Medical Specialties Commons^™

Small Gifts, Big Questions: The Ethical Dilemma In Accepting Gifts In Medicine, Meiqi Luo, Md

The Medicine Forum

I remember discussing the topic of gift-giving by patients in a small group session in medical school. When asked whether it’s ethical for medical professionals to accept gifts from patients, I responded, “It depends on the value of the gifts.” If the gifts were of appropriate value and given purely out of appreciation, they serve to strengthen the physician-patient relationship. However, what I failed to realize was the difficulty in determining the value and intention of a gift. My personal experience of receiving gifts from a patient made me aware of such ethical ambiguities.

At the community clinic where I …

Navigating Care And Loss Through Aging, Disease, And Decision-Making In The Covid Era, Michael Predi, Do

The Medicine Forum

There is only one of the loved one you know.
Often it can be hard to let go.
Five years old the world became cold.
Lost my mother to breast cancer.
A cold wound that can’t be answered
Father raised you in a foreign land.
Drove you to school, combed your hair, gave you a life you could have never planned.
Taught me that I would catch a cold from the wind.
No arguing about modern medicine, my dad was thick skinned,
Here comes college, first generation, what an exciting time.
Get to medical school so exciting; here comes the …

Existential Pain, Kian Waddell

The Medicine Forum

A new type of pain
Never covered in a lecture
Not neuropathic, visceral, post-procedural, cancer, phantom pains,
But existential.

She didn’t want pain meds
And she had her reasons -
We didn’t push.

What she wanted was to talk
To be heard
For us to be silent and stop
Asking her every second
If she’d moved bowels, vomited, slept…

What she wanted was to talk.
What other medication is there for pain of the soul?

Eternal Light, Anurag Modak, Md

The Medicine Forum

The microscope is held aloft in a sea of darkness,
Illuminating the gyri and sulci of the exposed brain below.
Its harsh, sterile light creates a veritable barrier
So hot, so intense, it threatens to explode forth at any moment.

The screens scattered across the room provide companionship to this lonely machine
And I, residing amidst the sea of shadows,
Bear witness to its solitude
To the silence of the light.

I have seen vessels tied and aneurysms clipped,
And an eon has gone by…
There’s an air of anticipation,
An expectation of something more.

But, solace and quietude prevail …

Unmasking The Dvt Mimic: A Rare Case Of Diabetic Myonecrosis In A Young Patient, Avish Patel, Md, Paul Endres, Md, Alexander Marchese, Md, Dianna Cheney-Peters, Md

The Medicine Forum

Diabetic myonecrosis is an uncommon complication of diabetes mellitus, often falsely believed to be a deep vein thrombosis (DVT). Patients present with similar presentations of edema and focal tenderness that are most often unilateral in a proximal lower extremity.¹ When venous ultrasound is negative, magnetic resonance imaging (MRI) is the preferred diagnostic modality over muscle biopsy, given the potential complications.^2,3 Treatment includes rest, analgesia, and improved glycemic control.⁴ Given the rise of metabolic disorders and insulin resistance, it is important to be aware of this diagnosis to prevent overutilization of healthcare resources.⁵

Recurrent Post-Viral Rhabdomyolysis In A 36-Year-Old Male: A Case Report, Warda Naqvi, Md, David Walz, Md, Lucy Checchio, Md

The Medicine Forum

Rhabdomyolysis is a syndrome of skeletal muscle breakdown, releasing intracellular contents such as creatine kinase (CK) and myoglobin into the bloodstream, which can precipitate acute kidney injury (AKI).¹ While trauma, extreme exertion, and toxins are frequent culprits, infections, particularly viral illnesses, represent a less common but significant trigger.² Influenza and other respiratory viruses have been implicated in sporadic cases of rhabdomyolysis, often presenting with acute myalgias and elevated CK levels following a viral prodrome.³ In contrast, recurrent rhabdomyolysis is typically associated with inherited metabolic myopathies (e.g., McArdle disease) or autoimmune myositis, conditions often marked by distinct genetic …

