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From The Editors, Andrew Lerner, Md, Tasha Kouvatsos, Md, Andrea Fennelly, Md

The Medicine Forum

The editorial staff would like to acknowledge the support of Dr. Diemer and Dr. Kane in producing this year’s Jefferson Forum. We appreciate your guidance and thank you for all that you have done to help bring this issue to print. We would also like to thank our internal medicine resident colleagues for contributing interesting and unique case reports, review articles, original research, travel experiences, and poetry. This issue of the Jefferson Forum could not have been done without your hard work and enthusiasm.

From The Desk Of The Residency Program Director, Gretchen Diemer, Md, Facp

The Medicine Forum

To the Friends of the Department of Medicine:

I am honored to be given the opportunity to lead this talented group of residents as they travel down the path toward completion of their residency training. On September 1st, Dr. Gregory Kane took the reins as the Interim Chair of the Department of Medicine here at Jefferson. A new Program Director could not ask for a more staunch supporter of education to occupy that role than Dr. Kane.

This edition of The Forum showcases the broad variety of patients our residents and students encounter during their training. The submissions to this …

Download Entire Issue-The Medicine Forum, Volume 12, 2010

The Medicine Forum

Download entire issue-The Medicine Forum, Volume 12, 2010

Poem, Andrew Lerner, Md

The Medicine Forum

She is a small lady,

85 years old.

Digital Clubbing, Yiu Tak Leung, Md, Phd

The Medicine Forum

This is a 66 year-old male with a history of cirrhosis who came into the office for a routine check-up and was noted to have “drumbstick fingers” or digital clubbing. Digital clubbing is a clinical sign most commonly associated with pulmonary diseases, such as lung cancer and interstitial lung disease, cyanotic heart disease and cirrhosis of the liver, but clubbing also may be idiopathic or congenital.

Chronic Tophaceous Gout, Sara Beltz, Md

The Medicine Forum

Gout, existing since antiquity as “the king of diseases and the disease of kings,” can present as an acute gouty arthritis or as achronic depositional arthropathy (chronic tophaceous gout). If left untreated, chronic tophaceous gout will develop in up to 30% of acute gout patients over 5 years.

Calciphylaxis, Darren Andrade, Md

The Medicine Forum

A 51-year-old man with a history of end-stage renal disease on hemodialysis and diabetes mellitus presents with suprapubic pain and a worsening penile ulcer that he first noticed two months ago. What finally prompted the patient to go to the emergency

Rare Gram-Negative Sepsis In A Non-Ventilated Neutropenic Patient With Aml, Jay Sellers, Md, Paurush Shah, Md

The Medicine Forum

Case Report

A 57-year-old man with history of hypertension, hyperlipidemia,and gout presented for evaluation of both a perioral infection and an infection in his right great toe from an injury on the beach at his shore house. The toe trauma was complicated by a massive hematoma and phlebitis, which required antibiotics. His primary care physician ordered basic laboratory studies thatshowed an anemia and thrombocytopenia. He was sent to a Hematology and Oncology specialist and subsequently directly admitted to Thomas Jefferson University Hospital for blood transfusion and further work-up. Upon further questioning, thepatient admitted to chills starting 2 weeks prior to …

Post-Pneumonectomy Changes, Charles-Lwanga Bennin, Md

The Medicine Forum

Case

A 71-year-old woman, with a history of non-small cell lung cancer (NSCLC) with subsequent pneumonectomy presented with worsening dyspnea on exertion and non-productive cough.

The patient first noted the shortness of breath and cough 4 weeks prior to presentation, which were refractory to albuterol nebulization. The patient also reported a 6 lb. weight loss duringthis time period. She denied fevers, chills, night sweats or chestpain. The patient was diagnosed with NSCLC 11 years ago andunderwent a right-sided extrapleural pneumonectomy at that time. She received no radiation or chemotherapy. She did not require home oxygen and reported a generally good …

A 35-Year-Old Man With New Onset Blindness, Cecilia Kelly, Md, Claire Raab, Md, Aimee Lee, Msiv

The Medicine Forum

Case Report

A 35 year-old homosexual male from Trinidad with no known past medical history presented with a complaint of new-onset blindness. He stated that his vision had become increasingly “dim” to the point that at presentation, he had minimal light perception in either eye. This decrease in vision had occurred over the course of a week. He denied any trauma, eye pain, headache, nausea or vomiting.

