The Not-So-Benign Sickle Cell Trait: A Case of Renal Medullary Carcinoma.

Sickle cell trait (SCT) has long been considered a benign carrier state with malarial protection, but carriers can be affected by increased venous thromboembolism, exercise-related injury, renal complications and very rarely a fatal renal malignancy. Renal medullary carcinoma is a very rare and aggressive renal tumor described almost exclusively in sickle cell trait. A review of the current literature provides clues to this link and describes trends expected in these cases. We report a case of renal medullary carcinoma in a 32-year-old female with known sickle trait who presented with cough, hemoptysis, left flank pain and gross hematuria. Initial presentation was concerning for pulmonary renal syndrome, but her labs did not show evidence of nephritic syndrome with negative autoimmune and infectious serologies. Abdominal CT imaging identified a large left renal mass with biopsy confirmation of renal medullary carcinoma and subsequent staging showing pulmonary and osseous metastases. Despite palliative chemotherapy, she died within 3 months of diagnosis following a protracted clinical course. Renal medullary carcinoma should be considered in patients with SCT presenting with hematuria.

Cases from a Community Hospital JCHIMP Series #2: 66-Year-old Man with Recurrent Painful Rashes and Oral Ulcerations.

This is part of a series of case reports detailing scenarios from our community hospital. The cases are selected to feature clinical dilemmas, provide a review on what is currently known about the topic with expert perspective. A 66-year-old black man presented to the primary care clinic with his fourth episode of generalized painful rash and oral ulcerations without a diagnosis despite two emergency room (ED) visits alongside doxycycline treatment. Symptoms interfered with daily activities with skin exam notable for widespread erythematous patches and plaques. In office biopsies were obtained with final diagnosis of erythema multiforme. Etiologic workup revealed positive HSV 1 IgG and active untreated hepatitis C infection. He was treated with prednisone, and acyclovir with resolution of lesions and no further recurrences over a nine-month follow up period. This case depicts an unusual presentation of a common skin disorder. It highlights the challenge of recognizing atypical target lesions in skin of color and the important role of primary care in bridging access to dermatological care.

A Rare Case of Pancolonic Ischemia Complicated by Fusobacterium Necrophorum Bacteremia: A Review of Colonic Ischemia for Internists.

The varied clinical presentation and objective findings associated with colonic ischemia (CI) overlap with multiple disease processes. A high index of suspicion is critical for timely diagnosis and prognostication to avoid delays in treatment. We present a case that highlights the challenges of diagnosing CI and the high morbidity associated with severe disease. Case report: A sixty-four-year-old female presented to our community hospital with acute onset abdominal pain, nausea, and diarrhea, complicated by septic shock. She was initially given a diagnosis of infectious colitis until a colonoscopy was performed revealing extensive pancolonic ulcerations. Histopathological features on biopsy were most consistent with colonic ischemia. Blood cultures grew Fusobacterium Necrophorum. Surgery was avoided due to the high morbidity and mortality of performing a total colectomy and ileostomy. The patient continued to struggle with abdominal pain, diarrhea, and hematochezia, consistent with continuous CI, leading to recurrent hospitalizations.

Cases from a Community Hospital JCHIMP Series #1: 55-Year-Old Male with Acute PE Who Developed Persistent Epistaxis.

This is the first in a new series of case reports that will present real scenarios from our community hospital. The cases are chosen to highlight clinical dilemmas and offer review and perspective on what is currently known about the topic. We present the case of a 55-year-old Caucasian male who presented to the emergency department of our community hospital for worsening dyspnea. Evaluation in the Emergency department revealed a diagnosis of extensive pulmonary emboli in the pulmonary vasculature. The patient was admitted to the ICU. A clinical decision was made to initiate treatment with low-dose tissue plasminogen activator (tpa) followed by intravenous heparin infusion. Several hours later the patient developed significant epistaxis. A decision was made to stop the heparin infusion. Later that day, the patient had abrupt clinical deterioration with subsequent cardiac arrest and did not recover. We discuss the classification and treatment of acute pulmonary embolism, the management of epistaxis in an anticoagulated patient, and the clinical conundrum of balancing active bleeding in patient requiring anticoagulation.

A novel early mobility bundle improves length of stay and rates of readmission among hospitalized general medicine patients.

Inpatient early mobility initiatives are effective therapeutic interventions for improving patient outcomes and decreasing use of hospital resources among adult ICU and general medicine patients. To establish and demonstrate guidelines for early patient ambulation, we developed and implemented a novel multidisciplinary mobility bundle utilizing the JH-HLM (Johns Hopkins Highest Level of Mobility) scale for mobility classification, on a single adult general medicine unit of a community hospital. Our results show that patients admitted to the unit after implementation of the mobility bundle had improved mobility scores, reduced rates of 30-day hospital readmission, and a shortened length of hospital stay. This study emphasizes the importance of measuring mobility using a systematic method, easing workflow among unit practitioners, and allowing mobility initiatives to be jointly driven by nursing, physical therapy, and physicians.

Breaking Bad: a case of Lactobacillus bacteremia and liver abscess.

We present a case of a 46-year-old Hispanic male with a past medical history significant for uncontrolled diabetes presenting with abdominal pain, nausea and vomiting and found to have Lactobacillus bacteremia and liver abscess. A PubMed and Clinical Key literature review of the other known cases of Lactobacillus liver abscess was performed. Through examination of previous case reports, the patient presented in this paper, and the associated risk factors of Lactobacillus liver abscess it is likely that the incidence of this rare condition will increase and would therefore be prudent to further study Lactobacillus as a pathogenic bacteria so that its complications may be better treated and prevented.

Prescribing physical activity in primary care.

Physical activity is a powerful weapon for individuals interested in health maintenance. Many benefits of regular physical activity are well known to the medical community including improved weight control, healthier cardiovascular system, and tighter diabetic control. Less recognized benefits of physical activity may include stronger bones, better sleep, lower blood pressure, improved mood, opportunities for personal enjoyment, cancer prevention, and even a longer lifespan. Despite these numerous incentives, less than a quarter of the U.S. population is active enough to gain the rewards (13). West Virginians are among the least physically active; more than 40% of state residents engage in no leisure time physical activity at all (15), so it is critical that physicians in the state take a much more active role in prescribing physical activity for their patients. Although more research is needed, data exists to suggest counseling by physicians does result in increased physical activity (20-23). Attention to risk factors and specific red flags can help decide when formal pre-exercise stress testing is necessary. An organized approach includes development of the mode, frequency, duration, intensity and progression of exercise by a physician who knows the patient's interests and limitations (28). The most current consensus guidelines suggest 30 minutes of moderate-intensity physical activity daily (12). Physicians need to encourage this goal during office visits and there appears to be benefit in putting specific physical activity advice in the form of a written prescription (21).