Internal Medicine Commons^™

Purpura Fulminans Due To Mssa Toxic Shock Syndrome, Leah Grant, Rachel Plotinsky

Providence St. Vincent Internal Medicine 2020

Introduction: Purpurafulminansis a rare and serious complication of anacute infectious process, characterized by large purpuricskin lesions, fever, hypotension, and DIC. The mostcommon infectious cause of purpurafulminansismeningococcal disease, though few case reports in theliterature describe Staph aureusas a causative organism.

Case Report: •A 53 year-old woman with a history of heart blocks/ppacemaker placement in 2002 presented to the ED withnausea, vomiting, fevers, chills, diffuse muscle pain and asyncopalepisode. •She was found to have multi-organ dysfunction on labs,including AKI and thrombocytopenia.On hospital day 2, shedeveloped acrocyanosis. She became febrile & hypotensive requiring transfer tothe ICU for vasopressor support. Blood cultures were obtained. …

Struck By Lightning Twice, Bao-Ngoc Nguyen, Emily Hitchcock

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: ANCA-associated vasculitides (AAV) refer to a group of disorders causing inflammation of small vessels which include granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA, Churg-Strauss). Here I present a case of MPA vasculitis in a patient with alpha-1-antitrypsin (AAT) deficiency, and describe a proposed causal link between these two rare disease processes.

CASE REPORT: • 43-year-old man with history of newly-diagnosed AAT deficiency liver disease. • Chief complaint of subacute shortness of breath associated with hemoptysis and fever for 5 months. • Symptoms had been progressively worsening despite multiple courses of antibiotics and inhalers. …

A Case Of Spontaneous Intercostal Artery Hemorrhage, Chang Min Lee, Veronica Schims, Craig Riley

Providence Portland Medical Center Internal Medicine 2020

A Case Of Spontaneous Intercostal Artery Hemorrhage

Chang Lee, MD

Providence Portland Medical Center – Portland, OR

Additional Authors: Veronica Schims, MD; Craig Riley, MD

Introduction: Spontaneous intercostal arterial bleeding is rare and usually related to trauma. We describe a patient with a history of cirrhosis and coagulopathy admitted with sepsis who spontaneously developed an expanding extrathoracic hematoma and subsequent hypovolemic shock requiring arterial embolization.

Case Presentation: 50-year-old male with a past medical history of alcoholic liver disease, esophageal varices, chronic coagulopathy, type 2 diabetes and hypertension on lisinopril was admitted to hospital with decreased urine output, dizziness, …

A Case Of Atypical Pml, Alexander Dreisin, Justin Jin

Providence Portland Medical Center Internal Medicine 2020

No abstract provided.

Be Careful What You Screen For: An Incidental Finding Of Tracheobronchial Amyloidosis, Emma White, Tricia James, Vikram Sahni, Jesse Powell

Providence Portland Medical Center Internal Medicine 2020

Introduction: The 2011 National Lung Screening Trial (NLST) demonstrated a reduction in morbidity and mortality with LDCT compared to CXR. In 2013 the USPSTF began recommending CT scan for lung cancer screening in appropriate patients but, the 2015 National Health Interview Survey (NHIS) demonstrated that less than 5% of eligible patients received screening. The NLST also demonstrated a high rate of false positives, incidental findings, and the need for further invasive testing. When deciding to screen, patients and providers are tasked with reconciling these risks and benefits. In this case, we explore one patient’s incidental findings, and the work-up …

Mixed Signals: A Case Of Hypothyroid-Induced Ogilvie’S, Brieanna Brown, Paul Wichienkeur

Providence Portland Medical Center Internal Medicine 2020

Mixed Signals:

A Case Of Hypothyroid-Induced Ogilvie’s

Brieanna Brown, MD

Providence Portland Medical Center – Portland, OR

Additional Author: Paul Wichienkeur, MD

Ogilve's syndrome, or acute colonic pseudo-obstruction (ACPO), is characterized by acute dilation of the colon, in the absence of a mechanical lesion, which obstructs the flow of intestinal contents. Pseudo-obstruction typically occurs in the critically ill, though the underlying pathophysiology is poorly understood and the etiology is often multifactorial. We present a case of a 51-year-old morbidly obese woman presenting with symptoms of severe hypothyroidism found to have massive acute colonic pseudo-obstruction.

