Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How would you approach a patient with MPO-positive isolated peripheral nerve vasculitis?
AAV can present with a peripheral neuropathy as a first manifestation. The first question we're often facing is whether a biopsy is necessary. If the neuropathy pattern is one of mononeuritis multiplex and there are no atypical features or other atypical serologic findings, I sometimes forego nerve ...
What is the risk of serious bacterial infection in a febrile solid tumor patient who has not yet started cancer-directed therapy and has normal cell counts with no central line?
This depends on the type of the tumor, the location, and the individual circumstances. It may not be wrong in this scenario to draw blood cultures and give a dose of ceftriaxone pending 24-hour results, but this practice may also vary based on these different variables e.g. RMS of paranasal-ear area...
For how long do you treat uncomplicated CRE bacteremia in an immunocompetent patient?
Assuming rapid resolution of the systemic inflammatory response, I generally recommend 7 days of antibiotic administration – and I am not aware of data that this should be prolonged when the pathogen is a CRE. One of the studies listed below [Soto et al] addresses CRE bacteremia and the duration of ...
In patients taking biologics who are planning joint replacement and are known MRSA carriers do you perform decolonization prior to surgery?
Is there a role for phlebotomy in secondary polycythemia?
Prefatory to answering the question, I think it's important to specify the full nature of the problem because there is confusion in the hematology literature about the criterion used to define erythrocytosis as well as the phlebotomy target in secondary erythrocytosis. Currently, hematologists use t...
Do you offer iron supplementation to a patient with iron studies that are normal (including normal ferritin) except for low iron saturation?
The answer is absolutely and positively yes. A low percent saturation of transferrin has an extremely high concordance with absent marrow hemosiderin and frankly, in today’s parlance is the best indicator of “iron need”. While the ferritin is marvelous at confirming iron deficiency if low (with or w...
How do you approach management of a patient with Sjogren's disease and lung mass biopsy revealing amyloidosis?
A lung mass showing amyloid in SjD may reflect systemic amyloid or local/focal amyloid. Interdisciplinary assessment is recommended (Fraenkel et al., PMID 34101376). Organ systems involved will guide the expertise needed.Immunohistochemistry and molecular studies are needed to define if there is an ...
How would you approach the work up of a patient with nasal septal perforation, a negative infectious workup, and negative ANCA titers?
This clinical scenario can be difficult for the rheumatologist to evaluate, and close collaboration with colleagues in ENT would be essential. Causes of nasal septal perforation include trauma, infectious etiology, and autoimmune conditions such as granulomatosis with polyangiitis or microscopic pol...
Is whole body PET scan sufficient to rule out cardiac involvement in sarcoidosis?
Whole-body PET scans, particularly using 18F-fluorodeoxyglucose (FDG), play a significant role in evaluating sarcoidosis, including cardiac involvement. Recent studies have investigated the effectiveness of whole-body PET scans in diagnosing isolated cardiac sarcoidosis and assessing both cardiac an...
Do you routinely screen for sleep apnea in patients with acute ischemic stroke?
We at least ask the patient and family about sleep apnea symptoms. In patients who answer positively, or in those who deny symptoms but have obvious risk factors such as obesity, we do make the referral to our sleep clinic.