Internal Medicine Commons^™

A Broken Heart: A Case Of Stress Induced Cardiomyopathy Precipitated By Community Acquired Pneumonia, Adam Foglesong, Abdulla Kara Balla, A Neil Bilolikar

Conference Presentation Abstracts

Takotsubo cardiomyopathy or stress-induced cardiomyopathy is a syndrome characterized by a transient reduction of systolic cardiac function generally in response to emotional or physical stressors. Stress-induced catecholamine excess is believed to be the main factor driving myocyte dysfunction. Most patients are female and postmenopausal. We present a case of a 62-year-old Caucasian male with a past medical history of hypertension who presented to the ED with the chief complaint of squeezing chest pain followed by multiple episodes of productive cough and epigastric discomfort. ECG showed sinus tachycardia with premature supraventricular complexes. Chest X-ray showed severe pulmonary vascular congestion. Labs showed …

Acute Renal Failure And An Acid-Base Dilemma, Kamil Sardarli, Russell Leong, Matthew Weatherhead, Bhavinkumar Dalal

Conference Presentation Abstracts

Introduction: Acute renal failure (ARF) is well-recognized to result in metabolic acidosis. The acidosis of ARF is associated with decreased ammoniagenesis and anion excretion. Alkalosis in the presence of ARF presents diagnostic uncertainty and therapeutic challenges. This vignette describes a case of ARF resulting in several electrolyte imbalances and metabolic alkalosis. Case Description: A 54-year-old female with past medical history of small bowel resection with colostomy presented for nausea and vomiting for two weeks. On presentation, she was noted to be tachycardic and lethargic. Her workup revealed a serum creatinine of 6.8 mg/dL, blood urea nitrogen of 147 mg/dL, bicarbonate …

Cushing’S Reflex And Bradycardic Arrest In Cryptococcal Meningitis, Scott Briggs, Trent Malcolm

Rowan-Virtua Research Day

Cushing’s reflex is a physiologic response to maintain cerebral perfusion pressure with elevated systolic blood pressure, widened pulse pressure, and bradycardia occurring in the setting of elevated intracranial pressure (ICP). The proposed mechanisms for reflexive bradycardia include ischemia to medullary brain tissue and compression of the intracranial segment of the vagus nerve leading to parasympathetic activation. (1) In acutely elevated ICP, bradycardia is a late finding of worsening intracranial pathology suggestive of impending herniation and cardiovascular collapse.

Cryptococcal meningitis has been identified by Infectious Disease Society of America for its association with elevated ICP. (2) Variety of pathogenic mechanisms occurring …

Omental Infarction: A Rare Cause Of Abdominal Pain, Eric Doane, Emily Nguyen

Rowan-Virtua Research Day

Omental infarction is a rare cause of acute abdomen pain first described by Eitel in 1899 and has been described in the literature with total numbers ranging from 250-400 worldwide with many coming from individual case reports. Risk factors for developing omental infarction are thought to be obesity, trauma, intense exercise or secondary to torsion from adhesions. Historically, the diagnosis of omental infarction was made incidentally in the operating room for patients with an acute abdomen with a different suspected diagnosis. Most often being appendicitis with associated right lower quadrant abdominal pain and smaller subset from suspected diverticulitis and cholecystitis …

Cardiovascular Complications Of Systemic Lupus Erythematosus: Impact Of Risk Factors And Therapeutic Efficacy--A Tertiary Centre Experience In An Appalachian State, Elise Danielle Mcveigh, Amna Batool, Arnold J. Stromberg, Ahmed K. Abdel-Latif, Nayef Mohammed Kazzaz

Statistics Faculty Publications

OBJECTIVES: Cardiovascular complications became a notable cause of morbidity and mortality in patients with lupus as therapeutic advancements became more efficient at managing other complications. The Appalachian community in Kentucky has a higher prevalence of traditional cardiovascular risk factors, predisposing them to cardiovascular events. Namely, the mean body mass index of the members of the Kentucky Appalachian community was reported at 33 kg/m² and 94.3% of male members of this community use tobacco. We sought to identify risk factors that predispose patients with lupus to cardiovascular morbidities and examine the effect of immunomodulatory drugs.

METHODS: We identified 20 UKHS …

A Tailored Multicomponent Intervention In Primary Care For Survivors Of Adverse Childhood Experiences (Aces), Rebecca L. Peterson

Evidence-Based Practice Project Reports

Adverse childhood experiences (ACEs) include 10 traumatic events of abuse, neglect, and household dysfunction that occur before 18 years of age. Adverse childhood experiences affect greater than 60% of the population, and approximately one in six individuals affirm that they have experienced four or more types of ACEs. They are associated with negative, long-term health outcomes in adults, including 9 out of the 10 leading causes of death in the United States (Centers for Disease Control and Prevention, n.d.; Felitti et al., 1998). The purpose of this evidence-based practice project was to implement a tailored, multicomponent intervention to mitigate the …

