Medicine and Health Sciences Commons^™

Silent Assassin: Coronary Artery Disease In A Type Ii Diabetic, Srinath Vemuri, Ms Iv, Neerav Sheth, Md

The Medicine Forum

Case Presentation

A 53 year old white male with a past medical history significant for type II diabetes mellitus and orthotopic liver transplant (December 2006) secondary to hepatitis B cirrhosis presents as a direct admission to Thomas Jefferson University Hospital in September 2007 for an orthopedic preoperative risk evaluation. Patient has had a dull, worsening, non-radiating back pain of six months duration, beginning after his liver transplant for which he has been to several outpatient orthopedic physicians. Upon admission, the patient appeared well, but admitted to a consistent 8/10 back pain that he had been managing at home with narcotic …

A 42-Year-Old Male With Blurry Vision, William H. Chong, Md, Dorothy Chang, Md

The Medicine Forum

Hypertension affects approximately 25% of the population of the United States. Complications from hypertension include ischemic heart disease and stroke, and rates increase progressively as blood pressure increases.1 In some cases, the elevation of blood pressure can be significant and be life threatening. Situations where there is severe elevation of blood pressure and evidence of target organ dysfunction are termed hypertensive emergency. In this report, an unusual cause of hypertensive emergency is presented.

Anomalous Origin Of The Right Coronary Artery Diagnosed By Cardiac Computed Tomography, Siva K. Kumar, Md, Faisal Shaikh, Md, Paul J. Mather, Md

The Medicine Forum

Case Presentation

A 34 year old female with no significant past medical history presented with intermittent left shoulder and chest pain. The pain was burning in nature over her left chest and radiated to her left arm. There were no alleviating or exacerbating factors. Initial electrocardiogram showed sinus bradycardia. Cardiac computed tomography angiography revealed anomalous origin of the right coronary artery, which arises from the left sinus of Valsalva (Figure 1) and then travels towards the right side between the pulmonary outflow tract and the aortic root, where it shows mild narrowing of about 50%, (Figure 2) for a length …

Giant Negative T Waves, Siva K. Kumar, Md, Rajesh M. Kabadi, Md, Paul J. Mather, Md

The Medicine Forum

Case Presentation

A 62 year old Caucasian man with a past medical history significant for (long standing and controlled) HTN, lymphoma (diagnosed 2 yrs ago and currently in remission), and diffuse esophageal spasm presented to an outside hospital with expressive aphasia and right sided weakness. He was treated with tissue plasminogen activator (t-PA) for left MCA embolic stroke with excellent clinical response with very minimal residual expressive aphasia. Further work up and evaluation there revealed a large left ventricular apical mass consistent with thrombus and he was subsequently transferred to our facility for further evaluation and management of this apical …

Man With Spontaneous Intracranial Hemorrhage On Therapeutic Enoxaparin, Clopidogrel, And Aspirin, Mihir K. Patel, Md, Sumeet K. Chhabra, Md, Michael Pfeiffer, Md

The Medicine Forum

Case Presentation

A 65 year-old Caucasian male originally presented to an outside hospital complaining of worsening paroxysmal nocturnal dyspnea, orthopnea, and recent exertional chest pain associated with dyspnea. The patient’s past medical history was significant for coronary artery disease status post coronary bypass, severe aortic stenosis status post bioprosthetic aortic valve repair, congestive heart failure, atrial fibrillation on anticoagulation, dual-chamber pacemaker placement, history of a transient ischemic attack, and type 2 diabetes mellitus. At the outside hospital, coronary angiography revealed occlusion of native vessels and previous grafts. He was considered a poor surgical candidate. He was transferred to Thomas Jefferson …

Clopidogrel-Associated Thrombotic Thrombocytopenic Purpura: A Case Report And Brief Review, Benjamin C. Creelan, Md

The Medicine Forum

Introduction

In 1991, Page and colleagues published a report of four cases of thrombotic thrombocytopenic purpura (TTP) attributed to treatment with the platelet ADP receptor antagonist, ticlodipine. Since then, ticlodipine has been established as an immunemediated cause of TTP with an incidence of approximately 0.02-0.06%. Due to its unfavorable side-effect profile, the use of ticlodipine has been mostly discontinued in the United States and replaced by clopidogrel. Both agents are thienopyridine-derivatives which differ only by a carboxymethyl moiety. In spite of their structural resemblance, no case of TTP was reported in phase III trials of clopidogrel with 19,185 patients. However, …

