Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you handle post-op, pre-radiation breast seromas and hematomas?
It depends on what I'm doing. If the patient is being treated to only the whole breast, like with the Canadian protocol, then I tend to do nothing. I just go ahead and treat. The hematoma usually won't resolve enough to change the volume over the three weeks. If I feel this patient needs a boost, th...
When do you perform HER2 testing in patients with colorectal cancer?
HER2 amplification is seen in a small but distinct subset of colorectal cancer. This subset has 2 unique characteristics: They are predominantly RAS wild type tumors. They do not respond to anti-EGFR agents, i.e. HER2 amplification is a negative predictor of anti-EGFR antibody (cetuximab and panitu...
How do you perform geriatric assessment for cancer patients?
This is a HUGE topic. I would like to suggest the following 2 resources that you may find helpful. https://www.mycarg.org/?page_id=898 and the following one helps predict residual life expectancy independent of cancer diagnosis: https://eprognosis.ucsf.edu
How do you manage dabrafenib fever?
Tough problem to manage. I've tried numerous strategies with unpredictable success. Prednisone 5mg BID usually works if you want to keep full dose. Otherwise, a dose delay and likely reduction of dab will be necessary.
For patients with brain tumors without a history of seizure, what is your policy on driving?
There is no standard in the United States.We have no written policy. However, if there is clear neurocognitive impairment or there are clinical findings that can impair one's driving ability, I report to the state with a form from the Driver License Bureau that is filled out and then the DMV perform...
When does a rising PSA after prostatectomy indicate growth just of normal prostate?
The concept of residual prostate tissue after prostatectomy has been around since the advent of the PSA. The idea that BPH could exist within this residual tissue has been suggested for nearly the same amount of time. Very little data exists regarding this concept. It has been demonstrated that resi...
What is the best way to discuss an early palliative care referral with a patient?
Patients (and providers) often struggle with the assumption that palliative care implies end of life care. While that is true in many cases, if you can overcome this false assumption, your patients can benefit. I often explain that palliative care like this: Palliative care serves as an extra set of...
How do you manage an open wound that is not healing after radiation treatment for an ulcerated SCC of the scalp?
There always has to be high suspicion for persistent disease, so consider a punch biopsy. Sometimes repeat biopsies are needed to confirm recurrence. Sometimes localized surgery without general anesthesia can be performed to freshen the wound and promote graft placement. Tertiary centers may have ex...
What scans do you order for follow-up in locally advanced non-small cell lung cancer patients who have completed definitive radiation with concurrent chemotherapy?
To my knowledge, there are no randomized studies that have examined the role and frequency of surveillance imaging in locally advanced NSCLC treated with chemoradiation. There is an ongoing randomized study looking at two follow up schedules in completely resected NSCLC (PMID 17519819).NCCN recommen...
How do you approach disease monitoring in patients with localized rectal cancer who have received treatment with chemoradiation?
MRI can provide useful results about tumor stage before and after re-operative chemoradiation. If tumors show a good response to chemoradiation this is a good prognostic sign. For tumors that are initially very large, another reason to do an MRI after chemoradiaiton is to see if the tumor is surgica...