Internal Medicine Commons^™

A Rare Clinical Presentation Of Metastatic Crohn's Disease, Kaitlyn L Streight, Tara L Braun, Nicholas Lowe, Soo Jung Kim

Faculty, Staff and Students Publications

A 31-year-old female with a history of systemic lupus erythematous, IgA nephropathy, and psoriasis presented with a one-month history of a painful, pruritic rash under the bilateral breasts and in the genital region. Cutaneous examination revealed a large, tender ulcer under the left breast with a shiny erythematous base and peripheral hypertrophic changes. Small ulcers were present on the bilateral inguinal folds, and the labia majora were edematous with multiple erythematous papules. Histological examination of the left breast revealed ulceration with granulomatous dermatitis, consistent with a diagnosis of metastatic Crohn's disease. Metastatic Crohn's disease is a rare cutaneous manifestation of …

A Rare Association Of Takotsubo Cardiomyopathy With Neuroleptic Malignant Syndrome, Waqas Ullah, Muhammad Arslan Cheema, Ammar Ashfaq, Maryam Mukhtar, Zain Ali, Mamoon Ur Rashid, Vincent Figueredo

Abington Jefferson Health Papers

Neuroleptic malignant syndrome is a potentially fatal neurological condition secondary toantipsychotic medication. It is characterized by distinctive clinical findings and autonomicdisturbances. NMS has not been associated with Takotsubo cardiomyopathy (TCM).

TCM is an abnormal response to physiological stressors resulting from the autonomicabnormalities which at times can mimic myocardial infarction (MI). We present a unique caseof a 54-year-old female with bipolar disease presenting with lithium and haloperidol-inducedNMS complicated by TCM. The purpose of this case is to make clinicians aware of this rareassociation.

Dieulafoy Lesion In The Jejunum: A Rare Cause Of Massive Gastrointestinal Bleeding, Olubunmi Oladunjoye, Adeolu Oladunjoye, Lydia Slater, Asad Jehangir

Reading Hospital Internal Medicine Residency

No abstract provided.

Pancreatic Stromal Gremlin 1 Expression During Pancreatic Tumorigenesis, Joy M. Davis, Binglu Cheng, Madeline M. Drake, Qiang Yu, Baibing Yang, Jing Li, Chunhui Liu, Mamoun Younes, Xiurong Zhao, Jennifer M. Bailey, Qiang Shen, Tien C. Ko, Yanna Cao

School of Medicine Faculty Publications

Chronic pancreatitis (CP) is a major risk factor of pancreatic ductal adenocarcinoma (PDAC). How CP promotes pancreatic oncogenesis remains unclear. A characteristic feature of PDAC is its prominent desmoplasia in the tumor microenvironment, composed of activated fibroblasts and macrophages. Macrophages can be characterized as M1 or M2, with tumor-inhibiting or -promoting functions, respectively. We reported that Gremlin 1 (GREM1), a key pro-fibrogenic factor, is upregulated in the stroma of CP. The current study aimed to investigate the expression of GREM1 and correlation between GREM1 and macrophages within the pancreas during chronic inflammation and the development of PDAC. By mRNA in …

Wound And Stoma Care Education For Primary Care Providers, Deanna Garza

Doctor of Nursing Practice (DNP) Projects

Abstract

Problem. Patients with percutaneous endoscopic gastrostomy (PEG) tubes and their families report physical and psychosocial changes associated with complications after gastrointestinal surgeries. They are at particular risk for tube dislodgement, leakage, infection, poor fit, and skin irritation. The lack of specialization and fundamental stoma care knowledge among community health care providers potentially results in unintended consequences, leaving the system inefficient with fundamental inequities of stoma care delivery. While there is an increasing amount of accessibility to specialty centers for other types of wound care, stoma care support resources are scarce and not readily available to patients.

