Internal Medicine Commons^™

Why Medicine Needs The Humanities: An Argument For Arguments, Suraj R. Nyalakonda, Md

The Medicine Forum

As medicine plunges deeper into the 21st century, there appear to be three forces coming together that hold both promise and peril as technology’s march of progress continues unabated through the healing profession.

Musings Of A House Staff Officer On The Wards, Suraj R. Nyalakonda, Md

The Medicine Forum

I am told I am part of the house staff. I am told I am a resident. I am told my predecessors, who are now my teachers, earned the title of resident by residing at their place of work, which was also their place of passion, which was the hospital, that institution that, with the advent of the industrial revolution, came to be a producer of health, a fixer of bodies. I am also now told that we residents are increasingly the sort of thing that can burn out. The other thing I know that can burn out - when …

Shadows And Echoes Of Understanding: A Physician's Reflection On Plato's Allegory Of The Cave And Medicine, Michael Dong, Md, Tamar Wolinsky Md, Benjamin Claxton, Md, Mph, Chantel Venkataraman, Md

The Medicine Forum

Plato's Allegory of the Cave offers a lens through which one can contemplate the complexities of medicine, where the shadows and echoes of illness obscure the true forms of disease. As physicians, we seek to illuminate the shadows that shroud our patients’ understanding of their illnesses and provide clarity to help patients navigate the labyrinth of diagnoses and treatments.

Unmasked, Rehana Persaud, Ms

The Medicine Forum

The world was quiet

A virtual reality

I existed

you lived

in it

We lived

In

a

world,

that was h u s h e d …

A quiet one

The silence was DeafeninG

But

I HEARD what consumed

me

Quantum Of Solace, Jeffrey White, Md

The Medicine Forum

Dr. R was back on 3 West and looking the worse for wear. Colon cancer, partial resection, bowel obstruction, ischemia, second surgery, bleeding, third surgery, infectious colitis, four days in the ICU—this 90-year-old man, who his wife assured us was bright and vibrant before his admission, was not long for this world. His baseline dementia had begotten daily delirium. He had had heart failure and COPD before his admission, and his fluid retention had swelled his already substantial body habitus to uncomfortable proportions.

Cadaver Dissection — A Reminder Of Humanity, Samuel De Matte, Ms

The Medicine Forum

I wash my hands, pick up a pair of purple forearm gloves, and gown up in an apron. The large overhead lights flood the room with sterile illumination, reflecting off the metal cabinets onto the white walls. I approach one of the thirty-four body bags with a group of classmates. The slow growl of the zipper fills the otherwise silent room. We pull back the formaldehyde-soaked sheet to reveal our cadaver. We all notice the rose tattoo on her chest.

A Curious Case Of Ards, Normonique Dyer, Do

The Medicine Forum

Acute respiratory distress syndrome (ARDS) is a well-known description of progressive respiratory decline. ARDS can be suspected in patients that meet the following criteria: (1) progressive dyspnea with onset within 1 week of a suspected clinical insult, (2) reduction in arterial oxygen saturation, and (3) bilateral alveolar infiltrates not due to a primary cardiogenic process.¹ The management of ARDS is largely unchanged regardless of the etiology and thus will not be within the scope of discussion for this report. However, the etiology of ARDS is of significance given that the cause of a patient’s respiratory failure has prognostic implications. …

A Case Of Reactivation Tuberculosis, Edwin Perez, Md, Avish Patel, Md, Taha Awan, Md, Amman Bhasin, Md, Gautam George, Md

The Medicine Forum

Approximately 22 percent of the world population is estimated to be infected with Mycobacterium tuberculosis. The largest number of cases are seen in Sub-Saharan Africa, India, and the islands of Southeast Asia, while North America and Western Europe are “low incidence” regions.¹ In the US, most cases are seen in foreign-born individuals who emigrate from high-incidence countries. Despite the low incidence in the US, prevention and control of Tuberculosis (TB) remain an important component of Public Health.² Here we present a case of a patient of Vietnamese origin with reactivation TB and rare manifestations of TB.

