Internal Medicine Commons^™

Assessment And Intervention For Health Behavior Change In Primary Care Across The Lifespan: A Guide For Residents In Primary Care Specialties, Stacy A. Ogbeide, Alexis Ramos, Bridget Murphy, Angel Ogbeide

HCA Healthcare Journal of Medicine

More than 45% of Americans have at least 1 chronic disease, with chronic disease also being a leading cause of death in the United States. In primary care settings, about 75% of visits are for management of multiple chronic diseases. Due to the increasing medical complexity of patients who present to primary care, these numbers make it more challenging for Primary Care Clinicians (PCCs) to manage these conditions alone and point to the need for innovative solutions to chronic disease care. One evidence-based innovation is team-based care to improve the treatment of these conditions. Clinicians such as clinical pharmacists, registered …

Navigating Complex Esophageal Perforations: A Case-Specific Approach To Successful Outcomes, Harsimran Kalsi, Anushree Rai, Kobina Essilfie-Quaye, Neeka Akhavan, Yaseen Perbtani, Tony S. Brar

HCA Healthcare Journal of Medicine

Esophageal perforation is a life-threatening condition requiring prompt diagnosis and effective management. While self-expanding metal stents (SEMS) are a first-line treatment, persistent leaks often necessitate adjunctive endoscopic interventions. A structured, multimodal approach is critical for optimizing outcomes and avoiding surgical intervention. A 44-year-old man developed an iatrogenic esophageal perforation following surgical leiomyoma enucleation. Initial treatment with overlapping fully covered self-expanding metal stents (FC-SEMS) failed to achieve closure, necessitating endoscopic suturing for defect reinforcement. Despite suturing, persistent leakage required placement of a larger-diameter FC-SEMS, secured with an endoscopic fixation system to prevent migration. Serial imaging confirmed successful defect closure, allowing the …

Optimizing Antibiotic Strategies With A Clinical Pathway Approach: Enhanced Initiation And De-Escalation In Community-Acquired Pneumonia, Ahmad Behzadpour

HCA Healthcare Journal of Medicine

Background

Community-acquired pneumonia (CAP) remains a leading cause of hospitalization, mortality, and health care expenditure worldwide. Inappropriate use of broad-spectrum antibiotics contributes to antimicrobial resistance, adverse drug events, and increased costs. Antibiotic stewardship and standardized clinical pathways are key strategies to improve prescribing practices.

Methods

This quality improvement (QI) initiative was conducted at a 240-bed tertiary care teaching hospital from January 2023 through January 2025. A CAP-specific digital clinical pathway was developed using Curbside Health® and integrated into the electronic health record (EHR), accessible through a structured order set to support real-time clinical decision-making. The intervention included provider education and …

Benign Transient Hyperphosphatasemia In Adults: Case Report And Literature Review, Jose L. Rodriguez Castro, Grettel Gonzalez Garcia, Daniel Heller, Bernardo J. Reyes

HCA Healthcare Journal of Medicine

Background

Benign transient hyperphosphatasemia (BTH) in children is characterized by temporary highly elevated serum alkaline phosphatase (ALP) activity in the absence of liver or bone disease and a return to normal within 3 to 4 months. Since its first description in the 1950s, several cases of BTH in infants and children have been reported. Although there is no known etiology for this illness, it has been associated with viral infections. This condition has rarely been seen in the adult population, and there is scarce available information. The sialylation of the ALP isoenzymes decreases their renal clearance from the circulation; however, …

Hughes-Stovin Syndrome: A Case Report Of A 24-Year-Old Male With Pulmonary Aneurysms And Deep Vein Thrombosis, Clara Liu, Zhiyin Li, Supriya Bhupathy, Bradley Todd Andersen, Andrew Hwang

HCA Healthcare Journal of Medicine

Background

Hughes-Stovin Syndrome (HSS) is a rare vasculitis characterized by pulmonary artery aneurysms (PAAs) and peripheral venous thrombosis. Anticoagulation, the standard treatment for venous thrombosis, is often contraindicated in HSS due to the risk of fatal pulmonary hemorrhage, especially since mortality rates of patients with a history of hemoptysis are reported at 50%-100% from PAA ruptures, yet treatment guidelines are limited due to the condition’s rarity with fewer than 90 reported cases globally. This report highlights the complex management decisions required.

