Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How should you work up calvarium or other osseous lesions when found during the initial staging of a patient with a new diagnosis of NSCLC otherwise non-metastatic?
In general, I try to "prove" metastatic disease to ensure appropriate staging. I have had several situations where a skull or other osseous lesion is suspicious on CT and have tried to assess by PET or NM bone scan - ultimately though, have referred for biopsy and have actually diagnosed several int...
How do you manage a diabetic patient with generalized myasthenia gravis post thymectomy previously treated with Imuran?
There is some additional information required to answer this question, specifically: a) did the patient have thymoma on pathological exam? and perhaps the most important b) What was the clinical status of the patient's MG prior to thymectomy (severity, MG ADL/QMG scores)? and c) Was azathioprine the...
Can APLS cause a false positive HIT ELISA?
Yes, that has been reported: Pauzner et al., PMID 19291166.
What is the optimal management of a patient needing surgical clearance for a knee replacement with VWF Ag and factor VIII between 40-50 and no bleeding history?
This is a difficult question. I would make sure that the patients had adequate "stress tests" of their hemostatic system before concluding they have no bleeding history. For example, it is difficult to estimate the bleeding risk if somebody has never had surgery or pregnancy and has been on OCP sinc...
What is your approach to tapering therapy in a patient with recurrent pericarditis now well-controlled on rilonacept?
Good question, since rilonacept was only approved 1.5 years ago, a lot of this is gleaned (i.e. expert opinion) from those that participated in the Rhapsody clinical trial.In terms of actual data, the long-term follow-up from Rhapsody was just presented at AHA.2022. Of those in the extension that de...
Do you prescribe antifibrotics to patients with combined pulmonary fibrosis and emphysema (CPFE)?
The definition of CPFE is not very well standardized. CPFE commonly presents with upper lung-predominant emphysema and basilar/peripheral-predominant fibrosis. Pulmonary fibrosis in CPFE could be due to IPF or other ILDs. I prescribe antifibrotics for patients with CPFE-IPF and CPFE-other ILDs with ...
How would you manage an adult patient status post subtotal resection of spinal osteoblastoma?
US can be helpful if performed serially. If/when there is evidence of growth, discuss ablation options with IR if feasible.
How do you counsel NSCLC patients receiving SBRT on fatigue?
The first thing is to warn the patient and their family that fatigue is possible, and that it peaks about 2 weeks after treatment ends. I also remind them that SBRT is like surgery in that it causes some damage that requires energy to repair, so some fatigue is to be expected. Finally, I tell them t...
Do you routinely screen for pulmonary artery aneurysm in patients with Behcet's?
I don't routinely screen Behcet syndrome patients for pulmonary artery aneurysms. They are a rare manifestation of Behcet syndrome; however, some clinical features increase the likelihood of pulmonary artery aneurysms. Behcet patients with thrombophlebitis are at increased risk of having pulmonary a...
Does recent COVID-19 infection result in elevated PSA?
A study from Turkey showed that PSA can increase sometimes dramatically in men with BPH (not necessarily with prostate cancer) during active COVID infection, from an average of 1.5 pre-COVID to 4.3 during active infection. (Cinislioglu et al., PMID 34626600). One can imagine a similar phenomenon may...