Care Physician Offices Research Articles

Population screening for hepatic fibrosis : who to screen, why and how ?

The development of liver fibrosis is the consequence of histological remodeling of the liver parenchyma, reflecting chronic inflammatory liver disease or hepatocyte necrosis. These tissue modifications result in structural changes to the extracellular matrix, predisposing to progression to cirrhosis and hepatocellular carcinoma, whatever the underlying etiology. Recent data demonstrate the potential benefits of screening for hepatic fibrosis, in particular in order to detect and treat the cause of the underlying liver disease as early as possible, which could ultimately lead to the many known complications in cirrhotic patients. Early identification of the population at risk of hepatic fibrosis should precede screening, which may be initiated in the primary care physician's office and continued at a later stage by the specialist.

Journey to STEEEP healthcare: A focus on systems through a patient's experience

Healthcare systems continue to struggle with providing safe, timely, effective, efficient, equitable and patient-centered (STEEEP) care. Upon audit by clinicians, treatment processes such as those completed following clinical pathways appear to manage care safely. However, when reviewing the treatment process through the patient and/or their family's lens, the experience is quite different. This article will use a vignette detailing care provided in a primary care physician's office along with the patient's outpatient testing experience to reveal opportunities for improvement, a glimpse into the patient's experience and share methods for achieving STEEEP healthcare.

First-time traumatic anterior shoulder dislocation: Approach for the primary health care physician.

Traumatic anterior shoulder dislocation is a very common injury encountered in emergency rooms as well as in the primary health care physician's office. This injury occurs either in the setting of competitive or recreational sports injuries or as a high-energy injury during a fall or a road traffic accident. Common complications such as a recurrent dislocation can be predicted, monitored and prevented. Early appropriate treatment of associated cuff tears or fractures is associated with improved outcomes. There is a plethora of literature on the assessment and management of the primary anterior shoulder dislocation in specialised fields such as sports medicine, orthopaedic surgery and shoulder surgery. These studies are often highly technical, addressed to a particular subset of readers and often deal with one aspect of the management of the injury. This narrative aims to provide the reader with a simplified, evidence-based assessment and management approach for the first-time acute anterior shoulder dislocation. Emphasis is on closed reduction techniques, position and duration of immobilisation, and return to activities of life or sports. Risk factors for recurrence and other indications for primary referral to the orthopaedic surgeon are discussed. Other forms of shoulder instability such as posterior shoulder dislocation, inferior dislocation and multidirectional instability will not be the focus of this narrative.

Examining the Utility of a Telehealth Warm Handoff in Integrated Primary Care for Improving Patient Engagement in Mental Health Treatment: Randomized Video Vignette Study.

A warm handoff from a physician to a mental health provider is often patients' first contact with psychological services and provides a unique opportunity for improving treatment engagement in integrated primary care (IPC) settings. In light of the COVID-19 pandemic, this study sought to examine the impact of different types of telehealth mental health referrals on both the anticipated likelihood of accepting treatment services and anticipated likelihood of continued treatment engagement. A convenience sample of young adults (N=560) was randomized to view 1 of 3 video vignettes: warm handoff in IPC, referral as usual (RAU) in IPC, or RAU in standard primary care. Logistic associations between referral type and the likelihood of referral acceptance (χ21=10.9, P=.004) and the likelihood of continued engagement (χ21=32.6, P<.001) were significant. Participants who received a warm handoff were significantly more likely to anticipate both accepting the referral (b=0.35; P=.002; odds ratio 1.42, 95% CI 1.15-1.77) and engaging in continued treatment (b=0.62; P<.001; odds ratio 1.87, 95% CI 1.49-2.34) compared with those who received RAU in the standard primary care condition. Furthermore, 77.9% (436/560) of the sample indicated that they would be at least somewhat likely to access IPC mental health services for their own mental health concerns if they were readily available in their own primary care physician's office. A telehealth warm handoff resulted in the increased anticipated likelihood of both initial and continued engagement in mental health treatment. A telehealth warm handoff may have utility in fostering the uptake of mental health treatment. Nonetheless, a longitudinal assessment in a primary care clinic of the utility of a warm handoff for fostering referral acceptance and continued treatment engagement is needed to hone the adoptability of a warm handoff process and demonstrate practical evidence of effectiveness. The optimization of a warm handoff would also benefit from additional studies examining patient and provider perspectives about the factors affecting treatment engagement in IPC settings.

