CASE CASE PRESENTATIONSPRESENTATIONS

An elderly woman with An elderly woman with gastroparesisgastroparesis

83 years-old83 years-old Admitted from GI clinic for failure to thriveAdmitted from GI clinic for failure to thrive 1 year history of gastroparesis of unclear 1 year history of gastroparesis of unclear

etiology; bloating, vomiting, progressive, etiology; bloating, vomiting, progressive, particularly in last 3mo.particularly in last 3mo.– Gastroparesis confirmed on prior emptying study (virtually no Gastroparesis confirmed on prior emptying study (virtually no

emptying at 4 hours)emptying at 4 hours)– Had required PICC for TPN during recent hospitalizationHad required PICC for TPN during recent hospitalization– Also progressive dyspnea, PND, orthopneaAlso progressive dyspnea, PND, orthopnea– In recent weeks, LE edema; started diuresisIn recent weeks, LE edema; started diuresis– Generalized weakness / fatigueGeneralized weakness / fatigue

Additional prior evaluation:Additional prior evaluation:– CT abdomen: gastric distensionCT abdomen: gastric distension– Colonoscopy: negativeColonoscopy: negative

PMH: PMH: – Partial mastectomy for breast CA (distant)Partial mastectomy for breast CA (distant)– CHF, recently diagnosedCHF, recently diagnosed

Meds: Meds: – Metoclopramide mg po q6hMetoclopramide mg po q6h

Social History:Social History:– Retired teacher / librarian; no smoking or alcoholRetired teacher / librarian; no smoking or alcohol

Vitals: 36.0, 87/60, 94, 16, 94% 2LVitals: 36.0, 87/60, 94, 16, 94% 2L NAD, frail appearingNAD, frail appearing Lungs: decreased sounds at bases Lungs: decreased sounds at bases

with bibasilar crackleswith bibasilar crackles Heart: RRR, no MRG; no JVD Heart: RRR, no MRG; no JVD

apparentapparent Abdomen: Distended, nontender, Abdomen: Distended, nontender,

hypoactive soundshypoactive sounds Ext: 2+ bilat LE pitting edemaExt: 2+ bilat LE pitting edema Neuro: A+Ox3; nonfocalNeuro: A+Ox3; nonfocal

Labs:Labs:– WBC 5.2K, Hgb 12.3, Plts 298WBC 5.2K, Hgb 12.3, Plts 298– BUN 8, Cr 0.6; Glu 103; bicarb 33, Ca 8.1, BUN 8, Cr 0.6; Glu 103; bicarb 33, Ca 8.1, alb 1.6,alb 1.6, Tpro Tpro

3.63.6 , ALT 23, AST 25, alkP 108, ALT 23, AST 25, alkP 108– LDH 384 LDH 384 (ULN 220)(ULN 220)– TSH 5.11; free T4 1.0TSH 5.11; free T4 1.0– ANA 1:160, speckledANA 1:160, speckled– ESR: 29ESR: 29– Transferrin 108 (LLN 200); 36% sat; ferritin 180Transferrin 108 (LLN 200); 36% sat; ferritin 180– Normal labs: Folate, B12, ferritin, A1c, coags, RPR, Normal labs: Folate, B12, ferritin, A1c, coags, RPR,

cryos, CK, lipid profile, complement levels, hep C ab, hep cryos, CK, lipid profile, complement levels, hep C ab, hep B ag B ag

– UA: UA: 3+ protein3+ protein ; trace LE, nitrite neg; SG 1.008; trace LE, nitrite neg; SG 1.008– 24h urine: 3.5g protein24h urine: 3.5g protein– UPEP: glomerular proteinuriaUPEP: glomerular proteinuria

FOR THE DIAGNOSIS, FOR THE DIAGNOSIS, COME TO THE COME TO THE PRESENTATIONPRESENTATION

71 year old white man in 71 year old white man in generally good health unti l he generally good health unti l he developed...developed... Fever (38-39Fever (38-39 oo C range) with sweats, C range) with sweats,

chil ls, anorexia, fatiguechil ls, anorexia, fatigue

Denied cough, dysuria, rash, joint Denied cough, dysuria, rash, joint complaints, abdominal symptoms, complaints, abdominal symptoms, other focal symptomsother focal symptoms

Past medical history of...Past medical history of...

