Medicine residents showcased their strangest, most complex, and puzzling cases they have seen while practicing at University of Iowa Health Care in this year’s American College of Physicians (ACP) Clinical Vignette Competition.

Attendees—made up of Internal Medicine faculty, learners, staff, and judges—of the final presentations on Monday, September 18, offered supporting questions to the four final cases.

• Michael Sauer, MD, PGY-3, mentored by Mony Fraer, MD, FACP, FASN, presented “The Case of the Bloated Abdomen,” a case of a woman who, after receiving negative test result after negative test result for tuberculosis, did in fact test positive for extrapulmonary tuberculosis, the tenth leading cause of death worldwide this year. A lively discussion about QuantiFERON-TB Gold testing spurred a brief debate among faculty during the question-and-answer portion of Sauer’s presentation.
• Stephen Brennan, MD, PGY-5, mentored by Aubrey Chan, MD, PhD, presented “Toxic Delusions,” a case in which a young woman presented with anxiety and was started on treatment with an SSRI. Following treatment, the patient developed acute psychosis characterized by delusions and mood lability. After appropriate medical workup, the patient was found to have thyrotoxicosis. In treating the underlying condition, the psychoses eventually abated after 16 weeks. This case highlighted that although rare, psychosis can be the only presenting symptom in thyrotoxicosis.
• Ashten Sherman, MD, PGY-2, under the mentorship of Alejandro Pezzulo Colmenares, MD, presented the case, “Where, Oh Where, Has My Red Blood Cell Gone?” A man visited the hospital, confused, with a clinical presentation that over his time in the hospital included severe MAHA, neurologic symptoms, cardiac involvement, renal dysfunction, and gastrointestinal symptoms. After several attempts to diagnose and treat his condition, the patient sought comfort cares, ultimately teaching the clinical staff that “at the end of the day, we may not always have the answer.”
• Alex Paschke, MD, PGY-3, who mentored under Mark Karwal, MD, presented the “Poetic Mystery: Weakness in a Young Male.” This 40-year-old patient presented with complaints of clumsiness and painful neuropathy, along with progressive weakness in his legs. Initially suspecting chronic inflammatory demyelinating polyneuropathy (CIDP), the differential was broadened to include POEMS Syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes), after bloodwork revealed an elevated VEGF, a major diagnostic criterion for the syndrome. This rare diagnosis is only one of a few hundred documented cases since the 1970s. The patient started DRd immunotherapy immediately upon diagnosis and has shown significant improvement after the first year of diagnosis.

After deliberation, the judges declared Paschke the winner in this final phase of the competition. He will present at the State of Iowa ACP Chapter Meeting on Thursday, October 5, 2023, during the Progress 2023 CME event.

Manish Suneja, MD, director of the internal medicine residency, offered his thanks to all the judges involved in this year’s competition, as well as to the organizing team: