Internal Medicine Commons^™

From The Editors, Neha Bansal Etherington, Md, Anita Modi, Md, Debbie Chen, Md, Brianna Shinn, Md, Colin Thomas, Md

The Medicine Forum

We are delighted to present you with the 19th annual edition of The Medicine Forum. Here in the birthplace of our nation, we like to think of The Medicine Forum as being of the housestaff, by the housestaff and for the housestaff. Undeniably, this publication would not be possible without the countless hours dedicated by our residents, students, fellows and faculty.

From The Desk Of The Residency Program Director, Emily Stewart, Md, Facp

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. This publication is just one example of the passion, dedication and creativity our residents continue to provide to the Jefferson Community. The residents are not just outstanding clinicians but excel in all aspects of medicine including: research, humanities and medical education.

The Medicine Forum: Volume 19

The Medicine Forum

The Medicine Forum: Volume 19

Posterior Reversible Encephalopathy Syndrome (Pres) After Bevacizumab Therapy For Metastatic Colorectal Cancer., Mohsin Hamid, Ali Ghani, Ida Micaily, Usman Sarwar, Md, Bilal Lashari, Md, Faizan Malik

Abington Jefferson Health Papers

Posterior reversible encephalopathy syndrome (PRES) is an increasingly recognizable neuro-clinical syndrome. Clinical and neurological manifestations of PRES include hypertension, headache, encephalopathy, seizures, and symmetrical white matter changes on brain MRI. Most common precipitants of PRES are acute medical illness, hypertensive crisis, eclampsia, immunosuppressive therapy, and chemotherapy. Bevacizumab is a monoclonal antibody that halts angiogenesis by inhibiting vascular endothelial growth factor. It has gained widespread popularity in oncology world especially for metastatic and recurrent cancers due to its inherent ability to stop angiogenesis; a vital step for tumor growth. Bevacizumab has also been implicated as the cause of PRES due to …

A Deadly Prescription: Combination Of Methotrexate And Trimethoprim-Sulfamethoxazole., Mohsin Hamid, Bilal Lashari, Irfan Ahsan, Ida Micaily, Usman Sarwar, Joseph Crocetti

Abington Jefferson Health Papers

Methotrexate (MTX) is a chemotherapeutic synthetic(s) phase cell cycle inhibitor, and its role has evolved as an immunological agent in autoimmune diseases like rheumatoid arthritis, psoriasis, and systemic lupus erythematosus, etc. Trimethoprim-sulfamethoxazole (TS) is one of the most widely prescribed antibiotics commonly used for urinary tract infections, exacerbations of chronic bronchitis, traveler's diarrhea, and pneumocystis pneumonia. Both MTX and TS can have significantly overlapping side effects involving dermatologic, renal, and hematological systems, and the combination of these can be deadly. Our case is about the combination of MTX and TS that leads to mucocutaneous ulceration, leukopenia, and renal insufficiency. The …

Cross-Departmental Educational Program On Complex Airway And Epistaxis Management, Adam Vasconcellos, Md, Meghan Crawley, Md, Michael Topf, Md, Ryan Gerritsen, Md, Dominick Gadaleta, Md, Joseph Spiegel, Md

House Staff Quality Improvement and Patient Safety Conference (2016-2019)

Internists, emergency medicine physicians, and intensivists routinely provide essential care for patients with complex airways (i.e. tracheostomy and laryngectomy) and patients with epistaxis. Any of these physicians may serve as first responder in a complex airway or epistaxis emergency situation. Therefore, a basic understanding of complex airway and epistaxis management is essential. The otolaryngology department aims to provide our colleagues with fundamental take-home points to improve crossdepartmental care of these patients.

Get With The Rhythm – Telemetry Education In Internal Medicine Residency, Rashesh Shah, Md, Hanna Sofie Ellingsen, Md, Molly Halloran, Md, Reetu Mukherji, Md, Juergen Kloo, Md, Yair Lev, Md

House Staff Quality Improvement and Patient Safety Conference (2016-2019)

Aim

• Our aim was to design and implement cardiac monitoring education for medical residents in order to help residents feel more comfortable navigating and assessing telemetry.
• Our objective was to create and pilot a telemetry education video among Internal Medicine residents (from March to May 2018) resulting in a 75% increase in ability to demonstrate essential telemetry skills as determined by a pre and post video assessment.