Case Presentation

A 24-year-old man with a 3-month history of PAAs, left lower extremity deep vein thrombosis (DVT), and …

Wilson’S Disease Psychosis In A Young Man With Autism Spectrum Disorder: A Case Report And Focus On Management, Landon C. Sowell, Barbara L. Gracious

HCA Healthcare Journal of Medicine

Introduction

Wilson's disease is a rare autosomal recessive disorder, affecting approximately 1 in 30 000 individuals and is characterized by abnormal copper accumulation in the body, primarily affecting the liver and brain. Psychiatric manifestations as a first presentation, particularly psychosis, are less commonly recognized resulting in failure to begin treatment early in the course of the disease. This case report highlights a patient that presented to the hospital with psychosis, who was later diagnosed with Wilson’s disease. This case underscores the importance of considering organic causes in first-episode psychosis.

Case Presentation

An 18-year-old man with a history of autism spectrum …

Upper Respiratory Tract Infection Leading To A New Diagnosis Of Sweet Syndrome And Monoclonal Gammopathy Of Unknown Significance, Nidhi Rawat, Meron Gebrehiwot, Jason Raw, Jeyaprakash Ramachandran

HCA Healthcare Journal of Medicine

Background

We present a rare case of Sweet syndrome with underlying monoclonal gammopathy of unknown significance (MGUS) which initially presented as upper respiratory tract infection.

Case Presentation

A 52-year-old woman presented with a complaint of sore throat for 6 days, productive cough and fever for 5 days, and red, pruritic, circular, tender rashes on face, arms and trunk for 2 days. There was a past history of similar self-limiting rashes presenting intermittently for 1.5 years. She also reported to be taking tablet ibuprofen, as required for the past 1-2 years, for cervical spondylosis. On integumentary examination, widespread, red, tender, annular …

Rectal Fidaxomicin As Salvage Therapy In Fulminant Clostridioides Difficile Infection After Total Colectomy: A Case Report, Akankcha Alok, Mohamed Ismail, Stephanie Pino Fabara, Mohammed Al Said, Vidya Sagar Kollu

HCA Healthcare Journal of Medicine

Introduction

Clostridioides difficile infection (CDI) is a significant cause of antibiotic-associated diarrhea and colitis, ranging from mild to severe and potentially life-threatening conditions, like fulminant colitis with toxic megacolon and bowel perforation. The 2021 guidelines from the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) recommend vancomycin and metronidazole for fulminant CDI (FCDI), with consideration of rectal vancomycin for cases with ileus. Fidaxomicin, though preferred for initial and recurrent CDI treatment, is not the first line for FCDI due to limited evidence. Fidaxomicin has a narrow spectrum of activity only targeting C difficile and …

Clinical Characteristics Associated With Hospital Mortality And Length Of Stay Among Older Adults Admitted With Delirium: Retrospective Analysis, Se Won Lee, Jeff J. Kim, Cole Kretchmar, Napatkamon Ayutyanont, Mooyeon Oh-Park

HCA Healthcare Journal of Medicine

Background

Limited information exists on the characteristics of older adults admitted with delirium at risk of poor hospital outcomes. This study aims to identify risk factors present on admission that are associated with hospital mortality and length of stay (LOS) among older adults admitted with delirium.

Methods

This is a retrospective study of 5598 patients 65 years of age or older who were admitted to acute care units at 8 community hospitals with an International Statistical Classification of Diseases, Tenth Revision code of delirium.

Results

Multivariate regression analyses revealed that in-hospital mortality increase was associated with increased age, Asian race, …

Nondominant Right Coronary Artery Occlusion Leading To An Anterior St-Segment Elevation Myocardial Infarction, Taha Ahmed, Taylor Wood, Austin Harris, Rajan Desai, Garima Handa, Naoki Misumida, Amartya Kundu

HCA Healthcare Journal of Medicine

Background

A nondominant right coronary artery supplies a small portion of the myocardium. Albeit rare, an acute occlusion of a nondominant right coronary artery is believed to be inconsequential with minimal clinical relevance.

