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Download Entire Pdf: The Medicine Forum, Vol 9, 2007

The Medicine Forum

Download entire PDF: The Medicine Forum, Vol 9, 2007

What's Undocumented, Tamara Solitro, Md

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There’s a calm stillness

To the sick at night—

The sound of quiet healing, I hope,

But inevitably, a few cannot be healed.

Man With Malaria In Delaware, Benjamin Ngo, Md

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Case Presentation

A 37-year-old African American male presented to the hospital complaining of high fevers over the past two weeks associated with severe posterior headache. He described having had a very poor appetite recently, but denied any cough, abdominal pain, diarrhea, or urinary symptoms. He did not recall sustaining any head trauma. He did relate, however, that he had recently returned from a three-month trip to Kenya ~1 month prior to this presentation. He had no past medical history and was not on any medications. He did not use IV drugs. Physical exam confirmed a fever of 102.1o F though …

Spiderbite, Ayana Cannon, Md

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Introduction

In North America alone, there are more than 3,000 species of spiders. While most are harmless, several species including the Latrodectus (black widow), Atrax (funnel-web), and the Loxosceles (brown recluse) have been known to inflict varying degrees of injury to humans. While an overwhelming majority of spider bites may go unnoticed, others result in local skin reactions, necrotic cutaneous lesions, or a severe syndrome associated with hemolysis and death.

While proper identification of spider bites is paramount to the prevention of rare, life-threatening systemic reactions, their misdiagnosis can be equally hazardous. According to the literature, Loxosceles reclusa bites are …

A Man With Abdominal Pain And Acute Renal Failure, Faisal Shaikh Md, Marina Serper, Md

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Case Presentation

A 33 year-old African American male with a past medical history significant for HIV on HAART therapy presented to the emergency department (ED) with acute onset of right upper quadrant abdominal pain and mild shortness of breath. The abdominal pain was not associated with any fevers, chills, nausea, vomiting or diarrhea. The patient denied any chest pain, palpitations, lightheadedness or syncopal episodes. He did report some dysphagia with solids more than liquids over the last 2 months as well as decreased oral intake. His review of systems was otherwise significant for weight loss which he was unable to …

Infliximab-Induced Interstitial Lung Disease In A Patient With Psoriatic Arthritis, Lan Quang, Md, Anthony Scarpaci, Md

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Introduction

Infliximab (Remicade, Centocor, Inc., Malvern, PA), a chimeric monoclonal antibody derived from both murine and human antibody sequences and directed against TNF-α, is one of the disease modifying anti-rheumatic drugs (DMARDs) used in the treatment of psoriatic arthritis and other autoimmune inflammatory conditions such as rheumatoid arthritis, ankylosing spondylitis, and Crohn’s disease. It is commonly used in combination with methotrexate for increased efficacy and reduction of the development of anti-infliximab antibodies. A concerning feature of infliximab therapy is its association with an increased risk of infection or reactivation of diseases that can cause pulmonary complications, most notably tuberculosis and …

Immunocomprised Heart Transplant Patient With Cryptosporidial Diarrhea, Michael Dominic Lee, Msiii, Rajesh Kabadi, Md, Siva K. Kumar, Md

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Case Presentation

A 22 year-old female with a past medical history of postpartum cardiomyopathy status post orthotopic heart transplant (OHT) was admitted for diarrhea of 12 days’ duration. The diarrhea was watery, non-bloody, and occurring at a rate of 10 episodes per day. She denied nausea, vomiting, fever, or chills, but reported abdominal cramps. On physical exam, she was afebrile, and vital signs were stable. The patient had a regular heart rate and rhythm. Lung sounds were clear to auscultation bilaterally. Her abdomen was soft, non-tender, without rigidity, guarding, or distention. There was no edema in the extremities.