Peripancreatic Tuberculosis With Involvement Of The Porta Hepatis In A 41-Year-Old Thai Female Diagnosed Via Fine Needle Aspiration, Paurush Shah, Md, Ali Siddiqui, Md

The Medicine Forum

Case Report

A 41-year-old Thai female with past medical history of gastroesophagealreflux disease and duodenal ulcer who immigrated to the United States six years ago presented with a complaint of intermittent right upper quadrant (RUQ) pain for the last several years. Over the last year, she reported that the pain had significantly increased in intensity. She described the pain as crampy, beginning in the RUQ and radiating around to her back. There was no associated nausea, vomiting or weight loss. The patient had initially presented to an outside hospital a few months prior, was diagnosed with costochondritis, and was subsequently …

Chest Pain And Troponin Leak In A Healthy 38-Year-Old Female, Gunjan Shah, Md

The Medicine Forum

A 38-year-old female with a medical history significant only for a cholecystectomy for cholelithiasis presented to an outside hospital with a one day history of sharp, non-radiating midsternal chest pain that began when she bent over to pick something up. She has associated light-headedness and dizzinesswhen she stood up, as well as palpitations, diaphoresis, and a sense of throbbing in her left arm. The symptoms persisted at rest for one hour before the patient arrived at the outside hospital. She was found to be in new-onset atrial fibrillation witha rapid ventricular rate up to 160 beats per minute. A diltiazeminfusion …

Gi Dysmotility: A Case Report, Katie Osley, Md, Yiu Tak Leung, Md, Phd

The Medicine Forum

Case Report

A 75-year-old male, with a medical history of diabetes, hypertension, coronary artery disease, status post coronary artery bypass graft, and left-sided breast cancer, status post left breast mastectomy, was transferred from an outside hospital with complaints of a month of constipation, nausea and vomiting. The patient presented to an OSH a month prior withrecent onset of constipation, with no bowel movements for 10 days, changed from his usual habit of daily bowel movements. He initially responded to lactulose with a bowel movement andwas discharged on a regimen of stool softeners and laxatives; however, upon returning home, he was …

Primary Cutaneous Nocardiosis In A Heart Transplant Patient: A Case Report, Kiran Devaraj, Md, Joanna Rodriguez, Md, Bryan Hess, Md, Paul Mather, Md

The Medicine Forum

Case

A 38-year-old female with history of longstanding non-ischemiccardiomyopathy underwent orthotopic heart transplantation (OHT). Her past medical history was significant for factor V leiden and methylenetetrahydrofolate reductase (MTHFR) heterozygous deficiencies with chronic pulmonary embolism, sickle cell trait, atrial flutter, type 2 diabetes mellitus, and hypertension. The patient had a long and complicated course post-transplantation. Immediately after OHT, she was noted tohave donor- specific human leukocyte antigen (HLA) antibodiestreated with 5 cycles of plasmapheresis. On further biopsies it wasnoted that she had acute cellular rejection requiring pulse-dose parenteral steroids on multiple occasions. Her immunosuppressiontherapy consisted of tacrolimus, mycophenolate and prednisone. Six …

A Rare Case Of Abacavir Hypersensitivity Syndrome, Charles-Lwanga Bennin, Md

The Medicine Forum

Case

A 56-year-old African American male with a history of type II diabetes mellitus complicated by neuropathy, infections with human immunodeficiency virus (HIV), with a known CD4 count of 25 per cubic millimeter, hepatitis B and hepatitis C presented with six months of generalized weakness over his lower extremities, poor balance, nausea and vomiting. The patient had recently started anti-retroviral therapy (ART) and noticed that the onset of his symptoms coincided with the initiation of this therapy. He was taking Trizivir, which consistsof abacavir (300mg each day), lamivudine (150mg each day), and zidovudine (300mg each day), atazanavir (300mg each day)and …

A 40-Year-Old Woman With Chest Pain, St Elevation, Elevated Troponin And Normal Coronary Arteries: A Case Report, Bhalaghuru Chokkalingam-Mani, Md, Avinash Chandra, Md

The Medicine Forum

Electrocardiographic changes resembling myocardial ischemia or infarction can be caused by a variety of causes other than ischemia. One of them is acute myocarditis which further confounds clinical judgment by causing elevation in troponins as well. We report a case of myocarditis which underscores the importance of identifying the clinical presentation of acute myocarditis and the electrocardiographic changes that can be associated with it.

