Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Is LP indicated for patients with recurrent thunderclap headaches over a 4-week period and negative head imaging for SAH?
Such benign presentation (recurrent thunderclap headaches only) may have been RCVS but the diagnosis may have been missed. Spasm peaks around 10 days after headache onset. When arterial imaging is done too early or too late, arterial spasm and specific RCVS diagnosis might be missed. CTA, MRA, and a...
What is the significance of elevated fractionated catecholamines in POTS?
Dear Dr. @Dr. First Last,I don't think we understand the pathophysiology of POTS well enough to comprehensively answer this question.There are a number of technical issues that come into play when drawing serum catecholamines.First of all, many things can elevate catecholamines temporarily: exercise...
How do you manage osteonecrosis and pelvic insufficiency fractures after pelvic radiotherapy?
I have never seen osteoradionecrosis happen before in the pelvis. It should not happen in the range of doses that are tolerable in the pelvis due to the constraints imposed by the sacral plexus and the luminal GI organs. Sacral insufficiency fractures happen uncommonly, but are more common in female...
Do you avoid PTH/PTHrP analogs in patients with recurrent/severe CPPD?
I assume Dr. @Dr. First Last meant PTH-related bone-building drugs, not bisphosphonates, in his answer. I agree that I would use these drugs if needed in someone with CPPD disease, but I have not come across the scenario outlined in the question and am not aware of any data on the use of these drugs...
What is the differential for a patient with unilateral arm swelling, MRI with muscle edema, and markedly elevated CPK?
The differential for focal myositis is broad, although many times no obvious etiology is revealed and in that case, it is considered to be idiopathic. Etiologies that need to be ruled out are: malignancy (usually confirmed by biopsy), infections (like mycobacteria, viruses, fungi; usually will have ...
What is the role of x-ray of the cervical or lumbar spine in patients presenting with radicular symptoms?
I agree that X-rays are useless the vast majority of the time. You can of course pick up lytic lesions from metastasis or plasmacytoma, or other bone-based cancers. Sometimes flexion/extension films are helpful, since MRIs are almost always static and supine (until dynamic MRIs obtain more widespre...
How does the FDA safety warning on the cardiac effects of lamotrigine, based on in vitro data, inform your clinical practice?
I am aware of it and will be careful in using it with patients who have any conduction abnormalities, though that doesn't mean I won't use it. I have been using it for many years (my program during fellowship was a research site for bringing it to the US) and never had a problem with it.
What is the most effective treatment for a patient with persistent post-stroke headache?
Although I have tried many of the traditional preventive treatments such as topiramate, propranolol, candesartan (esp if HTN), and amitriptyline (esp if insomnia), the results are variable at best. I believe that CGRP mab are safe in this situation and are probably the best option for episodic migra...
In your experience, is there an association between interstitial cystitis and systemic lupus erythematosus?
There are reports of interstitial cystitis associated with lupus. I have had two patients with that combination, one that is particularly severe. Lupus may or may not be active at the time. There are case reports in the literature of different treatments to try as the standard drugs may not be effec...
Why do we use dexamethasone for CNS edema and prednisone for pneumonitis?
Dexamethasone has better CNS penetration compared to prednisone and thus its established use for managing vasogenic edema. However, it has the most suppressive effect on ACTH, causes relatively more steroid myopathy and has less mineralocorticoid effect compared to prednisone hence, the general use ...