Medicine and Health Sciences Commons^™

Resident Reflection: Mrs. C, Rachel Nash, Md

The Medicine Forum

“Make friends with those critical care nurses in the ICU,” my friend from high school and general floor nurse whispered in my ear before the start of my MICU rotation. “They can really save your butt.” This was one of my many goals I set out to achieve during my first month in the intensive care unit as an intern. I wanted to become more comfortable managing very sick patients, get some procedures under my belt, and mostly “survive” the emotionally and physically taxing weeks that were sure to come.

The sign out I received on my 3-patient load suddenly …

Grand Rounds Panel Discussion: Provider Payment Reform: Past, Present, And Future, Neha Bansal Etherington, Md, Shuwei Wang, Md, Debbie Chen, Md, Anita Modi, Md, Jad Al Danaf, Md

The Medicine Forum

Panelists:

Gregory C. Kane, MD, FACP The Jane and Leonard Korman, Professor and Chairman, Department of Medicine

David B. Nash, MD, MBA The Dr Raymond C and Doris N Grandon Professor, and Dean of the Jefferson College of Population Health

Rhea E. Powell, MD, MPH Assistant Professor of Medicine

Rachel B. Sorokin, MD, FACP Associate Professor of Medicine and Medical Director of Safety and Quality

Lawrence D. Ward, MD, MPH Associate Professor of Medicine and Vice Chairman for Clinical Practice and Quality

Introduction:

The impetus for provider payment reform in healthcare grew out of the recognition that growth in healthcare …

Fatal Rituximab-Induced Nonspecific Interstitial Pneumonia: Case Report And Review Of The Literature, Rino Sato, Md, Jeremy Molligan, Md, Sameh Gaballa, Md

The Medicine Forum

Introduction:

Rituximab is a chimeric anti-CD20 monoclonal antibody that is used to treat some hematological malignancies such as B-cell lymphomas, and various autoimmune diseases including immune thrombocytopenic purpura, systemic lupus erythematous, rheumatoid arthritis, and autoimmune hemolytic anemia. The most common side effects include fever, chills, and rigors. Respiratory complications such as cough, bronchospasm, sinusitis, and rhinitis have also been reported in 30% of patients in clinical trials.1 Rituximab-induced lung injury is a very rare but potentially fatal complication. We report a case of fatal single agent rituximab-induced nonspecific interstitial pneumonia to increase awareness about this serious side effect and review …

Brugada Syndrome: Diagnosis And Management, Amit Vira, Md, Ehsanur Rahman, Md

The Medicine Forum

Introduction:

The vast majority of cases of sudden cardiac arrest (SCA) are caused by ventricular tachyarrhythmias (VT), with most cases associated with structural heart disease. SCA in a structurally normal heart is an uncommon occurrence, most often occurring in the third decade of life and accounting for 5-15% of total SCA cases1-2. Common causes include Brugada syndrome, congenital long QT syndrome, catecholaminergic polymorphic ventricular tachycardia, arrhythmogenic right ventricular cardiomyopathy, and idiopathic ventricular tachycardia1-3. The majority of these patients with a structurally normal heart are undiagnosed until presenting with sudden cardiac death. It is believed that cardiac arrest is the initial …

Acute Mitral Regurgitation Following Myocardial Infarction, Drew Johnson, Md, Colin Craft, Md

The Medicine Forum

Case Report

A 66-year-old Caucasian female with no past medical history presented with four hours of dyspnea. The patient stated that two days prior to presentation she developed severe, crushing substernal chest pain that awoke her from sleep. The pain was non-radiating, lasted 30 minutes, and was associated with diaphoresis, shortness of breath, nausea, and lightheadedness. Her medical history was unremarkable except for a 50-pack-year smoking history.

