Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you avoid PTH/PTHrP analogs in patients with recurrent/severe CPPD?
I assume Dr. @Dr. First Last meant PTH-related bone-building drugs, not bisphosphonates, in his answer. I agree that I would use these drugs if needed in someone with CPPD disease, but I have not come across the scenario outlined in the question and am not aware of any data on the use of these drugs...
What is the differential for a patient with unilateral arm swelling, MRI with muscle edema, and markedly elevated CPK?
The differential for focal myositis is broad, although many times no obvious etiology is revealed and in that case, it is considered to be idiopathic. Etiologies that need to be ruled out are: malignancy (usually confirmed by biopsy), infections (like mycobacteria, viruses, fungi; usually will have ...
What is the role of x-ray of the cervical or lumbar spine in patients presenting with radicular symptoms?
I agree that X-rays are useless the vast majority of the time. You can of course pick up lytic lesions from metastasis or plasmacytoma, or other bone-based cancers. Sometimes flexion/extension films are helpful, since MRIs are almost always static and supine (until dynamic MRIs obtain more widespre...
How does the FDA safety warning on the cardiac effects of lamotrigine, based on in vitro data, inform your clinical practice?
I am aware of it and will be careful in using it with patients who have any conduction abnormalities, though that doesn't mean I won't use it. I have been using it for many years (my program during fellowship was a research site for bringing it to the US) and never had a problem with it.
What is the most effective treatment for a patient with persistent post-stroke headache?
Although I have tried many of the traditional preventive treatments such as topiramate, propranolol, candesartan (esp if HTN), and amitriptyline (esp if insomnia), the results are variable at best. I believe that CGRP mab are safe in this situation and are probably the best option for episodic migra...
In your experience, is there an association between interstitial cystitis and systemic lupus erythematosus?
There are reports of interstitial cystitis associated with lupus. I have had two patients with that combination, one that is particularly severe. Lupus may or may not be active at the time. There are case reports in the literature of different treatments to try as the standard drugs may not be effec...
Why do we use dexamethasone for CNS edema and prednisone for pneumonitis?
Dexamethasone has better CNS penetration compared to prednisone and thus its established use for managing vasogenic edema. However, it has the most suppressive effect on ACTH, causes relatively more steroid myopathy and has less mineralocorticoid effect compared to prednisone hence, the general use ...
How would you approach a patient with imaging and labs suggestive of potentially resectable cholangiocarcinoma when several core biopsies reveal bridging fibrosis with no malignant cells?
I believe the first step would be presenting the patient's imaging and case at a multidisciplinary tumor board for input, especially from GI and surgical oncology, ideally at a higher volume center. You don't specify the route of prior biopsies but I am assuming they are percutaneous. Perhaps yield ...
What is your approach to treatment for a patient with progressive ILD (UIP pattern) with high titer RF but no articular symptoms?
Hello and thank you for this question. It is very important. But I need more facts to safely answer this question. My very first thought is that assessment (i.e., a thorough history and physical exam) is highly operator-dependent. In most cases, the historical and exam findings of systemic autoimmun...
How do you approach heparin management in patients who have suprathetherapeutic Xa levels on minimal heparin?
Assuming heparin is administered using standard weight-based dosing, that the infusion rate is being accurately monitored, and that the assay was done properly, very high anti-Xa levels that persist despite lowering the heparin dose would be most unusual. In that setting, I would suspect that either...