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Case Reviews
Case 1
A 33-year-old man has
A low HDL level.
Should you treat him?
2
Case #1
 A 33-year-old male had a fasting lipid profile as a part of his regular
screening.
Past medical history (PMH) and family medical history (FMH)
Negative.
 Medications
None.
Fasting lipid profile
Triglycerides 100 mg/dL
Total cholesterol 192 mg/dL
HDL 36 mg/dL
LDL 136 mg/dL
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What is abnormal?
Fasting lipid profile
Triglycerides 100 mg/dL
Total cholesterol 192 mg/dL
HDL 36 mg/dL
LDL 136 mg/dL

HDL is low.
LDL is mildly elevated.
4
Should you treat an isolated low HDL
level?
No medications are recommended.
Drug therapy is advised in patients with
low HDL if the 10-year Framingham risk
score is more than 20% or if the patient
has a significant FMH of early CAD. ATP
III provides a free online calculator of
Framingham risk score.
5
What is treatment for low HDL?
Statins are often used but they cause only
a modest increase in HDL level by 5-10%.
Niacin is more potent (30% HDL
increase) but less well tolerated than
statins (90% of patients complain of
flushing).
6
What lifestyle interventions can raise
HDL?
Aerobic exercise can raise HDL level by
10%-20%. Daily alcohol consumption
raises HDL level by 5-10%.
Weight loss does not always have a
positive short term affect on lipid levels.
For each kilogram of weight lost during
active dieting, HDL levels falls by 8%.
Once weight is stabilized, there is a mild
increase in HDL.
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Why is HDL cardioprotective?
HDL participates in moving cholesterol
from peripheral tissue to the liver. It also
has an antioxidant effect.
8
Can dietary changes help?
Adding mono-unsaturated fats and a
vegetable enriched diet helps.
Reference:
http://www.cmaj.ca/cgi/rapidpdf/cmaj.0921
28v1
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Case 2
 A female with asthma and allergic rhinitis
Who is trying to become pregnant:
 What medication changes may be needed?
10
History
 A 27-year-old Caucasian female is seen for allergic rhinitis and
asthma.
 She is on immunotherapy (grasses, trees, ragweed, weeds, cat,
dust mite), started one year ago.
 She stopped using Advair on her own 6 months ago and currently
reports symptoms of asthma 2 times per week which are partially
relieved by a rescue inhaler use.
 She has had no nighttime symptoms and no emergency room visits
in the past year. She reports symptoms of allergic rhinitis, although
since she started immunotherapy, the symptoms are mostly
seasonal, limited to runny nose in the fall.
She has been trying to become pregnant for the last 2 months and
Wants to know if any medication changes may be needed.
 PMH
Asthma, allergic rhinitis
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Medications

Dallergy* b.i.d. for three days around the time of
each allergy shot.
 She receives the immunotherapy every week.
 Fluticasone**, nasal spray.
 She also takes a prenatal multivitamin daily and
she stopped using Advair
(fluticasone/salmeterol***) 6 months ago.
 *Chlorpheniramine/Phenylephrine/Methscopolamine
 **steroid-pregnancy category C
 ***(sal-ME-ter-ol) LABA-used to prevent asthma attacks
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Physical examination

Well-developed, well nourished in no
apparent distress.
Vital signs: T98.5, P 81, R 12, BP 120/60.
Skin: No rash. Ears: Normal. Nose: Boggy,
pale turbinates. Ears: Normal. Chest:
Clear to auscultation bilaterally.
Cardiovascular: Clear S1, S2. Extremities:
No edema or clubbing.
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Lab Test

Spirometry shows FVC of 100%, FEV1 of
89% and FEV1/FVC of 0.79 (healthy adults this
should be approximately 75–80%)
Her ACT score is 18/25.
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?ACT= Asthma Control Test
5- question assessment tool
Range of 5 to 25
19 or less: asthma not under control
 visit www.asthmacontrol.com
 http://www.allergytampa.com/Portals/314/Skins/pb-loc/pdfs/MEDS-OV.pdf
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Should she change her medications
for
allergic
rhinitis?

In light of the fact that she is trying to become pregnant,
we recommended a category B intranasal steroid -Rhinocort Aqua (budesonide) one spray daily.*
 Advise her against using medications such as Allegra
(fexofenadine) or Dallergy (chlorpheniramine,
phenylephrine, and methscopolamine), which may have
an adverse affect on the fetus.
 Recommend Zyrtec (cetirizine) prn whenever she has
symptoms because Zyrtec is pregnancy category B.
 *Most intranasal steroids (INS) have a pregnancy C rating.
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Can immunotherapy be continued if
the patient is on it and becomes
pregnant?