Mcconnell’S Sign In The Absence Of Pulmonary Embolism, Alicia Bao, Md, Tendai Marume, Md

The Medicine Forum

McConnell’s sign is an echocardiographic finding characterized by hyperdynamic motion of the right ventricular (RV) apex with akinesis of the RV free wall. It is widely known as an indicator of RV strain in acute pulmonary embolism (PE) but has been described in other conditions such as sepsis-induced RV dysfunction, acute cor pulmonale, and right-sided heart failure. In critically ill patients, RV dysfunction is a major contributor to hemodynamic instability, respiratory failure, and poor outcomes. Given the overlapping signs of various underlying conditions, McConnell’s sign serves as a useful marker for assessing RV involvement but can be challenging to interpret …

A Case Of Streptococcus Pneumoniae Necrotizing Pneumonia With Pneumothorax And Abscess Formation, Susanna Betti, Md

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A 63-year-old female with a past medical history of left breast ductal carcinoma in situ, now post-left-sided lumpectomy and radiation in 2005, presented to an outside hospital with chest pain and a cough productive of green sputum. Computed tomography (CT) chest demonstrated patchy ground-glass opacities and dense consolidations in the right middle and lower lobe. Blood cultures and bronchoalveolar lavage culture were positive for Streptococcus pneumoniae, and she was started on antibiotics for community-acquired pneumonia. Her respiratory status rapidly worsened and she required intubation. She developed a large right-sided pneumothorax and had a chest tube placed for a …

A Complex Case Of Multifactorial Hypoxemia From Metastatic Testicular Cancer, Susanna Betti, Md

The Medicine Forum

A 27-year-old male with no known past medical history presented for evaluation of a 14.1 cm testicular mass (Figure A). He was found to have severe anemia (Hgb 2.8 g/dL), and biopsy demonstrated a non-seminomatous mixed germ cell tumor of testicular origin with imaging demonstrating widespread metastases to the brain, lungs, and liver. The patient received multiple blood transfusions and one dose of bleomycin, etoposide, and cisplatin followed by the development of acute respiratory failure. Computed tomography angiography (CTA) chest was negative for pulmonary thromboembolism but demonstrated diffuse ground-glass opacities (Figure B, arrows) and metastatic pulmonary masses containing dilated vessels …

Heart Core: A Framework For Leading With Empathy In Medical Education, Akash Patel, Do, Mark Liotta, Md

The Medicine Forum

In medical training, much of what defines leadership happens outside of clinical decision-making. It happens at 2 a.m. when a resident breaks down from burnout. It happens when a team is navigating interpersonal conflict or when a trainee is overwhelmed by grief, imposter syndrome, or failure. While these moments are deeply impactful, many of us are never taught how to lead through them.

This gap inspired us to create HEART CORE, a framework designed to help residents, faculty, and administrators approach complex, emotional, or high-stakes situations with clarity and compassion. Although it was originally built for chief residents handling difficult …

The Factor Viii Debate: An Auto-Cancelled Lab Near Miss, Avish Patel, Md, Daniel Elchediak, Md, Zachary Pang, Md, Charlotte Shields, Md, Bethanne Venkatesan, Md, Ananya Venkatesh, Md, Michael Alessandro, Bsn, Jeffrey Riggio, Md, Ms, Alexis Wickersham, Md

The Medicine Forum

Near misses, medical errors with no appreciable resultant harm, often go undetected and underreported despite great emphasis on patient safety event reporting over the past two decades.¹ Additionally, near misses are often not triggers for proactive institutional corrective action due to the widespread retroactive safety culture following more harmful or catastrophic safety events.² At Thomas Jefferson University Hospital, all internal medicine first-year residents (PGY1s) participate in an immersive safety event review curriculum of near miss or low-harm safety events, previously described in the literature.³ The following details the event review findings and implemented health-system level changes following …

Enhancing Community Health Center Safety Through Participatory Co-Design, Arman Afifi, Bs, Kelsey Smith, Bs, Megan Reed, Phd, Mph, Lara Weinstein, Md

