Case Study: Deaths caused by smoking
You are working at a family medicine clinic with Dr. Hill. She tells you, “The next patient, Mr. Smith, is a 53-year-old male with a chief concern of swelling and pain in his left lower extremity.”
Before you go to see Mr. Smith, a quick review of the chart reveals that he has type 2 diabetes, hypertension, and hyperlipidemia. You note that he has not been to the office in the past six months, and it appears that he should be out of all of his medications.
When you enter the examination room, Mr. Smith, an obese, middle-aged male, greets you from where he is sitting. You introduce yourself and ask him what brings him to the office today. Case Study: Deaths caused by smoking
He replies, “It’s my left leg. The past four days it has been red, swollen, and painful—and it seems to be getting worse.”
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You ask him to tell you more about this problem.
He says, “It began several days ago, and the swelling seems to be getting worse. It hurts all the time; it doesn’t even get better when I rest it. It seems to get a little worse when I move around. It hurts to walk as soon as I try to stand on it.”
Now that you have a general sense of Mr. Smith’s issue, you ask more focused questions.
“Did you do anything to injure your foot?”
He replies, “I do not remember any injury, but there has been this sore on the bottom of my foot for several months. There’s nothing draining out of the sore and it doesn’t hurt, although my foot doesn’t have much feeling in it.”
“Before this happened, were you sitting down for a long time without getting up and using your legs, such as taking a long airplane trip; or have you been on bed rest?”
“I wish I could go somewhere on an airplane and get a good vacation, but I can’t afford anything like that. I haven’t been on bed rest. I’ve been pretty busy lately.” Case Study: Deaths caused by smoking
“When was the last time you were in the office?”
“It has been a long time now because my daughter and new baby recently moved in with me and I have been trying to take care of the baby as well as keep my job as a bus driver,” he explains.
“Have you been taking your medication?”
He replies, “I have been out of my medication for several weeks now.”
After talking with Mr. Smith more, you discover:
Social History: Does not drink alcohol, but does smoke 1.5 packs of cigarettes daily, he is unmarried, and lives in public housing with his three children and one grandchild.
Review of Systems: No fever or chills, no chest pain, no shortness of breath, and no swelling of the right leg.
Question
Of the following risk factors which causes the most deaths in the U.S.? Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
A. Diabetes
B. Hypertension
C. Obesity
D. Smoking
Answer Comment
The correct answer is D. Smoking, including second hand smoke, causes more than 480,000 deaths annually in the U.S. In 2005 it was reported to alone have caused 467,000 deaths (1,2).
Incorrect options: In 2005, hypertension (B) caused 395,000 deaths, diabetes (A) caused 190,000 deaths and overweight-obesity (C) caused 216,000 deaths.(2) Case Study: Deaths caused by smoking
TEACHING POINT
U.S. Mortality Due to Smoking, Hypertension, Diabetes, and Obesity
Deaths caused by smoking
Smoking is the single greatest preventable cause of death in the U.S.
From 2005–2009 approximately 480,000 people in the United States annually died prematurely from cigarette smoking or exposure to secondhand smoke.
This figure has grown from an average annual estimate of approximately 443,000 deaths from 2000–2004, but this increase is predominantly due to population growth. Although deaths from cigarette smoking have not increased significantly, they remain high. Among adults, 160,848 (41%) of deaths were attributed to cancer, 128,497 (32.7%) to cardiovascular diseases, and 103,338 (26.3%) to respiratory diseases.
The three leading specific causes of smoking-attributable death were lung cancer at 127,200, ischemic heart disease at 124,800, and chronic obstructive pulmonary disease (COPD) at 100,600. An estimated 41,284 lung cancer and heart disease deaths annually were attributable to exposure to secondhand smoke. Smoking resulted in an estimated annual average of 278,500 deaths among males and 202,000 among females in the United States.
Deaths caused by hypertension
Hypertension is the single largest risk factor for cardiovascular mortality in the US. Overall uncontrolled hypertension decreases life expectancy by 20 years. Most of these deaths are due to the increased risk that hypertension incurs for coronary artery disease, hypertensive cardiomyopathy, cerebrovascular disease and chronic renal disease.