Yes, immunotherapy can be continued at
the maintenance dose. There should not
be a dose escalation during pregnancy.
The immunotherapy dose should not be
increased in a pregnant patient until after
delivery.
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Can immunotherapy be started if a
patient is pregnant or planning to
become pregnant?
No. It is generally not recommended to
start immunotherapy if a patient is
pregnant or planning to become pregnant.
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What did we learn from this case?
 In pregnant patients or in patients trying to
conceive who have allergic diseases, physicians
should prescribe medications which are rated
category B whenever possible.
Examples of pregnancy category B medications:
- inhaled steroids: budesonide (Pulmicort)
- intranasal steroids: budesonide (Rhinocort
Aqua)
- antihistamines: cetirizine
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Case 3
A
Case
Of
Food
Allergy
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An 8-year-old boy is seen by his
pediatrician for follow-up of abdominal
pain.
He had already visited the ER last week
for RLQ abdominal pain and acute
appendicitis had been ruled out.
He complained of abdominal pain radiating
to RLQ, nausea, vomiting, lack of appetite
and weight loss for 6 months.
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 Past medical history (PMH)
Allergic rhinitis and conjunctivitis for 3 years, skin prick testing
positive for house dust mite (2 years ago)
Fast medical history (FMH)
 Mother with allergic rhinitis.
Medications
 Prevacid (lansoprazole) daily.
Pets
 Outdoor hunting dogs.
 Physical examination
 Diffuse abdominal tenderness, no rebound, normal BS, otherwise
normal.
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What would you do?
 Refer to a gastroenterologist who performed an
EGD which showed 19 eosinophils per HPF.
 "Multi-ring esophagus" in eosinophilic esophagitis (left), infiltration of eosinophils (right).
 Diagnosis: Eosinophilic esophagitis.
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?Treatment
 Fluticasone (Flovent) PO was started with rapid
resolution of symptoms within 2-3 weeks. The
patient's appetite improved greatly and he
gained 10 pounds during a 6-month period.
 Pulmicort (budesonide) Respules, 0.5/2 mL PO
bid may work better than fluticasone spray since
the patients actually drinks the viscous liquid
rather than using a spray.
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Does he need a biopsy in the future?
Yes, a repeat biopsy should be done to
verify the effect of the treatment.
PPI augments the therapeutic effect of
inhaled fluticasone and a combination
therapy (ICS plus PPI) should be used in
all patients.
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What are the typical symptoms of
eosinophilic esophagitis in different
age
groups?

Infants present with vomiting.
Children present with abdominal pain and
vomiting.
Older children present with the feeling that
the "food is stuck."
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What is the prognosis for resolution of
eosinophilic esophagitis?
Uncertain.
85% of children with atopic dermatitis
eventually become asymptomatic.
85% of children with asthma eventually
become asymptomatic.
50% of children with allergic rhinitis
eventually become asymptomatic.
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Case 4
Diabetic
Foot
Infection
of
Stasis Ulcers
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 A 58-year-old African American male (AAM) was admitted from a
nursing home (NH) with a chief complaint (CC) of being lethargic
and not acting appropriately. The patient stated that his legs hurt,
and they had been hurting for a long time, and he rated his pain as
an 8 on a scale of 1 to 10.
Past medical history (PMH)
Diabetes type 2 (DM2), hypertension (HTN), venous stasis ulcers,
hepatitis C, peripheral vascular disease (PVD), congestive heart
failure (CHF).
Past surgical history (PSH)
Bilateral (B) LE stasis ulcers status post (S/P) extensive
debridements of both lower extremities and multiple failed skin grafts
2 years ago, right hallux amputation.
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











Medications
Acetaminophen (Tylenol),
Ambien (zolpidem),
hydrocodone,
FeSO4,
clonidine,
amitriptyline,
Oxycontin (oxycodone,
Lantus (insulin glargine),
furosemide (Lasix),
metformin,
Actos (pioglitazone),
metoprolol.
 Social history (SH)
A remote history of heroin and
cocaine abuse, former smoker
and drinker.
 Physical examination
VS 38-126-24-137/81.
Chest: clear
CVS: tachycardic but regular with
no murmurs.
Abdomen: Soft, NT, ND, +BS.
 Extremities: Severe venous
stasis ulcers of the lower
extremities, approximately 1/2 way
down and almost circumferential.
 The ulcers are full thickness and
third-degree. There is a good
granulation tissue.
 Neuro: He is slow to respond to
questioning. No focal neurological
deficits apart from diminished
sensation on (B) LE.
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Diabetic patient with (B) infected stasis ulcers. There is
only a small bridge of tissue covering the back of the right
leg and the front of the left shin.
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Left leg stasis ulcer. Note the
hypertrophic granulation tissue at the
bottom of the ulcer and the small bridge
of skin at the front
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Right leg stasis ulcer. Note the previous hallux amputation
and the grey-blue discoloration at the bottom of the ulcer.
This grey-blue to green discoloration may indicate a
Pseudomonas infection.
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What labs would you order?
CBCD, CMP, UA.
Wound culture, BCx x 2.
X-rays.
BUN was 51 mg/dL and creatinine 2.5
mg/dL. Hgb 8.8 mg/dL.
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What are the questions to ask now?
 What is his baseline?
A review of the old medical records, showed a BUN of 14
mg/dL and creatinine of 1.3 mg/dL, seven months ago.
WBC was 17.1/mm3, hemoglobin 8.8 mg/dL, hematocrit
26.7, hypochromic, microcytic peripheral smear. The
differential showed 69 neutrophils and 11 bands.
The patient has an infection and he is probably
dehydrated which may explain the rise in the BUN/Cr.
Mucosal membranes were dry.
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Antibiotic therapy
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What did we learn from this case?

Diabetic foot infections should be treated
promptly with the appropriate antibiotics.
A blue-green wound exudate may indicate
Pseudomonas, and Zosyn (Piperacillin and
Tazobactam) or other antibiotic with a good
antipseudomonas coverage is needed.
The management of diabetic foot ulcers is
complex and involves wound care, surgery or
podiatry and PT/OT.
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