Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
In patients with secondary osteoporosis due to primary hyperparathyroidism, should parathyroidectomy be recommended in the setting of recent prior bisphosphonate use?
I would recommend parathyroid surgery in a person with confirmed primary hyperparathyroidism and osteoporosis as the bone density will increase in most patients after surgery. Many of the patients with osteoporosis may have received bisphosphonates. In rare situations, a patient may have received a ...
How would you evaluate and treat a disabling tongue tremor?
This is a very interesting presentation. First, establishing phenomenology is needed. Is this a tremor or does it appear tremulous? Tremor is oscillatory and rhythmic. If these movements do not fit this pattern, consideration of neuromuscular disorders, like myorhythmia, or other movement disorders ...
What treatment options do you recommend in a patient with idiopathic granulomatous mastitis that has not improved on steroids and methotrexate?
I have multiple cases of IGM that I have treated successfully and have gone into remission or at least not needing any prednisone with azathioprine monotherapy and combo methotrexate and adalimumab.
Do you recommend monitoring IgG level in patients with AAV receiving rituximab?
Yes! At the OSU Vasculitis clinic, we check IgG before every rituximab infusion. At a minimum, it must be done yearly to ensure no impending CVID or to change rituximab.
How do you manage immunosuppressive medications in patients who develop a pneumonia?
For most bacterial pneumonia in transplant patients, I prefer to avoid changing immunosuppressives and simply administer appropriate antibiotic therapy. This approach is effective and minimizes the risk of triggering acute rejection. For viral etiologies, I will often reduce or hold cell cycle inhi...
How would you approach peri-operative immunosuppressive management of a patient with Behcet's, currently controlled on azathioprine, who needs genital surgery?
It might be helpful to know what kind of genital surgery is planned and why. Here are a few general thoughts: There are little data to guide a unified approach outside of BD patients who need vascular surgery. Standard rules of thumb are to 1) reduce surgeries to a necessary minimum and 2) regard mo...
For an asymptomatic patient discovered during workup for elevated PT/PTT to have mild prothrombin deficiency, would you suggest any preoperative prophylaxis?
In someone with normal liver function otherwise, who was found on preoperative screening to have both mildly prolonged PT and PTT, AND the only abnormality found was a factor II (2, prothrombin) level >60%, I would not administer preoperative prophylaxis. However, I find the question confusing as it...
How should one approach an incidentally found T-cell gene arrangement?
When I see an incidental T-cell clonal rearrangement without any manifestation, my first question is how was this being measured? Many PCR-based methods have a difficult time distinguishing oligoclonal versus monoclonal T-cell populations. My favored test here is looking by flow cytometry at the T-c...
Would you treat a hemochromatosis carrier with IV iron if they have iron deficiency anemia in conjunction with elevated ferritin?
This scenario, with numbers like these, suggests another underlying issue. A carrier of hemochromatosis cannot typically have a ferritin level of >900 due to hemochromatosis. The TSAT of <10% corroborates this statement. If this patient is real, they likely have an underlying inflammatory disorder ...
What is your approach to monitoring patients with cardiac sarcoid while tapering immunosuppression?
Monitoring of patients with cardiac sarcoidosis (CS) is critical to optimizing therapy and improving outcomes. Once a decision has been made to institute immunosuppressive therapy, it is important that the efficacy of therapy is demonstrated and that the duration of therapy is guided by the response...