Medicine and Health Sciences Commons^™

A Gram-Negative False-Negative: Normal Procalcitonin Level In A Patient With Multiple Klebsiella Pneumoniae Intra-Abdominal Abscesses: A Case Report And Literature Review, Mario Caldararo, Md

The Medicine Forum

Introduction

Despite over 3,000 peer-reviewed articles on procalcitonin (PCT) since 2004, guidance on its usage is sparse.1 An analysis of more than 500 United States hospitals in the Premier Healthcare Database found large differences in utilization exist across regions (115 PCT encounters per 10,000 patients in the Northeast vs. 408 to 576 in other regions) and teaching vs. non-teaching hospitals (345 vs. 530 PCT encounters per 10,000 patients, respectively).2 The purpose of this work is to describe a case that exemplifies the caveats in PCT interpretation and to summarize the current knowledge of the clinical utilization of PCT.

Can Our Hearts Take The New Guidelines?, Eitan Frankel, Md

The Medicine Forum

No abstract provided.

Resident Experiences With Journaling, Tara Sunder, Md, Gretchen Diemer, Md, Vikas Sunder, Md

The Medicine Forum

Background

Each year, medical school graduates don their long white coat for the first time and begin their residency. While residency promises the excitement of learning and increased autonomy, it also brings long duty hours and stressful situations worsened by inexperience. Due to these stressors, burnout affects many residents each year. Studies have been done to see if wellness curricula help decrease resident burnout, and since journaling is a known way to relieve stress and enhance reflection, journaling has become a common intervention in these curricula.1,2 While there are studies evaluating the impact of journaling on mental health and stress …

Pneumatosis Intestinalis In A Patient With Systemic Lupus Erythematosus, Sean Dikdan, Md, Michael Lake, Md

The Medicine Forum

Introduction

Pneumatosis intestinalis (PI) refers to the radiographic finding of gas within the small or large bowel wall. It can be seen in association with gas in the portal venous system. The clinical significance of these findings is variable and depends on the patient's etiology and initial presentation. PI can be seen anywhere in the gastrointestinal tract distal to the stomach and is caused by a myriad of conditions.1 We present a case of a patient admitted to the intensive care unit with PI and portal vein gas.

Hemothorax And Hemorrhagic Ascites: A Rare Presentation Of Endometriosis, Harry Wang, Md

The Medicine Forum

Introduction

Endometriosis is a common diagnosis in reproductive age women characterized by the presence of endometrial tissue outside the uterine cavity.1 Although it is typically confined to the pelvis, rare manifestations involving the thorax, abdomen or pericardium have been documented.2-5 Even more rare is the concurrent presence of endometriosis- associated hemorrhagic pleural effusion and ascites, which can prove a diagnostic challenge. We describe a case of hemothorax and hemorrhagic ascites in a woman with shortness of breath and abdominal pain.

Subacute Onset Hand Clumsiness In A Renal Transplant Patient With A Recent Icu Stay, William Bradford, Md

The Medicine Forum

Introduction

Solid organ transplant recipients carry a high burden of disease and are susceptible to opportunistic infections not seen in other patient subgroups. Signs and symptoms that would not necessarily warrant timely attention in other patient groups may call for an aggressive workup in this subset of patients. Here, we present one case in which a seemingly trivial complaint denoted serious underlying pathology, and timely attention to this minor but unusual concern led to early intervention with appropriate treatment of an uncommon disorder.

Hyperviscosity In Non-Igm Lymphoplasmacytic Lymphoma, Mario Fonseca-Paricio, Md, Sushil Chmire, Md, Adam Binder, Md

The Medicine Forum

The following is a case of how a non-IgM paraproteinemia can present with symptoms of hyperviscosity and coagulopathy, an uncommon occurrence.1-3 As this case demonstrates, this diagnosis must be considered even in patients with relatively normal coagulation laboratory results. Such pathology requires urgent treatment with plasmapheresis.

Worsening Autoimmune Neutropenia After Stopping Ibrutinib In A Patient With Chronic Lymphocytic Leukemia: Case Report And Review Of Literature, Natalie Rosen, Ba, Thomas Klumpp, Md, Sameh Gaballa, Md, Msc

The Medicine Forum

Introduction

Autoimmune cytopenia (AIC) is relatively common in patients with chronic lymphocytic leukemia occurring in 5-10% of patients during the course of their disease.1 Autoimmune hemolytic anemia (AIHA) constitutes the highest prevalence (5-10%) of CLL-associated AIC followed by idiopathic thrombocytopenic purpura (ITP) (2-5%), pure red cell aplasia (PRCA) (<1%), and autoimmune neutropenia (AIN) (<1%).2,3 The prevalence of AIN, however, may in fact be higher than reported due to a lack of awareness of the condition and difficulty in its diagnosis.4 Despite its rarity, autoimmune neutropenia can be a significant clinical challenge in patients with CLL and can increase the risk of infectious complications. Thus, the prompt diagnosis and resolution of CLL-associated AIN is essential to the management of these patients.