On presentation, the patient was tachycardic to 110 beats per minute, and tachypnic at 22 breaths per minute. Cardiac auscultation revealed a 4/6 holosystolic murmur radiating to the axilla that was audible throughout …

Subcutaneous Emphysema: A Case Report Of An Atypical Manifestation Of Pcp In An Hiv Patient, Drew Kotler, Md, Drew Johnson, Md

The Medicine Forum

Introduction:

Pneumocystis pneumonia (PCP), caused by Pneumocystis jirovecii (P. jirovecii), is a fungal opportunistic infection seen in poorly controlled Human Immunodeficiency Virus (HIV) and is considered an Acquired Immune Deficiency Syndrome (AIDS) defining illness. It is also found in other immunocompromised states, such as hyper IgM syndrome and in patients on immunosuppressive therapy. In the HIV+ population, a CD4+ T-lymphocyte count (CD4 count) less than 200 cells/mm3 is associated with an increased risk of PCP. Combination antiretroviral therapy in conjunction with PCP prophylaxis has significantly decreased the prevalence of this opportunistic infection. In the United States HIV-infected population, PCP prevalence …

A Rare Infectious Cause Of Optic Neuritis, Shuwei Wang, Md, Drew Kotler, Md, Mitchell Sternlieb, Md

The Medicine Forum

Introduction:

Optic neuritis (ON) is the most common type of inflammatory, demyelinating disorder of the optic nerve, most often caused by multiple sclerosis (MS). However, alternative diagnoses should be considered and investigated thoroughly in the setting of other systemic symptoms. Optic neuritis is a rare manifestation of Lyme disease that typically improves with antibiotics.

Case Presentation:

A 50 year-old woman with history of breast cancer treated with mastectomy and chemotherapy in remission for ten years presented with a right-sided headache and right eye vision changes.

She was feeling well until three weeks prior to hospital admission in June when she …

Case Report Of Mycobacterium Mageritense Soft Tissue Abscess In Immune Compromised Patient With Inconclusive Gram Stain And Wound Culture, Noha Ghusson, Md

The Medicine Forum

Introduction:

Rapidly growing atypical mycobacteria are non-motile, aerobic bacteria that are ubiquitous in both natural and nosocomial environments1. While the prevalence of these organisms is not well described2, they have become an increasingly common source of localized skin and soft tissue infections, particularly in immunocompromised patients. Despite its ever-growing presence, this bacterium is difficult to identify due to late presentation of symptoms and negative results from conventional bacterial cultures and gram stains3. Mycobacterium mageritense, a non-pigmented rapidly growing atypical mycobacteria4, is an example of a newly isolated source of cutaneous infections that is difficult to identify in laboratories. Repeat cultures …

Peripartum Cardiomyopathy: A Cause Of Heart Failure In Young Women, Frederick B. Peng, Bs, Ryan J. Hidalgo, Md

The Medicine Forum

Introduction:

Peripartum cardiomyopathy (PPCM), also known as postpartum cardiomyopathy, is an infrequent cause of systolic heart failure that can affect women in the last month of pregnancy and up to five months after delivery. While PPCM is a type of dilated cardiomyopathy, the etiology of this condition remains largely unknown.1 Given the infrequency with which PPCM is encountered and the potential for this condition to be fatal, proper diagnosis and management is critical for reducing maternal and fetal complications, as well as assessing the safety of future pregnancies.

Case Presentation:

A 33-year-old gravida 3, para 1, abortus 1 (G3P1011) at …

An Expanding Heart: A Case For A Left Ventricular Rupture, Stephen Huelskamp, Md, Jessica Dahmus, Md

The Medicine Forum

Introduction:

A ventricular aneurysm was once a common complication of a myocardial infarction (MI), seen in up to 35 percent of coronary occlusion with transmural tissue damage.1 The advent of percutaneous coronary intervention (PCI) and thrombolytic therapy, which produced effective arterial patency, had a direct correlation with the reduction in the number of myocardial infarctions complicated by aneurysm, with the current incidence at 15 percent.2 Aneurysmal formation and rupture is a life-threatening complication of an MI and clinicians should be aware of its signs and management. We present a case of ST elevation MI (STEMI) complicated by left ventricular aneurysmal …

Tumor Lysis Syndrome With Recurrence In A Patient With Multiple Myeloma Following Bortezomib Therapy-A Case Report, Kemarut Laothamatas, Md, Indira Laothamatas, Ba, Bilal Asif, Md

The Medicine Forum

Introduction:

Tumor lysis syndrome (TLS) is a life-threatening complication most commonly observed in highly proliferative hematologic malignancies. The rapid release of intracellular contents causes hyperkalemia, hyperuricemia, hyperphosphatemia, and secondary hypocalcemia. The constellation of metabolic abnormalities can manifest clinically as renal insufficiency, cardiac arrhythmias, seizures, and death due to multi-organ failure. Traditionally, TLS is rarely observed in relatively indolent malignancies such as multiple myeloma. However, its frequency may be increasing with the advent of more effective and targeted therapies such as bortezomib. We herein report a 62-year-old man with IgA kappa light chain multiple myeloma who developed two episodes of TLS …

