Previously Presented/Published - Staff IMPROVING WOMEN’S EXPERIENCE DURING SPECULUM EXAMINATIONS PERFOMED AS PART OF ROUTINE GYNECOLOGIC VISITS. Dean A. Seehusen, MD, MPH Dwight D. Eisenhower Army Medical Center, Department of Family Medicine, Fort Gordon, GA 30509 Objective: Over 50 million Papanicolaou (Pap) smears are done in the United States each year. This study was designed to determine if a standardized method of leg positioning that does not utilize stirrups reduces the physical discomfort and sense of vulnerability, and increases the sense of control, among women undergoing speculum examination as part of a routine gynecologic examination. Design: Randomized clinical trial. Setting: Family Medicine outpatient clinic. Study Populations: A convenience sample of 197 adult women at an outpatient Family Medicine clinic presenting for routine gynecologic examination and Pap smear. Interventions: Women receiving the no-stirrup examination rested their feet on the end of the table extension instead of metal stirrups during the speculum examination. Main Outcome Measures: One hundred millimeter visual analog scales were used after the examination to measure women’s perceived levels of physical discomfort, sense of vulnerability and sense of control during the examination. Statistical Tests Used: Student’s t-test for continuous outcomes and chi- square analysis for categorical outcomes. Results: Women undergoing no-stirrup examinations had a reduction in mean sense of vulnerability from 23.6 to 13.1 (95% CI of the difference = -16.6 to -4.4, p<0.001). Mean physical discomfort was reduced from 30.4 to 17.2 (95% CI of the difference = -19.7 to -6.8, p<0.001). No reduction in sense of control was found. There were no significant differences in the quality of Pap smears between the two groups. Two Pap smears from the no-stirrups group, and none from the stirrups group, were inadequate for evaluation (p = 0.16). Sixteen (16.8%) of the no-stirrups Pap smears did not contain endocervical cells compared to 15 (15.8%) of the stirrups Pap smears (p = 0.84). Conclusions: Women undergoing gynecologic examinations should be offered this no-stirrup technique as a way of reducing the stress associated with speculum examinations. Clinical Investigation - Staff PEDIATRIC OBESITY IN A MILITARY FAMILY MEDICINE CLINIC: Sandra L. Kimmer, MD, MPH. Naval Hospital Camp Pendleton, Camp Pendleton, CA 92055. Objective: To determine the prevalence of pediatric obesity, investigate demographic factors, and discover the rate of formal diagnosis. Design: Retrospective chart review. Setting: Madigan Army Medical Center, Tacoma, WA. Study Population: 1376 children age 6-11 years enrolled in the Family Medicine Clinic in 2004. Interventions: Extracted data including age, gender, sponsor’s rank and active duty status, type of provider seen, number of clinic visits, and diagnosis of obesity. Main Outcome Measures: Body mass index percentile (BMI%). Statistical Tests Used: Descriptive statistics for categorical variables. One- sample binomial test for comparison to a known prevalence. Chi-square and logistic regression for group comparisons. Results: 668 children had an accurate height and weight recorded, thus meeting criteria for inclusion in the analysis. 97 (14.5%) children were obese and an additional 92 (13.8%) were overweight. The prevalence of obesity in this cohort was not significantly different from the rate (15.3%) reported in the 1999-2000 National Health and Nutrition Examination Survey (p=0.307). Logistic regression revealed that both increasing age (p<0.001) and female gender (p=0.047) were independently associated with obesity. Of the 189 children whose BMI% met clinical criteria for overweight or obesity, 13 (6.9%) had been formally diagnosed. Conclusions: The prevalence of obesity among 6-11 year old children in this military population is comparable to the rate in the United States. Increasing age and female gender put children at greater risk for obesity. This study shows that only half of the children seen had an accurate height and weight recorded and 6.9% of those children meeting clinical criteria were formally diagnosed. Increased height and weight measurement and calculation of the BMI% at the point of care are needed to identify children with obesity allowing for early intervention and treatment. Clinical Investigation - Staff PREVALENCE OF HYPERTENSION IN A POPULATION OF ACTIVE DUTY SERVICE MEMBERS. Brian A. Smoley, MD, MPH, FAAFP, Naval Hospital Bremerton, Bremerton, WA 98312; Nicholas L. Smith, PhD, MPH, University of Washington, Seattle, WA 98195; Guy P. Runkle, MD, MA, FAAFP, Auburn, WA 98002; John A. Edwards, MD, MPH, Madigan Army Medical Center, Tacoma, WA 98431. Objective: To estimate the prevalence of hypertension and distribution of blood pressures in a population of active duty U.S. Servicemembers using recorded blood pressure readings. Design: Cross-sectional survey. Setting: I Corps Readiness and Outcomes Wellness Service, Fort Lewis, Tacoma, WA. Study Populations: All active duty Servicemembers, 17-65 years of age who completed mandatory annual and pre-deployment health risk assessments between January 1 and December 31, 2004. Interventions: Health Risk Appraisal survey (DA Form 5675, 1 Feb 92), including the recording of a single unaveraged blood pressure reading. Main Outcome Measures: 1) Prevalence of hypertension (measured blood pressure ≥ 140/90 mmHg or reported use of medicine for high blood pressure). 2) Prevalence of prehypertension (measured blood pressure of 120/80 to 139/89 mmHg). Statistical Tests Used: Descriptive statistics for categorical variables. Chi- square and Chi-square for trend tests for comparison of proportions. Multivariate logistic regression for independent associations between subject characteristics and hypertension and prehypertension. Results: 15,391 (98%) out of 15,735 subjects met all inclusion criteria. 1964 (13%) met the study criteria for hypertension of which 285 (out of 1964 or 15%) reported taking medicine for high blood pressure. 9560 (63%) out of 15,106 subjects not taking medicine for high blood pressure met the study criteria for prehypertension. Adjusting for a “white coat effect” reduced the prevalence of hypertension and prehypertension to 6% and 49%, respectively. Conclusions: Hypertension and prehypertension are more prevalent in the U.S. Armed Forces than has been previously reported, and prehypertension may in fact be quite common. These preliminary findings justify further research into the nature of hypertensive disease among U.S. Servicemembers. Clinical Investigation - Staff RACIAL DIFFERENCES IN HEALTH OUTCOMES FOR ADULTS WITH DIABETES IN A MILITARY SETTING Telita Crosland, MD, MPH, Madigan Army Medical Center Department of Family Medicine, Fort Lewis, WA 98431 Objectives: To test the hypothesis that nonwhite adult diabetics are more likely to have poorer outcome measures than white diabetic patients despite universal access. Design: Observational (cross-sectional). Setting: Tertiary care military hospital. Study Populations: All adult patients over 18 years old who have been in the diabetic database continually for at least one year. Interventions: None. Main Outcome Measures: Low density lipoproteins (LDL), glycated hemoglobin A1C (HbA1C), systolic blood pressure (SBP), diastolic blood pressure (DSBP), and presence of screening test. Statistical Tests Used: Descriptive statistics, bivariate analysis, ANOVA, Chi-square test, and multivariate regression. Results: There were 3789 patients who met the inclusion criteria; 48% Caucasians, 8 % African-American, 5.6% Asian, 5.1 % others and 11.1% unknown. Mean SBP was 137.3 mmHg, DSBP was 71.4 mmHg, HbA1C was 7.06 % and LDL was 92.6 mg/dl. After controlling for gender, age and rank, race was associated with a significant difference in SBP, DSBP, LDL and A1C. There was no significant difference in receiving urine test for protein. Conclusions: Minorities are more likely to have a higher blood pressure, LDL and HbA1C in a health care system that provides universal health coverage. This study suggests that access alone does not completely account for health care disparities. Case Report - Staff A PERTUSSIS OUTBREAK IN NORTH CAROLINA: THE FAMILY MEDICINE/ PUBLIC HEALTH TEAM. David C. Krulak, LCDR, MC, USN, MARFORSOCOM, Camp Lejeune, NC 28542 Introduction: Pertussis has decreased significantly since routine immunization began in the 1940’s. Pertussis is, however, re-emerging. Presented is a case of the community response to a pertussis outbreak aboard Camp Lejeune, NC. Case: In May, 2006 there was an outbreak of pertussis in Camp Lejeune, NC. The index case was identified clinically by a local physician and proven to be culture positive by the state laboratory. A second case was confirmed a week later. For epidemiologic purposes, the case definition was established as either a positive Bordetella pertussis culture or symptomatic contact of a culture positive patient. Close contacts were defined as individuals spending time in confined spaces with confirmed cases. A pertussis response team led by family physicians, pediatricians and public health officers deployed to local schools to evaluate patients and provide information. Nearly 900 patients were evaluated for symptoms with 88% treated or given chemoprophylaxis based on their clinical presentation. Many were placed in social isolation to contain the outbreak. This rapid response prevented any new cases of pertussis. The Marine force was operationally unaffected by the outbreak. Discussion: A recent literature review confirms that the number of pertussis cases has increased dramatically in the past decade. While the clinical presentation is often reviewed, the central public health role family physicians play is typically not addressed. Basic epidemiologic principles such as case identification criteria, contact reporting, and strategic containment were effectively applied by family physicians in our case to avoid a potentially troublesome spread of disease. Conclusion: This event demonstrates the successful containment of a pertussis outbreak due to partnership between public health officials and family physicians. We used basic principles of epidemiology to respond quickly and prevent further disease spread. The techniques used and lessons learned from this outbreak may apply equally to other infectious disease threats. Case Report - Staff NOT YOUR USUAL ACHING BACK Sara Saltzstein, LCDR, MC, USN; Naval Hospital Camp Pendleton, Camp Pendleton, California, 92055 Introduction/Objective: Low back pain is a common presenting complaint in primary care, with over 90% of cases being of a benign etiology. However, more serious causes occur, and need to be promptly identified in order to initiate appropriate treatment and optimize patient outcome. Case: Three months following a medevac from Iraq for sepsis, a 20 year old Marine presented with persistent low back pain. The pain began on Day #2 of his illness. Daily fevers over 102’F had recently resolved. Since his return, he had seen numerous primary and specialty care providers, and was consistently diagnosed with lumbago. His exam revealed lumbar vertebral tenderness and guarding against flexion. Lumbar radiographs taken six weeks prior demonstrated non-specific vertebral end plate abnormalities, which had been attributed to developmental variation. CT revealed lytic lesions of L1 and L2. An MRI established extensive osteomyelitis of these vertebrae, bilateral paravertebral abscesses, and signs of autofusion. He was admitted, and a CT guided aspiration grew pan-sensitive Salmonella. He was treated with four months of oral ciprofloxacin, a back brace, and close follow- up. Discussion: A comprehensive review published by Santos ascertained that between 1948 and 1998, there were 46 cases of Salmonella vertebral osteomyelitis reported in the English language literature, with three more since. However, the estimated annual frequency of all types of spinal infection is 1.1 per 10,000. This patient’s infection was likely caused by hematogenous spread after Salmonella bacteremia. His morbidity is expected to be high due to the delay between symptom onset and antibiotic treatment. Conclusion: While this specific bacterial cause is rare, infections of the spine are not uncommonly seen in our active duty population. Severe or persistent back pain with signs of potential infection should be imaged and worked up appropriately. Case Report - Staff ACUTE PSYCHOSIS WITH BUPROPION IN A HEALTHY 28 Y/O FEMALE Justin Bailey MD, AMC, Travis AFB, California, 94535 Introduction: Bupropion is a common treatment for smoking cessation. Presented is a case of acute psychosis following treatment with bupropion. It represents the first case of bupropion induced psychosis at a low dose in an otherwise healthy patient. Case: A 28 y/o female presented with a chief complaint of tobacco abuse with desire to quit. The patient was started on bupropion (Wellbutrin SR) 100mg daily. Seven days into treatment the patient developed paranoia, unable to leave her home fearing someone was going to hurt her and her children. Panic attacks, auditory hallucinations and suicidal ideation accompanied the paranoia. The bupropion was discontinued and all of her symptoms resolved over the course of one week. At a two month follow-up she displayed no residual symptoms. Discussion: The side effects from bupropion are many however cases of psychosis are rare. Of the few existing cases, most had a history of psychosis and were institutionalized for severe depression or bipolar disorder. All were on high dose (>450 mg/day) bupropion. One report showed psychosis develop in a patient treated for multi substance abuse at 300mg/day of bupropion. The psychosis induced may be due to the dopiminergic effects of bupropion or chemical relation of bupropion to amphetamine. The onset and complete resolution of the psychosis and paranoia associated with the start and stop of bupropion suggest it as the cause. Conclusion: Family physicians are well versed in the use bupropion for smoking cessation and depression. This represents the first cases of psychosis and paranoia in a previously healthy patient with low dose bupropion. It emphasizes the importance of recognition and rapid treatment of uncommon side effects in common medications. Case Report - Resident LEMIERRE’S SYNDROME IN A 17 YEAR OLD FEMALE Joseph K. Erbe, DO; Air Mobility Command Travis Department of Family Medicine Travis AFB CA 94535 Introduction: Lemierre’s syndrome occurs when an oropharyngeal infection causes secondary septic thrombophlebitis of