GI Patient Cases Flashcards
Enid is a 50 YO female who presents w/ pain with bowel movements for the past 3 days. She says she only notices the pain when she’s pooping and she sometimes sees a few drops of blood in the toilet after bowel movements. She has a hx of constipation. Vitals are WNL and PE is unremarkable except during her rectal exam you observe bleeding on the posterior midline of her anus. How do you dx and tx Enid?
Enid has an anal fissure, secondary to her constipation. You tell her to use Sitz baths and topicals like NTG intra-anal for pain and to add more fiber and fluid to her diet to reduce her constipation. She can also use a stool softener to reduce pain during bowel movements until the fissure has healed.
Nora is a 23 YO female who presents w/ sudden onset severe abdominal pain. She says she has no idea what caused it. She hasn’t eaten any strange foods recently and she hasn’t traveled or been around anyone sick. Vitals are BP 120/80, HR 116, RR 16, temp 100.2 F, and her BMI is 20. On PE you notice there her abdomen is generally TTP and is distended. You order a CT and see twisting of her sigmoid colon. What is this condition called? How do you tx?
Nora is experiencing volvulus, a twisting of the bowel that is common in the sigmoid colon because the mesocolon attached there is relatively loose. Tx involves endoscopic decompression.
Travis is a 62 YO male who presents w/ sudden onset abdominal pain. He says he feels nauseated. He rates his pain a 10. Travis has a hx of hyperlipidemia. He takes his atorvastatin when he remembers to. Vitals are BP 130/86, HR 22, RR 18, temp 99.2 F, and his BMI is 27. On PE you observe that his abdomen is generally very TTP, but you see nothing else abnormal on PE. His white count comes back elevated. When you order a colonoscopy, you see patchy, necrotic areas. What imaging do you order to confirm your dx? What is your tx? What is the most likely etiology?
Travis has acute mesenteric ischemia (acute ischemic bowel disease), likely d/t an embolus or thrombus. To confirm your dx, you get an angiogram. Tx involves surgical revascularization (angioplasty w/ bypass) or bowel resection if that portion of colon is not salvageable.
Vivian is a 25 YO female who presents w/ worsening abdominal pain over the past day and a half. She says it started around her belly button but has moved a little to the left. She hasn’t felt like eating and has developed a low grade fever. She says the car ride to the ER was awful - every bump in the road made her wince and feel nauseated. Vitals are BP 118/76, HR 100, RR 12, temp 99.8 F, and her BMI is 21. On PE you observe that she appears slightly bloated and her RLQ is extremely TTP. You palpate deeply in her LLQ and she winces and says the pain left of her belly button is much worse. You order labs and see that her white count is elevated. What special test did you perform? What other two special tests could you perform? What imaging do you order? What is your dx and tx for Vivian?
Vivian has appendicitis, inflammation of the appendix likely d/t blockage/bacteria in the lining of her appendix. You performed the Rovsing test, but you could also look for Psoas and Obturator signs. You order CT, US, or MRI to image the inflammation of her appendix. Tx is appendectomy and abx - e.g. Zosyn or Unasyn.
Mallory is a 44 YO female who presents w/ difficulty swallowing and regurgitation that’s worsened over the past month. She says she’s only been able to eat small amounts of soft foods and she’s losing weight. She says it feels like she has something caught in her throat. As she’s speaking you note that her breath is particularly malodorous. Vitals are WNL and her BMI is 25. On PE you find nothing abnormal but you order a barium esophagram and you see the dye is collecting where the pharynx meets the esophagus. What is your dx and tx for Mallory?
Mallory has a Zenker diverticulum, a false diverticulum that is an outpouching of the mucosa and submucosa through Killian’s triangle. Tx involves surgery or endoscopic treatment. The diverticulum can be excised or she can have a cricopharyngeal myotomy.
Sandra is a 40 YO female who presents w/ dry eyes and difficulty seeing well when she’s driving at night. She says she feels like food tastes differently than it used to, but she says she’s been on a fat-free diet for the past 2 months, so she thinks maybe she’s just tasting things differently now. Vitals are all WNL and BMI is 26. On PE you observe that Sandra has white spots on her conjunctivae. What are these spots called? What do you suspect is happening w/ Sandra? How do you tx?
Sandra is exhibiting sxs of Vitamin A deficiency, likely d/t her fat-free diet. The spots you observed on her conjunctivae are called Bitot’s spots. You tell her that she needs to make sure she is getting more Vitamin A and suggest a supplement and plenty of leafy greens.
