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Dr. Murray Photo Slide. Case #1 7 year old with pain vomiting and weight loss. What would you order next? 1. CT scan 2. Endoscopy with biopsy 3. Barium.

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Presentation on theme: "Dr. Murray Photo Slide. Case #1 7 year old with pain vomiting and weight loss. What would you order next? 1. CT scan 2. Endoscopy with biopsy 3. Barium."— Presentation transcript:

1 Dr. Murray Photo Slide

2 Case #1

3 7 year old with pain vomiting and weight loss. What would you order next? 1. CT scan 2. Endoscopy with biopsy 3. Barium enema 4. Surgical consult 5. pH probe 1. CT scan 2. Endoscopy with biopsy 3. Barium enema 4. Surgical consult 5. pH probe

4 Dr. Pfeil Photo Slide

5 Case #2

6 What would you recommend? 1. Endoscopic removal using a retrieval basket 2. Biopsy to determine composition 3. Immediate surgical consultation 4. No intervention 5. Evaluation for blue rubber bleb nevus syndrome 1. Endoscopic removal using a retrieval basket 2. Biopsy to determine composition 3. Immediate surgical consultation 4. No intervention 5. Evaluation for blue rubber bleb nevus syndrome

7 Case #3

8 How can you determine whether this girl is in trouble? 1. Weight for age growth curve 2. Tanner staging for pubertal maturation 3. Bone age 4. Albumin 5. Triceps skinfold thickness 6. Weight-for-height comparison curve 1. Weight for age growth curve 2. Tanner staging for pubertal maturation 3. Bone age 4. Albumin 5. Triceps skinfold thickness 6. Weight-for-height comparison curve

9 Case #4 A 35 year old female patient who works at a daycare facility presents with a several month history of diarrhea Stools are loose but non-bloody She reports “gas” and cramping No weight loss, fever, or extraintestinal symptoms Flexible sigmoidoscopy is unrevealing

10 Your next recommendation would be: 1. Begin mesalamine and prednisone as empiric therapy for Crohn’s disease 2. Suggest education about irritable bowel syndrome 3. Obtain 3 stool samples for O&P studies 4. Begin ciprofloxacin therapy for E. Coli 0157 5. Suggest a clear liquid diet until symptoms resolve 1. Begin mesalamine and prednisone as empiric therapy for Crohn’s disease 2. Suggest education about irritable bowel syndrome 3. Obtain 3 stool samples for O&P studies 4. Begin ciprofloxacin therapy for E. Coli 0157 5. Suggest a clear liquid diet until symptoms resolve

11 Case #5

12 Daily emesis in a healthy 3 month old: how should you treat this patient? 1. Upright positioning 2. Zantac, a histamine blocking antacid 3. Thickened feedings with cereal 4. Metoclopramide (Reglan) 5. Cisapride (Propulsid) 6. Do nothing and reassure the mother 1. Upright positioning 2. Zantac, a histamine blocking antacid 3. Thickened feedings with cereal 4. Metoclopramide (Reglan) 5. Cisapride (Propulsid) 6. Do nothing and reassure the mother

13 Case #6 A 50 year old woman presents with symptoms of a 30 pound weight loss, diarrhea, and abdominal bloating Stools are loose, large in volume, and non- bloody Initial laboratory studies show the following: - WBC 5.0 - MCV 79 - Ferritin 2 (normal 82-99) - Hgb 10.9 - B 12 190 - Albumin 2.5 (normal >220) - Endomysial Ab positive

14 Your initial recommendation would be: 1. Colonoscopy 2. Stool Cx, O+P, Cdiff 3. Abdominal pelvic CT scan 4. Trial of a lactose free diet 5. Duodenal biopsies (EGD) 1. Colonoscopy 2. Stool Cx, O+P, Cdiff 3. Abdominal pelvic CT scan 4. Trial of a lactose free diet 5. Duodenal biopsies (EGD)

15 Case #6 (con’t.) Endoscopy and duodenal reveal - Flattened villi - Crypt hyperplasia - Intraepithelial lymphocytes

16 What Would you recommend? 1. Treatment with steroids for Crohn’s disease 2. Lactose elimination 3. Gluten elimination 4. Empiric antibiotics 5. Referral to oncology 1. Treatment with steroids for Crohn’s disease 2. Lactose elimination 3. Gluten elimination 4. Empiric antibiotics 5. Referral to oncology

17 Case #7

18 Fecal impaction in the Emergency Department: what would be the appropriate treatment? 1. Metamucil daily 2. A senna laxative twice daily 3. Colace, a stool softener 4. 1 liter of Golytely, a lavage solution 5. Mineral oil by mouth and enema 6. Fleet’s phosphosoda enema 1. Metamucil daily 2. A senna laxative twice daily 3. Colace, a stool softener 4. 1 liter of Golytely, a lavage solution 5. Mineral oil by mouth and enema 6. Fleet’s phosphosoda enema

