Internal Medicine Commons^™

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.

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.

Telemedicine Coverage For Post-Operative Icu Patients., Tara Ann Collins, Matthew P. Robertson, Corinna P. Sicoutris, Michael A. Pisa, Daniel N. Holena, Patrick M. Reilly, Benjamin A. Kohl

Department of Anesthesiology Faculty Papers

Introduction There is an increased demand for intensive care unit (ICU) beds. We sought to determine if we could create a safe surge capacity model to increase ICU capacity by treating ICU patients in the post-anaesthesia care unit (PACU) utilizing a collaborative model between an ICU service and a telemedicine service during peak ICU bed demand. Methods We evaluated patients managed by the surgical critical care service in the surgical intensive care unit (SICU) compared to patients managed in the virtual intensive care unit (VICU) located within the PACU. A retrospective review of all patients seen by the surgical critical …

Can Contrast Harmonic Endoscopic Ultrasonography Replace Endoscopic Ultrasonography-Guided Fine-Needle Aspiration In Patients With Solid Pancreatic Lesions? An American Perspective., Joseph Yoo, Linda H. Yan, Ali A. Siddiqui

Division of Internal Medicine Faculty Papers & Presentations

No abstract provided.

From The Editors, Anusha Govind, Md, Loheetha Ragupathi, Md, Jad Al Danaf, Md, Mph, Shuwei Wang, Md

The Medicine Forum

Dear Students, Residents, Faculty, and Friends of the Forum,

We are excited to present you with the 17th annual edition of The Medicine Forum. This work reflects the talent, passion, creativity, and scientific inquisitiveness of Jefferson medical students, residents, fellows and faculty. It also celebrates the diverse patients who serve as the centerpiece for each story.

Unique to this issue is the initiation of Grand Rounds Discussions focusing on controversial medical topics with inputs from an array of experts. This year we discussed perioperative management of anticoagulation and antiplatelet agents, and we had exciting viewpoints from experienced cardiologists, a hematologist, …

A Difficult Conversation, Shuwei Wang, Md

The Medicine Forum

I put on my isolation gown, knocked on his hospital room door, and entered to initiate the family meeting. I had been dreading this meeting all morning. It is never easy telling the loved ones of a thirty-seven year old that his disease is terminal, and he is actively dying.

I greeted Mr. M, his girlfriend and sister with the help of a Spanish translator. He smiled and had a twinkle in his jaundiced eyes. He was debilitated, bed bound with anasarca, his right thigh tightly bound by multiple blood stained pressure dressings. "Hola", I greeted them with the little …

A Tribute To Our Nurses, Anusha Govind, Md

The Medicine Forum

I turned faint and weary as the page came through "Your patients heart rate is one hundred eighty" My legs shook as I ran up the stairs Thoughts racing a mile a minute, hoping someone more knowledgeable might be there first As I turned a corner, color draining from my face Then I spot my savior, the nurse, holding a syringe filled with the medication I knew now my patient and I were in good hands.

Grand Rounds Panel Discussion: Blood Thinners Peri-Operatively: What To Do?, Jad Al Danaf, Md, Anusha Govind, Md, Loheetha Ragupathi, Md, Shuwei Wang, Md

The Medicine Forum

PANELISTS

Mathew DeCaro, MD: Associate Professor of Cardiology, Director of the Coronary Cardiac Unit, Cardiology fellowship program director

John Doherty, MD: Professor of Cardiology

Gregary Markefka, MD: Associate Professor of Cardiology, Associate Director of the Coronary Cardiac Unit, Cardiology fellowship assistant program director

Geno Merli, MD: Professor of Vascular Medicine, Co-director of Jefferson Vascular Center

Srikanth Nagalla, MD, MS: Associate Professor of Medicine, Director, Clinical Hematology

Eric Schwenk, MD: Assistant Professor of Anesthesiology, Director of orthopedic anesthesia

Barry Ziring, MD: Clinical Associate Professor of Internal Medicine / Primary Care, Director of the division …

