NEWSLETTER - Hawaii Residency Programs

The University of Hawaii
Internal Medicine Residency Program
NEWSLETTER
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MAY - AUGUST 2014
2014 RESIDENTS’ END-OF-THE-YEAR BANQUET
The 2014 Residents’ End-of-the-Year
Banquet was held Friday, May 30, 2014
at the Hawaii Prince Hotel.
The night ran smoothly thanks to our two
talented emcees, Level 1 residents Drs.
Michael Tom and Raquel Tello.
The evening started with entertainment by
Level 3 resident Dr. Satomi Fujii on piano.
Next, attendings Drs. Alena VelascoHughes on the piano and David Spinks
on guitar accompanied Sandra Loo and
Kuo-Chiang Lian singing original songs;
see page 3 for lyrics. Finally, Level 2
residents Drs. Tui Lauilefue and Cesar
Palana showcased their beautiful singing
voices while Dr. Christian Kitamura wowed
everyone with her dancing skills.
Dr. Tui Lauilefue and Preliminary resident Dr.
Ruidi Wang created a video slideshow for
the graduates that weaved together photos
from Program events and residents’
adventures. The slideshow reflected the “work
hard, play hard” spirit of our residents! They
also compiled a video montage of residents,
faculty and staff answering fun questions like,
“If you were a car, what kind of car would
you be?”
Throughout the evening, faculty, graduates
and residents took the stage to honor and
acknowledge Program Director, Dr. Erlaine
Bello, who will be stepping down from her
position during the 2014-2015 academic
year. More information on the transitioning
position will be featured in the next
Newsletter.
After the entertainment, the evening moved
along to presenting hospital and Program
awards; see page 4 for a list of the winners.
The banquet concluded with the
acknowledgment of the graduating
Categorical, Preliminary and Transitional
residents; see page 2 for their post-residency
plans.
Inside This Issue:
Graduating Categorical residents at the EOY Banquet: (left to right, back to front) Drs. Suwarat
Wongjittraporn, Edison So, Thomas DeLeon, Panupong Jiamsripong, Ashlee Segawa, Ulysses Montero,
Lien-Thanh Kratzke, Satomi Fujii, Tamara Khatib, Keila Ching, Brita Aramaki, Mark Lebehn, Ornusa
Teerasukjinda, Jason Meadows, Masayuki Nogi, Bradley Tokeshi, Chawat Tongma
2014 End-of-Year Banquet
Pgs 1-4
2014 Graduates PostResidency Plans
Pg 2
2014-2015 Level 1 Class
Pg 5
2014-2015 Transitional Class
Pg 5
Case of the Month at Queen’s
Pgs 6-8
New Administrative Assistant:
Allison Dowd
Pg 8
Schedule of Events
Pg 8
CHIEF MEDICAL RESIDENTS
Our Chief Medical Resident (CMR), Dr. Marcus
Iwane fulfilled the role of CMR at Kuakini Medical
Center. Drs. Thomas DeLeon, Masayuki Nogi,
Lien-Thanh Kratzke, Bradley Tokeshi and Mark
Lebehn jointly fulfilled the role of CMR at Queen’s
Medical Center as 3rd year residents. All our
CMRs contributed greatly to the Program, hospitals
and teaching of residents and medical students.
They often went above the call of duty. Two are
continuing on as CMRs, three will be hospitalists
and one is beginning a Cardiology fellowship. We
wish them the best of luck in their future successes!
Kuakini CMR, Dr. Marcus
Iwane, at the EOY Banquet
QMC Co-CMRs at the EOY Banquet (left to right): Drs. Thomas
DeLeon, Masayuki Nogi, Lien-Thanh Kratzke, Bradley Tokeshi,
Mark Lebehn
MAY - AUGUST 2014
CATEGORICAL GRADUATES
PAGE 2
PRELIMINARY GRADUATES
After three years of training at UHIMRP, the
Categorical graduates are ready for the next
chapter of their careers in medicine. Seven will begin
sub-specialty fellowship training, eight will start
hospitalist positions, one will enter primary care and
two will stay on as UHIMRP Chief Medical Residents.