The Medicine Forum

Health and social service programs are often designed from the top down, with people in power making decisions that affect others. Integrating all staff and clients in the co-design process ensures that interventions are culturally competent and tailored to the unique challenges faced by the community. Participants bring firsthand knowledge, allowing for a more accurate assessment of needs and preferences. Additionally, involving marginalized individuals helps build trust between service providers and the community, creating a foundation for sustained collaboration and positive outcomes. Overall, participant inclusion is not only a practical necessity but an ethical imperative in delivering effective and equitable …

From Er To Mortality In 48 Hours: A Fatal Case Of Overwhelming Post-Splenectomy Infection, Miriam Stern, Ba, Blaise O’Malley, Bs, Amry Majeed, Md, Michael Grodsky, Md

The Medicine Forum

Overwhelming post-splenectomy infection (OPSI) is a known complication of asplenia.^1,2 While the precise rates of morbidity and mortality are unknown, estimates range from 38% to as high as 70%.² Because the spleen plays an important role in protecting against infections with encapsulated microorganisms, OPSI is most commonly caused by infection with encapsulated bacteria, specifically Streptococcus pneumoniae.^1–3 While pneumococcal vaccines have been shown to improve immunogenicity in asplenic people, OPSI remains a danger to both vaccinated and unvaccinated patients.^4,5 Additional measures to protect asplenic patients from overwhelming infection have been proposed, but the evidence remains mixed. …

String Theory - A Case Of Hypermucoviscous Klebsiella Pneumoniae Causing Distant Necrotizing Infections, Natasa Kostic, Md, Marina Gonzalez, Md

The Medicine Forum

Klebsiella pneumoniae is a Gram-negative, encapsulated bacterium belonging to the Enterobacteriaceae family. It is more frequently associated with nosocomial infections and is one of several bacteria developing high rates of antibiotic resistance.¹ Since the mid-1980s, there have been reported cases of Klebsiella pneumoniae causing life-threatening, invasive infections acquired in the community by otherwise healthy individuals. The propensity to form metastatic foci of infection in immunocompetent hosts is unusual for an enteric, Gram-negative pathogen.² This hypervirulent variant of K. pneumoniae was originally noted only in Asian-Pacific countries but is now being identified globally.³ The variant has unique mucoid …

Negative Urine Nucleic Acid Amplification Testing In A Case Of Disseminated Gonococcal Infection Presenting As Migratory Arthritis, Benjamin Richter, Md

The Medicine Forum

Disseminated gonococcal infection (DGI) is a well-documented complication of Neisseria gonorrhoeae infection, most characteristically presenting as migratory arthritis, tenosynovitis, and dermatitis. Although modern nucleic acid amplification tests (NAATs) and cultures from mucosal sites have significantly improved diagnostic capabilities, discrepancies between clinical manifestations and laboratory findings still occur.¹ One such challenge arises when the urine gonorrhea test returns negative despite strong clinical evidence pointing toward gonococcal involvement.

Migratory arthritis—a transient, shifting pattern of joint inflammation—has long been recognized as a hallmark of DGI.² Typically, the pathogen is detected in blood, synovial fluid, or from mucosal specimens; however, negative urine …

From Cure To Crisis: A Case Of Severe Hypoxic Respiratory Failure Due To Daptomycin-Associated Eosinophilic Pneumonitis, Muneeba Ali, Md, Enad Haddad, Md, Warda Naqvi, Md, Conrad Reed, Md

The Medicine Forum

Daptomycin is a cyclic lipopeptide antibiotic that commonly treats Gram-positive infections. Most frequently prescribed for osteoarticular infections.¹ Daptomycin is associated with numerous side effects, including myopathy, rhabdomyolysis, eosinophilic pneumonia, and anaphylactic hypersensitivity reactions.1 Daptomycin-induced eosinophilic pneumonitis (DIEP) is a rare but potentially life-threatening adverse effect associated with prolonged use.² There are several established criteria for diagnosing this medical condition. However, the variation in its clinical presentation, coupled with the favorable outcomes of early diagnosis and the severe consequences of delayed diagnosis, emphasizes the need for further discussions. This case highlights the importance of monitoring patients on prolonged daptomycin …