Nodular Al Amyloidosis — An Unusual Etiology Of A Solitary Pulmonary Nodule, Benjamin B. Claxton, Md, Mph, Shruti Nanivadekar, Md, Stacey Gargano, Md, Prarthna C. Kulandaisamy, Md

The Medicine Forum

Solitary pulmonary nodules (SPN) are defined as single intraparenchymal opacities less than 3 centimeters. The differential diagnosis of the SPN is broad. AL amyloidosis is a protein conformational disease which occurs when certain monoclonal light chains develop an unstable tertiary structure with resultant polymerization of insoluble amyloid fibrils that deposit in the extracellular space of sundry tissues. In the lung, diffuse interstitial amyloid deposition is the most common form of the disease.

When Obstruction Meets Infection: A Case Of Multi- Drug Resistant (Mdr) E. Coli Community Acquired Pneumonia In A Patient With Metastatic Melanoma, Victor Diaz, Ms, David Saeed, Ms

The Medicine Forum

Multidrug resistant Escherichia Coli (MDR E. Coli) is a less common cause of bacterial community-acquired pneumonia as compared to Streptococcus pneumoniae and Staphylococcus aureus. We present a case of MDR E. Coli community-acquired pneumonia diagnosed on culture of bronchoalveolar lavage specimens (BAL) after bronchoscopic debulking of a metastatic melanoma mass completely obstructing the left main stem bronchus (LMSB).

Renal Cell Carcinoma Manifesting As A Tumor Thrombus Identified On Transthoracic Echocardiography & Ct Scan, Kashka Mallari, Md

The Medicine Forum

This is a 60 year old male who presented with increased lower extremity edema for a month and right upper quadrant abdominal pain for a week. A CT of his abdomen showed a right renal mass consistent with renal cell carcinoma (Figure 1, red arrow), along with a tumor thrombus extending into the inferior vena cava (IVC) to the level of the junction with the right atrium (Figure 1, blue arrow, and Figure 2). An echocardiogram revealed an enlarged IVC with an increased echogenicity likely representative of an extensive tumor (Figure 3). Subsequently, he underwent a right radical nephrectomy, vena …

Case Study: Diagnosis Of Acute Myeloid Leukemia In A Middle-Aged Patient With A History Of Aplastic Anemia, Umma Fatemam Md, Marc Yorker, Md

The Medicine Forum

The clinical and diagnostic landscape of hematologic disorders such as Myelodysplastic Syndromes (MDS) and Acute Myeloid Leukemia (AML) is complex and multifaceted, with particular challenges arising in the identification and differentiation of related conditions like aplastic anemia and hypoplastic MDS.¹ MDS, a heterogeneous group of clonal marrow disorders, is typified by dysplasia and ineffective hematopoiesis, which often culminate in cytopenias. A subset of MDS patients may experience leukemic transformation, marked by the proliferation of undifferentiated blasts, ultimately progressing to AML, a malignancy characterized by rapid growth and accumulation of these cells.² Aplastic anemia shares the clinical hallmark of …

Primary Care Provider Awareness And Attitudes Regarding Updated Brca1/2 Screening Recommendations And Genetic Testing, Emily Foecke Munden, Ms, Maria Poluch, Ms, Jennifer S. Zeiger, Ms, Maya Rosenberg, Md, Swati Shroff, Md

The Medicine Forum

Detection of BRCA1/2 gene mutations opens the door for breast cancer prevention; however, many high-risk individuals are not screened until after their first cancer diagnosis. The United States Preventive Services Task Force (USPSTF) updated its BRCA1/2 screening recommendations in 2019. This study explores provider awareness of this update and attitudes towards BRCA1/2 genetic testing. A survey was sent to Obstetrics/ Gynecology (Ob/Gyn), Internal Medicine (IM), and Family Medicine (FM) providers at Thomas Jefferson University Hospitals (TJUH). 66% of responders felt familiar with BRCA1/2 screening guidelines, and 38% were aware of the 2019 USPSTF update. Ob/Gyn providers were more familiar with …

