Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you routinely obtain a CXR or CT after identifying an etiology for dyspnea on POCUS?
Sometimes, it depends on the patient. I usually do a POCUS in a patient with dyspnea or respiratory failure. If I think there is an ILD or another disorder causing dyspnea, then I would get a CT.
Are there any varying treatment considerations to make when managing patients with carbonate apatite versus hydroxyapatite kidney stones?
Both of these stone types require a relatively alkaline urine to crystallize. Not surprisingly, they are often found in combination within the same stone. My diagnostic and treatment considerations do not depend on which mineral composition predominates. Stephen B Erickson, MD
How do you utilize cytokine panels in your clinical practice?
It's become easier to order cytokine panels that get processed locally in my hospital. However, I think we're still far from knowing how to interpret these or make clinical changes as a result. While it's tempting to think, "If TNF is elevated, I will give the patient a TNF inhibitor, which will mak...
What additional treatment strategies would you recommend for a patient with a Mycobacterium chelonae and Mycobacterium abscessus infection following bilateral prophylactic mastectomies and implant insertion, who has undergone multiple surgeries and an extended course of IV antibiotics selected based on sensitivities?
I assume the implants have been removed. I have had no success trying to treat with retention of the implants (because the patients all want a trial of antibiotics first at the suggestion of the surgeon). If the implants are out, all you can do is continue long courses of antibiotics based on sensit...
What 24 hr urine calcium cut off value do you use for recommending parathyroidectomy in patients with asymptomatic hyperparathyroidism?
I use 5.0 mg/kg as a cut point.
Should I treat a patient who doesn't know she has cancer?
Interesting opinions. Wonder if anyone has their own experience. I will bite. My grandfather was diagnosed with mesothelioma (he had worked in a salt plant laden with asbestos). He had 9 children in North America and was staying with them. They chose, as a family, not to tell him he had cancer. We a...
Have you incorporated the use of linezolid in lieu of vancomycin plus clindamycin for empiric treatment of necrotizing fasciitis?
Clindamycin (with beta-lactam) vs linezolid use debate exists for severe invasive GAS infections like necrotizing fasciitis cases. Both inhibit protein synthesis via the 50s ribosome subunit, inhibiting translation and, thus, toxin production. The concern is rising clindamycin resistance in GAS isol...
How do you approach a patient with biochemical evidence of primary hyperparathyroidism, but normal parathyroid scan?
Negative sestamibi scans are not unusual in patients with primary hyperparathyroidism. Other imaging tests may be negative also. If the patient has biochemical evidence of the problem and has even mild complications referral to an experienced parathyroid surgeon would be warranted. Alternatively, ci...
How does one interpret an SPEP showing potentially obscured but non-quantifiable M-spike however an IFE showing monoclonal protein?
Not all patients with monoclonal gammopathies make a detectable paraprotein on SPEP, or, in some cases like IgA gammopathies, it may be 'hidden' in the beta-region of the SPEP, or the rare IgD and IgE gammopathies may be too low to detect on the SPEP. In addition, for the 15-20% of patients who have...
How often do you pursue malignant transformation screening In patients with lymphomatoid papulosis or pityriasis lichenoides?
In the case of patients with lymphomatoid papulosis (LyP) or pityriasis lichenoides, regular follow-up and monitoring for signs of malignant transformation is important, given the potential (though generally low) risk of progression to lymphoma, especially cutaneous T-cell lymphoma. For LyP, follow-...