On Booby Traps and Burner Phones
Jeffrey Bien, MD
Faculty mentor: Claire Zeigler, MD, MPH
Susac’s Syndrome is a rare neurologic disorder which can present as late-onset paranoia and psychosis.  Given its rarity and nonspecific constellation of symptoms, it can be difficult to recognize in primary care settings.

Breaking the Case, by Breaking the Blood
Curtis Lachowiez, MD
Faculty mentor: Gabrielle Meyers, MD
Fanconi Anemia is a rare congenital bone marrow failure syndrome typically presenting clinically in childhood, associated with certain physical, hematologic, and neoplastic conditions. Cases rarely have asubtler presentation without these classical features, thus requiring a high index of suspicion when considering the diagnosis. Prompt recognition is imperative. 

Bilateral Renal Artery Dissections from Segmental Arterial Mediolysis: A Rare Presentation of a Rare Condition
Molly Andreason, MD
Segmental arterial mediolysis (SAM) is a rare non-inflammatory, non-atherosclerotic arteriopathyinvolving lysis of the smooth muscle of the outer media wall, usually involving visceral abdominal arteries. It can have variable presentation based on the arteries involved, but requires promptrecognition as it carries high mortality upon presentation due to risk of acute rupture and hemorrhage.

The Folly of Following Your Heart: A Case of Late Onset Inflammatory Bowel Disease
Jane Babiarz, MD
The diagnosis of inflammatory bowel disease is often delayed in the elderly due to subtlety of abdominalsymptoms and prevalence of comorbidities with similar presentations. 

Hidden in Plain Sight: False Reassurances Obscuring a Case of Intravascular Lymphoma
Jeffrey Bien, MD; Renee Honeyfield, MD
Faculty mentor: Jonathan Pak, MD
​A patient with progressively worsening constitutional symptoms, profound weakness, elevated inflammatory markers, anemia and inexplicable shock physiology is found to have extensive organ involvement from intravascular lymphoma.

Treating Chronic Pain in a Rapid-Metabolizer
Stephen Cohen, MD
This case illustrates the difficulty of diagnosing opioid rapid metabolizers and the potential benefit of switching these patients off of opiates.  Using objective lab data in conjunction with the expert opinionsof a multidisciplinary group allowed us to diagnose the patient as a rapid-metabolizer.

IVIG HITs the Spot
Jessica Dreicer, MD; Jason Shatzel, MD
Faculty mentors: André Mansoor, MD; Ximena Levander, MD
Even after heparin exposure ceased, this patient had persistent thrombocytopenia suggesting a possible autoimmune pathophysiology.  Perhaps this explains the success in treating with IVIG, despite the fact that it is not recommended as treatment in typical HIT.  The success of using IVIG in this case as well as previously reported cases raises the prospect of efficacy in this subgroup of patients with HIT and highlights the need for additional research in this area.  Additionally increasing awareness of atypical HIT is imperative as heparin products are often reflexively given to these patients and thus re-exposure is likely pathologic.

Water, Water, Everywhere, but not a Drop in the Vasculature: A Case of Systemic Capillary Leak Syndrome
Kristy Duggan, MD
Faculty mentors: Sima Desai, MD; Tom DeLoughery, MD
The rare disorder, Systemic Capillary Leak Syndrome (SCLS), should be considered in the patient found to have the triad of severe hypotension, hypoalbuminemia, and hemoconcentration.

Under Pressure:  Anchoring, Ultrasound, and Cardiac Tamponade
Daniel Green, MD, MPH

Faculty mentor: Daniel Toms, MD
Diagnostic errors are a major and underappreciated contributor to the gap in quality health care delivery.  Anchoring bias is a common cognitive bias that over emphasizes the initial data despite new information that is contrary. Wards teams are at risk of making diagnostic errors due to anchoring bias when receiving hand off of newly admitted patients from ED physicians. When patients don’t fit into an illness script, or conceptual frame work for a chief complaint, further work up and thought is necessary.

The Eyes Have It:  An Unusual Case Of Blurry Vision
Daniel Guy, MD
Faculty mentor: Khaled Tolba, MBBS
Blurry vision is a common medical complaint that is often times obscure to the internal medicine provider. We present an unusual cause for blurry vision.  A thorough review of systems may be suggestive of systemic causes of blurry vision. 

