Medicine and Health Sciences Commons^™

A Case Report Of Suspected Choledocholithiasis 20 Years After Cholecystectomy, Maleeha Memon, Dhara Rana, Chandni Patel, Christine Leroy, Bijal Sheth

Rowan-Virtua Research Day

Gallstones are a common prevalence in western societies where approximately 15% of Americans have gallstones. The mainstay treatment for symptomatic cholelithiasis is laparoscopic cholecystectomy. It is estimated approximately 650,000 to 700,000 cholecystectomies are performed every year. Most patients feel relief after a laparoscopic cholecystectomy, but a small number of patients experience post cholecystectomy syndrome, which presents as biliary colic pain. Although the pathophysiology of the post cholecystectomy syndrome is unclear, one theory proposes that it is due to the alteration in bile flow after the removal of the gallbladder, which serves as a reservoir for bile. This bile is thought …

A Case Of Intracranial Empyema After Bacterial Sinusitis, Eric Doane, Bhumi Shah, Robert Belfer

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Acute sinusitis in the pediatric population is a common presentation in the emergency department. Most cases are viral and can be managed conservatively and will resolve spontaneously in 7-10 days. Even in cases of bacterial sinusitis, patients can typically be discharged with oral antibiotics and close follow up with the pediatrician.

There is however a small subset of patients who will develop a rare lethal complication, an intracranial empyema. While the incidence in the developed world has decreased as antibiotics become more available, it is still estimated to occur in up to 5% of severe cases requiring hospitalization (1) . …

A Case Of Acute Disseminated Encephalomyelitis In An Adult Male With Bipolar Disorder, Jinisha Patwa, Tracey Harris

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Acute disseminated encephalomyelitis (ADEM) is a rare demyelinating disease characterized by inflammation of the brain and spinal cord. The rapidly progressive inflammation in the central nervous system is known to occur in response to a prior infection or immunization.

The clinical signs of ADEM may manifest up to 60 days post illness or vaccination. Some develop encephalopathy and neurologic symptoms which include confusion, psychosis, and tetraparesis. Paresthesia of the limbs and muscular atrophy indicate a worse prognosis and higher risk of relapse as opposed to those with only CNS involvement. A predominantly psychiatric presentation is also possible.

Risk factors include …

A Case Of Diabulimia In A 23-Year-Old Woman With Extensive Comorbidities, Stephen Poos, Kaitlin Mcgowan, Ashaki Martin

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Diabulimia is defined as intentionally withholding insulin injections for the purpose of weight loss in the setting of type 1 diabetes mellitus (T1D).

It is characterized as an eating disorder (ED), although it does not yet have DSM diagnosis status.

Recognition of the condition among medical professionals is limited but growing.

Posterior Reversible Encephalopathy Syndrome (Pres), Brittany Fera, Andrew Caravello

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Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiographic syndrome that describes certain neuroimaging findings in association with clinical symptoms such as headache, seizure, encephalopathy and vision changes. Classically, PRES is associated with poorly controlled hypertension, and patients present with elevated blood pressure in addition to their symptoms. Most importantly, imaging findings and symptoms are typically reversible, and are a separate entity from ischemic or hemorrhagic cerebrovascular accidents or autoimmune causes of similar symptoms, such as multiple sclerosis.

Robotripping: The Dangers Of Abusing Dextromethorphan, Tiffany Sin, James Espinosa, Dana Fichter

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Dextromethorphan (3-methoxy-N-methylmorphinan), also known as “DXM,” is a synthetically produced drug available in many over-the- counter (OTC) cough and cold medications as a centrally acting cough suppressant that binds to NMDA receptors. In a 2006 national survey of 50,000 students, 4, 5, and 7% of 8, 10, and 12th graders reported DXM abuse in the past year. In high doses, DXM can cause euphoria, hallucinations, dissociations, and distortion of cognition and perception. DXM abuse is also known as “Robotripping,” “Robodosing,” “Dexing,” “Tussin,” or “Triple Cs” because Robitussin® and Coricidin® Cough and Cold are most frequently abused. DXM has replaced codeine …

Retrograde Thromboembolism From The Proximal Descending Thoracic Aorta Leading To Recurrent Acute Cerebrovascular Events, Mark Staroelsky, Akash Patel, Gregory Holland, Nishant Parikh, Peter Bulik

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In the United States, approximately 800,000 individuals experience a stroke every year

Nearly 25% of strokes are recurrent

Cryptogenic strokes, or those with unknown causes after testing, make up a significant portion of ischemic strokes, as many as 32%

Retrograde thromboembolic events originating from the proximal descending thoracic aorta should be considered as a potential etiology in cryptogenic strokes

The appropriate management of embolic events from aortic atheroma needs further research

Here, we present a case of a 55-year-old male who had recurrent cryptogenic strokes whose origin was discovered to stem from retrograde embolic phenomena from atheroma located within the …

Spontaneous Conus Medullary Infarction In The Absence Of Cardiovascular Risk Factors, Bavica Gummadi, Jaffer Ahmed, Swarna Rajagopalan

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Spinal cord infarction (SCI) is rare and most often occurs in individuals with predisposing cardiovascular risk factors and traumatic injuries

As there are no distinct diagnostic criteria for SCI, diagnosis is difficult in patients presenting without predisposing factors and is often mistaken for transverse myelitis.

