Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach a patient with IgM monoclonal gammopathy associated with severe neuropathy of unclear etiology?
I usually confirm if the patient does not have AL Amyloidosis or POEMS, and as part of work up for IgM MGUS, I order MYD 88 mutation. If all are negative and I still believe that neuropathy is caused from his/her MGUS, you can try IVIG for the neuropathy as a trial (of course after using gabapentin,...
What screening criteria do you use to give patients IV contrast for the CT sim?
This is an extremely frustrating and commonly encountered scenario in radiation oncology clinic (and the diagnostic CT suite). What is most frustrating is how stubbornly the dogma of contrast-induced nephropathy has persisted, and the vast amount of needlessly wasted resources spent worrying about i...
Do you insist on biopsy confirmation of invasive disease in the setting of in situ pathology findings but otherwise clinical/radiographic evidence of invasive cancer?
Not necessarily. I recently had a case of cervical cancer which was called CIN 3 on 2 consecutive biopsies with a palpable mass approximately 3cm in size on clinical exam. PET/CT showed intense FDG avidity in the cervix with a 5cm mass and pelvic lymph nodes. We treated as a IIIC invasive SCC. While...
Would you clear a patient who completed treatment for breast DCIS to donate her kidney to her husband?
Yes.
Do you routinely order a thoracic or brachial plexus MRI for patients with apical lung cancers?
For patients with superior sulcus tumors (or apical lung tumors), their clinical presentation usually drives the choices of imaging modality. In my experience, if a patient has an apical tumor and presents with no symptoms at all, then I would not see the utility or need to require MRI imaging, unle...
When a patient presents with 2 lung lesions, do you routinely recommend a biopsy of both lung lesions?
2nd lesion may be a satellite met.
Would you consider giving ESA for anemia secondary to chronic kidney disease in a patient with follicular lymphoma in remission and on rituximab maintenance?
Yes. The risk of ESA has been re-evaluated and is not considered a risk of NHL. Even with the prior retrospective data, follicular lymphoma is not a curable disease and therefore ESA would not have been contraindicated.
For rectal adenocarcinoma initially staged as T2N0 and treated with upfront surgical resection, but pathologically upstaged to pT3N0 without high risk features, how do you approach adjuvant therapy?
It is not uncommon for a rectal cancer which was initially felt to be T1-2 and node negative to be revealed to be more advanced stage after surgery. To know what to do in these settings, we have to go “old school” and revisit trials reported in the 1990s, combined with lessons learned in the 2000s.S...
Due to the thrombotic nature of COVID-19, should we be discontinuing tamoxifen temporarily in patients with an active infection?
It is not clear (at least to me) what the thrombogenic potential of COVID-19 is, or in what settings it manifests (i.e., hospitalized patient with an increasing O2 required or intubated, in which there are some preliminary reports, versus the asymptomatic or minimally symptomatic patients). It seems...
Should patients about to start radiation be required to have COVID-19 testing, if resources are available?
We are also pre-testing all procedural cases using PCR, but are doing symptom/question screening for all outpatients, not allowing visitors outside of special situations, and maintaining social distancing in the hospital (decreasing areas for patients to sit) so they are forced to remain apart. The ...