Connor is a 52 YO male who presents w/ increased difficulty swallowing over the past 2 months. He says he feels like he has a lump in his throat every time he eats. When it started, he tried to just eat softer foods like bananas and yogurt, but now he struggles with things that aren’t liquidy. He says he’s also been feeling fatigued. He has a hx of GERD and takes omeprazole daily. His vitals are WNL and his BMI is 27 - down from 29 on his visit earlier this year. You perform an upper endoscopy and see a mass in his esophagus and take a tissue sample for biopsy. Where in the esophagus did you likely find this mass? What do you suspect the mass is, specifically? What if Connor were an immigrant w/ the same sxs? What other imaging do you order and why? How do you tx?
Connor has esophageal cancer, most likely an adenocarcinoma in the distal esophagus. This is a complication of his GERD which likely caused Barrett’s esophagus that wasn’t caught because he never had his first screening d/t his relatively young age. If he were an immigrant, you might expect SCC above the tracheal bifurcation, as this is the more common esophageal cancer worldwide. You order an endoscopic US to stage the cancer and a CT of his chest/abdomen/pelvis to look for mets. Tx depends on the stage but may include endoscopic mucosal resection, chemo, and radiation.
Erin is a 5 YO female who presents w/ sudden episodes of extreme abdominal pain. When these happen, she tells her mother that her “tummy hurts bad” and curls up and cries. Nothing her mother does seems to help or make Erin stop crying. And then suddenly Erin’s ok again and says her “tummy is fine” and resumes whatever she was doing prior. This has happened 4 times now - once 2 months ago, once last month, and twice this month. During the latest episode Erin said it hurt even more and she threw up so her mother brought her in right away. Her mother has also noticed blood and mucus in her stools this week. Vitals are WNL and on PE you palpate a sausage-like mass on her right abdomen. What imaging do you order? What is your dx and tx for this pt?
Erin has intussusception, an invagination of part of the intestine into itself that is MC idiopathic. You order a US to image the condition or a barium enema. The enema may provide hydrostatic or pneumatic pressure that reduces the intestine so this may be your preferred imaging route. Alternately, the bowel may spontaneously reduce. If neither of these options work, surgery can be used to correct the problem.
Lola is a 78 YO female who presents w/ sudden onset difficulty swallowing, pain in her throat, and drooling. Her granddaughter said they were eating lunch - fish and chips - when this occurred and she was worried at first that her nana was choking, but she seems to be breathing ok. Lola has a hx of achalasia and HTN. She is currently taking HCTZ and lisinopril. Vitals are WNL and Lola’s BMI is 20. On PE you observe that Lola is resisting swallowing and is drooling quite a bit. She says the pain is worse with swallowing. What imaging do you order? What do you expect to see? How do you dx and tx Lola?
Lola likely has a food impaction, probably d/t a fish bone. Her hx of achalasia is a risk factor for this problem. Because fish bones can be sharp, you order a CT to image the object instead of an X-ray. If you see no perforation on CT, tx will be EGD for removal.
Lola likely has a food impaction, probably d/t a fish bone. Her hx of achalasia is a risk factor for this problem. Because fish bones can be sharp, you order a CT to image the object instead of an X-ray. If you see no perforation on CT, tx will be EGD for removal.
Gina is a 50 YO female who presents w/ difficulty swallowing and cracked lips that have been worsening for the past 3 months. She says the swallowing is worse w/ solid foods like bread and meat so she’s been eating lot of yogurt, bananas, smoothies, etc. She has no significant PMH or surgical hx and she has started taking biotin for her hair and nails. On PE you see that the the corners or her mouth are cracked and irritated and her tongue looks smooth and red. When you look at her hands you see that many of her nails are spoon-shaped. What lab do you order? What dx test? How do you dx and tx? What other similar malformation can cause dysphagia? What type is the MC?
Gina has Plummer-Vinson syndrome, a triad of iron deficiency anemia, dysphagia, and cervical web. You check her ferritin levels and order a barium esophagram or EGD to visualize the web. Tx involves iron supplementation and EGD w/ dilation. Esophageal rings can also cause dysphagia and the MC type is a Schatzki ring. These are MC d/t/ sliding hiatal hernias. They are dx’d and tx’d the same as webs plus a PPI after dilation.
Bart is an 80 YO male who presents w/ bleeding gums and “spots” on his skin. He’s not exactly sure when the sxs started, but he thinks a week ago or so. Bart has a hx of alcoholism and a 60 PYH of smoking. Vitals are WNL and his BMI is 22. On PE you observe that the “spots” are petechial and perifollicular. His gums looks tender and show signs of recent bleeding. Labs show that Bart is anemic. What is your dx and tx for Bart?
