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A Potpourri of Problems: An interesting case in General Medicine

Explore the complex case of an 80-year-old woman with severe chronic diarrhea, challenging medical history, and ongoing symptoms. Dive into the diagnostic process and treatment considerations in this intriguing general medicine case.

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A Potpourri of Problems: An interesting case in General Medicine

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  1. A Potpourri of Problems:An interesting case in General Medicine Kirsten Murray Advanced Trainee in General Medicine John Hunter Hospital Hunter New England Health

  2. Mrs EK • 80 year old female • German born. In Australia for 50 years • Lives with 2nd Husband in own home • Independent in self care • mobilises with A-frame indoors • wheelchair outdoors or in community • home modifications in place

  3. Mrs EK • Devoted husband who drives, cooks, cleans and does all home duties • Pt occasionally cooked sitting on bar stool • Shop together once a week • Visit local club for a meal once a week

  4. Mrs EK • Pt self-administered medications from packets • Husband occasionally assisted • Apparently good compliance

  5. Presenting Complaint • Severe chronic diarrhoea • progressive over six months

  6. Chronic Active Medical Problems • 1. Aortic Valve Replacement • 2. Angiodysplasia • 3. Chronic Leg Ulcers

  7. Aortic Valve replacement 1994 • Mixed aortic valve disease • Medtronic Hall 21mm prosthetic valve • warfarinised - target INR 2.5 • Recent trans-thoracic echo June 2004: • normal ejection fraction • normal valve function with periprosthetic aortic regurgitation

  8. Chronic Active Medical Problems • 1. Aortic Valve Replacement • 2. Angiodysplasia • 3. Chronic Leg Ulcers

  9. Angiodysplasia • Haematemesis and malaena 2002 and 2003 • Endoscopy: • 2 small angiodysplastic lesions (<5mm) at gastro-oesophageal junction and greater curve • adrenalin injection and gold probe diathermy in 2002 • proton pump inhibitor • intermittent anaemia, requiring transfusion when INR >2.5

  10. Chronic Active Medical Problems • 1. Aortic Valve Replacement • 2. Angiodysplasia • 3. Chronic Leg Ulcers

  11. Chronic Leg Ulcers • Chronic, for years • four on left, one on right • pain on walking --> wheelchair • extensively investigated

  12. Investigations • ANA 1:80 speckled • C3 low, C4 normal • cryoglobulin + • ANCA negative • ENA negative • AFB negative • Fungal Biopsy negative

  13. Investigations • Duplex 2/04 • right peroneal and posterior tibial artery occlusion • Biopsy 4/04 • nil malignancy • some calcium but not calciphyllaxis

  14. Treatments • Prednisone trial - no improvement--> stopped • Vac Dressings • Alprostadil infusion • left lumbar chemical sympathectomy (phenol)

  15. Inactive Problems • Ovarian Cancer 1982 • Hysterectomy and bilateral salpingo-oophorectomy • no documented recurrence • Tuberculosis in 1940’s with calcified lymph notes and granuloma in chest on CT • Partial thyroidectomy for goitre, aged 27 • Polymyalgia rheumatica 2001. On prednisone x months • Right renal calculus 2001 - haematuria

  16. Inactive Problems • Ischaemic heart disease • previous angiogram 2001 showed LAD disease • treated with nicorandil and atenolol • asymptomatic • Hypercholesterolaemia - Cholesterol 8.2 • Hypertension >10 years requiring multiple drugs • Primary hyperparathyroidism -->parathyroidectomy 1996 • osteoporosis --> bone fractures

  17. Medications on admission • Warfarin 2mg daily • fosinopril 20 mg daily • spironolactone 25 mg daily • nicorandil 20mg bd • atenolol 50mg daily • simvastatin 20 mg daily • caltrate 600mg daily • alendronate SR 70mg weekly

  18. Creatinine Clearance • Usual creatinine around 80 • weight 60kg • Calculated creatinine clearance via Cockcroft-Gault formula = 46ml/min

  19. Drug Intolerances • Allergy to sticking plasters • Intolerant to: • verapamil - ankle swelling • thiazides • Light ex-smoker 20 pyh. Nil x 15 yrs • Family history: nil significant