Hipertenzija kod dece i adolescenata

Until recently, secondary hypertension used to be the most common form of hypertension in the paediatric population. Due to the increasing prevalence of obesity-related hypertension in children and adolescents, the share of secondary hypertension has decreased from 85% to 9%. Today, primary hypertension has become the dominant form of hypertension in the paediatric population. The purpose of this paper is to show the prevalence of various forms of hypertension and the prevalence of primary hypertension in children and adolescents relative to sex, age and body weight category in the General Hospital "Dr. Laza K. Lazarević" in Šabac. In children with secondary hypertension, the impact of body weight was not assessed since an organic cause of hypertension had been identified in these patients. All children from the age of a new-born to the age of 18 years with a diagnosis of hypertension (International Classification of Diseases, tenth revision (IDC-10), code I10-I15) in the period from 1 January 2013 to 31 December 2022 were selected from the medical digital database. This analysis included all children who showed blood pressure values above 95th percentile for age, sex and height in children under 13 and above 120/80 mmHg in children over 13, upon repeated measurements of blood pressure in the General Hospital, who were presumed to have hypertension. These children were referred to further evaluation at tertiary healthcare institutions, where a diagnosis of hypertension was made. Of the 134 children referred to the General Hospital due to elevated blood pressure levels measured in the primary care physician's office, hypertension was diagnosed in almost one in four subjects (24.6%). Primary hypertension was diagnosed in 18 (54.5%), secondary hypertension in 8 (24.2%) and white coat hypertension in 7 (21.2%) children. Primary hypertension was more common in boys (70.6%) than girls (37.5%). Among children with primary hypertension, overweight and obese children represented 66.7% of the group at the time of diagnosis. Statistical data analysis did not find a statistically significant difference in the prevalence of primary hypertension among the body weight or age categories. Since primary hypertension is the most significant and potentially reversible factor for the development of cardiovascular disease, early detection and treatment of primary hypertension in children is crucial in the prevention of cardiovascular disease in adults.

LBSAT314 Diagnosis And Management Of A Rare Case Of Marine-Lenhart Syndrome

Abstract Introduction Marine-Lenhart syndrome is defined as Graves’ disease with co-existing toxic thyroid nodules. Approximately 25% to 30% of patients with Graves’ disease have accompanying nodules. More than 95% of these nodules are hypoactive, and thus, only a tiny percentage are hyperactive. In these patients, Graves’ disease and toxic nodules both contribute to thyrotoxicosis11. Here we present a case that details this syndrome's diagnosis, management, and treatment complication. Clinical Case A 68-year-old female presented to the primary care physician's office with complaints of anxiety and heat intolerance. Three years before this visit, the patient was diagnosed with Graves’ disease. She had achieved remission after one year of methimazole therapy. During the office visit, the patient was in sinus tachycardia at 112 BPM. There were no signs of exophthalmos on examination, and the thyroid was not palpable. Further testing revealed thyrotoxicosis with suppressed TSH of &amp;lt;0. 01 mcIU/mL (0.36-3.74) and elevated free T4 of 2.49 ng/dL (0.76-1.46). Thyrotropin receptor antibody (TRAb) was positive at 2.60 IU/L (0. 00-1.75). The patient was started on atenolol. Although TRAb was positive, thyroid ultrasound and radioactive iodine uptake scan (RAIU) were ordered to look for alternative diagnoses. The thyroid ultrasound showed four nodules in the left lobe, the largest of which was 1.8×1.5×1.3 cm. RAIU showed increased 24-hour uptake of 45% and three areas of increased focal uptake in the left thyroid lobe consistent with toxic nodules. Definitive treatment was needed due to both toxic nodules and Graves’ disease. The patient agreed to radioiodine ablation therapy (RAI) and received a dose of 21 uCi. One month after receiving RAI, the patient complained of worsening anxiety and heat intolerance. On repeat testing, TSH was &amp;lt;0. 01mcIU/mL, and free T4 was 4.78 ng/dL. The patient developed radiation thyroiditis and was given methimazole 10mg daily for two weeks. Three weeks after the course of methimazole, the patient became hypothyroid and was managed with 88 mcg of levothyroxine daily with no symptoms. Conclusion Common causes of hyperthyroidism are Graves’ disease or autonomous functioning thyroid nodules per the American Thyroid Association12. However, in hyperthyroid patients, Marine-Lenhart syndrome should be considered, especially those with thyrotoxicosis recurrence. This diagnosis steers management away from antithyroid drugs and toward RAI or thyroidectomy. For patients treated with RAI, antithyroid medications should be included as an adjunct therapy to reduce post-radiation thyroiditis. References 1 Cakir, Mehtap. "Marine-Lenhart Syndrome.," Journal of the National Medical Association 97, no. 7 (July 2005): 1036-38.12 Ross, Burch, et al., Thyroid. Oct 2016, 26(10): 1343-1421. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