Keeping Primary Care Providers Informed About Detecting Skin Cancer In Young Adults, Riley J. Spears

Evidence-Based Practice Project Reports

Skin cancer is a common, life-threatening disease that affects anyone, regardless of age or skin color (American Cancer Society [ACS], 2020). The incidence of melanoma is on the rise for young adults, with an estimated 2,400 new cases for individuals aged 15 to 29 (ACS, 2020). Although skin cancer is highly preventable, clinical guidelines are inconsistent regarding skin cancer screening. The purpose of this evidence-based practice (EBP) project was to determine if the implementation of the INternet curriculum FOR Melanoma Early Detection (INFORMED) program would improve primary care providers’ (PCPs’) confidence about skin cancer and the number of completed and …

Predictors Of Iron Consumption For At Least 90 Days During Pregnancy: Findings From National Demographic Health Survey, Pakistan (2017-2018), Sumera Aziz Ali, Savera Aziz Ali, Shama Razzaq, Nayab Khowaja, Sarah Gutkind, Fazal Ur Rehman, Nadir Suhail

Section of Internal Medicine

Background: Iron supplementation is considered an imperative strategy for anemia prevention and control during pregnancy in Pakistan. Although there is some evidence on the predictors of iron deficiency anemia among Pakistani women, there is a very limited understanding of factors associated with iron consumption among Pakistani pregnant women. Thus, this study aimed to investigate the predictors of iron consumption for at least ≥90 days during pregnancy in Pakistan.
Methods: We analyzed dataset from the nationally representative Pakistan Demographic Health Survey 2017-2018. The primary outcome of the current study was the consumption of iron supplementation for ≥90 days during the pregnancy …

Protecting Sanitation Workers In Low-Middle Income Countries Amid Covid-19, Muhammad Mainuddin Patwary, Md Riad Hossain, Faysal Kabir Shuvo, Sadia Ashraf, Rabeya Sultana, Md Ashraful Alam

Faculty, Staff and Student Publications

No abstract provided.

A Randomized Open-Label Study Of Two Methods Of Proton Pump Inhibitors Discontinuation, Emily Hendricks, Aman Ajmeri, Monider M. Singh, Milliejoan Mongalo, Lynne J. Goebel

Internal Medicine

Background: Proton pump inhibitors (PPIs) are effective in treating gastroesophageal reflux disease (GERD). Unfortunately, they are often inappropriately prescribed and long-term use has potential adverse effects. A single best method for discontinuation of PPIs does not currently exist. The objective of this study was to determine if there is a significant difference in successfully discontinuing PPI use at 12 months between patients discontinuing abruptly or tapering first.

Methodology: We conducted a randomized trial with 38 patients diagnosed with GERD. We collected six weekly and then monthly surveys of symptoms based on the Dyspepsia Symptom Severity Index. Chart review at 12 …

The Requirements Of Immunosuppressive Therapy And Clinical Features In Patients With Myasthenia Gravis Who Undergo Thymectomy Versus Non Thymectomy Management In East Africa, Nyawara Anthony Ochola

Master of Medicine in Internal Medicine

Background: Myasthenia gravis is an acquired autoimmune neuromuscular disease leading to fatigability of skeletal muscles. The thymus produces autoantibodies that target receptors to Acetylcholine or Muscle Specific Kinase. The resultant fatigability is generalized or limited to the ocular or bulbar muscles. Therapy has been targeted to reduce the autoimmune process by use of immunosuppressive agents or by thymectomy. In the African population, MG involves younger patients, more ocular involvement, is more aggressive and more resistance to immunosuppressive therapy. Methods: We conducted a retrospective study between January 2009 and December 2019 at Aga Khan University Hospital, Nairobi. Medical records of patients …

Characterization Of Young Hypertensive Patients Aged Between 18 – 40 Years, Kelvin Orare Nyanchoka

Master of Medicine in Internal Medicine

Background: Hypertension is the world’s most significant risk factor for morbidity and mortality. Sub-Saharan Africa has the highest prevalence of hypertension worldwide. In Kenya, the estimated overall prevalence of hypertension is at 24.5%. Young adult hypertensive patients have a lower proportion of controlled blood pressure compared to older adults. Uncontrolled hypertension, irrespective of age, increases cardiovascular risk. Methods: A total of 401 patients aged between 18 and 40 years were identified from the records department based on the ICD-10 codes for hypertension. Using their hospital identification numbers, files were sorted and analyzed including laboratory data on the hospital information management …

Bleeding Complications In Patients On New Oral Anticoagulants For Venous Thromboembolism In Kenya, Antonina Zebby Obayo