Case Presentation

We present a case of a middle-aged man who presented with chest pain and an electrocardiogram demonstrating anterior ST-segment elevation. An emergent coronary angiogram revealed acute thrombotic occlusion of the proximal nondominant right coronary artery with no significant obstructive atherosclerotic disease in the dominant left coronary circulation. Balloon angioplasty of the occluded vessel followed by implantation of a drug-eluting stent resulted in the resolution of …

Recurrent, Acute Limb Ischemia Secondary To Arterial Thrombosis: A Devastating Complication In The Setting Of Severe Covid-19 Infection, Shaikh Afaq, Kyle S. Strouse, Sini Saju, Olugbenga Oyesanmi, Mohamad Eid, Salman Muddassir

HCA Healthcare Journal of Medicine

Background

COVID-19 infection, particularly with the Delta variant, has been associated with a heightened risk of thromboembolic events due to a profound hypercoagulable state. While venous thrombosis is more commonly reported, arterial thrombosis—including acute limb ischemia—has emerged as a serious complication with significant morbidity and mortality.

Case Presentation

We report the case of a 53-year-old man with severe COVID-19 pneumonia who developed recurrent acute limb ischemia secondary to an aortic mural thrombus. Despite therapeutic anticoagulation and multiple surgical interventions—including thrombectomy, angioplasty, and stenting—the patient experienced repeated episodes of arterial thrombosis. His clinical course was further complicated by pneumothorax and hemothorax, …

Complications And Management Of Idiopathic Multicentric Castleman Disease, Kavanya Feustel, Jacob W. Keeling, Olivia Makos, Dmitriy Scherbak

HCA Healthcare Journal of Medicine

Background

The pathophysiology of idiopathic multicentric Castleman disease (iMCD) is poorly understood compared to the other subtypes of MCD, which has contributed to limited treatment options and poor prognosis for iMCD patients. The pathogenesis of iMCD is thought to be mediated in part by dysregulation of interleukin (IL)-6.

Case Presentation

We present a case report of a 39-year-old Caucasian man with siltuximab-refractory iMCD. He presented with severe lower extremity lymphedema and wounds. His disease progressed through standard-of-care siltuximab. Due to his severe disease-related morbidity, he contracted recurrent infections, often complicated by sepsis. Ultimately, he required a left lower extremity amputation. …

Covid-19 Vaccine-Induced Rhabdomyolysis In A 53-Year-Old Woman, Akash Hazari, Jack Chien, Daniel Nunez

HCA Healthcare Journal of Medicine

Introduction

COVID-19-induced rhabdomyolysis is a common complication in COVID-19 infection. However, only a handful of cases have been reported showing links between COVID-19 vaccine and rhabdomyolysis.

Case Presentation

We present the case of a 53-year-old woman, who recently received COVID-19 vaccine and presented to the hospital with progressive extremity weakness. Common reasons for rhabdomyolysis were ruled out as possibility and the patient was found to have rhabdomyolysis induced from COVID-19 vaccine.

Conclusion

Even though COVID-19 vaccine-induced rhabdomyolysis is rare, it should be considered in the differential diagnosis with patients presenting with neuromuscular complaints and a recent COVID-19 vaccine.

Clinical Outcomes After Hospitalization For Acute Coronary Syndrome In Patients Treated With Semaglutide Versus Bariatric Surgery: A Retrospective Multicenter Analysis, Nameer Ascandar, Charles Boadu, Gauthier Stepman, George Skaf, Olugbenga Oyesanmi, Sabry Omar, Rias Ali, Michael Schandorf-Lartey

HCA Healthcare Journal of Medicine

Background

Obesity is a chronic medical condition with a rising prevalence in the United States. A wide range of morbidity and mortality is associated with obesity, with coronary artery disease being among the most common. Ischemic heart disease continues to be the primary cause of death in the United States. Taken together, interventions to minimize the detrimental effects of obesity on patients at risk of heart disease will not only benefit the patient, but the health care system as well.