Context: This Doctor …

A Rare Case Of Coronary Artery Thrombosis In A Patient With Recently Diagnosed Giant Cell Arteritis: Is Anticardiolipin Antibody Involved?, Khine S. Shan, Qian Zhang, Sharmila Bisaria, Anubha Tewary

Abington Jefferson Health Papers

Giant cell arteritis (GCA) is an immune-mediated systemic inflammation of large-sized arteries that predominantly affects elderly women. It may be considered as one of the risk factors for acute coronary syndrome (ACS). Moreover, patients with GCA may have increased anticardiolipin antibodies (aCL). However, its relationship with antiphospholipid syndrome (APS) is not clear. We present a case of a unique presentation of GCA with a connection to both ACS and APS. A 76-year-old woman who initially presented to the hospital with a chief complaint of intermittent unilateral headache, blurry vision along with transient aphasia was found to have a biopsy confirmed …

A Rare Presentation Of Coronavirus Disease 2019 (Covid-19) Induced Viral Myositis With Subsequent Rhabdomyolysis., Qian Zhang, Khine S. Shan, Artem Minalyan, Conor O'Sullivan, Travis Nace

Abington Jefferson Health Papers

A 38-year-old gentleman with no significant past medical history but had recent COVID-19 exposure presented to the hospital with the chief complaints of fever, shortness of breath, and generalized myalgia. He was unfortunately found to be severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive. Laboratory findings showed creatine kinase (CK) >42,670 U/L along with elevated inflammatory markers and unremarkable creatinine, cardiac troponin level. The cause of his rhabdomyolysis was discovered to be due to COVID-19 as he had no evidence of other viral infections, strenuous exercise, seizure, or other nontraumatic exertional etiologies. He received aggressive fluid resuscitation while we trended …

Endobronchial Tuberculosis: A Rare Presentation, Nadeem Kassam, Omar M. Aziz, Samina Somji, Grace Shayo

Internal Medicine, East Africa

Endobronchial tuberculosis (EBTB) is an infection of the tracheobronchial tree by Mycobacterium tuberculosis. It is common among young females. Patient can present with fever, cough, wheeze, with or without any constitutional symptoms. It presents as a diagnostic dilemma, as patient sputum smear can be false negative. CT scan may or may not show any abnormality, or any endobronchial lesion. Bronchoscopy with bronchoalveolar lavage and biopsy offers the diagnostic choice. We hereby report a case of a young immunocompetent Asian female who was found to have endobronchial pathology, leading to diagnosis and timely therapy.

Efficacy Of A Mobile Application In A Chronic Kidney Disease Population, Jennifer R. Zamora

Evidence-Based Practice Project Reports

Chronic kidney disease (CKD) is associated with high healthcare costs, poor health outcomes and low quality of life (Donald et al., 2018). The US CKD prevalence is 15%, costing Medicare $79 billion in 2016 (United States Renal Data System, 2018). Self-management could reduce CKD burden (Jeddi, Nabovati, and Amirazodi, 2017). Mobile technology offers a low-cost, ease-of-access platform for chronic disease self-management (Whitehead & Seaton, 2016), potentially slowing disease progression and improving health outcomes (Jeddi, 2017). The purpose of this project was to utilize a CKD-specific mobile application, CARELogiQ, to facilitate symptom management; increasing patient satisfaction and decreasing hospitalizations and ER …

An Atypical Presentation Of Neuroleptic Malignant Syndrome, Rudy Forte, Shiwani Kamath, Debra Angelo, Johnathan Frunzi

West Florida Division GME Research Day 2020

Neuroleptic Malignant Syndrome (NMS) is a rare, but potentially life threatening condition associated with dopamine blockade, particularly first-generation antipsychotics. The complex pathophysiology of NMS remains somewhat unclear and debatable as the symptoms are not fully explained by dopamine blockade alone.¹ D2 dopamine receptor antagonism remains responsible for most cases of NMS, however a few cases have been reported in which little to no D2 blockade activity was present.¹

This poster is about an atypical presentation of NMS.

Carcinoid Syndrome Arising From The Descending Colon Causing Carcinoid Heart Disease, Julien A. Exposito, Adam Salomon, Oliver Fowler, Christopher Cooke, Joelle Ellis, Patricia Chun, Christiano Caldeira

West Florida Division GME Research Day 2020

No abstract provided.

Pneumonia: An Unexpected Graveyard Visitor?, Daniel A. Casas, Jigar Chauhan, Melanie Williams, Jan Sambataro, David Sukhai, Pablo G. Dubon, Jorge Perez

West Florida Division GME Research Day 2020

Community acquired pneumonia caused by Influenza can present with superinfection. On rare occasions, an unexpected organism is discovered.

Idiopathic Chylopericardium: A Rare Entity, Seema Jaga, Joseph Namey, Christiano Caldeira, Salah Al-Andary

West Florida Division GME Research Day 2020

• Idiopathic chylopericardiumis a rare entity in which the acculumation of chylousfluid surrounds the pericardial space.
• Herein, we present a case of a 50 year old healthy female patient with no known past medical history that was diagnosed with idiopathic chylopericardiumand was successfully treated using a pleurXcatheter drainage for two and a half weeks and a low fat diet.