Bart has vitamin C deficiency, or scurvy. His age, smoking, and drinking are all contributing factors. You tell Bart that smoking cessation and alcohol cessation would help his condition, as would getting plenty of vitamin C. You advise that he take a supplement and suggest eating fresh citrus fruits and fresh leafy greens.
Kale is a 68 YO male who presents w/ jaundice, fatigue, and abdominal pain that has developed over the past month or so. He says he just feels exhausted all the time and doesn’t have energy like he used to. He has a hx of Caroli disease. Vitals are BP 124/82, HR 80, RR 14, temp 98.8 F, and his BMI is 24 - you see that he’s lost 10 lbs since his physical 4 months ago. On PE you observe that he has pain on palpation in his RUQ and you notice that he seems to be itching a lot. You order a hep panel but the results are negative. Additional labs show 4x elevated AlkPhos and very mild elevations in ALTs and ASTs, What is your dx and tx for this pt? How do you confirm the dx?
You believe that Kale has a cholangiocarcinoma, cancer of the bile ducts that is likely a complication of his Caroli disease. You confirm this dx w/ a liver biopsy. Tx is resection of the tumor and chemotherapy. Very rarely, pts may undergo liver transplant.
Vanessa is a 25 YO female who presents w/ abdominal pain and “weird pooping.” She says she gets cramping pain, often after eating, but she’s not sure what’s causing it. When she gets the pain, she always has weird bowel movements. Sometimes she’s constipated, other times she has diarrhea. She also has gas and bloating during these episodes. You ask her to describe the stools more and she says the diarrhea is always watery or mucousy but small amounts. When she’s constipated, her poop is hard and pellet-like and she feels like her bowels are still full even after she goes. These episodes happen once or twice a wk, always during the day. Vitals are WNL, pts BMI is 24 and stable. She has no significant PMH and isn’t taking any medications. PE is unremarkable except for generalized abdominal tenderness. You order labs and all values are w/in range. What is your dx and tx for Vanessa? What pt education do you share?
Vanessa has mixed irritable bowel syndrome, the most commonly dx’d GI problem w/ no known organic cause. You reassure Vanessa that there’s nothing structurally wrong w/ her GI tract but you also assure her that you understand her sxs are very real. You discuss that this condition is chronic but doesn’t increase her risk of malignancy. In terms of tx, you tell her that she can start by making dietary changes. You encourage her to keep a food journal to discern any patterns in her sxs relating to what she eats. You tell her that avoiding foods that produce gas - e.g. alcohol, caffeine, beans, prunes, brussels sprouts, etc. - in addition to lactose and/or gluten may help reduce her sxs. You also discuss that she can try the FODMAPs diet - an eating plan that removes sugars from the diet and system then slowly reintroduces them to determine if they cause sxs. You refer her to a dietician to discuss this further. If dietary changes alone aren’t improving her QoL, you tell her she can try pharmacological tx. You suggest starting w/ metamucil for constipation and OTC anti-diarrheals as needed. You could also rx an antisposmodic for abdominal pain. You ask her to f/u in 4-6 weeks to check on her progress.
Marcus is a 32 YO male who presents w/ painful, difficult swallowing and chest pain that has worsened over the past month. He says he feels like the pain is behind his breastbone. He has a hx of GERD and a 15 PYH of smoking. He takes TUMS a couple times/wk to deal with his heartburn. Vitals are WNL, BMI Is 29. EKG reveals no abnormalities and cardiac anzymes aren’t elevated. What test do you order next? How do you dx and tx this pt?
Marcus has erosive esophagitis, a condition that is likely caused by his GERD, w/ smoking and being overweight acting as contributing factors. You order an upper endoscopy to look for inflammation and damage to his esophagus. Tx involves managing the underlying cause - GERD. You rx a PPI and discuss losing weight ,quitting smoking, and avoiding trigger foods like coffee, chocolate, and spicy foods.
Brad is a 50 YO male who presents w/ swelling and abdominal pain that have developed over the past few weeks. He has no significant medical hx. Vitals are WNL and BMI is 24. On PE you observe that his RUQ is TTP and you feel that his liver is enlarged. He is positive for ballottement and shifting dullness. You order a US and see no blood flow in the hepatic veins. What imaging would be the gold standard to confirm you dx? How do you dx and tx this pt?
