Medicine and Health Sciences Commons^™

A Tale Of Two Women: Is There A Benefit To Bilevel Ventilation In Pregnancy?, Laura Immordino, Md, Adam Kaufman, Md

The Medicine Forum

Case Presentation

The patient is a 24 year-old pregnant female at 31 and 6/7 weeksestimated gestational age, who presented to the emergencydepartment with complaint of intermittent right-sided abdominalpain, nausea, vomiting and fevers over the past twenty-fourhours. The patient’s vital signs at presentation were significantfor a heart rate of 130 beats/minute and a blood pressure of 90/32mm Hg. Her physical examination was otherwise unremarkable,and she was initially admitted to the maternal-fetal medicineservice and started on intravenous fluids. Over the next 12 hours,the patient remained tachycardic with blood pressures in the80s/40s. She began to develop respiratory distress, and an ICUevaluation was requested.

Man With Swollen Eye, Blurred Vision, And Fevers In The Setting Of Newly Diagnosed Mds, Rory Bowers, Md

The Medicine Forum

Case Presentation

An 82 year-old male with a past medical history of prostatecancer, atrial fibrillation, gout, and recently diagnosed myelodysplasticsyndrome presented with a chief complaint of left eyepain. The patient also reported peri-orbital numbness, swelling,and clear discharge as well as episodic blurry vision of his lefteye. Over the previous two months he had been admitted to thehospital multiple times complaining of cough and high feversand was subsequently treated with several courses of antibioticsfor presumed pneumonia. During the initial admission forpneumonia he was noted to have a relative pancytopenia. Abone marrow biopsy was eventually undertaken revealing adiagnosis of myelodysplastic syndrome (MDS).

A Case Of Severe Anemia In An Aids Patient, Amy K. Slenker, Md, Rahul Anand, Md

The Medicine Forum

Case Presentation

A 49 year-old African-American male presented to ThomasJefferson University Hospital in April of 2008 complaining ofgeneralized weakness and lightheadedness for 4 months. Thepatient had a medical history of HIV/AIDS diagnosed in 2002with a CD4 count of 0 cells/mm3 in 2005 and a history of noncompliancewith highly active retroviral therapy (HAART). InDecember of 2007 the patient was diagnosed with cryptococcalmeningitis and had a concomitant anemia with a hemoglobinof 5.3 g/dL. At that time laboratory studies for parvovirus B19(PB19) showed an IgG of 0.79 units and an IgM of 0.63 units( a value less than 0.89 is considered negative). PB19 …

Vitamins: Friend Or Foe, Anastasia Shnitser, Md, Dina Halegoua-De Marzio, Md

The Medicine Forum

Case Presentation

A 39 year-old male presented to the emergency department withgeneralized body aches after a recent fall. The patient underwenturgent trauma evaluation and incidentally was found to havemultiple medications in his right colon on radiography (Figures1 and 2). The patient was immediately screened for a drugoverdose, but he admitted to taking a large amount of Ultra-Startvitamins that he purchased on the internet. Due to suspicionfor possible drug overdose, a nasogastric tube was placed, andpolyethylene glycol was administered to help the patient pass thepills from his bowels. Despite the large ingestion of vitamins, thepatient remained asymptomatic throughout his hospitalization.

A Woman With Chest Pain, Syncope, And Transaminitis, Ankitkumar K. Patel, Md, Mph, Brendan O’Hare, Md

The Medicine Forum

Case Presentation

The patient is a 49 year-old female with past medical history ofanxiety and hyperlipidemia who presented to an outside hospitalwith complaints of five hours of substernal chest pain followed bythree episodes of syncope witnessed by her son. At presentationin the emergency department the patient denied any currentchest pain or shortness of breath. She received 325 mg of aspirinen route to the hospital by EMS. Her vital signs were temperature100° Fahrenheit, heart rate 60 beats/minute, blood pressure101/50 mm Hg, respiratory rate 20 breaths/minute, and a pulseoxygenation of 98% on room air. The patient’s EKG showed STelevations in the inferior …

A Case Of Drug-Induced Hepatotoxicity: Amiodarone Is Not Always To Blame, Brendan O’Hare, Md