Syncope, Melissa Gitman, Md, Cm

The Medicine Forum

A 45 year old white female rising from her seat to give a lecture at the Philadelphia Convention Center suddenly collapsed and lost consciousness. An automated external defibrillator device, on hand at the conference, demonstrated her rhythm to be in ventricular fibrillation. She was subsequently defibrillated and intubated in the field yet was unresponsive on arrival. Her husband related that his wife’s past medical history was significant for hypothyroidism and a questionable diagnosis of lupus. Her medications included levothyroxine and Pycnogenal, a popular herbal supplement. She had no known drug allergies. The patient had no known tobacco, alcohol, or illicit …

Palmarplantar Keratodermas, Melissa Gitman, Md, Cm

The Medicine Forum

Case Presentation

A 44 year old African American female with a history of seizure disorder and cirrhosis secondary to alcohol abuse was brought to the emergency department (ED) after a witnessed generalized tonic-clonic seizure on the street. While the patient was in the ED, she was observed to have 500cc of bright red hemetemesis and promptly transferred to the intensive care unit with successful stabilization of an upper GI bleed. It was not until transfer back to the telemetry that she was noted to have a shiny, scaly lesions on her hands and feet bilaterally

The Controversy Over Cocaine Use And Beta-Blockade Continues To Brew, Ankitkumar K. Patel, Md, Mph

The Medicine Forum

Cocaine Abuse Epidemiology

Cocaine is the second most commonly used illicit drug and the most frequent cause of drug-related deaths in the United States. Approximately 24 million people in the United States have used cocaine at least once, and five million abuse cocaine on a regular basis. Its use is associated with acute and chronic complications affecting many organ systems, the most common being the cardiovascular system.

Table Of Contents: The Medicine Forum, Volume 9, 2007

The Medicine Forum

Table of Contents: The Medicine Forum, Volume 9, 2007

From The Editors, Neilanjan Nandi, Md, Melissa Gitman, Md, Anthony Lanfranco, Md, Tamara Solitro, Md, Ankitkumar Patel, Md, Anastasia Shnitser, Md

The Medicine Forum

Every day our House Staff strive to deliver the most advanced and compassionate healthcare possible. Our clinical perspectives are constantly being challenged, prompting new avenues of inquiry and information to further our insight into the state of the human condition.

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

The Medicine Forum

A Growing Impact of Scholarly Work

To Friends of the Department of Medicine:

Each year, the House Staff further the impact of the Department of Internal Medicine through participation in research studies that are presented in their entirety or abstract form at society meetings throughout the country. This body of scholarly work reflects the breadth of interests of our residents and their energy and commitment to generating new knowledge to enhance the practice of medicine.

Download Entire Pdf: The Medicine Forum, Vol 8, 2006

The Medicine Forum

Download entire PDF: The Medicine Forum, Vol 8, 2006

Anomalous Origin Of Left Circumflex Artery From The Right Coronary Artery, Sivakumar Srinivasan, Md, Sandeep Anreddy, Md

The Medicine Forum

A 56 year-old male with past medical history significant for diabetes and obesity presented for an elective diagnostic cardiac catheterization.

Persistently Elevated Troponin Levels With A Negative Cardiacworkup: Now What?, Pamela Cines, Md

The Medicine Forum

A 44 year-old female with a past medical history significant only for iron deficiency anemia and syncope presented to an outside hospital with abdominal pain. The patient initially noted the pain while shopping; she described it a sharp sensation, regionalized to the right-epigastric region. When the pain recurred with greater intensity an hour later now with resulting nausea and right-arm radiation, she proceeded to her nearest ED.