You Are What You Eat-Your Lab Values Are What You Drink:  An Unusual Etiology Of Pleural Effusion
Daniel Guy, MD
Faculty mentor: Avital O'Glasser, MD
Boerhaave syndrome is a term used to describe esophageal perforation which occurs due to vomiting.  This is usually a full-thickness tear in the esophageal wall due to sudden increase in intra-esophageal pressure combined with relatively negative intra-thoracic pressure caused by vomiting. In this case the patient had a prior caustic ingestion leading to a long esophageal stricture and predisposing him for esophageal rupture.

Traveling Arthralgias In A Returning Traveler
Richie Hegarty, MD
Faculty mentor: Avital O’Glasser, MD
​This case illustrates that the differential diagnosis of arthralgias in a returning traveler is very broad and includes both exotic infectious etiologies as well as conditions unrelated to travel history. This patient complained of numerous nonspecific symptoms but the combination of arthralgias, enthesitis, and possible uveitis the onset of which followed a discrete GI illness in the setting of a family history of spondyloarthropathies makes reactive arthritis the most likely diagnosis.

The Curious Case of Subcutaneous Sarcoidosis
Meagan Herda, MD
Sarcoidosis is a relatively common condition with a variety of clinical manifestations. Although as many as 25% of patients with sarcoidosis have skin findings, it is far less common for a patient to initially present with subcutaneous sarcoidosis.

A Dropsical Diagnosis
Evthokia Hobbs, MD
Resident co-author: Ann Perrin, MD
​Faculty mentor: Tim Kerrigan, MD; Shona Hunsaker, MD
Out of the many causes of exudative ascites, hypothyroidism is among the least documented.  We present a case of myxedema ascites diagnosed in a patient with end stage renal disease (ESRD) secondary to polycystic kidney disease. 

A Painful Syncope – Glossopharyngeal Neuralgia
Brianna Ketterer, MD
Head and neck cancers can be associated with syncope and pain in and of themselves. However, there is a rare disorder of the ninth cranial nerve called glossopharyngeal neuralgia in which paroxysms of severe pain are associated with excessive vagal outflow resulting in bradycardia, hypotension, syncope and even cardiac arrest.  

C’est La Vie… de la Valve
Milla Kviatkovsky, DO, MPH; Meryl Paul, MD; Luke Yeager
Faculty mentor: Avital O'Glasser, MD
When a patient does not improve with initial treatment, we must distinguish between treatment failures versus diagnostic mishaps. Cognitive biases of anchoring and status quo perhaps favor the treatment failure choice, however we must re-visit our diagnostic tests, to evaluate their sensitivity in ruling out alternative etiologies.

What is green on the inside and yellow on the outside?
Milla Kviatkovsky, DO, MPH; Meryl Paul, MD
Faculty mentor: Avital O'Glasser, MD
Pressure to obtain an ideal body image in today’s society often drives both men and women to seek supplements for performance enhancement and weight loss. These supplements are readily available both online and in stores with no FDA regulation. Despite the perception that products sold in major US stores are safe, clinicians treating the consequences thereof know better.

Anchors Aweigh! Catecholamine Surge Disguised as Postpartum Anxiety
Sarah Larsen, MD
While anxiety during pregnancy and post-partum is common, in rare circumstances, it may be a manifestation of pheochromocytoma, where the consequences of missing the diagnosis may be grave.

Complications of Primary Varicella Zoster Virus in Adults
Melissa LeBlanc, MD

Faculty mentor: Joe Chiovaro, MD
Varicella-zoster virus (VZV) presents in two forms, primary infection (chicken pox) and zoster(shingles).  The majority of primary cases are seen in children and are self-limited and treated symptomatically. In adults, there is increased risk of complications including pneumonitis, hepatitis, encephalitis/meningitis and secondary bacterial infections, which are more commonly seen in immunocompromised persons. We present the case of a previously healthy man presenting with diffuse rash.

CKD and Occult Type I RTA Manifesting as Cryptic Paroxysmal Weakness and Hypokalemia

Taylor Locke, MD

Faculty mentor: Alan Hunter, MD
This case frames an illness script for distal RTA by highlighting its distinct pathophysiology, history and laboratory findings.