A Case Report Of Gemcitabine-Induced Steatohepatitis Associated With Adjuvant Monotherapy For Pancreatic Adenocarcinoma, Maria Vershvovsky, Md, Dina Halegoua-De Marzio, Md

The Medicine Forum

Introduction:

Drug induced liver injury [DILI] is the most common cause of fulminant liver failure in the Western hemisphere. There are databases logging the myriad of herbs, supplements and medications that can cause DILI. Gemcitabine, a cytotoxic chemotherapy used most commonly in lung and pancreaticobiliary malignancy, has been well described as causing cholestatic liver injury. There are several case reports remarking on fatal hepatic failure with gemcitabine. This case describes steatohepatitis, a pattern of liver injury not previously described with gemcitabine.

Case Presentation:

This case involves a 51-year-old healthy Caucasian female who presented to her primary care physician with jaundice …

Case Report: Paroxysmal Nocturnal Hemoglobinuria, Harsh Doshi, Ms, Neha Bansal Etherington, Md

The Medicine Forum

Introduction:

Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired, life-threatening hematopoietic stem cell disorder characterized by the triad of hemolytic anemia, thrombosis, and impaired bone marrow function. PNH arises due to an acquired mutation in the synthesis of the glycosylphosphatidylinositol (GPI) anchor protein, which leads to a deficiency of complement regulatory proteins and unregulated complement-mediated hemolysis.1 With a reported incidence of 1 to 10 cases per million and a 3-5% risk of developing leukemia, new therapeutic advances have emerged to decrease the 10-year mortality associated with PNH.2,3 Here, we discuss the presentation of a 59-year-old male with PNH, strategies to diagnose …

Case Report: Cytarabine-Induced Pericarditis And Pericardial Effusion, Rino Sato, Md, Robert Park, Md

The Medicine Forum

Introduction:

Cytarabine (cytosine arabinoside, Ara-C) is an antimetabolite analogue of cytidine that is used as a chemotherapeutic agent for the treatment of acute myelogenous leukemia and lymphocytic leukemias1 . The most common side effects of this therapy include myelosuppression, pancytopenia, hepatotoxicity, gastrointestinal ulceration with bleeding, and pulmonary infiltrates2. Cardio-pulmonary complications of cytarabine therapy are uncommon, but include supraventricular and ventricular arrhythmias, sinus bradycardia, and recurrent heart failure2, 3. Occasionally, patients may develop pericarditis leading to pericardial tamponade, which can be fatal. We report a case of cytarabine-induced pericarditis and pericardial effusion to increase awareness about this serious side effect of …

Neurosarcoidosis: Granulomatous Disease Presenting With Confusion And Gait Disturbance, Jasmine Mitchell, Ms, Divya Chalikonda, Md, Drew Kotler, Md

The Medicine Forum

Introduction:

Sarcoidosis is a multisystem disorder characterized by noncaseating granulomas that frequently presents with pulmonary infiltrates, hilar lymphadenopathy, and ocular and skin lesions. Sarcoidosis affects about 20 per 100,000 individuals in the US with a higher prevalence among African Americans than in Caucasians.1 The average age of presentation ranges from 33 to 41 years.1 Less than 10% of people with sarcoidosis have CNS involvement, with cranial neuropathy, aseptic meningitis, hydrocephalus, seizures, psychiatric symptoms, and cerebral lesions with endocrine manifestations included among the possible manifestations.2 This case report describes a woman with neurosarcoidosis presenting with confusion and gait disturbances.

Case Presentation: …

A Case Of Amanita Phalloides Poisoning That Avoided Liver Transplantation, Tomoyuki Hongo, Md, Matthew Zheng, Md, Mark Malamood, Md, Steven K. Herrine, Md

The Medicine Forum

We describe a 49 year old male admitted with acute liver failure from likely Amanita phalloides poisoning, treated with NIH clinical trial protocol.

Case Presentation:

The patient is a 49 year old male with a history of chronic untreated hepatitis B and intraductal papillary mucinous neoplasm of the pancreas who initially presented to an outside hospital (OSH) with intractable nausea and non-bloody, non-bilious vomiting that began twelve hours after eating seven gray-white mushrooms from his backyard.