POST-RESIDENCY PLANS
Brita Aramaki - Geriatric Medicine Fellowship, UH
Thomas DeLeon - Chief Medical Resident, UH Internal
Medicine Residency Program
Satomi Fujii - Hospitalist, MSH
Panupong Jiamsripong - Hospitalist, Kaiser Moanalua
Tamara Khatib - Hospitalist, MSH
Graduating preliminary residents (left to right): Drs. Spencer Drotman, Sara Richards,
Christopher Lim, Michael Doherty, Andrew Sung, Ruidi Wang
Michael Doherty - Radiology, UC, Davis
ADVANCED
PROGRAMS
Keila Ching - Geriatric Medicine Fellowship, UH
Lien-Thanh Kratzke - Hospitalist, Kaiser Moanalua
Mark Lebehn - Cardiovascular Disease Fellowship, UH
Spencer Drotman - Anesthesiology, New York University
Christopher Lim - Anesthesiology, University of Southern CA
Sara Richards - Anesthesiology, UC, San Francisco
Andrew Sung - Radiology, UC, San Diego
Ruidi Wang - Ophthalmology, NY Eye and Ear Infirmary
TRANSITIONAL GRADUATES
Jason Meadows - Palliative Medicine Fellowship,
Memorial Sloan Kettering Cancer Center New York, NY
Ulysses Montero - Hospitalist, Casa Grande Regional
Medical Center Casa Granda, AZ
Masayuki Nogi - Chief Medical Resident, UH Internal
Medicine Residency Program
Ashlee Segawa - Primary Care Durham, NC
Edison So - Endocrinology Fellowship, Brown University
Bradley Tokeshi - Hospitalist, MSH
Chawat Tongma - Infectious Disease Fellowship, Rush
University
Matthew Uechi - Geriatric Medicine Fellowship, UH
Suwarat Wongjittraporn - Hospitalist, Tourney Hospital,
SC
Graduating Transitional residents at the EOY Banquet (left to right): Drs. Michael Yim, Jaryd
Yee, Steven Lau, Crystal Tan, Rajiv Rao
ADVANCED PROGRAMS
Ornusa Teerasukjinda - Hospitalist, Tourney Hospital,
SC
Jason Bluth - Anesthesiology, Duke University
Dan Ishihara - Radiology Oncology, University of TX Southwestern
Matthew Landherr - Dermatology, University of IA Hospitals & Clinics
Steven Lau - Radiology Oncology, University of TX Southwestern
Vishal Patel - Radiology, UC Los Angeles Medical Center
Rajiv Rao - Radiology, UC, Davis
Crystal Tan - Anesthesiology, Massachusetts General Hospital
Jaryd Yee - Radiology, Santa Barbara Cottage Hospital
Michael Yim - Ophthalmology, Bascom Palmer Eye Institute, University of Miami
UH JOHN A. BURNS SCHOOL OF MEDICINE 2014 GRADUATION AWARDS
The Match revealed that nine UH John A. Burns School of Medicine (JABSOM) graduates would be joining the UHIMRP and five would be
joining the UHTRP; see page 5 for a complete list of the Match results. At their graduation ceremony, the following JABSOM graduates that
will be joining UHIMRP and UHTRP received the awards listed. Congratulations!
ACP Award for Excellence in Internal Medicine - Jodi Kagihara
E. E. Black Community Service Scholarship - Jodi Kagihara
Hawai’i Medical Association Alliance Endowment Award - Anh Tran (Transitional)
Friends of Medical School Aequanimitas No’ono’o Pono Award - Ryder Onopa
Yazawa Family Endowed Award - Anh Tran (Transitional)
MAY - AUGUST 2014
PAGE 3
END-OF-THE-YEAR BANQUET SONGS
The End-of-the-Year Banquet is the perfect setting for residents and faculty to share their talents and creativity outside of medicine. Drs.
Sandra Loo and Kuo-Chiang Lian do just that with the lyrics they wrote, which reflect with humor on the important task of graduate medical
education and everyday life on the wards, and sang at the Banquet. For those that attended, we’re sure you’ll enjoy these ju st as much the
second time!
"Do You Want A New Admission?"
(to the tune of “Do Want to Build A Snowman?” from Frozen)
"I Wanna Be A Hospitalist"
(to the tune of “Billionaire” by Bruno Mars)
(knocking on the door) Teppei?
Do you want a new admission?
Aren't you on call today?
How come you're giving me that face?
It's a learning case....
Syncope, HOORAY!!!
We used to be best buddies....
And now, we're not.
Is it because I'm now so wise?
Do you want a new admission?
I don't have to ask permission.