Diagnosis Under Pressure:  Peripheral T-Cell Lymphoma as An Elusive Cause of Progressive Eosinophilic Myocarditis
Dylan Mart, MD; Jacob Luty, MD
Faculty mentor: Rebecca Harrison, MD; Cristina Fuss, MD
Eosinophilic myocarditis (EM) is a rare cause of progressive myocardial dysfunction that has a broad array of inciting diseases and many distinct complications. An elusive cause of EM is peripheral T-cell lymphoma (PTCL), a protean entity with varied presentations. We present a case of PTCL that defied diagnosis, stressing the importance of a broad differential for causes of EM.

When the Cure Becomes the Cause: A Case of Post-Amoxicillin Aseptic Meningitis
Suvi Neukam, DO; Anushka Shenoy
Faculty mentor: Stephen Mehanni, MD
Aseptic meningitis is inflammation of the meninges not caused by traditional bacterial infections. A misnomer, the most common etiologies of aseptic meningitis include viral infections and atypical bacterial infections.  Although less established in the literature medication induced aseptic meningitis of increasing relevance.  Most commonly drug-induced aseptic meningitis (DIAM) occurs secondary to exposure to NSAIDs, but causality from other medications is possible. Here we present the ninth known case of amoxicillin induced aseptic meningitis (AIAM) and first case reporting focal deficits that presented post-cessation of amoxicillin.  

A Case of “Thrombotic Storm” 
Sven Olson, MD
Faculty mentor: André Mansoor, MD
​Malignancy is a well-known cause of venous thromboembolism (VTE). Rarely, malignancy can precipitate a severe thrombotic phenotype known as the “thrombotic storm.”  Though treatment of malignancy eliminates the associated thrombophilia, this depends on proper identification of a primary tumor, which is sometimes easier said than done.

Dissecting the Workup for Syncope
Mario Padilla, MD
Faculty mentor: Kevin Piro, MD
Syncope is a common presenting symptom for admission to a medicine ward. It has abroad differential, including diagnoses which are emergencies. The work up is also part of the Choosing Wisely campaign because it can include unnecessary and low yield testing.

When Neck Deep in Red Herrings, Take a Deep Breath
Meryl Paul, MD; Milla Kviatkovsky, DO, MPH; Luke Yeager
Faculty mentor: Avital O'Glasser, MD
​Dyspnea is a common complaint for which patients seek medical attention; it carries significant morbidity, both psychologically and somatically. In approaching its broad differential, the astute clinician must wade through numerous data points, keeping in mind that all that wheezes is not reactive airway disease.

A Veritable Vascular Quandary
Christopher Purtell, MD
Faculty mentor: Kyle Kent, MD
​The various elements of mimicry that can occur with a vasculitis process must be weighed carefully in approaching a final diagnosis, often requiring an extensive workup and close follow-up.

Rituximab for the management of severe recurrent granulomatosis with polyangiitis
Bethany Roy, MD
Faculty mentors: Akram Khan, MD; Anjay Wanchu, MD
Granulomatosis with polyangiitis (GPA) is a small-vessel, immune-mediated vasculitis associated with increased production of autoantibodies known as anti-neutrophil cytoplasmic antibodies (ANCA). Prior to the availability of immunosuppressive therapy, the mortality rate of ANCA-associated vasculitis was nearly 100%. Now, these vasculitides can be treated with induction therapy followed by maintenance therapy once remission is achieved. Traditionally, the gold standard for induction and maintenance was cyclophosphamide in combination with high-dose corticosteroids. However, relapse rates on this regimen can be as high as 50% and chronic cyclophosphamide is associated with a significant risk of toxicity.  This case describes the use of rituximab for induction and maintenance in a patient with severe, recurrent GPA.

Subliminal and Trigeminal—A Case of Trigeminal Neuralgia as the Initial Manifestation of Leptomeningeal Carcinomatosis 
Carlton Scharman, MD
Faculty mentor: Ximena Levander, MD
Leptomeningeal carcinomatosis (LMC) is an uncommon form of solid tumor metastasis most associated with cancers of the lung and breast. Rarely, is LMC the initial manifestation of these cancers, and do to non-specific symptoms can make diagnosis challenging. Presented here is a case of trigeminal neuralgia due to LMC as the initial manifestation of non-small-cell lung cancer (NSCLC).

