Clincial Mgmt Question

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Seaglass

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60 yo WF c type 2 DM has recently started on statin with complaints of severe fatigue. Has had episodes of DOE on climbing stairs daily that resolve with rest lying down. EDIT- the patient has also complained of chest tightness with these epispodes. This morning has similar episode with nausea that persists after rest. This person's DM has been well controlled so far.

EDIT - more info below.

Should she

a) go to endocrinologist or PCP ASAP
b) go to ER for RO-MI/ eval rhabdo
c) other

Please, discuss. I thought B.

C
 

NinerNiner999

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I would think B as well, especially with the recent addition of a statin. Metformin and Statins both hit the liver pretty hard (the statin probably more so) I would think. Is she also taking Glucophage? Insulin? R/O MI, AAA, GI Bleed, etc sounds prudent. The DOE is interesting, though, and sounds like new-onset CHF or effusion. She could have an effusion secondary to pancreatitis, albeit rare.

CBC, CMP, UA, B-HCG, Lipase, PT/PTT, CXR

It would be interesting to find out what time she takes her statin and if she does it with a meal. But what do I know, I'm just a 4th year...


I hate multiple choice, so I'll go with B and C.

P.S. I didn't know there was such thing as STAT endocrinology :D
 

spyderdoc

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Originally posted by NinerNiner999


CBC, CMP, UA, B-HCG, Lipase, PT/PTT, CXR

It would be interesting to find out what time she takes her statin and if she does it with a meal. But what do I know, I'm just a 4th year...


I hate multiple choice, so I'll go with B and C.

P.S. I didn't know there was such thing as STAT endocrinology :D

B-HCG in a 60 yo?!? Wow, did I miss something in my training???
Prob add a CPK to r/o rhabdo...
 

Kalel

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Why does he need to see an endocrinologist stat if his DM is under control? I agree with the r/o MI, I also might draw a BNP too.
 

Seaglass

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I changed endo to include a PCP. This is a real patient BTW.

C
 

Seaglass

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I guess the larger question is- Do you feel (with the limited info you have) that this patient is at risk to have an emergent illness that warrants evaluation OR is she likely to be OK and worked up as outpt (keeping in mind the rather loooong timeframe of outpt).

C
 

Kalel

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what's the time course? is this new DOE and nausea at rest since yesterday? last week? Also, what have his finger sticks been like? Any CV history? Since he had at least one "episode" of something today, I think that any ER would either admit the patient or do a 24 hr r/o in the ER, especially since the patient is diabetic and therefore is more predisposed to have a "silent" or "atypical" MI. On a side note, midiagnosis of MI is one of the most common malpractice lawsuits in this country, and these days, even the most "careful" ER misses 2-3% of MI's that present.
 

Seaglass

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Finger stick at the time was 160 which is about normal for her. DOE has been since starting the statin 1 week ago. Same time course for fatigue. Nausea is new with most recent episode of DOE. She has a crystal clear CV hx EXCEPT that she is a diabetic, and we all know what that means. But to answer your question directly, there is no MI/CVA hx, no angina hx, no smoking hx. Hyperchol/lipid recently diagnosed.

C
 

edmadison

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Originally posted by NinerNiner999
P.S. I didn't know there was such thing as STAT endocrinology :D

I guess you'd need one if you thought your patient had the dreaded THYROID STORM or ADDISONIAN CRISIS -- boy those endocrinologists are melodramatic. :cool:

Ed
 

edinOH

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Just based on this limited info the answer has to be B.

Before investigating the other stuff in too much greater detail, her cardiac status must be evaluated. This person at the very least will get three sets of enzymes along with further work up and, depending upon your institution, admission.
 

Seaglass

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Ok, some followup.

The pt's husband convinces her to see her Endocrinologist instead of going to the ER as advised. The endocrinologist orders same day RUQ/Liver US and some unknown labwork. No EKG.

C
 

NinerNiner999

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Originally posted by spyderdoc
B-HCG in a 60 yo?!? Wow, did I miss something in my training???
Prob add a CPK to r/o rhabdo...

