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.