The ‘Med History Note’: A Standardized Method Of Reducing Medication History Errors Among Internal Medicine Residents In A Teaching Hospital, Odunayo Banjoko, Md, Babatunde Ogunnaike, Md, Genene Amoia-Pigliacelli, Pharmd, Doron Schneider, Md

House Staff Quality Improvement and Patient Safety Conference (2016-2019)

Problem Statement

According to the institute of medicine’s preventing medication errors report, the average hospitalized patient is subject to at least one medication error per day. Errors have been known to occur during admission, transfer and discharge of patients. An accurate medication history on admission is crucial and can go a long way in preventing medication reconciliation errors. Of note, more than 40% of medication errors occur from inadequate reconciliation, during admission, transfer and discharge of patients. Of these, 20% result in harm.

A Bibliometric Analysis Of The Top 100 Cited Articles On Hepatic Magnetic Resonance Imaging., Waqas Ullah, Hafez Mohammad A. Abdullah, Ejaz Ahmad, Mamoon Ur Rashid, Muhammad Bashir, Asad Ur Rahman, Asrar Ahmad, Abu Hurairah

Abington Jefferson Health Papers

The purpose of this study is to guide the readers to the impact of the articles published on hepatic magnetic resonance imaging (MRI). We searched Scopus using 10 different search terms for hepatic MRI. The selected studies were thoroughly reviewed by two independent authors and any disagreement was sorted out by mutual consensus. The list of articles and journals was downloaded into an excel spreadsheet. Only the top 100 cited articles were selected by mutual consensus among all the authors. These articles were further read in the full-text form and were further categorized into subgroups. Three authors independently reviewed the …

Understanding Patient Uncertainty As A Driver Of Emergency Department Utilization: A Concept Mapping Approach, Angela Gerolamo, Phd, Rn, Shannon Doyle, Mph, Rhea E. Powell, Md, Mph, Amanda M.B. Doty, Ms, Marianna Lanoue, Phd, Kristin L. Rising, Md, Mshp

Department of Emergency Medicine Posters

Background and Purpose

• Most previous research regarding factors associated with increased risk of emergency department (ED) use has been done via retrospective review of medical records rather than obtaining patients’ perspectives.
• Recent research identified patient uncertainty related to symptoms as a primary motivator for seeking ED care, and ongoing uncertainty at the time of ED discharge as an unmet need (Rising et al. 2015; Rising, Hudgins, Reigle, Hollander, & Carr 2016).
• While providers have limited ability to influence many factors identified by retrospective medical record review (e.g. financial concerns), patient uncertainty can be addressed by providers directly. To do so …

Large, Long Range Tensile Forces Drive Convergence During, David R. Shook, Eric Kasprowicz, Md, Lance A. Davidson, Raymond Keller

Division of Internal Medicine Faculty Papers & Presentations

Indirect evidence suggests that blastopore closure during gastrulation of anamniotes, including amphibians such as Xenopus laevis, depends on circumblastoporal convergence forces generated by the marginal zone (MZ), but direct evidence is lacking. We show that explanted MZs generate tensile convergence forces up to 1.5 mN during gastrulation and over 4 mN thereafter. These forces are generated by convergent thickening (CT) until the midgastrula and increasingly by convergent extension (CE) thereafter. Explants from ventralized embryos, which lack tissues expressing CE but close their blastopores, produce up to 2 mN of tensile force, showing that CT alone generates forces sufficient to close …

Deciphering A Case Of Pulmonary Hypertension In A Young Female: Partial Anomalous Pulmonary Venous Drainage The Culprit, Hiten R. Patel, Suchit Bhutani, Fayez Shamoon, Hartaj Virk

Abington Jefferson Health Papers

Partial anomalous pulmonary venous drainage (PAPVD) is a rare congenital cardiac defect and is associated with sinus venosus atrial septal defect. While most cases are asymptomatic, a patient can present with pulmonary hypertension (PHTN) and it can be difficult to diagnose. Here, we discuss the case of a young female with PHTN who was found to have two right-sided PAPVD. Through this case, authors try to emphasize the importance of meticulous and thorough investigation when evaluating PHTN, which allows for correct diagnosis and a timely intervention before PHTN becomes irreversible.