Methods

In this retrospective study, we used the HCA Healthcare enterprise data warehouse to identify all adult patients who were …

Efficacy And Safety Of Lotilaner Ophthalmic Solution 0.25% In Demodex Blepharitis: A Systematic Review, Stephanie P. Fabara, Thalia Fabara, Akankcha Alok, Nausheen Khuddus

HCA Healthcare Journal of Medicine

Demodex blepharitis is a chronic eyelid inflammation caused by Demodex mites, which are ubiquitous skin parasites. Lotilaner, a newly United States Food and Drug Administration (FDA)-approved drug, is an antiparasitic agent that selectively inhibits parasite-specific γ-aminobutyric acid chloride channels, inducing spastic paralysis and death of Demodex mites. It is applied as an ophthalmic solution, 0.25%, twice a day for 6 weeks, and it has a long half-life and high lipophilicity, facilitating the penetration of the drug into the eyelash follicles and meibomian glands where the mites reside. This study systematically reviewed 6 clinical trials that compared lotilaner with placebo for …

Intracolonic Migration Of A Dislocated Acetabular Cup Prosthesis, Jack R. Lubka, Cyrus Tamboli, Philip Brunetti, Sarosh Tamboli, Alex Davis, Hamish Patel, Olugbenga Oyesanmi, Michael Strobbe, Shaival Thakore, Subhasis Misra, Jeffrey Mino

HCA Healthcare Journal of Medicine

Background

Acetabular cup migration is a rare complication of hip replacement surgery. If the acetabular socket of the ilium is weak, the prosthesis can erode or pass through it. There have been multiple reports of acetabular cup prosthesis migration to the colon, creating a coloarticular fistula between the hip joint and the cecum, sigmoid colon, or rectum. We report a rare presentation of a complete intracolonic migration of a prosthetic acetabular cup without creating a fistula.

Case Presentation

A 53-year-old female patient with a remote history of a total right hip replacement presented with abdominal pain and rectal bleeding. Computed …

Combating Physician Burnout And Fostering Wellness In Graduate Medical Education For Resident Physicians, Abdulaziz Mheir, Zohare Khan, Franklin Hernandez, Alaa Mohamed, Chandan Mitra

HCA Healthcare Journal of Medicine

Background

Over the last 2 decades, there has been a cultural shift in the graduate medical education (GME) space, focusing on an important facet: physician burnout. Burnout is defined as a combination of emotional exhaustion, depersonalization, and a lack of personal accomplishment. With increasing awareness of physician burnout, various wellness initiatives have begun to be implemented throughout training programs, and their results have been measured for effectiveness in reducing burnout rates. Due to the increasing rates of burnout emerging throughout GME programs, an initiative to evaluate our internal medicine (IM) residency on this matter was discussed with all residents at …

The Black Fungus: A Rare Case Of Pulmonary Mucormycosis, Stephanie Wong, Elsa Lesley Tchouambou Pougoue, Joanna Polanco, Betty Kirimi, Choudhry Poonam

HCA Healthcare Journal of Medicine

Background

Mucormycosis, commonly known as the "black fungus," is a severe infection affecting multiple organ systems, including the skin, brain, lungs, and gastrointestinal tract. This case report is focused on pulmonary mucormycosis, which is frequently observed in organ transplant recipients. Diagnostic challenges arise from nonspecific symptoms.

Case Presentation

Our case involved a 61-year-old male with a history of renal transplantation. The patient initially presented with a persistent cough and bloody sputum and was treated unsuccessfully for a presumed fungal infection. A lung biopsy confirmed pulmonary mucormycosis, emphasizing the heightened vulnerability of immunocompromised individuals.

Conclusion

This case highlights the intricate nature …

Updating A Rural Clinic In Tiburón, Haiti, Akankcha Alok, Mohamed Bakhit, Djenie Helne, Philipe Milord, Marcellas Socrate, Camil Clermont, Marie A. Kima

HCA Healthcare Journal of Medicine

Background

Tiburón is a small fishing village in Haiti with a clinic overseen by the Oblate missionaries and the Ministry of Public Health and Population (MSPP). This village was hugely impacted by Hurricane Matthew in 2016, leading to increased health care demands. The clinic was inaccessible from the furthest parts of the village and lacked basic medication supplies and adequate manpower. We aimed to reinforce the infrastructure and update the clinic using a multifaceted approach.

