Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you typically treat aortitis associated with spondyloarthritis?
This is a complicated question - I typically think about combination therapy or CellCept/methotrexate plus TNFis. Depending on the severity, Cytoxan is always a good option to start. Typically IL-6 blockade does not help for the spondy patient - so I only use IL-6 when the spondy symptoms are not pr...
What is your go to steroid regimen for post SRS headache?
Start with Dex 2mg. If that works, then that's it. If it continues, can take a second dose later in the day. It is usually transient, so I don't prefer to give high/long doses and just manage as it comes. Typically, in a day or two, it appears to resolve in my experience.
How do you manage an infection that occurs in the treatment field while under treatment?
I believe it is rare to develop an infection within the treated volume. When it does happen, treating with antibiotics and continuing treatment is probably best. If it is an abscess, then sometimes drainage with possible re-planning is necessary. I generally do not stop treatment unless the patient ...
Would you consider clearing a patient with essential thrombocytosis for a kidney donation?
For brevity, I am assuming that the patient is already medically approved for surgery and organ donation, and I will focus on the clinical significance of the essential thrombocytosis (ET) with regard to both. I am also going to assume that the patient actually has ET, and not masked polycythemia ve...
How would you approach a patient with incidentally noted infrarenal periaortitis with positive C-ANCA, normal inflammatory markers and no systemic symptoms?
Based on data we and others have published over the past 20 years, the specificity of testing for ANCA depends on testing for antibodies to the specific antigens proteinase 3 (PR3) and myeloperoxidase (MPO) by ELISA or other newer methods. Immunofluorescence (IF) testing alone for ANCA is not accept...
How do you approach low to moderate titer of APLS when working up unprovoked DVT if it is persistent on repeat testing?
I have a low threshold to recommend long term (indefinite) anticoagulation for unprovoked thrombosis, regardless of whether there is positive APLS testing. I do agree with Dr. @Dr. First Last, however, that shared decision-making is important when committing a patient to prolonged anticoagulation, a...
What is your approach to managing RA patients with history of organ transplant already on immunosuppressive therapy such as cyclosporine or cellcept?
In contrast to my esteemed colleague, @Dr. First Last, in 38+ years in clinical rheumatology practice (maybe those 3 years make a difference), I have seen RA occur in 3 patients with solid organ transplants. All 3 were renal transplants; all 3 were recurrent diseases that had been previously control...
What is your approach for using anticoagulation/aspirin in patients with multiple myeloma?
Excellent question with lots of nuances but no clear answer. I'll start with my gestalt approach, which is to consider a DOAC for every patient with myeloma if all of the following are true: They are receiving an IMiD (lenalidomide or pomalidomide) They set off my 'spidey sense' with one or more of ...
Are there any possible scenarios where you would do phlebotomies for heterozygous hemochromatosis?
The answer is yes but unusual. Occasionally, a heterozygote or double heterozygote will be weakly phenotypically positive. If the ferritin and TSAT (on overnight fasting sample) are high, I will. I prefer that blood donation be used but if not an option, I will take it. The iron parameters must be...
How do you approach the workup for a patient with persistently elevated inflammatory markers (CRP and ESR) whose history and exam do not point to a clear cause?
Our hematologist/oncologist referred just such a patient. No evidence of malignancy, but elevated CRP &ESR. I did an “internist’s” workup as I would for dermatomyositis, starting with the most important and therefore most thorough aspect: taking a full and very “invasive” history, followed by a comp...