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Disclosures. . Case 1: 76 yo with AMS. 76 y.o. female presented to her PCP with crampy abdominal painWoke her up at 3 AM that morningInitially intermittent, became continuousCrampy and diffuseNo vomitingBowel habits unchanged. Case 1: 76 yo with AMS. While in clinic, she became confused, aski
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1. Clinical Problem SolvingJuly 28, 2009 Discussant: Gustavo Heudebert
Presenter: Andy Sellers
2. Disclosures
3. Case 1: 76 yo with AMS 76 y.o. female presented to her PCP with crampy abdominal pain
Woke her up at 3 AM that morning
Initially intermittent, became continuous
Crampy and diffuse
No vomiting
Bowel habits unchanged
4. Case 1: 76 yo with AMS While in clinic, she became confused, asking:
how she got to the clinic
why she was there
how long she had been sick
She also vomited several times
She remained oriented to person and place
5. Case 1: 76 yo with AMS No loss of consciousness
No seizure activity
No other focal symptoms
6. Past Medical History Non-Hodgkin’s Lymphoma in 2005
Low grade follicular NHL
s/p CHOP-Rituxan
Depression and Anxiety
Fibromyalgia
Hyperlipidemia
GERD
Constipation
7. Medications Sertraline 50mg daily
Senna
Esomeprazole 40mg daily
Rosuvastatin 5mg daily
8. Social and Family Social History
Lives alone in Birmingham
Denies tobacco and illicit drug use
1 or 2 drinks daily (vodka)
Family History
Mother with stomach cancer
9. Physical Exam (in clinic) VITAL SIGNS: BP 178/90, pulse 68, respirations 18, AF
GENERAL: NAD until she started vomiting
HEENT: no icterus or pallor
LUNGS/CV: ctab, rrr, no edema
ABD: soft, nt/nd
NEURO: oriented to person and place, moved all extremities without focal deficit
10. Case 1: 76 yo with AMS At this point, her PCP sent her to the ER
Further history was obtained from her family
She had spoken to son by phone on the night prior to admission and nothing seemed abnormal
the patient did not remember the conversation
She continued to ask how she arrived at the clinic and remained disoriented to time only
GI symptoms had resolved
11. Lab studies CBC normal
Chem 18 normal
Amylase and lipase normal
Acetaminophen and salicylate negative
UA normal, UDS negative
12. Imaging Head CT: normal for age
CT abd & pelvis: mild ascites but no mass or LAD, diverticulosis without diverticulitis
CT chest: unremarkable, no evidence of lymphoma
13. Case 1: 76 yo with AMS At this point, she is admitted to the hospitalist service for AMS
14. Physical Exam (in hospital) VITAL SIGNS: BP 140/63, pulse 65, RR 18, AF, O2 98%
GENERAL: NAD until she started vomiting
HEENT: no icterus or pallor
LUNGS/CV: ctab, rrr, no edema
ABD: soft, nt/nd
NEURO: oriented to person, place, time and situation, but did not remember the clinic visit or dinner the night before, strength 5/5, sensation intact, gait, reflexes, cerebellar tests all normal
15. MRI MRI of brain:
tiny focus of restrained diffusion in the left hippocampus
16. Case 1: 76 yo with AMS The following day, her memory had returned
Except several hours surrounding her clinic visit
Completely oriented at this point
Had regained memories of the night prior to presentation
17. Transient Global Amnesia Syndrome of reversible anterograde amnesia
Annual incidence of 5-10 per 100,000
Among those >50 yo, 23-32 cases per 100,000
Etiology unknown
Ischemia, venous congestion, migraine, epilepsy and psychogenetic causes have all been postulated
Variable triggering events (33-89%)
Emotional stress, Valsalva, medical procedures
18. Transient Global Amnesia:clinical findings Anterograde amnesia: inability to form new memories
Leads to disorientation to time
repetitive questioning about the date and environment
Retrograde amnesia is also common