Delay in early diagnosis contributes to the high case fatality rate of SCI.

This case highlights the importance of including SCI in the differential of a patient with acute paraparesis even in the absence of co-existing risk factors.

A Peculiar Presentation Of Cardiac Sarcoidosis As Third-Degree Atrioventricular Heart Block Complicated By Right Ventricle Perforation, Yash Suthar, Pooja Patel, Nikhita Kothari, Kristofer Hillegas

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• Cardiac sarcoidosis is a rare, inflammatory multisystem disorder that manifests as noncaseating granulomas of multiple organs.

• The clinical presentation of sarcoidosis is variable and may be underrecognized by clinicians.

• Individuals may be asymptomatic during their lifetimes and may be incidentally diagnosed with the disease for the first-time during autopsy.

• Patients with cardiac involvement of sarcoidosis may initially present with complications including arrhythmias, heart block, bundle branch block, congestive heart failure, pericardial effusion, pulmonary hypertension, and/or sudden cardiac death.

A Terrible Prank Gone Horribly Wrong The Development Of Delusional Infestation As An Adjustment Reaction To A Traumatic Hoax, Timothy Wong, Nardin El-Shammaa, Munaza Khan, Stephen Scheinthal

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Delusional infestation (DI) is a somatic type delusional disorder, characterized by a fixed belief that one is infested by living or nonliving pathogens (1,3) . DI is a relatively rare disorder (4,5), with an estimated 20-80 cases per million people annually (6). Effective management of patients suffering from DI is crucial, as patients may cause significant harm to themselves in their attempts to remove the pathogens (7,8). Regarding treatment options, antipsychotic medications such as pimozide and risperidone have been promising (8,10). However, there remain many barriers to care (11), and patients are hardly ever seen in psychiatry as they preferably …

Rheumatoid Nodule Mimicker Mycobacterium Haemophilum: A Case Presentation, Elisa Griswold

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Mycobacterium haemophilum is a rare infection that can present in humans as subcutaneous nodules and cutaneous lesions. With a growing number of immunocompromised patients, M. haemophilum infections are becoming more common. Rheumatoid nodules in comparison are very common and can occur in approximately 25% of patients with Rheumatoid Arthritis (RA). Here we discuss a case in a patient with Rheumatoid Arthritis who developed subcutaneous nodules that mimicked rheumatoid nodules, but were later determined to be infectious nodules from Mycobacterium haemophilum.

Septic Arthritis With Concomitant Pseudogout, Ravin Patel, James Schuck, Nicole Zucconi, David Aderholdt

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Monoarticular joint pain is a common complaint, however it demands a broad differential diagnosis. These differentials include fracture, dislocation, septic arthritis, gout, pseudogout and several others. The diagnosis of septic arthritis requires a high index of suspicion as early diagnosis is a vital part of initial treatment.

We present a case with multifactorial joint pathology contributing to a patient’s presentation, specifically septic joint and pseudogout. The incidence of these entities being present in the same patient, let alone the same joint, is not well documented in the literature.

The presentation of these diseases have a multitude of similarities and differences, …

The Coumadin Ridge: Incidental Finding Mimicking Thrombus On Echocardiogram, Keith Brown Jr., Matthew Everwine, Keith R. Anacker, Jose Nieves

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The left atrial ridge or “coumadin ridge” is a cardiac anatomic structure located between the left pulmonary vein and the orfice of the left atrial appendage. Historically, patients were misdiagnosed with intra-atrial thrombus and were incorrectly placed on anticoagulation with warfarin, ultimately acquiring the name of the “coumadin ridge”. Fortunately this anatomical variant is now more commonly recognized, however when improperly identified can lead to unnecessary testing, cost, diagnosis anxiety, and inappropriate treatment for the patient. This purpose of this case is to bring awareness to this common clinical dilemma in an attempt to reduce ambiguity and unnecessary workups surrounding …