Vocal Cord Dysfunction In Asthmatics, Yvonne L. Mccarey, Md

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Case Presentation

A 44 year old female with a past medical history of type 2 diabetes, hypertension, congestive heart failure, coronary artery disease, 2 strokes, 2 myocardial infarctions, questionable history of pulmonary embolus twice, bipolar disorder, schizophrenia, and multiple asthma exacerbations presented to the Emergency Department (ED) with SOB and wheezing. Her symptoms began at home earlier that day and were not improved by bronchodilators. On arrival to the ED, she was lethargic in severe respiratory distress with laboring accessory muscle use. She had only an allergy to latex. Outpatient medications included albuterol inhaler, fluticasone/salmeterol inhaler, inhaled budesonide, furosemide, and …

Acuphagia, Saurabh Bansal, Md

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A 29 year old male with a history of swallowing objects and recent abdominal surgery presented to the emergency department (ED) after “accidentally” swallowing a pen. A chest radiograph was performed that verified the presence of the pen. The gastroenterology service performed an emergent EGD to remove the pen. Six hours after the procedure the patient signed out against medical advice. The patient returned to the ED 10 days later with complaints of hematemesis that was unwitnessed by any medical staff. On laboratory evaluation his hemoglobin was the same as the previous admission. Psychiatry subsequently interviewed the patient and found …

Foreign Body In The Small Intestine, Benjamin Creelan, Md

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Case Presentation

This adult was working on a ladder during a home restoration project. She placed the bit in her mouth while changing the screwdriver bit, then fell from the ladder and inadvertently swallowed the bit. In the emergency room, her review of systems and laboratories were unremarkable. Imaging revealed the bit to be within the duodenal lumen and after four days of serial xrays, the bit was retrieved by snare colonoscopy at the ileocecal junction. The patient remained asymptomatic and had no complications.

Chest Pain As A Presenting Symptom For Gastric Phytobezoar, Ankitkumar K. Patel, Md, Mph, Sandarsh Kancherla, Md, Darren Seril, Md

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Introduction

Chest pain is a common chief complaint of patient presentation to the emergency room. It also presents itself as one of the most challenging symptoms for clinicians to manage. The differential diagnosis for chest pain involves a multitude of organ systems. Failure to recognize potentially serious life-threatening causes such as acute ischemic heart disease, aortic dissection, tension pneumothorax, or pulmonary embolism can lead to serious morbidity and mortality. At the same time, overly conservative management of low-risk patients leads to unnecessary hospital admissions, studies and procedures.1 The following case illustrates the need to broaden the differential diagnosis for chest …

Trust Your Gut, Roger Coron, Md, Jennifer Hurd, Md, Steven Ludwin, Md, Patricia Kozuch, Md

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Case Presentation

MG is a 56-year-old female with no significant past medical history who presented to TJUH in October 2007 with a two year history of abdominal pain and weight loss. At presentation, she described her pain as non-radiating, 7 out of 10, gnawing, burning and located in the epigastrum and left upper quadrant. The pain initially occurred approximately 15 minutes postprandially and lasted 30 minutes. Over the two year period, the pain progressed to lasting for hours following meals. Dietary modifications and food consistency did not help the pain. The patient began avoiding oral intake, and her weight declined …

A 70-Year-Old Male With Abdonimal Pain, William H. Chong, Md

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Introduction

Acute pancreatitis is an acute inflammatory process of the pancreas. It is usually associated with severe acute upper abdominal pain and elevated blood levels of pancreatic enzymes. Serum amylase and lipase are common tests obtained as biochemical markers for acute pancreatitis. Pancreatitis, however, is not the sole cause of elevated pancreatic enzymes. Non-pancreatic causes of hyperamylasemia include inflammation or trauma to the salivary glands, bowel perforation or infarction, renal failure, abdominal trauma, and macroamylasemia.2 An unusual cause of elevated pancreatic enzymes is reported in this case report.

Hemochromatosis, Benjamin Creelan, Md

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Case Presentation

This 50 year-old adult male suffered from iron overload due to repetitive blood transfusions for HbSS sickle cell anemia. Computed tomography (CT) scan of the abdomen revealed high attenuation and massive enlargement of the liver consistent with hemochromatosis. A normal liver and spleen is included for comparison (inset). Splenic calcification is also noted, a rare finding in sickle cell anemia.

A 22-Year-Old Woman With Systemic Lupus Erythematosus Develops Cardiac Tamponade, Brooks Kuhn, Ms-Iii, Arthi Reddy, Md, Sorin Lazar, Md

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Introduction

Systemic lupus erythematosus (SLE) is a common cause of pericardial effusion and acute pericarditis, but very rarely it can cause cardiac tamponade.1 We describe the case of a young female with SLE who developed cardiac tamponade after finishing treatment for acute pericarditis with a small pericardial effusion.