Looking For The Unseen: Application Of Wood’S Lamp In The Ambulatory Clinic, Alexandros Grivas, Md, John Caruso, Md

The Medicine Forum

A 56-year-old female patient with a personal medical history of class III obesity and uncontrolled DM presented to the ambulatory clinic with a pruritic rash behind her knees. The rash was of 4 weeks duration and did not improve with topical application of nystatin powder. Examination revealed an erythematous patch in the intertriginous area behind the knees bilaterally, associated with mild desquamation and clear demarcation from the normal skin. No satellite lesions were noticed. (figure 1A) The patient was evaluated for an intertriginous skin rash. The differential diagnosis included intertrigo, fungal infection, psoriasis, and lichen planus. Wood’s lamp examination was …

Minocycline-Induced Hyperpigmentation In A Patient With Multiple Causes Of Skin Discoloration, Jeffrey White, Md, Amman Bhasin, Md, Gregary Marhefka, Md

The Medicine Forum

Minocycline-induced hyperpigmentation is a well-documented but poorly understood adverse effect of the popular tetracycline antibiotic minocycline, mainly affecting patients who use it for a prolonged duration. When patients develop dark skin lesions, the etiology may be clouded if a patient on minocycline has other risk factors. We describe a patient on suppressive minocycline therapy as well as anticoagulation and a history of chronic venous stasis who developed ecchymosis after an invasive procedure.

Statin-Induced Necrotizing Autoimmune Myopathy: A Case Report, Eric M. Teichner, Ms, Arjun B. Ashok, Ms

The Medicine Forum

In the landscape of contemporary medicine, statins stand out as a cornerstone in the prevention and management of atherosclerotic cardiovascular diseases. By inhibiting the 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase enzyme, statins effectively lower cholesterol levels, thus mitigating the risk of heart attacks and strokes.¹ Despite their widespread adoption and generally well-tolerated nature, the clinical panorama of statin therapy is occasionally marred by side effects, including muscle-related adverse events. These range from relatively common and benign myalgias to the rare and severe statin-induced necrotizing autoimmune myopathy (SINAM), a condition marked by muscle weakness and profoundly elevated levels of creatine kinase (CK) …

A Case Report Of Acute Idiopathic Hepatitis Requiring Liver Transplant, Nathan Rim, Nevin Varghese, Md, Zachary Pang, Md

The Medicine Forum

Acute liver injury may be very difficult to treat, especially when the etiology is unknown. We describe a case of a patient who presented with signs and symptoms of acute liver injury and went through an extensive work-up that did not reveal a definitive cause. The lack of diagnosis can be distressing for the patient, so it is important to regularly communicate the current plan and potential future necessary steps (such as a transplant surgery) to facilitate smooth, informed decision-making throughout the whole process.

A Rare Case Of Upper Gastrointestinal Bleeding And Esophageal Candidiasis In Severe Achalasia, Nevin Varghese, Md, Bertilia Tavárez, Md, Justin Robbins, Md

The Medicine Forum

Achalasia is an esophageal dysmotility disorder characterized by failure of relaxation of the lower esophageal sphincter (LES), accompanied by aperistalsis of the distal esophagus. Recent data show that the prevalence of achalasia in the United States is 10 per 100,000 individuals.¹ Complications of achalasia include esophagitis, esophageal ulcer, esophagealtracheal fistula, esophageal rupture, aspiration pneumonia, and squamous cell carcinoma. We report a rare case of upper gastrointestinal bleeding associated with esophageal ulcer and candidiasis in a patient with severe achalasia requiring multiple endoscopic interventions.