The Medicine Forum

Case Presentation

A 54 year-old male presented to the hospital with a two weekhistory of new onset jaundice, anorexia and fatigue. Thepatient has a past medical history of hypertension, coronaryartery disease, and ischemic cardiomyopathy with an ejectionfraction of 10% to 15%. He also has a history of atrial fibrillationand paroxysmal ventricular tachycardia with an automatedimplantable cardioverter-defibrillator placed. He deniedany history of blood transfusions, alcohol use, intravenousdrug abuse, or known hepatitis. He also denied taking herbalmedications or vitamins. The patient denied fevers, night sweats,nausea, shortness of breath, abdominal pain, blood in his stool,or easy bruising. Four weeks prior to admission, the …

A College Student With Fulminant Hepatic Failure, Christie Crawford, Md

The Medicine Forum

Case Report

A 19 year-old female college student presented to her pediatrician’soffice after experiencing three weeks of fatigue, abdominalpain, and nausea. At that time, the patient was diagnosed witha urinary tract infection and a viral illness and was given aprescription for Keflex. Over the next three days, the patient’ssymptoms worsened, and she developed weakness, shortnessof breath, and anorexia. She also noticed yellowing of her skinand darkening of her urine, which prompted her to go to theemergency department at an outside hospital. At the outsidehospital, many laboratory results were abnormal and her clinicalcondition worsened. She was transferred to the intensive careunit …

A 55 Year-Old Man With Mental Status Change And Severe Anemia, Sugeet Jagpal, Md, Anastasia Shnitser, Md

The Medicine Forum

Case Presentation

A 55 year-old male with past medical history significant for mentalretardation, a stage IV sacral decubitous ulcer, iron deficiencyanemia and gastrointestinal bleeding presented from a long termcare facility for acute onset of respiratory distress and change inmental status. On presentation the patient was found to have aGCS of three, and he was emergently intubated in the emergencydepartment for airway protection. Following intubation his vitalsigns were stable.

Primary Care Follow Up Post Mitral Valve Surgery At Ambulatory Clinic, Andrew Yin, Md

The Medicine Forum

Case Presentation

A 67 year-old Cantonese speaking male was seen at primary careclinic with complaints of dyspnea on exertion and decreasedexercise tolerance. His medical history includes rheumaticheart disease, tricuspid regurgitation, tricuspid repair threemonths ago, mitral regurgitation, mitral valve replacement witha bioprosthetic valve three months ago, atrial fibrillation onanticoagulation therapy, permanent pacemaker implantation,severe pulmonary hypertension, benign prostatic hypertrophy,gastroesophageal reflux disease, and iron deficiency anemia.The patient reports that in the last two weeks, he has beenunable to ambulate more than two blocks limited by shortnessof breath, which represents an acute change. He also complainsof bilateral lower extremity edema. He reports that two …

A 61 Year-Old Man With Delayed Hypersensitivity Reaction To Joint Prosthesis, Regina C. Lee, Md

The Medicine Forum

Case Presentation

61 year-old male with a past medical history of coronary arterydisease complicated by myocardial infarction in 1984, type 2diabetes mellitus, hyperlipidemia, hypertension, and right totalknee replacement in 2006 presents to the outpatient allergist’s officefor evaluation. The patient reports that he never fully recoveredafter the knee surgery and never regained function. The right kneeremained swollen and painful with limited range of motion andweight bearing as a result. He denies any rash, redness, or itching inthe area. He also denies any history of reactions to metals in the past.The orthopedic surgeon referred the patient to an allergist to assessfor an …

A 57 Year-Old Man With Prolonged Shortness Of Breath And Fevers, Loren Chen, Md

The Medicine Forum

Case Presentation

A 57 year-old Caucasian male was initially admitted to MethodistHospital from an outside hospital for dehydration, increasedheart rate, and weight loss. He has a past medical history ofcoronary artery disease status post myocardial infarction andcoronary artery bypass graft, congestive heart failure, paroxysmalatrial fibrillation on coumadin, diabetes type II on insulin, andan orthotopic liver transplant in 1997 for end-stage liver diseasesecondary to hepatitis C virus and alpha-1 antitrypsin disorder.