No you didn't miss anything - I missed her age in the original post. ;) I also miss the ED - hmmm, I wish residency would begin soon...
 

EMIMG

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This is an anginal equivalent until ruled out. Remember...elderly, females, and diabetics can have atypical presentations.

In addition, one of the most common symptoms of MI in the elderly is DIB.

Statins can mess with the liver...With this discomfort and Nausea would probably add a lipase and AST and ALK Phos just to make sure this is not epigastric pain....and with the statin would also do CPK.

The other things to be concerned about but would judge based on physical exam and patient body habitus would be Hypothyroidism as well as the possibility of a PE.

But, I think this patient deserves at least a cardiac workup.

Also, don't forget the every popular UDS.
 

DrQuinn

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Yeah. since she's a diabetic, big thing if she came into my ED is the "suspect cardiac ischemia" (I like that better than R/O MI). Her diabetes is a "MI" equivalent, and should be considered as such.

Q, DO
 

jashanley

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Imagine this patient presenting to your outpatient clinic.
She has DM, with weakness, DOE and chest tightness with exeriton. She was recently started on a statin obviously to improve her lipid status and protect her from future coronary events. My concerns/questions re: her hx, would be: DM well controlled in past? recent hgba1c?; has she been on a statin before?, h/o retinopathy/nephropathy?, h/o PVD, CVA or CAD? previous h/o chest pain/angina; smoker? Weight loss?
(i am ignoring hx given--so don't chastise me for re-asking questions please)

Immediate concerns/problem list:
1. like everyone before me is this unstable angina (change from baseline: chest tightness) or anginal equivalent. Does this warrant ED visit and admission? EKG, possible echo and eventually DSE vs treadmill stress. She will eventual need a cath
2. Rhabdo, due to myositis from statin
3. Liver disease/hepatitis, also from statin
4. low BG or high BG (with weakness episodes) her BG may be normal now but what is it when she has these episodes
5. Dyspnea
Anemia: 60 yo female, dyspneic with exertion, does she have occult bleeding?
CHF, story is not fleshed out enough to decide if this is heart failure (any h/o CAD, MI or ETOH)
COPD (maybe she is a smoker) (any reason for PFTs)
Pneumonia: early on: CXR would be nice
Hypothyroidism: lower on my list but possible. Weakness w/u includes TSH
Malignancy: possible lung, colon Ca; if new onset DM at age 60, (starts to raise red flag for pancreatic CA -- not something to screen for in every new diabetic, but keep in back of your mind); may cause DOE due to mets, anemia, effusion, etc....
6. Meds: insulin vs glucophage; beta blockers, etc. All can cause weakness/fatigue. Nausea/GI complaints secondary to statin is common

The other issue, does she need three sets of enzymes based on a 1 week h/o of this? I didn't start hours ago. It started a week ago. This is a fuzzy area. Everyone uses three sets and I don't agree with that. She at most needs 2 sets.

Someone called her elderly....I don't agree. She is older, but I certainly wouldn't call my dad, who is 60, elderly.

Finally, a lot of outpatient care and evaluation could be done prior to patient leaving. CXR (some places have them on site), labs (also on site), EKG (certainly every office should have one), Accucheck (also available on site). The only initial test I might want not quickly available might be an echo.
Some offices even have treadmill stress labs. I wouldn't stress her until I got my labs, CXR and EKG.
In my clinic, we send patients with c/o DOE (without CP mind you) for DSE all the time). It can be done.
What was done for the patient?
I would have to talk to her, know her pmh, and examine her before deciding on her dispo. Certainly, I would not send her to endo; Either ED or other are my initial choices left
 

imagin916

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Originally posted by spyderdoc
B-HCG in a 60 yo?!? Wow, did I miss something in my training???
Prob add a CPK to r/o rhabdo...

I was thinking the same thing...Beta HCG!?!?

Well, actually, the guys in x-ray department wouldnt take a patient of mine who was 60 w/o a UCG test...Needless to say we argued that one out, and to top it all off, the woman had a hysterectomy 10 years before!! :wow:
 

Seaglass

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It's ok 99-er, we still love you. At least you didn't ask to check the prostate.

C
 
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