Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
In what circumstances do you pursue labial salivary gland biopsy in an asymptomatic patient with high titer ANA and positive SSA?
I seldom, if ever, suggest a lip biopsy in the work-up of patients with Sjogren's syndrome. It is invasive, and even the histo-pathological interpretation is often open to question. I typically refer patients to an ophthalmologist for a diagnosis of keratoconjunctivitis sicca, if present, and if nec...
Which medications have the lowest risk of tuberculosis reactivation in patients with uncertain tuberculosis history and active rheumatologic disease?
Conventional synthetic DMARDs used in RA are at lower risk for reactivation of latent TB. Steroids do confer some risk of reactivation. The highest risk is the class of biologic DMARDs used to treat RA and many rheumatic diseases with the exception of rituximab.
What is your practice for work up and treatment of incidental splenic infarcts with or without splenomegaly in patients without sickle cell disease?
I obtain CBC/diff, CMP, and LDH in all patients. I assume a CT of the abdomen has already been done because that is what usually leads to the diagnosis of incidental infarcts. Of course, it is important to rule out intra-abdominal pathology which should be visible by CT. I obtain a thrombophilia scr...
For treatment of ITP, what would you add to dexamethasone to achieve the fastest recovery in a patient waiting for a procedure?
I usually use IVIG, particularly if the patient has responded in the past.
How do you approach the symptomatic management of central vertigo in a patient with minimal improvement on (or contraindication to) meclizine?
Central vertigo is a difficult symptom to manage and can be frustrating for the patient (and their doctor). Depending on the etiology, treating the underlying cause would be the best first step (e.g. migraine prophylaxis). However, some causes of vertigo may be intractable or take a long time to rec...
How do you treat lupus-associated small fiber neuropathy?
Treatment of small fiber neuropathy associated with SLE consists mainly of symptomatic treatment for neuropathic pain and, if present, autonomic symptoms. Commonly used treatments for neuropathic pain include topical agents such as lidocaine, tricyclic antidepressants such as amitriptyline or nortri...
When staging prostate cancer, does MRI pelvis/prostate replace CT A/P?
The NCCN guidelines and recent NRG protocols allow for either CT or MRI to stage the pelvis. Assuming the MRI includes imaging of the pelvic LNs, I am not aware of an added benefit of a CT. With the increasing use of novel imaging for staging such as PSMA PET (which can be more sensitive at detectin...
Is LP indicated for patients with recurrent thunderclap headaches over a 4-week period and negative head imaging for SAH?
Such benign presentation (recurrent thunderclap headaches only) may have been RCVS but the diagnosis may have been missed. Spasm peaks around 10 days after headache onset. When arterial imaging is done too early or too late, arterial spasm and specific RCVS diagnosis might be missed. CTA, MRA, and a...
What is the significance of elevated fractionated catecholamines in POTS?
Dear Dr. @Dr. First Last,I don't think we understand the pathophysiology of POTS well enough to comprehensively answer this question.There are a number of technical issues that come into play when drawing serum catecholamines.First of all, many things can elevate catecholamines temporarily: exercise...
How do you manage osteonecrosis and pelvic insufficiency fractures after pelvic radiotherapy?
I have never seen osteoradionecrosis happen before in the pelvis. It should not happen in the range of doses that are tolerable in the pelvis due to the constraints imposed by the sacral plexus and the luminal GI organs. Sacral insufficiency fractures happen uncommonly, but are more common in female...