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Published Abstract Final Illinois Chapter Northern Region Top 100 Posters University of Illinois at Chicago October 21, 2015 Abdul Majeed, Hamza Lombard, IL First Author: Resident Category: Clinical Vignette Institution: Advocate Lutheran General Hospital Program Additional Authors: Hina Omar Abstract Title: Charcot''s Triad Abstract Text: A 15-year-old high functioning autistic boy with a past medical history significant for congenital heart defects and primary sclerosing cholangitis (PSC), initially diagnosed at age 2, presented with fevers, nausea, vomiting and abdominal pain for 3 days. His physical exam was remarkable for mild scleral icterus and jaundice, a narrow jaw with small facial features and a loud systolic murmur heard at the right upper sternal border. Abdominal exam was unremarkable. Labs on admission showed a total serum bilirubin of 8.0 mg/dl, alkaline phosphatase (ALP) of 201 units/L, and a serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) of 86 units/L and 232 units/L, respectively. Lipase and amylase values were elevated at 17455 and 1519, respectively. Magnetic Resonance Cholangiopancreatography (MRCP) and CT imaging revealed intrahepatic and common bile duct (CBD) dilatation with tapering and strictures distal to CBD along with nonspecific gallbladder wall thickening. The patient was initially treated for what seemed to be a recurrent bout of ascending cholangitis due to his underlying history of PSC. The recurrence of his presentation and hospitaliZations prompted further review and comparison of prior imaging and pathology. Over the past 13 years, the patient had undergone several liver biopsies (most recent in 2012) that all yielded very similar findings. There were minimal changes and no significant fibrosis or inflammation that would be characteristic of PSC. Upon further review, his current MRCP showed increased dilatation of common bile duct and intrahepatic ducts since prior study. Increased dilatation along with elevated liver enZymes raised concern for an acute obstruction. An ERCP then confirmed the presence of a choledochal cyst with intrahepatic biliary tract involvement. Biopsy and brushings obtained during ERCP revealed normal portal triads without any neoplastic or inflammatory characteristics. The location of dilated CBD with distal tapering, hemifacial microsomia and congenital heart defects are other congenital developmental abnormalities often associated with the presence of choledochal cysts. The patient upon further assessment was diagnosed with having a type 1a choledochal cyst. The cyst was successfully resected without any complications and the patient is doing well without any recurrent hospitalization. Choledochal cysts are rare presentations of biliary cystic disease that present as single or multiple cystic dilatations classified based on their number and location. They were divided into 5 types to include the intra and extrahepatic dilatations by Todani (1977). Complications include ductal strictures, cholangitis, biliary cirrhosis, and cholangiocarcinoma. It is thought to be due to an abnormal development with an unequal proliferation of the embryological biliary epithelial cells before the complete cannulation process of the bile duct. Other associated developmental anomalies include colonic atresia, ventricular septal defects, and aortic hypoplasia. The treatment is excision of cysts and in more severe cases requires liver transplant. Abraham, Geethi Berwyn, IL First Author: Medical Student Category: Research Institution: University of Illinois College of Medicine at Chicago Program Additional Authors: Susan Shey, BA, Patricia Nordman, RN, MS, MPH, ANP/CNP, and Alesia Jones, Ph.D. Abstract Title: Inadequate Screening for Pediatric Type 2 Diabetes in Rural Illinois Primary Care Setting Abstract Text: Background Type 2 diabetes mellitus (T2DM) is reaching epidemic proportions among children. Although previously considered a disease of adult onset, the incidence of T2DM in the pediatric population has increased significantly in the United States over the past two decades. In 2013, as many as 1 in every 400 children and adolescents had T2DM. The increased prevalence of child and adolescent T2DM correlates with increased rates of childhood obesity, with Illinois currently ranking fourth in the nation for childhood obesity rates. The ADA now recommends screening of all asymptomatic overweight pediatric patients at risk for developing T2DM every three years. Given the increasing prevalence of pediatric T2DM and the recent revision of screening guidelines, there is a need for research investigating T2DM screening practices by primary care providers particularly in the rural primary care settings. Purpose The purpose of this study was to assess T2DM screening