Woman With Polyuria And Polydipsia, Jeffrey Clough, Msiv

The Medicine Forum

A 20 year-old Caucasian female with a past medical history significant only for occasional headaches and anemia presents with a chief complaint of increasing thirst for two weeks. The patient was in her usual state of health until approximately two weeks prior to admission when she noted the gradual onset of increasing thirst and began drinking more and more water over the next few days. Her thirst increased to the point where she drank an estimated 18 liters of fluid during the 24 hours prior to admission. This thirst was accompanied by frequent urination, which would often awaken her during …

Woman With Aids And Status Epilepticus, Bonnie Callahan, Md

The Medicine Forum

A 42 year-old female with a medical history of HIV presented to the Emergency Department with nausea and vomiting for the past five days. Six days prior to presentation, she had one week of symptoms of progressive dyspnea and non-productive cough which were evaluated by her primary care physician. At that time, blood work revealed a CD 4 count of 150 cells/mm3 and a chest x-ray was suggestive of pneumonia. She was given a prescription of trimethoprim-sulfamethoxazole (TMP/SMX) and guaifenesin with codeine. Within twenty-four hours of starting the prescribed medications, she developed nausea and vomiting, and she stopped taking both …

Man With Methadone-Induced Polymorphic Ventricular Tachycardia, Sivakumar Srinivasan, Md

The Medicine Forum

A 55 yr old male with past medical history significant for end stage liver disease, intravenous drug abuse and hypertension presents to the ED with complaints of bright red blood per rectum for the past 3 days and non-specific chest discomfort. Medications on admission were amlodipine, valsartan /HCTZ, xanax, terazosin, and high dose methadone maintenance therapy.

Treatment Of Crohn’S Disease In A Patient With Concomitant Hepatitis C And Hemophilia, Donna Williams, Md

The Medicine Forum

Treatment of Crohn’s disease often involves the use of immunomodulating drugs. Most trials of these drugs have excluded patients with coexisting illness by study design. The purpose of this case report is to describe the treatment of a rare case of Crohn’s disease in the face of concomitant hepatitis C and hemophilia.

Man With Increasing Fatigue And Myalgia, Lax Gadde, Md, Martin Kerrigan, Md

The Medicine Forum

A 69 year-old male with a past medical history of hyperlipidemia, GERD, and transitional cell carcinoma of the bladder currently in remission was admitted to the hospital with increasing fatigue, arthralgias, and myalgias. He noted that his symptoms began approximately four weeks prior to admission after working outside in his yard and on his swimming pool. He stated that one week later he developed red blotches on his thighs, abdomen and chest followed by arthralgias and myalgias. He noted there were ticks where he was working but could not recall a definite tick bite, nor did he find evidence of …

T-Wave Alternans In A Patient With Left Ventricular Dysfunction, Saum Shamimi-Noori, Md

The Medicine Forum

A 78 year-old man with a history of type 2 diabetes mellitus, hypertension, hyperlipidemia, seizure disorder, dementia, and alcohol abuse was admitted to the Wilmington VA Medical Center for treatment of deep vein thrombosis of the lower extremity. During the hospital course, the patient had a brief episode of supraventricular tachycardia. An echocardiogram revealed dilated cardiomyopathy, an ejection fraction of 20%, and apical and inferolateral akinesis-hypokenesis. On the following day, the patient developed cardiac arrest with ventricular fibrillation (VF) that was terminated by electric defibrillation. An electrocardiogram (Figure 1) obtained immediately after defibrillation demonstrated sinus bradycardia, a prolonged QT interval, …

Man With Blurry Vision, Brandy Kaneshiro, Md, Albert Yeung, Md

The Medicine Forum

A 35 year-old Caucasian man with Pre-B cell ALL on day 197 post allogenic stem cell transplant and with a chest tube for pneumothorax post VATS was admitted for pain at his chest tube site. Sixteen days into his admission he developed acute onset of blurry vision. The patient first noticed some difficulty reading a wall clock when he woke up in the morning followed by a subsequent worsening of his visual acuity over the next eight hours. By late afternoon he could only detect light. Review of systems was significant only for an intermittent headache over the preceding week.

