Medical Specialties Commons^™

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.

Pembrolizumab-Associated Hypothyroidism: Case Report And Review Of Literature, Niranjan Tachamo, Saroj Lohani, Salik Nazir, Rishikesh Joshi, Mrunalini Deshmukh

Reading Hospital Internal Medicine Residency

Pembrolizumab is a Programmed Death 1 (PD-1) inhibitor used to treat advanced malignant melanoma and metastatic non-small cell lung cancer. It causes various endocrinological side effects including immune mediated thyroiditis. Thyroiditis caused by Pembrolizumab can mimic other immune mediated thyroiditis like Hashimoto thyroiditis and Grave’s disease.

A Functional Algorithm For Weight Loss And Obesity Practice: Guide For Clinical Decision-Making For Treating Women, Jennifer A. Tice Williams

Dissertations

ABSTRACT

Background

Overweight and obesity have significant impact and consequences on women leading to reduced quality of life, comorbid conditions and premature mortality. Many healthcare providers lack adequate training and the time to properly treat overweight and obesity. Algorithms have been shown to improve clinical knowledge and save time.

Objectives

To develop an algorithm for weight loss assessment and treatment to aid in the clinical decision-making process while improving the quality of care for overweight and obese clients in an efficient manner that can be replicated.

Methods

After an extensive literature review to identify best-practice guidelines for weight loss a …

Hypersensitivity Pneumonitis: An Overlooked Cause Of Cough And Dyspnea., Ryan S. D'Souza, Anthony A. Donato

Reading Hospital Internal Medicine Residency

Hypersensitivity pneumonitis (HP) is an immune-mediated pulmonary disorder involving inflammation of the lung interstitium, terminal bronchioles, and alveoli caused by the immune response to the inhalation of an offending environmental airborne agent. It can manifest as exertional dyspnea, fatigue, weight loss, and progressive respiratory failure if left untreated. Because of its protean features, it can be misdiagnosed as other common obstructive lung conditions such as asthma. If triggers are not avoided, it can progress to irreversible pulmonary fibrosis. In this article, we present the case of a 51-year-old male who presented to our hospital with recurrent bouts of dyspnea and …

Clara's Final Christmas Gift, Gus W Krucke

Faculty, Staff and Student Publications

No abstract provided.

Exploring Autonomy Support In Shared Decision Making And Patient Activation Of Diabetes Self-Care Behaviors, Carol Mahler Hamersky

Seton Hall University Dissertations and Theses (ETDs)

Introduction:

Chronic disease places a different set of demands on an individual and family. Self-care behaviors and daily decision making is an integral part of diabetes management. According to the CDC (2014), the prevalence of Diabetes is estimated at 29.1 million and an alarming 86 million Americans have Pre-diabetes. Despite a plethora of evidence on the importance of diabetes self-care behaviors on clinical outcomes, studies have highlighted the current disconnect of patients not able to follow self-care behavior recommendations and not asking for help from their health care providers. There is no literature on the impact of an autonomy supported …

Diagnostic Effectiveness Of High-Sensitivity Troponins, Sean R. Bodin, Jacqueline Ramirez

Physician Assistant Capstones, 2016 to 2019

Background: Acute myocardial infarctions (AMI) are a leading cause of death in the United States. The key to increasing survivability is early recognition to expedite the proper treatment modalities. In conjunction with the clinical presentation and electrocardiograms, the use of cardiac biomarkers is exponentially important in not only recognizing a cardiac event but also determining the extent of injury. Advancement in laboratory technology has led to the development of high-sensitive troponin (hs-troponin) assays which can detect smaller cardiac troponin serum levels compared to conventional troponin assays. This implies that the use of hs-troponin assays is more effective in the …

Demographics, Patterns Of Care, And Survival In Pediatric Medulloblastoma, Emily V. Dressler, Therese A. Dolecek, Meng Liu, John L. Villano

Internal Medicine Faculty Publications

We evaluated the American College of Surgeon’s National Cancer Data Base (NCDB) to describe current hospital-based epidemiologic frequency, survival, and patterns of care of pediatric medulloblastoma. We analyzed NCDB 1998–2011 data on medulloblastoma for children ages 0–19 years using logistic and poisson regression, Kaplan–Meier survival estimates, and Cox proportional hazards models. 3647 cases of medulloblastoma in those aged 0–19 years were identified. Chemotherapy was received by 79 and 74% received radiation, with 65% receiving both therapies. Those who received radiation were more likely to be older than four, while those who received chemotherapy were more likely to be age four …

Dislodging Anchored Diagnoses: An Unusual Presentation Of Acute Appendicitis, Talal Asif, Ravali Gummi, Zara Wadood, Kristy E. Steigerwalt, Rebecca R. Pauly

Marshall Journal of Medicine

Cognitive errors are the most common cause of diagnostic errors in the process of clinical decision making. Recently, there has been an immense focus on the new science of error prevention in health care. Anchored thinking or heuristics is a form of cognitive error that portrays shortcuts or abbreviated thinking in the light of diagnostic uncertainty. The risk is of comfort in a typical scenario and not being able to adapt to a new situation. Here we present an intriguing case of acute appendicitis in a patient who was initially admitted and treated for hypothermia and alcohol withdrawal. As the …

Image-Guided High-Dose Rate Intracavitary Brachytherapy In The Treatment Of Medically Inoperable Early-Stage Endometrioid Type Endometrial Adenocarcinoma, Scott E. Jordan, Md, Ida Micaily, Md, Enrique Hernandez, Md, J. Stuart Ferriss, Md, Curtis T. Miyamoto, Md, Facr, Shidong Li, Phd, Bizhan Micaily, Md

Division of Internal Medicine Faculty Papers & Presentations

To report the experience with high dose rate, image guided intracavitary brachytherapy in the treatment of medically inoperable, early stage endometrial cancer.

Poster presented at:

American Brachytherapy Society Annual Meeting April 20-22, 2017 in Boston MA.

Gastrointestinal Stromal Tumor Induced Hypercalcemia, Aram Barbaryan, Stefania Bailuc, Padma Poddutoori, Aida Richardson, Aibek E. Mirrakhimov

Internal Medicine Faculty Publications

Hypercalcemia in patients with cancer is a common laboratory finding affecting up to 44% of that patient population. 1,25-Dihydroxyvitamin D₃ mediated hypercalcemia is one of the rare mechanisms of this endocrine emergency in cancer patients. It is even rarer for solid organ neoplasms to present with hypercalcemia mediated through the production of 1,25-dihydroxyvitamin D₃. We report a case of a 77-year-old female who presented to the hospital with hypercalcemia and later was found to have metastatic gastrointestinal stromal tumor. There have been only 5 cases of gastrointestinal stromal tumor described in literature resulting in hypercalcemia. In our …

Removing Barriers To Care For The Underserved: Provider And Patient Perception Of Direct To Consumer Telemedicine, Robert M. Grell, Rachel Hatcliffe, Sean M. Gillen, Craig Sable, Vanessa Grant, Matthew Ledda, Mary Fuska, Shireen Atabaki

GW Research Days 2016 - 2020

Purpose of Study: Lack of access to pediatric subspecialty care is a major barrier to pediatric health for underserved populations in the Washington DC, Virginia and Maryland area. Lack of access to transportation, long office wait times, and missed school and work are barriers that prevent access to subspecialty care. Direct to consumer (DTC) telemedicine provides this service to our underserved population by bringing care into their own home through use of computers, tablets, and smart phones.

Methods Used: Structured interviews of parents and providers were performed prior to implementation of a subspecialty DTC telemedicine program for underserved children in …