CLASSIC PRESENTATION OF SCLERODERMA-RELATED INTERSTITIAL LUNG DISEASE IN A YOUNG FEMALE

CLASSIC PRESENTATION OF SCLERODERMA-RELATED INTERSTITIAL LUNG DISEASE IN A YOUNG FEMALE

A Case of Membranous Nephropathy Hypothesized to be Associated With COVID-19 Vaccine

A 56-year-old male patient with a medical history of essential hypertension was referred to the emergency room after he was found to have a serum creatinine level of 13 mg/dL at his primary care physician’s office. The patient reported that he had developed a coronavirus disease 2019 (COVID-19)-like infection six months prior that was not confirmed. Two months later, he started to notice dyspnea on exertion and bilateral lower limb swelling and was started on furosemide. He received the first dose of the Moderna COVID-19 vaccine a month before the presentation but did not receive the second dose. Subsequently, his lower limb swelling and exertional dyspnea started worsening. He denied any new medication, dysuria, oliguria, hematuria, fever, or any other symptoms. Initial evaluation was consistent with kidney failure. Hypocalcemia and hyperphosphatemia were noted, along with medical renal disease on renal ultrasound. Eosinophils and nephrotic-range proteinuria were found in the urine. His serum phospholipase A2 receptor (PLA2R) antibodies were positive. A renal biopsy showed membranous glomerulonephritis with moderate segmental sclerosis, as well as tubulointerstitial fibrosis with neutrophils, consistent with acute interstitial nephritis. Positive staining for PLA2R in the glomerular deposits suggested primary membranous nephropathy (MN). He was treated with prednisone first, and when the kidney biopsy was conclusive for membranous glomerulopathy, he was started on rituximab. On admission, he received hemodialysis intermittently, but this was stopped a month after discharge as his renal function normalized. Recently, there have been numerous cases reported with new onset of glomerular disease after receiving the COVID-19 vaccine. Further studies of vaccinated patients are needed to determine whether the severe acute respiratory syndrome coronavirus 2 virus vaccination is associated with a higher risk of MN and to identify potential predisposing factors and mechanisms of kidney injury in patients in whom it occurs.

Atypical Herpetic Rash: ‘Knife-Cut’ Sign

A 73-year-old woman initially presented to her primary care physician's office with complaints of a linear rash in the right groin and lower abdominal region. Her past medical history included systemic lupus erythematosus, rheumatoid arthritis, hypertension, depression, and chronic kidney disease (baseline serum creatinine around 1.8 mg/dL). There was concern for herpes zoster and a coexisting cutaneous fungal infection. Oral valacyclovir and topical betamethasone with clotrimazole were prescribed.

