most common cause of disability in US adults. Many people miss work because of LBP. This disease has a 10% population prevalence with LBP for more than 2 weeks prevalent in 14%. Factors associated with LBP are work (exposure to high vibrations such as truckers and jackhammer constructioners), obesity, physical inactivity, arthritis/osteoporosis, age greater than 30, bad posture, and stress or depression.

In acute and chronic LBP, some mechanical causes are dislocation, compression, muscle strain and sprain, herniated disk. Non-mechanical causes are aortic aneurysm, infection, epidural abscess, ectopic pregnancy, diseases of the bone, metastases, and fibromyalgia.

Can we prevent it? In the physical exam check the spinous processes, check the greater trochanter on the hip. The ischial tuberosity and paraspinal muscles are usually tender. Do some maneuvers to see how well someone can bend or move, muscle strength testing in toes and ankle. Also do a neuro exam for numb dermatomes which all end in the feet, check patellas, do the straight leg raise for pain, and test gait such as toe walking and heel walking.

Lasegue's Sign: a straight leg raise physical exam finding. When you stretch the sciatic nerve you can decide if the patient has some sort of LBP. Symptom severity does not correlate well with outcome, so the pain can go away at any time.

Waddell's signs: inappropropriate tenderness superficial or widespread, LBP on axial loading of the head, inconsistent straight leg raise test seated or standing, sensory deficit without nerve root innervation, 3/5 psychological distress.

Discerning what the red flags are will let you know who to look at under an x-ray.

Red flags:

• Urinary retention, stool incontinence
• Neurologic symptoms such as tingling or loss of sensation. 
• People older than 70 often get imaged
• Unexplained weight loss, 
• Prolonged use of corticosteroids, 
• IV drug use, 
• Saddle anesthesia

Patient History:

• Does the patient have a systemic disease? 
• Do they have neurologic compromise or the need for surgery? 
• Do they have social or psychological distress?

Take home points: 

• In the physical exam, be systematic with palpation and inspection.
• Do a dorsi flex and plantar flex for any pain to confirm the straight leg raise test.

Image of the Week 07/01/2014

A patient with poorly controlled type-2 diabetes comes in with complaints of pain, swelling and erythema in both feet. What is the diagnosis and what tests should be done to confirm?

The Crimson Care Collaborative: Reviving the Pipeline for Primary Care

Christine Bishundat

Med Ed Committee

            The Benjamin Lipson Memorial Lecture was held at the Simches Research Center on June 19. The speakers included Marya Cohen, MD, MPH, Jessica Zeidman, MD, Talia Kraower, MD, Charlotte Ward, MPH, and medical students Tomi Jun, Simin Lee, and Katherine Schiavoni, who each addressed different aspects of the CCC model at HMS.

            Simin Lee's talk described the founding and evolution of CCC at HMS. In 2006, universal healthcare coverage became law in Massachusetts, transforming the landscape of healthcare and medicine in the state. While the number of uninsured patients has fallen following healthcare reform, there remains an insufficient number of primary care providers to meet the growing need.  In addition, between 1999-2009 the number of medical students matching into primary care dropped substantially [1]. 

            Recognizing the need for more primary care providers in Massachusetts, a group of students at HMS sought to expand primary care opportunities by creating the first CCC site at MGH IMA in 2010. The CCC mission emphasized a desire to provide excellent care while developing the next generation of primary care leaders. Currently, five CCC sites exist, treating a variety of patients including immigrants, refugees, youth, and those with chronic illness.

            Charlotte Ward, a researcher at the Stoekle Center and Benjamin Lipson Memorial Lecture speaker, analyzed data on the relationships between CCC and primary care match rates. She published an article in the New England Journal of Medicine in 2010 suggesting that CCC at HMS had, in fact, increased the number of graduating students matching into primary care.

The remaining speakers highlighted additional projects underway at CCC which are summarized here:

Interprofessional Education (IPE): Since modern medicine requires working in a team, CCC has nurse practitioner students, pharmacy students, medical students, interpreters, social workers, faculty preceptors, and undergraduates provide care as a unit. The students and faculty address medical concerns as well as social needs.

Longitudinal mental healthcare: A care manager enhances communication between the patients and PCPs around issues related to mental health.

Patient-reported outcomes: iPads are distributed to patients at their appointments to assess what outcomes are important to them and how well CCC addresses these needs.

Longitudinal care teams: CCC hopes to follow-up with patients and build lasting relationships through phone calls, text messages, and home visits.

Patient outreach: CCC is posting information in the communities it serves regarding workshops on nutrition labels reading and exercise habits.

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1. Ganguli, Inshani. The Case for Primary Care- A Medical Student’s Perspective. NEJM. Available online at: http://www.ishaniganguli.com/pdfs/GanguliPerspectiveNEJM.pdf