Giant Splenic Artery Pseudoaneurysm Rupture Presenting As Hemorrhagic Shock, Jaya Sanapati, Parth R. Desai, Locke W. Barber, Johnathan Frunzi, Timothy Lee

West Florida Division GME Research Day 2020

A 56-year-old Asian male was brought to the emergency department by first responders after he developed severe, sudden-onset headache and chest pain at his home. Past medical history was insignificant. On arrival to the emergency department, the patient was in respiratory distress. Vital signs revealed temperature of 36.0°C, blood pressure of 71/44, heart rate of 90 beats per minute, respiratory rate of 18 breaths per minute, and oxygen saturation of 95% with delivery of oxygen at 2 liters per minute via nasal cannula. Examination of the abdomen revealed diffuse tenderness. Laboratory findings and arterial blood gas analysis revealed normocytic anemia …

A Multicomponent Tailored Intervention Program Protocol For Weight Loss In An Underserved Adult Patient Population With Obesity, Rita R. Arnold

Evidence-Based Practice Project Reports

Obesity is a multifactorial, individualized, chronic disease that increases known risk factors for significant comorbidities and mortality. The primary purpose of this Evidence-Based practice project was to improve indicators of obesity (weight, BMI) among patients served by a free medical clinic, using a tailored multicomponent intervention. The secondary purpose was to determine if the weight loss intervention was associated with a decrease in blood pressure and depression symptoms. The intervention was guided by the Health Promotion Model by Nola Pender. The Johns Hopkins Nursing Evidence Based Practice Model (JHNEBP) guided implementation of the project. A comprehensive literature review was completed …

Cervical Cancer Recurrence In The Colon, Samantha A. Erb, Shreyash Pandya, Johnny Johnson

West Florida Division GME Research Day 2020

Cervical cancer is the fourth leading cancer worldwide in women, ranking only after breast cancer, colorectal cancer, and lung cancer. Because it is typically diagnosed at a younger age compared to other major cancer types, it leads to a proportionally greater loss in life-years. Most cancers occur in squamo-columnar junction, the transition point between squamous and columnar cells; squamous cell carcinoma accounts for approximately 70% of cervical cancer cases. Treatment options vary depending on the stage at diagnosis and include surgery (conization or hysterectomy), radiation, chemotherapy, targeted therapy, and immunotherapy. Prognosis is affected by stage, tumor volume, age and performance …

Iatrogenic Pneumothorax With Subsequent Subcutaneous Emphysema, George Michael, Eric Yuschak, My Myers

West Florida Division GME Research Day 2020

Lung cancer is the leading cause of cancer-related death in the United States, accounting for 13% of all new cancer diagnoses and 24% of all cancer deaths.1 Transthoracic CT-guided biopsy (CTGB) is commonly used as a diagnostic tool for lung cancer, with high diagnostic accuracy, sensitivity, and specificity. 2 This procedure, however, is not without its risks which include pulmonary hemorrhage and iatrogenic pneumothorax (IPNX). Emergent chest tube placement is standard care of treatment for massive or symptomatic IPNX, commonly with the use of smaller caliber chest tubes. 2 There is, however, a growing discussion over use of larger caliber …

Acute Hypoxic Respiratory Failure Due To Organizing Pneumonia With Lipoid/Cholesterol Component Caused By Thc Vaping With E-Cigarette, Jinal K. Patel, Kiran Tirumalasetty, Jessica Khabra, Imran Khan, Johnathan Frunzi

West Florida Division GME Research Day 2020

Vaping has been the new and deemed “safer” way to inhale addictive chemicals such as nicotine and tetrahydrocannabinol (THC), but it does not encompass the detrimental effects of other ingredients in these vaping cartridges that can cause lung injury[1,2]. Similar studies with dabbing (heating THC wax concentrate at high temperatures with butane) showcase rapidly progressing lung injury with massive consolidation and lasting effects on lung parenchyma over a period of time [3]. This case report aims to educate people, especially the younger generation, of the dangers of newer ways of combustible alternatives that have been marketed as a “safer” way …

The Difficult Airway: Developing A Consistent Approach, Catherine Divingian, Tammy Ferro, Dudith Pierre-Victor

West Florida Division GME Research Day 2020

The primary objectives were to determine the best practices in managing difficult airways (DAs) and to generate a simplified algorithm for a consistent approach. Additional objectives included organizing a DA cart, and integrating the information into the electronic medical record (EMR).

