Medicine and Health Sciences Commons^™

Download Entire The Medicine Forum, Volume 14, 2012.

The Medicine Forum

Download entire The Medicine Forum, Volume 14, 2012.

Smartphone App Reviews, Jonathan A. Dunn, Md, Jacqueline V. Kraft, Md, Mitul Kanzaria, Md

The Medicine Forum

Smartphone App Reviews for Doximity, ECG Source, Heart Failure Trails, QX Calculate.

Too Tall For Guatemala, Evan M. Lapinsky, Md

The Medicine Forum

I was clearly out of place. I came to the highlands of Guatemala during my fourth year of medical school to study Spanish, work in a rural clinic, and experience a different way of life. For a month, I lived with a Guatemalan family, ate plantains with every meal, and generally tried to immerse myself in the rich Mayan culture surrounding me. Almost a year later, my Spanish is fading fast. The handful of days I spent in volunteer clinic is a distant memory at this point. Why did I go there again?

I was the epitome of an outsider. …

Discharge Summaries: How Long Is Too Long?, Kevin M. Curl, Md

The Medicine Forum

The Graduate Medical Education (GME) committee is composed of all Jefferson residency and fellowship program directors, as well as ten selected housestaff members. The committee meets monthly to discuss a wide array of topics, including Accreditation Council for Graduate Medical Education compliance, duty hours violations, and program reviews. One recently covered topic was the timeliness of discharge summary dictations. Implementing changes to improve transitions of care remains a focus of all healthcare systems. Jefferson is attempting to take an innovative approach to this issue, and discharge summaries are only one of the areas being examined.

The current policy requires house …

Easing The Pain: An Argument For Prescribing Opiates In Continuity Clinic, Lindsay Wilde, Md

The Medicine Forum

Continuity clinic can be painful. The patients are often non-adherent, the no-show rate is high, and the paperelectronic records hybrid system is less than ideal. Added to that is the stress of caring for patients with a variety of medical issues and the burden of being expected to prescribe opiates for them. Given all of the difficulties associated with opiate prescribing, including the potential for abuse, limited continuity with providers, and poor overall adherence to medical advice, it has been proposed that these medications should no longer be prescribed at our resident clinic, and many residents support this plan. However, …

An Argument Against Prescribing Opiates In Continuity Clinic, Hasan Bayat, Md

The Medicine Forum

Chronic pain is one of the most common complaints a primary care physician faces while in practice. As resident physicians at Jefferson Hospital Ambulatory Practice (JHAP), it is a frequently addressed concern, which ultimately leads to the question of whether or not opiates should be prescribed at JHAP to those patients who have failed non-narcotic alternatives.

The hesitation most physicians have in prescribing such medications is the potential for abuse, addiction and diversion. The Drug Enforcement Administration (DEA) shares these concerns and consequently monitors and restricts the prescription of opioids, stimulants and anxiolytics by requiring a separate license. Most resident …

Metastatic Uveal Malignant Melanoma: A Case Report, James W. Walter, Md, Rebecca Matro, Md, Daniel M. Quirk, Md, Mph

The Medicine Forum

Case Report

A 77-year-old woman presented with a chief complaint of one day history of severe, acute abdominal pain. The patient described the pain as "intense," non-radiating, and located primarily in the left upper abdominal quadrant.The pain was associated with nausea and multiple episodes of non-bilious, non-bloody emesis. She denied melena and hematochezia. On physical examination, her abdomen was soft and exquisitely tender in the left upper quadrant and epigastric regions. Aside from trace lower extremity edema.the remainder of her physical examination was unremarkable. Laboratory results at the time of admission were notable for:hemoglobin 10.8 g/dL, alkaline phosphatase 459 U/L, …

A Young Female Who Develops Tachycardia And Orthostatic Intolerance Following A Recent Infection, Michael A. Valentino, Md, Phd

The Medicine Forum

Case Presentation

The patient is a 20-year-old female with a history of asthma and anxiety with panic attacks who presented with palpitations and lightheadedness/pre-syncope. The morning of admission, she was attending a seminar and experienced an acute onset of palpitations. The palpitations started while she was seated and worsened upon standing. They were associated with lightheadedness, shortness of breath, and chest tightness. A nurse attending the seminar recommended that she go to the emergency room.

On presentation to the emergency department (ED) her vital signs were: Temperature: 99.2°F, Blood pressure (BP): 140/98; Heart rate (HR): 140; Respiratory rate (RR): 16; …

A 73-Year-Old Female With Palpitations, Kevin M. Curl, Md, Jacqueline V. Kraft, Md, Malinda Wu, Msiii, Carlos Fernandez-Ortega, Msiii

The Medicine Forum

Background

Atrial fibrillation is a commonly encountered clinical problem. Although a large percentage of patients have no dearly identifiable precipitant, secondary atrial fibrillation is a well-documented clinical entity.'

Case presentation

A 73-year-old female with a history of obstructive sleep apnea, hypertension, and chronic obstructive pulmonary disease presents with complaints of intermittent palpitations, substernal squeezing chest pressure, and shortness ofbreath for two weeks. Her most recent episode occurred on the bus, prompting her to come to the emergency room for evaluation. Further questioning revealed mild weight loss and diarrhea over the prior few weeks. Home medications included amlodipine, baby aspirin, albuterol …

Uncommon Hepatic Sequelae From An Acute Sickle Cell Crisis, Kimberly Lim, Md, James W. Walter, Md

The Medicine Forum

Background

Sickle cell crises are commonly treated at our institution given its large sickle cell patient population and well-established hematology department. While pain management is a crucial aspect to these patients' care, it is important to remember that a vasa-occlusive crisis can be life threatening. Many organs can be at risk, including the lungs (acute chest syndrome), brain (stroke), eyes (retinopathy) and as in our case, the liver. We hope this case report can become incorporated in future differential diagnoses pertaining to sickle cell crises.

Case Presentation

A 48-year-old black female with a past medical history of sickle cell anemia, …

A Case Study Of Pseudo-Neuropathic Pseudogout, Christina Cress Lindenmeyer, Md, Adam C. Sobel, Md, Levon N. Nazarian, Md, Steven Mandel, Md, Steven M. Raikin, Md, Homyar N. Karanjia, Dpm

The Medicine Forum

Background

This interesting case highlights the clinical progression of a rare disease process and the important role of a multi-disciplinary team in achieving a diagnosis and successful management plan.

Case Presentation

A 76-year-old male with a history of coronary artery disease, hypertension and hyperlipidemia presented as an outpatient with left foot pain and swelling. He had spent a week bicycling in Colorado one month prior to presentation. The pain was initially localized to the plantar surface of his foot and progressed to involve the lateral and dorsal aspects of the foot, as well as his great toe. The pain was …

Paraneoplastic Acral Vascular Syndrome, Daniel M. Kopolovich, Msiii, Dean D. Lagonosky, Msiii, Allison A. Greco, Msiv, Emma Weaver, Md, Rahul Malhotra, Md, Phoebe Holmes, Md, John R. Stewart, Md

The Medicine Forum

Introduction

Cases of rheumatologic phenomena coinciding with malignancy have been well-documented in the medical literature. These syndromes may be associated with common autoimmune markers, potentially masking the underlying diagnosis of malignancy. The association between malignancy and its coinciding rheumatologic manifestations is poorly understood. These paraneoplastic symptoms are more prevalent in high-stage adenocarcinomas of the lung, breast, and ovary. Possible mechanisms may include cytokine derangements, blood hyperviscosity, and circulatory disruption. While some evidence suggests that control of the primary tumor alleviates its associated paraneoplastic symptoms, other proposed therapies include heparin, prednisone, aspirin, and vasodilatory agents. Efficacy is limited due to association …

A 47-Year Old Female With Muscular Rigidity, New-Onset Diabetes And Hypothyroidism, Michael A. Valentino, Md, Phd

The Medicine Forum

Background

This case highlights a rare but devastating neurologic condition, Stiff Person Syndrome (SPS). While symptoms of muscular rigidity andspasms areassocia ted with numerous neuromuscular conditions, the association between SPS, autoimmune diabetes, and other autoimmune disorders such as thyroiditis, pernicious anemia, and vitiligo, could aid in the early diagnosis of this debilitating condition.