the internal jugular vein. It frequently results in metastatic complications. The last decade has seen resurgence in cases of this syndrome. This case highlights the importance of a rare, but potentially serious complication of pharyngitis. Case: A previously healthy 17 year old female presented to clinic on two separate occasions with complaint of fever, sore throat and dysphagia. Tests for streptococcal pyogenes and Ebstein Bar Virus were negative and she was sent home without antibiotics. Two days later she presented to the emergency room with fevers, rigors and respiratory distress. A chest x-ray showed bilateral pulmonary infiltrates at the bases with pleural effusion. A computerized tomography scan of the chest showed bilateral pleural effusions with cavitary lesions. Antibiotic therapy was started. Blood cultures were later positive for fusobacterium necrophorum in 2/2 bottles. The association with internal jugular vein as a source of septic emboli was investigated. An ultrasound of the neck showed thrombosis at inferior aspect of the right internal jugular vein. Antibiotic therapy was tailored to sensitivity and the patient progressed to recovery. Discussion: Fusobacterium necrophorum is a gram negative obligate anaerobe ubiquitous to the oral flora. Lemierre’s Syndrome occurs when bacterial overgrowth with local invasion of the lateral pharyngeal space causes internal jugular septic thrombophlebitis. It generally occurs in previously healthy young adults. Metastatic complications frequently involve the lungs. This patient displayed a classic presentation of this process. She responded well to antibiotics. Conclusion: Lemierre’s Syndrome is a potentially devastating complication of pharyngitis. It can be recognized by the triad of phayngitis, swollen neck and pulmonary infiltrates . High clinical suspicion and knowledge of the disease process are essential for prompt diagnosis, recognition of metastatic complications and aggressive antimicrobial therapy. Case Report - Resident STROKE AS THE INITIAL PRESENTATION OF A LEFT ATRIAL MYXOMA Ryan D Arnold, MD, LT, MC, USN, Department of Family Medicine, Naval Hospital, Camp Lejeune, NC 28547. Leah Soley, MD, LT, MC, FS, USN, Department of Family Medicine, Naval Hospital, Camp Lejeune, NC 28547. Introduction: Myxomas are the most common primary cardiac tumors. They are usually benign and have variable clinical features. We report a left atrial myxoma presenting as an acute cerebral ischemic event. Case: A 58-year-old female with a history significant for atherosclerotic peripheral vascular disease (manifested as a prior transient ischemic attack), hypertension and hyperlipidemia presented four hours after the onset of an expressive aphasia and dense right hemiparesis. Other exam findings included normal vital signs and an accentuated second heart sound. She was anemic and in acute renal failure. A non-contrast computed tomogram of the head showed an old ischemic lesion and no acute hemorrhage. Thrombolysis was withheld because of her delayed presentation. Due to the constellation of her clinical findings and suspicion for vasculitis, an erythrocyte sedimentation rate was obtained and was markedly elevated (>140 mm/h). High dose steroids were initiated. As part of her ongoing stroke workup, an echocardiogram showed a mobile mass occupying 75% of the left atrium. Previous echocardiography 4 years prior was normal. The patient was transferred for surgical excision of the mass. Discussion: Cardiac myxomas are histologically benign tumors. Presenting symptoms depend on the size, mobility, and location of the tumor, and result in cardiac obstruction, embolism or constitutional symptoms. Half of patients with left atrial myxomas present with symptoms of mitral valve obstruction: dizziness, palpitations, dyspnea, cough, and pulmonary edema. Fewer than one-third of patients present with embolic phenomenon. The primary site of embolization is the central nervous system, resulting in a clinical picture similar to atherogenic cerebrovascular accidents. Systemic symptoms (malaise, fatigue) are the presenting symptom in a minority of cases. Conclusion: The presentation of atrial myxomas can mimic non-cardiac disease. Diagnosis is based on echocardiography. The treatment of choice is surgical excision. Case Report - Resident AVASCULAR NECROSIS IN AN ADOLESCENT FEMALE WITH A HISTORY OF AN EATING DISORDER Erik Richardson, DO, Capt, MC, USAF, Eglin Air Force Base, FL, 32542 Introduction/Objective: Presented is a case of an adolescent female with an established eating disorder, diagnosed with advanced avascular necrosis of the hip after several years of symptoms. Eating disorders in adolescent female athletes place them at higher risk for stress fractures1. Untreated stress fractures can lead to avascular necrosis2. This case reinforces the importance of fully evaluating recurrent orthopedic symptoms. Case: A 17-year-old Caucasian female was referred to orthopedic surgery for evaluation of left-sided hip pain. Plain radiographs and MRI revealed prominent necrosis of the left femoral head. The patient described chronic hip pain since age 14. There was no history of trauma, steroid use or hip dysplasia. Family history was non-contributory. Her medical history was notable for severe calorie restriction, irregular menses and regular vigorous exercise since age 13. A full evaluation failed to reveal any rheumatologic or hematological etiologies. Hip replacement has been recommended by orthopedic surgery due to the severity of disease. Discussion: The Female Athletic Triad includes amenorrhea, disordered eating and osteoporosis. Intense exercise and disordered eating can lead to the dysregulation of the hypothalamic-pituitary-ovarian axis causing menstrual irregularities, decreased bone mass and increased risk of fractures. In this case, it may have led to stress fractures of the femoral neck resulting in avascular necrosis of the femoral head. The long duration of symptoms without clinical intervention likely contributed to the advanced presentation of disease. A search of MEDLINE found no other cases linking eating disorders with avascular necrosis of the hip. Conclusion: Presented is a case of avascular necrosis, a previously unreported complication of an eating disorder, which may have been preventable with earlier diagnosis and intervention. Case Report - Resident NON-TRAUMATIC PARAPLEGIA IN A FIRST-TIME SURFER Moses H. Cheng DO, Tripler Army Medical Center, TAMC, HI 96859, Elizabeth A. Durbin DO, Tripler Army Medical Center, TAMC, HI 96859, Melissa A. Meyer MD, Tripler Army Medical Center, TAMC, HI 96859 and John E. Glorioso MD, Weed Army Community Hospital, Fort Irwin, CA 92310 Introduction: Most surfing injuries are traumatic. We present a case of paraplegia resulting from non-traumatic surfer’s myelopathy, a condition that may be more prevalent than the medical literature demonstrates, meant to aid the Family Physician and other providers in better recognizing this condition. Case: A 37 year-old healthy male presented to the emergency department with acute low back pain, sensory complaints and bilateral leg weakness several hours after surfing for his first time. He reported extended time on his surfboard in the prone position with neck hyperextension but denied trauma. Lumbosacral radiographs