Deaths caused by diabetes
Deaths caused by diabetes in the U.S.: 213,062. The majority of deaths from diabetes also results primarily from the increase in cardiovascular disease and chronic renal failure. Diabetics have twice the mortality of non-diabetics. The risk of cardiovascular disease in diabetics is so high that it is assumed that they have cardiovascular disease if they have diabetes.
Deaths caused by obesity
Deaths caused by obesity in the US: 300,000. Obesity is rapidly gaining on smoking as the single greatest cause of mortality in our country. A body mass index (BMI) of over 32 kg/m2 has been associated with a doubled mortality rate among women over a 16-year period and obesity is estimated to cause an excess 111,909 to 365,000 death per year in the United States. Obesity on average reduces life expectancy by six to seven years. A BMI of 30–35 reduces life expectancy by two to four years while severe obesity BMI > 40 reduces life expectancy by 20 years for men and 5 years for women. Case Study: Deaths caused by smoking
References
Centers of Disease Control and Prevention. Strategies for reducing morbidity and mortality from diabetes through health-care system interventions and diabetes self-management education in community settings. A report on recommendations of the Task Force on Community Preventive Services. MMWR Recomm Rep. 2001;50(RR-16):1‐15.
Danaei G, Ding EL, Mozaffarian D, et al. The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors [published correction appears in PLoS Med. 2011 Jan;8(1). PLoS Med. 2009;6(4):e1000058. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress. A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. https://www.cdc.gov/tobacco/data_statistics/sgr/50th-anniversary/index.htm. Accessed June 24, 2020.
Whitlock G, Lewington S, et al. Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Lancet. 2009;373(9669):1083‐96. Case Study: Deaths caused by smoking
You examine Mr. Smith and find:
Lower extremity exam:
Mr. Smith’s entire left leg is swollen and erythematous. The measurement of the circumference of the largest left calf section is 3.5 cm larger than his right calf at the same location.
While his affected limb is swollen, it is still soft and pits easily. Mr. Smith’s left leg is warm and tender to the touch, especially along the distribution of the deep venous system.
Dorsalis pedis and posterior tibialis pulses are palpable on both feet. Digital capillary refill time is two seconds. Deep tendon reflexes are present (2+).
He has decreased sensation and is unable to determine the location of a monofilament test on either foot up to the ankle in a stocking distribution.
You note an ulceration on the plantar surface of Mr. Smith’s left foot.
Cardiovascular and lung exam:
Unremarkable.
At this point, you excuse yourself to discuss your findings with Dr. Hill, assuring Mr. Smith you will return in a few moments.
Answer Comment
Mr. Smith is a 53-year-old man with obesity, type 2 diabetes, hypertension, hyperlipidemia, and tobacco use who presents with a four-day history of left lower extremity edema. He reports no fever, chest pain, dyspnea, known malignancy, trauma, or period of inactivity. There is an ulcer on the plantar surface of his left foot and edema and erythema involving the entire left leg.
The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:
Epidemiology and risk factors: 53-year-old man with obesity, type 2 diabetes, hypertension, hyperlipidemia, and tobacco use
Key clinical findings about the present illness using qualifying adjectives and transformative language: Case Study: Deaths caused by smoking
Four-day history
Unilateral
No fever, chest pain, dyspnea, known malignancy, trauma, or period of inactivity
Associated plantar ulcer
Edema and erythema involving entire leg
Most Likely Diagnoses
Mr. Smith’s concern of swelling that is unilateral is an important finding to support the diagnosis of cellulitis, lymphedema, or deep vein thrombosis (DVT). In contrast, for venous insufficiency or peripheral artery disease (PAD), one would expect bilateral leg swelling.
Cellulitis and DVT are acute processes. Lymphedema, PAD, and venous insufficiency are less likely, given the acute nature of Mr. Smith’s symptoms.
Which of the following diagnostic tests is the best initial test with high predictive value for determining whether your patient has cellulitis or DVT? Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
· A. Complete blood count
· B. Culture and sensitivity of the ulcer
· C. D-dimer
· D. MRI of the affected extremity
· E. Venous Doppler of the lower extremity
SUBMIT
Answer Comment
The correct answer is E.