Other cognitive functions are spared, including complex motor tasks
Mean duration is 6 hours (range is typically 1-10 hours)
Retrograde amnesia typically resolves
Amnestic gap remains
19. Transient Global Amnesia Differential diagnosis
Epileptic amnesia, TIA, hypoglycemia, anoxic event, intoxication or withdrawal, delirium, encephalitis
Diagnosis
Absence of trauma and LOC
Absence of other neurologic symptoms except amnesia
Memory loss resolves within 24 hours
Workup
Oxygenation, glucose, electrolytes, toxicology screen
MRI may show lesions in hippocampus, which resolve within months
20. Transient Global Amnesia Treatment
Thiamine initially
Admission and observation during the event
Prognosis
2-5% annual recurrence
No increased risk of mortality, epilepsy or stroke
Some studies have shown increased rates of cognitive impairment
21. Case 1: Take Home Points Characterize symptoms accurately
Altered mental status ? aphasia ? amnesia
Transient Global Amnesia
Not uncommon
Give thiamine and rule out other causes
Benign prognosis
Listen to the PCP
23. Case 2: 66 yo with back pain 66 y.o. male with history of chronic low back pain presents to Red Walk-in with back pain
Pain increased about 2 weeks ago
Continuous
Throbbing
Does not radiate
Moderate to severe intensity, 8/10
24. Case 2: 66 yo with back pain This pain is different from his chronic pain
He denies trauma, lifting, pulling, etc.
He denies incontinence and weakness
No fever or chills
No recent infections
No weight loss
25. Past Medical History Low back pain
COPD
Coronary Artery Disease
Hypertension
Hyperlipidemia
40 pack year tobacco use
26. Medications Albuterol/ipratroprium inhaler
Simvastatin
Metoprolol
Aspirin
27. Physical Exam VITAL SIGNS: BP 118/68, pulse 71, respirations 18, AF
GENERAL: NAD, ambulatory
BACK: Paraspinal tenderness in lower thoracic and upper lumbar region with spinous process point tenderness at T12-L1
RECTAL: Normal sphincter tone, prostate unremarkable
NEURO: strength and sensation intact in LE’s, gait intact, straight leg raise negative, DTR’s 2+ bilaterally
28. Lab studies CBC normal
Chem 18 normal, Ca 9.8, TP 7.0, Alb 4.5
PSA -0.7
29. Imaging
30. Imaging T-12 compression fracture with loss of vertebral height
31. What Next? DEXA scan shows osteopenia
More history
He reports chronic fatigue
Erectile dysfunction and decreased libido
Further workup
iPTH normal
SPEP/UPEP negative
Vitamin D normal
Total testosterone 2.3, repeat 1.7
32. Case 2: Course Patient diagnosed with hypogonadism
Started on testosterone injections
PSA increased
He refused prostate biopsy
Testosterone therapy was stopped
33. Back Pain Common ambulatory problem
Lifetime prevalence 80%
5th most common reason for physician visit in US
Most is due to nonspecific musculoskeletal strain and resolves within days to a few weeks
35. Back Pain Red Flags Cancer
History of cancer
Unexplained wt loss
Age >50
Pain lasting > 4-6 weeks
Pain when supine
Infection
Fever
IVDU
Recent infection
Immunosuppresion Compression Fracture
h/o osteoporosis
Use of corticosteroids
Older age
Point tenderness
Cauda equina
Urinary retention or bowel/bladder incontinence
Progressive motor deficits
Saddle anesthesia
36. Osteoporosis in Men Diagnosis usually suspected after low-trauma fracture or incidental finding on an X-ray
Evaluate of secondary causes of low bone mass
Renal or liver disease
Hyperparathyroidism
Cushing’s syndrome
Celiac disease or other malabsorptive states
Hypercalciuria
Hypogonadism
37. Osteoporosis in Men Initial evaluation
H & P
CBC, BMP, LFT
Testosterone, calcium, alk phos, Vit D 25-OH
24-hr urine calcium
Further workup
iPTH
TTG
SPEP, UPEP
Urine cortisol
38. Case 2: Take Home Points Chronic low back pain can change
Red flags help identify serious causes