Case presentation:

A 51-year-old African-American …

Hiv-Associated Burkitt Lymphoma: More Than A Starry Sky Appearance, Rahwa Ghebremichael, Amy Dechet

Providence Portland Medical Center Internal Medicine 2020

Introduction: •People with HIV infection are at least 50 times more likely to get lymphoma as compared to the general population. •25-40% of these lymphomas will be Burkitt Lymphoma (BL) – an aggressive B cell malignancy with a high proliferative rate and potentially fatal within months if not diagnosed and treated in a timely manner. •This translates to a 10-20% individual life-time risk of BL for an HIV infected person. •The incidence of BL declined after the introduction of highly active antiretroviral therapy (HAART), but to a lesser extent than other HIV-associated malignancies. •Epidemiologic studies suggest the incidence of BL …

Autoimmune Hemolytic Anemia In Chronic Lymphocytic Leukemia, Kelley Newton, Janan Markee

Providence Portland Medical Center Internal Medicine 2020

Autoimmune Hemolytic Anemia In Chronic Lymphocytic Leukemia

Kelley Newton, MD

Providence Portland Medical Center – Portland, OR

Additional Authors: Janan Markee, MD

Patients with chronic lymphocytic leukemia have a 5-10% risk of developing autoimmune complications, the most common of which is autoimmune hemolytic anemia. Here we present a case of AIHA in a patient with suspected CLL that underscores several of the diagnostic and treatment challenges unique to this process. A 79-year old man with a history of hypertension, atrial fibrillation, type 2 diabetes and hypothyroidism was undergoing workup for suspected CLL due to a persistent leukocytosis. He then presented …

Soft Rock – When Blasting It Doesn’T Work, Mark Schneider, Jesse Powell

Providence Portland Medical Center Internal Medicine 2020

Soft Rock – When Blasting It Doesn’t Work

Mark Schneider, MD

Providence Portland Medical Center – Portland, OR

Additional Authors: Jesse Powell, MD

Case-History of Present Illness: 68-year-old female presents with several days of malodorous urine and fevers. Brought to the ED by her daughter who diagnosed urinary tract infection (UTI) due to the distinct urine odor. No hematuria, dysuria, retention, or incontinence.

Past Medical History: Recent hospitalization for UTI with culture that grew P.mirabilis, completed course of cefdinir, with follow-up culture ordered by PCP that grew extended-spectrum beta lactamase (ESBL) E.coli.

Physical Exam and Vital Signs: Vitals: 115/48, 101, …

The Dangers Of Gardening – Nocardia Infection In An Immunocompromised Patient, Gerald Hutfles, Justin Jin

Providence Portland Medical Center Internal Medicine 2020

The Dangers Of Gardening –

Nocardia Infection In An Immunocompromised Patient

Gerald Hutfles, DO

Providence Portland Medical Center – Portland, OR

Additional Authors: Justin Jin, MD

Introduction: Nocardia is a gram-positive, partially-acid fast, aerobic, branching bacillus that can be found in soil and water. It is typically an opportunistic pathogen, with most infections occurring in the immunocompromised. Disease can be localized or disseminated, preferring pulmonary, nervous, and cutaneous tissues. Optimal antimicrobial therapy depends on speciation of the isolate, as Nocardia may exhibit variable antimicrobial susceptibility. A high clinical suspicion and appropriate empiric antimicrobial therapy is necessary. This clinical case …

A Perplexing Case Of Episodic Abdominal Pain And The Role Of Mast Cells Gastroenteritis, Hayden Smith, Mari Kai

Providence Portland Medical Center Internal Medicine 2020

Here we present a case of chronic intractable vomiting and diarrhea of unknown cause, and introduce the relatively new entity of mast cell gastroenteritis.

