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INPATIENT SMALL FEEDINGS ACP CHAPTER MEETING TURF VALLEY, FEBRUARY, 2013

This chapter discusses two cases of elderly women with diverse symptoms, including acute facial droop, rash, and gastroparesis. The cases highlight the challenges in diagnosing and managing these conditions.

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INPATIENT SMALL FEEDINGS ACP CHAPTER MEETING TURF VALLEY, FEBRUARY, 2013

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  1. INPATIENT SMALL FEEDINGSACP CHAPTER MEETINGTURF VALLEY, FEBRUARY, 2013 Daniel J. Brotman, MD, FACP, FHM Director, Hospitalist Program, Johns Hopkins Hospital Associate Professor of Medicine

  2. Disclosures (active): • Gerson LehrmanGroup (consulting) • The Dunn Group (consulting) • AHRQ (research funding) • QuantiaMD (consulting) • CMMI (research funding)

  3. Case #1: An elderly woman with acute facial droop and rash

  4. Case #1, cont • 78 y/o F • PMH of CVA, mild dementia, HTN, DM, brought in by daughter for left facial droop • Increased somnolence • Difficulty ambulating with stumbling to left • L frontal headache • 2 weeks of facial rash

  5. Case #1, cont

  6. Case #1, cont

  7. Case #1, cont

  8. Case #2: An elderly woman with gastroparesis

  9. 83 year-old woman • CC: Admitted from GI clinic for failure to thrive, albumin • HPI: 1 year history of gastroparesis of unclear etiology; bloating, vomiting, progressive, particularly in last 3mo. • Gastroparesis confirmed on prior emptying study (virtually no emptying at 4 hours) • Had required PICC for TPN during recent hospitalization • Also progressive dyspnea, PND, orthopnea • In recent weeks, LE edema; started diuresis • Generalized weakness / fatigue

  10. Case #1 cont, • Prior evaluation: • CT abdomen: gastric distension • Colonoscopy: negative • PMH: • Partial mastectomy for breast CA (distant) • CHF, recently diagnosed • Meds: • Metoclopramide mg po q6h • Letrozole (self-d/c’d due to GI symptoms) • Social History: • Retired teacher / librarian; no smoking or alcohol

  11. Case #1, cont • Vitals: 36.0, 87/60, 94, 16, 94% 2L • NAD, frail appearing • Lungs: decreased sounds at bases with bibasilar crackles • Heart: RRR, no MRG • Abdomen: Distended, nontender, hypoactive sounds • Ext: 2+ bilat LE pitting edema • Neuro: A+Ox3; nonfocal

  12. Case #1, cont • Labs: • WBC 5.2K, Hgb 12.3, Plts 298 • BUN 8, Cr 0.6; Glu 103; bicarb 33, Ca 8.1, alb 1.6,Tpro 3.6, ALT 23, AST 25, alkP108 • LDH 384 (ULN 220) • TSH 5.11; free T4 1.0 • ANA 1:160, speckled • ESR: 29 • Transferrin 108 (LLN 200); 36% sat; ferritin 180 • Normal labs: Folate, B12, ferritin, A1c, coags, RPR, cryos, CK, lipid profile, complement levels, Hep C ab, hep B ag, • UA: 3+ protein; trace LE, nitrite neg; SG 1.008 • 24h urine: 3.5g protein • UPEP: glomerular proteinuria

  13. Case #1, cont

  14. Case #1, cont

  15. Case #1, cont

  16. Case #1, cont

  17. Case #1, cont

  18. Case #1, cont • A diagnostic procedure was performed

  19. Case #3: Another elderly woman with gastroparesis

  20. Case #3, cont • 85 y/o F with wasting illness over prior year. • N/V and post-prandial abdominal pain progressive x months • Bloating, followed by either vomiting or diarrhea • 50 lbwt loss • Intolerant of solid and liquid PO intake, but variable

  21. Case #3, cont • Prior workup: • Non-contrast CT scan 6 mo prior showed no pathology except gastric dilatation • Gastric emptying study at Bayview 4 mo prior showed severe delayed gastric emptying (<50% emptying at 4 • EGD 3 mo prior with antral gastritis; Congo red stain negative • Cine esophagram: occasional esoph spasms; slow esophageal emptying

  22. Case #3, cont • PMH: • Chronic osteomyelitis of RLE following distant trauma (intermittent antibiotics) • Transitional cell bladder cancer 2y prior (endoscopically treated) • Raynaud’s • EF 45% with small vessel CAD • COPD attributed to second-hand smoking • Meds: Domperidone, pantoprazole; rifaxamin, bisoprolol, long-acting nitrate, digoxin, azithroqod for COPD, albuterol, formoterol, miralax, zinc, failed recent Marinol trial

  23. Case #3, cont • SH: No alcohol, tobacco or illicits; retired nurse. • Exam: • Vitals: 37.5, 61, 134/85, 16, 100% RA • NAD • RRR, no MRG • CTAB • Abdnondistended; benign • Chronic RLE infection

  24. Case #3, cont • Labs: • Normal CBC • Normal CMP • ANA 1:80 • Negative SCL 70 and centromere

  25. Case #3, cont • A diagnostic procedure was performed

  26. Case #4, a young woman with gastroparesis • 28 y/o F transferred to Hopkins from a community hospital MICU for gastric pacemaker placement • Gastroparesis confirmed by emptying study; N/V began about 6mo prior and progressed • 25 lbwt loss over prior 5 months • Type 1 DM since childhood • In and out of hospital with DKA, dehydration, sometimes severe enough to require MICU care

  27. Case #4, cont • Failure to respond to metoclopramide and ondansetron • Glycemic control erratic (both hypo- and hyper-glycemia with at least one seizure) • Ongoing delirium • In ICU at outside hospital had been started on TPN, group B strep in urine  levofloxacin • ROS positive for nausea, abdominal pain, diffuse joint and leg pain, lightheadedness, extreme weakness

  28. Case #4, cont • PMH: • Type 1 DM • Fibromyalgia • Hypothyroidism on replacement • Meds on transfer • Docusate, ondansetron, levothyroxine, metoclopramide, albuterol PRN, insulin glargine 4u SC daily with SSI, famotidine IV

  29. Case #4, cont • Meds on transfer • Docusate, ondansetron, levothyroxine, metoclopramide, albuterol PRN, insulin glargine 4u SC daily with SSI, famotidine IV • Exam: Vitals: 38.1, 110, 12, 92/58 • Gaunt and fatigued; flat affect • HEENT, neck, chest, heart all NL • No JVD • Abdomen benign • Extremities well perfused • Nonfocal but decreased strength (vs effort) diffusely

  30. Case #4, cont • CBC: WBC 2140 (46% PMNs, 6% Eos, 38% lymphs, 10% monos; no bands); Hgb 8.2, plts 99. • Na 143, K 4.4, BUN 17, Cr 0.7, Glu 233, alb 3.3, NL liver enzymes, bicarb 20; Ca 11.8, ionized Ca 1.53 (ULN 1.32) • Lipase 13 • TSH 0.35 • Intact PTH 6.0 (LLN 10); Ca 10.6 at the time • 1-25-OH Vit D 10 (LLN 18); 25-OH-Vit D 18 (LLN 32); urinary Ca 42.5 (ULN 38) • A1c = 7.5 • Coags NL • CXR: no infiltrates; ECG sinus tach

  31. Case #4, cont • Hospital course: • Antibiotics continued • IVF for borderline BP; progressive tachycardia despite IVF • Transient hypervolemia • A diagnostic procedure was performed

  32. QUESTIONS/COMMENTS?

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