Medicine and Health Sciences Commons^™

Resident Reflection: A Missed Date, Timothy Kuchera, Md

The Medicine Forum

Resident Reflection: A Missed Date

The Opioid Epidemic – Addressing Provider Roles And Responsibilities, Anita Modi, Md, Debbie Chen, Md, Neha Bansal Etherington, Md, Brianna Shinn, Md, Colin Thomas, Md

The Medicine Forum

INTRODUCTION

This year marks the 19th volume of Jefferson’s annual publication spearheaded by Internal Medicine residents and supported by its fellows. Our Editorial Board includes Neha, Debbie, Anita, Brianna, and myself. Our mission is to further medical knowledge by sharing each other’s observations and studies both through our publication, which you can find online, as well as through annual discussion at Grand Rounds.

This year, we’ve chosen to focus on our roles as providers in the midst of the National Opioid Epidemic. The National Institute on Drug Abuse has reported that the number of opioid-related overdose deaths from both illegal …

White Paper: Improving Handoff Culture In Intensive Care Unit To Floor Handoffs, Grant Turner, Md, Kristin Lohr, Md, Andrew Brown, Md, Allison Greco, Md, Rebecca C. Jaffe, Md

The Medicine Forum

The frequency of handoffs between providers has increased since the 2011 Accreditation Council for Graduate Medical Education (ACGME) work hour restrictions, generating concerns over the quality of these handoffs and their impact on patient safety. At Thomas Jefferson University Hospital (TJUH), the 2016 Safety Culture Survey revealed that across all specialties, many residents felt that “things fall through the cracks” when transferring patients from one unit to another. The interdepartmental Housestaff Quality and Safety Leadership Council (HQSLC) at TJUH sought to improve handoffs at our institution and identified two areas of focus: (1) standardizing the language of handoffs with a …

Syncope Diagnosed By Inducible Sustained Ventricular Tachycardia, Amit Vira, Md

The Medicine Forum

INTRODUCTION

Syncope is a common complaint in the emergency department (ED), accounting for approximately 3% of all ED visits.1 Although most causes of syncope are benign and self-limited, others are associated with significant morbidity and mortality.

Sclerosing Mesenteritis: Clinical Presentation, Imaging Findings, And Treatment, Jennifer Nauheim, Bsc, Rose Onyeali, Md

The Medicine Forum

CASE PRESENTATION

A 67-year old male with a history of myocardial infarction status post percutaneous coronary intervention and stage IV bladder cancer status post radical cystoprostatectomy with ileal neobladder reconstruction and chemotherapy (cisplatin and gemcitabine) presented with progressive, severe epigastric and lower abdominal pain associated with nausea. The pain had intensified over the previous week and was associated with a recent fifteen pound weight loss in the setting of poor oral intake. He denied nausea or diarrhea. His physical exam was notable for abdominal tympany and tenderness. His labs were notable for mild hyperkalemia (potassium 5.0 mmol/L), normal white blood …

Adverse Effects Of Checkpoint Inhibitor Immunotherapy In Medical Oncology, Michael Brister, Md, Colin Thomas, Md

The Medicine Forum

No abstract provided.

Amyotrophic Lateral Sclerosis Presenting As Chronic Cough, Marjorie Friedman, Md

The Medicine Forum

INTRODUCTION

Amyotrophic Lateral Sclerosis (ALS) is a debilitating, uniformly fatal disease. While it most commonly presents with limb weakness, patients may also present with neurocognitive, respiratory, or bulbar symptoms. Despite its poor prognosis, an early diagnosis can save patients from unnecessary and expensive testing, lead to interventions that improve quality of life, and give patients and family time for advanced planning.1 This case highlights an unusual presentation of ALS.

KEY POINTS

• Our patient presented with chronic cough and restrictive lung disease and after extensive workup was diagnosed with ALS.
• Bulbar and respiratory symptoms are uncommon initial presentations of ALS.
• Early …

A Case Of Cryptogenic Organizing Pneumonia Managed Without A Diagnostic Biopsy, Kamal Amer, Md, Mckensie Walker, Bsc, Vincent Yeung, Md

The Medicine Forum

INTRODUCTION

Organizing pneumonia (OP) is a type of diffuse interstitial lung disease characterized by a specific histopathologic pattern of response to lung injury. When the etiology of the injury is unknown and in the absence of inflammatory or connective tissue disease, this entity is termed cryptogenic organizing pneumonia (COP) or primary organizing pneumonia (POP). Disease states in which the etiology of underlying injury is known is termed secondary organizing pneumonia (SOP). Causes of SOP include drug toxicity, chronic heart or renal failure, rheumatic disease, collagen vascular disease, infection, immunodeficiency, autoimmune disease, and interstitial lung disease.