and computed tomography were unremarkable. Fifteen hours from onset, neurologic symptoms progressed to urinary retention and near complete lower extremity paralysis. L-spine MRI was consistent with an ischemic cord infarct. Despite lumbar drain placement and high-dose steroids, complete lower extremity T11 paraplegia developed. Discussion: Surfer’s myelopathy is a recently named syndrome of non- traumatic spinal cord injury affecting inexperienced surfers and described in nine patients over five years in one coastal community. All were new adult surfers without preexisting spinal pathology. Presentations included back pain, sensory deficits, urinary retention and paraparesis. MRI demonstrated infarct anywhere from lower thoracic levels to conus. This patient is different because his symptoms began several hours after surfing while others had pain that began with surfing. The common denominator was the hyperextended spinal positioning. It is postulated that a prolonged prone hyperextended posture may contribute to ischemic cord injury in watershed areas of perfusion. Treatments have included steroids and supportive care. Although several patients recovered, outcomes have included residual weakness, urinary retention and complete paraplegia. Conclusion: Surfer’s myelopathy is a potentially devastating syndrome affecting novice surfers. As the popularity of surfing continues to increase, this case illustrates the need for increased awareness of this condition and further study to decrease neurologic sequelae. Case Report - Resident THE CASE OF ORANGE SWEAT-- CHROMHIDROSIS Kristen Wyrick, MD, David Grant Medical Center, Travis AFB, CA 94534 Timothy Cragun, DO, Malcolm Grow Medical Center, Andrews AFB MD, 20762 Brian Russ, MD, Malcolm Grow Medical Center, Andrews AFB MD, 20762 Introduction: Chromhidrosis is a rare gland disorder that produces pigmented sweat. We describe a previously asymptomatic patient who presented with bronzing of the skin and orange stained nails and clothing. The etiology of this disorder is often unknown and the clinical presentation can be varied. Case: A 44 year-old female was seen for a chief complaint of “orange skin and nails.” She reported noticing over the past year that any light colored clothing she wore would become stained orange across her chest. Her family and friends repeatedly asked her about tanning due to her bronzed appearance. Eighteen months prior to the onset of these skin pigment symptoms, she had undergone a prophylactic hysterectomy with bilateral oophorectomy due to Breast Cancer Gene-1. Her past medical history was otherwise unremarkable. A daily multivitamin was the only medication that she took at the onset of her symptoms and her diet did not contain excessive amounts of pigmented fruits or vegetables. Lab work performed included Homogentisic acid analysis of the urine, a complete blood count, electrolyte panel, adrenocorticotropic hormone and cortisol levels; all normal. Discussion: Apocrine excretion of oxidized lipofuscins or eccrine secretion of ingested chemicals are hypothesized mechanisms for the production of pigmented sweat in localized areas of the body including the axillae, face, and areola. The incidence of chromhidrosis in other locations of the body is unknown due to limited case reports. Our patient is unique in that she is the first reported patient with orange-colored sweat in chromhidrosis and the first to initially present in the post-menopausal state. Conclusion: Chromhidrosis is a rare disorder characterized by the production of colored sweat and can be a significant disturbance to the patient. In this report we present a post-menopausal patient with chromhidrosis producing orange secretions and bronzing of the skin. Case Report - Resident PORTAL VEIN THROMBOSIS: AN UNEXPECTED FINDING IN A 28 YEAR OLD MALE WITH ABDOMINAL PAIN Jason L. Ferguson, DO, CPT, MC, USA and Duane R. Hennion, MD, MAJ, MC, USA, Tripler Army Medical Center, HI 96859 Introduction/Objective: Abdominal pain is a common primary care complaint. Portal vein thrombosis (PVT) is a rare cause of abdominal pain, typically associated with cirrhosis or thrombophilia. The following describes the clinical presentation of PVT in a young male, the subsequent search for risk factors and underlying etiology, and the debate over anticoagulation therapy. Case: A 28-year-old male presented with periumbilical pain, post-prandial nausea and sporadic hematemesis for three weeks. The work up included a RUQ ultrasound demonstrating an enlarged spleen and decreased diameter of the portal vein, suggestive of portal vein thrombosis. The diagnosis was confirmed with a triphasic liver CT. This unexpected finding prompted investigation for intrinsic hepatic disease and potential hypercoagulable disorders. Laboratory analysis revealed the patient to be heterozygous for the prothrombin 20210G/A mutation, which has been identified as a significant risk factor for thrombosis. Discussion: Recommendations concerning anticoagulation for PVT in the absence of cirrhosis are not clearly defined. Review of current literature describes the following factors as indications for anticoagulation: acute thrombus, lack of cavernous transformation, absence of esophageal varices, mesenteric venous thrombosis, and specific thrombophilias. This patient had clinical indications both for (mesenteric venous thrombosis and hypercoagulable state) and against (chronic thrombus, cavernous transformation, active esophageal varices) anticoagulation. Weighing this individual’s clinical circumstances, we concluded the risk of thrombus in the setting of a hypercoagulable disorder outweighed the risk of variceal bleeding, and six months of anticoagulation was initiated. Conclusion: PVT is an uncommon cause of abdominal pain, and the absence of hepatic disease should raise the index of suspicion for an underlying thrombophilia. Specific recommendations for anticoagulation are not well defined in the medical literature, demonstrating the importance of weighing the individual risks and benefits in treatment with anticoagulation for young persons with thrombophilia. Case Report - Resident FATAL HYPERKALEMIA IN A YOUNG MAN WITH SUCCINYLCHOLINE- RELATED MALIGNANT HYPERTHERMIA AND AN OVERDOSE OF INSULIN: A CASE REPORT Francesca Cimino, Naval Hospital Jacksonville, Jacksonville, FL 32214 and Michael Arnold, Naval Hospital Jacksonville, Jacksonville, FL 32214 Introduction: Anabolic steroids have made headlines as the drug of choice for many elite athletes. Steroids are often combined with other substances to further enhance performance. Presented is a case report of a popular combination of insulin and steroid abuse that led to a lethal side effect of anesthesia. Case: A twenty-one year-old active duty seaman was brought to the emergency department via ambulance. Upon arrival, he was stuporous. Evaluation revealed a hypoglycemia resistant to several ampules of high concentration dextrose solution. He required emergent intubation, using the paralytic succinylcholine. Within two hours of intubation, he demonstrated hyperthermia generalized tetany that persisted despite treatment with dantrolene. His potassium peaked at 7.8 mg/dl, which contributed to a fatal arrhythmia. Discussion: Many active duty members use supplements for muscle enhancement. This seaman