Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
For a rectal cancer with questionable T3 or questionable N+ by MRI, can short course radiation be given followed by surgery and the pathology still be interpreted to guide adjuvant chemotherapy?
This is a somewhat common scenario. In these situations, I have strongly favored short course RT followed by immediate surgery such that there is not a sufficient time interval between RT and surgery to allow any significant pathologic response. I think you can be confident in that the pathology aft...
How do you manage dermatomyositis related to underlying malignancy?
Treat underlying malignancy with urgency Steroid + IVIG is the best treatment for dermatomyositis with active malignancy.
How do you manage a case of dermatomyositis that is proven on skin biopsy and clinically has proximal muscle weakness but normal muscle enzymes, including CK, aldolase?
About 20-30% of Active Dermatomyositis patients may have normal muscle enzyme level. Also, sometimes muscle enzymes other than CK and aldolase are elevated such as LDH, AST and ALT. So check all 5 muscle enzymes. Can also do EMG or MRI or muscle biopsy to confirm muscle involvement. First line trea...
How would you treat active rheumatoid arthritis in a patient in complete response on loralatinib for stage IV ALK positive NSCLC?
I would do my best to minimize immunosuppression. I would use IL-6 or Abatacept and possibly rituximab. Have done all to minimize DMARDs and have had success with all 3.
Do you continue to utilize ESR and CRP in patients on tocilizumab?
Yes, it is still worthwhile getting these tests. Anti-Il-6 therapy will reduce CRP and ESR values to very low levels, so when a result returns higher than expected, it may imply limited compliance with the drug. In some patients with very high CRP values at baseline, the CRP may take some time to re...
Do you treat secondary erythrocytosis caused by SGLT2 inhibitor?
I have seen this once, and stopped the SGLT2 inhibitor, and recommended they identify an alternative strategy to treat his DM. It seemed to help overall.
How do you work up a young patient with increasing ferritin and normal TSAT without infectious, inflammatory, or liver disorders?
This is a tough one. If the ferritin is increasing and the TSAT is normal and there is no evidence of hemochromatosis, the ONLY possible explanation is some underlying morbidity, inflammatory, rheumatologic, malignant, or infectious is present. In pediatrics, HLH (hemophagocytic lymphohistiocytosi...
Are there any risk factors for IO induced rhabdomyolysis and how do you approach and manage it?
IO can affect the muscle in many ways. There is a myasthenia gravis and myositis overlap. I am not sure we know whether it is rhabdomyolysis versus a CK leak vs steroid myopathy vs muscle necrosis due to something else. Did the patient have EMG or muscle biopsy? There is a lot we do not understand a...
How do you follow up a patient with esophageal adenocarcinoma who is not a surgical candidate after finishing chemoradiation?
I am assuming that this patient has adenocarcinoma and also had definitive dosing radiation (50.4 Gy +) and not neoadjuvant dosing as was used in the CROSS trial (41.4 Gy). If that is the case, you would use the same surveillance as you would after surgery which is H&P every 3-6 mo with labs and sca...
How would you approach an elderly patient with tibial plateau insufficiency fracture and normal DEXA?
Tibial plateau fractures are common among young individuals and often the result of trauma or injury. In the elderly, they can be related to injury but as well as poor bone strength and quality. In the aging population if DXA testing is normal and the fracture is not the result of major injury searc...