  20. Recent Admission April 04 • Diarrhoea, nausea, vomiting, abdominal pain • Elevated amylase and lipase • amylase 309 (RR 0 - 95) • lipase 662 (RR 665) • Upper abdominal ultrasound - gallstones, nil else • + Faecal occult blood • Clostridium difficile toxin negative

  21. April 04 admission • Empiric treatment with metronidazole • Improved and discharged • Dx: ? viral gastroenteritis

  22. Presenting Complaint • 6 months of diarrhoea • loose, brown, watery • no blood • nocturnal • initially 2-3 x per night

  23. Last two months….... • nocturnal, 3-6 x per night • associated lower abdominal crampy pain • partial relief with opening of bowels • precipitated by food • weight loss of 15- 20 kg • usual weight 58 - 60 kg

  24. Last two weeks…. • Poor oral intake • vomiting after many meals • anorexic + + + • extreme lethargy and weakness • husband having difficulty caring for her

  25. Last two days…. • Eaten and drunk nothing • passed no urine • continued all medications including • spironolactone • fosinopril • warfarin

  26. Absence of: • Back pain • chest pain • gynaecological symptoms • fevers or night sweats • Denied sick contacts • Denied recent antibiotics

  27. On examination • Orientated but very drowsy • Looked very ill • Cachectic • Afebrile • Facial telangiectasiae • BP 105/58 (usual systolic 140) • PR 118 (beta-blocked) • RR 20 Sats 97% RA

  28. Cardiovascular examination • Dry mucous membranes • HS dual with 3/6 ESM, max. LLSE • soft calves • mild peripheral oedema • leg ulcers • no stigmata of infectious endocarditis

  29. Abdominal examination • Abdomen soft, non distended • moderate tenderness left side with no guarding • PR: empty, normal tone and no masses • U/A: requested but not documented

  30. Examination • Chest clear with mild reduction in air entry • no clubbing • breast examination normal • no lymphadenopathy

  31. Investigations • ECG - sinus rhythm • Partial LBBB (old) • CXR - old granuloma right mid zone • heart size upper limit of normal • bilateral apical pleural thickening and upper lobe scarring • AXR - localised ileus of the distal small bowel • extensive vascular calcification

  32. Differential Diagnosis ??

  33. Blood tests

  34. Differential Diagnosis?

  35. Full Blood Count and Coagulation

  36. Diagnosis ?

  37. Other investigations • TSH 1.71 (RR 0.40 - 4.00) • Serum and urine IEPG : no monoclonal bands • LFT : albumin 28 > 24 > 21 • other LFT normal • Iron studies:

  38. Other Investigations

  39. Wound Swab left leg • Profuse methicillin-sensitive staph. aureus • Scanty pseudomonas

  40. Faeces samples • WCC Nil • RCC Nil • Culture Negative • Giardia screening test Negative • Cryptosporidium screening test Negative

  41. Treatment and Progress • IVF resuscitation • warfarin withheld • Day 2: • Good urine output and creatinine 201 -->117 • Persisting severe diarrhoea • INR 4.6 • Gastrointestinal consult

  42. Management of INR ??

  43. Day 3 • Large spontaneous bleed from leg ulcers • 500ml blood loss • dizzy BP 98/36 PR 95 (beta-blocked) • INR 5.8 Hb 99 Cr 104 • Fevers to 38.3 degrees • Rx • 1 mg Vitamin K IV • Transfused 1 unit packed cells

  44. Day 4 • Hb 92 INR 1.5 • Clexane commenced • Warfarin ceased • Creatinine 104 --> 79 • Abdominal CT scan: • markedly dilated gall bladder • small gall bladder calculi • slight dilatation of intrahepatic ducts, common bile duct and pancreatic duct • atrophic pancreas. Granuloma in spleen else normal • slight reduction in kidney size else normal

  45. Day 5 • Clostridium difficile in stool culture • in 1st of 4 • Vancomycin commenced 125mg QID po

  46. DAY 3 4 5 6 7 8 9 VANCOMYCIN

  47. DAY 10 11 12 13 14 15 16

  48. Progress…. • Fevers ceased four days after commencing vancomycin • ERCP (with antibiotic cover) - NAD • possibility of need for placement noted in notes • GIT symptoms began to improve • Albumin 15 on day 7, now slowly improving

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