used dehydropiandrosterone and other testosterone analogs, causing chronic hepatitis and symptoms of testosterone overload. He used exogenous insulin as an anabolic accessory to his steroid use. The literature illustrates few cases of self-induced hypoglycemia by illicit insulin use and no deaths. Malignant hyperthermia is a well-described hypermetabolic condition triggered by several anesthetic agents in genetically predisposed patients. A similar condition has been described in the resuscitation of patients in diabetic crises, and may be due to the large doses of insulin provided. The combination of illicit insulin and succinylcholine administration may have caused this patient’s malignant hyperthermia. Conclusion: The combination of insulin abuse and succinylcholine appears to have triggered malignant hyperthermia unresponsive to dantrolene in this susceptible patient. A combination of metabolic derangements led to a fatal arrhythmia. This tragic outcome highlights the importance of identifying anabolic supplement use and the need for primary care providers to address this abuse of dangerous medications. Case Report - Resident A FATAL CASE OF COMMUNITY ACQUIRED METHICILLIN-RESISTANT Staphylococcus aureus (CA-MRSA) Samya Varuschka Cruz, MD, LT, MC, USN(SWO), Naval Hospital Pensacola, FL 32512 Introduction: Increasing reports of community-acquired methicillin-resistant Staphylococcus aureus are occurring in non-nosocomial settings creating a significant public health concern. Presented is a case of a 20-year-old active duty Marine who died from CA-MRSA sepsis. It forced us to shift our paradigm in practice management of skin and soft tissue infections (SSTI), especially pertaining to our military population. Case: A 20-year-old Marine initially presented to the emergency department with a scalp abscess that was incised and drained. The patient was discharged with instructions to follow-up. Analgesics and dapsone were prescribed for a diagnosis of “spider bite”. Later, he was found in the barracks diaphoretic and dyspneic. He was transported back to the emergency department in profound respiratory distress. The initial chest radiograph showed diffuse, patchy infiltrates. His condition rapidly declined despite aggressive fluid resuscitation, antibiotics, and supplemental oxygen. He developed multi-lobar pneumonia, leukopenia, thrombocytopenia and acute renal failure. He was transferred to a tertiary care center and died 48 hours later. All of the blood cultures were positive for MRSA. Discussion: In the United States, the prevalence of CA-MRSA is 2-3%1, while 58% of our Staphylococcal isolates account for CA-MRSA2. Our facility’s response was to educate command staff and students as to the dangers of CA-MRSA and how to prevent it. Distribution and awareness of the current recommended practice management guidelines were reinforced and more follow-up of patients diagnosed with SSTI’s was incorporated. Conclusion: Though most cases of CA-MRSA are mild, soft tissue infections may respond readily to early management. The prevalence of CA-MRSA is increasing, particularly in military populations. Early recognition may avert horrendous morbidity and, as in this case, death due to overwhelming sepsis. Case Report - Resident PFAPA SYNDROME: PERIODIC FEVER, APHTHOUS ULCERS, PHARYNGITIS, AND ADENOPATHY, A RECENTLY DEFINED ENTITY WORTH CONSIDERING AMONG THE ETIOLOGIES OF PEDIATRIC FEVERS. Cormac J. O'Connor, MD, LT, MC, USN, Naval Hospital Camp Pendleton, CA 92055 Introduction: Pediatric fevers are a common complaint. Presented is a case of periodic fevers with fluctuating physical presentations, highlighting a recently identified syndrome, PFAPA.1 Case: A 3 year old presented to a civilian hospital with rapid onset of high fevers and unilateral neck swelling, without respiratory symptoms. His evaluation was negative and symptoms resolved within days. Similar symptoms returned in 4 weeks, accompanied by tender cervical adenopathy. Seen in a pediatric clinic at that time, ethnic origin, family and travel history, laboratory and clinical evaluation, were unremarkable. Similar episodes occurred at 4 week intervals over 18 months before spontaneously resolving. The child is now well, without fevers for 2 years. Discussion: Pediatric fever is a well researched and often evaluated complaint, but periodic fevers are less common. After performing Google.com and OVID searches for periodic pediatric fevers, similarities were noted to a recently characterized clinical syndrome, PFAPA syndrome, or Periodic Fever, Aphthous ulcers, Pharyngitis, and Adenopathy. First described in 1987, this syndrome, often seen in children under 5 years old, is characterized by an average of 3 days of fever and associated symptoms every 3-4 weeks with healthy intervals.2,3 The etiology of PFAPA, whether infectious or immunologic, is unknown.4 Though treatment with prednisone, cimetidine and tonsillectomy has been proposed, this clinical diagnosis is treated symptomatically, with clinical resolution of most cases by age 8.5,6,7,8 Conclusion: Periodic fevers are described in the literature and represent a subset of the pediatric fevers presenting to primary care clinics. Reported is an example of a newly described clinical syndrome. Case Report - Resident MEASLES INVOLVING HEPATITIS IN A TRAVELER TO CHINA: A CASE REPORT AND REVIEW OF THE LITERATURE Heather M. Schlesinger, DO, CPT, MC, USA and Douglas M. Maurer, DO, FAAFP, MAJ, MC, USA, Madigan Army Medical Center, Ft Lewis, WA 98431 Objective: Classic measles presents with fever, coryza, conjunctivitis, and cough followed by a maculopapular rash. This case presents a patient with measles involving hepatitis. Although rare in the United States, measles remains a significant health threat worldwide. Case: A 38-year-old female presented to the ER with fever, rash, headache, facial edema, URI symptoms, nausea and diarrhea after returning from a trip to China. The patient was on day two of amoxicillin for sinusitis when she developed a maculopapular rash on her chest and face, presented to the ER, and was advised to stop the amoxicillin. She represented 48 hours later with continued fevers and progression of her rash to her trunk and arms. Laboratory studies demonstrated an AST of 528, ALT of 490, and a GGT of 295. A head CT was remarkable for sinusitis. The patient was admitted for further work-up to include hepatitis panel, monospot, EBV/CMV titers, and stool studies. The patient improved with conservative management. Subsequently, two other travel companions developed fever and a rash. IGM titers for all three tested positive for measles. Discussion: The measles vaccine was introduced in 1963, decreasing measles incidences by 99% in the United States. There were an average of 80 measles cases reported annually in the United States from 1999-2003. Worldwide, more than 30 million cases occur annually resulting in 454,000 deaths. Systemic manifestations of measles can include encephalitis, myocarditis, mesenteric lymphadenitis, appendicitis, diarrhea, and hepatitis which occur in up to 80% of adults. Conclusion: Nearly all measles cases seen in the United States today are the result of importation with subsequent domestic spread. Family physicians must be alert to the possibility of measles in international travelers and