Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach a patient with biochemical evidence of primary hyperparathyroidism, but normal parathyroid scan?
Negative sestamibi scans are not unusual in patients with primary hyperparathyroidism. Other imaging tests may be negative also. If the patient has biochemical evidence of the problem and has even mild complications referral to an experienced parathyroid surgeon would be warranted. Alternatively, ci...
How does one interpret an SPEP showing potentially obscured but non-quantifiable M-spike however an IFE showing monoclonal protein?
Not all patients with monoclonal gammopathies make a detectable paraprotein on SPEP, or, in some cases like IgA gammopathies, it may be 'hidden' in the beta-region of the SPEP, or the rare IgD and IgE gammopathies may be too low to detect on the SPEP. In addition, for the 15-20% of patients who have...
How often do you pursue malignant transformation screening In patients with lymphomatoid papulosis or pityriasis lichenoides?
In the case of patients with lymphomatoid papulosis (LyP) or pityriasis lichenoides, regular follow-up and monitoring for signs of malignant transformation is important, given the potential (though generally low) risk of progression to lymphoma, especially cutaneous T-cell lymphoma. For LyP, follow-...
How would you manage elevated vWF and FVIII levels in a patient with a family history of coagulopathy?
Hard to be specific without more clinical details. I would not repeat levels. Although the higher the FVIII and VWF levels, the higher the risk of thrombosis, but there is no known specific cut-off. Currently, there is no role for empiric anticoagulation. As with all patients, DVT prophylaxis in hig...
How do you manage tacrolimus-related psychosis?
The mechanism of tacrolimus-related psychosis is unclear, but some papers have suggested that calcineurin (which is involved in the regulation of dopaminergic, glutamatergic, and GABAergic systems and implicated in psychotic disorders) may play a role (1). As a result, antipsychotics are often a mai...
What work up do you pursue for splinter hemorrhages in an otherwise healthy patient?
I would take a good history, ask for a thorough review of systems, review their medications, etc., and do a physical exam to rule out signs of a systemic illness. The workup (for endocarditis, etc.) can be directed by those findings, if present. Otherwise, the most common cause of splinter hemorrhag...
Do you take any different approaches for patients with end stage kidney disease who are about to be initiated on intermittent hemodialysis and have residual renal function?
The main consideration I have in these patients is making sure I do not try to remove extra fluid; if there is enough residual renal function to provide at least 1,000 ml/day of urine output, most likely this patient will not require net ultrafiltration, only dialysis. By paying attention to this on...
What is your approach to patients with chronic kidney disease who are found to have pelviectasis without hydronephrosis on renal ultrasound imaging?
Good question. I would involve urology early on. I would get more history as to other signs/symptoms of urinary obstruction (nocturia, BPH symptoms, history of retroperitoneal fibrosis). Then, consider a Lasix urogram.
At what stage of the neuropathy workup do you screen for B6 toxicity?
In my experience, vitamin B6 deficiency due to poor oral intake is very uncommon. However, toxicity may occur with supplementation typically more than 2 gm/day, although chronic use of 50 mg/d may also be a cause. Vitamin B6 is present in many supplements and toxicity may cause direct damage to the ...
How would you treat a patient with rectal cancer with a solitary lung metastasis, who now has no evidence of disease after total neoadjuvant therapy followed by rectal surgery and resection of the solitary metastasis?
Surveillance! Assuming this patient received “complete” total neoadjuvant therapy with at least 3-4 months of systemic therapy, preoperative radiotherapy to the pelvis and curative intent operations to the pelvis and lung with no evidence of residual disease on post-op imaging- this is the early out...