Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Would you treat a patient aggressively for lupus nephritis if they have persistent proteinuria over 1 gram but cannot get a timely kidney biopsy?
It all depends. I would keep pushing for a biopsy and try to overcome the barriers ASAP. If it is the patient who is the barrier (not wanting the biopsy), I would educate them on how a biopsy ends up not even being due to SLE in some cases and immunosuppressant treatment therapy would be exposing t...
Is it safe to use quinacrine in SLE patients with a history of hydroxychloroquine-associated retinopathy?
To my knowledge, quinacrine, an anti-malarial, is not FDA-approved for use in the US. It may be obtained from compounding pharmacies but the FDA makes no assertions regarding either its safety or its efficacy. For lupus, it has been used primarily as adjunctive therapy for cutaneous disease, e.g. ad...
How would you confirm the diagnosis of splenic marginal zone lymphoma without utilizing splenic biopsy or splenectomy?
You can usually make the diagnosis by immunophenotyping of peripheral blood and bone marrow. The typical morphology of circulating cells is "villous cells"; cells with long cytoplasmic projections around the entire perimeter of the cell. The typical phenotype is CD20+ (bright), CD5-, CD10-, CD23- as...
What is your threshold to repeat a kidney biopsy in a patient with a history of lupus nephritis who is on maintenance therapy and develops subtle changes in urinary protein excretion or microscopic hematuria?
There have been a number of lupus biopsy and treatment questions here lately. The management of lupus nephritis is VERY difficult with innumerable permutations of past and present, biopsy nuances, symptoms, and treatment histories. The answer to this question depends on more than "subtle changes in...
How would you manage an elderly patient with mild pancytopenia who refuses bone marrow biopsy and whose flow cytometry is suggestive of CMML/MDS?
My management would be tailored depending on the age of the patient, and more importantly, their goals of care. For geriatric patients who are not transplant eligible, the goals of therapy are focused on improving quality of life. Depending on the counts, you may still be able to obtain valuable NGS...
For patients with central hypothyroidism and a clear etiology (such as recent head irradiation), do you recommend brain imaging prior to starting thyroid hormone replacement therapy?
Levothyroxine does not cause tumor growth, and therefore you do not need to image before starting therapy. However, in general, it takes a long time for central hypothyroidism to develop after radiation, therefore in the presence of an early reduction in FT4 you must consider the possibility of the ...
How do you counsel patients with postmedian sternotomy plexopathy?
Brachial plexopathy after median sternotomy is not very common. Its frequency varies in different studies but it's most likely between 0.5-5%. The most likely mechanism is traction of the anterior rami of the C8>T1 roots, often associated with a fracture or upward displacement of the first rib. A re...
Is there a role for inpatient EMG/NCS in patients who present with rhabdomyolysis with unclear etiology?
Great question. This is something we are frequently asked to do, but frankly, it is useless most of the time or perhaps it doesn't add any information to what we already know. When a person presents with myalgia, muscle weakness, and very high CK levels (defined as well over 10 times the upper limit...
In a patient with bisphosphonate induced bilateral atypical femur fractures, how would you approach timing of alternative osteoporosis treatments and surgical management?
Unfortunately, this is still a very common problem. Although the information that oral bisphosphonates should likely be limited to 5 years duration has been available for many years, my large orthopaedic practice continues to see 2-4 atypical femur fractures per month and often the patient has been ...