The Medicine Forum

Photo Essay

Jennifer Wilhelm — Wed, 31 Oct 2012 08:30:31 PDT

Poem and Original Art

Thoai Q. Tran — Wed, 31 Oct 2012 08:30:30 PDT

A Kidney for Christmas

Stephen Scholand — Wed, 31 Oct 2012 08:30:29 PDT

When Asmar Lawrence first walked into the small examining room in the Jefferson Hospital Ambulatory Practice (JHAP) Clinic, we both had no idea what the future would hold. It was July, 1998 and I was fresh from medical school. Each week, I looked forward to the JHAP experience to develop my clinical skills and follow patients longitudinally. No longer was my learning prescribed from a textbook, this was the 'real world' of medicine where anything could happen and I was supposed to be in control of it. The long white coat probably helped perpetuate some of that illusion. Fortunately our seasoned faculty mentors provided us residents with reassurance and guidance. What I was about to learn from this young man and his family, however, were lessons of love and compassion which no text, syllabus or mentor could provide. It was, and remains, something which is best "experienced."

A Pilot Study of Diabetes Management in the Managed Care Setting

Rachel Wagman — Wed, 31 Oct 2012 08:30:28 PDT

Diabetes mellitus represents a disease entity that primary care providers commonly encounter in the outpatient setting. Patient visits encompass a broad range of concerns, from optimizing management of hyperglycemia to the sequelae of chronic disease. The third National Health and Nutrition Exam Survey, (NHANES III) 1988-1994 has reported the prevalence of diabetes mellitus type 2 in the U.S. adult population at 12.3%. The cost of diabetes in 1998, estimated at $77 billion, is a formidable challenge to the health care community and third-party payers. Historically, Health Maintenance Organizations (HMOs) have encouraged more preventative tests, procedures, and exams to curtail the development of chronic disease than indemnity plans. The influx of patients of all ages into these capitated plans has spurred such organizations to reconcile cost-conscious initiatives with the expense of chronic disease using treatment algorithms. Aetna U.S. Healthcare (USHC) has developed Healthy OUtlook Programs to manage patients with diabetes using patient education, treatment recommendations, and a U.S. Quality Algorithm (USQA) Diabetes Performance Report for providers. It is not clear whether this program has helped patients with Type 2 diabetes achieve improved glycemic control, receive enhanced screening, and earlier interventions for disease complications compared with indemnity patients. This pilot study seeks to evaluate the effectiveness of managed health care initiatives in improving the quality of care for Type 2 diabetes. In addition, it considers whether differences exist in the care between capitated and indemnity diabetic patients.

Brachytherapy: A New Weapon Against Coronary Restenosis

Rob Silver — Wed, 31 Oct 2012 08:30:27 PDT

Since its introduction in the late 1970's, coronary angioplasty has become a common procedure for treating coronary atherosclerotic disease. It offers significant improvement in symptoms of coronary artery disease through a less invasive procedure than coronary artery bypass grafting (CABG). Each year, over 500,000 percutaneous transluminal coronary angioplasty (PTCA) procedures are performed in North America alone. In larger epicardial vessels that are 3 millimeters or greater in diameter, a metal stent can be placed during angioplasty to reduce the incidence of restenosis. In fact, stents are now deployed in approximately 80 percent of PTCA procedures. The success rate of PTCA in achieving significant dilation of stenotic lesions and relief of symptoms of angina approaches 90 percent. However, restenosis occurs in approximately 30 to 40 percent of patients within six months of PTCA alone, and in 20 to 30 percent of patients who undergo stent placement. Repeat PTCA can be performed following restenosis, but the risk of further episodes of restenosis increases as well.

Melena with Fever

Monica Patel et al. — Wed, 31 Oct 2012 08:30:26 PDT

The patient is a 62 year old Indian male with a past medical history significant for myasthenia gravis, hypertension, and diabetes mellitus, who presented to an outside hospital with fever, fecal incontinence, and melena. Work up at that hospital was remarkable for elevated liver function tests, heme-positive brown stool and a CT of the abdomen showing a thick ascending colon suggesting possible mass. The patient had an episode of desaturation and fever to 105 degrees Fahrenheit prior to transfer to Thomas Jefferson University Hospital for further evaluation. Upon arrival, the patient was in respiratory distress with oxygen saturation of 70% on 5 liters of oxygen by nasal cannula. He was immediately intubated.