Man Feeling Tired And “Lousy” Five Days Following Myocardial Infarction, Andra Popescu, Md

The Medicine Forum

A 70 year-old male presents to his cardiologist’s office with complaints of feeling fatigued and “lousy”. His past medical history is significant for HTN and HL, but until a recent hospitalization, he was non-compliant with his outpatient medical regimen. Of note, he also has a history of heavy alcohol consumption and a 30 pack-year smoking history. The patient reports that he was recently discharged after acute myocardial infarction (AMI) from an outside hospital. At that time, he underwent a diagnostic cardiac catheterization, but no intervention was performed secondary to 100% RCA stenosis and technical difficulties. He was sent home on …

When It Rains, Marshall Fleurant, Md

The Medicine Forum

You ever stand in the rain,

Especially on a hot summers day,

And feel the rain drops drip from the top of your head,

Straight down till it soaks into the seams of your socks

Woman With Fatigue, Shortness Of Breath, And Chest Pressure, Neilanjan Nandi Md, Sivakumar Srinivasan Md

The Medicine Forum

A 62 year-old African American female with past medical history significant for scleroderma, Raynaud’s phenomenon, and hypertension presented to the ED with 6 weeks of worsening fatigue, shortness of breath and a new onset of left sided chest pressure. Her outpatient medications included metoprolol 50 mg every 12 hours and nifedipine XR 90 mg once daily. On physical examination, the patient was noted to have a blood pressure of 189/62 mmHg and a pulse of 44 beats per minute. Her laboratory data including chemistry panel, complete blood count, and cardiac enzymes were unremarkable.

Woman With Facial And Neck Swelling, Meredith Chiaccio, Msiii, Donna Mscisz Williams, Md

The Medicine Forum

A 28 year-old Caucasian female, 3.5 months postpartum, presented to the TJUH ED with facial and neck swelling. She was in her usual state of health until approximately 1 month prior to admission when she noted the gradual onset of neck swelling. The neck swelling progressed to her face 4 days prior to admission; swelling in both areas was progressive and increasingly uncomfortable. Two months prior, the patient was treated for sinusitis with a course of antibiotics by an allergist; this treatment was unsuccessful, and she was referred her to an otolaryngologist, who performed a neck ultrasound and lab work. …

Man With New-Onset Jaundice And Severe Cholestasis, Aarati Malliah, Md

The Medicine Forum

The patient is a 69 year-old male with new onset jaundice of two weeks and a 6 month history of progressive hyperbilirubinemia with cholestasis who was admitted for evaluation. Physical examination revealed a well developed and well nourished, jaundiced male with scleral icterus, a II/VI systolic murmur at apex, mild abdominal discomfort over epigastrum on palpation without discernable hepatomegaly, normal distal pulses, no lower extremity edema, and no stigmata of chronic liver disease. Laboratory investigation revealed a total bilirubin of 19.3 mg/dL, alkaline phosphatase 693 U/L, and AST and ALT of 140 U/L and 117 U/L, respectively. CT scan of …

Infiltrated Epinephrine, Utpal Sagar, Md, Bonnie Callahan, Md, Ted Martynowicz, Do

The Medicine Forum

The patient is a 67 year-old male with past medical history of CAD s/p CABG, CHF with EF of 15%, BiV- ICD, who was recently admitted to an outside hospital in Delaware with SOB and weakness, and was found to have frequent bouts of VT. During that hospitalization, he had suffered cardiac arrest as well, and epinephrine was administered emergently through a peripheral IV site located in his right hand. He was thereafter loaded with amiodarone for the ventricular tachycardia. It was later found that the epinephrine had infiltrated into the skin of his right hand from the peripheral IV …

Woman With Anemia And Abdominal Pain, Joanna Kipnes, Md, Marina Serper Md

The Medicine Forum

The patient is a 36 year-old African American female with a 15 year history of Crohn’s disease complicated by severe perianal involvement not responsive to steroids or immunomodulating medication. The patient had undergone a proctocolectomy and diverting ileostomy two years ago secondary to refractory disease and had been symptom-free until 6 months prior to admission. At that time, the patient noted pain, vaginal discharge, and ulcerations in the perineal region. Three weeks prior to admission, she began to have almost daily vaginal bleeding as well as weakness, dizziness, and increased fatigue. She had no subjective fevers or chills and had …

Acute Myocardial Infarction After Blunt Chest Trauma, Sivakumar Srinivasan, Md, Sandeep Anreddy, Md, Paul Mather, Md

The Medicine Forum

Coronary artery injury rarely occurs after blunt chest wall trauma. It can, however, lead to extensive myocardial infarction. We report a rare case of acute anterolateral myocardial infarction in a young man after blunt chest trauma.