INPATIENT SMALL INPATIENT SMALL FEEDINGSFEEDINGS

ACP CHAPTER MEETINGACP CHAPTER MEETINGTURF VALLEY, TURF VALLEY,

FEBRUARY, 2013FEBRUARY, 2013

Daniel J. Brotman, MD, FACP, FHMDaniel J. Brotman, MD, FACP, FHMDirector, Hospitalist Program,Director, Hospitalist Program,Johns Hopkins HospitalJohns Hopkins HospitalAssociate Professor of MedicineAssociate Professor of Medicine

Disclosures (active):Disclosures (active): Gerson Lehrman Group Gerson Lehrman Group

(consulting)(consulting) The Dunn Group (consulting)The Dunn Group (consulting) AHRQ (research funding)AHRQ (research funding) QuantiaMD (consulting)QuantiaMD (consulting) CMMI (research funding)CMMI (research funding)

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

Case #1, contCase #1, cont 78 y/o F78 y/o F PMH of CVA, mild dementia, HTN, DM, PMH of CVA, mild dementia, HTN, DM,

brought in by daughter for left facial brought in by daughter for left facial droopdroop

Increased somnolenceIncreased somnolence Difficulty ambulating with stumbling to Difficulty ambulating with stumbling to

leftleft L frontal headacheL frontal headache 2 weeks of facial rash2 weeks of facial rash

Case #1, contCase #1, cont

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Case #2: An elderly Case #2: An elderly woman with woman with gastroparesisgastroparesis

83 year-old woman83 year-old woman CC: Admitted from GI clinic for failure to thrive, albumin CC: Admitted from GI clinic for failure to thrive, albumin HPI: 1 year history of gastroparesis of unclear etiology; HPI: 1 year history of gastroparesis of unclear etiology;

bloating, vomiting, progressive, particularly in last 3mo.bloating, vomiting, progressive, 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

Case #1 cont,Case #1 cont, Prior evaluation: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– Letrozole (self-d/c’d due to GI symptoms)Letrozole (self-d/c’d due to GI symptoms)

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

Case #1, contCase #1, cont 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 with Lungs: decreased sounds at bases with

bibasilar cracklesbibasilar crackles Heart: RRR, no MRGHeart: RRR, no MRG 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

Case #1, contCase #1, cont 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 3.6Tpro 3.6, ALT 23, AST 25, , ALT 23, AST 25,

alkP 108alkP 108– LDH 384 (ULN 220)LDH 384 (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, cryos, CK, lipid profile, Normal labs: Folate, B12, ferritin, A1c, coags, RPR, cryos, CK, lipid profile,

complement levels, Hep C ab, hep B ag, complement levels, Hep C ab, hep 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

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Case #1, contCase #1, cont A diagnostic procedure was A diagnostic procedure was

performedperformed

Case #3: Another elderly Case #3: Another elderly woman with woman with gastroparesisgastroparesis

Case #3, contCase #3, cont 85 y/o F with wasting illness over prior 85 y/o F with wasting illness over prior

year.year. N/V and post-prandial abdominal pain N/V and post-prandial abdominal pain

progressive x monthsprogressive x months Bloating, followed by either vomiting or Bloating, followed by either vomiting or

diarrheadiarrhea 50 lb wt loss50 lb wt loss Intolerant of solid and liquid PO intake, Intolerant of solid and liquid PO intake,

but variablebut variable

Case #3, contCase #3, cont

Prior workup:Prior workup:– Non-contrast CT scan 6 mo prior showed no Non-contrast CT scan 6 mo prior showed no

pathology except gastric dilatationpathology except gastric dilatation– Gastric emptying study at Bayview 4 mo prior Gastric emptying study at Bayview 4 mo prior

showed severe delayed gastric emptying showed severe delayed gastric emptying (<50% emptying at 4(<50% emptying at 4

– EGD 3 mo prior with antral gastritis; Congo red EGD 3 mo prior with antral gastritis; Congo red stain negativestain negative

– Cine esophagram: occasional esoph spasms; Cine esophagram: occasional esoph spasms; slow esophageal emptyingslow esophageal emptying

Case #3, contCase #3, cont PMH:PMH:

– Chronic osteomyelitis of RLE following distant trauma Chronic osteomyelitis of RLE following distant trauma (intermittent antibiotics)(intermittent antibiotics)

– Transitional cell bladder cancer 2y prior (endoscopically Transitional cell bladder cancer 2y prior (endoscopically treated)treated)

– Raynaud’sRaynaud’s– EF 45% with small vessel CADEF 45% with small vessel CAD– COPD attributed to second-hand smokingCOPD attributed to second-hand smoking

Meds: Domperidone, pantoprazole; rifaxamin, bisoprolol, Meds: Domperidone, pantoprazole; rifaxamin, bisoprolol, long-acting nitrate, digoxin, azithro qod for COPD, albuterol, long-acting nitrate, digoxin, azithro qod for COPD, albuterol, formoterol, miralax, zinc, failed recent Marinol trialformoterol, miralax, zinc, failed recent Marinol trial

Case #3, contCase #3, cont SH: No alcohol, tobacco or illicits; SH: No alcohol, tobacco or illicits;

retired nurse.retired nurse. Exam: Exam:

– Vitals: 37.5, 61, 134/85, 16, 100% RAVitals: 37.5, 61, 134/85, 16, 100% RA– NADNAD– RRR, no MRGRRR, no MRG– CTABCTAB– Abd nondistended; benignAbd nondistended; benign– Chronic RLE infectionChronic RLE infection

Case #3, contCase #3, cont Labs:Labs:

– Normal CBCNormal CBC– Normal CMPNormal CMP– ANA 1:80ANA 1:80– Negative SCL 70 and centromereNegative SCL 70 and centromere

Case #3, contCase #3, cont A diagnostic procedure was A diagnostic procedure was

performedperformed

Case #4, a young Case #4, a young woman with woman with gastroparesisgastroparesis

28 y/o F transferred to Hopkins from a 28 y/o F transferred to Hopkins from a community hospital MICU for gastric community hospital MICU for gastric pacemaker placementpacemaker placement

Gastroparesis confirmed by emptying study; Gastroparesis confirmed by emptying study; N/V began about 6mo prior and progressedN/V began about 6mo prior and progressed

25 lb wt loss over prior 5 months25 lb wt loss over prior 5 months Type 1 DM since childhoodType 1 DM since childhood In and out of hospital with DKA, dehydration, In and out of hospital with DKA, dehydration,

sometimes severe enough to require MICU sometimes severe enough to require MICU carecare

Case #4, cont Case #4, cont Failure to respond to metoclopramide and Failure to respond to metoclopramide and

ondansetronondansetron Glycemic control erratic (both hypo- and hyper-Glycemic control erratic (both hypo- and hyper-

glycemia with at least one seizure)glycemia with at least one seizure) Ongoing deliriumOngoing delirium In ICU at outside hospital had been started on In ICU at outside hospital had been started on

TPN, group B strep in urine TPN, group B strep in urine levofloxacin levofloxacin ROS positive for nausea, abdominal pain, diffuse ROS positive for nausea, abdominal pain, diffuse

joint and leg pain, lightheadedness, extreme joint and leg pain, lightheadedness, extreme weaknessweakness

Case #4, cont Case #4, cont PMH:PMH:

– Type 1 DMType 1 DM– FibromyalgiaFibromyalgia– Hypothyroidism on replacementHypothyroidism on replacement

Meds on transferMeds on transfer– Docusate, ondansetron, levothyroxine, Docusate, ondansetron, levothyroxine,

metoclopramide, albuterol PRN, insulin metoclopramide, albuterol PRN, insulin glargine 4u SC daily with SSI, famotidine glargine 4u SC daily with SSI, famotidine IVIV

Case #4, cont Case #4, cont Meds on transferMeds on transfer

– Docusate, ondansetron, levothyroxine, metoclopramide, Docusate, ondansetron, levothyroxine, metoclopramide, albuterol PRN, insulin glargine 4u SC daily with SSI, albuterol PRN, insulin glargine 4u SC daily with SSI, famotidine IVfamotidine IV

Exam: Vitals: 38.1, 110, 12, 92/58Exam: Vitals: 38.1, 110, 12, 92/58– Gaunt and fatigued; flat affectGaunt and fatigued; flat affect– HEENT, neck, chest, heart all NLHEENT, neck, chest, heart all NL– No JVDNo JVD– Abdomen benignAbdomen benign– Extremities well perfusedExtremities well perfused– Nonfocal but decreased strength (vs effort) diffuselyNonfocal but decreased strength (vs effort) diffusely

Case #4, cont Case #4, cont CBC: WBC 2140 (46% PMNs, 6% Eos, 38% lymphs, 10% monos; no CBC: WBC 2140 (46% PMNs, 6% Eos, 38% lymphs, 10% monos; no bands); Hgb 8.2, plts 99.bands); Hgb 8.2, plts 99.Na 143, K 4.4, BUN 17, Cr 0.7, Glu 233, alb 3.3, NL liver enzymes, 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)bicarb 20; Ca 11.8, ionized Ca 1.53 (ULN 1.32)Lipase 13Lipase 13TSH 0.35TSH 0.35Intact PTH 6.0 (LLN 10); Ca 10.6 at the timeIntact PTH 6.0 (LLN 10); Ca 10.6 at the time1-25-OH Vit D 10 (LLN 18); 25-OH-Vit D 18 (LLN 32); urinary Ca 42.5 1-25-OH Vit D 10 (LLN 18); 25-OH-Vit D 18 (LLN 32); urinary Ca 42.5 (ULN 38)(ULN 38)A1c = 7.5A1c = 7.5Coags NLCoags NLCXR: no infiltrates; ECG sinus tachCXR: no infiltrates; ECG sinus tach

Case #4, contCase #4, cont Hospital course:Hospital course:

– Antibiotics continuedAntibiotics continued– IVF for borderline BP; progressive IVF for borderline BP; progressive

tachycardia despite IVFtachycardia despite IVF– Transient hypervolemiaTransient hypervolemia

A diagnostic procedure was A diagnostic procedure was performedperformed

QUESTIONS/COMMENTS?QUESTIONS/COMMENTS?