Transcript 2010 GastroIntestinal 2 PLM Cases - 3.47 MB

Janice A. Knebl, DO, MBA
Reynolds Geriatrics Education and Training in Texas
Project Director
Dallas Southwest Osteopathic Physicians Endowed
Chair in Clinical Geriatrics
Chief, Division of Geriatrics
UNTHSC/TCOM
•
A 80-year-old man has difficulty swallowing solids
and liquids. At times he regurgitates undigested
food. His dysphagia has progressed slowly over 8
months and he has lost 20 pounds.
•
The patient reports no pain.
•
Barium radiograph demonstrates a narrowed distal
esophageal segment 4.1 cm long and no dilated
esophageal segment proximal to the narrowed
portion.
•
Esophageal manometry demonstrates failure of the
lower esophageal sphincter to relax with
swallowing, and aperistalsis of the esophageal body.
Based on his history and findings which of the
following is the most likely diagnosis?
A.
A.
Zenker’s Diverticulum
B.
B.
Diffuse Esophageal Spasm
C.
C.
Presbyesophagus
D.
D.
Achalasia
•
Which of the following diagnostic procedure(s)
should be performed first?
(A)
Esophagoscopy
(B)
Endoscopic ultrasonography
(C)
Computed tomography
(D)
Chest magnetic resonance imaging
(E)
Laparotomy
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83 year old retired choir director presents to your office
with symptoms of some chest and epigastric pain, and
hoarseness that has increased over the past few
months. Her weight has been stable and she has not
experienced any nausea or vomiting.
She has a PMHx of HBP, hyperlipidemia, osteoporosis
and was recently diagnosed with Parkinson’s Disease.
Medications consist of HCTZ 12.5mg daily, Simvastatin
40mg daily, Alendronate 70mg once weekly and
Carbidopa/Levadopa 25/100 QID.
Physical Exam is WNL except for a resting tremor and
mild cogwheeling of upper extremities.
Laboratory WNL
What additional information might you ask Mrs.
T during her clinic visit?
Which of the following would be the most likely
diagnosis given her history and physical
examination ?
A.
A. Peptic Ulcer Disease
B.
B. Atypical Angina Pectoris
C.
C. Gastroesophageal Reflux Disease
D.
D. Zenker’s Diverticulum
Which of the following medications that she is
taking may have caused a reduction in the LES
pressure?
A.
A. HCTZ
B.
B. Simvastatin
C.
C. Alenodrate
D.
D. Carbidopa/Levadopa
Which of the following is the most common cause
of GERD in older adults ?
A.
A.
B.
B.
C.
C.
D.
E.
D.
Increased LES pressure and length
Sliding Hiatal Hernia
Poor esophageal peristalsis and delayed
clearance
No change in salivary secretions
What would you recommend to this patient
regarding her symptoms?
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
An 88 year old retired stripper presents to the office with
complaints of difficulty swallowing. She feels that food is
getting “stuck” at times but she denies significant pain. She
is able to drink liquids without difficulty. She has had
minimal weight loss. This symptom has been getting
gradually worse over the past 4 months.
Her PMH consists of HBP, thoracic aortic aneurysm,
hyperlipidemia, PVD, osteoporosis and anemia
Medications: Alendronate 70mg weekly, ASA 81mg daily,
amlodipine 5mg daily, simvastatin 80mg daily, cilostazol
100mg BID and FeSO4 325mg BID.

PE:

Vitals: BP 130/50, P 70BPM, Afebrile, RR 16 unlabored

Gen- conversant, in NAD, in good spirits, cognitively intact

Neck - carotids with a Corrigan pulse


Heart – Grade 2/6 holosystolic murmur LSB to apex;
Grade 3 / 4 diastolic murmur RSB

Lungs – clear

Abd – benign

Extremities – decreased peripheral pulses
Which of the following is the most likely cause of her
dysphagia?
A.
A.
B.
B.
C.
C.
D.
D.
E.
E.
Peptic stricture
Achalasia
Dysphagia Aortica
Diffuse Esophageal Spasm
Esophageal Carcinoma