Methods

We developed a quality improvement project to strengthen the clinic's infrastructure and modernize its facilities with a comprehensive approach focused on enhancing health care …

Acute Exacerbation Of Idiopathic Pulmonary Fibrosis In The Setting Of Acute Eosinophilic Pneumonia, Duncan A. Mckinney, Noah R. Kosnik, Shahzeib Syed, Gretchen Junko

HCA Healthcare Journal of Medicine

Idiopathic pulmonary fibrosis (IPF) is a progressive disease characterized by gradual destruction and replacement of pulmonary parenchyma with fibrous tissue, which occurs in conjunction with chronic inflammation. It is often considered a prototypical interstitial lung disease and is both the most prevalent and perhaps the most dangerous in that family. Although the disease is uncommon in the general population, its prevalence increases with age and is typically diagnosed around the age of 65. This does not preclude the development of IPF in younger individuals, and the mean survival is 2 to 5 years post-diagnosis regardless of age. Contemporary studies have …

Veillonella Discitis: A Rare Presentation And Review Of Literature, Akankcha Alok, Vidya Sagar Kollu, Gautam Kalyatanda

HCA Healthcare Journal of Medicine

Background

Veillonella is an anaerobic gram-negative coccus found as a commensal organism in the oral, respiratory, gastrointestinal, and genitourinary tract of humans. Rarely, it can cause serious infections by the production of lipopolysaccharide, an endotoxin. Although most Veillonella infections occur in immunocompromised individuals, we herein describe cases of Veillonella discitis, a rare presentation of Veillonella, in immunocompetent patients.

Case Presentation

The first presented case was encountered in a patient admitted at our facility. All patient data were obtained from the hospital's electronic medical record system. Thereafter, a literature search and subsequent review was done on PubMed with the MEDLINE …

Hemophagocytic Lymphohistiocytosis Due To Ehrlichiosis: A Case Series, Ajay Iyer, Mattias D'Anna, Shruti Verma, Thomas Pritchard, Vladimir Begilman, Himal Bajracharya, Kaveh Naemi

HCA Healthcare Journal of Medicine

Background

Hemophagocytic lymphohistiocytosis (HLH) is an immunologic syndrome characterized by excessive inflammation and tissue injury due to uncontrolled activation of the phagocytic system. The underlying mechanism is a lack of downregulation of activated macrophages and lymphocytes by natural killer and T cells. Unfortunately, the diagnosis is often delayed or missed due to the rarity of the disease, decreased awareness, and clinical picture variability. Ehrlichiosis is becoming a more prevalent tick-borne illness in endemic regions and a relatively uncommon but increasingly considered cause of HLH.

Case Presentation

We describe the cases of 2 patients diagnosed with secondary HLH as per the …

Second Generation Antipsychotics And Cardiovascular Adverse Effects: Developing Evidence-Based Recommendations For Primary Care Medicine, Sana Borda, Ahn-Dao Lee, Paul F. Bell

HCA Healthcare Journal of Medicine

Background

Second-generation antipsychotic medications (SGAs) are often used by primary care physicians (PCPs) to treat multiple psychiatric diagnoses. SGAs have been connected to a number of adverse effects, including cardiovascular disease. Currently, there are no published evidence-based recommendations addressing SGAs and cardiotoxicity that are directed toward PCPs. This project aims to fill this gap.

Methods

Relevant search terms related to SGAs and cardiovascular disease were identified and then used to search databases (PubMed, PubMed Central, and AccessMedicine). Research studies obtained from the searches were narrowed to include systematic reviews and meta-analyses. The Assessment of Multiple Systematic Reviews-2 (AMSTAR-2) tool was …

Enhancing Patient Safety: The Role Of Interdisciplinary Teams In Reducing Blood Culture Contamination, Austin Patrick Eisenberg, Fady M. Awad, Brian Watson, Mohammed Faris

HCA Healthcare Journal of Medicine

Background

Blood cultures are vital to diagnostic workups among many hospitalized patients, providing valuable information about bloodstream infections (BSIs), which cause roughly 250 000 deaths annually between North America and Europe. Despite advances in health care, blood culture contamination remains a substantial problem, with deleterious effects on patient mortality, patient and hospital costs, and microbial resistance. This article reviews the repercussions of blood culture contamination on the health care system and delineates evidence-based strategies to decrease contamination rates.

