Dissecting Case Reports

1. Dissecting Case Reports USAFP Judges 2008

2. The perils of Dissection Truth is that which was often thought, But ne’er so well expressed… --Alexander Pope

3. Actual Quotes from Feedback “Good tie to FP, could be made stronger” “Proof that this is first case?” “Better compare and contrast to existing literature would strengthen” “Don’t like the title: ‘protective’ against what?” “Don’t tell me things are rare. How rare are they?” Feedback - What does it mean?

4. Objectives • Discuss each section of the case report abstract • Critique individual case report sections • Re-Tread case report abstract • Real-time scoring, feedback, interaction with USAFP Judges

5. Statement of Purpose Justification of Uniqueness Applicability to Family Medicine Clarity What’s in a Section: Introduction

6. Examples - Introductions • Objective: Petechial rash in the setting of other signs and symptoms of meningitis is almost diagnostic for meningococcal disease. This case is describes a more benign etiology of meningitis with petechiae.

7. Examples - Introductions • Introduction/Objective: Illegal anabolic steroid use is a problem fostered by ease of access through internet pharmacies and the pseudo legitimacy of internet physicians. Facing unclear Air Force guidance and blurred legality, we present a case of anabolic steroid use in an airman who obtained the substance with a legally-obtained prescription given to him over the internet.

8. Examples - Introductions • Introduction/Objective: Family physicians routinely see labial adhesions in young girls and menopausal women and successfully treat them with topical estrogen. However, postpartum labial adhesions are infrequently encountered. This case and a review of the literature suggest that surgical dissection is the treatment of choice for post-partum labial adhesions.

9. Summary of Clinical Data Chronological Relevant Med Terms: Yes Jargon: No Clarity Case Outcome What’s in a Section: Case Report

10. Examples - Case Reports • Case: A 33 year old had an uncomplicated epidural during vaginal delivery. Twelve days postpartum she was awakened at 0100 by a “crushing” occipital headache that was made markedly worse with standing. The initial diagnosis was “possible subarachnoid hemorrhage”. A lumbar puncture and CT-angiogram were normal. She was treated with fluids, ketorolac, morphine and metoclopramide. A severe postural headache persisted and she was referred for an epidural blood patch (EBP). Subspecialty consultants felt the late onset of her headache made PDPH unlikely and diagnosed her with migraine. Despite sumatriptan, her severe postural headache remained. A third consultant felt PDPH was possible and an EBP was performed with immediate resolution of her headache.

11. Examples - Case Reports • Case: A newborn female infant at approximately 5 hours of life was noted to have markedly sallow trunk and extremities, mild scleral icterus and hepatosplenomegaly. Prenatal history was unremarkable. Baby had been born via repeat c-section. Baby's labs were remarkable for a total bilirubin of 14 at 5 hours of life, marked erythroblastosis and hemolytic anemia. Baby was also DAT negative. Of note, baby's 8 yo sister had G6P isomerase deficiency with hx of chronic hemolysis. Baby was started on intensive phototherapy and eventually transferred to a tertiary care facility where she underwent exchange transfusion. Baby was continued on phototherapy and was discharged 6 days later with a bilirubin of 10.3.

12. Examples - Case Reports • Case: A 27 year old multiparous Caucasian female at 37 weeks gestational age presented to Labor and Delivery with a complaint of right flank pain, nausea, and vomiting. Prenatal labs, including glucose tolerance test, were unremarkable. She was admitted to the antepartum ward for observation. On hospital day two, she developed epigastric abdominal pain radiating to the back. Laboratory evaluation showed a markedly elevated amylase and lipase. An abdominal ultrasound revealed absence of gallstones and an edematous pancreas consistent with pancreatitis. After consultation, her labor was augmented and she had an uncomplicated vaginal delivery. Post-partum, she improved both clinically and by laboratory data and was discharged home. Three weeks post-partum, she presented with a four day history of vomiting, polyuria, weight loss, and fatigue. Evaluation revealed hyperglycemia, serum ketones, and an anion gap acidosis. She was admitted for management of DKA. In follow up, she has been doing well on insulin therapy.