TEACHING POINT
Predictive Value of Diagnostic Tests to Evaluate DVT vs Cellulitis
| Complete blood count | Elevated white blood cell count might make you consider cellulitis. However, a normal white count would not rule it out, nor is a leukocytosis specific enough to give you the diagnosis. |
| Culture and sensitivity | Would not tell you whether cellulitis is present, and is usually not useful in evaluating chronic ulcers. |
| D-dimer | Is a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis. It is a relatively sensitive, but poorly specific test for the presence of DVT. While a negative result (low D-dimer concentration in the blood) practically rules out thrombosis, a positive result can indicate thrombosis, but does not rule out other potential causes, such as infection. Its main use, therefore, is to exclude thromboembolic disease where the probability is low. Case Study: Deaths caused by smoking |
| MRI | Could identify the presence of thrombus. Expensive compared to venous doppler. |
Venous Doppler of the lower extremity should tell you with good sensitivity and specificity if DVT is present.
Dr. Hill asks:
“What test do you think we should order?”
You tell Dr. Hill, “I guess we should have a Doppler ultrasound done because it has the best predictive value for a DVT.”
“Suppose I told you that this test was relatively expensive and often overused,” Dr. Hill proposes, “Would that change your thinking?”
You respond, “Well you mentioned that the D-dimer test is highly sensitive. Perhaps we could rule out DVT by doing that one.”
“Very good thinking. That is precisely the appropriate role of that study. But, remember that the D-dimer test is best used to rule out a DVT if the pretest probability of having a DVT is relatively low.”
“Is there some way to estimate Mr. Smith’s pretest probability of having DVT?”
“I have read that no singular clinical finding is helpful in that,” you tell her.
“That is true,” Dr. Hill concurs. “But if we use several clinical findings, we may be able to do a better job of predicting pretest probability. I am speaking here of the Wells criteria.” Case Study: Deaths caused by smoking
TEACHING POINT
Wells criteria for the diagnosis of DVT
| Active cancer (treatment ongoing or within previous six months or palliative) | 1 |
| Paralysis, paresis, or recent plaster immobilization of the legs | 1 |
| Recently bedridden for more than three days or major surgery within four weeks | 1 |
| Localized tenderness along the distribution of the deep venous system | 1 |
| Entire leg swollen | 1 |
| Calf swelling by more than 3 cm compared with the asymptomatic leg (measured 10 cm below the tibial tuberosity) | 1 |
| Pitting edema (greater in the symptomatic leg) | 1 |
| Collateral superficial veins (non-varicose) | 1 |
| Alternative diagnosis as likely or more likely than that of deep vein thrombosis | -2 |
Low probability 0 or less, moderate probability 1–2, high probability 3 or more.
Question
Given what you know of Mr. Smith so far, which of the following is likely to represent his pretest probability of DVT? Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
· A. Cannot determine
· B. High probability
· C. Low probability
· D. Moderate probability
SUBMIT
Answer Comment
The correct answer is B.
Review of Mr. Smith’s history and physical exam reveals that he has:
· Localized tenderness along the distribution of the deep venous system (1)
· Entire leg swollen (1)
· Calf swelling by more than 3 centimeters compared with the asymptomatic leg (measured 10 centimeters below the tibial tuberosity) (1)
· Pitting edema (greater in the symptomatic leg) (1)
Note, one aspect of the Wells criteria for the diagnosis of DVT is an alternative diagnosis as likely or more likely than that of deep vein thrombosis (-2). While cellulitis is a possible explanation for Mr. Smith’s condition, DVT is much more likely, especially given his obesity and history of smoking.
Mr. Smith’s score is 4; a high pretest probability (B).
Incorrect Answers: You can determine his pretest probability using the Wells Criteria. A low probability score is 0 (C), a moderate probability score is 1–2 (D).
You conclude, “Given Mr. Smith’s high pretest probability of DVT, I don’t think I would trust a negative D-dimer result even with its high sensitivity. I think we have to get Mr. Smith a Doppler ultrasound instead.”
Dr. Hill agrees and adds, “Are there other diagnostic studies that you would order now?”
Question
Which of the following would you order at this point? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
· A. Arterial blood gas
· B. Chest x-ray
· C. Complete blood count
· D. C-reactive protein
· E. Electrolytes, glucose, creatinine, and blood urea nitrogen (BUN)
· F. Hemoglobin A1C
· G. Sedimentation rate
· H. Thyroid studies
SUBMIT
Answer Comment
The correct answers are C, E, F.
| CBC (C) | Leukocytosis might make you consider an infectious process |
| Electrolytes, glucose, BUN & creatinine (E) | Evaluate diabetic control and renal function |
| Hemoglobin A1C (F) | Determine diabetic control |
Thyroid studies (H) are unlikely to provide any useful information about the absence of signs and symptoms of thyroid disease.