Brad has hepatic vein obstruction, or Budd Chiari syndrome. The gold standard for dx’ing this condition is venography. Tx involves TIPS to decompress the liver, angioplasty w/ stent, anticoagulation (e.g. heparin), and diuretics for his ascites (e.g. furosemide).
Mildred is a 50 YO female who presents w/ diffuse pain and weakness. She’s been to many doctors and nobody seems to know what’s wrong. She has been a vegan since she was 20 and has lived in MN her whole life. You order a lab based on your suspicion. When it comes back, you also order xrays of her pelvis and femurs. You observe radiolucent lines on her pelvis. What are these called? What lab did you order? What is going on with Mildred?
Mildred has vitamin D deficiency, or osteomalacia, a softening of the bones that leads to the sxs Mildred is experiencing. You suspect lack of sun exposure and lack of dairy are both contributing factors - this is why you ordered a serum vitamin D. The lines you see are called Looser lines or pseudofractures - indicative of where her bones are being most affected. Tx is Vitamin D supplementation. You also suggest that Mildred eat foods high in Vitamin D like leafy greens and almonds.
Carl is a 62 YO male who presents w/ heartburn and painful, difficult swallowing for the past 2 months. He says he’s known about the heartburn for years, but he hates being on medications so he tries to avoid triggers foods and eat small meals, but he still gets regular flareups. He decided to finally come in because he can no longer eat any of his favorite foods because they’re too painful to swallow and he’s started losing weight. Vitals are WNL and BMI is 24. You find nothing abnormal on PE, but you order a barium esophagram and observe narrowing. What is your dx and tx for Carl?
Carl has an esophageal stricture d/t his severe, long-term GERD. Tx is EGD w/ dilation - either mechanical or balloon dilators - and an esophageal stent. You also tell Carl you’d like him to use a PPI to prevent further damage. Given his age and hx, you likely want to biopsy Carl’s esophagus to look for any histological changes indicative of BE or malignancy. He may require surgery and further tx dependent upon the success of the dilation/stent and the results of the biopsy.
Evelyn is a 42 YO female who presents w/ difficulty swallowing and regurgitation for the past few weeks. She said she’s started having chest pain when she eats and heartburn. She’s tried her husband’s omeprazole but it doesn’t help. She says everything is tough to swallow, even soft foods and liquids. She has a hx of migraines and takes propanalol. Her PE is unremarkable. You order cardiac enzymes and get an EKG and both are negative for any abnormalities or elevation. You order an esophagram and observe a bird’s beak shape in her esophagram. What other testing do you order? What is your dx and tx for Evelyn? What nerve plexus is involved?
Evelyn has achalasia, a failure of the LES to relax d/t failure of Auerbach’s plexus which is responsible for smooth muscle relaxation. You also order manometry, the gold standard for achalasia dx, which will show aperistalsis and incomplete LES relaxation. Because Evelyn is in otherwise good health, she’s a good candidate for the preferred tx - Laparoscopic Heller myotomy w/ partial fundoplication.
Tamra is a 63 YO female who presents w/ increasingly recurrent episodes of dull abdominal pain that are noticeably worse after eating. She says she hasn’t been eating as much as she used to because over time she’s been unwilling to deal w/ the pain after meals. She’s started to lose weight as a result. She has a hx of atherosclerosis but hasn’t been able to afford her gemfibrozil for almost two years now. On PE you observe some tenderness, but find nothing remarkable. You order a colonoscopy and see muscle atrophy w/ loss of villi. What imaging do you order to confirm your dx? What is your tx?
Tamra has chronic mesenteric ischemia (chronic ischemic bowel disease), d/t inadequate perfusion, likely at the splenic flexure. You get an angiogram to confirm you dx. Tx involves bowel rest (enteral nutrition) and surgical revascularization (angioplasty w/ bypass).
Pat is a 20 mo male who presents w/ nausea/vomiting and abdominal pain that have developed over the past month. His parents said at first they thought he had the stomach flu but the pain seems to be getting worse and he’s saying his “tummy hurts.” Vitals are WNL but you see that he’s lost weight since his last well-child visit. On PE you observe that his eyes are tinged very slightly yellow and you palpate an abdominal mass in his RUQ. What imaging do you order? How do you dx and tx this pt?
You believe that Pat may have a hepatoblastoma, a very rare liver tumor, but the most common primary liver tumor in childhood. You could order CT or MRI to image the tumor and you get a biopsy to confirm the dx. Tx involves resection, chemo, radiation, and possibly liver transplant.