I wanna be a hospitalist, so freakin’ bad
Treating all diseases that one has
I wanna be thinkin’ up, differential diagnoses
Choosing wisely from the tests I have
(Shouted, from off-stage:) "Go away, Sandra!"
Ok, Bye....
I wanna be a hospitalist, so freakin’ much
Teaching my team on the wards a bunch
I’m sorry if I’m pimpin’ out every boy and girl
I just wanna share a clinical pearl
Verse 2&3:
Do you want a new admission?
A transfer from Molokai....
There's lots of records to peruse,
She was on some cruise,
Go give it all the eye.
I'm making too much money....
To do that stuff.
I'm just watching the time tick by....(Sandra: Hang in there,
Tui!)
(tick-tock, tick-tock)
Do you want a late admission?
It isn't your decision.
Where's the chief?!
Come on, please, I know you're in there....
People are asking where you've been.
They say have courage,
I can teach a lot,
I stole another talk from Dr. Dinh!
We already have another,
It's just you and me....
But really, it's mostly you.
Do you want a new admission,
Or a consult in Kekela?
(Offstage:) "Okay."
Oh, every time I close my eyes
Core measures I see flying by
Quality and safety, my oh my
I swear, the world better prepare
For when I’m a hospitalist
Oh, every time I close my eyes
I’d see my resident’s shining eyes
Movin’ up from intern to be residents
I swear, the world better prepare
For when I’m a hospitalist
Yeah, I could be like Bolger, Ikeda, maybe even Bello
Educatin’ residents, just like Raquel Tello
You better be bringin’ your A game to mornin’ report
Or else the chiefs are gonna see that you’re comin’ up short
Oh, every time I close my eyes
I see my resident’s shining eyes
UH Medicine, there’s nothing to compare,
I swear, the world better prepare
For when you’re hospitalists
Oh oh, oh oh
For when you’re hospitalists
Oh oh, oh oh
For when you’re hospitalists
I wanna be a hospitalist so freakin’ bad
MAY - AUGUST 2014
PAGE 4
END-OF-THE-YEAR BANQUET AWARD WINNERS
THE QUEEN'S MEDICAL CENTER AWARDS
 Outstanding Intern Award: Dr. Jennifer Katada (photo 2)
1
 Outstanding Resident Award: Dr. Masayuki Nogi
KUAKINI MEDICAL CENTER AWARDS
 Outstanding Intern Award: Drs. Kimberly Theos
 Outstanding Resident Award: Drs. Teppei Shimasaki (photo 5)
CRITICAL CARE AWARD
 Outstanding Straub ICU Intern Award: Drs. Jennifer Katada and
Christian Kitamura
2
QUEEN EMMA CLINICS AMBULATORY EXCELLENCE AWARDS
3
 L1: Dr. Michael Tom
 L2: Dr. Tui Lauilefue
 L3: Drs. Masayuki Nogi
KAISER CONTINUITY CLINIC AWARD
 Outstanding Resident: Dr. Jason Meadows
TRANSITIONAL PROGRAM AWARDS
 Excellence in Resident Teaching: Drs. Masayuki Nogi and Travis
Watai
 Excellence in Teaching Award: Drs. Christopher Fiack and Reid
Ikeda
 Resident of the Year: Drs. Crystal Tan and Rajiv Rao (photo 6
pictured with Dr. Sam Evans)
4
INTERNAL MEDICINE PROGRAM AWARDS
 Clinical Faculty Award for Excellence in Teaching: Drs.
Thomas Maglinao, David Spinks, Ator Yacoub, Lisa
Camara, Amanda Haley, Chris Fiack, Hiro Sung
 Excellence in Teaching Awards at Hospitals
6
5
 The Queen’s Medical Center: Dr. Reid Ikeda (photo 4)
 Kuakini Medical Center: Dr. Royce Shimamoto
 Critical Care Teaching Award at Straub Clinic &
Hospital: Dr. Heath Chung (photo 4)
 Excellence in Ambulatory Medicine Teaching: Drs.
John Misailidis, Fritzie Igno, Dominc Chow (photo 4)
 Excellence in Research Awards: Drs. Jason Meadows,
Masayuki Nogi, Edison So, Chawat Tongma, Nicholas
Leo (photo 1)
 Diagnostic Laboratory Services Community Service Award: Dr. Masayuki Nogi
 Irwin J. Schatz Primary Care Award: Dr. Marcus Iwane
 Excellence in Medical Student Teaching Award: Dr. Bradley Tokeshi (photo 7
pictured with Dr. Linda Anegawa)
 Intern of the Year: Drs. Nani Morgan and Michael Tom (photo 3)
 Resident of the Year: Dr. Masayuki Nogi
7
MAY - AUGUST 2014
PAGE 5
WELCOME LEVEL 1 RESIDENTS!