Isoniazid Induced Pure Red Blood Cell Aplasia

Pure red blood cell aplasia (PRCA) is one of the uncommon causes of anemia. Drug-induced PRCA is even more infrequent. Only a few drugs are implicated in PRCA. Isoniazid is a widely used drug for the treatment of tuberculosis all over the world. It is known to cause hepatotoxicity, but in rare instances, it can lead to PRCA. A 72-year-old Caucasian male, who was started on isoniazid after the diagnosis of latent tuberculosis, presented two months later with episodes of syncope to primary care physician’s office. The initial blood work showed severe anemia. There were no signs of acute or chronic gastrointestinal blood loss, and the stool hemoccult test was negative. Iron, vitamin B12, folate, lactate dehydrogenase, bilirubin, transaminases, and erythropoietin were within normal limits. Peripheral blood smear showed normochromic and normocytic anemia. A reticulocyte count was less than 1,000 per microliter. Thymoma, human immunodeficiency virus, and parvovirus B19 were ruled out. Further work-up with bone marrow biopsy confirmed pure red blood cell aplasia. A detailed review of recently started medications revealed isoniazid as the offending drug. Isoniazid was stopped. Reticulocyte count and bone marrow recovered a few days after stopping with eventual improvement in hemoglobin level, thus confirming the diagnosis of isoniazid induced red blood cell aplasia.Isoniazid is the first-line therapy for tuberculosis. Rarely, it can cause pure red blood cell suppression and severe anemia, an untoward effect, worth remembering.

3083 Campylobacter coli bacteremia: How Common Is It?

INTRODUCTION: Campylobacter species are known to cause enteritis, usually self-limited, but with the risk of developing Guillain Barre Syndrome. However, over the past 40-50 years, there have been reports of varying presentations, such as cellulitis, spondylodiscitis, and bacteremia. Of the Campylobacter species, C. jejuni is the most common culprit for causing bacteremia, however, C. coli bacteremia is becoming more prevalent. Here we discuss an unusual case of C. coli bacteremia in a patient with decompensated liver cirrhosis. CASE DESCRIPTION/METHODS: 59 y/o with history of cirrhosis secondary to alcohol abuse complicated by esophageal varices, who presented with black, watery stools in the previous one week with concurrent scrotal swelling. Vital signs were stable with temperature of 97.6 degrees F, heart rate 84 bpm, respiratory rate 16, blood pressure 117/72, and oxygen saturation 99% on room air. Physical exam was remarkable for voluntary guarding, and right upper quadrant tenderness. Lab tests revealed a white blood count of 2300/cm2, hemoglobin 9.9 g/dL, alkaline phosphatase 132 IU/L, aspartate aminotransaminase 65 U/L, alanine aminotransaminase 26 U/L, lactic acid 5.0 mmol/L, magnesium 1.2 mg/dL, and phosphorus 2.2 mg/dL. Computed tomography abdomen/pelvis with contrast showed findings of colitis. Ultrasound of the scrotum showed possible scrotal cellulitis. Stool culture returned positive for Campylobacter antigen, for which doxycycline was initiated. Blood cultures resulted with gram negative rods, which were later confirmed to be C. coli. Blood cultures continued to grow the bacteria and antibiotics were switched to imipenem until the day of discharge. Unfortunately, the patient left the hospital against medical advice and was sent home with ciprofloxacin to complete a total antibiotic course of 2 weeks after the last negative blood culture. Patient was seen at his primary care physician's office 4 days after leaving the hospital and reported complete resolution of his symptoms. DISCUSSION: Campylobacter bacteremia is rare. We must be aware of the possibility of a Campylobacter bacteremia and consider this organism when choosing empiric antibiotics. Additionally, once confirmed of a Campylobacter bacteremia, we must be mindful of resistance and choose treatment wisely. As Campylobacter infections have a wide array of presentations, it is imperative that cases are shared amongst the medical community so that prompt recognition, diagnosis, and treatment can be offered.