OP is characterized by the …

Fifty Shades Of Sarcoidosis: A Case Report Of Löfgren Syndrome, Arpana Parachuri, Md

The Medicine Forum

INTRODUCTION

Sarcoidosis is a multi-organ disorder that is characterized by the presence of noncaseating granulomas in involved organs. It commonly affects young and middle-aged individuals of all races, but is 3-4 times more common in African Americans and typically presents earlier with more severe symptoms.1 The lungs are affected in 90% of patients and pulmonary disease accounts for the majority of the morbidity and mortality associated with this disease. However, approximately 30% of patients can present with extrapulmonary findings and can have involvement of other organs such as the skin and eyes.1 The various presentations of sarcoidosis can make it …

Use Of Venovenous Extracorporeal Membranous Oxygenation Following Iatrogenic Tracheal Rupture, Rajiv Kabadi, Md

The Medicine Forum

INTRODUCTION

Iatrogenic tracheal rupture is a rare complication of endotracheal intubation and has a high risk of morbidity and mortality. Risk factors include female gender, short stature (height less than 160-cm), difficult airway anatomy, underlying connective tissue disorder, chronic obstructive pulmonary disease, use of a rigid stylet, inadequate intubation tube size, cuff over-inflation, emergent intubation and intubation performed by non-anesthesiologists. 1 Early recognition is important and diagnosis requires bronchoscopic confirmation.2,3 We describe a case where emergent venovenous extra-corporeal membrane oxygenation (VV-ECMO) was utilized in the management of tracheal rupture.

KEY POINTS

• Tracheal rupture is an uncommon but severe complication of …

A Case Of Eosinophilic Granulomatosis With Polyangiitis, Anita Modi, Md, Lily Ackermann, Md

The Medicine Forum

INTRODUCTION

Eosinophilic granulomatosis with polyangiitis (eGPA) is a small- and medium-sized-vessel vasculitis with multi-organ manifestations. Given the rarity of eGPA, patients are often misdiagnosed for decades and may initially present with life-threatening manifestations of late-stage disease. Therefore, it is important to raise awareness of this condition and its associated signs and symptoms. This case report serves to describe a classic presentation of a patient with eGPA, as well as to delineate the diagnostic workup, acute management, and early outpatient follow-up required.

KEY POINTS

Given the life-threatening complications of this rare condition, it is important to raise awareness about eGPA. This …

Tenofovir Cons The Kidneys: A Case Of Acquired Fanconi, Ritu Nahar, Md, Emma Lundsmith, Md

The Medicine Forum

INTRODUCTION

Proximal (Type 2) renal tubular acidosis (RTA) is a relatively rare diagnosis, especially in adults. It is characterized by a reduction in proximal bicarbonate reabsorption resulting in urinary bicarbonate wasting. Proximal RTA can also be associated with additional defects in proximal tubular function including impaired reabsorption of phosphate, glucose, uric acid, and amino acids. Generalized proximal tubular dysfunction is termed Fanconi syndrome. While there are primary causes of Fanconi syndrome including sporadic and familial sources, this syndrome can also be acquired. Two major culprits include monoclonal gammopathies resulting in increased excretion of immunoglobulin light chains and drug-induced nephrotoxicity to …

Abdomen Actin’ Up: A Unique Presentation Of Disseminated Abdominal Actinomycosis, Arpana Parachuri, Md, Brianna Shinn, Md, Rino Sato, Md

The Medicine Forum

INTRODUCTION

Abdominal actinomycosis is a chronic, indolent disease characterized by nonspecific symptoms such as fatigue, weight loss, fever, and abdominal pain. Actinomyces is a genus of fastidious, gram-positive, non-acid-fast, branching filamentous bacilli characterized by sulfur granules that is normally found in oral flora and inhabits the gastrointestinal (GI) tract. Actinomyces infections are relatively rare, however when present, they have the ability to invade multiple organs and disseminate throughout multiple body cavities. Factors that increase the risk of developing actinomycosis include poor oral hygiene, alcoholism, and preexisting dental disease. Intrauterine devices (IUDs) also increase the risk of developing pelvic actinomycosis. Over …

Resistant Raoultella Ornithinolytica Bacteremia In A Patient With New Acute Myeloid Leukemia, Mario Caldararo, Md

The Medicine Forum

INTRODUCTION

Members of the Raoultella genus were formerly considered to be Klebsiella species until they were differentiated based on phylogenetic Deoxyribonucleic acid (DNA) analysis.1 Since then, Raoultella ornithinolytica has been sparsely implicated in clinically-apparent disease, though more case reports are appearing as of late. Here we report the first documented instance of R. ornithinolytica bacteremia in a patient with new acute myeloid leukemia (AML).