A Patient With Recently Diagnosed Hiv Found To Have Cryptococcus Meningitis With Course Complicated By Pneumocystis Jirovecii Pneumonia, Cmv Colitis, And Kaposi Sarcoma, Benjamin Richter, Md

The Medicine Forum

Opportunistic infections (OIs) remain a major cause of morbidity and mortality in individuals with advanced human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), particularly in those with severe immunosuppression. Among the most life-threatening OIs are cryptococcal meningitis, Pneumocystis jirovecii pneumonia (PJP), cytomegalovirus (CMV) colitis, and Kaposi sarcoma (KS), each of which poses significant diagnostic and therapeutic challenges.

Here is a case of a man with recently diagnosed HIV who was admitted to the hospital with a chief complaint of headache and was found to have cryptococcal meningitis with a hospital course complicated by Pneumocystis jirovecii pneumonia (PJP), CMV colitis, and Kaposi sarcoma. …

A Case Of Varicella Zoster Virus Meningitis Presenting As Idiopathic Vocal Fold Paralysis, Dustin Sneed, Md, M. D. Kilpatrick, Md, Alicia Bao, Md

The Medicine Forum

The typical presentation of a patient with herpes zoster, the reactivation of varicella zoster virus (VZV), involves a painful dermatomal vesicular rash known as shingles. However, as the following case demonstrates, VZV reactivation can present with atypical symptoms, sometimes without the characteristic rash. This presentation is known as zoster sine herpete. This case focuses on a patient presenting with dysphagia and dysphonia, who was diagnosed with VZV meningitis with suspected laryngeal involvement. We discuss workup and treatment for this disease, and the importance of a wide differential and multidisciplinary consultation to improve patient outcomes.

When The Cure Complicates: Ifosfamide, Methylene Blue, And A Life-Threatening Dilemma, Michael Predi, Do, Sarah Sulkowski, Md, Anika Patel, Ba, Evan Nardone, Md

The Medicine Forum

Ifosfamide, an alkylating agent and a cyclophosphamide analog, can be used alone or in combination with other agents as salvage therapy for metastatic soft tissue sarcoma. Neurotoxicity, often presenting as encephalopathy, is a common side effect of ifosfamide therapy, affecting up to 60% of patients.¹ Symptoms can range in severity from mild cognitive disturbances to severe, potentially fatal neurological impairments, such as hallucinations, confusion, drowsiness, and coma, which may develop within 2 to 96 hours of drug administration.²

Treatment of neurotoxicity includes cessation of ifosfamide and initiation of methylene blue (MB), which is used as both a therapeutic …

An Unusual Complication Of Metastatic Colorectal Cancer: Port-Site Hematoma As The First Sign Of Bone Marrow Involvement And Disseminated Intravascular Coagulation, Michael Predi, Do, Julia Palecki, Md, Jordan M. Isaacs, Ba, Ruben Rhoades, Md

The Medicine Forum

Disseminated intravascular coagulation (DIC) is a life-threatening condition marked by a spectrum of thrombosis due to activation of procoagulant factors and bleeding due to eventual consumption of these factors. DIC invariably occurs secondary to an underlying condition, including infection, inflammatory conditions, trauma, and malignancies. Treatment of DIC primarily involves treatment of the underlying cause.¹

Bone marrow invasion occurs when tumor cells infiltrate the hematopoietic marrow space, displacing progenitor cells and causing cytopenias. This process is distinct from bone metastases, where malignant cells spread to the cortical or trabecular bone, typically causing bone pain, pathologic fractures, or hypercalcemia. Disseminated carcinomatosis …

Immune Thrombocytopenic Purpura In The Setting Of Newly Diagnosed Colorectal Cancer: A Case Report, Beatriz Torre, Md, Karlie Brasch, Md, Christopher Henry, Md

The Medicine Forum

Immune thrombocytopenic purpura (ITP) is an acquired thrombocytopenia caused by autoantibodies against platelet antigens. ITP is most often associated with infection or autoimmune disease, but it has also been linked to malignancy.¹ In this case, we discuss the relationship between ITP and colon cancer.

