Clinical Problem Solving July 28, 2009

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