A Case Of Secondary Hemophagocytic Lymphohistiocytosis In An Adult Patient Treated With Concurrent Dexamethasone And Interleukin-1 Receptor Blockade, Vikas Sunder, Md

The Medicine Forum

INTRODUCTION

Hemophagocytic Lymphohistiocytosis (HLH) is a rare, life-threatening syndrome of overwhelming inflammation caused by activation and proliferation of T-lymphocytes and hemophagocytic macrophages. This uncontrolled proliferation of macrophages creates a cytokine storm with resultant tissue damage. HLH is associated with clinical and laboratory findings which include fever, cytopenias, hepatic dysfunction, splenomegaly, and marked hyperferritinemia.1-3 There exists limited epidemiologic data on adult (age ≥ 18 years) cases of HLH, and its incidence is uncertain. HLH can be due to inherited mutations causing immune system dysregulation or secondary to underlying malignancy, infection, or rheumatologic condition. Macrophage activation syndrome (MAS) refers to HLH that …

Death By Delirium: A 71-Year-Old Male With Poor Post-Operative Recovery, William Bradford, Md

The Medicine Forum

INTRODUCTION

Delirium is an acute decline in attention and cognition not better explained by another medical condition.1 It is multifactorial in origin, with risk factors including advanced age, male sex, baseline decreased cognitive status, sensory impairment, poor baseline functional status, polypharmacy, and multiple comorbid conditions. Acute precipitants for delirium include administration of psychoactive medications (particularly benzodiazepines, narcotics, anticholinergic medications, and general anesthesia), sleep deprivation, major surgery, and new illness or worsening of current illness.Delirium accounts for some 49% of all hospital days in older patients, increases rates of mortality and morbidity, and is associated with lasting cognitive impairment after discharge, …

When Dequervain’S Depigments: A Case Of Iatrogenic Hypopigmentation, Tatiana Bekker, Md

The Medicine Forum

INTRODUCTION

Localized joint and soft tissue corticosteroid injections are being increasingly utilized to decrease inflammation, improve pain, and recover mobility. Adverse effects from injections are rare, with a 1% incidence of skin depigmentation.

Maggots—Friend Or Foe? Treating Myiasis In A Patient With Chronic Wounds, James Harrigan, Pharmd, Anita Modi, Md, Gretchen Diemer, Md

The Medicine Forum

INTRODUCTION

Myiasis, or the infestation of living vertebrates with dipterous (two-winged fly) larvae, can take many forms. Depending on their species, maggots will feed on living or dead tissue, liquid body substances, or even ingested food.1 The anatomical classification system of such larvae is based on the host location of infestation: sanguinivorous, cavitary, or cutaneous, including furuncular, migratory, or wound.1 While pathologic myiasis can result in significant morbidity in both humans and livestock, therapeutic myiasis has played an important role in wound debridement for centuries. This article will explore the varying forms of pathologic cutaneous myiasis and the evolving role …

Liver Abscess Turned Metastatic Infection In An Otherwise Healthy Patient: A Case Report, Samik Shah, Md, Ritu Nahar, Md, Neha Bansal Etherington, Md

The Medicine Forum

INTRODUCTION

The most common type of visceral abscesses are liver abscesses, which have a mortality rate of at least 2.5 percent.1,2 Most liver abscesses are polymicrobial, containing both facultative and anaerobic enteric pathogens, and develop secondary to another infection such as peritonitis and cholangitis, or from hematogenous spread.2-4 Liver abscesses are sometimes associated with systemic diseases such as colorectal cancer and diabetes mellitus.5,6 Rarely, as in our case presentation, primary liver abscesses occur spontaneously in patients with no identifiable precipitating or predisposing conditions.

Octreotide-Induced Hypoglycemia In A Cirrhotic Patient, Debbie Chen, Md

The Medicine Forum

INTRODUCTION

Hepatorenal syndrome (HRS) is characterized by functional renal impairment in patients with end-stage liver cirrhosis and no parenchymal kidney disease. It is due to splanchnic vasodilation, which results in renal vasoconstriction with consequent reduction in renal plasma flow and glomerular filtration rate.1 In the United States, treatment is with a combination of octreotide, midodrine, and human albumin to increase the effective blood volume and subsequently improve renal function.2 While octreotide, a long-acting somatostatin analog, is used to induce splanchnic vasoconstriction in this setting, it also affects the secretion of insulin and glucagon.