Severe Dyspnea and Cough

Traci Mellinger Kohl et al. — Wed, 31 Oct 2012 08:30:24 PDT

A 43 year-old white male with a history of hypertension and a smoking history of 30 pack-years presented to the emergency room coplaining of cough, severe dyspnea, nausea, and vomiting. Ten days prior to presentation, he experienced flu-like symptoms with a low-grade fever, myalgias, and malaise that lasted approximately four days but resolved spontaneously. He had a cough productive of white sputum and blood-tinged nasal drainage for one week. Three days prior to presentation he began to experience right upper quadrant abdominal pain and bilious vomiting. The patient worked as a bar inspector and had a routine PPD check 9 months prior to presentation which was negative. However, his daughter did have a recent positive screening PPD with a negative chest x-ray.

A Case of Hypercalcemia

Daniel Lin — Wed, 31 Oct 2012 08:30:23 PDT

A 79-year-old man with a past medical history of diet-controlled type 2 diabetes mellitus, hypertension, and chronic lower extremity venous stasis ulcers requiring two skin grafts was admitted to the hospital due to dehydration. He was in his usual state of health intermittently being wheelchair bound due to leg ulcers until four days earlier, when he accidentally spilled hot tea on his left arm while in the kitchen. In his attempt to maneuver the wheelchair away from the spill, the wheelchair turned over, pinning him on the floor and against the cabinets. He remained in that position for four days until he was found by a neighbor in semi-conscious state lying in urine and feces. The patient was agitated and combative when aroused and was transported to the emergency room.

Hematuria Status Post Renal Biopsy

Bill McElhaugh — Wed, 31 Oct 2012 08:30:22 PDT

This is a case of a 66 year old Caucasian woman admitted to the hospital following a ureteroscopic biopsy of the left renal pelvis. The biopsy was performed for asymptomatic hematuria, with a retrograde intravenous pyelogram revealing a mass in the left renal pelvis. The patient developed lightheadedness and left flank pain 12-24 hours following the procedure and was found to have a 3 gram drop in hemoglobin compared to blood work performed during the previous week.

Editor's Statement

Rajani Dinavahi — Wed, 31 Oct 2012 08:30:20 PDT

From the Acting Chairman of Medicine

Geno Merli — Wed, 31 Oct 2012 08:30:19 PDT

Table of Contents for Volume 3 Number 1, Fall 2001

Wed, 31 Oct 2012 08:30:17 PDT

Histology Slide

John Farber — Tue, 23 Oct 2012 13:40:39 PDT

A 45 year old Black female without significant past medical history was admitted with insidious cough, dyspnea, nausea, vomiting, and progressive weight loss. She suddenly went into respiratory distress and succumbed to death. Autopsy subsequently showed widespread granulomatous disease. This slide of one of the lung lesions shows a noncaseating granulocyte with a fibrotic center surrounded by palisading histiocytes, consistent with a diagnosis of nodular sarcoma.

Candidal Retinitis

Carl D. Mele — Tue, 23 Oct 2012 13:40:37 PDT

Mr. R.T. was a 49 year old male with recurrent Hepatitis C infection after orthotopic liver transplant, who presented with complications related to hemorrhagic pancreatitis. While on long term total parenteral nutrition, he developed blurry vision and Candida albicans fungemia. A fundus photograph revealed fungal endopthalmitis with focal areas of chorioretinitis. His vision improved significantly with serial intravitreal antifungal injections.

Validation of a Novel, Non-Invasive System for Autonomic Profiling in Healthy Volunteers

Agostino Ingraldi et al. — Tue, 23 Oct 2012 13:40:36 PDT

Noninvasive profiling of the autonomic nervous system has been shown to have prognostic value in patients with myocardial infarction, CHF and diabetes. The ANSAR system (ANX 3.0, Philadelphia, PA) is a new commercially available system that utilizes respiratory rate, HR and BP to assess on-going sympathovagal modulation during various maneuvers known to evoke autonomic perturbations. Instead of using conventional Fast Fourier Transform for frequency domain analysis, a Continuous Wavelet Transform (CWT) is used to generate numerical and graphical data. The system calculates Low Frequency Area (LFA, analogous to LF Power) and Respiratory Frequency Area (RFA, analogous to High Frequency Power.) A time domain index (pNN50 is also calculated.

