Here - American Geriatrics Society

P OSTER
A BSTRACTS
is on the rise. Thus, more severe and complicated sports-related injuries
are likely to be encountered by emergency room physicians in
the near future.
These “fit” elderly are often still employed and despite being
high-performing, sports injuries sustained in this older group may be
more devastating and potentially disabling.
A28
Hands Tell All.
V. Nurpeisov, 1 A. Akintan, 1 N. Holland. 2 1. geriatric medicine, VA
Medical Center, Decatur, GA; 2. Geriatric medicine, Emory University
School of Medicine, Atlanta, GA.
An 85 year old gentleman with a history of hypertension, hyperlipidemia,
and tobacco use presented to the geriatric clinic with a history
of craving ice chips for several months and a twenty pound
weight loss over the previous six months. He denied any noticeable
change in stool habits, hematemesis, abdominal pain, or vomiting. He
did not use alcohol and had smoked cigarettes for the past 60 years.
His medications were: Lisinopril 5 mg daily, Aspirin 81mg daily, and
Hydrochlorothiazide 12.5 mg daily.
On exam he was a thin and cachectic. His vitals were stable.
There was no noticeable jaundice. His lungs were clear and heart
exam was unremarkable. His abdominal exam didn’t reveal any palpable
masses but revealed an enlarged liver.
His nails revealed spooning, evidence of nicotine staining and
changes consisitent with Terry’s nails. His labs showed normal
chemistries and urinalysis. TSH and vitamin B12 levels were normal.
He had a microcytic anemia, hemoglobin of 9 g/dl.
This patient was admitted and by CT colonoscopy, diagnosed
with colon cancer with metastasis to the liver. He and his family
elected for him to receive hospice care.
His Terry’s nail changes were consistent with hepatic disease.
These are usually seen with cirrhosis but in this case we felt these
changes were the result of hepatic metastasis. His nails also revealed
spooning consistent with an iron deficiency anemia as well as nicotine
staining on the second and third finger nails.
Based only on this gentelman’s history and nail changes as described,
colon cancer with liver metastasis was a leading diagnosis before
getting any diagnostic studies. Subsequent CT colonoscopy confirmed
this diagnosis. To our knowledge, this is the first case of
association of Terry’s nails with hepatic metastasis without hepatic
cirrhosis.
In this age of growing technology getting back to the bedside
and taking the time to listen, as well as look for subtle but important
physical exam findings still remains an important art and skill which
should not be overlooked.
Nail changes are easy to observe and often are associated with
important clues to underlying systemic illness in older patients.
This case report emphasizes Sir William Osler’s quote that “
every patient you see is a lesson in much more than the malady from
which he suffers.”
This poster will show pictures of this gentelman’s hands and nail
findings as well as other diagnostic nail changes in systemic disease.
A29 Encore Presentation
Metformin-associated severe hypomagnesemia; A Case report.
V. Kaushik. Geriatrics, UTMB, Galveston, Galveston, TX.
Supported By: UTMB
Introduction
Metformin is a oral hypoglycemic agent which decreases hepatic
glucose production, decreases intestinal absorption of glucose, and
improves insulin sensitivity by increasing peripheral glucose uptake
and utilization. The main use for metformin is in the treatment of diabetes
mellitus type 2, especially in overweight patients. Metformin reduces
diabetes complications and overall mortality. Hypomagnesemia
is not referred to as a side effect in the drug’s summary of product
characteristics information, but diarrhea is an important side effect
of metformin and various degree of hypomagnesemia and other
electrolyte imbalance from diarrhea have been reported in the literature.
One report describes a patient on metformin who developed diarrhea
and symptomatic hypomagnesemia (1).
Case presentation
Patient is an 78 year old Caucasian female with h/o diabetes
type II for more than 15 years, hypertension, hyperlipidemia and osteoarthritis.
Her diabetes was fairly controlled by glipizide and metformin.
Metformin was added to her medications three years ago for
better control of her diabetes. Her other medications include
enalapril, Felodipine, Clopidogrel (Plavix), Rosuvastatin (Crestor),
Hydrocodone-acetaminophen and Temazepam (Restoril). Patient
had normal serum magnesium levels prior to adding metformin. Two
months after adding metformin, her routine evaluation showed an
unexplained hypomagnesemia (1.0 mg/dl). Serum calcium, phosphorus,
potassium and renal function were normal. She did not report any
diarrhea. She continued to have chronic moderate to severe hypomagnesemia,
mostly in 0.9 -1.4 mg/dl range. Oral magnesium supplementation
was not very helpful . Her Metformin was discontinued six
months ago and since then her serum magnesium level is improving
slowly, now mostly in 1.5 -1.8 mg/dl range.
Conclusion
The lab findings in this case suggest severe hypomagnesemia,
without any evidence of diarrhea. Hypomagnesemia resolved with
discontinuation of metformin. Based on this association with metformin
and the lack of other clear precipitating causes, the most probable
cause of hypomagnesemia in this patient appears to be metformin.
Clinician should consider the possibility of
metformin-associated hypomagnesemia in patients with otherwise
unexplained hypomagnesemia.
References:
(1) A patient presenting with symptomatic hypomagnesemia
caused by metformin-induced diarrhea: a case report. Svare A. Cases
J. 2009 Oct 16;2:156.
A30
Birds Don’t Make the Best Companions: Hypersensitivity
Pneumonitis In The Elderly.
W. Ooi, S. Dahiya. Internal Medicine, Baystate Medical Center, West
Springfield, MA.
Hypersensitivity pneumonitis, also known as extrinsic allergic
alveolitis, represents a spectrum of immunologic-driven response to a
variety of inhaled allergens. The diagnosis requires a known exposure
to the offending agent along with compatible clinical, radiological
and laboratory studies.
A 67 year old lady with a history of bilateral pulmonary embolisms
presented with progressive dyspnea associated with productive
cough over one month. Patient denied fever, chills or night
sweats. No hemoptysis or lower extremity swelling. Past medical history
includes schizoaffective disorder, morbid obesity and osteoarthritis.
Physical exam was significant for hypoxia requiring 5L of
oxygen supplementation by nasal cannula. Lung and cardiac exam
were otherwise unrevealing. Laboratory studies were significant for
chronic anemia with hemoglobin of 9.8 gm/dL and elevated N-terminal
pro-brain natriuretic peptide of 826 pg/mL. Patient underwent a
computed tomography (CT) angiogram of the chest which revealed
mosaic pattern of lung attenuation bilaterally and mediastinal lymphadenopathy.
She was started on ceftriaxone and azithromycin for
treatment of atypical community-acquired pneumonia. Collateral history
from patient’s family later during her hospitalization revealed
that patient keeps 17 birds; parrots and macaws for the past 15 years.
Her house was revealed to be in an unhygienic condition with animal
excreta and clutter in her bedroom. Pulmonary recommended a
serum precipitin panel which revealed a positive qualitative titer of
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AGS 2012 ANNUAL MEETING