The incoming class is a very diverse group of residents:
nine from our own John A. Burns School of Medicine, three
of mainlaind schools, three from the Caribbean, and three
from Japan.
While most have gone through the traditional educational
route, some took detours to practice in rural areas or
participate in significant research before applying for
internship.
Some are returning home while others are staying home,
but everyone has a passion for living and working in
Hawaii. We look forward to a great year with this hardworking, enthusiastic group of residents!
Left: 2014-2015 Level 1 Residents at Orientation
2014-2015 Intern Class:
*indicates Preliminary Resident
Jodi Kagihara, MD
UH John A. Burns School of Medicine
Thomas Jessie “TJ” Aldan, MD
UH John A. Burns School of Medicine
Christina Klein, MD*
Oregon Health & Science University (PM&R:
Stanford University)
Akika Ando, MD
Hokkaido Daigaku Igakubu, Japan
Nobuhiro Ariyoshi, MD
Kumamoto University, Japan
Loni Belyea, MD
Tufts University School of Medicine
Jenny Chan, MD
UH John A. Burns School of Medicine
Ali Chisti, MD
Oregon Health and Sciences University
Lindsey Fix, MD*
East Carolina University School of Medicine
(Dermatology: NYP Hospital-Columbia
University Medical Center)
Aaron Hoo, MD
UH John A. Burns School of Medicine
Josef Lassan, MD
Saint George’s University
Dayna Lucuab-Fegurgur, MD
UH John A. Burns School of Medicine
Lorrance Majewski, DO
A.T. Still University School of Osteopathic
Medicine
Thuan Nguyen, MD
American University of the Caribbean
Ryder Onopa, MD
UH John A. Burns School of Medicine
Kristy Ratkowski, MD*
University of Missouri School of Medicine
(Radiology: Barnes-Jewish Hospital)
2014-2015 TRANSITIONAL RESIDENTS
Andrew Rong, MD*
UC Davis School of Medicine (Ophthalmology:
Bascom Palmer Eye Institute)
Scott Serrano, MD
UH John A. Burns School of Medicine
Tommy Sheu, MD*
Baylor College of Medicine (Radiation Oncology:
University of TX MD Anderson Cancer Center)
Dante Sorrentino, MD*
Florida International University COM
(Ophthalmology: University of Pittsburgh
Medical Center)
Faye Tachibana, MD
UH John A. Burns School of Medicine
Brandon Takase, MD
UH John A. Burns School of Medicine
Sari Umekawa, MD
Jichi Medical University, Japan
Rajive Zachariah, MD
Saint George’s University
Kristin Hirabayashi, MD
UC Irvine School of Medicine
(Ophthalmology: UC San Francisco)
Charles Hua, MD
UH John A. Burns School of Medicine
(Radiology: Icahn School of Medicine St. Lukes-Roosevelt)
Myles Mitsunaga, MD
UH John A. Burns School of Medicine
(Radiology: UC Davis Medical Center)
Osama Mohamad, MD
Emory University School of Medicine
(Radiology: University of Texas Southwestern)
2014-2015 Transitional Residents at Orientation
Andrew Bussey, MD
UH John A. Burns School of Medicine
(Anesthesiology: UC, Davis Medical Center)
John Colby, MD
Johns Hopkins University School of Medicine
(Dermatology: University of Texas Southwestern)
Anh Tran, MD
UH John A. Burns School of Medicine
(Dermatology: NY-Presbyterian Hospital/Weill Cornel Medical
Center)
Cherisse Wada, MD
UH John A. Burns School of Medicine
(Radiology: Icahn School of Medicine St. Lukes-Roosevelt)
MAY - AUGUST 2014
PAGE 6
CASE OF THE MONTH AT QUEEN’S
The Case of the Month is selected based on case content, case and presentation quality, and the educational value of knowledge
dissemination. Block 9’s Case of the Month is from Level 1 Resident Dr. Hideaki Watanabe (edited by Dennis Bolger, MD, MPH):
Shortness of breath for one month
A 36 year-old Marshallese man living in
Guam was brought by his family to Hawaii
for progressively worsening shortness of
breath. The patient was in his usual state of
good health until one month ago. He
experienced shortness of breath associated
with productive cough. The mucus was
yellow in color and without blood. Initially,
the dyspnea he experienced was not
associated with activity, but one week prior
to admission, his symptoms progressed to the
point that he could only walk 6 steps. The
patient noted gradually worsening mild right
-sided chest discomfort. He also endorsed a
decrease in appetite, low-grade fevers, and
10 lb. weight loss.