Case Report Of Gastritis As A Complication Of Immunotherapy Treatment Of Metastatic Endometrial Cancer With Lenvatinib And Pembrolizumab, Bret Mccarty, Md, Nia Johnson, Bs, Suchit Bhutani, Md

The Medicine Forum

Immune checkpoint inhibitors (ICIs), such as pembrolizumab (a PD-1 inhibitor), have been shown to be effective in the treatment of a variety of malignancies, including progressive endometrial cancer. ICIs help to activate the patient’s immune system to attack neoplastic cells. However, this immune activation can trigger autoimmune side effects throughout the body, known as immune-related adverse events (irAEs). Immunotherapyassociated hepatitis, colitis and diarrhea have been well documented as irAEs, but gastritis is much less common.1 In this case report of immunotherapy-related gastritis, we attempted to better characterize this more rare condition to assist with early recognition and initiation of appropriate …

Investigating The Link Between Ulcerative Colitis And Papillary Thyroid Carcinoma: A Case Report, Sonali Shah, Md, Emily Chiacchiaro, Md, Priya Sehgal, Md

The Medicine Forum

Inflammatory bowel diseases (IBD) are chronic inflammatory conditions that primarily involve the gastrointestinal tract, but also cause widespread systemic inflammation. There have been multiple studies investigating the link between ulcerative colitis (UC) and crohn’s disease (CD) and thyroid diseases, as the incidence is greater than the general population.¹ In addition, patients with IBD have been found to be at increased risk of developing both intestinal malignancies and extra-intestinal malignancies.² Literature review suggests a possible connection between ulcerative colitis and papillary thyroid cancer, with most studies concluding there is a higher risk of PTC in patients with UC, but …

Complexities In Alcoholic Necrotizing Pancreatitis: A Case Report Of Severe Vascular And Infectious Complications, Dawood Tahir, Md, Shravya Ginnaram, Md, Jacob Lipkin, Md

The Medicine Forum

Acute pancreatitis (AP) incidence has been increasing, with an annual incidence of approximately 5 to 40 cases per 100,000.¹ Several complications occur with AP, including splanchnic vein thrombosis (SVT), pseudocyst, and pseudoaneurysm (PSA). Moreover, 15-20% of patients develop necrotizing pancreatitis (NP) following an episode of AP with a mortality rate of up to 32%,² which can be further complicated by infected necrosis in up to one-third of patients.² Hemorrhage is estimated to occur in less than 6% of patients with NP by pseudoaneurysm.³ The endoscopic step-up approach is the standard treatment for walled-off necrosis, whereas alternative …

Use Of Novel Agent Purastat® For Post-Sphincterotomy Bleeding, Ananya Venkatesh, Md, Bertilia Tavarez, Md, Ms, Pedra Palacios Argueta, Md, Donna Leet, Md, Afshin Khan, Md, Abdul Kouanda, Md, Anand Kumar, Md, Alana Persaud, Md, Yasi Xiao, Md, Alexander Schlachterman, Md, Thomas Kowalski, Md, Faisal Kamal, Md

The Medicine Forum

Endoscopic sphincterotomy is commonly performed during endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic sphincterotomy (ES) is associated with adverse events such as bleeding.¹ PuraStat® is a new synthetic hemostatic gel being used for treatment of gastrointestinal bleeding. We aim to report and outcomes of PuraStat® for post-sphincterotomy bleeding.

Use Of Novel Agent Purastat® For Post-Ampullectomy Bleeding, Bertilia Tavarez, Md, Ms, Ananya Venkatesh, Md, Pedra Palacios Argueta, Md, Anand Kumar, Md, Alana Persaud, Md, Yasi Xiao, Md, Alexander Schlachterman, Md, Faisal Kamal, Md, Thomas Kowalski, Md

The Medicine Forum

Endoscopic ampullectomy is the first line treatment modality for major papilla neoplasms that have not invaded the muscularis propria.¹ Complications of endoscopic ampullectomy include bleeding, pancreatitis, perforation, papillary stenosis, and cholangitis with the incidence of post-ampullectomy bleeding reported to be as high as 30%.^1,2 PuraStat® is a new synthetic hemostatic gel being used for the prophylaxis and treatment of gastrointestinal bleeding.^3-5 To date, there are no reports on the use of PuraStat® for post-ampullectomy bleeding. We hope to investigate the use and outcomes of PuraStat® for post-ampullectomy bleeding.