Case Presentation

A 47-year-old African American female presented with six months of progressively worsening rigidity and spasticity of her axial muscles and extremities. The patient was in good health until one and a half years prior to admission when she lost consciousness while driving and was subsequently …

Palpable Purpura In A Vietnamese Teenage Girl, Akram Mustafa, Md, Edward K. Len, Md, Alan Chiu, Msiii

The Medicine Forum

A 19-year-old Vietnamese female with no significant past medical history presented to the emergency department (ED) with fevers, sore throat, generalized myalgias, arthralgias, and a worsening lower extremity rash for the past two weeks. Approximately one week after the onset of constitutional symptoms, the patient noticed a rash developing on the anterior surface of her legs. Three days prior to hospitalization, her primary care physician prescribed cephalexin for her, but she didn’t recall what it was for. When her symptoms continued to worsen the next few days, she presented to the ED. In the ED, she also complained of abdominal …

A Devastating Storm, Eve Merrill, Md

The Medicine Forum

Case Report

A 26-year-old female with no significant medical history presented with palpitations and shortness of breath. Two weeks prior, she experienced rhinorrhea and congestion.Vital signs on admission were temperature 96.6°F, heart rate 252 beats per minute, blood pressure 127/74 mmHg, respiratory rate 24 breaths per minute, oxygen saturation 98% on room air. On exam, the patient was tachycardic and had a large, homogenous thyroid without any palpable nodules. The rest of her physical exam was unremarkable.

Laboratory data revealed total bilirubin 4.4 mg/dL, aspartate aminotransferase 245 units/L, alanine aminotransferase 263 units/L, thyroid stimulating hormone (TSH) 0.02 miU/L, free thyroxine …

A 19 Year Old Male With Hiv Presents With Diffuse Lymphadenopathy, Brian R. Curtis, Md, Subhashini Appulingam Sellers, Md, Jay Sellers, Md, Jackrapong Bruminhent, Md

The Medicine Forum

Background

In 1872, Moritz Kaposi first described "an idiopathic multiple pigmented sarcoma of the skin;'' now identified as Kaposi's sarcoma (KS).' While multiple forms ofKSexist, over9S% of the cases diagnosed in the US since 1981 are of the AIDS associated variety.2 Kaposi originally described KS as skin lesions that can progress to visceral involvement. However, in a small number of cases, KS can appear in the viscera without skin involvement. These alternate presentations of KS are difficult to diagnose; therefore, it is critical to recognize them when considering differential diagnoses, particularly in patients with HIV.

Case Presentation

An 18-year-old African …

Sudden Onset Blindness In A Patient With Mixed Connective Tissue Disease, Chris Terry, Msiii, Prachi Thanawala, Md, Erika Villanueva, Md

The Medicine Forum

Case Presentation

A 66-year-old Caucasian female recently diagnosed with mixed connective tissue disease presented with acute onset vision loss in the left eye. The patient first noted a “hazy-shower” that caused blurry vision with loss of peripheral vision. Her vision progressively worsened over a four-day period, resulting in complete blindness in the left eye and the onset of blurry vision in her right eye. She denied any eye pain, discharge, photophobia or similar symptoms in the past. The patient did note a very mild headache for four days but denied any other symptoms.

Metastatic Lip Cancer Of Unknown Primary, Jonathan A. Dunn, Md, Jerry Hsieh, Md

The Medicine Forum

Background

As housestaff, we seldom have the chance to admit a patient with cancer of unknown primary. Even if a patient presents with metastatic cancer, it is frequently evident what the primary cancer is based on epidemiology and imaging. However, in this case we have the unique opportunity of describing a metastatic cancer that presented as a lip carcinoma with several possible primary sources. Our goal is to guide the reader through the thought process involved with determining the primary malignancy in patients presenting with metastatic disease.