3226 Complications of Meckel's Diverticulum from Helicobacter pylori

INTRODUCTION: Meckel's diverticulum is a disease most prevalent in children. It is rare for it to present in adulthood, especially with complications. Below is a unique case of Helicobacter Pylori (H. Pylori) causing an abdominal abscess which led to the discovery of an adult male's Meckel's diverticulum. CASE DESCRIPTION/METHODS: A 26-year-old male with no past medical history presented to the emergency room complaining of intermittent midline abdominal pain in the lower quadrant for the past two weeks, with associated decrease in appetite, fever, nausea, and vomiting that started two days prior to arrival. The pain was worsened with eating and ambulation, and improved when lying down. One week ago he was in the emergency room for similar symptoms and was discharged home with given intravenous fluids, omeprazole, ranitidine, calcium carbonate and then subsequently discharged home. His pain did not improve, so three days later he went to his primary care physician's office where outpatient CT was ordered and patient was prescribed azithromycin, ciprofloxacin, and tramadol. Primary care physician contacted patient after obtaining CT scan results, and instructed him to immediately go to the emergency room. In the emergency room physical exam was significant for periumbilical and suprapubic tenderness with palpation and mild guarding. The CT scan showed a complex multiloculated 5 cm abscess in the mesentery of the midline lower abdomen. Patient was admitted and started on ceftriaxone and metronidazole. Surgery evaluated the patient and recommended laparoscopic exploration. During the procedure the perforated small bowel was resected and mesenteric abscess was suctioned. While in the hospital patient complained of a history of dyspepsia for the past three years which worsened 1-2 hours postprandially. This prompted him to be tested for H. Pylori IgG antibody and stool antigen. Serum IgG antibody was positive and stool antigen was negative. Ciprofloxacin and flagyl were continued, and he was also treated for H. Pylori with metronidazole prior to being discharged home. Etiology of patient's abdominal pain was determined to be a complicated H. Pylori infection and transmural perforation followed by auto seclusion via the mesentery. DISCUSSION: This case presents with unusual etiology for a diagnosis that is uncommonly discovered in adults. It highlights the importance of getting a thorough history with supportive diagnostic labs and imaging while maintaining a wide differential diagnosis during the initial workup.

Promoting Earlier Access to Pediatric Behavioral Health Services with Colocated Care.

This study aimed to determine whether youth access behavioral health (BH) care earlier (i.e., when problems are less severe) when receiving services in colocated pediatric primary care clinics. Six primary care clinics in the Midwest with a colocated BH provider participated in this study. Data on number of sessions attended/not attended with the BH provider, BH symptom severity as measured by the Child Behavior Checklist, parent report of length of presenting problem, and improvement ratings were collected and compared for on-site referrals and off-site referrals. Descriptive, independent sample t tests and regression analyses compared those referred from on-site physicians versus off-site referral sources. Results demonstrated that youth receiving BH services at their primary care physician's office accessed services when problems were less severe and had been impacting their functioning for a shorter duration. This study is among the first to explore whether youth receiving BH services in primary care are accessing those services earlier than those who are referred from outside sources, resulting in improved patient outcomes.

Prognosis of Concussion in Children

Concussion in children is a common complaint in the emergency room, at the primary care physician's office and at the pediatric neurology clinic. The objective of this paper is to review the literature about prognostic factors that influence recovery from concussion. Also, we provide an overview of the duration of the symptoms, criteria to return to school and sports, and retirement of sports. It is important to remember that the factors provided could be used as a guide, but each case should be individualized and does not replace a detailed history-taking and physical examination.