Ibrutinib is a selective inhibitor of Bruton tyrosine kinase and induces a durable response in patients with CLL.5 The activity of ibrutinib in CLL-associated AIC is largely unknown as pivotal clinical trials excluded patients with AIC. We report a case of a patient with CLL who experienced worsening of AIN after …

Bilateral Choroidal Metastases As Initial Presentation Of Widespread Follicular Thyroid Cancer, Jennifer Hong, Md

The Medicine Forum

Introduction

Follicular thyroid cancer (FTC) is the second most common malignancy of the thyroid gland and comprise 10-15% of all thyroid tumors; the usual mode of spread is via hematogenous dissemination with the most common sites of metastases being the lungs and bones.4 A case is presented to demonstrate the unusual presentation of follicular thyroid cancer as bilateral choroidal metastases. Although exceptional, a diagnosis of choroidal metastases should be considered in any decline in visual acuity in patients with thyroid cancer.

Complicated Persistent Peritonitis, Lindsey Roth, Ba, Kumar Sarkar, Md

The Medicine Forum

Introduction

Spontaneous bacterial peritonitis (SBP) is a common complication of end-stage liver disease. SBP can present with many symptoms such as abdominal pain, fever and altered mental status.1 The diagnosis of SBP is made when ascitic fluid from a paracentesis has an absolute neutrophil count (ANC) more than 250/uL, there is a positive ascitic fluid culture, and no secondary source of infection can be idenitifed.2 However, nearly 60% of patients with SBP have negative fluid cultures.3 These patients can still potentially have SBP and should be treated as such since in-hospital mortality ranges from 20-40%.1,4 Conventional treatment for SBP includes …

Sealing The Diagnosis Of Celiac Disease In Pregnancy, Ritu Nahar, Md, Avani Aman, Md

The Medicine Forum

Introduction

Celiac disease (CD) is an immune mediated condition that results from a reaction to dietary gluten and primarily affects the small intestine. Genetically predisposed individuals develop a chronic inflammatory state of the small intestine which leads to malabsorption. The disease is mediated by HLA DQ2 or DQ8 haplotypes, which bind the gliadin peptides of gluten, present the peptides to CD4+ T lymphocytes and trigger cytokine and B lymphocyte responses.1

The prevalence of CD in the United States is approximately 1% and can reach up to 4-5% in at-risk groups.2 Serologic study of asymptomatic elderly patients in the United Kingdom …

Thyrotoxic Periodic Paralysis – A Case Report Of A Rare Cause Of Paralysis In A 39-Year-Old Asian Man, R. Benson Jones, Md, James Uricheck, Md

The Medicine Forum

Introduction

Uncontrolled hyper thyroidism has a myriad of presentations. Classically, symptoms include weight loss, tremor, palpitations, shortness of breath, diarrhea, anxiety, and heat intolerance. A rare manifestation of hyperthyroidism is thyrotoxic periodic paralysis (TPP). Periodic paralysis is a musculoskeletal channelopathy manifested by episodes of painless muscle weakness often precipitated by heavy exercise, fasting, or high carbohydrate meals. Although classically associated with painless weakness; cramping, myalgias, and stiffness can also occur prior to the episodes as prodromal symptoms. Neurologic examination during an attack typically demonstrates proximal more than distal muscle weakness, and the upper extremities are more commonly affected than the …

A Case Report Of Pseudohypoglycemia In A Patient With Leukocytosis, Michael Weintraub, Md, Deepika Nandiraju, Md, Monika Shirodkar, Md

The Medicine Forum

Introduction

Hypoglycemia is most convincingly documented by Whipple’s triad: low plasma glucose, symptoms of hypoglycemia and relief of symptoms after treatment.1 Pseudohypoglycemia is a condition where there is an artifactually low glucose concentration and an absence of hypoglycemic symptoms. We present a case of pseudohypoglycemia where leukocytosis played a role in lowering venous glucose.

A Case Of Left Ventricular Myocardial Calcification In A Patient With Severe Sepsis, Carly Sedlock, Md, Randi Zukas, Md, Hillary Landon, Md

The Medicine Forum

Introduction

Sepsis is an important source of morbidity and mortality among patients admitted to the Intensive Care Unit (ICU) and can cause critical damage to all organ systems. Regarding cardiac complications, sepsis can acutely result in cardiomyopathy characterized by ventricular dilatation and a depressed ejection fraction.1 Myocardial calcification is a more rare, delayed cardiac complication of severe sepsis that has been reported in literature.1-6 Herein we report a case of a patient with Acute Myeloid Leukemia (AML) admitted to the TJUH ICU requiring prolonged vasopressor support for severe sepsis whose clinical course was complicated by left ventricular myocardial calcification.