CABG in 1997: CABG in 1997: Very functionally f it since then Very functionally f it since then

(eg, chopping down trees with (eg, chopping down trees with chain saw)chain saw)

HTNHTN

Home medications:Home medications:

daily aspirindaily aspirin atorvastatinatorvastatin atenololatenolol

Social HistorySocial History Retired computer science teacher Retired computer science teacher

from Grafton, OHfrom Grafton, OH No foreign travelNo foreign travel Only pet was a f ish, but had Only pet was a f ish, but had

passing exposure to farm animals passing exposure to farm animals (visited relatives at their farms)(visited relatives at their farms)

Wife had had flu-l ike i l lness prior to Wife had had flu-l ike i l lness prior to his i l lness (about 2-3 months prior); his i l lness (about 2-3 months prior); no other sick contactsno other sick contacts

No excessive alcohol, i l l icit drugsNo excessive alcohol, i l l icit drugs

At community hospital.. .At community hospital.. . Admitted to outside hospital 2 Admitted to outside hospital 2

weeks after onset of i l lnessweeks after onset of i l lness

BP = 113/58; HR = 66; RR = 18. Oral temperature = 38.4o C. Diaphoretic. Lungs, heart, abdomen, extremities:

normal

At community hospital.. .At community hospital.. . Creatinine = 1.1 glucose = 128 WBC = 5,400 (NL Diff) HCT = 37.3% (MCV NL) Plts = 168 Urinalysis: + bacteria, but no pyuria. CXR: no infiltrates.

Empiric antibiotics?Empiric antibiotics?

Treated with ciprofloxacin + Treated with ciprofloxacin + ampicil l in/sulbactam for ampicil l in/sulbactam for “presumptive UTI”“presumptive UTI”

Liver tests drawn the day Liver tests drawn the day after admissionafter admission

AST = 150 AST = 150 ALT = 188 ALT = 188 Alk phos = 130Alk phos = 130 Bili = 1.0Bil i = 1.0

– conjugated = 0.2 mg/dLconjugated = 0.2 mg/dL Albumin 3.0Albumin 3.0

Abdominal CT:Abdominal CT:

No abscess, adenopathy or No abscess, adenopathy or hepatic/bil iary tract hepatic/bil iary tract abnormalit iesabnormalit ies

Over next 2 weeks…Over next 2 weeks… Fevers to 39.0 CFevers to 39.0 C Creatinine: 1.1 Creatinine: 1.1 2.9 mg/dL 2.9 mg/dL Bilirubin: 1.0 Bil irubin: 1.0 6.0 mg/dL (conjugated = 5.3) 6.0 mg/dL (conjugated = 5.3) INR: (first measured on day 5) 1.4 INR: (first measured on day 5) 1.4 1.7 1.7 Albumin: 3.0 Albumin: 3.0 1.4 g/dL 1.4 g/dL WBC: 5,400 WBC: 5,400 18,000/ųL (left shift 18,000/ųL (left shift

unchanged)unchanged) Platelets: 168,000 Platelets: 168,000 563,000/ųL 563,000/ųL Oxygen requirements: Room air Oxygen requirements: Room air 5 L 5 L

FOR THE DIAGNOSIS, FOR THE DIAGNOSIS, COME TO THE LIVE COME TO THE LIVE PRESENTATIONPRESENTATION

MONDAY, MARCH 30MONDAY, MARCH 30 THTH ATAT 10:35 10:35

Clinical Reasoning: How Some Doctors Think and the Clinical Reasoning: How Some Doctors Think and the Rest of Us Try toRest of Us Try to