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A Potpourri of Problems: An interesting case in General Medicine

A Potpourri of Problems: An interesting case in General Medicine. Kirsten Murray Advanced Trainee in General Medicine John Hunter Hospital Hunter New England Health. Mrs EK. 80 year old female German born. In Australia for 50 years Lives with 2nd Husband in own home.

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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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