Our patient is a 38-year old female with PMH of seronegative rheumatoid arthritis, mixed connective tissue disorder, and several recent hospitalizations over the past 4 months at outside hospitals for suspected colitis with associated vomiting and diarrhea. Current symptoms include 4 days of nausea with intractable vomiting, and 2 days of rectal fullness with mucoid rectal discharge. Previous workup at outside hospitals included multiple abdominal CT scans, flexible sigmoidoscopy, colonoscopy, and exploratory laparotomy. Prior to admission …

When Less-Virulent Becomes Virulent!! An Atypical Presentation Of Streptococcus Viridians., Samreen Khan, Stavan Patel, Mary Anne Nidiry

Providence Portland Medical Center Internal Medicine 2020

When Less Virulent Becomes Virulent!!

An Atypical Presentation Of Streptococcus Viridians

Samreen Kahn, MBBS

Providence Portland Medical Center – Portland, OR

Additional Authors: Stavan Patel MS, MD

Introduction: There are several cardiac and non-cardiac causes and risk factors for the development of infective endocarditis (IE) in young healthy adults. Some risk factors include prior IE, history of valvular or congenital heart disease, IV drug use, indwelling intravenous lines, immunosuppression, or a recent dental or surgical procedure. Most two common sites of IE are mitral and aortic valve. We present a case of a 45-year-old man with no-known risk factors, …

Wrap It Up – Sexually Transmitted Primary Cytologmegalovirus Proctitis In Immunocompetent Host: A Case Report, Vanessa Nwaokocha, Brinton Clark, Ronald Dworkin

Providence Portland Medical Center Internal Medicine 2020

Background: In persons who presents with fever, rectal pain and bleeding, CMV proctitis should be considered if other workup is negative, especially if recent unprotected anal receptive intercourse.

Case Presentation: A 26-year-old bisexual man presented with chief complaints of fever, malaise, rectal pain, and rectal bleeding after anal insertion of foreign body. He initially denied any unprotected sexual intercourse. CBC, CMP, stool pathogen, rectal gonorrhea, and rectal chlamydia were unremarkable. He returned after 1 week with the similar complaints, however admitted to unprotected anal receptive intercourse a month prior. His vitals were notable for temperature of 102 with …

A Case Of Multifactorial Orthostatic Hypotension Complicated By Chemotherapy Associated Autonomic Toxicity, Christopher Bender, Amy Dechet

Providence Portland Medical Center Internal Medicine 2020

A Case Of Multifactorial Orthostatic Hypotension Complicated By Chemotherapy Associated Autonomic Toxicity

Christopher Bender, MD

Providence Portland Medical Center – Portland, OR

Additional Authors: Amy Dechet, MD

Introduction: Autonomic neuropathy is known to occur as a side effect of some chemotherapy drugs, including cisplatin. This reports presents a patient with new onset of autonomic instability and orthostatic hypotension after receiving multiple rounds of cisplatin and gemcitabine chemotherapy.

Case Presentation: An 81-year-old man with history of stage III lung cancer presented after a fall at home that occurred while getting out of bed in the middle of the night …

Empiric Treatment For Suspected Malaria In The United States: A Case Report., Jonathan C. Li, Emma Lundsmith

Division of Internal Medicine Faculty Papers & Presentations

Malaria in the United States is rare and most commonly presents among returning travelers from endemic areas. Diagnosis is classically dependent on a positive blood smear or polymerase chain reaction (PCR) test. The objective of this case report is to highlight a case of suspected malaria in a high-risk individual with negative diagnostic testing where a trial of empiric treatment was initiated based on clinical presentation after a thorough discussion of risks and benefits. However, empiric treatment based on a single case is limiting. We present a case of a 56-year-old man with extensive travel history throughout Asia, who presented …

Chronic Hepatitis B Reactivation: Deadly, But Preventable, Sarah Xie, Jesse Powell, Andrea Roast

Providence Portland Medical Center Internal Medicine 2020

Chronic Hepatitis B Reactivation:

Deadly, But Preventable

Sarah Xie, DO

Providence Portland Medical Center – Portland, OR

Additional Authors: Andrea Roast, MD, FACP; Jesse Powell, MD

A 51-year-old Vietnamese male with chronic hepatitis B presents with symptoms of acute hepatitis. 2 months prior, his PCP had discontinued Tenofovir, for which he had been taking for the past decade, based on an undetectable viral load and a negative HBeAg. 1 month later, his viral load soared to 796 million so Tenofovir was restarted. On admission a few days later, the patient had scleral icterus and jaundiced skin. He had severe transaminitis, …

A Rare Case Of Metastatic Insulinoma In A Patient With Huntington’S Disease, Olesya Petrenko, Brinton C. Clark

Providence Portland Medical Center Internal Medicine 2020

A Rare Case Of Metastatic Insulinoma

In A Patient With Huntington’s Disease

Olesya Petrenko, DO

Providence Portland Medical Center – Portland, OR

Additional Authors: Brinton Clark, MD, FACP

A 49-year-old female with past medical history of Huntington’s disease presents to the ED after being found unresponsive at her assisted-living facility. She was noted to be hypoglycemic with a glucose of 21 and responded to dextrose. For the past several months, patient had symptoms of dizziness, tremors. She has no history of diabetes, and only home medication is Zyprexa. Patient required D10 drip to maintain glucose levels. Given patient’s psychiatric history, …

A Case Of Gluten-Induced Delirium: Using Capsule Endoscopy To Diagnose Occult Gi Bleeding, Rachael Starcher, Lisa Sanders

Providence Portland Medical Center Internal Medicine 2020

A Case Of Gluten-Induced Delirium:

Using Capsule Endoscopy To Diagnose Occult GI Bleeding

Rachael Starcher, MD

Providence Portland Medical Center – Portland, OR

Additional Authors: Lisa Sanders, MD

Introduction: Despite an increasing prevalence of celiac disease worldwide, many patients remain undiagnosed, putting them at risk for late stage complications of unidentified and untreated celiac disease. Ulcerative jejunoileitis is a rare cause of occult GI bleeding seen only in refractory celiac disease or in atypical celiac disease at the time of diagnosis. When left untreated, ulcerative jejunoileitis can lead to bowel perforation, blood loss anemia, and T-cell lymphoma.

Case Presentation …

Beck’S Tetrad? Adding Pocus To The Clinical Exam For Pericardial Tamponade Improves Diagnostic Accuracy In Obstructive Shock, Cody Wiench, Benjamin Pedroja

Providence Portland Medical Center Internal Medicine 2020

Beck’s Tetrad?

Adding POCUS To The Clinical Exam For Pericardial Tamponade Improves Diagnostic Accuracy In Obstructive Shock

Cody Wiench, MD

Providence Portland Medical Center – Portland, OR

Additional Authors: Benjamin Pedroja, MD

Introduction: Obstructive shock due to tamponade is an important, but rare, cause for sudden cardiovascular collapse. Accurate treatment requires prompt (and correct) diagnosis. Bedside echocardiogram can provide rapid and accurate diagnosis, however the physical exam can provide important clues to consider tamponade. In patients with conditions that predispose them to pericardial disease, such as SLE, one must have a high index of suspicion for tamponade when …

Comparative Detection Of Airway Mrsa In Patients With Community-Acquired Pneumonia (Cap), Hiromichi Park, Shirin Ferdosian Najafabadi, Lian Wang, David Gilbert

Providence Portland Medical Center Internal Medicine 2020

Comparative Detection Of Airway MRSA In Patients With Community-Acquired Pneumonia (CAP)

Hiromichi Park, DO

Providence Portland Medical Center

Portland, OR

Additional Authors: Shirin Ferdosian Najafabadi; Lian Wang, PhD; David Gilbert, MD, MACP