Jaundice In A Leukemia Patient Status-Post Allogeneic Stem Cell Transplantation, Esther Lee, Md

The Medicine Forum

Case Presentation

A 61 year-old Caucasian female with a past medical historysignificant for chronic lymphocytic leukemia (CLL) presented withdark amber-colored urine, jaundice, and nausea for three days. Shereported increased fatigue and poor appetite but denied fever, chills,shortness of breath, chest pain, vomiting, abdominal pain, diarrhea,constipation, or bleeding. She denied any change in her medicationsor recent travel history.

Severe Heart Failure And Large Left Ventricular Thrombus Following Acute Myocardial Infarction, Ankitkumar K. Patel Md, Mph, Scott Silvestry, Md, Paul J. Mather, Md

The Medicine Forum

Case Presentation

A 58 year-old man who recently underwent a left superficialfemoral artery thrombectomy presented with a three-day historyof worsening exertional dyspnea and bilateral pedal edema. Hispast medical history is significant for coronary artery disease,myocardial infarction, and insulin dependent diabetes mellitus.The patient initially presented to an outside hospital where hedeveloped ventricular tachycardia that warranted cardioversionthree times. Initial electrocardiogram showed inferior lead STsegment elevations and lateral lead ST depression.

A Man With Invasive Community Acquired-Mrsa Infection In The Icu Setting, Jason Korenblit, Md, Mba

The Medicine Forum

Case Presentation

A 66 year-old male presented to the emergency department (ED)with complaints of two days of shortness of breath and pruritis.The patient claimed that he had not had regular medical care formore than 15 years and admitted to no past medical history orchronic medications. One week prior, he reported an itchy rashon both his forearms. He sought treatment at a local free clinicand received a low-potency steroid cream which he used withoutrelief. While at a family event, he became increasingly dyspneicand was brought to the ED by his family. He reported no surgicalhistory and no drug allergies or food …

Case Reports A 31 Year-Old Man With Chest Pain, Rash, And Ekg Changes, Neerav Sheth, Md,, Rahul Anand, Md, Matthew Stopper, Md

The Medicine Forum

Case Presentation

A 31 year-old Caucasian male with no significant past medicalhistory presents with increasing dizziness, chest pain, andshortness of breath of one day duration. On returning from acamping trip to Northern Pennsylvania three weeks prior toadmission, he noted high fevers, “joint pains all over,” and a pinkblotchy rash all over his chest and back. He did not recall anyinsect, tick or animal bites. His primary physician, who clinicallysuspected Lyme disease, ordered Lyme serologies and offered aprescription for doxycycline which the patient declined. Twoweeks later, the patient presented to the emergency departmentafter the onset of chest pain that he described …

A 68 Year-Old Woman With Leukemia Under Her Skin, Ben Creelan, Md, Hari Nair, Msiii, Joanne Filicko-O’Hara, Md

The Medicine Forum

Introduction

A wide spectrum of skin manifestations occurs in leukemia.Skin lesions are often due to infection, drug reaction, orinflammation.1 Rarely, extramedullary leukemia can invadethe skin and is called leukemia cutis.2 Leukemia cutis isthe infiltration of neoplastic leukocytes into the dermis orsubcutaneous tissue, resulting in an identifiable skin lesion.These lesions show a varied morphology, and confirmatoryimmunohistochemical stains are needed for the diagnosis.Leukemia cutis may occur before, after, or concomitantlywith the onset of systemic leukemia.3 Here we report a case ofleukemia cutis occurring simultaneously with newly diagnosedacute myelogenous leukemia.

Embracing Quality Improvement At Resident Clinic: A Report Card On Our Diabetes Care, Tamara Solitro, Md

The Medicine Forum

Background

The age of embracing the status quo or the “if it ain’t broke,don’t fix it” philosophy in medical practice is long gone. Thegoal of quality improvement in the medical field is one we canall appreciate: to optimize the delivery of health care and useadvanced knowledge and technology to improve patient care.Many industries, such as automobile and engineering, alreadyapply the scientific method to quality improvement efforts, andthe time has come for medical practices to follow suit.