13. Contribution to Literature Compare/Contrast to Literature Deal with Contradictions Clarity What’s in a Section: Discussion

14. Examples - Discussion • Discussion: Alpha(1)-antitrypsin is one of several serine proteinase inhibitors that regulate physiologic pathways responsible for processes such as fibrinolysis, coagulation, and complement activation. AAT deficiency is classically associated with emphysema and cirrhosis of the liver, although recent evidence suggests that dysfunctional forms of these proteinase inhibitors can pathologically alter a number of physiologic pathways. MEDLINE search of the literature from 1966 to 2004 revealed one case of Budd-Chiari syndrome in a heterozygous AAT deficient phenotype. This contrasts with our patient who had genotypic abnormalities. These two cases suggests that the theoretical hypercoagulability of AAT deficiency may indeed be a real factor in thrombosis.

15. Examples - Discussion • Discussion: Mastocytosis is a disorder of an increased number of mast cells. The exact prevalence is unknown, however it can have devastating consequences if unrecognized. Patients may experience episodic attacks of flushing and urticaria, which may progress to anaphylaxis. It is recognized that patients with mastocytosis may have worsening of their symptoms during pregnancy. A Medline search revealed no other cases of this complication occurring during the postpartum period.

16. Examples - Discussion • Discussion: Visceral leishmaniasis, also known as kala-azar, is transmitted by the female phlebotomine sand fly. Depending on the species of leishmaniasis, patients may develop CL within the first few weeks of a bite, or VL up to months or years after infection. In CL an indolent ulcer forms at the bite site that heals slowly with no associated mortality. VL entails weight loss, hepatosplenomegaly, fever, pancytopenia, and diarrhea, and it accounted for 42,000 deaths worldwide in 2000.

17. Based on Relevant Data Implications Clarity Twist What’s in a Section: Conclusions

18. Examples - Conclusion • Objective: Petechial rash in the setting of other signs and symptoms of meningitis is almost diagnostic for meningococcal disease. This case is describes a more benign etiology of meningitis with petechiae. • Conclusion: Differentiating bacterial from aseptic meningitis can be difficult in some patients. A complete physical, including genital exam may help shed light on the correct answer.

19. Examples - Conclusion • Introduction/Objective: Illegal anabolic steroid use is a problem fostered by ease of access through internet pharmacies and the pseudo legitimacy of internet physicians. Facing unclear Air Force guidance and blurred legality, we present a case of anabolic steroid use in an airman who obtained the substance with a legally-obtained prescription given to him over the internet. • Conclusion: Anabolic steroid use is common in an age group that is frequently treated in military clinics. Ease of access and confusing AFIs can lead patients into a false sense of security and can cause injury to patients’ health and career. Greater vigilance and patient education is needed.

20. Examples - Conclusion • Introduction/Objective: Family physicians routinely see labial adhesions in young girls and menopausal women and successfully treat them with topical estrogen. However, postpartum labial adhesions are infrequently encountered. This case and a review of the literature suggest that surgical dissection is the treatment of choice for post-partum labial adhesions. • Conclusion: Topical estrogen therapy for postpartum labial adhesions cannot be recommended. Rather, surgical dissection done under local anesthesia should be attempted as first line therapy. Physicians and nurses might consider including periodic separation of the labia in their post-partum instructions, especially in women with labial lacerations.

21. Essential Elements Style & Logic Grammar and Spelling Title What’s in a Section: Structure

22. Turtle Soup: Hazards Of Reptile Rescue Varicella Zoster Virus (Vzv) Related Central Nervous System (Cns) Complication Following Herpes Zoster Chronic Vulvadynic Pain From Zoster Sine Herpete Successfully Treated With Antiviral Therapy Supplement Induced Hepatitis: A Case Of Possible Chromium Picolinate Toxicity Visceral Leishmaniasis In A Returning Soldier Reversible Posterior Leukoencephalopathy Syndrome As A Complication Of Poststreptococcal Glomerulonephritis Goodness Gracious Great Balls Of Fire! Without A Leg To Stand On: An Unusual Presentation Of A Hypertensive Emergency Examples - Titles

23. Re-Tread & RealTime Scoring USAFP Judges

24. Truth is that which was often thought, But na’er so well expressed… --Alexander Pope The End Truth is Beauty, Beauty Truth. That is all you need to know on earth, And all you need to know. --John Keats