Case Presentation

A 54-year-old female with a 30-pack-year smoking history presented to the …

A Benign Cause Of Widened Mediastinum: A Case Of Mediastinal Lipomatosis, Natasha Fonseka, Md, Ewa Ruel, Md

The Medicine Forum

Introduction

We report a patient with a widened mediastinum secondary to a rare and benign condition known as mediastinal lipomatosis (ML). ML is caused by accumulation of adipose tissue within the mediastinum. Case reports associate JvlL with obesity, diabetes, Cushing's syndrome, steroid use while other cases remain idiopathic.'.. We report a patient with Glioblastoma Multiforma (GBM) on chronic steroids, who was found to have ML on imaging despite lack of obesity or Cushing's syndrome. This case provides significant educational benefit in approaching a patient with a widened mediastinum.

Case Presentation

A 59-year-old male with a history of recurrent GBM status …

An Interesting Case Report Of Diabetic Myonecrosis, Manjula Nagaraja, Md, Jim Zhang, Md

The Medicine Forum

Case Presentation

A 49-year-old male with a history of ischemic cardiomyopathy, New York Heart Association class II heart failure with an ejection fraction of 35% status post biventricular implantable cardiac defibrillator (ICD), end stage renal disease on dialysis, diabetes mellitus II, and pancreatitis complicated by pseudocyst presented with a sudden onset of left thigh pain with a palpable mass. He denied trauma to the site, numbness, tingling, weakness, fevers, or chills. Review of systems was otherwise negative. Vital signs at presentation were as follows: temperature 98.8°F, pulse 77 beats per minute, blood pressure 150/88 mm Hg, respiratory rate 18 breaths …

Overview Of Diuretic Strategies In Edematous States, Kedar Mahajan, Md

The Medicine Forum

Considering potential physiologic causes of volume overload in clinical practice, such as heart failure, renal failure, nephrotic syndrome, or portal hypertension, may yield insight into directing therapy beyond switching from oral to intravenous diuretic therapy. Appropriate oral therapies that achieve effective diuresis may reduce costs, address shortages of intravenous loop diuretics, reduce the need for unnecessary inpatient admissions by facilitating outpatient management, allow earlier optimization of outpatient regimens, and decrease the length of hospital stay.

Newly Diagnosed Aids With Multiple Opportunistic Infections Despite A Recent Negative Rapid Hiv Test, Soham Vakil, Md, Rene Daniel, Md, Phd, William Short, Md, Mph

The Medicine Forum

Background

Human Immunodeficiency Virus (HIV) is a fairly prevalent disease in the United States, with an estimated 1 million persons infected with HIV-1.1 Despite a decrease in Acquired Immunodeficiency Syndrome (AIDS), the prevalence of HIV is increasing, which has led to recent changes in HIV testing guidelines.2 Newly diagnosed patients should ideally be linked to care and receive intervention and antiretroviral therapy (ART) allowing them to maintain a near normal life expectancy.

Case Presentation

The patient is a 23-year-old African American male with no significant past medical history. He presented to the emergency department (ED) with fevers, weakness, worsening right-sided …

Cerebrovascular Accident Caused By Embolic Atrial Myxoma, Eugene Han, Md, Andrew Garrett, Md

The Medicine Forum

Background:

Atrial myxomas, the most common type of cardiac tumors, can cause life-threatening complications. As most cardiac myxomas are surgically curable, early diagnosis is crucial. Cardiac tumors can present with cardiac and embolic manifestations, and should be considered in the differential diagnosis of patients presenting with such symptoms. In this case report, we describe a young, healthy patient who presented with stroke symptoms secondary to embolic atrial myxoma.

Case Presentation:

Case Presentation A 45-year-old male with no past medical history presented with an acute onset of dysarthria, described as garbled speech. He also experienced weakness and heaviness of his right …

Table Of Contents, The Medicine Forum, Volume 14, 2012

The Medicine Forum

Table of Contents, The Medicine Forum, Volume 14, 2012

From The Desk Of The Residency Program Director, Gretchen Diemer, Md, Facp

The Medicine Forum

To the Friends of the Department of Medicine:

“The only thing that is constant is change.” What a year we have had!

From new time slots for morning report, patient surges in the hospital, moving the fellowship match to December and the addition of Dim Sum Fridays, things are in a constant state of flux. The hallmark of a Jefferson resident is the ability to evolve and adapt to the circumstances while continuing to think of further changes to benefit our patients, colleagues and ourselves. I cannot contain the pride I have in our residents and what they can achieve. …