consider it in the differential of viral hepatitis. Previously Published/Presented Poster - Resident GASTROINTESTINAL ENDOSCOPY BY A FAMILY PHYSICIAN: A CASE SERIES DEMONSTRATING HEALTHCARE SAVINGS Lloyd Runser, MD, MPH, CPT, MC, USA; Matthew W. Short, MD, MAJ, MC, USA; Kevin M. Kelly, MD, CPT, MC, USA, Madigan Army Medical Center, Department of Family Medicine, Tacoma, WA, 98431 Objective: To determine if a military family physician (FP) credentialed in endoscopy during residency saved healthcare dollars at an Army community hospital (ACH) by decreasing civilian endoscopy referrals. Design: Case series, economic analysis Setting: ACH Study Population: All patients receiving a colonoscopy (CSP) or esophagogastroduodenoscopy (EGD) by a FP from September 2003 to May 2005. Intervention: Procedure reports from 182 CSPs and 95 EGDs were reviewed. The total facility cost was determined using the labor cost of procedure personnel, opportunity cost of FP lost clinic hours, equipment depreciation, supplies, medications, and continuing medical education. Medical records were reviewed for eight months after the procedure to determine the cost of complications, missed diagnoses, and need for additional studies or referral. The potential referral cost was determined using local civilian billing codes and TRICARE reimbursement rates for 2004. Main Outcome Measures: 1) Total facility cost, 2) Potential referral cost, 3) Total healthcare savings Statistical Tests Used: Descriptive statistics Results: The total facility cost was $75,288 ($289.19 per CSP, $238.48 per EGD). The total referral cost would have been $211,813 ($858.23 per CSP, $585.42 per EGD). Utilizing a family physician saved the hospital $136,525 ($569.04 per CSP, $346.94 per EGD). Conclusion: An endoscopy-trained FP saved significant healthcare dollars at an ACH. Poster - Resident PYOMYOSITIS IN AN ACTIVE DUTY SOLDIER Darrell Edward Jones D.O. CPT, USA Womack Army Medical Center, Fort Bragg, NC 28310-5000 Objective: Musculoskeletal complaints are one of the most common reasons for patients to visit a family physician. While usually benign, these complaints can represent significant pathology, as seen in this patient with pyomyositis. Case: A 29 yo active duty soldier presented with unilateral calf pain of two weeks duration, with the pain worsening when he moved his leg. He denied any direct trauma to the area. Past medical history was benign; no HIV, DM, IV drug use, or recent illness was identified. He denied chest pain, shortness of breath, fevers, chills, or skin changes. Physical exam was significant for a fever to 102° F, a positive Thomas test, and tenderness with motion. No erythema or rubor of his calf was noted; D dimer was 3.4, and WBC was 18.2. Ultrasound showed a five by seven centimeter fluid mass in his left calf. Orthopedics evacuated 100 cc of purulent fluid from this area, and the patient subsequently left the hospital on oral antibiotics recovering without complication. Discussion: Pyomyositis presents with muscle soreness, fevers, chills, and cramping; treatment options vary based on the severity of the disease. Treatment options for some patients with mild disease include oral or IV antibiotics; however, if detected later in the disease process, surgery is usually required. Certain populations are at increased risk, including diabetics, trauma victims, IV drug users, and HIV patients. Diagnosing the disease in a young healthy soldier with zero risk factors presents a significant challenge to the primary care physician. Conclusion: Musculoskeletal complaints are prevalent in primary care settings. Reported is a case of a common presentation of muscle soreness that involved significant pathology, teaching us that prompt recognition affects treatment options and influences morbidity and mortality. Poster - Resident PNEUMOCEPHALUS: CAN BLOWING YOUR NOSE MAKE YOU AN AIRHEAD? Molly J. Nelsen, D.O., CAPT, USAF, MC, Scott Air Force Base, Illinois 62220. Ellen McDermott, M.D., Saint Louis University Family Medicine Residency, Belleville, IL, 62220. Paul E. Lewis, M.D., MAJ, USAF, MC, Scott Air Force Base, IL, 62220. Introduction/Objective: Sinusitis and otitis media are common illness that can have unusual and serious complications. In this case, pneumocephalus resulted from aggressive nose-blowing in the presence of both sinusitis and otitis media. Case: A 56 year-old female presented to the family practice clinic for evaluation of cold symptoms for 2 weeks. She was diagnosed with otitis media and given amoxicillin. The following morning, she was taken to an emergency room for markedly decreased mental status. Computed tomography (CT) of this patient’s head revealed anterior and temporal lobe intracranial air collections. Repeated CT scans of the patient’s brain and sinuses confirmed the pneumocephalus, as well as otitis media and pansinusitis. The inpatient family medicine team consulted an otolaryngologist, who proposed that her pneumocephalus was caused by vigorous nose-blowing leading to dehiscence of the thin bones separating the sinuses from the brain. She received aggressive antibiotic therapy with subsequent improvement of her disposition. No surgery was required, but the patient was told to refrain from blowing her nose for 2 weeks. Discussion: Although sinusitis and otitis media are two of the most common conditions seen by family physicians, the finding of pneumocephalus is rare and can be serious. Pneumocephalus usually is seen in scuba divers, and the literature has focused on these patients. Symptoms of pneumocephalus include headache, sinus pain, and altered mental status. Prophylactic antibiotics for meningitis are recommended for treatment along with close observation. If these interventions do not help, sinus surgery can be performed. In the aforementioned case, nose-blowing was the suspected culprit, so avoidance of the aggravating factor was advised. Conclusion: Sinusitis and otitis media are frequent presentations to the family medicine clinic. One cannot forget that serious complications of such common illnesses do occur and may be caused by something as simple as blowing one’s nose. Poster - Resident LIFE-THREATENING RHABDOMYOLYSIS IN A POST-PARTUM PATIENT Kelly Gray Koren, LT, MC, USN, Naval Hospital Bremerton, WA 98312 Introduction/Objective: Musculoskeletal pain is a common post-partum complaint. Presented is a case of life-threatening idiopathic rhabdomyolysis occurring five days post-partum that emphasizes the importance of a comprehensive differential diagnosis and workup. Case: A 23-year-old, gravida-1 para-1, presented to the Emergency Department five days post-partum from an uncomplicated pregnancy and vaginal delivery with diffuse muscle aches and fatigue, worsening over the past three days. She denied any recent trauma, strenuous physical exertion, or medication/drug use. Initial laboratory studies showed creatine kinase significantly elevated at 37,525U/L. She was diagnosed with rhabdomyolysis, and admitted to the inpatient service for aggressive IV fluid hydration and supportive care. Her creatine kinase continue to rise above 100,000U/L, and her muscle fatigue progressed to the point of respiratory failure neccessating intubation. The patient was transferred to a tertiary care center for subspeciality evaluation. Extensive