Sedimentation rate (G) and c-reactive protein (D) might be elevated, but would be in both cellulitis and DVT, so it is not particularly useful in determining a diagnosis at this point.
Arterial blood gas (A) or chest x-ray (B) in a patient without symptoms of respiratory difficulty is unlikely to be useful. Case Study: Deaths caused by smoking
You and Dr. Hill return to Mr. Smith’s room together. After greeting him, Dr. Hill explains, “Mr. Smith, we have a good idea of what may be causing the issues with your leg. We would like to gather some more information by taking a blood sample and sending you over to radiology for a Doppler ultrasound so that we can determine the best course of treatment for you.”
After Mr. Smith assents to the plan, Dr. Hill washes her hands and asks to take a look at his leg. She agrees with your assessment.
She walks you through a diabetic foot examination:
On Mr. Smith’s exam, Dr. Hill finds 3 out of 10 sites imperceptible using the 10-gram monofilament test, indicating some loss of protective sensation.
She finds Mr. Smith’s dorsalis pedis and posterior tibialis pulses intact bilaterally.
She notes a 2 cm ulcer on the plantar surface of his foot, with some surrounding erythema, and callous formation. The ulcer is deep, including full skin thickness, down to muscles and ligaments, but no exposed tendons, or bony involvement, and there appears to be no abscess formation.
She finds that the skin on Mr. Smith’s feet is dry and his toenails are dystrophic and incurvated, demonstrating inappropriate self-care.
At the end of the diabetic foot exam, Dr. Hill turns to you and asks, “What do you think we should do about his foot ulcer?”
You admit, “I’m not sure about that. Would antibiotics help?” Case Study: Deaths caused by smoking
“They would if his wound is infected, but first we should evaluate the grade of the ulcer,” Dr. Hill explains.
TEACHING POINT
Ulcer Classification: The Wagner Grading System
The Wagner Grading System
1. Grade 1: Diabetic ulcer (superficial)
2. Grade 2: Ulcer extension (involving ligament, tendon, joint capsule or fascia)
3. Grade 3: Deep ulcer with abscess or osteomyelitis
4. Grade 4: Gangrene forefoot (partial)
5. Grade 5: Extensive gangrene of foot
Images for the corresponding ulcer classifications.
Question
Which of the following describes the grade of Mr. Smith’s ulcer? Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
· A. Grade 1
· B. Grade 2
· C. Grade 3
· D. Grade 4
· E. Grade 5
SUBMIT
Answer Comment
The correct answer is B.
· Mr. Smith’s ulcer is grade 2 (B).
It is a deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation. However, Mr. Smith’s wound does not demonstrate any signs of infection.
· Mr. Smith’s ulcer is more serious than grade 1 because it is not superficial (A)
· Mr. Smith’s ulcer is not as serious as grade 3 (C) because it does not involve abscess formation or osteomyelitis. It is not grade 4 (D) or 5 (E) because it does not involve gangrene.
Dr. Hill emphasizes at this point that based on clinical examination, it does not appear that Mr. Smith has cellulitis and more likely his diagnosis will be a DVT.
TEACHING POINT
Ulcer Management
· Grade 1 and 2 ulcer management generally can be done as outpatient and should include extensive debridement, local wound care, and relief of pressure. If there is significant erythema and/or purulent exudate, then treatment for infection is warranted.
· Grade 3 lesions require evaluation for possible osteomyelitis as well as peripheral artery disease. Both of these conditions may need to be addressed prior to resolution of the ulcer. Typically at least a brief hospitalization is required to address these issues.
· Grade 4 and Grade 5 lesions require emergent hospitalization and surgical consultation, often resulting in amputation.
You and Dr. Hill determine that Mr. Smith’s foot ulcer does not require antibiotics at this time, but does require debridement, which you will address after he’s had his tests done. Mr. Smith has his blood drawn and a Doppler ultrasound performed. Case Study: Deaths caused by smoking
A few hours later, you see that the results of the labs have returned:
Complete Blood Count: Case Study: Deaths caused by smoking
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