He denied lower
extremity edema, orthopnea, night sweats,
sick contacts, recent travel, animal exposure,
choking or vomiting. His family noted wicked
breath odor. The patient smokes and chews
tobacco. He drinks 12 cans of beer daily
and occasionally gets drunk. He works in a
bakery. A PPD skin test in April 2013 was
negative.
On physical exam, vitals were: T 37.2 °C
(98.9 °F),RR 18, HR 95 BP 104/52SpO2
94% on room air, BMI 32.3. The patient
presented in mild respiratory distress. Right
lung had no breath sounds, was dull to
percussion, and had egophony with
decreased tactile fremitus at the lower 2/3s.
Left lung had clear breath sound. Oral/
dental exam showed tobacco-stained teeth
throughout but there were no obvious
abscesses. Cardiac exam, and extremity
exams were normal. Acanthosis nigricans was
noted on the back of neck.
Differential diagnosis: Respiratory tract
obstruction (intrinsic and extrinsic), aspiration,
pleural effusion, pneumothorax, interstitial
lung dieases, asthma, cardiomyopathies,
pulmonary embolism, pneumonia, COPD
exacerbation, lung abscess, empyema and
pulmonary malignancies.
Labs and Diagnostics: CBC: WBC: 16.93x10
(3)/ul (Abs Neutrophils 13.75x10(3)/ul, Abs
Im m G ra nu u lo 0 .1 4x1 0 (3)/ u l, Im m
Granulocyte 0.8%), Hgb: 7.6 g/dl, Hct:
24.3%, Platelet: 440x10(3)/ul.
Chest radiography showed mass like
opacification of the right mid and lower
lung.
1
Figure 1: Chest radiography
2
performed. The pleural fluid culture result
was positive for MRSA, Actinomyces meyeri,
Strep intermedius and negative for
tuberculosis, fungal infection. Histopathology
showed no evidence of malignancy or
granuloma.
Diagnosis: Lung abscess with empyema
due to mixed infection of MRSA,
Actinomycesmeyeri, Strep intermedius
infection
Parapneumonic effusions are effusions that
occur in the pleural space adjacent to a
bacterial pneumonia. In general,
parapneumonic effusions, except those that
are small (layer less than 10 mm on a lateral
decubitus film) and free flowing, should be
sampled by thoracentesis. Empiric, broad
spectrum antibiotics that include coverage
for anaerobic organisms should be initiated
promptly, as empyemas often harbor
multiple species of bacteria, particularly
anaerobes like this case. Prompt drainage of
any remaining pleural fluid is unequivocal
and crucial treatment. We may also have to
consider intrapleural administration of a
combination of tissue plasminogen activator
(TPA) and deoxyribonuclease (DNase) in
patients with inadequate drainage.
Moreover, if continued failure of pleural
drainage, thoracoscopic debridement with
possible decortication is indicated.
References:
Figure 2: CT chest
CT chest showed complex septated thickwalled cystic and solid lesion- right
hemithorax- measuring approximately 19 X
12 cm. CT guided thoracenthesis,
decortication and lobectomy were
1. Colice GL, Curtis A, Deslauriers J et al. Medical and
surgical treatment of parapneumonic effusions : an evidencebased guideline. Chest. 2000;118(4):1158.
2. Maskell NA, Davies CW, Nunn AJ, et al.U.K. Controlled
trial of intrapleural streptokinase for pleural infection. N Engl
J Med. 2005;352(9):865.
CASE OF THE MONTH AT QUEEN’S
Block 10’s Case of the Month is from Level 2 resident Dr. Travis Watai (edited by Dennis Bolger, MD, MPH):
Liver Failure
Mr. R is a 50-year-old single Chuukese man
with a past medical history significant for
hepatitis B and alcohol abuse who was
referred to Oahu from his primary care
physician in Chuuk for treatment of hepatitis
B. Four months prior to admission the patient
started to notice increasing abdominal girth
but no other symptoms. Three months prior to
admission the patient states he had a liver
ultrasound performed, which was significant
only for ascites. One month prior to
admission the patient developed shortness of
breath and was hospitalized in Chuuk for 3
weeks.
