Resident Knowledge and Perception of Pain Management.

Chronic pain involves a complex mechanism that afflicts 50 million adults in the United States and incurs societal costs upwards of $560 billion annually. The consequences of this epidemic have resulted in an epidemic of its own, with the opioid crisis becoming a top priority in healthcare. Historically, the sub-optimal practices of overprescribing opioids and inadequate monitoring of iatrogenic addiction have contributed to this problem. If progress is to be made in this area, it is imperative that we examine how future physicians are being trained to manage pain. We examined internal medicine resident knowledge regarding pain as well as their satisfaction with medical school preparation in this regard using two surveys: The Knowledge and Attitudes Survey Regarding Pain (KASRP) and The Medical School Pain Curriculum Survey (MSPCS). Residents scored an overall 60.7% on the knowledge assessment survey, and less than 50% of respondents agreed that their medical school curriculum had prepared them sufficiently. This suggests that improvements can be made in medical school curricula regarding pain management education to better train physicians on how to manage pain, particularly in an era that demands expertise in this area.

An Unusual Presentation of a Cardiac Foreign Body in a Pediatric Patient.

Cardiac foreign bodies (FBs) are rare. Their etiology can be attributed to penetrating injuries although they are also often found incidentally. The approach for removal of these FBs is variable and patient dependent. Although there is debate regarding indications for removal, there is a general consensus that symptomatic FBs presenting acutely, as well as asymptomatic FBs posing a greater risk of complication to the patient, should be removed. We present the case of a 14-year-old patient with a cardiac FB and a step-wise approach for removal.

A Challenging Diagnosis of Eosinophilic Cholangitis Requiring Resection of Extrahepatic Bile Ducts.

Eosinophilic cholangitis (EC) is a rare benign disease characterized by transmural eosinophilic infiltration of the biliary tree that may result in biliary stricture and obstructive jaundice. The pathophysiology remains unknown but is theorized to involve an allergic mechanism. EC is diagnostically challenging as it may mimic cholangiocarcinoma (CCA) clinically and radiographically and involves a broad differential diagnosis including benign and malignant pathologies. In addition to tumor markers, ultrasonography, contrast-enhanced computed tomography (CT), and magnetic resonance cholangiopancreatography (MRCP), proper evaluation of malignant processes may need biopsy through endoscopic retrograde cholangiopancreatography (ERCP) and surgical exploration. We present the case of a 47-year-old female diagnosed with EC upon exploratory laparotomy.

An Unusual Presentation of Arteriovenous Malformation in a Pediatric Patient.

Arteriovenous malformations (AVMs) are defined as tortuous connections between arteries and veins that bypass the capillary system. Cerebral AVMs are rare with a general prevalence of 0.5%-1% with approximately one-fifth of these being diagnosed in infancy or childhood. Although most AVMs go undetected, the most common presenting symptom is hemorrhage. Despite a broad differential diagnosis for syncope described in the pediatric literature, there has been no report of AVM as the underlying etiology. We present a case of a seven-year-old female who presented with a single syncopal episode and was later found to have a large AVM involving mainly the thalamus on the right side and the basal ganglia with large intraventricular draining veins into the galenic venous system. To our knowledge, this is the only case reported of an AVM presenting as syncope in a pediatric patient.