Way Off From Korsakoff – A Case of Confabulation due to Anterior Communicating Artery Aneurysm Rupture
Carlton Scharman, MD; Wendy Tseng, MD
Faculty mentor: Avital O'Glasser, MD
Although many definitions exist, confabulation can be described as the compensation for memory loss by the verbal production of erroneous and fabricated material without the desire to mislead. Although confabulation is classically associated with Wernicke-Korsakoff syndrome, the differential diagnosis is much wider than one may expect. This is case of confabulation as a sequela of a ruptured anterior communicating artery (ACoA) aneurysm.

The Boo-Boo that Wouldn’t Go Bye-Bye
Amy Semritc, MD
Faculty mentor: Drew Oehler, MD
Skin and soft tissue infections are a common clinical entity treated by the general internist in both the inpatient and outpatient settings. Having a broad differential diagnosis and avoiding anchoring or availability bias are important when one or more features of the patient’s presentation do not fully align with the diagnosis.  

Shoulder Pain as a Harbinger of Rectal Cancer
Anil Sharma, MD
Faculty mentor: Carrie Sailer, MD
The initial evaluation of shoulder pain includes consideration of a variety of intrinsic and extrinsic etiologies.  At times, there can be red flag signs and symptoms that suggest the involvement of systemic pathologies.  Distal osseous metastases can be associated with colorectal cancer; thus shoulder pain with bony lesions should raise an index of suspicion for malignancy. 

A Real Pain in the Neck
Kelsey Shaver, MD
Faculty mentor: Kyle Kent, MD
Benign recurrent aseptic meningitis or “Mollaret’s meningitis” named after the French neurologist Pierre Mollaret who first described the syndrome, is a rare benign form of painful meningitis in which patients have recurrent episodes that often resolve spontaneously.   The majority of these cases are secondary to herpes simplex virus type 2 (HSV2).  This clinical vignette highlights the controversy of suppressive antiviral therapy in patients with benign recurrent aseptic meningitis.

An Atypical Presentation of a Common Disease
Lucy Shi, MD, Casey Luce
Faculty mentor: André Mansoor, MD
Chest wall masses are uncommon and underlying causes are primarily neoplastic or infectious. Thelikelihood of infection is increased in patients with a history of intravenous (IV) drug abuse and immunocompromised state. Of the chest wall masses that are neoplastic, the most common causes in adults include metastasis, local invasion of an underlying adjacent tumor, benign tumor, chondrosarcoma and lymphoma.

Fevers, Fasciculations, Hallucinations…F.U.Oh My!
Lucy Shi, MD
Faculty mentor: Avital O'Glasser, MD
Fever of unknown origin (FUO) is a clinically defined condition with distinct criteria. The term is frequently used for syndromes that do not meet this exact description, but true FUO remains uncommon. Up to 50% of FUOs are from an unidentified etiology. In patients who remain undiagnosed after six months, it becomes unlikely a diagnosis will ever be found.

Expect the Unexpected: An Atypical Cause of Fatigue in the Elderly
Emilio Sulpizio, MD; Christopher Fine, MD
Faculty mentor: Sima Desai, MD
Fatigue is a common complaint in the elderly and is often quickly attributed to normal aging or possible malignancy. We present a case of a previously active elderly woman with hypertension and asthma who developed subacute progressive severe fatigue leading to being bed-bound over one month.   

In the Glow of a Coma
Wendy Tseng, MD
Faculty mentor: Matthew Drake, MD
Ethylene glycol is a rare, but potentially fatal cause of anion gap metabolic acidosis. While we have classically been taught the MUDPILES approach to anion gap acidosis, recall of ethylene glycol as the “E”in the algorithm can be delayed due to infrequency of cases. Prompt recognition and treatment of ethylene glycol poisoning, however, is essential for preventing morbidity and mortality.

Acute Management of Severe Hypertriglyceridemia
Garrett Waagmeester, MD; Deron Amador, MD
Faculty mentor: Kate Mackey, MD; James Lundblad, MD
Eruptive xanthomas are associated with primary dyslipidemia disorders as well as secondary causes of hypertriglyceridemia due to underlying medical conditions or medications. Acute management involves lowering triglycerides to prevent acute pancreatitis. Long-term therapies focus on risk factor reduction through lifestyle modification and management of chronic medical conditions.

SAPHO:  A Case of Skin and Bones
Teena Xu, MD
Faculty mentor: Cong-Qiu Chu, MD
​SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome is a chronic, relapsing inflammatory disease involving the skin, bones, and joints. It is a rare syndrome involving a constellation of common symptoms that requires high clinical suspicion to unify the diagnosis.