A.
B.
C.
D.
E.
He is a 68 year old healthy and happy retired
gastroenterologist who comes to the office for a physical
examination. Ten years ago he had four adenomatous polyps
removed; follow-up colonoscopy 5 years ago was negative.
Which of the following is the most appropriate colon cancer
screening recommendation for him?
A.
B.
C.
D.
E.
Immunohistochemical fecal occult blood testing
No further screening
Colonoscopy
Flexible sigmoidoscopy plus occult blood testing
Virtual Colonoscopy
He is a 78 year old man who presents to the ED following the
abrupt onset of rectal bleeding.
He has PMH of CAD, CHF, CKD, GERD and DJD.
Medications: metoprolol, celecoxib furosemide, potassium
chloride, simvastatin and lansoprazole.
The bleeding stops spontaneously.
Diagnostic colonoscopy, performed after oral cleansing with
polyethylene glycol and electrolyte solution, demonstrates
residual blood in the ascending colon, scattered diverticula in
the sigmoid colon and multiple 5-mm, flat cherry red lesions
in the cecum
What is the most likely cause for bleeding in this
patient?
A.
A.
B.
B.
C.
C.
D.
D.
E.
E.
Angiodysplasia
Ulcerative colitis
Aortoenteric fistula
Upper gastrointestinal lesion
Colon carcinoma
Tracy Truelove is an active 85 year old retired nurse who
comes to your office for a routine office visit. As a new
complaint, she mentions that she is having some
discomfort with her hemorrhoids and thinks it may be
worsened by her infrequent BMs. She frequently will miss
a daily BM but mentions that when she was younger she
would have a movement every day. She also states that
her stools are harder than they used to be during every
bowel movement.
Her medical history includes HBP, Urinary incontinence,
GERD and iron deficiency anemia. Surgical history reveals
only a deviated nasal septum repair.
1. Does she meet the ROME III criteria for
constipation ?
2. Could her medical problems be contributing to her
complaints?
3. What questions would you ask her next ?
Which medication class is generally NOT
implicated in constipation ?
A.
A.
Calcium channel blockers
B.
B.
Opioids
C.
C.
Iron preparations
D.
D.
Proton pump inhibitors
E.
E.
Antidepressants

An 86 yr old nursing facility resident is
transferred to the hospital for the treatment of
pneumonia where she received a 7 day course
of ceftriaxone and azithromycin. She returns to
the nursing home after a 3 day hospitalization.
Five days after being back at the nursing
facility she experiences watery diarrhea,
cramping lower abdominal pain and
tenderness, low-grade fever and leukocytosis
on recent lab testing.
Which of the following would be the most
appropriate next step in diagnosing her
condition?
A.
A.
B.
B.
C.
C.
D.
D.
E.
E.
Stool for fecal leukocytes
Abdominal CT scan
Stool culture
Stool immunoassay for CDT
Blood cultures X 2
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78 year old retired rancher presented to the Emergency
Department with vertigo, nausea and vomiting, hoarseness,
dysphagia and facial numbness 20 hours after the onset of
symptoms. He is diagnosed with a completed stroke.
Which of the following artery(ies) were most likely
involved?

A. Middle cerebral artery

B. Anterior cerebral and choroidal artery

C. Vertebral and posteroinferior cerebellar artery

D. Postcommunal posterior cerebral artery
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He was admitted to the hospital because of the stroke and
associated symptoms.
You have determined him to be at increased nutritional risk
because he has dysphagia as a result of the stroke. What
would be your first step in considering nutritional
intervention?

A. Order a video swallow study

B. Start enteral feedings via NG tube
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C. Thicken all of the liquids to honey-like consistency
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D. Start the patient on liquid nutritional supplements
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E. Order a general diet as tolerated
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An 85 year old retired dietician presents to your office with
complaints of decreased appetite and weight loss over the past 3
months. When considering weight loss in older adults, which of the
following is NOT responsible for reduced calorie intake?
A. Social factor such as decreased income, social isolation and
depression
B. Medications that can suppress appetite or impair
absorption
C. An increase in smell and taste sensations
D. Increased functional problems that make it difficult to prepare
food
E. Improperly fitting dentures
1. Geriatric Medicine: An Evidence-Based Approach.
4th Edition. Cassel, Leipzig, Cohen, Larson, Meier 2003
2. Primary Care Geriatrics: A Case Based Approach
5th Edition. Ham, Sloane, Warshaw, Bernard, Flaherty 2007
3. AGS Teaching Slides/ Geriatric Syndromes
4. Geriatrics Review Syllabus 6th Edition 2006
5. Geriatric Medicine and Gerontology, 6th Edition. Hazzard et
al., 2009.
6. Troutman’s DSA’s and Cecil references..