The Improvement Guide: A Practical Approach to EnhancingOrganizational Performance1 describes a model of improvementthat can be used in a variety of settings, including medicalpractices. …

The Use Of Statins In Liver Disease: Risk Versus Benefit, Dina Halegoua-De Marzio, Md

The Medicine Forum

Introduction

The National Cholesterol Education Program periodicallyproduces Adult Treatment Panel (ATP) updates as warranted bycurrent clinical scientific research in cholesterol management.1Each of the guideline reports, ATP I, II, and III, has a major rolein guiding physicians how to treat abnormal cholesterol levels.Recent clinical trials demonstrate that LDL-lowering therapywith statins (HMG-CoA inhibitors) reduces total mortality,coronary mortality, major coronary events, coronary proceduresand strokes in patients with established coronary heart disease.1However, the ATP III has cited active or chronic liver disease as anabsolute contraindication to the use of statins. The reason for thiscontraindication goes back to the initial clinical trials of Lipitor(atorvastatin), which …

Tjuh Adherence To Idsa Guidelines For The Treatment Of Cryptococcal Meningitis, Matthew Grant, Md

The Medicine Forum

Introduction

Cryptococcal meningitis is an infectious complication of immunecompromised states that carries a high rate of mortality orrelapse. Although Infectious Disease Society of America (IDSA)guidelines outline the recommended treatment regimen forcryptococcal meningitis, clinicians take a heterogenous clinicalapproach. This study examines the use of antifungal regimens intreating cryptococcal meningitis at a tertiary care hospital.

Understanding Hyperparathyroidism In Renal Disease, Rosemary Nwoko, Md, Kara Chenitz, Md

The Medicine Forum

The parathyroid glands are four pea-sized glands located onthe four corners of the thyroid gland. They secrete parathyroidhormone (PTH), which maintains calcium and phosphorushomeostasis. PTH regulates calcium such that when serumlevels of calcium fall too low, it increases the serum calciumlevel by stimulating more calcium release from the bones,increasing intestinal absorption of calcium and decreasingcalcium excretion into the urine. When the serum calciumnormalizes, the parathyroid gland shuts off the production ofPTH. An excess of PTH in the system throws off the calciumphosphorushomeostatic balance, resulting in various symptomsand clinical effects.

Congestive Heart Failure And Vitamin D Deficiency, Ankitkumar K. Patel, Md, Mph, Matthew Decaro, Md, Paul J. Mather, Md

The Medicine Forum

Introduction

Congestive heart failure (CHF) is a chronic medical condition whoseincidence is rising. The prevalence of CHF is approximately 1% to3% in Western countries. Despite innovations in medical therapy,CHF is associated with high morbidity and mortality rates.

CHF patients commonly experience muscle weakness and fatigueas two major symptoms. An altered intracellular handling ofionized calcium has been suggested to play a vital role in impairedmyocardial contraction. In isolated myocytes from patientswith end stage heart failure, systolic ionized calcium levelswere markedly decreased, while diastolic levels were elevated ascompared to healthy controls. In addition, digitalis and betablockermedical therapy is frequently used in CHF …

Table Of Contents, The Medicine Forum, Volume 10, 2008

The Medicine Forum

Table of Contents, The Medicine Forum, Volume 10, 2008

From The Editors, Tamara Solitro, Md, Anthony Lanfranco, Md, Ankitkumar Patel, Md, Anastasia Shnitser, Md, Andrew Foy, Md, Claire Raab, Md, Tina Shah, Md

The Medicine Forum

Argentina, California, Kenya, Alaska — these are just a fewof the places visited by our internal medicine residents andcaptured in breathtaking photographs that are exhibitedthroughout this issue of The Jefferson Medicine Forum. It iseasy to appreciate the beauty of nature when taking in thesepictures of stunning aerial views and colorful landscapes.Their display in this journal is fitting amongst the academicarticles that speak to the intellectual curiosity of our residentsand the diversity of pathology seen at Thomas JeffersonUniversity Hospital.