evaluation returned negative results for all suspected etiologies including hypokalemia, hypophosphatemia, infection, endocrinopathies, and metabolic myopathies. She maintained normal renal function throughout her hospitalization, and her rhabdomyolysis spontaneously resolved. Discussion: Muscular pain and fatigue is a common presenting complaint in a Family Medicine clinic. In the post-partum period, rapidly changing maternal physiology and the stress of labor and delivery should prompt the Family Physician to diligently construct a broad differential for these complaints. A Medline search revealed one similar case in a post-partum patient with known carnitine palmitoyltransferase deficiency. While this particular patient’s diagnosis is rare, early diagnosis and aggressive management avoided renal failure, and proved to be lifesaving. Conclusion: Muscle pain and fatigue is a common complaint and requires a broad differential and a high index of suspicion to quickly and accurately establish a diagnosis. Reported is a case of life-threatening post-partum rhabdomyolysis that serves as a reminder of the importance of a comprehensive approach to a common complaint. Poster - Resident ALTERED MENTAL STATUS IN A CHILD FOLLOWING ACCIDENTAL INGESTION OF CLONIDINE Henry Luu, DO, LT MC USN, Ryan Arnold, MD, LT MC USN, Naval Hospital Camp Lejeune, NC Introduction: Clonidine, a centrally acting α2 receptor agonist, is a commonly used medication for hypertension. Cardiovascular effects include decrease peripheral resistance, renal vascular resistance, heart rate and blood pressure. In children, it is use as adjunctive therapy for ADHD and Tourette’s syndrome. Case: A 2-year-old male presented to the emergency department with an accidental ingestion of unknown quantity of clonidine 0.1mg. Five tablets missing from bottle, with unknown quantity previously present. Pills were spilled onto floor and during cleanup, pieces of clonidine were noticed in child’s mouth. Over the next 1-2 hours became increasingly drowsy and fell asleep during dinner. Parents brought child to ED at that time. While in the ED, child became increasingly difficult to arouse and upon initial evaluation by pediatrics, child would only wake with vigorous sternal rub. After discussion with ED staff, this was felt to be a worsening of his condition from initial presentation and naloxone 0.02mg/kg was given. GCS prior to naloxone was 8 and within 1-2 minutes child was awake and verbally responsive. After consultation with Poison Control, pt was transferred to facility with PICU capabilities. Discussion: As the number of children diagnosed with ADHD, the potential for medication misadventures increases. In children age 0-12, the most common major adverse events are coma, respiratory depression and hypotension, with drowsiness/lethargy being the most common effect. There have been reports of ingestion as low as 0.015mg/kg associated with coma. In addition, although naloxone can reverse the neurologic effects, it has no effect on respiratory depression. Conclusion: Clonidine is a commonly used medication in adults and may become increasingly common in children. This increases the potential for overdoses, either accidental or intentional. Although we can treat the mental status change with naloxone, the potential for respiratory depression is still present and needs to be monitored . Poster - Resident RADIATION PNEUMONITIS WITH SUPERIMPOSED INVASIVE PULMONARY ASPERGILLOSIS Andrea S. Otto, MD, CPT, MC, USA; Matthew W. Short, MD, MAJ, MC, USA; Madigan Army Medical Center, Department of Family Medicine, Tacoma, WA, 98431 Introduction: Radiation pneumonitis is a progressive, potentially fatal complication of external beam radiation therapy for thoracic malignancies. Presented is a rare case of radiation pneumonitis with subsequent invasive pulmonary aspergillosis in an immunocompetent patient. A delay in correct diagnosis can result in patient death. Case: A 55 year-old man with a history of recurrent lung cancer previously treated with external beam radiation 6 months prior to admission presented with intermittent cough and worsening dyspnea despite antibiotic treatment. Physical exam was notable for tachypnea, fever, and decreased breath sounds in the right upper lobe. Initial evaluation revealed leukocytosis, negative sputum culture, and opacities in the right middle and upper lung on chest radiograph. When the patient failed to improve with treatment for pneumonia, a CT scan revealed a dense infiltrate with linear borders consistent with the radiation port. Radiation pneumonitis was diagnosed and intravenous steroids were initiated. Despite treatment with steroids and broadened antibiotic coverage, his condition worsened. Cultures from bronchial washings during bronchoscopy later revealed heavy growth of Aspergillus. Antifungals were then initiated, but the patient developed chest pain, gross hemoptysis, and subsequent death from invasive pulmonary aspergillosis at the radiation site. Discussion: Only 4 similar cases have been previously reported in the literature, and all occurred in immunocompromised patients. No current recommendations exist for either early diagnostic testing or empiric use of broad spectrum antifungal agents. In patients with radiation pneumonitis, it is reasonable to consider broad-spectrum antifungal treatment, early bronchoscopy, or antigen testing prior to the initiation of systemic corticosteroids. Conclusion: Radiation lung injury and aspergillosis can be difficult to diagnose. In patients with a history of radiation therapy, clinicians should have a high level of suspicion for radiation pneumonitis and consider early bronchoscopy or empiric antifungal treatment to prevent adverse patient outcomes from delay of diagnosis. Poster - Resident DISSEMINATED HSV IN A NEONATE BORN TO AN ASYMPTOMATIC MOTHER David A Duncan, DO, LCDR (sel), MC, USN (FS), Naval Hospital Bremerton, WA 98312 Introduction/Objective: Neonatal HSV is a potentially devastating infection in the newborn which presents a challenge in both maternal screening and neonatal diagnosis. Presented is a case of disseminated HSV in a neonate born by Cesarean section to a mother without history of HSV disease. Case: A female newborn presented to the Emergency Department on day of life six with parental complaint of decreased feeding and lethargy. The infant had been delivered via C-section after arrest of dilatation at seven centimeters with AROM and had an uneventful post-partum course. On presentation to the Emergency Department, the infant was found to be toxic-appearing, hypothermic and hypoglycemic. IV antibiotics and antivirals were started, and the infant was transported to the nearest tertiary care children’s hospital where she ultimately expired from overwhelming sepsis. PCR of both serum and CSF confirmed high viral loads of HSV-1. Discussion: With nearly 2000 cases in the U.S. per year and mortality cited at over 30% for disseminated infection, neonatal HSV poses a significant threat in the neonatal period. Though HSV-1 is less common, it is more likely to cause severe infection than HSV-2. Additionally, 60-80% of primarily infected mothers are asymptomatic, making the prediction of at-risk infants difficult, and a review of the literature fails to demonstrate any cost-effective screening