Man With Flu-Like Symptoms, Sandarsh Kancherla, Md, Ankitkumar Patel, Md, Mph

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Case Presentation

A 69 year-old male presents to the Emergency Department with complaints of malaise, myalgias, rhinorrhea, increased congestion, and occasional fevers for one week. The symptoms have gradually worsened over the past week, and Tylenol has minimally alleviated his symptoms. He denies exacerbating factors. He denies any trauma, shortness of breath, chest pain, or recent weight change. He has no sick contacts or recent travel history.

A Case Report Of Idiopathic Giant Cell Myocarditis, Bao Bui, Md, Sumeet Chhabra, Md, Siva K. Kumar, Md

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Case Report

A 32 year old African American male was admitted to an outside hospital in July 2007 with symptoms of severe heart failure that required implantation of a short-term left ventricular assist device (LVAD). He was subsequently transferred to our facility due to worsening left ventricular heart failure, episodes of Torsades de Pointes, and monomorphic ventricular tachycardia. His device was replaced with a longer-term LVAD and he was discharged home in October. Fortunately, he underwent successful orthotopic heart transplant in November 2007.

A 41-Year-Old Woman With Rheumatic Mitral Stenosis, Atrial Fibrillation, And Right-Sided Heart Failure, Stephen Koczirka, Ms-Iii

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Case Presentation

A 41 year old Southeast Asian woman presented to the Emergency Department (ED) complaining of acute onset of nausea and abdominal pain as well as a two weeks of palpitations and two months of cough productive of white sputum. The patient also complained of fever, shortness of breath and dyspnea on exertion over the previous week. Patient history revealed a past medical history of asthma. The patient had no prior surgical or psychiatric history, had no known drug allergies, and consumed no chronic medications. The patient reported that she had immigrated to the United States from Laos in …

Left Atrial Myxoma, Siva K. Kumar, Md, Rajesh M. Kabadi, Md, Paul J. Mather, Md

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Case Presentation

A 65 year-old female with a past medical history of hypertension and diabetes presented to her cardiologist’s office with symptoms consistent with progressive heart failure over an eight month period. A transthoracic echocardiogram done in the office demonstrated a normal-appearing mitral valve and normal left ventricular systolic function. Additionaly, it also revealed a large left atrial myxoma (pictured above). The mass obstructed flow through the mitral valve, resulting in a mean valvular gradient of 18 mm Hg, consistent with mitral stenosis-like physiology. As a result of these findings, the patient was admitted to our institution for further evaluation. …

Silent Assassin: Coronary Artery Disease In A Type Ii Diabetic, Srinath Vemuri, Ms Iv, Neerav Sheth, Md

The Medicine Forum

Case Presentation

A 53 year old white male with a past medical history significant for type II diabetes mellitus and orthotopic liver transplant (December 2006) secondary to hepatitis B cirrhosis presents as a direct admission to Thomas Jefferson University Hospital in September 2007 for an orthopedic preoperative risk evaluation. Patient has had a dull, worsening, non-radiating back pain of six months duration, beginning after his liver transplant for which he has been to several outpatient orthopedic physicians. Upon admission, the patient appeared well, but admitted to a consistent 8/10 back pain that he had been managing at home with narcotic …

A 42-Year-Old Male With Blurry Vision, William H. Chong, Md, Dorothy Chang, Md

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Hypertension affects approximately 25% of the population of the United States. Complications from hypertension include ischemic heart disease and stroke, and rates increase progressively as blood pressure increases.1 In some cases, the elevation of blood pressure can be significant and be life threatening. Situations where there is severe elevation of blood pressure and evidence of target organ dysfunction are termed hypertensive emergency. In this report, an unusual cause of hypertensive emergency is presented.

Anomalous Origin Of The Right Coronary Artery Diagnosed By Cardiac Computed Tomography, Siva K. Kumar, Md, Faisal Shaikh, Md, Paul J. Mather, Md

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Case Presentation

A 34 year old female with no significant past medical history presented with intermittent left shoulder and chest pain. The pain was burning in nature over her left chest and radiated to her left arm. There were no alleviating or exacerbating factors. Initial electrocardiogram showed sinus bradycardia. Cardiac computed tomography angiography revealed anomalous origin of the right coronary artery, which arises from the left sinus of Valsalva (Figure 1) and then travels towards the right side between the pulmonary outflow tract and the aortic root, where it shows mild narrowing of about 50%, (Figure 2) for a length …

Giant Negative T Waves, Siva K. Kumar, Md, Rajesh M. Kabadi, Md, Paul J. Mather, Md