Brain Zygomycosis In A Patient With High Risk Myelodysplastic Syndrome After Initiation Of Chemotherapy, Sameh Gaballa, Md, Ali Al-Ameri, Md

The Medicine Forum

Introduction

Zygomycetes are a group of fungi that can cause a variety of life-threatening infections particularly in immunocompromised patients. Zygomycosis manifests as a spectrum of diseases including stroke.1-3 We present a case of disseminated zygomycosis with central nervous system (CNS) involvement in a patient with myelodysplastic syndrome (MDS) after initiationof chemotherapy.

A 52-Year-Old Female With Ramsay Hunt Syndrome, Ketki Soin, Msiii, Eric Struble, Md, Whitney Jackson, Md

The Medicine Forum

Case Report

A 52 year-old female with a history of poorly controlled type IIdiabetes and a recent admission of right-sided pre-septal orbitalcellulitis presented with a facial rash and severe ear and eye painfor three days. The patient noted sudden right-sided vision lossand associated right-sided face, ear and eye pain three days prior toadmission. The pain was a 9/10 and was worsening since its onset.Upon questioning she also noted decreased taste sensation. Shedenied tinnitus, vertigo, hearing loss, nausea, vomiting, or fevers.

Acute Hiv, Rhabdomyolysis, Renal Failure, And Hepatitis: A Case Report, Eve R. Merrill, Md

The Medicine Forum

Case Report

A 19 year old African-American male with no significant past medical history presented to an outside hospital with two days of diffuse abdominal pain, myalgias, muscle weakness, and darkurine. Two weeks prior to presentation, the patient was treated as an outpatient with an unknown antibiotic for symptoms of a sore throat, nausea, and non-bloody, non-bilious emesis. The patient denied any sick contacts, recent travel, trauma, strenuousexercise, or the use of non-steroidal anti-inflammatory drugs, acetaminophen, alcohol, or illicit drugs. The patient reported being sexually active with one female partner and had no historyof sexually transmitted infections. The patient was …

West Nile Virus Encephalitis In A Patient With Renal Transplant, Charles-Lwanga Bennin, Md, Steve Krawitz, Md, Emma Weaver, Md

The Medicine Forum

Introduction

Most cases of West Nile Virus infection are asymptomatic. 60% to 70% of neuro-invasive cases of West Nile virus infection result in meningitis or encephalitis; however, West Nile encephalitis occurs in less than 1% of patients infected with the West Nile virus.1

A Case Of Metastatic Breast Cancer To The Meninges, Carolyn M. Ross, Msiii, Jie Cui, Md

The Medicine Forum

Case Report

A 44-year-old woman with a history of triple-negative breast cancer metastatic to the brain presented with changes in mentalstatus, lower back pain, and a left facial Bell’s palsy.

The patient had previously been ambulatory and fully cognizantof her surroundings until one week prior to presentation when she began to exhibit progressively worsening confusion. As hermental status began to change, the patient developed new onsetpain over her lumbar spine, supra-pubic area, bilateral flanks, hips, and knees. The pain was refractory to an epidural injectioninto her lumbar spine performed at the patient’s local hospital. Other complaints included a recent onset …

Paraneoplastic Pemphigus In A Patient With Carcinosarcoma Of The Uterus, Georgia Giebel, Msiv, Gunjan Shah, Md

The Medicine Forum

Case Presentation

The patient is a 68-year-old female with hypertension, chronic obstructive pulmonary disease, without medical follow-up for several years, who initially presented with skin blisters and orallesions, which were biopsied by her dermatologist and found tobe bullous pemphigoid. She was treated with a course of oral prednisone and had resolution of her skin and oral lesions. Threemonths later, she presented with a swollen leg and was diagnosed with a deep venous thrombosis, for which she was started on coumadin and had an inferior vena cava filter placed. She then had hemoptysis a few days later, after which the coumadin …