Case Report: Coexistence Of Papillary Thyroid Cancer And Thyroid Lymphoma, Christine Mathai, Md, Edward Ruby, Md

The Medicine Forum

We describe a case of a 75-year-old female found to have concurrent papillary thyroid cancer and diffuse large B cell lymphoma of the thyroid.

Cat Scratching Your Valve: An Elusive Case Of Bartonella Endocarditis, Ritu Nahar, Md, Evan Caruso, Md

The Medicine Forum

INTRODUCTION

Bartonella Henselae is an uncommon, but significant cause of “culture-negative” endocarditis. While six Bartonella species have reportedly caused infective endocarditis (IE) in humans, the vast majority of cases are secondary to either B. quintana or B. henselae. The epidemiologic features of patients predisposed to Bartonella endocarditis are varied. Alcoholism, body lice infestation, and homelessness have been associated with B. quintana endocarditis, while B. henselae endocarditis has been linked to prior valvular disease and cat exposure.1-4 Patients with Bartonella endocarditis have clinical manifestations similar to those seen with traditional forms of subacute bacterial endocarditis. However, the rarity of the disease …

Acute Aortic And Mitral Valve Insufficiency Precipitated By Infective Endocarditis, Raj Patel, Md, Tatiana Bekker, Md, Daniel Kramer, Md

The Medicine Forum

INTRODUCTION

Acute severe valvular regurgitation is a medical emergency requiring prompt recognition and diagnosis. Both mitral and aortic valve rupture, if left untreated, inevitably lead to advanced heart failure, cardiovascular collapse, and death. As such, rapid diagnosis is critical and surgical valve repair or replacement is a life-saving intervention. We present a case of a patient with both mitral valve and aortic valve bacterial endocarditis who developed acute valvular rupture, regurgitation, and cardiovascular collapse.

Roth Spots In Bacterial Endocarditis, Michael Weintraub, Md

The Medicine Forum

CASE PRESENTATION

A 30-year-old female with a history of intravenous drug use presented to the hospital with left wrist pain. Physical exam revealed a left volar ulnar wrist abscess with purulent drainage, a holosystolic murmur heard best at the apex radiating to the axilla and Janeway lesions on the right hand and bilateral feet. A transthoracic echocardiogram revealed a 20 mm mobile vegetation on the mitral valve along with valve perforation and severe regurgitation consistent with bacterial endocarditis. On eye exam, Roth spots (Figure 1) were noted bilaterally. Roth spots are present in less than 2% of all infective endocarditis …

Massive Pneumoperitoneum, Harry Wang, Md

The Medicine Forum

CASE PRESENTATION

A 72-year-old man with a past medical history of pancreatic adenocarcinoma status post biliary and duodenal stent placement presented to the emergency department for one week of cramping abdominal pain in the setting of a surveillance abdominal/pelvis computed tomography (CT) scan done two days prior to admission that showed massive pneumoperitoneum (Figure 1). The patient felt bloated but otherwise had no complaints on presentation. His physical exam was significant for marked abdominal distension with mild diffuse tenderness on palpation, normal bowel sounds, and no peritoneal findings of guarding or rebound. Given concern for perforated viscus causing pneumoperitoneum, he …

Clinical Image: Halo Sign, Brandon Menachem, Md, Alan Gandler, Md

The Medicine Forum

CASE PRESENTATION

A 68-year-old man with no significant past medical history was transferred to our hospital for evaluation of newly diagnosed acute leukemia. His bone marrow biopsy showed acute undifferentiated leukemia. He was initiated on standard induction chemotherapy with cytarabine and idarubicin. His hospital course was complicated by neutropenic fever secondary to Fusobacterium bacteremia. He was started on antibiotic therapy with intravenous cefepime and oral metronidazole. Intravenous vancomycin was added in the setting of recurrent intermittent fevers. On hospital day 20, he developed minimal hemoptysis, pleuritic chest pain, and recurrent fevers. A CT scan of the chest showed a right …

Table Of Contents: The Medicine Forum Volume 19, 2017-2018

The Medicine Forum

Table of Contents: The Medicine Forum Volume 19, 2017-2018

From The Editors, Neha Bansal Etherington, Md, Anita Modi, Md, Debbie Chen, Md, Brianna Shinn, Md, Colin Thomas, Md

The Medicine Forum

We are delighted to present you with the 19th 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, Facp

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.

The Medicine Forum: Volume 19

The Medicine Forum

The Medicine Forum: Volume 19