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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 enema 4. Surgical consult 5. pH probe Dr. Pfeil Photo Slide Case #2 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 Case #3 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 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 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 Case #5 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 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 nonbloody • Initial laboratory studies show the following: - WBC 5.0 - MCV 79 - Ferritin 2 (normal 82-99) - Hgb 10.9 - B12 190 (normal >220) - Endomysial Ab positive - Albumin 2.5 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) Case #6 (con’t.) • Endoscopy and duodenal reveal - Flattened villi - Crypt hyperplasia - Intraepithelial lymphocytes 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 Case #7 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 Case #8 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 Case #9 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 Case #10 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 Case #11 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 Case #12 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 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 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 Case #14 • A 25 year old previously healthy college student presents with symptoms of: - Nausea - Early satiety - 10 pound weight loss - EDG is normal 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 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 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 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)