The Financial Dialogue In The Development Of Medical Treatment Plans, Christopher D. Busack, Ms3, Bethany Fox, Ms3

The Medicine Forum

As patients face increasingly high out-of-pocket costs and difficulties navigating the healthcare system, failing to discuss available treatment options in financial terms can lead to grave consequences for patients. Medical bills are responsible for the majority of bankruptcies in the United States. Given the severe financial implications of medical bills, it is imperative that patients become more involved in discussions of their treatment plans and become aware of the costs of their decisions up front. Counseling about costs ensures that physicians avoid placing a debilitating financial burden on patients and maintain adherence to the ethical principle of non-maleficence. Various studies …

Pemphigoid Gestationis: A Rare Dermatosis Of Pregnancy, Victoria Tran, Ms3, Meghan Belamorich, Md

The Medicine Forum

INTRODUCTION

Pemphigoid gestationis is a rare dermatosis of pregnancy that often goes unrecognized or misdiagnosed. It can lead to adverse fetal outcomes including preterm delivery, low fetal birth weight, and even neonatal pemphigoid gestationis1. As such, proper diagnosis and management is critical in reducing fetal risk.

Identification And Management Of Cobalt Toxicity: A Case Report Of Rapidly Progressing Toxicity After Hip Arthroplasty Revision, Neena Mohan, Md, Eric Kasprowicz, Md

The Medicine Forum

INTRODUCTION

Patients undergoing total hip arthroplasty represent a growing portion of the population. More than 330,000 hip replacements are performed annually1, and more than 2.5 million Americans are living with a hip prosthesis2. Many hardware configurations utilize metal alloys for the femoral head and/or acetabulum. Although their use is decreasing due to safety concerns, cobalt-chromium femoral heads were still used in 51% of total hip arthroplasties in 20143. There is rising concern about the adverse effects of metal ions released from these joint replacements. However, little published evidence is available supporting specific interventions for the management of cobalt toxicity.

Given …

Kikuchi Disease: Recognizing A Common Presentation Of An Uncommon Condition, Ramya Punati, Md

The Medicine Forum

INTRODUCTION

Kikuchi disease, also known as histiocytic necrotizing lymphadenitis or Kikuchi-Fujimoto disease, is a rare condition that typically presents with fever and cervical lymphadenopathy in previously healthy young women. First described by Dr. Kikuchi and independently by Dr. Fujimoto in Japan in 1972, the disease is benign and usually self-limited. However, because it can present dramatically and mimic more serious conditions such as lymphoma and tuberculous adenitis, recognizing Kikuchi disease is crucial to avoid misdiagnosis and inappropriate treatment. This case describes a patient who presented with severe manifestations of Kikuchi disease that generated an extensive workup and differential diagnosis prior …

A Case Report Of Multiple Aseptic Facial And Spinal Abscesses In A 45-Year-Old With Inflammatory Bowel Disease, Matthew Zheng, Md, Kristen Jackson, Md, Gloria Francis, Md, Bolin Niu, Md

The Medicine Forum

INTRODUCTION

Sterile abscess syndrome is a rarely described entity that is often associated with auto-inflammatory disorders. Although clinically similar to septic abscesses, sterile abscesses are known to be unaffected by antibiotic regimens and instead highly sensitive to steroids. The association of sterile abscesses with inflammatory bowel disease has been well-described. The majority of sterile abscess syndromes described in the literature are intraabdominal abscesses related to a primary gastrointestinal inflammatory disease. We describe a unique case of extra-abdominal sterile abscess syndrome associated with inflammatory bowel disease presenting as facial and paraspinal lesions.

