An 83-year-old woman presented with a 1-year history of gastroparesis of unclear etiology, manifesting as bloating, vomiting, and failure to thrive. Tests confirmed delayed gastric emptying. She also had a history of breast cancer, congestive heart failure, and was taking metoclopramide. On presentation, she appeared frail and had distended abdomen, hypoactive bowel sounds, and lower extremity edema. Labs showed mild anemia, hypoalbuminemia, and 3.5g protein in 24-hour urine. The patient's gastroparesis and generalized decline require further evaluation and management.

1. CASECASE
PRESENTATIONSPRESENTATIONS

2. An elderly woman withAn elderly woman with
gastroparesisgastroparesis

3.  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 unclear1 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 noGastroparesis 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

4.  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

5.  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 basesLungs: decreased sounds at bases
with bibasilar crackleswith bibasilar crackles
 Heart: RRR, no MRG; no JVDHeart: 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


6.  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, TproTpro
3.63.6, ALT 23, AST 25, alkP 108, ALT 23, AST 25, alkP 108
– LDH 384LDH 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, hepcryos, CK, lipid profile, complement levels, hep C ab, hep
B agB 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

12. FOR THE DIAGNOSIS,FOR THE DIAGNOSIS,
COME TO THECOME TO THE
PRESENTATIONPRESENTATION

13. 71 year old white man in71 year old white man in
generally good health until hegenerally good health until he
developed...developed...
 Fever (38-39Fever (38-39oo
C range) with sweats,C range) with sweats,
chills, anorexia, fatiguechills, anorexia, fatigue
 Denied cough, dysuria, rash, jointDenied cough, dysuria, rash, joint
complaints, abdominal symptoms,complaints, abdominal symptoms,
other focal symptomsother focal symptoms

14. Past medical history of...Past medical history of...
 CABG in 1997:CABG in 1997:
 Very functionally fit since thenVery functionally fit since then
(eg, chopping down trees with(eg, chopping down trees with
chain saw)chain saw)
 HTNHTN

15. Home medications:Home medications:
 daily aspirindaily aspirin
 atorvastatinatorvastatin
 atenololatenolol

16. Social HistorySocial History
 Retired computer science teacherRetired computer science teacher
from Grafton, OHfrom Grafton, OH
 No foreign travelNo foreign travel
 Only pet was a fish, but hadOnly pet was a fish, but had
passing exposure to farm animalspassing exposure to farm animals
(visited relatives at their farms)(visited relatives at their farms)
 Wife had had flu-like illness prior toWife had had flu-like illness prior to
his illness (about 2-3 months prior);his illness (about 2-3 months prior);
no other sick contactsno other sick contacts
 No excessive alcohol, illicit drugsNo excessive alcohol, illicit drugs

17. At community hospital...At community hospital...
 Admitted to outside hospital 2Admitted to outside hospital 2
weeks after onset of illnessweeks after onset of illness
 BP = 113/58; HR = 66; RR = 18.
 Oral temperature = 38.4o
C.
 Diaphoretic.
 Lungs, heart, abdomen, extremities:
normal

18. 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.

19. Empiric antibiotics?Empiric antibiotics?
 Treated with ciprofloxacin +Treated with ciprofloxacin +
ampicillin/sulbactam forampicillin/sulbactam for
“presumptive UTI”“presumptive UTI”

20. Liver tests drawn the dayLiver tests drawn the day
after admissionafter admission
 AST = 150AST = 150
 ALT = 188ALT = 188
 Alk phos = 130Alk phos = 130
 Bili = 1.0Bili = 1.0
– conjugated = 0.2 mg/dLconjugated = 0.2 mg/dL
 Albumin 3.0Albumin 3.0

21. Abdominal CT:Abdominal CT:
 No abscess, adenopathy orNo abscess, adenopathy or
hepatic/biliary tracthepatic/biliary tract
abnormalitiesabnormalities

22. Over next 2 weeks…Over next 2 weeks…
 Fevers to 39.0 CFevers to 39.0 C
 Creatinine: 1.1Creatinine: 1.1  2.9 mg/dL2.9 mg/dL
 Bilirubin: 1.0Bilirubin: 1.0  6.0 mg/dL (conjugated = 5.3)6.0 mg/dL (conjugated = 5.3)
 INR: (first measured on day 5) 1.4INR: (first measured on day 5) 1.4  1.71.7
 Albumin: 3.0Albumin: 3.0  1.4 g/dL1.4 g/dL
 WBC: 5,400WBC: 5,400  18,000/ųL (left shift18,000/ųL (left shift
unchanged)unchanged)
 Platelets: 168,000Platelets: 168,000  563,000/ųL563,000/ųL
 Oxygen requirements: Room airOxygen requirements: Room air  5 L5 L

24. FOR THE DIAGNOSIS,FOR THE DIAGNOSIS,
COME TO THE LIVECOME TO THE LIVE
PRESENTATIONPRESENTATION
MONDAY, MARCH 30MONDAY, MARCH 30THTH
ATAT 10:3510:35
Clinical Reasoning: How Some Doctors Think and theClinical Reasoning: How Some Doctors Think and the
Rest of Us Try toRest of Us Try to