Fibrous Web In The Right Atrium: A Complication Of Fungal Endocarditis And Previous Lead Infections, Harry Wang, Md

The Medicine Forum

A 57-year-old woman with a past medical history of severe non-ischemic cardiomyopathy undergoing orthotopic heart transplant evaluation on milrinone, prior extraction of multiple pacemaker and implantable cardioverter defibrillator (ICD) leads due to Staphylococcus epidermidis endocarditis, and multiple central venous catheter infections presented with several days of worsening dyspnea on exertion, orthopnea and lower extremity edema, prompting admission for congestive heart failure exacerbation.

Table Of Contents: The Medicine Forum Volume 20, 2018-2019

The Medicine Forum

Clinical Images

Case Reports

• Cardiology
• Endocrinology
• Gastroenterology and Hepatology
• Hematology and Oncology
• Infectious Disease
• Pulmonary Medicine
• Rheumatology

Original Article

Editorial

Literature Review

Creative Writing

From The Editors, Colin Thomas, Md, Eitan Frankel, Md, Guy Katz, Md, Michael Weintraub, Md, Brianna Shinn, Md, Navdeep Sangha, Md, Rachel Redfield, Md, Mario Caldararo, Md

The Medicine Forum

We are delighted to present you with the 20th annual edition of The Medicine Forum. Here in the birthplace of our nation, we like to think of The Medicine Forum as being of the housestaff, by the housestaff and for the housestaff. Undeniably, this publication would not be possible without the countless hours dedicated by our residents, students, fellows and faculty.

From The Desk Of The Residency Program Director, Emily Stewart, Md

The Medicine Forum

It has been another wonderful year in the Jefferson Internal Medicine Residency Program. Our program continues to train the best and brightest residents in the country. This publication is just one example of the passion, dedication and creativity our residents continue to provide to the Jefferson Community. The residents are not just outstanding clinicians but excel in all aspects of medicine including: research, humanities and medical education.

Safe Care For Seizure Patients On An Epilepsy Monitoring Unit, Deborah Bachand, Lauri Wilson, Rachel Caiola, Lynne Keller, Megan Selvitelli, Mary Jo Farley, Jennifer O'Neill, Sara Shrock, Hannah Plummer, Sally Prokey, Amy Sparks, Stephen Tyzik, Suneela Nayak, Ruth Hanselman

Operations Transformation

Seizure patients admitted to an Epilepsy Monitoring Unit located within an academic tertiary medical center have a high potential to impact patient safety. As a result, a unit based team identified a need for a higher level of training for both their staff and float companions to ensure safe and standardized care for this group of patients.

The goal of this quality improvement project was to create an educational tool that would assist 100% of staff in better recognizing and responding to seizures. Baseline metrics and root cause analysis demonstrated a lack of consistent information being taught, a poorly identified …

June 2019, Randy Curry, Cindy Brooks

RURAL ROCKS

Rural Rocks, the Rural Health Network newsletter by the SWOSU College of Pharmacy

Patient And Student Experience On An Interprofessional Hotspotting Team, Steven Elsesser, Md, Elizabeth Feeney, Bsn, Katherine Petty, Spt, Kevin Shaloo, Spt, Nancy Tang, Pharmd

JCIPE Posters

The purpose of the Student Hotspotting initiative is to identify these individuals, understand their barriers and intervene by:

• Connecting them with community resources
• Improving coordination and communication between both providers and the patient
• Empowering these individuals to better manage their health

Our patient (DW) lives in a close-knit, 4-generation household that just welcomed their newest member: a black-and-white kitten

DW is a 61 year-old female who recently received orthotopic heart transplant. Her comorbidities include sleep apnea, GERD, OA, chronic pain syndrome, COPD and a history of a CVA

We identified 3 main barriers to address with DW

• Transportation difficulties
• Management …

Bridging The Gaps: Team 6 Hotspotting Experience, Sean O'Sullivan, Rebecca Schuck, Sean Tonnesen, Gabrielle Sallade, Emily Osisek, Avninder Ubhi

JCIPE Posters

Healthcare spending in the U.S. reached $3.5 trillion in 20171. Half of this spending was due to only 5% of patients. Hotspotting is the practice of identifying high-utilizing patients and providing them ancillary care. Supporting such patients with nutrition information, care coordination, clinician communication, health education, and treatment adherence coaching benefits the patients, clinicians, and healthcare system. The Jefferson Interprofessional Student Hotspotting Program places students of different educational programs into teams to identify high-utilizing patients and provide them individualized and holistic care. It is an intimate longitudinal clinical experience for students and an opportunity to improve the health of complex …

