Case Study

[VA Hopeful Dr]

As promised. I will try to do one of these every week or two, assuming I don't run out of interesting cases.

48 y/o female presents to establish care. Has not seen a doctor in several years owing to lack of insurance. No concerns from the patient. Nothing noteworthy on exam, diastolic pressure up just a tad at 90. CBC, CMP, and lipids drawn (my standard for new patients over 30).

All labs stone cold normal except a calcium of 12.0.

What would y'all do from here?

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[mommy2three]

Parathyroid hormone, PTH related hormone and vitamin d levels
I would also ask lab for ionized calcium

 

[SuckySurgeon7]

Maybe also urine calcium, serum phosphate and magnesium.

 

[TorMed]

Maybe also urine calcium, serum phosphate and magnesium.

Probably check for proteinuria too

 

[VA Hopeful Dr]

Good thoughts all around. I will preface this with saying that this patient in uninsured, so my approach is not going to be exactly textbook since I'm trying to avoid ordering any tests that I don't absolutely have to. I think this has particular value as it forces me to really think before I reflexively order anything.

First, recheck the calcium. The week before I had a patient with an iron of 270. I got everything ready for a hemachromatosis work up then decided to repeat iron levels. Stone cold normal. Always recheck an abnormal if its not something you're expecting to find.

In this case, a repeat was 11.8.

Ionized calcium is a excellent idea, but if you have a normal albumin, normal total protein, normal bicarb, and the patient isn't hyperventilating in front of you, then you've accounted for almost everything that can cause the serum level to be inaccurate.

PTH-related protein is also a good idea as its always wise to distinguish between hyperparathyroid and cancer, however in this case I have an asymptomatic patient with no pain, weight loss, or really any symptoms at all so I'm not too worried about cancer. Plus, even at my prices its expensive - I offered but didn't argue very hard when the patient declined.

PTH ended up being 215, so primary hyperparathyroid is likely what's going on here.

Normally surgery is indicated for these patients, but for self-pay that's not really an option. What would you do from here to manage medically?

 

[deleted87716]

I'd probably refer her to endocrinology, personally. If you're going to follow her yourself, you should see her every 6 mo. to monitor for symptoms, follow her calcium and renal function, and check a DEXA annually.

You may not be worried about malignancy, but you should encourage her to have a mammogram.

http://www.aafp.org/afp/topicModules/viewTopicModule.htm?topicModuleId=67

 

[smq123]

I'd probably refer her to endocrinology, personally. If you're going to follow her yourself, you should see her every 6 mo. to monitor for symptoms, follow her calcium and renal function, and check a DEXA annually.

You may not be worried about malignancy, but you should encourage her to have a mammogram.

http://www.aafp.org/afp/topicModules/viewTopicModule.htm?topicModuleId=67

Again, patient is uninsured. It depends on the region, but the specialists in my area would never take an uninsured patient, even on a payment plan. I had a patient who somehow lost his insurance get turned away from his oncologist's office (he was in the middle of chemo treatment for metastatic prostate CA).

Otherwise, I agree with what you've said.

 

[VA Hopeful Dr]

This was supposed to be a case study for the students/residents, I know y'all know what to do in this case...

 

[medimedimedi]

According to medscape:

• surgery may be cheaper than the constant monitoring?
• "alendronate can be considered in patients with primary hyperparathyroidism and low BMD who cannot, or will not, undergo surgery" although I have no idea how much bisphosphonates cost out of pocket

 

[SqEdSaint]

is this a DPC patient? if so shouldn't constant monitoring be cheap as long as she is paying her monthly fee?

 

[deleted87716]

According to medscape:

• surgery may be cheaper than the constant monitoring?
• "alendronate can be considered in patients with primary hyperparathyroidism and low BMD who cannot, or will not, undergo surgery" although I have no idea how much bisphosphonates cost out of pocket

Fosamax (alendronate) is $24 for a 90-day supply at Target.