Master of Medicine in Internal Medicine

Background: The past five years have seen an increase in the use of new oral anticoagulants (NOACS) for treatment and prophylaxis against venous thromboembolism. These agents are as effective as warfarin, with much fewer bleeding complications. The incidence of bleeding complications in patients with venous thromboembolism on NOACS (New oral anticoagulants) has not been widely studied in Africa's contemporary practice. The purpose of this study is to determine the rates of major bleeding and clinically relevant non-major bleeding (CRNM) associated with new oral anticoagulant use in daily contemporary clinical practice. Methods: A retrospective review of adult patients diagnosed with venous …

Fentanyl-Induced Wooden Chest Syndrome Masquerading As Severe Respiratory Distress Syndrome In Covid-19, Grace Judd, Rachael Starcher, David Hotchkin

Providence Portland Medical Center Internal Medicine 2021

Case Presentation

History •47 yo M with no PMH presented with fever and respiratory distress •Admitted for COVID-19 pneumonia Hospital Course •Intubated for moderate acute respiratory distress syndrome (ARDS) on hospital day 11 •Fentanyl infusion started •Hypoxia improved within 36 hrsbut plateau pressures consistently >30 cm H2O despite minimizing dead space •Trial of airway pressure release ventilation worsened hypercarbia •Bronchoscopy w/o mucous plugging, airway collapse, or purulent secretions •Lung compliance worsened (Pplat=50 on 4 cc/kg) w/o change in oxygenation •Developed suspicion for wooden chest syndrome (WCS) and discontinued fentanyl Outcome •Pplatnadired at 16 within one hour after stopping fentanyl •Pt …

When Your Patient Does Know Best: A Lesson In Geriatrics, Daphne Sy, Jeff Youker

Providence St. Vincent Internal Medicine 2021

Introduction

An athletic elderly woman presented to the emergency department (ED) with subjective leg weakness, most notably while climbing stairs. The patient’s insistence that we acknowledge her change in functional status prompted a workup that exposed an active pauci-immune crescentic glomerulonephritis. She was diagnosed with an unusual presentation of granulomatosis with polyangiitis (GPA) which was discovered in time to initiate treatment and prevent renal failure.

Case Report

A 77 year-old woman with a past medical history of chronic kidney disease (CKD) and biopsy-negative pulmonary nodules presented to the ED with a unique complaint: she could no longer climb multiple stairs …

Avoiding Rash Decisions: A Guide To Adverse Cutaneous Drug Reactions, Caleb Freeman, Tom Chau

Providence St. Vincent Internal Medicine 2021

No abstract provided.

A Dramatic Presentation Of Plasmablasticlymphoma In Untreated Hiv, Joshua Genstler, Alex Schafir

Providence St. Vincent Internal Medicine 2021

No abstract provided.

Are Elevated Inflammatory Markers And Acute Phase Reactants Associated With More Severe Disease In Covid 19 Patients?, Joanna Bove, Robert Kim, Shelley Sanders

Providence St. Vincent Internal Medicine 2021

Introduction Inflammatory markers and acute phase reactants (from here referred to as “markers”) are associated with COVID-19 infection and may be able to predict disease severity.1,2We collected markers including d-dimer (ug/mL), ferritin (ng/mL), CRP (mg/dL), and creatinine kinase (CK) (IU/L) on admission and periodically throughout the hospital stay for 50 patients admitted with COVID-19 infection. We hypothesized that higher levels of markers at admission and during hospitalization are associated increased severity of disease, such as ICU admission and placement on mechanical ventilation.

Methods From March to May 2020, we identified 50 patients admitted to Providence St. Vincent Medical Center with …

A Case Of Succinylcholine-Induced Postoperative Myalgia, Nancy Ha, Stephanie Griffith

Providence St. Vincent Internal Medicine 2021

Introduction

Succinylcholine is a commonly used depolarizing neuromuscular blocking agent in anesthesia for relaxation of the skeletal muscles during endotracheal intubation. It is ideal for use in shorter surgical cases and situations where a rapid sequence intubation is warranted due to its quick onset and short duration of action. One documented side effects of succinylcholine is postoperative myalgia, which was first described in the literature in 1952.

Case Report

An 88 y.o. male presented two days following transurethral resection of a bladder mass with complaints of diffuse myalgias that were severely limiting activity. The pain was greatly exacerbated by any …

When Two Isn’T Better Than One: A Case Of Severe Hyponatremia From Combination Thiazide Diuretic And Arb Therapy, Jillian Catral, Emily Hitchcock

Providence St. Vincent Internal Medicine 2021

Introduction

Thiazide diuretics and angiotensin II receptor blockers (ARB) are common medications for hypertension and are widely used together to counteract thiazide-induced hypokalemia •Thiazide-associated hyponatremia (TAH) is fairly common. There are also multiple case series in the literature of severe hyponatremia in elderly pts attributed to initiation of a thiazide-ARB combination, even when the thiazide dose was low. This is a unique case of hyponatremia in which ARB on thiazide therapy seems to have precipitated severe hyponatremia.

Case Report This is a 74-year-old female with a history of essential hypertension with intolerance to several antihypertensive medications, post-operative hyponatremia after laminectomy …