The Curious Case of M.M.

David Fang

11/19/10

Family Medicine Case Study

 Introduction

At the outset of March 2010, MM is a generally healthy 40-year-old man with medical
history significant only for hyperlipidemia, well controlled with fenofibrate, and plantar
fasciitis. He had always been in good shape which he maintained with running. Running
was his hobby, and it was always a great stress reliever for him. He had run a marathon
in 1998 and did a few half-marathons in the years afterwards. In the last couple of years,
he had toned down his running a little bit but was still in very good shape. His only vice
he reports is that he drinks a little “way too much pop”. His medical history at this point
is pretty unremarkable.

Past Medical History: Hyperlipidemia, plantar fasciitis

Past Surgical History: None
Medications: Fenofibrate
Allergies: NKDA
Social History: Full-time human resources at Ford. Non-smoker, occasional alcohol use,
no drug use. Enjoys running, looking to get back into running after a bout of plantar
fasciitis in November 2009.

Family History/Genogram
MM is very close to his family. He has three kids, AM, CM, and ZM with his wife, KM.
AM is a 12 year-old middle school student who is getting ready to try out for the
basketball team. CM is a 10 year-old elementary school student who loves science. ZM
is the 6 year-old baby of the family. Willow is a 1 year-old part-Labrador and part-
German Shepherd. He is close to his older brothers, JM and KM, and younger sisters, B
and M, most of whom live nearby around southeastern Michigan. His wife’s parents who
live nearby also play an integral role in family life, spending much time with AM, CM,
and ZM. KM’s step-mother is a retired nurse who worked at Oakwood Hospital.

MM’s family history is significant for his mother who was diagnosed with Charcot-
Marie-Tooth in 1975. MM has observed her progress from walking unimpeded ->
walking with a leg brace -> walking with a cane -> walking with crutches -> to now
currently immobile as her hands and arms deteriorate in strength. 2-3 years ago, MM’s
mother and family agreed to undergo testing for Charcot-Marie-Tooth in order to benefit
future generations of people with CMT. He reports that of the 36 varieties of CMT, his
mother has one of the rarest. His family history is also significant for his father who died
of a heart attack at the early age of 48. He was also told that his maternal grandfather had
“thick blood”.

Assessment

As of March 2010, MM was in overall good health. He has been with his family
physician, Dr. S, since his son AM was born 12 years ago. He is only on fenofibrate for
his hyperlipidemia, which is well controlled. Due to his high arches, he also has plantar
fasciitis for which he saw a podiatrist in October 2009. X-rays and doppler ultrasound at
that time were negative. In November 2009, a flare-up of fasciitis led him to limit his
running from over the winter. Now March 2010, he was ready to resume his regular
running regimen.

The Journey

On Thursday, 3/18/10, MM resumed his running regimen with a 4 mile run. The next
day he felt a “big tightness” in his left leg which he attributed to his long layoff. By that
Sunday, he began feeling a sharp poking pain in his leg. When his pain had not gotten by
the following Friday, 3/26/10, he presented to Dr. S’s clinic. MM was immediately
referred for a Doppler ultrasound which showed a big clot from mid-calf up to his mid-
thigh.

His unusual presentation with a large deep venous thrombosis was extremely concerning
given his lack of other risk factors. MM recalls no injury to his left leg nor did he
remember a prolonged period of immobility. During the week of leg pain prior to his
presentation to clinic, MM recalls that he did have some very mild fevers, but never
exceeding 100, and some night sweats. He was put on Tylenol 3, Coumadin, and told to
take a couple days off from work. Dr. S made a referral for MM to see Dr. K, a
hematologist.
Dr. K saw MM on 4/1/10, the Thursday before Easter and recommended a battery of 40-
60 tests including Factor V Leiden, prothrombin 20210A, lupus anticoagulant, Factor
VIII antigen, Cardiolipin antibodies, and antiphospholipid antibodies. All of the labs
turned out to be negative/normal. MM was also scheduled for CT scans the next day on
Good Friday in order to rule out occult malignancy, another cause of thrombogenesis. He
also had plain films to rule out fractures. He completed all the imaging at 4 pm too
mentally exhausted to contemplate what he had just gone through. However the next
day, Saturday, 4/3/10, MM recalls that he began “freaking out” about the possibility of
cancer and having to wait until Monday for the results. Also on Saturday, his left leg
started turning a blanching bluish-purple color. He presented to the Oakland ER where
he was seen by a vascular surgeon. He was told that the coloration of his left leg was due
to the natural resolution of the clot. The physicians there had also discussed surgery
and/or lytic therapy, but it was ultimately decided to manage the DVT with Coumadin.
After spending the entirety of Easter weekend in the hospital, MM was finally able to go
home Sunday evening. He was given good news on Monday that imaging showed no
signs of malignancy.

