Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
In a patient with a history of treated stage II seminoma with rising bHCG while on surveillance, do you routinely recheck the bHCG with a different assay?
In this setting, it depends a lot of the confidence you have in the treatment and the degree of HCG elevation. It also depends to some degree on whether the patient had an HCG elevation when he presented with stage II disease. In most of these cases these are very low level HCG elevations that bounc...
When TPN is a barrier to enrollment in hospice for an eligible cancer patient with an irreversible malignant bowel obstruction, how do you approach the conversation about discontinuation of TPN?
This is such a tough question with no great answer. With any difficult conversation like this, I usually take this approach: 1) Understand what the patient's goals are. ("What's most important to you?") 2) Usually they say living as long as possible/as well as possible 3) Acknowledge that goal as r...
How do you treat hiccups in cancer patients?
Personal success has lead me to use Baclofen to control chemotherapy induced hiccups. A single 10 mg dose is usually effective for patients who experience hiccups upon administration of chemotherapy. Occasionally 10 mg q 8 h prn is needed for a few doses. I have seen this side effect and used Baclof...
Do you treat pre- or post-operatively for HO prophylaxis?
At our institution, we typically treat postoperatively rather than preoperatively, although many studies have shown preoperative to be as effective as postoperative. That said, there is one study by Seegenschmeidt et al reported in IJROPB in 1997 that showed preopeartive was less effective for Brook...
How do you manage a rib fracture caused by SBRT?
Chest wall pain, with or without a radiographically evident rib fracture, is an infrequent complication of SBRT--and, it should be remembered, rib fracture is also an infrequent complication of conventionally fractionated RT, reported in numerous series of patients treated with RT to the breast/ches...
How do you manage dental care, oral hygiene, and nutrition in patients with trismus?
This can be remarkably challenging. Each case must be tailored to the oncologic presentation and discussed with the multidisciplinary team (surgeon, med onc, rad onc, dentist, speech pathologist) and patient. Ideally, your team can try to anticipate short and long-term expections regarding resolutio...
Would you ever omit adjuvant therapy for rectal cancer in patients who underwent primary resection (TME), without any neoadjuvant therapy?
When is it appropriate to recommend a diverting colostomy for treatment of anal cancer or low lying rectal cancer?
If there is bowel obstruction/ near obstruction, recto-vaginal or rectovesical fistula formation.
How do you interpret and utilize PSA values in patients on dialysis?
There appears to be no clinically relevant impact on total serum PSA, whereas free PSA and % of total can be impacted in a membrane type-dependent manner to where % free PSA is of less utility for screening. Thus, total serum PSA seems reasonable to continue as marker of biochemical control post-tre...
How would you qualify and treat a patient with neutropenia, anemia, and abnormal NK cell population with normal trilineage marrow maturation?
I would run a molecular test to confirm that the clonality does not show a CD8-positive clone, as that is more common in LGL. The findings of a clonal NK population by flow cytometry would be enough, in the setting of neutropenia and anemia, to consider a diagnosis of NK cell LGL.