Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
In what conditions can you see roving eye movements?
Roving eye movements are seen in comatose patients with intact oculomotor/ brainstem function. These movements can be conjugate or dysconjugate with no pathological significance between the two. Movements are usually horizontal, but vertical eye movements can also occur. Their presence rules out psy...
Are there best practices or data regarding the use of open notes among oncology patients?
The 21st Century Cures Act regulation (effective April 2021) required that clinical notes such as consult and office notes be shared with patients, e.g. “open notes.” In general, surveys of patients with cancer and their clinicians suggest that open notes are viewed favorably (Salmi et al., PMID 330...
Do you offer adjuvant therapy for rectal intramucosal carcinoma within a large rectal adenoma?
Not if the margins are negative and it’s not into the muscularis.
How do you approach treating cutaneous PAN?
I've had personal experience with treating at least a dozen patients with cutaneous polyarteritis nodosa. The diagnosis was made by the clinical appearance of the lesions usually erythematous nodules that spontaneously may disappear leaving behind a livedo pattern. A biopsy of the lesion verified th...
Do you recommend patients wait to have a total hip sx after salvage radiation for RP?
No, I would not require a waiting period because of the total hip replacement. I standardly use IMRT and we typically avoid incoming beams through artificial joints anyways because of the attenuation. Thus, more likely to use a static multi-beam plan than VMAT if the patient has an artificial hip. U...
Do you routinely monitor the QTc when adding voclosporin to hydroxychloroquine in a patient with lupus nephritis?
I approach this situation similar to any drug that can potentially prolong QTc intervals when used with hydroxychloroquine (HCQ). [see final comment at the bottom]Quick answer: No, I do not monitor ECGs (QTc) in patients taking voclosporin (VOC) plus HCQ unless they are at high risk for QTc prolonga...
Why do we not typically see features of rhabdomyolysis or acute kidney injury with idiopathic inflammatory myopathies?
Because rhabdomyolysis leading to AKI means acute massive necrosis of a large number of muscle fibers with resulting release of myoglobin In blood and precipitation of myoglobin in renal tubules, leading to tubular necrosis. This acute extensive myonecrosis typically does not occur with IIMs, with t...
Would you consider using DOACs in a young patient with SLE and Libman-Sacks endocarditis, who is negative for APS?
In this scenario, our patient with lupus is young and does not have features of APS. Nevertheless, any patient with Libman Sacks endocarditis carries a heightened risk for embolization. Regarding anticoagulation, the literature on this subject is anecdotal and conflicting with some authors recommend...
What are the alternatives to anticoagulation in an individual with an atrial thrombus and absolute contraindications to anticoagulation?
This is not an easily answered question in this sort of a forum. This clinical situation requires multidisciplinary input and individualized approach. Factors to consider include but not limited to, 1) estimated risk of systemic arterial embolism (note, current tools/calculators provide the annual r...
Is there a role for antifibrotic therapy in post COVID-19 pulmonary fibrosis?
As you may know from working with these patients in the acute and post-infection (PASC - post-acute sequelae of COVID-19) settings, there is a spectrum of lung injuries that can ensue after infection with SARS-CoV-2. This spectrum is composed of mild GGOs to organizing pneumonia to fibrosis (or, fre...