Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you balance aspiration risks with encouraging PO intake for HN cancer patients during and after chemoradiation?
The main challenge is to identify the patients who are most prone to aspirate during and after Tx. Chemo-RT-related aspiration is frequently “silent”: the patient does not recognize he/she aspirates, and neither does the observer. The risk of aspiration is assessed by modified barium swallow perform...
How do you manage urgency and frequency of bowel movements secondary to radiation proctitis?
In the acute setting we try anusol HC suppository to decrease tenesmus like symptoms
Is it possible to have diffuse, bilateral pulmonary fibrosis as a late side effect of unilateral radiation therapy for breast cancer?
The only context you may see this is in a patient with underlying Interstitial Lung Disease (ILD). I had a woman with a small pulmonary nodule adjacent to the heart and was unresectable. She had moderately severe ILD, and I used a proton plan to try and keep the low dose RT out of the rest of the lu...
How would you manage a patient who presented with synchronous squamous cell carcinoma of the anus (cT2N0) and adenocarcinoma of the rectum (cT3N0) at 7cm from the anal verge?
There is clearly no "correct" answer to questions such as these. However, a reasonable approach would be to treat as one would treat an anal cancer with pelvic RT with 5-FU and mitomycin C and then follow with a low anterior resection for the rectal cancer. If this were a small T2 cancer it would be...
How would you manage a patient with a very large adenocarcinoma of the rectum (10 cm) that extends to the anal verge with positive peri-rectal and inguinal lymph nodes, but no distant organ involvement?
Anyone with locoregionally confined rectal cancer that is medically operable should be considered for definitive surgery after neoadjuvant chemoradiation without any question. The survival of node positive rectal cancer based on historical data when the chemotherapy was not as active as today was 50...
If a patient develops intermittent painless hematuria during standard prostate RT do you attribute this to cystitis or would you work it up further?
While acute mucosal deepithelialization may be to blame, painless hematuria may unfortunately mark the beginning of a conundrum. It's good medicine to always develop a broad DDx and remember that radiation injuries are waste basket diagnoses. It's also wise to start with a UA/UCx, and if negative do...
How would you approach a biopsy proven NSCLC patient with mediastinum negative disease and contralateral suspicious spiculated PET avid nodule without pathologic diagnosis?
This is a scenario I have faced before. Sometimes unfortunately in spite of staging studies, the stage a lung cancer patient has might remain a bit unclear. In this situation if this is a functioning patient with good PFTs who is a surgical candidate I would consider treating him like he has 2 separ...
Is there anything you use for patients with anticipatory nausea who has failed Ativan and Zyprexa?
I know of no data, but I would consider hypnosis, mediation and mindfulness, cognitive behavioral therapy, acupuncture, and medical marijuana as possible options for anticipatory nausea refractory to lorezapam and Zyprexa. Hypnosis, mindfulness, and cognitive behavioral therapy are in a sense are re...
What is your preferred treatment to ameliorate bone pain from G-CSF?
Loratadine (or cetirizine) used prophylactically before each dose is very effective. There are published cases : https://www.ncbi.nlm.nih.gov/m/pubmed/24664474/ and my experience is this is effective in a vast majority of cases.
What are your recommendation for vaccines in patients while on immunotherapy?
It's ok to give.