Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How would you approach the work up of SLE in a patient over 80 years old?
Elderly onset lupus is uncommon and in the past twenty-five years has been reported to occur in as few as 6% of patients to as many as 19% of patients with the diagnosis of lupus. Typical clinical presentations tend to include arthritis/arthralgias, fever, weight loss, lymphadenopathy, serositis, si...
What is your approach to considering geriatric patients for complex PCI given their overall frailty and increased risk of complications such as bleeding and stroke?
I would do everything I could with respect to medical and lifestyle therapy for such a patient. They are at very high risk for a bad outcome in the cath lab.
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?
Acute interstitial nephritis is the more common type of kidney injury associated with immune checkpoint inhibitors. However, there is also associated acute tubular necrosis secondary to cytokine release from activated T cells. ATN can be also due to chemotherapy used in conjunction with ICI such as ...
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?
I always check it for prolactin levels that are abnormal, but below 100 ng/mL. Macroprolactinemia is rather common in mild/moderate hyperprolactinemia, but it is very rare as sole cause of hyperprolactinemia when level is higher than 100 ng/mL. Importantly, even real hyperprolactinemia may appear mo...
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...