Peter is a 68 YO male who presents w/ erratic movement, confusion, and problems with his eyes. He was found outside by the police who brought him to the hospital. They say he’s been homeless previously and that he has been “in the drunk tank” on multiple occasions but they’ve never seen him like this. Peter is very unsure about his surroundings and doesn’t remember how he got to the hospital or where he was picked up from. Vitals are WNL and BMI is 20. On PE you observe that Peter’s eyes aren’t working together d/t his left lagging laterally. What is your dx and tx for Peter?
Peter has vitamin B1 (thiamine) deficiency, or dry beriberi, a condition likely d/t his alcoholism. In particular, Peter is exhibiting sxs of Wernicke-Korsakoff syndrome. Tx is vitamin B1 supplementation IV and dietary changes including foods like pork and grains that contain thiamine, as well as alcohol cessation. Unfortunately some of the neurologic sxs of Peter’s condition may not be reversible.
Gordon is a 48 YO male who presents w/ chronic cough and worsening heartburn for the past month. He says he first noticed the heartburn after a big family potluck and he says it’s always worse after big meals and at night. Initially he had sxs 1x/wk, but now he has them almost daily. He’s not exactly sure when the cough started, but it was before the heartburn. He says it’s nonproductive. Vitals are all WNL, BMI is 29, general appearance is a WNWD male in no acute distress. PE findings are unremarkable except that Gordon has slight discomfort on epigastric palpation. Do you order any tests? What is your dx and tx for Gordon? What pt education do you perform.
You suspect that Gordon has gastroesophageal reflux disease (GERD). You don’t order any tests now, but will if his condition is refractory to initial tx. You tell Gordon you want to avoid meds if possible and educate him on lifestyle changes that may help - elevating the head of his bed 6-8 inches, avoiding laying down for an hour after meals, chewing gum, and losing weight to get back into a normal BMI range will all help. You also discuss trigger foods to avoid - anything acidic, mints, chocolate, alcohol, etc. You suggest he keep a food journal to identify any personal triggers and avoid big meals, instead eating small frequent meals. You suggest starting w/ an over the counter antacid w/ every meal and at night to help his sxs. You tell him this will hopefully also help his cough, which is also likely a byproduct of the GERD. You ask him to f/u w/ you in 2 wks to discuss his progress and further medications (H2RAs or PPIs) if the initial changes aren’t helping.
Minnie is a 32 YO female who presents w/ severe abdominal pain and diarrhea for the past 3 days. She says she has terrible cramping pains and watery, bloody diarrhea several times/day. She hasn’t been able to keep any food down either - she vomits every time she tries to eat. She just returned from her honeymoon in Bali last week - she woke up and did yoga and grabbed a fruit smoothie on the beach every morning before waking up her husband for their day trips. He brought her in because she doesn’t seem to be getting any better. Vitals are BP 90/74, RR 18, HR 100, temp 100.6 F, and BMI is 20. On PE you note that her general appearance is an acutely ill female who looks thin, pale, and weak. Her abdomen is generally TTP and she has delayed capillary refill. Do you order any labs? How do you dx and tx Minnie? What is the most likely etiology?
Minnie has infectious diarrhea. Because she recently returned from Bali and frequently ate fresh fruit, you expect it is d/t enterotoxigenic E. coli, which is strongly associated w/ traveler’s diarrhea and cruise ship diarrhea and causes sporadic outbreaks in the US. Because she has blood in her stool, you choose to culture it. Because Minnie is so weak and clearly dehydrated you may choose to admit her. Addressing her dehydration is your first focus - ORT is first choice, but if she can’t tolerate this, you can use IV fluids. Once you have the results of the culture you will report the case to the public health department.
Frank is a 30 YO male who presents w/ sudden onset lower abdominal pain. He says he feels bloated. He describes the pain as dull and says it doesn’t radiate anywhere. He has no significant PMH. Vitals are WNL and BMI is 23. On PE you observe that the pain is localized in his RLQ. Psoas sign is negative and he displays no rebound tenderness. Labs come back normal. You order a CT and see a 2 cm, oval-shaped, fat-density mass w/ thickened lining and fat stranding. What is your dx and tx for this pt?
Frank has epiploic appendagitis, inflammation of some of the epiploic appendages. Tx is supportive - you instruct Frank to take ibuprofen and tell him his sxs should resolves in w/in a week.