During his hospitalization he
underwent a thoracentesis which he states
had bloody fluid but no other studies were
available. In addition, Mr. R now
experienced nausea and vomiting after
each meal for 3 weeks prior to admission
but denied any hematemesis. He endorsed
40 pound loss during this period. He also
experienced intermittent subjective fevers
without chills, a cough productive of white
sputum, and diffuse abdominal pain which
occasionally radiated to his back. He
became short of breath when lying down on
his right side and with any exertion.
Of note, the patient denied ever being
diagnosed with tuberculosis, however, 3
years prior to admission a relative that was
living with him died from complications of
pulmonary tuberculosis. He was recently
started on lactulose and spironolactone
while hospitalized in Chuuk for liver failure.
He had no allergies or surgical history.
Family history was not contributory. He was
born and raised in Chuuk where he worked
as a teacher.
He drank about 24 beers on the weekends
for more than 10 years. He denied any
tobacco or illicit drug use. Continued on page 7
MAY - AUGUST 2014
PAGE 7
CASE OF THE MONTH AT QUEEN’S (CONT.)
The patient is a well-developed Chuukese
man in no acute distress. His temperature
was 37.1 C, BP 120/84, pulse 82, RR 16,
O2 saturation 98% on room air, and BMI of
26 kg/m2. Sclerae were anicteric,
oropharynx was not erythematous or
jaundiced. Neck was supple and without
adenopathy. His cardiac exam was normal.
Pulmonary exam revealed dullness to
percussion on the left posterior chest up to
the mid scapula with decreased breath
sounds to the entire left lung field without
adventitious breath sounds, no egophony, or
whispered pectoriloquy. His abdomen was
slightly distended and soft with slight
tenderness to deep palpation in the right
upper quadrant and periumbilical area
without guarding or rebound tenderness.
Shifting dullness was present at both flanks.
His liver was palpated 1 finger breath
below the subcostal margin. Neurological
exam was normal. He had no skin rashes,
telangiectasias, palmar erythema, or caput
medusa. Pitting edema was present in the
legs.
Differential diagnosis: Chronic hepatitis with
cirrhosis and ascites, Subacute bacterial
peritonitis, hepatoma, metastatic liver
cancer, metastatic lung cancer, liver abscess,
lung abscess, hepatic hydrothorax, pleural
effusion s, ly mphoma , tubercu losis
(pulmonary, disseminated, extra-pulmonary,)
chronic heart failure, AIDS, chronic renal
failure with volume overload, germ-cell
cancer.
Labs and Diagnostics: BMP: Na 135, K 3.1,
Cl 97, CO2 24, BUN 22, creatinine 1.9,
glucose 95, calcium 13.8. CBC: WBC 9.51,
eosinophil 12.9%, Hgb 12, Hct 35.3,
Platelet count 368. LFTs: ALT 13, AST 8,
alkaline phosphatase 58, total bilirubin 0.4,
albumin 3.7. INR 1.2, PTT 34.1.
1
2
Figure 1: Normal laparoscopic view of the abdomen.
Figure 2: Nodular thickening and infiltration of
omentum and mesentery
Chest x-ray showed a large left pleural
effusion Thoracentesis was performed and
was significant for yellow and hazy fluid
with 2,070 WBC with 65% lymphocytes,
21% polys, LDH of 170 and total protein of
7.1 with a glucose of 84. Serum LDH was
136 and total protein 9.1. CT abdomen &
pelvis: moderate abnormal nodular
thickening of peritoneal surfaces in
perihepatic and perisplenic space as well as
paracolic gutters and mesentery; nodular
infiltration of omentum and mesentery with
abnormal thickening of the stomach, small
bowel, and colon. Sputum AFB negative x3,
pleural fluid AFB negative x2, urine AFB
negative x1. Peritoneal biopsy obtained
through laparoscopy was AFB positive and
culture later grew M. tuberculosis.