On initial presentation to the OSH, his hepatic function panel and coagulation markers were within normal limits. He was treated symptomatically with intravenous (IV) …

Localization Of An Insulinoma By Endoscopic Ultrasound: A Case Report And Review Of Diagnostic Modalities, Kristen Jackson, Md, Joseph Yoo, Md, Bolin Niu, Md

The Medicine Forum

Insulinomas are a type of pancreatic neuroendocrine tumor (pNET) that arises from pancreatic endocrine tissue. They are rare, with an estimated incidence of 4 cases per 1 million person-years7. While typically larger pNETs are detectable using conventional imaging studies such as transabdominal ultrasound, CT, or MRI, insulinomas are frequently missed by conventional imaging due to their relatively small size. We present the case of a 66-year-old African American male with an insulinoma undetected by contrast-enhanced MRI, that was ultimately localized and diagnosed via endoscopic ultrasound (EUS) with fine needle aspiration (FNA).

Case Presentation:

A 66-year-old African American male with past …

Case Report: Thyrotoxic Pediodic Paralysis, Jesse Edwards, Md

The Medicine Forum

Introduction:

Thyrotoxic Periodic Paralysis (TPP) presents as a triad of acute attacks of muscle weakness, hypokalemia, and thyrotoxicosis. TPP was first described in East Asian countries, specifically Japan and China, where it was found to occur at an overall incidence of 2% and preferentially affected males.1,2 TPP also develops in other ethnicities, however, and given the growing ethnic heterogeneity of global society, it is becoming increasingly important for all physicians to be familiar with the diagnosis and management of TPP. The following case represents a typical presentation of TPP and serves as a valuable resource for informing our differential diagnoses …

Clinical Images: Sigmoid Volvulus, Divya Chalikonda, Md, Brian Lutman, Do, Alan Gandler, Md

The Medicine Forum

Case Presentation:

A 72-year-old male with a history of Parkinson's disease, Type 2 diabetes, hypertension, hyperlipidemia, and cerebral vascular accident presented to the emergency room for 10 minutes of unresponsiveness at his nursing home. A workup for the unresponsiveness was unrevealing. His hospital course was complicated by constipation, a condition that resulted in multiple hospitalizations in the prior 6 months. Abdominal exam was notable for mild distension, and an initial x-ray demonstrated an ileus. The severity of his distention acutely worsened two days after it was initially noted, and was associated with borborygmi and high-pitched bowel sounds. A repeat x-ray …

Clinical Images: Physical Diagnosis: When Blue Is A Clue, Matthew A. Murphy, Md

The Medicine Forum

Figure 1:

The classic blue sclera of a patient with type 1 osteogenesis imperfecta. Due to a defect in type 1 collagen, the overlying sclera is abnormally thin, resulting in increased visibility of the underlying choroidal veins and the blue color of the eyes. This patient also had a history of more than forty bone fractures throughout his life.

Table Of Contents: The Medicine Forum Volume 18, 2016-2017

The Medicine Forum

Table of Contents: The Medicine Forum Volume 18, 2016-2017

From The Editors, Neha Bansal Etherington, Md, Shuwei Wang, Md, Anita Modi, Md, Debbie Chen, Md, Jad Al Danaf, Md

The Medicine Forum

Dear Students, Residents, Faculty, and Friends of the Forum,

We are delighted to present you with the 18th annual edition of The Medicine Forum. Each year, we continue to be humbled by the dedication and passion of our students, mentors and colleagues and thankful for the opportunity to work with and among them.

At Jefferson, we are privileged to treat a diverse and complex panel of patients in the heart of Philadelphia, making this institution and this city a wonderful place to learn medicine. The backbone of The Medicine Forum has always been a place for Jefferson students, residents, and …

From The Desk Of The Residency 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. During the three years we are fortunate to have them at our program. It is my distinct pleasure to watch them grow into confident, dedicated, compassionate clinicians. The residents are not just outstanding clinicians but excel in all aspects of medicine including research, humanities and medical education.

From The Editors, Anusha Govind, Md, Loheetha Ragupathi, Md, Jad Al Danaf, Md, Mph, Shuwei Wang, Md

The Medicine Forum

Dear Students, Residents, Faculty, and Friends of the Forum,

We are excited to present you with the 17th annual edition of The Medicine Forum. This work reflects the talent, passion, creativity, and scientific inquisitiveness of Jefferson medical students, residents, fellows and faculty. It also celebrates the diverse patients who serve as the centerpiece for each story.