Introduction: Vancomycin is often included in the empiric therapy of CAP to ensure activity against MRSA. The current gold standard for detection of MRSA in the airway is a nasal swab PCR. The FilmArray sputum pneumonia panel includes PCR probes for MRSA. This study compares the detection performance of the nasal swab versus the sputum PCR detection of MRSA. Clinically, the absence of airway-detectable MRSA allows cessation …

Vocal Cord Dysfunction Masquerading As Exercise-Induced Bronchoconstriction, Brandon Tempte, Meera Jain, Jason Wells

Providence Portland Medical Center Internal Medicine 2020

Vocal Cord Dysfunction Masquerading As

Exercise-Induced Bronchoconstriction

Brandon Temte, DO

Providence Portland Medical Center – Portland, OR

Additional Authors: Meera Jain, MD, FACP; Jason Wells, MD

Intro: Exercise-induced bronchoconstriction (EIB), previously exercise-induced asthma, has a high prevalence in the community. Patients with these symptoms are typically diagnosed clinically and treated empirically with pre-exercise albuterol. Eucapnic voluntary hyperventilation (EVH) has been used to objectively test for EIB and can help to confirm the diagnosis, as well as rule out other causes such as exercise-induced vocal cord dysfunction (EIVCD), which may mimic EIB.

Case Description: A 42-year old female with …

Drugging Chemokine Receptors: Biased Cxcr3 Agonists Differentially Regulate Chemotaxis And Inflammation, Jeffrey Smith, Dylan Eiger, Chia-Feng Tsai, Lowell Nicholson, Rachel Glenn, Priya Alagesan, Amanda Macleod, John Jacobs, Tujin Shi, Sudarshan Rajagopal

Providence Portland Medical Center Internal Medicine 2020

Drugging Chemokine Receptors: Biased CXCR3 Agonists Differentially Regulate Chemotaxis And Inflammation

Jeffrey Smith, MD, PhD

Providence Portland Medical Center – Portland, OR

Additional Authors: Dylan Eiger, BS; Chia-Feng Tsai, PhD; Lowell Nicholson,MD; Rachel Glenn, BS; Priya Alagesan, BS; Amanda MacLeod, MD; John Jacobs, PhD; Tujin Shi, PhD; Sudarshan Rajagopal, MD,PhD

Introduction: G protein-coupled receptors (GPCRs) are the largest class of transmembrane receptors and the target of ~30% of FDA approved drugs. It is now well established that GPCRs can signal through multiple transducers, including classical heterotrimeric G proteins but also GPCR kinases and β-arrestins (1). While these signaling pathways can …

Unpainfully Sweet, Khoi Nguyen, Alex Schafir

Providence St. Vincent Internal Medicine 2020

Introduction: Sweet's syndrome (ss), or acute febrile neutrophilic dermatosis, is characterized by sudden onset of fever, leukocytosis and erythematous plaques or nodules infiltrated by neutrophils. There are three main clinical settings in which Sweet's syndrome has been described: The diagnosis of Sweet’s syndrome often has a temporal association with the discovery or relapse of cancer as reported in this case.

Case Report: A 64-year-old woman with recurrent breast cancer on targeted and hormonal therapy presented to the ED with acute onset of fever and diffuse non-tender body rash. Vitals suggested sepsis and she was treated with broad spectrum …

Delirium: Delirious Elders, Implementing Reduction Interventions Using Mobility, Michael Silvas, Joe Miller, Shelley Schoepflin Sanders

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: This quality improvement project involved hiring, training, and managing 3 Delirium Mobility Aids to implement a non-pharmacologic delirium prevention bundle package, including early mobility, on hospitalized patients age >65.