Diagnosis: Extra-pulmonary/peritoneal
tuberculosis
Diagnosis of peritoneal tuberculosis is
difficult as the clinical presentation is highly
variable. Non-specific symptoms and subacute presentations require a high index of
suspicion. Risk factors for developing extrapulmonary tuberculosis include diseases that
cause immunosuppression/compromise: HIV,
malignancy, alcohol abuse, corticosteroid or
immunosuppressive use, connective tissue
disease, renal failure, diabetes, and
pregnancy. Infection of the peritoneum is
usually secondary to reactivation of latent
tuberculosis in the peritoneum that is
established from hematogenous spread of
tubercles from a pulmonary focus. Ascites
develops secondary to exudation of
proteinaceous fluid from the tubercles, and
as the disease progresses the viscera and
parietal peritoneum become increasingly
studded with tubercles. Lymphocytosis of
ascitic fluid is highly suggestive of peritoneal
tuberculosis, however, the diagnostic gold
standard is culture growth of M. tuberculosis
of ascitic fluid or from a peritoneal biopsy.
Finally, as our case demonstrates, a
meticulous evaluation of the actual patient
compliant(s) (rather than reliance on another
clinician’s unconfirmed diagnosis) combined
with a corroborative physical exam and
basic lab/imaging investigation result in a
broad and accurate differential diagnosis.
References:
1. Mimidis K., Ritis K., & Kartalis G. "Peritoneal Tuberculosis."
Annals of Gastroenterology 2005, 18(3):325-329
2. Chahed J et al. "Contribution of laparoscopy in the
abdominal tuberculosis diagnosis: retrospective study of
about 11 cases." Pediatr Surg Int. 2010, 26(4):413
CASE OF THE MONTH AT QUEEN’S
Block 11’s Case of the Month is from Transitional Resident Dr. Matthew Landherr (edited by Dennis Bolger, MD, MPH):
signs, cardiac and respiratory exams. No vitamin E deficiency, malignancy with
ulcers or lesions were noted in the mouth or paraneoplastic syndrome, multiple sclerosis,
The patient is a 70-year old female with a
pharynx.
The tongue was normal in tabes dorsalis.
history of hypothyroidism who presented
appearance. Neurological exam showed
with ascending, bilateral leg numbness of
Labs and Diagnostics: Chemistry panel,
bilateral 2+ reflexes in the upper and lower
3.5 months duration.
At the time of
including LFTs, and serum CK, copper and
extremities with the exception of diminished
presentation, she had numbness to a level
zinc were unremarkable.
CBC was
Achilles reflexes.
Sensory exam was
just above her umbilicus that also included
remarkable for mild thrombocytopenia
significant for diminished soft touch and
both hands and proximal forearms. She was
(platelet count 115,000), hemoglobin
pinprick, proprioception, and vibratory
having severe shooting pains and "spasms",
13.2g/dL (though this declined to 10.9g/dL
sense, with loss of vibratory sense more
difficulty balancing, and could no longer
after fluid administration) and MCV of
pronounced distally. Finger-to-nose and
drive as she was unable to tell where her
110.5 fL. TSH was elevated at 9.89 uIU/mL
rapid alternating movements were intact.
feet were in space. Additionally, she had
though free T4 was normal at 1.0 ng/dL.
Muscle strength was 5/5 diffusely with
loss of appetite with concurrent loss of
normal tone, bulk and no tremor or Serum homocysteine was high at >100.0
~40lbs, constipation and intermittent fevers.
fasciculations. Romberg test was positive. umol/L ( normal is <15.0 umol/L). Vitamin
Prior to this illness, she ate a balanced diet
Gait was slightly unsteady but not broad- B12 level later returned low 64 pg/mL
complete with fruits, vegetables, dairy,
(normal 211-946 pg/mL) and intrinsic factor
grains, and meats.
Family history is based. Mentation was intact.
blocking antibody was positive.
EGD
significant for paternal grandmother with DDx: Vitamin B12 deficiency (pernicious
showed gastric atrophy with chronic gastritis
breast cancer and maternal aunt and uncle anemia, malabsorption, N20 exacerbation
but no malignancy. Continued on page 8
of low Vitamin B12 level), zinc deficiency,
with gastric cancer.
zinc overload-toxicity, copper deficiency,
Physical exam revealed unremarkable vital
Bilateral leg numbness
MAY - AUGUST 2014
PAGE 8
SCHEDULE OF EVENTS
HAPPY BIRTHDAY TO OUR RESIDENTS!