Bicuspid Aortic Valve With Right Coronary Cusp And Noncoronary Cusp Fusion On Transesophageal Echocardiogram, Kashka Mallari, Md

The Medicine Forum

A 39 year old male with a bicuspid aortic valve (BAV) developed progression of aortic valve regurgitation and enlargement of the ascending aorta, despite showing no symptoms. BAV, affecting approximately 2% of the population, poses risks such as aortic stenosis, aortic regurgitation, endocarditis, and aortic dilation, which can lead to aortic aneurysm and potential rupture. Due to the risk of further progression, he underwent a trans-esophageal echocardiogram (TEE) to facilitate aortic valve repair. While majority of patients with BAV exhibit fusion between the right coronary cusp (RCC) and left coronary cusp (LCC), this patient displayed fusion between the RCC and …

Hypertrophic Cardiomyopathy Illustrated On A Transthoracic Echocardiogram And Cardiac Mri, Youssef Elfatatry, Md, Marina Gonzalez, Md

The Medicine Forum

A 46-year-old woman presented to the hospital with subacute dyspnea on exertion and syncope. She had three syncopal episodes in the months prior, all of which occurred after standing from seated position and were associated with complete loss of consciousness. Echocardiogram showed severe concentric left ventricular hypertrophy (LVH) with preserved systolic function (Panels A and B). Cardiac magnetic resonance (CMR) imaging was performed which confirmed asymmetric septal hypertrophy measuring 28-mm in thickness (Panel C, arrow). Patchy, late gadolinium enhancement was also seen within the myocardium (Panel D, arrows). A diagnosis of hypertrophic cardiomyopathy (HCM) was made. The patient had no …

Wellens' Syndrome On Electrocardiogram, A Highly Specific Indicator Of Critical Stenosis Of The Left Anterior Descending Coronary Artery, Youssef Elfatatry, Md, Ryan Gardner, Md

The Medicine Forum

An 85-year-old male with a past medical history of hyperlipidemia presented to his primary care physician with chest pain. The patient had experienced an acute episode of substernal chest pain that resolved spontaneously three days prior to presentation. An electrocardiogram (ECG) was obtained in the office which showed inverted and biphasic T-waves throughout the precordial chest leads (Panel A, arrows). The patient was sent to the emergency department and underwent an emergent cardiac catheterization which revealed a 99% proximal left anterior descending (LAD) artery occlusion (Panel B, arrow). A drug-eluting stent was placed with successful revascularization (Panel C, arrow). Wellens …

Investigating The Etiology Of Non-Ischemic Cardiomyopathy; A Case Report Of Cardiac Amyloidosis, Zachary Pang, Md, Joshua M. Riley, Md, Yair Lev, Md

The Medicine Forum

Amyloidosis is the result of misfolded protein deposition in organs and tissues, including the heart also known as cardiac amyloidosis. We describe a case of a patient presenting with decompensated heart failure, which highlights the importance of identifying the etiology of the patient’s cardiomyopathy through a thorough history and physical. This led to a diagnosis of cardiac amyloidosis. The patient was subsequently initiated on tafamidis, a medication that is associated with reductions in all-cause mortality and cardiovascular-related hospitalizations, reduced decline in functional capacity, and improved quality of life of the patient.

Laao Device Mass: A Classic Condition Involving A Not - So - Classic Device, Ryan Gardner, Md, Rabia Naheed, Md, Youssef Elfatatry, Md, Irfan Ahsan, Md, Alyson N. Owen, Md

The Medicine Forum

Current evidence suggests Class 2a recommendation for a left atrial appendage occlusion with a closure device in patients with atrial fibrillation who have moderate to high risk of stroke (CHA2DS2-VASc score ≥2) and a contraindication to long-term oral anticoagulation due to a nonreversible cause.¹ Watchman device (WD) related infection is infrequent due to complete endothelialization of the device in a few weeks.² We report a highly challenging case of possible WD-related infection that involved complex decision-making.