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

The Medicine Forum

To Friends of the Department of Medicine:

Earlier this academic year, The Institute of Medicine(IOM) issued their most recent report, “Resident DutyHours: Enhancing Sleep, Supervision, and Safety,” whichrecommends changes to medical residents’ duty hours andworkloads to “promote conditions for safe medical care,improve the education of doctors in training, and increasethe safety of residents and the general public.” While theIOM simply makes recommendations, the AccreditationCouncil for Graduate Medical Education (ACGME) makesthe actual rules that a residency program must follow inorder to maintain accreditation. Under the leadership ofthe ACGME, one of the Residency Review Committees(RRC) establishes these accreditation guidelines for internalmedicine residency …

Oncogene-Induced Nrf2 Transcription Promotes Ros Detoxification And Tumorigenesis., Gina M. Denicola, Florian A. Karreth, Timothy J. Humpton, Aarthi Gopinathan, Cong Wei, Kristopher Frese, Dipti Mangal, Kenneth H. Yu, Charles J. Yeo, Eric S. Calhoun, Francesca Scrimieri, Jordan M. Winter, Ralph H. Hruban, Christine Iacobuzio-Donahue, Scott E. Kern, Ian A Blair, David A. Tuveson

Department of Surgery Faculty Papers

Reactive oxygen species (ROS) are mutagenic and may thereby promote cancer. Normally, ROS levels are tightly controlled by an inducible antioxidant program that responds to cellular stressors and is predominantly regulated by the transcription factor Nrf2 (also known as Nfe2l2) and its repressor protein Keap1 (refs 2-5). In contrast to the acute physiological regulation of Nrf2, in neoplasia there is evidence for increased basal activation of Nrf2. Indeed, somatic mutations that disrupt the Nrf2-Keap1 interaction to stabilize Nrf2 and increase the constitutive transcription of Nrf2 target genes were recently identified, indicating that enhanced ROS detoxification and additional Nrf2 functions may …

Identification Of Factors Associated With Good Response To Growth Hormone Therapy In Children With Short Stature: Results From The Answer Program®., Peter A Lee, John Germak, Robert Gut, Naum Khutoryansky, Judith Ross

Department of Pediatrics Faculty Papers

UNLABELLED: ABSTRACT:

OBJECTIVE: To identify factors associated with growth in children on growth hormone (GH) therapy using data from the American Norditropin Studies: Web-enabled Research (ANSWER) Program® registry.

METHODS: GH-naïve children with GH deficiency, multiple pituitary hormone deficiency, idiopathic short stature, Turner syndrome, or a history of small for gestational age were eligible (N = 1,002). Using a longitudinal statistical approach, predictive factors were identified in patients with GHD for change from baseline in height standard deviation score (ΔHSDS) following 2 years of treatment.

RESULTS: Gradual increases in ΔHSDS over time were observed for all diagnostic categories. Significant predictive factors …

Download Entire Pdf: The Medicine Forum, Vol 9, 2007

The Medicine Forum

Download entire PDF: The Medicine Forum, Vol 9, 2007

What's Undocumented, Tamara Solitro, Md

The Medicine Forum

There’s a calm stillness

To the sick at night—

The sound of quiet healing, I hope,

But inevitably, a few cannot be healed.

Man With Malaria In Delaware, Benjamin Ngo, Md

The Medicine Forum

Case Presentation

A 37-year-old African American male presented to the hospital complaining of high fevers over the past two weeks associated with severe posterior headache. He described having had a very poor appetite recently, but denied any cough, abdominal pain, diarrhea, or urinary symptoms. He did not recall sustaining any head trauma. He did relate, however, that he had recently returned from a three-month trip to Kenya ~1 month prior to this presentation. He had no past medical history and was not on any medications. He did not use IV drugs. Physical exam confirmed a fever of 102.1o F though …

Spiderbite, Ayana Cannon, Md

The Medicine Forum

Introduction

In North America alone, there are more than 3,000 species of spiders. While most are harmless, several species including the Latrodectus (black widow), Atrax (funnel-web), and the Loxosceles (brown recluse) have been known to inflict varying degrees of injury to humans. While an overwhelming majority of spider bites may go unnoticed, others result in local skin reactions, necrotic cutaneous lesions, or a severe syndrome associated with hemolysis and death.

While proper identification of spider bites is paramount to the prevention of rare, life-threatening systemic reactions, their misdiagnosis can be equally hazardous. According to the literature, Loxosceles reclusa bites are …