An Unusual Cause of Obscure Gastrointestinal Bleed: Ileal Inflammatory Polyp

A 58 year old male presented to his primary care physician's office with a complaint of increased fatigue with exercise over the preceding nine months. His blood work at the initial visit was notable for microcytic anemia with a hemoglobin of 8.2 g/dL, hematocrit 28.4% and MCV 65.8 fL. On further investigation, he was also found to be iron deficient. The patient had no history of anemia prior to this visit. His colonoscopy from one year prior had been unremarkable. An EGD was performed and was notable for esophagitis grade B and duodenitis on biopsy, but no other significant findings. A video capsule endoscopy revealed an area of polypoid, ulcerated mucosa in the distal small bowel. This study was followed by a CT enterography notable for a 4.5 centimeter ovoid intraluminal lesion in the distal ileum (Figure 1). A double-balloon retrograde enteroscopy performed at an outside hospital was unremarkable. The patient underwent a diagnostic laparoscopy with findings of an ileal mass proximal to the tattoo-mark of the previous retrograde double-balloon enteroscopy. The ileal segment was resected and a macroscopic examination was notable for a 3 x 2 x 1.6 cm polypoid mass with intraluminal prolapse (Figure 2). Microscopic review was notable for markedly inflamed small intestinal mucosa with edema and enlargement of intestinal villi. The inflammatory infiltrate consisted of lymphocytes, plasma cells and neutrophils with muscle wall in the middle indicating prolapse and attachment of the muscularis propria. There was no evidence of atypia or Crohn's disease. The mass was diagnosed as an inflammatory polyp of the ileum. The patient recovered without complication and his anemia resolved.1992_A Figure 1. 4.5 cm ovoid intraluminal lesion in distal ileum on CT enterography (arrows)1992_B Figure 2. Surgical specimen of ileal resection containing 3 x 2 x 1.6 cm inflammatory polypSmall bowel lesions account for approximately 5-10% of all gastrointestinal bleeding1. The most common etiologies in individuals 41-65 years of age consist of vascular anomalies, small intestinal tumors and non-specific enteritis1-3. Of these etiologies, tumors account for 5-10%4. Inflammatory polyps are nondysplastic lesions consisting of inflamed and regenerating mucosa above the mucosal surface4. These polyps are commonly found in the colon where they can be associated mainly with inflammatory bowel disease and infection5. However, small bowel inflammatory polyps are less commonly reported. When located in the small bowel, inflammatory polyps are associated with abdominal pain, iron deficiency anemia and intussusception6-9.

Analysis and development of mobile perinatal mental health system

Perinatal depression includes major and minor depressive episodes during pregnancy or in the first 12 months after birth. The American College of Obstetricians and Gynecologists recommends that clinicians screen patients at least once during pregnancy for depression and anxiety symptoms using a standardised tool. This paper attempts to consolidate current depression screening tools into an electronic application that can be accessed from a computer, tablet or cell phone and can be sent directly to the primary care physician's office for review. The object-oriented approach was used to analysis and design the system. The systems requirements are first gathered using questionnaire and interviews with practitioners; then, analysed based on unified modelling language techniques such as use case, class, and sequence diagrams. This system will aid healthcare providers in identifying patients who are at risk of perinatal depression.

Analysis and development of mobile perinatal mental health system

Perinatal depression includes major and minor depressive episodes during pregnancy or in the first 12 months after birth. The American College of Obstetricians and Gynecologists recommends that clinicians screen patients at least once during pregnancy for depression and anxiety symptoms using a standardised tool. This paper attempts to consolidate current depression screening tools into an electronic application that can be accessed from a computer, tablet or cell phone and can be sent directly to the primary care physician's office for review. The object-oriented approach was used to analysis and design the system. The systems requirements are first gathered using questionnaire and interviews with practitioners; then, analysed based on unified modelling language techniques such as use case, class, and sequence diagrams. This system will aid healthcare providers in identifying patients who are at risk of perinatal depression.

Adrenal incidentalomas: are they being worked up appropriately?

IntroductionAdrenal incidentalomas are defined as masses picked up on imaging studies that were done for apparently different reasons. With frequent use of imaging modalities, incidental adrenal masses are commonly encountered in clinical practice. Guidelines are currently available for the diagnosis and management of adrenal incidentalomas, but the appropriateness of initial work-up and subsequent follow-up of incidental adrenal masses in the community hospital setting is unknown.ObjectiveWe studied the appropriateness of initial work-up and follow-up of incidental adrenal masses discovered on abdominal computerized tomography (CT).MethodsIn our retrospective study, we reviewed sequential CT scans of the abdomen performed in the month of January 2010 at a community hospital. Once patients with one or more adrenal masses were identified, outpatient charts for initial biochemical testing and follow-up imaging were obtained either through directly accessing the electronic medical records or through contacting primary care physician's offices. Patient charts were reviewed to assess the data for the next 2 years following the discovery of an adrenal abnormality.ResultsTwenty adrenal masses were incidentally discovered on 723 abdominal CTs performed within the month of January 2010 resulting in an overall incidence of 2.76%. Of the patients with incidentally discovered adrenal masses, appropriate biochemical and follow-up imaging were only performed in patients referred to an endocrinologist (2 of 20 patients). Thirty percent of patients with incidental masses received a repeat CT scan for non-adrenal reasons, and no change in the mass size was noted.ConclusionDespite published guidelines, the initial work-up and follow-up of patients with an incidentally discovered adrenal mass is unsatisfactory. There is a desperate need for education of providers regarding appropriate work-up of incidental adrenal masses.