The Association Of Hyponatremia With Race, Ethnicity, And Gender In Patients Admitted For Acute Decompensated Heart Failure Diagnoses, Vikas Sunder, Md, Rene Alvarez, Md, Evan Carabelli, Md

Division of Internal Medicine Faculty Papers & Presentations

Background: Hyponatremia, defined by a serum sodium concentration less than 135 mEq/L, is seen in approximately 25% of patients admitted with congestive heart failure (CHF). Hyponatremia on admission has been shown to increase in-hospital mortality and to be an independent predictor of 6month mortality. Prior work has shown that CHF patients with hyponatremia on admission are more likely to be Caucasian. Given its prognostic significance, hyponatremia and its association with patient characteristics warrants further study.

Methods: We queried for unique admissions to Temple University Hospital between 2011 and 2015 with a DRG code of "291-293" to represent a …

A Rare Case Of Hemophagocytic Lymphohistiocytosis Of Unknown Etiology, Ida Micaily, Marie Helene Gagnon, Richard Friedenheim, Jason A. Damsker

Division of Internal Medicine Faculty Papers & Presentations

Hemophagocytic lymphohistiocytosis (HLH) is an uncommon cytokine storm syndrome marked which can cause high mortality. In adults, acquired HLH usually has an underlying infectious, autoimmune or malignant process that triggers the syndrome. In this case report, we present a 64-year old Caucasian male presenting with productive cough, fevers, weight loss and altered mental status who was ultimately found to have HLH of unknown etiology.

Resident Reflection: Mrs. C, Rachel Nash, Md

The Medicine Forum

“Make friends with those critical care nurses in the ICU,” my friend from high school and general floor nurse whispered in my ear before the start of my MICU rotation. “They can really save your butt.” This was one of my many goals I set out to achieve during my first month in the intensive care unit as an intern. I wanted to become more comfortable managing very sick patients, get some procedures under my belt, and mostly “survive” the emotionally and physically taxing weeks that were sure to come.

The sign out I received on my 3-patient load suddenly …

Grand Rounds Panel Discussion: Provider Payment Reform: Past, Present, And Future, Neha Bansal Etherington, Md, Shuwei Wang, Md, Debbie Chen, Md, Anita Modi, Md, Jad Al Danaf, Md

The Medicine Forum

Panelists:

Gregory C. Kane, MD, FACP The Jane and Leonard Korman, Professor and Chairman, Department of Medicine

David B. Nash, MD, MBA The Dr Raymond C and Doris N Grandon Professor, and Dean of the Jefferson College of Population Health

Rhea E. Powell, MD, MPH Assistant Professor of Medicine

Rachel B. Sorokin, MD, FACP Associate Professor of Medicine and Medical Director of Safety and Quality

Lawrence D. Ward, MD, MPH Associate Professor of Medicine and Vice Chairman for Clinical Practice and Quality

Introduction:

The impetus for provider payment reform in healthcare grew out of the recognition that growth in healthcare …

Fatal Rituximab-Induced Nonspecific Interstitial Pneumonia: Case Report And Review Of The Literature, Rino Sato, Md, Jeremy Molligan, Md, Sameh Gaballa, Md

The Medicine Forum

Introduction:

Rituximab is a chimeric anti-CD20 monoclonal antibody that is used to treat some hematological malignancies such as B-cell lymphomas, and various autoimmune diseases including immune thrombocytopenic purpura, systemic lupus erythematous, rheumatoid arthritis, and autoimmune hemolytic anemia. The most common side effects include fever, chills, and rigors. Respiratory complications such as cough, bronchospasm, sinusitis, and rhinitis have also been reported in 30% of patients in clinical trials.1 Rituximab-induced lung injury is a very rare but potentially fatal complication. We report a case of fatal single agent rituximab-induced nonspecific interstitial pneumonia to increase awareness about this serious side effect and review …

Brugada Syndrome: Diagnosis And Management, Amit Vira, Md, Ehsanur Rahman, Md

The Medicine Forum

Introduction:

The vast majority of cases of sudden cardiac arrest (SCA) are caused by ventricular tachyarrhythmias (VT), with most cases associated with structural heart disease. SCA in a structurally normal heart is an uncommon occurrence, most often occurring in the third decade of life and accounting for 5-15% of total SCA cases1-2. Common causes include Brugada syndrome, congenital long QT syndrome, catecholaminergic polymorphic ventricular tachycardia, arrhythmogenic right ventricular cardiomyopathy, and idiopathic ventricular tachycardia1-3. The majority of these patients with a structurally normal heart are undiagnosed until presenting with sudden cardiac death. It is believed that cardiac arrest is the initial …

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) …