REMINDERS:
 Resident reminders for Program requirements are sent
quarterly
 1st of each month: Continuity Clinic Stats due for the
previous month
May
Christina Klein
Sari Umekawa
UPCOMING EVENTS:
 September 30: Intern retreat at Kapiolani Community
College
 October-November: First Half Resident-Firm Advisor
Meetings
UPCOMING DUE DATES:
 October 31: Documentation of flu shot submitted to the
Program
June
Kristie Akamine
Jenny Chan
Ryohei Horie
Charles Hua (Transitional)
Ynhu Le
Lorrance Majewski
Pichaya O-charoen
Jun Onitsuka
Howard Yang
Cherisse Wada (Transitional)
Nath Zungsontiporn
July
Kristin Hirabayashi (Transitional)
Tommy Sheu
Dante Sorrentino
Travis Watai
Cawin Wong Mizuba
August
Tui Lauilefue
Brent Matsuda
Myles Mitsunaga (Transitional)
Andrew Rong
Michael Tom
Hideaki Watanabe
CASE OF THE MONTH AT QUEEN’S (CONT.)
Diagnosis: Subacute
Combined
Degeneration of the Posterior Columns due
to Vitamin B12 deficiency secondary to
Pernicious Anemia
As in our patient, these symptoms tend to be
bilateral and affect the legs more than the
arms. Patients may also demonstrate
cognitive decline and/or personality
changes or even bowel/bladder
incontinence. Some of the lesser known
symptoms of Vitamin B12 deficiency include:
c o n s t i p a t i o n ,
osteoporosis, fevers, and 1
thrombocytopenia.
If considering Vitamin
B12 deficiency, one must
consider that the classic
macrocytosis may be
masked by a concurrent
microcytic anemia, such
as iron deficiency or
thalassemia, which is
especially pertinent in
the Hawaiian population.
Additionally, relying only
on the serum Vitamin B12 level is ill-advised
as deficient patients may actually have a
vitamin B12 level that is low-normal. These
patients tend to have elevated homocysteine
and methylmalonic acid levels, which are
more sensitive tests for Vitamin B12
deficiency. These levels normalize with
Vitamin B12 supplementation. Similarly, up
to 28% of patients may not have anemia
and 17% may not have macrocytosis, so
clinical suspicion should remain high in
symptomatic patients despite the absence of
some classical findings.1
Figure 1: T2-weighted axial view of the
patient's cervical spinal cord. Notice the
hyperintense signal corresponding to the
area of the dorsal columns.
Newer evidence has shown that
high dose oral Vitamin B12
supplementation is as effective as
IM Vitamin B12 injections,
regardless of the cause of
deficiency.2 This is especially
important in populations in which
weekly or monthly injections
would be difficult to comply with,
such as the outer island Hawaiian
population.
inconsistent results, it is believed that
pernicious anemia increases the risk of
gastric cancer by 2- to 3-fold. Therefore, it
was recommended by the American Society
of Gastrointestinal Endoscopy that patients
with pernicious anemia undergo one
screening esophagogastroduodenoscopy
around the time of diagnosis.3
References:
1. Langan RC and Zawistoski, KJ. Update on Vitamin B12
Deficiency. Amer Fam Phys 201; 83:12.
2. Vidall-Alaball J, Butler CC, Cannings-John R, et al. Oral
vitamin B12 versus intramusuclar vitamin B12 for vitamin B12
deficiency. Cochrane Database Syst Rev. 2005;
3:CD004655
3. Hirota WK, Zuckerman MJ, Adler DG, et al. ASGE
guideline the role of endoscopy in the surveillance of
premalignant conditions of the upper GI tract.
Gastrointestinal Endoscopy 2006; 63:4.
Lastly, though studies have shown
NEW ADMINISTRATIVE ASSISTANT: ALLISON DOWD
Allison joined UHIMRP in May 2014. She assists with Continuity
Clinic, Yale Curriculum, and Blue Firm residents.
I moved to Hawaii from Portland, Oregon three years ago. My
background includes experience in property management and
office management.
I obtained my Bachelor of Arts in Social Science with a minor in
Women’s Studies from Portland State University.
Allison and her partner, Arys, enjoying a cup
of Stumptown coffee.
My passion for helping others drives me to volunteer regularly.
UHIMRP offers me an exciting opportunity to gain experience
in a healthcare non-profit organization.
Please give us feedback on
our Newsletter!
We welcome your thoughts!
Is there something you would
like to share in a featured
article?
Contact Traci Randolph at
[email protected]
University of Hawaii Internal
Medicine
Residency Program
1356 Lusitana Street, 7th Floor
Honolulu, Hawaii 96813
Phone: 808-586-2910