69-Year-Old Woman With Confusion and Fatigue

Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN (H.M.K.); Advisor to resident and Consultant in Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN (A.E.K.). A 69-year-old woman presented to her primary care physicianwith a 4-day history of fatigue and dizziness. She was 45 minutes late for her appointment because she had trouble driving to the office. She reported no motor or sensory deficits but had difficulty with coordination. Review of systems was positive for dysuria and urinary frequency. She did not have fever, chills, weight or appetite changes, respiratory, cardiac, or gastrointestinal symptoms, or recent head trauma. The patient’s medical history was remarkable for hypertension, hyperlipidemia, type 2 diabetes mellitus, osteoporosis, and gastroesophageal reflux disease. Medications included metoprolol tartrate, lisinopril with hydrochlorothiazide, lovastatin, cholecalciferol, and as-needed calcium carbonate. She had smoked half a pack of cigarettes per day for 40 years but had quit smoking 6 years previously. She didnot use alcohol or illicit drugs. On examination, the patient was afebrile with a blood pressure of 104/67 mm Hg, heart rate of 76 beats/min, respiratory rate of 17 breaths/min, oxygen saturation of 94% while breathing room air, and body mass index (calculated as weight in kilograms divided by height inmeters squared) of 39 kg/m. Shewas alert and oriented to person, place, and time. Her speech was dysarthric, and she had difficulty following simple commands. Her coordination was impaired with symmetric dysmetria on finger-to-nose testing, heel-kneeshin testing, and rapid alternating movements. Cranial nerves II through XII were intact. Results of motor and sensory examinations were within normal limits. Reflexes were symmetric. Lymph node, thyroid, cardiac, respiratory, gastrointestinal, musculoskeletal, and skin examinations identified no abnormalities.

Carcinoid of the Duodenal Bulb: A Rare Occurrence

Introduction: The incidence of neuroendocrine tumors has increased significantly in the last few decades. Carcinoid tumor, a subtype of neuroendocrine tumors, arises from the enterochromaffin cells of the epithelial lining of the gastrointestinal tract, retroperitoneum and large bronchi. Duodenal carcinoids are extremely rare and can present with a variety of symptoms including epigastric pain, vomiting, anemia, and weight loss. We report a rare case of a patient who presented with iron deficiency anemia and was found to have multiple carcinoids of the duodenal bulb. Case: 60 year-old male presented to his primary care physician's office to establish care and reported a history of GERD for which he was taking Omeprazole 20 mg daily in the morning. He underwent routine laboratory investigations revealing iron deficiency anemia which prompted the need for an endoscopy. His initial EGD showed a 5 mm duodenal bulb polyp with biopsies showing changes suggestive of a hyperplastic polyp. Given his persistent anemia and an inconclusive workup otherwise including a colonoscopy, he underwent a second-look EGD after six months which showed two submucosal duodenal bulb lesions, 15 mm and 5 mm, both of which were biopsied with cold biopsy forceps and showed a neoplasm formed by nests of cells with moderately clear-to-pale eosinophilic cytoplasm and nuclei with finely stippled chromatin. A chromogranin stain was performed and was positive, thereby rendering a diagnosis of a carcinoid tumor. He underwent an octreoscan and a CT scan which showed no metastatic disease. The patient underwent a Billroth procedure. Intra-operatively, no evidence of diffuse peritoneal disease or metastases to the intra-abdominal viscera was observed. The liver did not have any palpable masses. He tolerated the procedure well and was discharged home with a surveillance EGD showing no evidence of recurrence. Discussion: Duodenal carcinoids, although rare, should be kept in the differential diagnosis of the polypoid lesions of the duodenum and may occasionally cause anemia. Two duodenal carcinoids occurring concomitantly and presenting as iron deficiency anemia is extremely rare. These lesions typically have a low metastatic potential and have a good curative rate if localized and diagnosed early.