Unique to this issue is the initiation of Grand Rounds Discussions focusing on controversial medical topics with inputs from an array of experts. This year we discussed perioperative management of anticoagulation and antiplatelet agents, and we had exciting viewpoints from experienced cardiologists, a hematologist, …

A Difficult Conversation, Shuwei Wang, Md

The Medicine Forum

I put on my isolation gown, knocked on his hospital room door, and entered to initiate the family meeting. I had been dreading this meeting all morning. It is never easy telling the loved ones of a thirty-seven year old that his disease is terminal, and he is actively dying.

I greeted Mr. M, his girlfriend and sister with the help of a Spanish translator. He smiled and had a twinkle in his jaundiced eyes. He was debilitated, bed bound with anasarca, his right thigh tightly bound by multiple blood stained pressure dressings. "Hola", I greeted them with the little …

A Tribute To Our Nurses, Anusha Govind, Md

The Medicine Forum

I turned faint and weary as the page came through "Your patients heart rate is one hundred eighty" My legs shook as I ran up the stairs Thoughts racing a mile a minute, hoping someone more knowledgeable might be there first As I turned a corner, color draining from my face Then I spot my savior, the nurse, holding a syringe filled with the medication I knew now my patient and I were in good hands.

Grand Rounds Panel Discussion: Blood Thinners Peri-Operatively: What To Do?, Jad Al Danaf, Md, Anusha Govind, Md, Loheetha Ragupathi, Md, Shuwei Wang, Md

The Medicine Forum

PANELISTS

Mathew DeCaro, MD: Associate Professor of Cardiology, Director of the Coronary Cardiac Unit, Cardiology fellowship program director

John Doherty, MD: Professor of Cardiology

Gregary Markefka, MD: Associate Professor of Cardiology, Associate Director of the Coronary Cardiac Unit, Cardiology fellowship assistant program director

Geno Merli, MD: Professor of Vascular Medicine, Co-director of Jefferson Vascular Center

Srikanth Nagalla, MD, MS: Associate Professor of Medicine, Director, Clinical Hematology

Eric Schwenk, MD: Assistant Professor of Anesthesiology, Director of orthopedic anesthesia

Barry Ziring, MD: Clinical Associate Professor of Internal Medicine / Primary Care, Director of the division …

The Financial Dialogue In The Development Of Medical Treatment Plans, Christopher D. Busack, Ms3, Bethany Fox, Ms3

The Medicine Forum

As patients face increasingly high out-of-pocket costs and difficulties navigating the healthcare system, failing to discuss available treatment options in financial terms can lead to grave consequences for patients. Medical bills are responsible for the majority of bankruptcies in the United States. Given the severe financial implications of medical bills, it is imperative that patients become more involved in discussions of their treatment plans and become aware of the costs of their decisions up front. Counseling about costs ensures that physicians avoid placing a debilitating financial burden on patients and maintain adherence to the ethical principle of non-maleficence. Various studies …

Pemphigoid Gestationis: A Rare Dermatosis Of Pregnancy, Victoria Tran, Ms3, Meghan Belamorich, Md

The Medicine Forum

INTRODUCTION

Pemphigoid gestationis is a rare dermatosis of pregnancy that often goes unrecognized or misdiagnosed. It can lead to adverse fetal outcomes including preterm delivery, low fetal birth weight, and even neonatal pemphigoid gestationis1. As such, proper diagnosis and management is critical in reducing fetal risk.

Identification And Management Of Cobalt Toxicity: A Case Report Of Rapidly Progressing Toxicity After Hip Arthroplasty Revision, Neena Mohan, Md, Eric Kasprowicz, Md

The Medicine Forum

INTRODUCTION

Patients undergoing total hip arthroplasty represent a growing portion of the population. More than 330,000 hip replacements are performed annually1, and more than 2.5 million Americans are living with a hip prosthesis2. Many hardware configurations utilize metal alloys for the femoral head and/or acetabulum. Although their use is decreasing due to safety concerns, cobalt-chromium femoral heads were still used in 51% of total hip arthroplasties in 20143. There is rising concern about the adverse effects of metal ions released from these joint replacements. However, little published evidence is available supporting specific interventions for the management of cobalt toxicity.

Given …