A Case of Invasive Thymoma

Jon Geddes — Tue, 23 Oct 2012 13:40:34 PDT

A 52 year-old man with a past medical history of an isolated seizure presented to the Veterans Affairs hospital complaining of weakness which was most prominent in the face and upper extremities. About 6 months prior to this admission he developed intermittent episodes of weakness when chewing and swallowing. He would often have to use his hands to close his jaw when eating or talking. He noticed that his voice had developed a nasal quality but he did not have slurred speech. He denied drooling, ptosis, cramping or muscle twitches. He was seen 6 months ago at another VA hospital where a neurologic workup was done. This included a cranial nerve EMG positive for denervation of cranial nerves, R arm and T- and L-spine. MRI and CT scans could not be done because the patient aspirated when supine. He was given a presumptive diagnosis of motor neuron disease, specifically bulbar ALS. At that time he was told he would need a PEG-feeding tube placed due to significant weight loss. The patient refused the feeding tube and did not follow up until 6 months later when the symptoms had worsened.

Cord Compression by Extramedullary Hematopoiesis in Polycythemia Vera

Lisa Reale et al. — Tue, 23 Oct 2012 13:40:32 PDT

A 73-year-old male with polycythemia vera and a history of prostate cancer presents to an outside hospital complaining of back pain of two months duration. He denied fevers, chills, night sweats, weight loss, lower extremity weakness and decreased sensation. Other than chronic constipation and urinary hesitancy, his review of systems was unremarkable. A spinal x-ray revealed a T12 vertebral fracture and the patient was transferred to Thomas Jefferson University Hospital for further management.

A Case of Thrombosis and Thromboembolic Events

Daniel Lin — Tue, 23 Oct 2012 13:40:31 PDT

A 65 year old black woman with hypertension (HTN), gastroesophageal reflux disease (GERD), and anxiety had complained to her primary care physician of vague abdominal pain. Initial empiric treatment as an outpatient for worsening GERD was unsuccessful. The patient had insidious development of generalized fatigue, early satiety, nausea, vomiting, and weight loss. An ultrasound of the abdomen revealed multiple liver lesions, with the largest lesion being 2.5 cm x 2.5 cm. She subsequently underwent a CT scan of the abdomen and pelvis, which confirmed multiple hyperdense liver lesions. The remainder of the scan was unremarkable. Esophagogastroduodenoscopy (EGD) as well as colonoscopy was performed, revealing a duodenal mass and a sigmoidal polyp. Biopsy of these two lesions showed an adenomatous polyp and a tubular adenoma, respectively, and subsequent liver biopsy diagnosed poorly differentiated adenocarcinoma. The patient was then admitted to TJUH for further management.

A Case of a Male with Fever and Fatigue

Steve Ting — Tue, 23 Oct 2012 13:40:29 PDT

This is a case of a 78 year old Caucasian gentleman who presented to the hospital in the early summer with complaints of high fevers and progressive fatigue. The patient lives near Philadelphia and enjoys doing yard work. He reported finding a tick attached to the skin near his groin approximately 3 weeks prior to admission. The tick was removed; however the patient was unsure of the duration of the tick attachment. He also denied developing any significant rash in that area. He had no recent sick contacts and no recent history of travel. He began developing fever spikes up to 39.2 C (102.5 F) associated with chills and sweats. Patient complained of progressive fatigue over the ensuing few days which become so severe he did not even have the energy to walk across the room. He also had generalized muscle aches and a decreased appetite.

Nevirapine Hepatotoxicity: Case Report and Discussion

Matt Baichi — Tue, 23 Oct 2012 13:40:28 PDT

Nevirapine (viramune) is a nonnucleoside reverse transcriptase inhibitor commonly used in combination with other antiretroviral medicines in the treatment of HIV/AIDS. The safety profile of nevirapine, as determined by review of prospective clinical trials, reports rash with an incidence of 16% as the most common side effect. Clinical hepatitis is reported to occur with an incidence of 1%. A review of the literature shows many case reports of nevirapine-induced hepatotoxicity in patients receiving both treatment and prophylaxis for HIV. The purpose of this case report is to stress the importance of early recognition and withdrawal of the offending drug.