19 Case #8

20 What Would you recommend? 1. Discontinuation of herbal laxatives 2. Immediate surgical consultation 3. Search for primary melanoma 4. Discontinuance of excess coffee ingestion 5. Screen for toxic metals 1. Discontinuation of herbal laxatives 2. Immediate surgical consultation 3. Search for primary melanoma 4. Discontinuance of excess coffee ingestion 5. Screen for toxic metals

21 Case #9

22 3 year old with pain, gas, bloating, and night-time vomiting. What test would you order next? 1. Upper GI barium study 2. Liver function tests 3. Stool cultures 4. Ova and parasite exams X 3 5. Endoscopy with biopsies 1. Upper GI barium study 2. Liver function tests 3. Stool cultures 4. Ova and parasite exams X 3 5. Endoscopy with biopsies

23 Case #10

24 What is the most likely diagnosis? 1. Reflux esophagitis 2. Pill induced esophagitis 3. Herpetic infection 4. HIV infection with solitary esophageal ulceration 5. Candida esophagitis 1. Reflux esophagitis 2. Pill induced esophagitis 3. Herpetic infection 4. HIV infection with solitary esophageal ulceration 5. Candida esophagitis

25 Case #11

26 16 month old with vomiting and diarrhea: what is the most likely treatment? 1. Lytes, CBC, and urine 2. Gatorade, 1 ounces every 3 hours 3. Frequent sips of Isomil 4. Pedialyte, an oral rehydration solution 5. I.V. saline, 20 cc / kg bolus 6. Imodium AD, 0,5 mg twice daily 1. Lytes, CBC, and urine 2. Gatorade, 1 ounces every 3 hours 3. Frequent sips of Isomil 4. Pedialyte, an oral rehydration solution 5. I.V. saline, 20 cc / kg bolus 6. Imodium AD, 0,5 mg twice daily

27 Case #12

28 A 4 year old with mild diarrhea: what would you advise? 1. Keep NPO until diarrhea resolves 2. Offer a soy formula 3. Pedialyte, an oral rehydration solution 4. An elemental formula 5. BRAT diet (Bananas, Rice, Applesauce and Toast) 6. Regular diet for age 1. Keep NPO until diarrhea resolves 2. Offer a soy formula 3. Pedialyte, an oral rehydration solution 4. An elemental formula 5. BRAT diet (Bananas, Rice, Applesauce and Toast) 6. Regular diet for age

29 Case #13 13 year old girl is seen for weight loss 5 feet 4 inches, she has gone from 135 pounds to her current 102 pounds Feels fit and even participated in soccer camp last month, but she’s wrapped in a sweatshirt in August Her resting heart rate is 42

30 What would you do next? 1. CT scan of the abdomen: r/o cancer 2. Thyroid screen: r/o hypertension 3. Admit to hospital 4. Upper GI films: r/o Inflammatory Bowel Disease 5. A psychiatric evaluation for an eating disorder 1. CT scan of the abdomen: r/o cancer 2. Thyroid screen: r/o hypertension 3. Admit to hospital 4. Upper GI films: r/o Inflammatory Bowel Disease 5. A psychiatric evaluation for an eating disorder

31 Case #14 A 25 year old previously healthy college student presents with symptoms of: - Nausea - Early satiety - 10 pound weight loss - EDG is normal

32 What would you recommend? 1. Upper GI X-ray 2. Gastric emptying study 3. Colonoscopy 4. 24 hour pH study 5. Referral to the student counseling service 1. Upper GI X-ray 2. Gastric emptying study 3. Colonoscopy 4. 24 hour pH study 5. Referral to the student counseling service

33 Bonus A 25 year old in the ICU for 2 weeks ventilated with multiple organ system failure Today she vomited bright red blood and coffee grounds She has no prior history of GI complaints

34 What is the most likely diagnosis? 1. Excessive acidity 2. Gastro-esophageal reflux and esophagitis 3. Gastric ulcer 4. Stress ulcers 5. Bile reflux gastritis 6. Mallory-Weiss tear of the cardia 1. Excessive acidity 2. Gastro-esophageal reflux and esophagitis 3. Gastric ulcer 4. Stress ulcers 5. Bile reflux gastritis 6. Mallory-Weiss tear of the cardia

35 In this patient, which treatment would be most helpful? 1. A psychiatric evaluation 2. Phenergan 3. Parenteral nutriction (TPN) 4. Enteral nutrition 5. Prilosec made up as a liquid 6. Misoprostel (Prostaglandin E2) 1. A psychiatric evaluation 2. Phenergan 3. Parenteral nutriction (TPN) 4. Enteral nutrition 5. Prilosec made up as a liquid 6. Misoprostel (Prostaglandin E2)


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