Cancer
Fracture
Infection
Neurologic compromise
Diagnose and treat secondary causes in men with compression fractures or osteoporosis
40. Case 3: 25 yo with vomiting & wt loss 25 yo AAF presents to Russell Clinic and complains of vomiting and weight loss
Started vomiting 12-18 months prior
Intermittent, but worse after meals
Initially unrelated to specific foods
41. Case 3: 25 yo with vomiting & wt loss Progressive
Now she is waking up at night to vomit
Everything she eats “comes back up”
Partially digested or undigested food
Seen at OSH and treated for acid reflux, but now can’t keep the medicine down
42. Case 3: 25 yo with vomiting & wt loss No hemetemesis, no diarrhea or constipation
No fever or chills
No odynophagia
No abdominal pain
She is having chest pain
Due to food getting stuck in her chest
43. More History Vaginal delivery 4 months prior
Baby is healthy
No complications during pregnancy and symptoms improved somewhat
Currently taking no medications
Smokes about 1 pack per week
No alcohol or illicit drug use
Father had a stroke at 31, other family members with diabetes and hypertension
44. Physical Exam VITAL SIGNS: BP 140/94, pulse 76, respirations 18, AF
Not orthostatic
Weight: 215 initially, up to 262, now 172
GENERAL: NAD but anxious
HEENT: Moist membranes, no lesions; no dental erosions
NECK: no LAD, thyromegaly or palpable masses
ABD: mild epigastric tenderness but soft and without rebound or guarding, had redundant skin c/w weight loss
45. Lab studies CBC normal
Chem 10 normal, glc 81
LFT’s normal
UCG, UDS negative
TFT’s normal, HbA1C 5.3, ESR 2
46. What next?
47. What next?
48. Imaging Upper GI
no passage of barium into the stomach. The distal esophagus has a smooth tapered appearance with “beak-like” appearance. No irregularity is identified in this region to suggest tumor. At 5 minutes, the barium column in the esophagus remained unchanged at the level of the clavicles and there was minimal passage of contrast into the stomach.
49. Follow-Up EGD 2 days after UGI
Esophageal manometry 2 weeks later
LES pressure 67mmHg, incomplete relaxation
No primary esophageal peristalsis
Successful laparoscopic Heller myotomy and Dor fundoplication 1 month after initial Upper GI
50. Dysphagia Oropharyngeal or esophageal
Solids or liquids
Progressive or intermittent
51. Dysphagia Evaluation depends on suspected etiology
Barium swallow if concern for motor dysphagia, proximal lesion or high risk of perforation (prior surgery, cancer, radiation or caustic injury)
Endoscopy if mechanical cause is more likely
52. Achalasia Uncommon, incidence ~1/100,000
Degeneration of ganglion cells in myenteric plexus
Loss of peristalsis in distal esophagus
Failure of LES relaxation
Dysphagia for solids (91%) & liquids (85%)
Weight loss, regurgitation, chest pain and heartburn also occur (40-60%)
53. Achalasia Mean time to diagnosis is 4.7 years
Diagnosis
Barium swallow: dilated esophagus with beak-like narrowing
Manometry: elevated LES pressure, incomplete relaxation of LES, aperistalsis
Endoscopy: to rule out malignancy
Differential Diagnosis
Pseudoachalasia: malignancy, Chagas disease, amyloid, sarcoid
54. Achalasia Treatment
Surgical myotomy
70-90% effective, ~20% get reflux esophagitis
Mortality 0.1% (vs. 0.2% for pneumatic dilation)
Pneumatic dilation
60-80% short term success, 50% retreated in 5 years
2-6% complicated by esophageal perforation
Botulinum toxin injection
Reserved for patients intolerant of above treatments
16-fold increased risk of esophageal cancer
No recommendations for surveillance endoscopy
55. Case 3: Take Home Points Differentiate dysphagia based on history
Evaluation depends on most likely etiology
Achalasia is uncommon but treatable
Upper GI is initial test of choice