Fracture Blisters, Jessica Khabra, Jinal K. Patel, Gauthier L. Stepman, Kulveer Dabb, Kenny Hernandez, Debra Angelo, Johnathan Frunzi

West Florida Division GME Research Day 2020

Fracture blisters are tense vesicles or bullae that develop on edematous skin following some acute long bone fractures. Fracture blisters are infrequently seen, as the reported incidence is 2.9% to 6.6%.¹ This rare complication, may not regularly be encountered by Physicians in the hospital. Fracture blisters typically occur within 24-48 hours following high energy trauma injuries & may last up to several weeks. Ultimately, this condition can lead to prolonged hospital stay due to an increased risk of infection and delay in surgical intervention.² Early recognition of this dermatologic complication may be helpful in reducing hospital stays.

Progressive Collateral Stenosis Leading To Symptomatic Chronic Total Occlusion, Farhan Shah, Andrew Maiolo

Capital Division GME Virtual Research Day 2020

Chronic total occlusion is defined as the complete obstruction of a coronary artery, with TIMI 0 or TIMI 1 flow, and an occlusion duration of greater than 3 months. We present a case of symptomatic chronic total occlusion in a functional 79 year old female with no past history of coronary artery disease, previously asymptomatic due to robust collateral circulation.

A Case Of Babesiosis Seen Outside Of Its Endemic Area And Outside Of Its Incubation Period, Kiran Tirumalasetty, Jinal K. Patel, Gauthier L. Stepman, Bassem Zeidan, K V. Sundaresh, Parth R. Desai, Johnathan Frunzi

West Florida Division GME Research Day 2020

Babesiosis Microti is a parasitic alveolate that is usually transmitted by Ixodes scapularis ticks. In the United States, the endemic areas of Babesiosis include the Northeast and Upper Midwestern regions [1]. Symptoms include fever, malaise, fatigue, vomiting, and jaundice [1]. Current therapy primarily consists of a combination of azithromycin and atovaquone. Clindamycin and quinine may be administered in severe cases. For its emerging health risk worldwide, clinicians must be aware of the several presenting manifestations of babesiosis. Since 2017, the Centers Disease Control and Prevention (CDC) has deemed Babesiosis is a reportable disease. This case focuses on the importance of …

Impact Of Order Set Use On Stroke Care, Bilal Nadeem, Edward Waseleski, Meryem Maras-Casey, Sabih Alam, Adnan Faruqui, Michael Gutierrez, Maruthsakhi Molugu, Christina Oricompil, Ashar Mahmood, Katherine Torralba, Fatima Agha, Nour Tlimat, Olu Oyesanmi, Salman Muddassir, Nikolay Mitzov

West Florida Division GME Research Day 2020

A case control study of 118 patients from Oak Hill Hospital between the months of August 2019 and January 2020 was recently completed for a hospital research quality improvement study. The objective was to determine if the use of either Hemorrhagic or Ischemic Stroke Order Set had an effect on the length of stay (LOS) or adherence to current stroke guideline recommendations when compared to its disuse. Results indicate use of either the Hemorrhagic or Ischemic Stroke Order Set led to a decreased length of stay and an increased adherence to current stroke guideline recommendations. Limitations of the study included …

A Case Of Medication-Induced Diffuse Alveolar Hemorrhage In Neurofibromatosis Type 1, Ashar Mahmood, Liz Palmer, Rebecca Schuyler, Svitlana Sharpovalova, Bilal Nadeem, Mukesh Mehta, Salman Muddassir, Nikolay Mitzov, Monicka S. Felix

West Florida Division GME Research Day 2020

• Amiodarone, an antiarrhythmic and apixaban, an anticoagulant have been associated with diffuse alveolar hemorrhage (DAH).
• Cases have been documented demonstrating DAH in the setting of amiodarone and apixabantreatment, however there are few cases examining DAH in combination therapy.
• We present a case of diffuse alveolar hemorrhage in the setting of amiodarone and apixaban treatment for paroxysmal atrial fibrillation.
• NF1 is know to have higher risk for major bleeds due to their friable vasculature.

A Rare Cause Of Pneumoperitoneum, Robert Zusman, George Michael, Anna E. Augustin, My Myers, Dudith Pierre-Victor

West Florida Division GME Research Day 2020

Pneumoperitoneum is most commonly associated with a perforated viscus. When free air is seen on imaging, the most common course of action is an emergent exploratory laparotomy. However, pneumoperitoneum may not always be indicative of a perforated bowel. In the case described below, we will discuss a patient who developed acute peritonitis and pneumoperitoneum after undergoing chest compressions during cardiopulmonary resuscitation (CPR) and positive pressure mechanical ventilation.