and follow-up practices of healthcare providers in a rural Illinois primary care clinic. Methods A retrospective chart review was conducted at Mount Morris Primary Care Clinic affiliated with University of Illinois Health System. The study included patients 10 to 18 years of age with a BMI≥25 seen in clinic between January 1, 2011 and January 1, 2015, excluding patients with a history of pregnancy and/or thyroid disorder. Demographic and clinical data including T2DM risk factors (BMI, race, family history, and insulin resistance) were collected. Data was analyzed using descriptive analyses, as well as, Fisher Exact test and the Mann-Whitney test to examine risk factors. Results Eighty-three patients met inclusion criteria. Mean patient age was 15 years. Mean patient BMI was 36. Patients were 53% men and 47% women. Eighty-two percent of patients were Caucasian with 72.3% of patients having one or more risk factors for developing T2DM. The most prevalent risk factor was having a family history of diabetes (59.0%). Family history of diabetes was the only risk factor associated with T2DM screening (p=0.046). Based on BMI, race, family history, and insulin resistance, 44.6% of patients met ADA criteria for screening. Of those patients, 83.8% had at least one time diabetes screening. However, only 32.4% had appropriate follow-up screening compliant with ADA screening guidelines. Conclusion The findings of this study suggest that although the majority of overweight pediatric patients in this setting are being screened for T2DM, screening is not being conducted according to current ADA guidelines with regard to appropriate follow-up testing. Improving provider documentation of patient risk factors in health records is needed to track and monitor patient care. Increasing provider awareness of the latest ADA guidelines may improve rates of compliance to guidelines and encourage more stringent screening and documentation of risk factors associated with T2DM. Abraham, Ivy Chicago, IL First Author: Resident Category: Clinical Vignette Institution: University of Illinois College of Medicine at Chicago Program Additional Authors: Lauren Estep Abstract Title: Coughing up Renal Cell Carcinoma: An Atypical Presentation of Malignancy Abstract Text: Renal Cell Carcinoma accounts for 3% of malignancies nationwide and is increasing in incidence with tobacco use, obesity and end stage renal disease as contributing risk factors. There are over 60,000 new cases and 14,000 deaths from renal cell carcinoma each year. While it is usually spread through the vascular system, in rare cases it can be detected as lymphangitic metastasis. We present one such case of metastatic renal cell carcinoma with suspected lymphangitic spread. A 68 year old male with a history of end stage renal disease due to hypertension and Type II diabetes mellitus presented to the emergency room with progressive dyspnea on exertion, paroxysmal nocturnal dyspnea and cough. His admission chest radiograph demonstrated bilateral airspace opacities and he was initiated on broad- spectrum antibiotics for presumptive pneumonia. His hospital course was complicated by acute hypoxemic respiratory failure requiring intubation and follow up chest imaging demonstrated peripheral consolidation bilaterally in addition to multiple pulmonary nodules. A broad differential was entertained, but workup was largely unrevealing, including a trans-esophageal echocardiogram (TEE) negative for vegetation, bronchoscopy negative for infection and eosinophilia and pathology from broncheoalveolar lavage (BAL) consistent with benign alveolar cells. A video-assisted thorascopic surgery (VATS) with lung biopsy was performed and pathology ultimately revealed intravascular tumor emboli and lymphatic invasion, final pathology consistent with renal cell carcinoma. Renal cell carcinoma classically presents as a triad of hematuria, flank pain and a palpable abdominal mass. Curative therapy is surgical excision of the primary mass; however one-third of patients present with metastatic disease as our patient did. The lung is a common location for metastases and is seen in 50- 60% of these patients while metastatic disease to the bone, liver and brain disease is also common. In addition to metastasis, renal cell carcinoma is associated with paraneoplastic syndromes such as anemia, hepatic dysfunction, hypercalcemia, erythrocytosis, thrombocytosis, and polymyalgia rheumatica which are clues to diagnosis, though in some cases, as with our patient, they may not be present. Lymphangitic metastisis of renal cell carcinoma is much less common with very few cases reported. Pulmonary lymphangitic carcinomatosis accounts for 6- 8% of lung metastasis, but is seen more commonly with breast, lung, pancreatic, colon, uterine,
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