Distal Renal Tubular Acidosis And Diabetes Insipidus Leading To The Diagnosis Of Sjögren's Syndrome, Loheetha Ragupathi, Md, Elijah Grillo, Md, Jonathan Yadlosky, Md, Ravi Sunderkrishnan, Md

The Medicine Forum

INTRODUCTION

Sjögren's syndrome is a chronic inflammatory disease characterized by the infiltration and progressive destruction of salivary and lacrimal glands. A common presentation involves the complaints of dry eyes and dry mouth, known as the “sicca complex.” Extra-glandular involvement is not uncommon, and is known to involve the lungs, vascular and peripheral nervous system, and kidney.1 The reported renal involvement ranges broadly from 2 – 67%,and is variably defined: the most commonly reported renal pathology is an a tubulo- interstitial nephritis resulting in tubular dysfunction and immune-mediated glomerular disease; however distal renal tubular acidosis (RTA) in particular can be present …

Bilateral Adrenal Hemorrhage In A Patient With Antiphospholipid Syndrome, Silpa Yalamanchili, Md

The Medicine Forum

INTRODUCTION

Bilateral adrenal hemorrhage is relatively uncommon, with a reported incidence in the United States of 0.3-1.8% in hospital post-mortems1.Clinical manifestations of adrenal hemorrhage are widely variable, making diagnosis a challenge. Left undiagnosed and untreated, bilateral adrenal hemorrhage may lead to cardiovascular collapse and/or death. Here we present a rare case of bilateral adrenal hemorrhage in a patient with antiphospholipid syndrome; the aim of this case, and the corresponding literature review, is to highlight risk factors for and management of this condition.

Amiodarone-Induced Thyrotoxicosis And Ventricular Arrhythmias: Case Report And Review Of The Literature, Ashish Shah, Md

The Medicine Forum

INTRODUCTION

Amiodarone is a common drug used to treat arrhythmias and its side effects are diverse. An important adverse effect is amiodarone-induced thyrotoxicosis (AIT), which can potentially lead to a pro-arrythmogenic state. There have been limited studies on the pathogenesis of how thyrotoxicosis increases the risk of ventricular arrhythmias, which causes providers to face a therapeutic challenge in patients who require this medication for the prevention of life threatening arrhythmias. This case report will present a patient with a left ventricular assist device (LVAD) who had recurrent ventricular arrhythmias on chronic amiodarone therapy in the setting of AIT.

Two Cases Of Vibrio Infection And Sepsis In The Delaware Estuary, René Daniel, Md, Joseph Yoo, Md, Roberto Fratamico, Md, Robert Measley, Md

The Medicine Forum

INTRODUCTION

Vibrio is a genus of Gram-negative motile rods. Several species are pathogenic, including Vibrio vulnificus and Vibrio parahaemolyticus. The interest in this genus is due to its extreme virulence and often fatal outcomes. In healthy patients, these infections are typically self-limited; however, in immunocompromised and cirrhotic patients, infections can result in bacteremia, which has a high fatality rate1. Both pathogens may cause acute gastroenteritis, necrotizing wound infections, and if severe, subsequent bacteremia. In this report, we present two cases of Vibrio infections recently identified in the Delaware River Estuary that resulted in severe sepsis and, in one case, death.

Unexplained Recurrent Fevers And The Importance Of Inquiring About Occupation: A Case Report, Zachary Reese, Ms4, Poonam Maru, Do

The Medicine Forum

INTRODUCTION

Many different tick-borne diseases are identified in various geographical areas throughout the United States. Ixodes scapularis tick-borne diseases can present unique diagnostic challenges because of their constellation of vague symptoms. The Ixodes scapularis tick, more commonly known as the blacklegged tick, is responsible for three specific tick-borne infections: Lyme disease (Borellia burgdorferii), Babesiosis (Babesia microti), and Anaplasmosis (Anaplasma phagocytophilum) also known as human granulocytic anaplasmosis. Although these three tick-borne diseases are characteristically found in the New England area, the geographical distribution of the Ixodes tick has expanded to encompass much of the northeastern United States and even states in …

Case Report: Pthrp Related Hypercalcemia In Diffuse Large B-Cell Lymphoma, Ankita Mehta, Md, Evan Caruso, Md

The Medicine Forum

INTRODUCTION

Hypercalcemia is commonly associated with solid tumor malignancies, but less often with hematologic malignancies. When present in hematologic malignancies, hypercalcemia is often secondary to overproduction of Vitamin D from the tumor cells. Very few cases with parathyroid hormone related peptide (PTHrP) induced hypercalcemia in B-cell lymphomas have been reported. Here we present a 44 year old male with a history of chronic lymphoctic leukemia who presented with hypercalcemia and an elevated PTHrP, found to have a transformation to Diffuse Large B-cell Lymphoma (DLBCL).

