Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When do you pursue interventional treatments in a lung transplant patient with anastomotic dehiscence complicated by a bronchopleural fistula?
Very small areas of dehiscence are typically managed conservatively with serial bronchoscopy for observation. However, for larger areas of dehiscence associated with a higher risk of mediastinal or pleural infection, we typically opt for mechanical debridement and airway stent placement to cover the...
For bone metastases requiring surgical stabilization, what time interval from the date of surgery do you use for post-op radiation?
Generally, the surgical stabilization minimizes the capability of short-term catastrophe in (like path fracture), what I presume to be a long bone that has undergone surgical stabilization. I'd probably want to give a few days just to maximize local wound healing but starting sometime, maybe 1-2 wee...
What are your management strategies for acute kidney injury attributed to pembrolizumab in patients with a kidney biopsy showing predominately acute tubular injury?
If ATN is indeed the predominant lesion, then I’d work up for usual causes (meds, infection, hemodynamic shifts, etc.). I would not advise holding pembrolizumab in this case unless there are other indications to do so.
Do you pursue a malignancy workup beyond age-appropriate malignancy screening in patients with antibody negative necrotizing myopathy?
This is a great question that speaks to the nuanced (and still-being-elucidated) association between malignancy and the increasingly better sub-divided different autoimmune myositis subtypes:While anti-SRP and anti-HMGCR are the two myositis-specific antibodies (MSA) most closely associated with imm...
Do you pursue a skin biopsy or kidney biopsy in patients whom you suspect have X-linked Alport syndrome?
The approach to the diagnosis of Alport syndrome has changed over the past decade with heavier reliance on molecular genetic testing sometimes prior to or in lieu of tissue diagnosis, however, this is dependent upon many factors including insurance coverage and availability of electron microscopy. G...
When do you check macroprolactin in the evaluation of hyperprolactinemia?
Macroprolactin is usually biologically inactive so if a patient has high prolactin without any symptoms, I would check macroprolactin.
What is your approach to a patient with IgG4RD with past pulmonary involvement (biopsy proven) managed with steroids alone, now with new hematuria/proteinuria, but stable renal function?
Significant hematuria is not a typical feature of IgG4-related kidney disease. IgG4-RKD most commonly presents as tubulointerstitial nephritis (TIN), which presents as mild, non-nephrotic range proteinuria. In fact, urinalysis in the context of TIN is often normal, as the proteinuria is largely non-...
What additional testing besides LAC/APLS, factor V Leiden, prothrombin gene mutation, JAK 2 do you draw for unprovoked cerebral venous sinus thrombosis?
Cerebral venous sinus thromboses (CVST) are often put into the category of "thromboses of unusual sites,"--as opposed to the more common lower extremity thromboses or pulmonary emboli.Provoked causes of CVST include pregnancy or exogenous estrogen use, infection of the head/neck or CNS, head trauma,...
How do you approach treating patients with lupus profundus?
For lupus profundus/lupus panniculitis, I would first confirm the diagnosis with a deep punch biopsy or incisional biopsy. The differential for lupus profundus includes factitial panniculitis, traumatic panniculitis, morphea profundus, and subcutaneous panniculitis-like T-cell lymphoma.Once the diag...
How long can you treat dermatomyositis with IVIG?
Typically, in best-case scenarios, you can treat dermatomyositis with IVIG for 1 year, but some patients require it for 18-24 months, and the minority of patients continue to require it over several years. Some patients may only need it until you achieve improvement, especially in some countries whe...