The Medicine Forum

Case Presentation

A 62 year old Caucasian man with a past medical history significant for (long standing and controlled) HTN, lymphoma (diagnosed 2 yrs ago and currently in remission), and diffuse esophageal spasm presented to an outside hospital with expressive aphasia and right sided weakness. He was treated with tissue plasminogen activator (t-PA) for left MCA embolic stroke with excellent clinical response with very minimal residual expressive aphasia. Further work up and evaluation there revealed a large left ventricular apical mass consistent with thrombus and he was subsequently transferred to our facility for further evaluation and management of this apical …

Man With Spontaneous Intracranial Hemorrhage On Therapeutic Enoxaparin, Clopidogrel, And Aspirin, Mihir K. Patel, Md, Sumeet K. Chhabra, Md, Michael Pfeiffer, Md

The Medicine Forum

Case Presentation

A 65 year-old Caucasian male originally presented to an outside hospital complaining of worsening paroxysmal nocturnal dyspnea, orthopnea, and recent exertional chest pain associated with dyspnea. The patient’s past medical history was significant for coronary artery disease status post coronary bypass, severe aortic stenosis status post bioprosthetic aortic valve repair, congestive heart failure, atrial fibrillation on anticoagulation, dual-chamber pacemaker placement, history of a transient ischemic attack, and type 2 diabetes mellitus. At the outside hospital, coronary angiography revealed occlusion of native vessels and previous grafts. He was considered a poor surgical candidate. He was transferred to Thomas Jefferson …

Clopidogrel-Associated Thrombotic Thrombocytopenic Purpura: A Case Report And Brief Review, Benjamin C. Creelan, Md

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Introduction

In 1991, Page and colleagues published a report of four cases of thrombotic thrombocytopenic purpura (TTP) attributed to treatment with the platelet ADP receptor antagonist, ticlodipine. Since then, ticlodipine has been established as an immunemediated cause of TTP with an incidence of approximately 0.02-0.06%. Due to its unfavorable side-effect profile, the use of ticlodipine has been mostly discontinued in the United States and replaced by clopidogrel. Both agents are thienopyridine-derivatives which differ only by a carboxymethyl moiety. In spite of their structural resemblance, no case of TTP was reported in phase III trials of clopidogrel with 19,185 patients. However, …

Syncope, Melissa Gitman, Md, Cm

The Medicine Forum

A 45 year old white female rising from her seat to give a lecture at the Philadelphia Convention Center suddenly collapsed and lost consciousness. An automated external defibrillator device, on hand at the conference, demonstrated her rhythm to be in ventricular fibrillation. She was subsequently defibrillated and intubated in the field yet was unresponsive on arrival. Her husband related that his wife’s past medical history was significant for hypothyroidism and a questionable diagnosis of lupus. Her medications included levothyroxine and Pycnogenal, a popular herbal supplement. She had no known drug allergies. The patient had no known tobacco, alcohol, or illicit …

Palmarplantar Keratodermas, Melissa Gitman, Md, Cm

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Case Presentation

A 44 year old African American female with a history of seizure disorder and cirrhosis secondary to alcohol abuse was brought to the emergency department (ED) after a witnessed generalized tonic-clonic seizure on the street. While the patient was in the ED, she was observed to have 500cc of bright red hemetemesis and promptly transferred to the intensive care unit with successful stabilization of an upper GI bleed. It was not until transfer back to the telemetry that she was noted to have a shiny, scaly lesions on her hands and feet bilaterally

The Controversy Over Cocaine Use And Beta-Blockade Continues To Brew, Ankitkumar K. Patel, Md, Mph

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Cocaine Abuse Epidemiology

Cocaine is the second most commonly used illicit drug and the most frequent cause of drug-related deaths in the United States. Approximately 24 million people in the United States have used cocaine at least once, and five million abuse cocaine on a regular basis. Its use is associated with acute and chronic complications affecting many organ systems, the most common being the cardiovascular system.

Table Of Contents: The Medicine Forum, Volume 9, 2007

The Medicine Forum

Table of Contents: The Medicine Forum, Volume 9, 2007

From The Editors, Neilanjan Nandi, Md, Melissa Gitman, Md, Anthony Lanfranco, Md, Tamara Solitro, Md, Ankitkumar Patel, Md, Anastasia Shnitser, Md

The Medicine Forum

Every day our House Staff strive to deliver the most advanced and compassionate healthcare possible. Our clinical perspectives are constantly being challenged, prompting new avenues of inquiry and information to further our insight into the state of the human condition.