Curtis is a 40 YO male who presents w/ “eye and mouth” problems. He says his lips are chapped constantly and cracking and he’s noticed his eyes hurt when he’s out in the sun and he has to squint so they don’t ache. He says he’s also been having some discomfort in his groin. Vitals are WNL, BMI is 23. On PE w/ a slit lamp exam, you observe he has corneal lesions and you see that the corners of his mouth are fissured and look raw and painful. When you examine his groin you see that his scrotum looks scaly, red, and irritated. What is your dx and tx for Curtis?
Curtis has a vitamin B2 (riboflavin) deficiency. You tell him to take riboflavin supplements and suggest making sure he gets more riboflavin in his diet - eggs, kidney, liver, fortified bread, and leafy greens are all good sources. You also refer him urgently to ophthalmology to address his corneal ulcers.
Thomas is a 32 YO male who presents w/ worsening “bum pain.” He says he first noticed the pain last week and it has gotten worse every since and he says he feels it “in his inner buttcheeks” now as well. He says it’s started to feel swollen too. Thomas has a hx of fistulas but no other PMH. He isn’t on any medications. Vitals are BP 118/76, HR 110, RR 18, temp 99.8 F, and BMI 22. PE shows his perianal area is erythematous and indurated. The area is extremely sensitive to TTP and he has to anesthetized for DRE. You order a CBC and see that his white count is elevated. What is your dx and tx for this pt?
Thomas has an anorectal abscess, a condition strongly associated w/ fistulas. Tx is I&D in the OR or procedure room. Because Thomas is not immunocompromised, elderly, or diabetic and didn’t present w/ concomitant cellulitis, he doesn’t require abx.
Graham is a 55 YO male who presents w/ abdominal pain for the past 5 days. He says he feels nauseated and he’s vomited twice. The pain is constant, regardless of what he does. He has a hx of asymptomatic cholelithiasis, no surgical hx, and is not taking any medications. Vitals are BP 140/92, HR 108, RR 24, temp 98.8 F, and BMI is 23. On PE you observe bruising around his umbilicus and you note that his abdomen is distended. You auscultate decreased bowel sounds and find that his epigastrium is TTP. What lab would be most helpful in making this dx? What is the bruising you observed called? Do you order any imaging? How do you tx? How might this pt’s presentation differ if he had a hx of alcohol abuse? Triglyceridemia?
Graham has acute pancreatitis, inflammation of the pancreas d/t obstruction of biliary flow that causes bile reflux and autodigestion of the pancreas. The bruising you observed is known as Cullen’s sign. If this pt were an alcoholic, you might have also seen spider angiomas, palmar erythema, asterixis, and encephalopathy. If he had hypertriglyceridemia, you might have observed arcus senilis and xanthelasma. The most helpful lab to make this dx is lipase - elevated at least 3x. Imaging is not normally used to make a dx but may be used to follow the course of the disease. Tx is admission, IV fluids, pain control, electrolyte abnormality correction, NG tube for N/V, and referrals to GI and surgery.
Gloria is a 72 YO female who presents w/ difficulty swallowing and chest pain. She says it started about a month ago and hasn’t gotten any better. She’s having difficulty w/ both solids and liquids and has started to lose weight so she decided to come in. She has a hx of GERD and currently takes omeprazole and vitamin D and calcium supplements. Vitals are WNL, BMI is 19. Her PE is unremarkable. You perform an EGD and barium esophagram and find no abnormalities. On manometry you see high pressure contractions in her esophagus. What is your dx and tx for Gloria?
Gloria has jackhammer esophagus, or nutcracker esophagus, a condition of excessive contractions during peristalsis. You tell her she may want to increase her PPI dosage slightly and you also rx nitroglycerin to help relax her esophageal smooth muscle. If she doesn’t want to be on another medication, you can recommend peppermint oil instead. Other pharmacologic options include amlodipine, imipramine, EGD w/ botox injection and others.
Clancey is a 45 YO male who presents w/ painful swallowing and chest pain that have been worsening over the past two weeks. He has a hx of HIV but hasn’t been taking his medications since he lost his job and insurance. Vitals are WNL, BMI is 19. You order an EKG and see nothing abnormal and troponin isn’t elevated. PE is unremarkable so you order an upper endoscopy and see linear, whitish plaques lining Clancey’s esophagus. What is your dx and tx for this pt?
Clancey has infectious esophagitis, an opportunistic infection d/t HIV, in this case caused by candida albicans. You tell him you can put him in touch w/ a community resource officer who can help him find access to ART so he can start that therapy again and you also rx PO fluconazole to treat his candidiasis.