Dissecting The Literature: A Systematic Review Of Conservative Therapy Versus Revascularization In Spontaneous Coronary Artery Dissection, Avinash Saraiya, Ms, Brian Schonewald, Md

The Medicine Forum

Spontaneous coronary artery dissection (SCAD) is a rare, but increasingly recognized cause of acute coronary syndrome (ACS). While previously only described in case series, the advent of advanced imaging techniques such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT) has increased its prevalence dramatically. Anatomically, SCAD results from the formation of an intramural hematoma with or without intimal tear in a coronary artery, potentially leading to occlusion and ischemia. This phenomenon is especially common in women, accounting for 35% of ACS in women under the age of 50, and representing the leading cause of peripartum myocardial infarct.¹ There …

From The Chief Residents, Michael Dong, Md, Chantel Venkataraman, Md, Tamar Wolinsky Md, Benjamin Claxton, Md

The Medicine Forum

As we introduce the latest edition of The Medicine Forum, the journal of our Internal Medicine residency program, we're thrilled to showcase the diverse talents and perspectives of our resident physicians. Evolving alongside our program, this publication serves as both a platform for scientific inquiry and a canvas for creativity, reflecting the dynamic interests of each resident cohort.

We must extend our heartfelt gratitude to our current editors, Amman Bhasin, Suraj Nyalakonda, Mez Kamanu, and Alex Grivas, for their unwavering dedication and tireless efforts in shepherding this journal to new heights. Their commitment to excellence and their vision for …

From The Editors, Amman Bhasin, Md, Suraj Nyalakonda, Md, Chukwuemezie Kamanu, Md, Alexandros Grivas, Md

The Medicine Forum

We are honored to present the 25th Annual edition of The Medicine Forum, carrying forth a quarter-century tradition of scholarly work produced by faculty, residents, and students -- proudly shared with the Jefferson community and beyond. The Medicine Forum embodies the collective voice and spirit of our residency, serving as a vibrant platform for scholarly and artistic expression, and showcasing the remarkable talents and diverse perspectives of our program’s faculty, residents, and students.

Throughout the years, The Medicine Forum has evolved alongside our program, adapting to the changing interests and passions of each new cohort of residents. It serves …

Foreword From Faculty Advisor, Dagan Coppock, Md, Msce

The Medicine Forum

The latest edition of The Medicine Forum celebrates our community’s efforts toward scholarly inquiry and creativity. Our current editors have approached this project with a true passion. Throughout the academic year, it has been my pleasure to work with Amman, Suraj, Mez, and Alex, not only on this project, but also on the medical wards. They have applied the same thoughtfulness and joy to editing this journal that they do to the care of patients. I am in awe of their efforts.

As a department, we are a productive group of writers, thinkers, scientists, and artists. So much of our …

From The Desk Of The Residency Program Director, Christopher Henry, Md, Facp

The Medicine Forum

As we celebrate the silver jubilee of our beloved Jefferson Forum, it is with great pride and admiration that I extend a warm welcome to each of you. For a quarter-century, this annual publication has stood as a testament to the dedication, passion, and scholarly pursuits of our internal medicine residents.

Within the pages of the Jefferson Forum, you will find the embodiment of our residents' commitment to excellence in patient care, education, and research. As the Program Director, I have had the privilege of witnessing firsthand the remarkable growth and development of our residents. Their journey from eager learners …

Table Of Contents: The Medicine Forum, Volume 25, 2023-2024

The Medicine Forum

Table of Contents: The Medicine Forum, Volume 25, 2023-2024

The Medicine Forum: Volume 25

The Medicine Forum

The Journal of Thomas Jefferson University Hospital - Department of Internal Medicine, Volume 25, 2023-2024

TABLE OF CONTENTS

• Case Reports
• Clinical Images
• Humanities & Reflections