For about a month and a half, MM felt fine. He had no leg pain during this time.
However, on a Friday in May during lunch hour at work, he started feeling an ache in his
back. He drove home from work when his pain started getting worse. He recalls having
band-like pain across his chest and abdomen. Given his recent hospitalization in April,
he was reluctant to go to the Emergency Room again. He kept waiting hoping that his
pain would improve. By the evening when his kids were already eating dinner, the pain
was so severe that MM finally decided that he had to go to the ER. He called KM’s
parents and made another trip to the ER at Oakwood hospital, where KM’s step-mother
had worked as a nurse. He had normal EKG on presentation, and was then made to wait
in the waiting room. He remembers the ER waiting room being “really cold” during the
wait. As went to get a fleece, he started feeling terribly nauseous and began vomiting
into a dish pan. At this point, his wife was horrified that something was terribly wrong.
The staff there seemed overwhelmed, so KM’s step-mother grabbed a staff member and
made them take MM back to the ER. He was given another EKG which was normal and
received 2 shots of morphine which alleviated his pain. An ultrasound showed that the
clot in his left leg was shrinking. A CT scan of the abdomen revealed that he had
numerous stones in his gallbladder. He was admitted and put on Coumadin due to his
DVT. In order to have a cholecystectomy however, he needed to be off of Coumadin.
He had to wait the whole weekend until Monday morning to have the Greenfield filter
put in, at which point the Coumadin was stopped and he was transitioned to Lovenox.
The OR schedule was so busy that he could not get a cholecystectomy until Wednesday
night at 10:30 pm. Thankfully, the surgery went without complications. He was released
at 1 pm on Thursday. From Thursday until the following Wednesday, he was off of work
to recover. He was finally able to start working the following Thursday and Friday at
home. The next Monday, he started working back at the Ford office. He was put back on
Coumadin and stayed on it until August. In August, he had his Greenfield filter out due
to concerns about it being a thrombogenic source. A “quick” 30 minute procedure turned
into a 1.5 hour procedure as it was somewhat difficult to remove the device. He recalls
that his wife was again quite worried at the time. Everything did turn out okay.
On Saturday, 10/2/10, he took a flight to Germany for a week. He was put on Lovenox
prophylactically due to his history of DVTs. He was instructed to take one injection one
day before the flight and one injection the day of the flight. He made it to Germany
without difficulty taking both shots as instructed. On the way back to the U.S. on
10/9/10, he had forgotten to take the shot the day before the flight. He did however take
a shot the day of the flight. That weekend when he returned, he remembers watching the
Michigan-Michigan State game. At halftime, went to play touch football with his
brother-in-law and other family members. After 3 plays, he couldn’t catch his breath.
Given his history as a marathoner, this feeling was quite unusual to him. However, he
attributed this to being exhausted from his trip in Germany. On Sunday, he went to
Home Depot and was still out of breath. On Monday, 10/11/10, he again went to see Dr.
S, who examined his left leg and again ordered another ultrasound. He had another clot,
despite being on Lovenox! He was again sent to Oakwood ER where a PECT picked up
bilateral pulmonary embolus! He was told by a nurse there that he was “lucky the pieces
of clot are not bigger” as they would have “shut his lungs down”. He stayed in the ICU
for 2 days and had an echo to rule out cardiac involvement. His heart function was
normal. On Wednesday, 10/13/10, he was moved to a regular room and stayed there until
Sunday, 10/17/10. He was managed on Heparin and Coumadin until his INR was within
the 2.5-3 range. While MM was in the hospital, KM was busy managing the household,
taking care of their 3 kids with school, preparing dinner, and visiting MM in the hospital.
It was overwhelming for KM to say the least. After discharge, he had to take another
week off work, using up all his sick days until his medical leave kicked in.

Current status

At present, his clotting disorder still has no known etiology and is being managed on
Coumadin. As Coumadin is a drug which is notoriously difficult to dose, a therapeutic
level is still yet to be determined. He has blood draws every two weeks on Monday
mornings before work for PT/INR. At the beginning of November, he was on 6 mg daily
Coumadin; he was recently changed to 5 mg daily. Since March, he has some new
updates to his medical history.

Past Medical History: Clotting disorder NOS, PE (10/11/10), Cholelithiasis (5/2010),

DVT (3/26/10)
Past Surgical History: IVC Filter placement (5/2010) and removal (8/2010),
Cholecystectomy (5/2010)

Coping with the unknown

He has an appointment with a hematologist at the University of Michigan on 12/30/10 in

the hopes that he will be able to get an answer. He states that he “would like to know the
why?” and “Is this curable?” Even if this disorder is not curable, he believes that an
answer would be fulfilling particularly so that his sons will be better able to understand
the condition and how it may affect them.
From one standpoint, his current management may seem similar to a patient with atrial
fibrillation who is on Coumadin; however, the pathophysiology of his disease is at yet
unmapped- it is unknown whether Coumadin will be effective at preventing another
episode from occurring. There is always the distressing thought in the back of the mind
that another clot may form.

Given the circumstances, MM is coping extremely well with his condition. He is keeping
a positive attitude and feels lucky that his pulmonary embolism was caught in time. He
seems to be using humor as a coping mechanism. He was quite amused at getting the
Russell Viper Venom test. He seems to be okay with getting PT/INR blood draws every
2 weeks if that is what it takes. He is thankful that his bosses at work have been very
understanding of his condition despite the number of days that he has had to take off from
work this year. The impact on his employment is thus far negligible. From a financial
perspective, MM and his family seems to be doing okay. It is quite remarkable how
much he has gone through and yet managed to adjust so well. I believe that his strong
social support with his family plays a big part. He has 3 siblings in the area and is close
to his in-laws. His mother-in-law, a nurse, is able to assist with his medical needs as well
as help take care of the kids. He has a very good relationship with his family physician,
Dr. S, whom he and his family have seen for 12 years. As this is an unusual case without
a clear solution, it is even more imperative that there is trust and understanding in the
physician-patient relationship as MM seeks out answers. Despite not yet having an
answer, MM has believed in everything Dr. S and his hematologist, Dr. K have done thus
far.

Nevertheless, this past year has definitely been trying from multiple angles. Waiting for
answers, such as whether the CT shows malignancy, or for a procedures to happen such
as waiting a weekend for the Greenfield filter to be placed during MM’s May
hospitalization has been at times almost unbearable. MM has also had to give up one of
his primary hobbies, running. He has been told “no running, no contact sports, no
exercise”. This is a big blow to a former marathoner and a guy who up until last year was
used to running 4-5 miles 3 times a week. He is now restricted to just walking. His
oldest son, AM, is trying out for basketball this season, and MM is unable to participate
as he would like. His middle son, CM, has been confused about why his father has been
gone so often and has unable to talk much about the whole ordeal. His youngest son,
ZM, is now bedwetting despite being toilet trained. ZM mentions that he misses
“Daddy” tremendously. His wife, KM, hates the fact that he is seeing a
hematologist/oncologist. She is concerned about whether malignancy is still lurking as a
cause of this condition, and the fact that he is seeing an oncologist constantly reminds her
of this risk.

Comparison with FCE patient

My FCE patient during M1 year, EC, was a 20-year-old woman diagnosed with type I
diabetes mellitus around the age of 8. She also was a single mother taking care of a baby
with cerebral palsy. Some similarities can be made between EC and MM’s cases. Both
have chronic conditions with no cure (as of yet). EC takes insulin and checks her sugar
daily, while MM must be on Coumadin and have his blood drawn every couple of weeks.
Although, EC’s disease was understood from a pathophysiologic standpoint, it did not
make it any easier to manage from a medical perspective. In fact, EC reported that there
were good and bad days, during which she would be more or less so compliant with
checking her daily sugars. Managing a chronic disease is by no means an easy task if it is
something you must face everyday for the rest of your life. Indeed, MM’s optimistic
outlook may or may not remain intact if he has already had to deal with this problem on
an ongoing basis for 12+ years as EC has had to with her diabetes. It is possible that
although MM states that he is okay with being on Coumadin indefinitely, he is also
hoping that he will find out that his condition is temporary and/or curable. A significant
distinction between EC and MM was that MM appeared to have a much better family
support system than EC did. EC’s support network came not from the family, but from
the online forums and groups where she could discuss her disease with people who also
had diabetes type I. No one else in her family had to deal with her diabetes on a daily
basis. Moreover, EC had to not only deal with her own condition, but also raise a child
with a disability on her own. MM’s children are healthy and appear to be raised in a
supportive home environment.

Conclusion

As a family physician who has to deal with whatever walks in the door, the variety of
cases seen is truly mindboggling. An apparently healthy patient who you’ve seen for 10+
years with no significant risk factors can all of a sudden present with a life-threatening
condition requiring quick and accurate diagnostic skills. The family medicine physician
must also be coordinator of care making referrals to specialists, following up on ER
visits, and providing continuity of care to the patient as he or she goes in and out of
hospitalizations. Unique to family medicine is the field’s focus on the family. Dr. S
takes care of not only MM, but also KM, AM, CM, and ZM.

At this point, the case on MM’s journey is not yet finished. I would be curious as to the
nature of the unusual clotting disorder, and I hope that MM can get an answer to his
unusual condition in the near future. In the interim, Dr. S will continue to monitor his
blood work to make sure that his Coumadin remains at therapeutic levels. In case a
genetic cause is found for the condition, Dr. S’s intimate knowledge of the family
situation and strong bond with the family will allow her to be well equipped to counsel
MM and his kids on not only the risk of getting the condition as well as its impact, but
also how to manage the disease from a psychosocial standpoint.