The Β3-Adrenergic Receptor Agonist Mirabegron Improves Glucose Homeostasis In Obese Humans, Brian S. Finlin, Hasiyet Memetimin, Beibei Zhu, Amy L. Confides, Hemendra J. Vekaria, Riham H. El Khouli, Zachary R. Johnson, Philip M. Westgate, Jianzhong Chen, Andrew J. Morris, Patrick G. Sullivan, Esther E. Dupont-Versteegden, Philip A. Kern

Internal Medicine Faculty Publications

BACKGROUND. Beige adipose tissue is associated with improved glucose homeostasis in mice. Adipose tissue contains β3-adrenergic receptors (β3-ARs), and this study was intended to determine whether the treatment of obese, insulin-resistant humans with the β3-AR agonist mirabegron, which stimulates beige adipose formation in subcutaneous white adipose tissue (SC WAT), would induce other beneficial changes in fat and muscle and improve metabolic homeostasis.

METHODS. Before and after β3-AR agonist treatment, oral glucose tolerance tests and euglycemic clamps were performed, and histochemical analysis and gene expression profiling were performed on fat and muscle biopsies. PET-CT scans quantified brown adipose tissue volume and …

Provider-Led Intervention For Overweight Or Obese African American Women Ages 18-65 With A Bmi 25 Kg/ M₂, Tonya A. Harvey

Evidence-Based Practice Project Reports

Overweight and obese African American women tend to suffer most from the impacts of diseases, health disparities, disabilities, and decreased qualities of life (Sutton et al., 2016). Most weight loss programs are not culturally specific, despite the benefits of dietary changes and increased physical activity for all groups. The purpose of this EBP project was to implement a provider-led program including lifestyle, dietary, and activity components to decrease weight, BMI, waist circumference and blood pressure in African American women. The Iowa Model of Evidence-Based Practice to promote quality care was used to guide the EBP project, aimed to address obesity …

The Implementation Of Diabetic Foot Care Into Primary Care, Shelby D. Strong

Evidence-Based Practice Project Reports

Diabetes mellitus (DM) is one of the most common metabolic diseases worldwide. It can lead to complications in many parts of the body and can increase overall risk of dying prematurely (World Health Organization (WHO), 2016). Diabetic peripheral neuropathy (DPN) in the feet is one of the most frequent complications of DM (Wang et al., 2017). Other lower extremity complications which can occur as a result of diabetic foot complication (DFC) includes peripheral artery disease (PAD), infection, ulcer and amputation. One of the obstacles for preventing (DFC) is the lack of examinations of the feet in clinical practice (Feitosa et …

A Protocol To Increase Referral Rates To Diabetic Education, David M. Rokser

Evidence-Based Practice Project Reports

In 2015, approximately 30.3 million Americans, including 10.5% of the population of Minnesota, had been diagnosed with diabetes mellitus (American Diabetes Association, 2019). Increased risk of diabetic complications including neuropathy, retinopathy, nephropathy, cardiovascular disease, and chronic wounds has been associated with an elevated hemoglobin A1C (HgA1C). Formal diabetic education has been shown to be a cost-effective intervention to reduce HgA1C. The Office of Disease Prevention and Health Promotion published an objective within HealthyPeople 2020 that seeks to increase the percentage of diabetics receiving formal diabetic education in the United States from 46.9% of adults to 58.4%. The purpose of this …

Point-Of-Care Reminders To Prompt Provider Adherence With Diabetes Care Guidelines For Adults, Eric E. Spohn

Evidence-Based Practice Project Reports

Diabetes is a complex, chronic illness, and a leading cause of morbidity and mortality (ODPHP, 2019). Gaps in diabetes care exist between clinical guidelines and interventions provided in the clinical setting (ADA, 2015; Chauhan et al., 2017; Renders et al., 2001; Worswick et al., 2013). Improved diabetes management strategies and interventions among healthcare providers are essential to close the quality gap. The purpose of this evidenced-based practice (EBP) project was to prompt providers to adhere to diabetes care guidelines using a paper point-of-care reminder over a 12-week period. Provider performance rates covering four specific guidelines were measured: HbA1c, microalbuminuria, diabetic …