Methods

To reduce blood culture contamination rates, our health care facility undertook a quality improvement initiative. A task force was created, consisting …

Idiopathic Granulomatous Lobular Mastitis: A Case Report, Wendy M. Timirau, Esra Sari, Maham Shahid, Nilmarie Guzman, Augusto Villegas

HCA Healthcare Journal of Medicine

Introduction

Idiopathic granulomatous mastitis (IGM), also known as nonpuerperal mastitis or granulomatous lobular mastitis, is a rare, benign, chronic inflammatory breast disease first characterized in 1972. IGM is characterized by sterile noncaseating lobulocentric granulomatous inflammation, usually affecting parous premenopausal women with a history of lactation.

Case Presentation

We present a 38-year-old African American woman presenting to our continuity clinic complaining of a painful right breast mass discovered during a self-breast examination. An initial right breast ultrasound demonstrated an area of concern with asymmetry, architectural distortion, and a questionable mass correlating to a 5.1 cm hypoechoic mass at the 12:30 position. …

Clinical And Radiological Identification And Management Of Sapho Syndrome, Obyda Al-Housni, Jessica M. Alonso, Matthew Thornburg, Enny Cancio

HCA Healthcare Journal of Medicine

Introduction

Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome is an autoinflammatory disease whose acronymic name stands for the symptoms commonly seen in the disease. These symptoms typically occur simultaneously, in different combinations, in patients during exacerbations of the disease. SAPHO syndrome is a rare disease, most frequently seen in patients aged 30 to 50. It is estimated to be found in 1 in 10 000 persons in White populations, with an even lower incidence seen in non-White populations.

Case Presentation

A post-menopausal woman with a medical history of SAPHO presented to the emergency department with left foot pain and …

Steroid-Dependent Recurrent Iga Vasculitis In A 19-Year-Old Woman, Hannah Berrett, Shivangi Gohil, Rebecca Kurian, Patricia Neyman

HCA Healthcare Journal of Medicine

Background

Immunoglobulin A (IgA) vasculitis is common in children and typically resolves spontaneously. However, when presenting in adults, it is more likely to be severe and recurrent.

Case Presentation

We present the case of a 19-year-old female patient with recurrent steroid-dependent IgA vasculitis. She had a history of a prolonged episode of IgA vasculitis in childhood. She presented to our hospital with proteinuria and a painful, palpable purpuric rash on her bilateral lower extremities. She was treated with high-dose intravenous steroids. When steroids were tapered, the patient had a recurrence of her painful rash. Over several months, she developed steroid-induced …

A Pilot Physician Mentoring Program In A Large Hospital System, Crista C. Keller Md

HCA Healthcare Journal of Medicine

This article summarizes the development and implementation of a mentoring program designed to support and educate physicians new to practice in a large, outpatient hospital system. The program addresses organizational, operational, and financial elements of medical practice. Topics include efficiency and time management, coding education, leadership, and burnout. These topics are often not directly addressed in medical education, yet are crucial to physician well-being. The article describes the program structure, initial feedback, and recommendations for program replication and expansion.

The Effects Of The Covid-19 Pandemic On Resident Education And Burnout, Timbre Backen, Oliwier Dziadkowiec, Jeffery S. Durbin, Gregory Guldner, Glenda Quan

HCA Healthcare Journal of Medicine

Background

The COVID-19 pandemic has impacted the residency experience for physicians across all specialties. There have been studies examining resident perspectives on changes in curriculum and clinical experiences due to the pandemic; however, little research has been conducted on how residents in different specialties interpreted their educational experience and rates of burnout during the pandemic.

Methods

We extended surveys to 281 residents across 15 separate residency programs between November 17, 2020, and December 20, 2020. The questions pertained to burnout and the effects of the pandemic on their careers. Differences between general and specialty medicine resident responses were analyzed using …

A Case Series Of Unusual Iga Vasculitis, Jared Bradley, Ian Whitaker, Brittany Lyons, Amy Mangla

HCA Healthcare Journal of Medicine

Introduction

Immunoglobulin A vasculitis (IgA)is a rare condition characterized by palpable purpura, often involving the skin, gastrointestinal tract, joints, and kidneys. Presentation is usually acute and is more common in children and adolescents of Southeast Asian and European descent. In the adult population, it is less common and therapies are not as well-established.

Case Presentation

Disease prevalence of IgA vasculitis outside Southeast Asian and European populations is not well-documented. In this case series, we present 2 cases of IgA vasculitis in 2 older adult males, one of Native American descent and one of African American descent.

Conclusion

IgA vasculitis must …