Interprofessional Student Hotspotting: Impact Of Federally Qualified Health Centers (Fqhc) On Complex Patients, Alexis Amendola, Pallavi Chary, Andrew Day, Graziella Holland, Michelle Murray, Jesse Simpson

JCIPE Posters

Individuals with complex health and social needs drive much of the total cost of care, accounting for nearly 50% of annual costs. Studies show that patients’ use of community health centers is associated with lower health care costs, less frequent use of emergency departments, and fewer preventable hospitalizations, compared to patients who do not use the health centers. Federally qualified health centers (FQHCs) provide patients with medical homes where they can build ongoing, personal relationships with treatment teams, resulting in continuous, comprehensive and integrated care.

Additionally, addressing these individuals' needs and decreasing costs requires interprofessional teams to engage with communities …

Interprofessional Student Hotspotting Learning Collaborative: A Student Initiative To Together Help Patients In Tangible And Intangible Ways, Kristin Brannon, Saskia Levy-Sheon, Michael Murphy, Megan Rankel, Caroline Christianson, Carly Alexander, Tejash Patel, Mariana Kuperman, Md, Leigh Ann Hewston, Pt, Dpt, Med, Ceeaa

JCIPE Posters

The Interprofessional Student Hotspotting Learning Collaborative brings together a team of students who work closely with individual patients with complex medical histories who are “super-utilizers” of health care resources.

Our goals:

• Provide a targeted, patient-centered approach to patient care
• Learn about our patient’s health from their perspective and develop a plan based on the patient’s goals and perceived needs
• Minimize misuse and miscommunication that had previously hindered the patient healthcare experience.
• Bring unique perspectives from each of our respective disciplines to improve upon inefficiencies in care
• Our team consisted of students from the colleges of Occupational Therapy, Physical Therapy, Nursing, …

Interprofessional Perspectives: Challenges & Lessons Learned From Participation In The Student Hotspotting Program, Alex Faus, Bs, Jennifer Newman, Ba, Stephanie Quist, Bm, John Ra, Bs, Madeline Runyen, Ba, Kelsie Wilhelm, Bsfs

JCIPE Posters

By participating in the Student Hotspotting Program, students learned that:

• Coordinating the care of a complex patient requires an interprofessional team
• Hotspotting interventions can often be complicated by uncontrollable circumstances
• Building trust is key to working with patients who may be hesitant to engage with the healthcare system
• Successful interprofessional healthcare teams are characterized by specific attributes
• As future healthcare practitioners, we can apply these lessons into our own interprofessional interactions to optimize our treatment plans for complex patients

An Overview And An Experience Of Hotspotting, Adam Myer, Allyson Psillos, Brianna Brown, Anne Bono, Stephen Kern, Phd, Otr/L, Faota, Jamie Smith, Michele Zawora, Md

JCIPE Posters

United States Healthcare Dilemma

In the United States, a large proportion of healthcare resources and costs are utilized by a small percentage of the population.

• Approximately 25% of the United States healthcare costs are incurred by 1 percent of the population, while 5% are of healthcare costs are incurred by 50% of the population. The small percentage of the individuals who consume large amounts of resources has led to the term “super-utilizers.”
• These patients usually have complex and hard-to-manage conditions, as well as socioeconomic barriers to care, which frequently lead to potentially avoidable emergency department and hospital admissions and complications. …

Student Hotspotting: A Novel Dynamic For Learners And Patients, Richard Jeffries, Lydia Glick, Katherine O'Rourke, Mi Bui, Jennifer Morelli, Katherine Cambareri, Florencia Campbell, Miranda Aragon, Tracey Vause-Earland

JCIPE Posters

About the Student Hotspotting Program:

A team of interdisciplinary students working with patients with complex medical and social needs

Identify "super-utilizers" of the healthcare system

• These patients frequently use the Emergency Department as primary source of medical care
• A "super-utilizer" of the ED is costly to the patient and system

Goals:

• Build relationships
• Identify needs and goals
• Provide support to navigate healthcare system and increase independence

Shortness Of Breath In A Swimming Athlete, A. Spinelli, A. Getzin

International Journal of Exercise Science: Conference Proceedings

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Unusual Headaches After A Concussion In A Basketball Player, H. Saleemi, A. Getzin

International Journal of Exercise Science: Conference Proceedings

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Foot And Ankle Injury - Soccer, R. Reese, M. Lavallee

International Journal of Exercise Science: Conference Proceedings

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