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Transcript of case 2
What are the abnormalities detected on physical exam?
nausea, vomiting, weight loss, abdominal pain:
disorder involving the gastrointestinal tract?
history of bypass: nutritional disorder?
central nervous system cause of vomiting less likely...why?
31yo F with a history of morbid obesity s/p gastric bypass 5 yrs ago (lost 45 kg), migraine, presents to hospital with inability to eat or drink for 1 week
nausea, vomiting, epigastric pain for 8 months
weight loss, loss of appetite, fatigue
normal bowel movements, loose, pale stools occasionally, not different from baseline
Soc hx: 1 glass wine/day, 1 ppd x 15 yrs, no other drugs
2 diagnoses...and 2 questions
B12 deficiency, other vitamin deficiencies
Malabsorption after gastric bypass, iron, B vitamins, vitamin D, fatty acids
ROS: (pertinent positives)
new headaches, constant, dull, not like migraines
tingling in hands/feet x 3 months
Difficulty walking x 1 month
Length-dependent sensory loss and decreased reflexes: peripheral neuropathy
Elevated BP with nausea/vomiting: elevated intracranial pressure?
PE: Afebrile, HR 115, BP 184/119, RR 14
normal cardiovascular and pulmonary exams
abdominal pain: epigastric pain, no guarding,
enlarged liver and normal spleen size
Neuro: sensation decreased to light touch below knees
Vibration decreased at toes and ankles bilaterally
deep tendon reflexes decreased at knees and ankles
Babinksi sign not present
normal strength exam
normal cranial nerves
Elevated MCV: folate or B12 deficiency?
Elevated AST compared to ALT: Alcoholic liver disease?
Labs: CBC normal except mean corpuscular volume (MCV) 109
AST 210, ALT 44, Alk phos 191, remainder of liver enzymes and coagulation tests normal
Normal amylase/lipase, negative beta HCG
ultrasound of the abdomen: diffuse fatty liver
what are some of the laboratory tests we might order?
Ataxia, oculomotor dysfunction, encephalopathy
Wernicke’s encephalopathy: thiamine deficiency (vitamin B1)
Amnesia rules out sole spinal cord disorder and peripheral neuropathy
Giving glucose prior to thiamine can worsen Wernicke’s encephalopathy
Why? Remember the Krebs cycle
She was admitted and given 5% dextrose with ½ normal saline (0.45%)
Next day: she woke up and fell while walking. She complained of blurry vision and was noted to be confused, not answering questions appropriately.
Change in neurologic exam:
Impaired lateral gaze both eyes; vertical and horizontal nystagmus, positive Romberg test
Wide-based, unsteady gait
On questioning: vague responses, decreased recall, perseveration
Does anything strike you as unusual about this change?
What is the Romberg test and what does it test?
Probably malabsorption from gastric bypass
Roux en Y: small intestine portion removed
U.S. National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health
Treated with IV thiamine
B1 level found to be ½ normal
Also low B12, copper, zinc, vitamin D
Folate normal, urine and serum tox screen negative
Wernicke: Usually begins with double vision. ataxia, ophthalmoplegia, confusion. can progress to…
Korsakoff syndrome: anterograde and retrograde amnesia, confabulation
repeated or severe attacks of Wernicke’s encephalopathy
neurologic abnormalities may become irreversible --> emergency
typically observed in malnourished patients with alcoholism
Electromyography: a generalized, length-dependent polyneuropathy with involvement of sensory axons but no evidence of a demyelinating polyneuropathy
MRI: enhancement and enlargement of mammillary bodies
Results consistent with Wernicke’s encephalopathy
coronal T1, post contrast
(how) do these symptoms fit in with your two diagnoses?
what do you expect to find on physical exam?