Mortality Risk Factors Among Those with Peripheral Arterial Disease
Stephen Amrock, MD, SM
Faculty mentor: Michael Shapiro, MD
Rates of peripheral arterial disease (PAD), a leading cause of atherosclerotic cardiovascularmorbidity, continue to increase. Traditional cardiovascular risk factors are implicated in thedevelopment of PAD, yet the extent to which such risk factors correlate with mortality in suchpatients, and how clinicians ought to prioritize secondary prevention, remains insufficiently assessed

Redesigning Care Transitions: Standardizing the Interprofessional Discharge Process at the VA Portland Healthcare System (VAPORHCS)
Molly Andreason, MD; Megan Molleck, MD; Jean Liew, MD; Kelsey Shaver, MD; Jeff Dueker, MD
Faculty mentors: Matthew DiVeronica, MD; Renee Segura, MD; Shona Hunsaker, MD
Communication of transitional care needs between inpatient and outpatient settings isfacilitated primarily by discharge documentation, with increased risk of errors by unclear orincomplete documentation. Standardized discharge documentation can improve the safety ofcare transitions. In a review of 100 randomly selected patients discharged from the medicineservice at the VAPORHCS from July 2013 to June 2014, discharge documentation lacked areconciled medication list (41%), clear delineation of follow-up care responsibility (54%) and acomplete list of post-discharge follow-up appointment needs (46%).  Follow-up care needs werenot completed 40% of the time. We created a standardized, interprofessional discharge processat VAPORHCS to improve provider communication and increase patient engagement across thecare transition.

Finding a Voice for the Voiceless: A Housestaff-Led Initiative to Facilitate Advance Care Planning Through Documentation of Surrogate Decision Maker in the Electronic Medical Record
Alex Perry, MD; Jake Luty, MD; Jeffrey Dueker, MD
​Faculty mentor: Matthew DiVeronica, MD
Advance care planning (ACP) is a difficult but powerful step toward preserving patient autonomyin clinical situations in which the patient may not be able to participate in decision making oftheir clinic care. Identification of a surrogate decision maker was identified as a vital piece ofACP and thus preserving patient  autonomy.Beginning in August 2015, the Housestaff Qualityand Safety Council (HQSC) at OHSU, led a hospital-‐‐wide initiative to increase rates ofdocumentation of patients’ SDMs to 40% of all adult, non-‐‐observation, non-‐‐psychiatric patientsadmitted by April 2016. This work was initiated in cooperation with the Caring Wisely team, aninstitution-‐‐prioritized workgroup focused on improving ACP. The completion of this goalconnected to a retirement bonus for all housestaff.

Slippery When Wet:  Cleaning Up the Fluid Administration Order Menu by Combining Principles of Usability Testing and Improvement Science
Suvi Neukam, MD; Charles DeDeaux, MD
Faculty mentor: Renee Segura, MD
Usability testing is a method of quality improvement that assesses the ability of a system toallow its users to carry out tasks safely, effectively, efficiently and enjoyably (1). In this projectwe describe the role of usability testing in improving an intravenous fluids (IVF) ordering menu and in doing so demonstrate that usability testing is a feasible and effective method for residents to engage in quality improvement efforts.

A "Surprising" Approach to Advanced Care Planning Rounds at the VA Portland Health Care System
Linda Wang, MD; Megan Moody, MD; Sarah Larsen, MD; Maria Peila, MD; Emma Peiris, MD; Jeff Dueker, MD
Faculty mentors: Matthew DiVeronica, MD; Renee Segura, MD; Shona Hunsaker, MD
Physicians overestimate life expectancy even in terminally ill patients and this discomfort withprognostication is one of many barriers that can delay advanced care planning (ACP) discussions.Local palliative care experts suggest approaching ACP as a continuum may help providers andpatients engage in these conversations earlier and more often. Previous investigation revealedone year post hospital discharge mortality rates for VAPORHCS between 2010 and 2013 rangedfrom 16.1-‐‐18.2%.  In a random sample of 100 patients discharged from medicine in 2013 whodied within one year of discharge, rates of POLST completion and palliative care or hospiceconsultation were 26%, 11%, and 9% respectively. Comparing the one year mortality rate withour rates of POLST completion and expert consultation highlights the gap in ACP needs.