New York Chapter ACP Resident and Medical Student Forum Saturday, November 14, 2015 SUNY Upstate Medical University Institute for Human Performance 505 Irving Avenue Syracuse, NY 13202 3 New York Chapter ACP Resident and Medical Student Forum Medical Student Clinical Vignette 1 Medical Student Clinical Vignette Author: Rebecca Abi Nader Author: Brandon Brown Additional Authors: Adewale Olajubelo MD, Avery Additional Authors: Vadim Zarubin, MD; In-suk Seo, Davis( MS III), Omar Guitterez MD MD; Kevin Tsai, MD; Elizabeth Guevera, MD Institution: Kingsbrook Jwish Medical Center Institution: The Brooklyn Hospital Center Title: Unexplained Acute Abdominal Pain- Appendicitis Title: Combined Subcutaneous, Intra-abdominal and Epiploicae Thoracic Splenosis: A Noninvasive Diagnosis in the Age of Nuclear Medicine Acute abdominal pain lends itself to various etiologies depending on the location, character, and consistency of the pain. Splenosis is a benign entity whereby splenic tissue Appendicitis epiploicae is an uncommon cause and can present with symptoms mimicking ovarian cyst, appendicitis, diverticulitis autotransplants, generally in the abdominal or or ectopic pregnancy especially in a young woman of child peritoneal cavity, following spleen rupture or bearing age. splenectomy. Ectopic splenic implants in the thoracic A 26 year old female presents to the ED with complaints of acute cavity and subcutaneous tissue are comparatively rare. abdominal pain for 4 days. Pain was located in the upper In the majority of cases, splenosis remains quadrant and radiates to the left lower quadrant and flank. The asymptomatic and is diagnosed incidentally. Previously pain was sharp and 8/10 in severity. Pain is alleviated by lying down and exacerbated by movement. Associated symptoms reported cases often are limited to a single include nausea, loss of appetite and constipation. Her past compartment, abdominal or thoracic. Moreover, a medical history was significant for mild asthma which is majority of those involving intra-thoracic or controlled with albuterol. She has no pertinent surgical history or subcutaneous splenosis are histopathologic diagnoses family history. She takes no medications. She is allergic to after invasive biopsy. We describe a case of combined penicillin and has anaphylactic reaction if used. intra-abdominal, thoracic and subcutaneous splenosis She is G0P0, not sexually active and has no history of STDs. Her LMP was on 06/14/15 with regular cycle lasting 3 to 4 days. in a 42-year-old male resultant to a gunshot wound Review of systems was significant for fatigue, and decrease requiring splenectomy 26 years prior diagnosed on frequency of urination. At the time of presentation, she was in nuclear imaging. This case uniquely features vast mild distress but alert, awake, oriented to place, time and person. anatomic disbursement and is only the second such Vital signs were within normal limits. Physical exam shows case to be reported. In this report and literature review, hypoactive bowel sounds with positive rebound tenderness and guarding of the left upper quadrant. Laboratory studies reveals we emphasize the need for a high index of suspicion for negative beta HCG, low: MCV (75.3), MCH (23.2) MCHC (30.8), splenosis in the setting of relevant imaging findings with and platelets (115). RDW was high at (15.1). These values were history of splenic rupture or splenectomy. As the not specific enough to rule in any particular cause of these ectopic implants often resemble malignancy on patient’s symptoms. Urinalysis was significant for WBC >20 with imaging, patients may undergo undue testing including positive cocci. A radiologic study was done to rule out other invasive procedures while splenosis may be easily possible etiologies. CT of the abdomen without contrast reveals the following: diagnosed on radionuclide scanning - An isodense soft tissue nodule anterior to the spleen measuring 1.6 cm typical for accessory spleen - Bowel shows small foci of infiltration adjacent to distal descending colon with small amount of fluid in paracolic gutter. The right quadrant inferior to the cecum has a second pocket of infiltrative fluid. Appendix was unremarkable, terminal ileum is intact and no bowel dilatation. - Fluid density structure and dilated fallopian tube typical for hydrosalpinx Radiological studies confirmed a diagnosis of Appendicitis epiploicae. She was managed with normal saline, Ketorolac 30mg for pain and 4mg of zofran for nausea.She was discharged home with TMP/SMX, Percocet and Ibuprofen with instructions to follow up at the clinic in 1 week Appendicitis epilploicae presentation is based on where the epiploic tissue is inflamed usually by the sigmoid colon. Initial management is often conservative through symptomatic management; therefore it should not be confused with other causes of acute abdomen thereby preventing unnecessary intervention. 