Internal Medicine - Acting Internship: Days 1,2,3,4,5

On Monday, I began my Acting Internship in General Internal Medicine. It's going pretty much as I expected - a lot of hours, a lot of reading, a lot of learning, a lot of patient problems. So far, my most interesting cases include:

A 62y/o male with a history of IVDA and Alcoholism presents to the ED with RUQ abdominal pain and distension for the past several weeks. On physical examination, he was found to have scleral icterus, tenderness to palpation in the right upper quadrant, abdominal distension, and bilateral 2+ pitting edema in the lower extremities. After some laboratory work up, it was discovered that the patient was slightly anemic, with thrombocytopenia, elevated LFTs, and prolonged PT/INR. A CT of the abdomen with contrast was completed, which revealed a mass in the liver. Evaluation of the mass is currently pending, as are some important labs related to these findings (namely alpha-fetoprotein). So, what are we anticipating this mass to be? There are a few possibilities: benign etiologies may include hemangioma, cysts, hepatic adenoma, focal nodular hyperplasia, and abscess; malignant etiologies may include metastases (typically they appear in several focal areas with nodular margins) and hepatocellular carcinoma. Given the history of alcohol abuse, I am leaning towards the dx of HCC, but we will need a biopsy to confirm such findings before one can say for sure.

A 42y/o male with recurrent clostridium difficile presents to the ED with complaints of bouts of diarrhea occurring every 15-20minutes. C.diff is a bacteria which may reside in a spore form in the intestines; if normal, healthy gut flora are wiped out after the use of antibiotics. Other risk factors which can predispose you to overgrowth of C.Diff include: recent use of antibiotics (especially clindamycin, fluoroquinolones, penicillins, and cephalosporins), hospitalization, age over 65, severe illness, immunosuppression (steroid use, chemotherapeutics), inflammatory bowel disease (like Crohn's or Ulcerative Colitis), use of proton-pump inhibitors, gastric surgery, gastric bypass, recent major surgery. So, how do we treat C.Diff? This seems like a straight-forward answer any medical student can answer when the attending pimps them. We learn Metronidazole, if it persists give another round of Metronidazole, if it still persists give PO Vancomycin. But sometimes C.Diff persists even after this extensive treatment (especially as antibiotic-resistance increases). What do we do then? Well, we can give other antibiotics, such as Fidamoxicin or Rifaximin (there are many other options available to try if it persists after those treatments). So if we've exhausted our medical therapy without finding that the infection subsides, we have the option of fecal transplant. In order for this therapy to be effective, it is best to obtain stool from a relative or spouse, screen the stool for certain bacteria/viruses/parasites (like shigella, salmonella, campylobacter, etc), then emulsify the stool into a more liquid form, and to deliver it into the patient's GI tract via enema or via an NG tube into the duodenum. Kind of disgusting, but I would imagine a person would be desperate for a definitive treatment after months of constant, profuse, watery diarrhea.

Busy week! And I'm enjoying my time on the wards!