Anorectal Melanomas: Case Series, Jinyu Zhang, Md, Matthew Sochat, Md, Edward R. Feller, Md

The Medicine Forum

INTRODUCTION

Melanoma is the most common tumor to metastasize to the gastrointestinal (GI) tract. 60% of patients who die with malignant melanoma have GI involvement at autopsy1. Symptomatic disease presenting during life is unusual. Anorectal melanoma, a rare tumor that represents 1% of all melanomas and less than 4% of all anal malignancies, manifests with a range of non-specific symptoms and physical exam findings2. In fact, about one-third of lesions may be amelanotic3,4. Initial misdiagnosis as a benign lesion such as hemorrhoid is common.

We report 3 cases of anorectal melanoma presenting as primary GI complaints all without known cutaneous …

Case Report: Uncontrolled Anasarca: Capillary Leak Syndrome, Ankita Mehta, Md, Mansi Shah, Md

The Medicine Forum

INTRODUCTION

Capillary leak syndrome (CLS) is a rare clinical disease that causes edema, hypoproteinemia, episodic hypotension, dyspnea, hyponatremia, and weight gain that can be life threatening1. Although the underlying pathology is currently unknown, CLS is thought to be secondary to a systemic process associated with hyperpermeability of the body's microcirculation, resulting from a diffuse and severe disruption of the endothelium and causing generalized edema and often acute respiratory distress2.

Limitations Of The Perioperative Cardiovascular Evaluation For Assessing Coronary Artery Disease: A Case Report, Rady Ho, Md, Mitul Kanzaria, Md, Paul Walinsky, Md

The Medicine Forum

INTRODUCTION

The American College of Cardiology (ACC) and the American Heart Association (AHA) publ ished pre-operative risk stratification guidelines in 2014. These guidelines have routinely been used by physicians to pre-operatively risk stratify patients. In this case report, a patient was found to have multi-vessel coronary artery disease post-operatively in the setting of unremarkable cardiac work-up preoperatively. This case highlights a limitation of the 2014 ACC/AHA guidelines.

Case Report: Diagnosis Of Dual-Biopsy Negative Severe Cardiac Amyloidosis, Kristin Lohr, Md, Eric Kasprowicz, Md

The Medicine Forum

INTRODUCTION

Amyloidosis is a rare disorder that involves the deposition of misfolded protein in extracellular tissue. Disease manifestations vary depending on the affected organs. Areas most often involved include the kidneys, gastrointestinal tract, heart, nervous system, and musculoskeletal system. The most common type is AL amyloidosis, in which plasma cells produce an abundance of a monoclonal proteins that affect numerous organ systems. A second variety, AA amyloidosis, is associated with inflammatory diseases such as rheumatoid arthritis and inflammatory bowel disease. Finally, a heritable version of amyloidosis mediated by mutations in the transthyretin protein (TTR) has a predilection for deposition in …

Coronary Subclavian Steal Syndrome, Rady Ho, Md, Jonathan A. Dunn, Md

The Medicine Forum

INTRODUCTION

Coronary subclavian steal (CSS) syndrome is a rare complication of coronary artery bypass graft surgery (CABG) involving the left internal mammary artery (LIMA) graft to the left anterior descending (LAD) artery. It results from stenosis of the left subclavian artery proximal to the LIMA, which compromises myocardial blood flow. The incidence of CSS syndrome is between 0.1-3.4% in the United States.1 Most cases occur as a result of long-standing subclavian stenosis due to progres-sion of the stenosis following CABG. We report a case of CSS syndrome, which presented as a non-ST elevation myocardial infarction (NSTEMI).