2 Medical Student Clinical Vignette Author: Daniel Jipescu Author: Daniel Jipescu Additional Authors: Barie Salmon MD, Allison Hoyle DO, Additional Authors: Bankim Shah MD, Karthik Donuur Tracy Salmon MD, Abdul A. Ameen MD, David Flores MD, Hassan Qureshi DO, Abdul A. Ameen MD, Amer MD, Amer Syed MD FACP Syed MD FACP Institution: Barnabas Health, Jersey City Medical Center Institution: Barnabas Health, Jersey City Medical Center Title: THE UNIQUE CASE OF A LARGE DEBILITATING STROKE IN A YOUNG PATIENT WITH CORONARY Title: ANOMALOUS LEFT CORONARY ARTERY - DID THE ARTERY ECTASIA PATIENT TAKE AN ANOMALOUS DECISION? 29 yo African American male with PMH of CVA, HTN, CHF, 68 YO female with PMH significant for hypertension, IDDM, DVT, dilated cardiomyopathy, hypertensive nephropathy and TIA, gastritis, dyslipidemia, paroxysmal A-Fib, and vitiligo was obstructive sleep apnea was brought to emergency sent to ED by her primary physician because of an abnormal department with altered mental status for 4 hours. His co- finding on abdominal CT. This showed a possible thrombus in workers called 911 after they noticed that the patient was not the left ventricle. Patient had been complaining of epigastric verbally responsive and was staring off into space for a long pain and exertional dyspnea for a month. V/S: T 97.8, HR 63, period of time. They reported that the patient was able to BP 158/59, RR 18, O2 Sat 100% RA. Allergies: percocet and speak for a very short period of time prior to EMT arrival. The codeine. Family history: stroke and diabetes mellitus in her EMT personnel however found the patient to be non-verbal. mother. ROS: noncontributory, except epigastric pain of In emergency department, the patient was noted to have variable intensity, that occasionally was increased by walking. memory loss and complained of mild generalized headache. PE: HEENT: NC/AT, PERRLA, EOMI; Neck: supple, no JVD; CV: He denied photophobia, blurry vision, dizziness, or seizure. He S1, S2, RRR, no M/R/G; Abd: soft, NT/ND, obese. Troponin I: also denied chest pain or abdominal pain. Family history was 0.02/0.03/0.02. EKG showed inferior and anterior myocardial significant for early-onset heart disease in his mother and two infarct. Nuclear stress test showed fixed perfusion defect of her sisters. PE: V/S: R arm BP: 171/121, L arm B/P 161/121, throughout the apex and hypoperfusion of the distal anterior HR: 116, O2sat: 96% RA. RR: 16-35, AAOx3 - with intermittent wall region, compatible with prior myocardial infarction; a confusion; HEENT: NC/AT, PERRLA, EOMI. CV: Soft S1, S2, RRR, fixed perfusion of the mid to distal inferolateral segment and tachycardic, grade 2 apical and left lower sternal systolic distal lateral wall, compatible with prior infarction. 2D murmur and a grade 2 systolic murmur in the second IC space Echocardiography presented: Apical wall motion abnormality, on the right. Troponin I: 0.21 / 0.2 / 0.14. CT head showed EF of 72%, and intraluminal thrombus. Cardiac catheterization mild diffuse atrophy slightly greater than expected for the showed anomalous left coronary artery origin. A single right patient’s age. MRI of head showed acute infarction in the coronary artery originated from the right coronary cusp; the right middle cerebral artery distribution involving the majority left circumflex (LCX) originated from the same cusp but a of the right temporal lobe. 2D Echocardiogram revealed separate ostium; what appeared to be the left anterior severe dilatation of all cardiac chambers and severe descending artery (LAD) originated from the proximal right biventricular dysfunction with EF of 10%. Hospitalization coronary artery (RCA). The posterior descending artery was records from a different hospital were obtained. A diagnosis noted to have a subtotal occlusion. What was considered to of Coronary Artery Ectasia (CAE) was noted. The CCU team be the LAD was noted to have 90% stenosis. Obstructive discussed the benefits of an S-ICD with the patient and his disease was noted in the proximal sections of multiple family. After the S-ICD placement and comprehensive medical medium size coronary arteries. After thorough consultation treatment, the patient recovered well. with the cardiothoracic team, the patient was recommended This is a unique case of a young patient with extensive for coronary artery bypass graft surgery. The patient cardiovascular pathology that presented with a large discussed with her family and requested comprehensive debilitating stroke. CAE is dilatation of a coronary artery meetings with the medical and surgical team. In the end the segment to a diameter at least 1.5 times that of the adjacent patient decided to choose only medical management of her normal coronary artery. It has an incidence of 1-5% in patients condition. According to the patient’s wishes, she was undergoing coronary angiography. More than half of CAE are managed medically and discharged in a well and stable due to coronary atherosclerosis, but occasionally they are condition. related to other pathological entities. As the first report of The incidence of coronary anomalies in patients undergoing coronary dilatation in a patient with syphilitic aortitis, CAE has coronary angiography varies from 0.64% to 1.3%.