 

[VA Hopeful Dr]

Fosamax (alendronate) is $24 for a 90-day supply at Target.

$6 for 90 days at my office

 

[VA Hopeful Dr]

is this a DPC patient? if so shouldn't constant monitoring be cheap as long as she is paying her monthly fee?

Correct, I was just trying to get some of the folks still in training to think about what type of monitoring would be a good idea in this patient.

 

[deleted87716]

$6 for 90 days at my office

Sure, but then they'll miss out on the Target shopping experience.

 

[VA Hopeful Dr]

Sure, but then they'll miss out on the Target shopping experience.

Normally I'd agree, but they had a whole aisle of Pumpkin Spice stuff. My wife damned near lost her mind at the sight of it.

 

[Ericslv]

This was supposed to be a case study for the students/residents, I know y'all know what to do in this case...

What was her Vit d level.

 

[VA Hopeful Dr]

What was her Vit d level.

17

 

[SqEdSaint]

Should we be concerned about hypophosphatemia given that the Vit D level is low? What's her phosphate level? Also she should receive bone scan to look for osteoporosis. Correct Vit D with oral calcitriol and phosphate supplement if she is symptomatic (which she doesn't appear to be) or has renal tubular dysfunction.

 

[Ericslv]

Should we be concerned about hypophosphatemia given that the Vit D level is low? What's her phosphate level? Also she should receive bone scan to look for osteoporosis. Correct Vit D with oral calcitriol and phosphate supplement if she is symptomatic (which she doesn't appear to be) or has renal tubular dysfunction.

I would correct the vit d before anything else. Everything else may be a sign of that. Bone scan is important with a vitamin D that low but he said she didn't have much money so she probably can't afford it. Perhaps step by step letting her know she needs to save up for a scan etc.

 

[Ericslv]

17

Good case. Not the most common but not uncommon. I think most importantly it demonstrates some of the problems a DPC practice may run into. Many of the patients can't afford many tests/labs etc. VS. a concierge who most likely will be able to pay for some of these labs and tests.

 

[SuckySurgeon7]

I liked this case. Looking forward to the next one.

 

[VA Hopeful Dr]

Good case. Not the most common but not uncommon. I think most importantly it demonstrates some of the problems a DPC practice may run into. Many of the patients can't afford many tests/labs etc. VS. a concierge who most likely will be able to pay for some of these labs and tests.

The tests are all easy to afford, and I've negotiated good rates for imaging and diagnostics, she just doesn't want to pay for labs that might not be needed.

For example, back in regular practice with a high repeat calcium I would have reflexively ordered PTH, PTH-rp, and 24-hour urine calcium. Instead, I just got the PTH which was high enough combined with the elevated calcium to give me a diagnosis without needing everything else. Its how we all should be practicing, but most other docs don't have any incentive to save money so why would they?

 

[JustPlainBill]

Mind if I jump in?

A 53 y/o WM presents to your clinic for the first time to be seen for "cough/congestion". While you're in with another patient, your MA knocks on the door and asks you to step into the triage area -- upon entering the triage area, you see the patient shaking in a non-tonic/clonic fashion while stating,"I can't make it stop" and stating that this just started while walking in from the parking lot --- where do you go from here? Your MA quickly tells you the patient was treated for a sinus infection with augmentin at a local UC 2 days ago, is NKDA with stable vital signs -- You have a full lab with STAT capability, full imaging center in the building also ---

 

[medimedimedi]

For sure check blood glucose. Then stat CMP and offer some benzos. I'm not terribly worried because his vital signs are stable and he's coherent with no altered mental status.

- student who knows nothing
​

Edit: I just realized it's a patient being seen for the first time, so of course, get a history! Past medical history, any other medications, HPI: anything like this ever happened before? any recreational drug us? dietary changes like relating to caffeine or nicotine?