Syncope Or Seizure?, Joseph Heron, Kevin Dwyer

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Syncope is a common complaint in the emergency departments, accounting for 1-2% of visits, and can approach admission rates of a staggering 85%. The causes and conditions can be numerous, ranging from benign to life threatening. A good background history can go a long way in determining the etiology of the patient’s syncope. We describe a case of an elderly male who presented with a reported chief complaint of seizures, another syncope-mimic seen in the emergency department. He had a history of CAD, HTN, AAA, and osteoarthritis but no prior history of cardiac arrhythmia, MI, or structural heart disease. The …

Stercoral Colitis Leading To Hypotension And Ivc Syndrome With Respiratory Failure Following Fecal Disimpaction, Kelly Schuitema, Nicholas Tomasello

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Constipation is an extremely common chief complaint in the emergency department, contributing to approximately 700,000 emergency department visits in 2011. Severe constipation can result in stercoral colitis, which in turn can lead to development of ulceration and colonic perforation leading to fatal peritonitis. As a result, prompt recognition and treatment of this condition with bowel cleansing and fecal disimpaction are often recommended. Here, we will discuss a case of a 62-year-old male with a history of schizoaffective disorder who came into the Emergency Department (ED) hypotensive with stercoral colitis secondary to severe constipation. Following bedside fecal disimpaction, the patient developed …

Spontaneous Splenic Laceration Presenting As Stable Angina In The Ed, Lea Rowson, James Baird

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We present a case of a 62-year-old female who presented to the emergency department complaining of classic cardiac chest pain and was ultimately diagnosed with hemoperitoneum due to a splenic laceration sustained during recent colonoscopy. The signs and symptoms between these two diagnoses can be vaguely similar, and a missed diagnosis of either leads to increased morbidity and mortality. To make an appropriate diagnosis, a thorough history and physical examination is imperative. Observation of non-musculoskeletal left shoulder pain in addition to abdominal tenderness should lead the astute clinician down a different path towards diagnosis. Kehr’s sign is present in many …

Use Of Point Of Care Ultrasound In The Emergency Department For Diagnosis Of Femoral Pseudoaneurysm, Stephen Janssen, Jeffrey Gardecki, Giovanna Finocchio

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Iatrogenic pseudoaneurysm after puncture or intervention of the femoral artery is a rare complication of arterial surgical intervention occurring in 0.05-0.50% of diagnostic and therapeutic catheterizations and can present weeks after initial presentation. Today we present a 57-year-old gentleman 3 months status post femoral artery stent who presented with swelling to his right groin. Point of care ultrasound was used to diagnose an actively bleeding pseudoaneurysm with hematoma that ultimately led to repeat stenting. This case shows how point of care ultrasound can expedite diagnosis and intervention and is a useful tool for the emergency physician at initial presentation.

Triad Of Acute Pancreatitis Coexisting With Diabetic Ketoacidosis And Very Severe Hypertriglyceridemia Successfully Resolved With Insulin Therapy Alone, Akash Patel, Monica Patel, Yvette Wang

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Diabetic ketoacidosis (DKA) is known to cause mild elevations in triglyceride levels.

Severe hypertriglyceridemia (HTG) is a well-known cause of acute pancreatitis; however, in unique cases, DKA has been shown to cause severe HTG leading to the development of acute pancreatitis (AP).

HTG causing AP only accounts for 1-4% of cases of AP

From the few cases in literature that have reported this triad of DKA, HTG, and AP, even fewer have shown to be successfully treated with insulin therapy alone with the severe degree of HTG that we discuss.

In our case, we have treated a triad of DKA, …

Case Report: The Value Of Vigilance And Iterative Evaluations With An Uncooperative Patient In The Emergency Department, Duwayne Campbell

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Discussion

A Flexible and Vigilant Approach: The initial presenting information from EMS could have led to anchoring bias. A flexible approach led to new information, which led to interative testing.

Iterative physical examination. There are cases, as seen in this case report, where the physical examination was unreliable or even impossible. Iterative evaluations ultimately led to appropriate imaging and accurate diagnosis.

Iterative testing: In the case presented, the radiologist reported a finding as being present on a prior CXR; however, given the patient’s clinical presentation, further imaging studies were necessary.

Phyllodes Tumor Containing Invasive Ductal Carcinoma: A Rare Case Description & Review Of Literature, Kathryn Eckert, John Ground, Alyssa Imperatore, Victoria Tiedemann, Linda Szczurek

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Phyllodes tumors are uncommon, often benign, malignancies of the breast and account for approximately 0.5% of all breast malignancies. These tumors were first described in 1838 by Johannes Muller as cystosarcoma phyllodes and were later more aptly renamed phyllodes tumors (as they were neither cystic nor sarcomatous).(1) As a mixed connective tissue and epithelial tumor, these behave similar to benign fibroadenomas, though their growth is much more rapid and they tend to occur in older patients.(2) Hallmarked by their large size at presentation, these tumors average between 4 and 7 cm at the time of diagnosis. The only known risk …