Racial Disparities In Response To Ibd Directed Therapy In Crohn’S Disease And Ulcerative Colitis: A Single Center Experience, Ananya Venkatesh, Md, Justin Robbins, Md, Zach Breslin, Md, Cuckoo Choudhary, Md

The Medicine Forum

Crohn’s disease (CD) and ulcerative colitis (UC) are chronic inflammatory bowel diseases (IBD) associated with significant morbidity and mortality. Current clinical guidelines recommend a range of therapies, including tumor necrosis factor alpha (TNFα) antagonists, anti-integrins, interleukin-12/23 (IL12/23) inhibitors, Janus kinase (JAK) inhibitors, and/or corticosteroids for both induction and maintenance of remission. Determining the optimal medication for individual patients can be challenging due to the complexity of treatment options and the need to consider numerous phenotypic factors. While treatment guidelines do not address racial differences explicitly, prior research has highlighted significant phenotypic disparities based on race. This study aims to explore …

Williams Syndrome Presenting With Pericardial Effusion And Left Ventricular Apical Aneurysm: A Case Report, Zachary Pang, Md, M. D. Kilpatrick, Md, Sairamya Bodempudi, Md, Darius Farzad, Md, Daniel L. Fischman, Gregary D. Marhefka, Md

The Medicine Forum

Williams syndrome (WS) is a genetic disorder caused by a gene deletion involving the protein elastin on chromosome 7q11.23. WS is associated with intellectual disability and characteristic facial features, including a short nose with a flat nasal bridge, medial eyebrow flare, and long philtrum.^1-2 WS is also associated with cardiovascular manifestations, most commonly supravalvular aortic stenosis. Patients with WS have an estimated risk of sudden cardiac death that is 25 to 100 times greater than the healthy age-matched population.³ This case highlights the importance of keeping acute coronary syndrome on one’s differential when caring for patients with Williams …

A Shock To The Heart? A Case Of Phantom Shocks In A Patient With Brugada Syndrome, Virginia Gonzalez, Md, Rebecca Goldfinger-Chanin, Md, Behzad B. Pavri, Md

The Medicine Forum

Brugada syndrome is an inherited condition characterized by an increased risk of sudden cardiac death (SCD) secondary to lethal ventricular arrhythmias occurring most often in the fourth decade of life. Implantable cardioverter-defibrillators (ICDs) are recommended in patients who have documented ventricular tachycardia (VT) or ventricular fibrillation (VF) and in patients presenting with a spontaneous type 1 Brugada pattern on electrocardiogram (ECG) and a history of arrhythmic-sounding syncope.¹ However, patients with ICDs are at risk of developing “phantom shocks” which occur when a patient reports the sensation of receiving a shock that is not confirmed upon subsequent device interrogation.^{2 …}

Protamine Sulfate-Induced Coronary Vasospasm Resulting In Takotsubo Cardiomyopathy, Matthew J. Bierowski, Md, Andre Cunningham, Do, Jordan Feingold, Md

The Medicine Forum

Takotsubo syndrome (TTS), also known as stress-induced cardiomyopathy, is characterized by new left ventricular (LV) dysfunction out of proportion to any known coronary artery disease that usually follows an emotional or physical stress. The disease process mimics acute coronary syndrome (ACS), with acute chest pain, moderate elevations in serum troponins, and electrocardiographic changes. While spontaneous return to normal left ventricular function is typical, the morbidity and mortality of TTS is significant, with increased risk for major adverse cardiac events and disease recurrence.¹

The understanding of the pathogenesis of TTS is incomplete, although recent work has identified that several processes …