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.

______________________

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

Image of the Week 06/17/2014

A patient presents with burning, stinging vesicles at the vermilion border of the lip.  What may have caused this lesion and what is the treatment?