strategies. Rapid PCR at delivery could eventually prove to be useful, but its routine use is still experimental. As in this case, there were no factors that predicted primary infection of the mother. Conclusion: Neonatal HSV predominantly occurs in patients without any significant risk factors. This case emphasizes the importance of having a high suspicion for HSV in a potentially septic infant, despite what may seem to be a negative history. Poster - Resident TB OR NOT TB: THE CLINICAL QUESTION Ethan E Zimmerman, MD, CAPT, MC, USAF, Scott Air Force Base, IL 62225 Michael W Nash, MD, CAPT, MC, USAF, Scott Air Force Base, IL 62225 Introduction/Objective: Patients with a myriad of physical complaints are frequently encountered in primary care. Establishing a unifying diagnosis to sufficiently account for the entire clinical presentation can be challenging. Case: A 64-year-old male steel mill worker with a history of alcohol and tobacco abuse has insidious onset weakness, hip pain, anorexia, vomiting, diarrhea, weight loss, fever, cough with yellow sputum, scrotal swelling, and urinary incontinence. Lab evaluation reveals sodium 127, albumin 1.8, hematocrit 11.6, MCV 80, hematuria, pyuria, and mixed bacteria in sputum. Testing is negative for HIV, RPR, and PPD. Chest radiograph shows diffuse reticulonodular infiltrate. Ultrasound demonstrates caliectasis, epididymal enlargement, and pyocele. Hip MRI reveals bilateral osteoarthrosis and avascular necrosis. Initial inpatient treatment includes chlordiazepoxide, nutritional support, bronchodilators, fluoroquinolones, and physical therapy. No clinical improvement is appreciated. Approximately one month later, sputum and urine samples return positive for tuberculosis. The patient clinically improves on quadruple antibiotic therapy for miliary tuberculosis. Discussion: Tuberculosis currently affects one-third of the world’s population. PPD testing has a low sensitivity in patients with miliary tuberculosis due to a higher proportion of anergy in this population. Sputum, gastric aspirate, and/or urine culture should be obtained when military tuberculosis is suspected. Tuberculosis patients with a negative PPD may convert to a positive PPD on repeat testing one to three weeks later due to the booster phenomenon. Conclusion: The clinical manifestations of miliary tuberculosis are protean. Diagnosis hinges on maintaining a high index of clinical suspicion when evaluating patients with multisystem disease. Common primary care presentations such as diffuse lung disease, normocytic anemia, hyponatremia, hip pain, enteritis, hematuria, sterile pyuria, and epididymitis may be manifestations of tuberculosis, even in the absence of a positive PPD. In the preceding case, treatment for tuberculosis was delayed as other diagnoses seemed to adequately account for the clinical presentation. Poster - Resident ABDOMINAL PAIN CLINICAL EXAMINATION AS AN INITIAL ASSESSMENT TOOL OF PGY-1 CORE COMPETENCIES OLIVIA S. LOCKER, MD, CPT, MC, USA; MATTHEW W. SHORT, MD, FAAFP, MAJ, MC, USA, MADIGAN ARMY MEDICAL CENTER, TACOMA, WA 98431 Introduction / Background: The Accreditation Council for Graduate Medical Education (ACGME) has defined six core competencies by which residency Program Directors (PDs) evaluate residents. Prior to Graduate Medical Education (GME) training, PDs have limited information on intern competencies. An Objective Structured Clinical Examination (OSCE), administered during internship orientation, may identify deficiencies in core competencies. Methods / Intervention: Sixty-one new interns from primary care (47) and surgical (14) specialties received a peer-reviewed case scenario involving a young, female standardized patient (SP) with right lower quadrant abdominal pain. They examined the same patient, and developed management plans. A single staff physician evaluated performances in the five ACGME core competencies of Patient Care (PC), Medical Knowledge (MK), Interpersonal and Communication Skills (ICS), Professionalism (PRO), and Systems-Based Practice (SBP), awarding scores on a peer-reviewed grading sheet using a 5- point Likert scale. The non-medical SP also independently evaluated the core competencies of ICS and PRO. Prior to the OSCE, the ten PDs from each specialty assigned scores to their new interns in the same core competencies. StatView software was used to compare the PD evaluations to the OSCE evaluations in ANOVA tables, setting p < 0.05 as significant to trigger a Fisher’s PLSD analysis. For ICS and PRO, OSCE data from the staff and SP evaluators were compared separately and together. Evaluation: Only the comparison involving MK achieved significance (p = 0.0436). From this data, Fisher’s PLSD analysis detected significant differences only between Likert scores of 2 and 4, and 3 and 4. Conclusion / Discussion: This study demonstrates that PDs from ten different specialties were not able to predict their interns’ performance on an abdominal pain OSCE administered during residency orientation. This lack of association suggests that the limited information available to PDs prior to residency may be inadequate to determine core competency deficiencies. Poster - Resident BUPROPION TOXICITY PRESENTING AS A SEIZURE IN A TODDLER Faye Rozwadowski, MD, LT USNR, Naval Hospital Jacksonville, Jacksonville, Florida, 32214 Introduction: The pediatric population is high risk for toxic ingestion. Seizure is a common presentation of these ingestions. This case demonstrates the toxicity associated with bupropion overdose and the diagnostic challenge of urine drug screen evaluation. Case: A healthy 18 month old female became somnolent and irritable at home. The child’s mother described the child as “unfocused”, quiet, and with a chill-like tremor. Enroute to the hospital, the toddler developed gran mal seizure activity. In the emergency department, seizure activity was temporarily suppressed with medication. A urine drug screen was positive for amphetamines. The mother reported a total of only two medications in the house, bupropion and alprazolam. Consultation with poison control revealed that bupropion can cause a false positive amphetamine on urine drug screens. Discussion: Toxic ingestions are common in the toddler age group and often manifest as seizure activity. A urine drug screen is helpful for evaluating a toxic exposure but identifying the actual toxin can be difficult. In this case, the child gained access to a bupropion tablet and ingested it unbeknownst to her mother. The patient began to manifest symptoms of central nervous system depression characteristic of anti-depressant toxicity and also observed in adult toxic ingestions. The confusing variable to the case is the positive amphetamine on urine drug screen. Literature searches on MDconsult and Ovid revealed evidence of bupropion toxicity as an etiology for childhood seizures, as well as a positive amphetamine drug screen. Conclusion: Toxic ingestions in toddlers may manifest as seizure activity. Determining what the toxic agent is can be challenging, but is important to be able to appropriately treat the patient. Due to the popularity of bupropion prescriptions, this drug is considered a potential toxic ingestant in family households. This case necessitates parent and patient education on prescription drugs in the home.