Time For Reassessment: A Review Of Beta-Blockers In The Setting Of Cocaine Associated Chest Pain And Acute Coronary Syndrome, Jonathan Finkel Md, Gregary Marhefka, Md

The Medicine Forum

Introduction

Cocaine is the second most commonly used illicit drug in the United States, 1 and is the most frequent illicit substance to precipitate an emergency room visit, responsible for over 550,000 visits in 2007 alone. 2 The majority of patients present with a chief complaint of chest pain3, and approximately 6% are diagnosed with cocaine associated myocardial infarction.4For decades it has been thought that beta-blockade in the setting of cocaine use would precipitate coronary vasospasm and worsen cardiovascular outcomes due to unopposed alpha receptor stimulation. In 1999 this thinking was incorporated into the ACC/AHA guidelines, which currently recommend beta-blockers …

Thrombotic Thrombocytopenic Purpura: A Review Of The Disease Entity, Its Clinical And Laboratory Features, And Management Strategies, Rosemarie Beckford, Md, Gunjan Shah, Md

The Medicine Forum

Case 1

The patient is a 47-year-old female with a history of coronary artery disease, hypertension, asthma, diabetes and obstructive sleep apnea who presented to an outside hospital with shortnessof breath and lethargy. The patient was found to be in diabetic ketoacidosis, which was treated with an insulin drip. She also had a platelet count of 8 x 109/L on initial laboratory studies. She was presumed to have immune thrombocytopenic purpura(ITP) and treated with five days of intravenous immunoglobulin(IVIG) without improvement. She was transferred to Thomas Jefferson University Hospital for further management.

Ventilator Management For The Non-Intensivist, David R. Manoff, Md, Christine Feldmeier, Msiv

The Medicine Forum

The management of the mechanical ventilator is one of the most complex and dynamic, yet ubiquitous issues to face the critical care physician. As we as a medical community have become more advanced, so too, have our ventilators, with new modes and variables having been added beyond more traditional modeslike Assist Control and Intermittent Mandatory Ventilation. This article is designed to give a very basic understanding of what the individual ventilatory modes do and how they are set.It is in no way meant to be a replacement for either a medical intensivist or a respiratory therapist.

Disruptive Innovation, Peregrine Dalziel, Mbbs, Tina Shah, Md

The Medicine Forum

Introduction

“Disruptive innovation” (DI) has recently been heralded as a tool to mitigate out of control health care spending in the UnitedStates,1,2,3 however few doctors are familiar with the concept. Overall, there is a tendency in medical culture to regard changes to established treatment and management models with some reticence, increasing the difficulty for reform. In this article we will introduce readers to the concept of DI as a means to reduce costs in the American health sector. We will illustrate current uses of DI in health care, using the particular example of the expanding role of nurse practitioners (NPs). …

Table Of Contents, The Medicine Forum, Volume 12, 2010

The Medicine Forum

Table of Contents, The Medicine Forum, Volume 12, 2010.

From The Editors, Sameh Gaballa, Md, Toshimasa Okabe, Md, Tina Shah, Md

The Medicine Forum

We are proud to publish the 11th version of the Medicine Forum. Over the years, theforum has served as an opportunity for medical students and housestaff to pursue scholarly activities alongside learning clinical medicine. This peer-reviewed journal has also served as a platform for rising residents to gain invaluable experience with the editing process as well.

From The Desk Of The Residency Program Director, Gregory C. Kane Md, Facp, Fccp

The Medicine Forum

In September 2010, the ACGME Board of Directors voted to implement work rules which would among other things limit intern shifts to 16 hours effective July 2011. At Jefferson, our leadership team began working on our program’s process and specific plans in attempting to rapidly adapt to the new ACGME mandates even before they were formally adopted. Together with our Chief Residents, Drs. Doug Guggenheim, Dina Halegoua, and Emily Stewart, we planned a retreat for October 22, 2010. It was held at the Union League with assembled residents from all three levels, senior administrators, and faculty that we forged our …

Download Entire Issue-The Medicine Forum, Volume 11, 2009

The Medicine Forum

Download entire issue-The Medicine Forum, Volume 11, 2009