Background: Delirium affects 20-30% of older hospitalized patients [1]. Patients with delirium have double the mortality rate [3], which increases with delirium duration [4]. Delirium worsens long term cognitive functioning [9,10,11,12]. Hospital costs increase by $2,500 per patient, totaling $6,900,000,000 in Medicare expenditures [7]. A single delirium episode increases total yearly costs by ~$64,421 [2]. Research suggests the best treatment is non-pharmacologic multicomponent interventions [6], and those with most …

Addressing The Social Determinants Of Health In The Clinic Setting, Larissa Sharma, Man Tran

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: It is estimated that clinical care accounts for only 20% of health, while behaviors, physical environment, and social and economic factors determine the rest. The social determinants of health include the basic life needs of housing, food, transport, along with other factors that include employment, education, drug and alcohol use, dental and eye care, etc. Insecurity in these socioeconomic factors are expressed in chronic medical illness, mental health problems, substance use, all leading to high healthcare utilization. Healthcare costs and utilization decrease when when these needs are provided for. In a survey of 6,000 Providence patients, 50% expressed …

Accidental Botulism Poisoning: A Case Of Pickled Herring, Garrett Spencer, Greg Flick

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: Botulism is a rare cause of neuromuscular weakness that presents a diagnostic challenge in the face of respiratory collapse. Pupil and bulbar paralysis aid prompt recognition and treatment, as clinical confirmation can be time intensive and limited by sample integrity. Early treatment can halt paralysis and prevent ICU and ventilator days.

CASE DESCRIPTION: A 74-year-old male with hypertension and DVT presented with acute weakness and respiratory failure after three days of cough and diarrhea. Upon ICU admission for mechanical ventilation, we discovered sluggish pupils, mild ptosis, and proximal muscle weakness. Symptoms then progressed to unresponsive pupils, complete ptosis, and …

Battling The Stigma: Hiv Screening In Resident Primary Care Clinic, Garrett Spencer, Laura Loertscher, Shelley Schoepflin Sanders

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: HIV affects ~1.2 million in the US, with 25% unaware of their statusand annual incidence of 50,000. Early detection and treatment reduces risk of AIDS-related deaths and transmission. Both the CDC and the US Preventative Service Task Force recommend routine HIV screening. The Providence Medical Group at St Vincent (PMG-STV) resident clinic has no routine screening protocol. • 24% (757/3139) of all clinic patients have ever been screened. • Of active clinic patients seen quarterly, 5% are offered screening with only 3% completing screening. We implemented and measured a clinic-wide HIV screening protocol leveraging existing clinic workflows. We aimed …

Implementing Inter-Professional Patient-Family Centered Plan Of Care Meetings On An Inpatient Hospital Unit, Nicolas Hernandez, Alice Fornari, Sage Rose, Leanne Tortez

Patient Experience Journal

Inpatient plan of care meetings support efforts to encourage collaborative practice and patient-family centered care and result in an effective strategy to enhance communication and patient satisfaction. Clinical team members participated in patient/family centered plan of care meetings at a community hospital in a selected inpatient unit with full time hospitalist physicians. Quantitative data were gathered pre/post implementation from the external Hospital Consumer Assessment of Health Care Providers (HCAHPS) survey. HCAHPS data were collected independently, specifically for questions related to communication between patients, family members/guardians and the medical team and also the effects of care transition. There was a slow …

Living Sweet: A Multi-Functional Mobile-Phone Application Strategy For Adults With Uncontrolled Type 2 Diabetes Mellitus, Chantel K. Anderson

Evidence-Based Practice Project Reports

Type 2 Diabetes Mellitus (T2DM), one of the most common chronic diseases, is increasing worldwide, and once diagnosed, lifetime self-management is critical to maintain glycemic control (Vermeire et al., 2005; American Diabetes Association (ADA), 2018). Management of T2DM has been acknowledged as challenging due to the need for strict lifestyle adaptations. From a public health perspective, uncontrolled diabetes leads to increased healthcare costs, secondary complications, and ultimately severe disabilities (ADA, 2018). The purpose of this evidencebased practice (EBP) project was to evaluate the effectiveness of a diabetes-specific mobile health application (MHA) on glycated-hemoglobin (HbA1C), self-care perception (SCP), and self-care behaviors …

How Immune T-Cell Augmentation Can Help Prevent Covid-19: A Possible Nutritional Solution Using Ketogenic Lifestyle, Ravi K. Kamepalli Md,Fidsa,Cwsp

The University of Louisville Journal of Respiratory Infections

No abstract provided.