 

[JustPlainBill]

fingerstick glucose 98, STAT CBC WNL, never happened before, no significant PMH, at the patient's request, you contact previous PCP who states that patient has no major medical issues, is a little anxious but not on treatment for it, occasional UTI; Brief PE: RRR, No M/R/G, CTAB, No W/R/R, CN II-XII grossly intact, no focal deficits appreciated ---

And---- go

 

[SqEdSaint]

pgy 1 here --- aside from serum glucose level i would want to know electrolyte status (Na, K, Ca, Mg) and other meds that he's on.

Edit: should viral meningitis be considered? can have normal temperature and may not necessarily show in CBC and could be complication of sinusitis.

 

[medimedimedi]

so what exactly is the shaking like? Is it high amplitude hand tremors or whole body shivering or chorea or myoclonus or hemibalismus?

 

[*brobro*]

Has the patient taken augmentin before? Maybe we should go ahead and discontinue that.

 

[Ericslv]

The tests are all easy to afford, and I've negotiated good rates for imaging and diagnostics, she just doesn't want to pay for labs that might not be needed.

For example, back in regular practice with a high repeat calcium I would have reflexively ordered PTH, PTH-rp, and 24-hour urine calcium. Instead, I just got the PTH which was high enough combined with the elevated calcium to give me a diagnosis without needing everything else. Its how we all should be practicing, but most other docs don't have any incentive to save money so why would they?

The only problem I see with that is the lawyers. If something did go wrong they would now ask you on the witness stand why you chose to cut corners and if you would have done the same thing in a regular insurance based practice. There could be many argument and you are correct in my opinion. But my opinion would only count if I was on the jury. And since the average malpractice case take 4+ years to get to a jury, you would be having to deal with it for that time. I suggest lots and lots of documentation stating the patient refused all the tests I recommended.

 

[VA Hopeful Dr]

The only problem I see with that is the lawyers. If something did go wrong they would now ask you on the witness stand why you chose to cut corners and if you would have done the same thing in a regular insurance based practice. There could be many argument and you are correct in my opinion. But my opinion would only count if I was on the jury. And since the average malpractice case take 4+ years to get to a jury, you would be having to deal with it for that time. I suggest lots and lots of documentation stating the patient refused all the tests I recommended.

OK first, I have had insured patients not want tests due to costs.

Second, I'm so glad you're here. I would have never thought to document my recommended plan and the patient's refusal otherwise. Thank goodness for you good sir.

 

[Ericslv]

OK first, I have had insured patients not want tests due to costs.

Second, I'm so glad you're here. I would have never thought to document my recommended plan and the patient's refusal otherwise. Thank goodness for you good sir.

Wow. So defensive. what is it with you? You sound like your 4 years old.

 

[Doctor4Life1769]

Wow. So defensive. what is it with you? You sound like your 4 years old.

You speak to someone who is BC physician as if he was a resident and wonder why he responded the way he did.

 

[Ericslv]

You speak to someone who is BC physician as if he was a resident and wonder why he responded the way he did.

Who cares. So am I. Get over it. Your ego is over inflated. And why do you need to come to his rescue? Co dependent much? If he is so defensive that he can't have a regular conversation and gets offended then he is the one with the problem. Or problems. Get over yourself. lol Board certified attending. lol.

 

[Doctor4Life1769]

Who cares. So am I. Get over it. Your ego is over inflated. And why do you need to come to his rescue? Co dependent much? If he is so defensive that he can't have a regular conversation and gets offended then he is the one with the problem. Or problems. Get over yourself. lol Board certified attending. lol.

Lol, ok Napoleon.

