Journal of community hospital internal medicine perspectives
-
J Community Hosp Intern Med Perspect · Jan 2015
Case ReportsKey clinical features a general internist needs to know about Brugada syndrome: a case-based discussion.
Brugada syndrome (BrS) is an autosomal dominant genetic disorder involving the abnormal function of cardiac voltage-gated sodium ion channels. Sodium channel loss of function can lead to early repolarization and loss of the Phase 2 action potential dome in cardiomyocytes. In BrS, this sodium channelopathy occurs in some, but not all, epicardial cells thus creating 1) juxtaposition of depolarized and repolarized cells in the epicardium and 2) a transmural voltage gradient. Together, these conditions can set up a Phase 2 reentry and resultant malignant cardiac arrhythmia. Of the three types of electrocardiogram (EKG) changes seen in BrS, only the Type 1 EKG is considered diagnostic. In a controlled setting, sodium channel blockers and Brugada EKG leads may be used to unmask this diagnostic EKG finding. Fever and certain medications that interfere with the sodium channel can also trigger these changes, which can be catastrophic. ⋯ Due to the gravity of symptoms that can manifest in the BrS patient, it is important to recognize and treat this condition promptly and effectively. BrS patients require admission for continuous cardiac monitoring when febrile and certain medications interfering with the sodium channel should be avoided in this population. Although medications may be used as one treatment modality, definitive therapy is placement of an ICD device.
-
J Community Hosp Intern Med Perspect · Jan 2015
Critical gastrointestinal bleed due to secondary aortoenteric fistula.
Secondary aortoenteric fistula (SAEF) is a rare yet lethal cause of gastrointestinal bleeding and occurs as a complication of an abdominal aortic aneurysm repair. Clinical presentation may vary from herald bleeding to overt sepsis and requires high index of suspicion and clinical judgment to establish diagnosis. Initial diagnostic tests may include computerized tomography scan and esophagogastroduodenoscopy. ⋯ A combination of MeSH terms and Boolean operators were used to device search strategy. In addition, a bibliography of clinically relevant articles was searched to find additional articles (Appendix A). The aim of this review is to provide a comprehensive update on the diagnosis, management, and prognosis of SAEF.
-
J Community Hosp Intern Med Perspect · Jan 2015
Case ReportsTaking it to the next level: lumbar radiculopathy from thoracic nerve schwannoma.
Compression or irritation of the sciatic nerve and its branches, the common fibular and tibial nerves, causes sciatica which is a common syndrome characterized most often by radiating pain from the lower back down the legs and also manifesting as sensory and motor deficits. Sciatica is a common presentation of lumbosacral disc prolapse and degenerative disease of the lumbar spine in ambulatory settings. Schwannomas rarely cause sciatica; hence, it is seldom considered in evaluation of a patient with radiculopathy. ⋯ Thoracolumbar spine MRI revealed the schwannoma in the thoracic region. He recovered neurologic function after tumor excision. This case highlights the diagnostic challenge that may arise in evaluating a patient with lumbar radiculopathy, negative lumbosacral spine imaging, and failure of conservative therapy.
-
J Community Hosp Intern Med Perspect · Jan 2014
Feasibility of an innovative third-year chief resident system: an internal medicine residency leadership study.
The role of the internal medicine chief resident includes various administrative, academic, social, and educational responsibilities, fulfillment of which prepares residents for further leadership tasks. However, the chief resident position has historically only been held by a few residents. As fourth-year chief residents are becoming less common, we considered a new model for rotating third-year residents as the chief resident. ⋯ The feasibility of preparing internal medicine residents for leadership roles through a rotating PGY-3 (postgraduate year) chief residency curriculum was explored at a small internal medicine residency, and we suggest extending the study to include other programs.
-
J Community Hosp Intern Med Perspect · Jan 2014
Case ReportsLow-pressure cardiac tamponade masquerading as severe sepsis diagnosed with a bedside ultrasound and as the initial presentation of malignancy.
We report a patient with low-pressure cardiac tamponade masquerading as sepsis and as the initial presentation of malignancy. A quick diagnosis was done by the intensivist performing a bedside ultrasound. ⋯ Because low-pressure cardiac tamponade is life-threatening and difficult to diagnose, evaluation of the pericardium with a bedside ultrasound should be considered in patients with syncope, severe sepsis, or shock.