 

[DrMidlife]

re: seizure pt, depending on location consider naegleria

 

[medimedimedi]

re: seizure pt, depending on location consider naegleria

That can't be. A quick uptodate search shows that people with Naegleria infection have meningitis symptoms, including fever, headache, photophobia, altered mental status and meningeal signs. It also sounds too rare to be on the differential this early with barely any symptoms

 

[DrMidlife]

any of the big kids want to advise on the reasonableness of the following thought process? (i ignore persistent nutjobs.)

having a thing on a differential is not the same as having a thing HIGH on a differential. differentials start wide, get narrow as things are ruled out starting with common things. if common things not ruled out, continue to focus on common things.

prob want to keep nearly-always-fatal things on a differential, given a couple hits ("sinus ix" not responsive to abx, meningeal sx). if we're in Louisiana and the guy used a neti pot and tap water to fight that "sinus infection", that's 3 hits. thus I mentioned location.

meningitis sx include sz. in this case http://www.cdc.gov/parasites/naegleria/clinical-features.html

neurology workup for sz starts with VITAMINACDE (or similar). Vascular, inflammatory, trauma/toxin, autoimmune, metabolic/meds, infection, neoplastic, acquired, congenital, degenerative, endocrine/electrical. personally my goal for being a decent diagnostician is to not fail to keep all that in mind as I'm trying to narrow down something more common like viral mening.

 

[Ericslv]

Lol, ok Napoleon.

I think your projecting. You should call yourself that. lmao

 

[medimedimedi]

any of the big kids want to advise on the reasonableness of the following thought process? (i ignore persistent nutjobs.)

having a thing on a differential is not the same as having a thing HIGH on a differential. differentials start wide, get narrow as things are ruled out starting with common things. if common things not ruled out, continue to focus on common things.

prob want to keep nearly-always-fatal things on a differential, given a couple hits ("sinus ix" not responsive to abx, meningeal sx). if we're in Louisiana and the guy used a neti pot and tap water to fight that "sinus infection", that's 3 hits. thus I mentioned location.

meningitis sx include sz. in this case http://www.cdc.gov/parasites/naegleria/clinical-features.html

neurology workup for sz starts with VITAMINACDE (or similar). Vascular, inflammatory, trauma/toxin, autoimmune, metabolic/meds, infection, neoplastic, acquired, congenital, degenerative, endocrine/electrical. personally my goal for being a decent diagnostician is to not fail to keep all that in mind as I'm trying to narrow down something more common like viral mening.

You're not going to be a very good diagnostician either if you're always chasing zebras. From 2005-2014, there were a total of 35 cases in the US of naegleria. You have a better chance of winning the lottery than diagnosing this guy with naegleria, especially with an atypical presentation that doesn't suggest encephalitis at all.

Either way, a lumbar puncture sounds like a good way to rule out aseptic meningitis.

 

[DrMidlife]

again, having a thing on a differential is different from chasing a thing on a differential

 

[SqEdSaint]

this was supposed to be a good thread....lol

 

[smq123]

HEY! If you can't maintain a polite thread, I'm turning this car around and we're going straight home!

Be nice, or this thread is getting locked.

 

[VA Hopeful Dr]

Wow. So defensive. what is it with you? You sound like your 4 years old.

Perhaps, but I grow weary of your constantly condescending tone. On a prior thread you asked why we were all being so mean to you - this is why.

 

[Ericslv]

Perhaps, but I grow weary of your constantly condescending tone. On a prior thread you asked why we were all being so mean to you - this is why.

Perhaps I feel the same from your tone. Read the post again. I don't believe there was any condescending tone in there unless you read into from an insecure perspective.

 

[Doctor4Life1769]

Eric's come backs are to take what you say and flip it. It's a strategy used by 4 year olds. Even Trump for all his condescension is funny because he takes it an extra step or two.

 

[deleted87716]

 

[Ericslv]

Eric's come backs are to take what you say and flip it. It's a strategy used by 4 year olds. Even Trump for all his condescension is funny because he takes it an extra step or two.

Actually I don't have any come back. I really don't have anything else to say to you or your friend.

 

[smq123]

This is why we can't have nice things.

Closing thread.