Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you identify the subset of heart failure patients who are likely to benefit from cardiac resynchronization therapy in the setting of an RBBB pattern?
There are no good criteria to delineate which patients with RBBB will benefit from traditional CRT. The best contemporary strategy is to consider CRT if a patient has an RBBB > 150 ms, an atypical morphology (suggesting an underlying delay in the LBBB or an IVCD), and Class III-IV HF symptoms. One m...
How would you evaluate a patient with an isolated high RBC count but with a normal hemoglobin and hematocrit?
My first question would be, how long has the elevated red cell count been present? I ask this because, in a study of 10,000 individuals, erythrocytosis was initially found in 88 but after a year only 11 still had this finding (Ruggeri et al., PMID 13679323). If therefore, the observation is recent, ...
How do you think about biologic use in patients with underlying HIV infection?
This is always a difficult problem, and a tough clinical call. However, over the years of seeing these people, I have come to realize that following their viral load and CD4 counts while looking for immunologic recovery allows us as Rheumatologists a lot of opportunities to treat. While I have class...
How would you approach the workup of unilateral chorea with a normal MRI?
I would first rule out Sydenham chorea by checking ASO titers, DNase B titers, ESR, and CRP, and performing an echocardiogram and EKG. I would also recommend an MR angiogram if not already done for Moya-Moya. Following that, I would check copper levels, ceruloplasmin, serum amino acids, serum lactat...
What is your approach to differentiating RA-ILD from medication toxicity (I.e. from methotrexate)?
RA-ILD occurs in about 7-10% of patient with RA. It is more common in males and in those with a history of smoking. Most are seropositive. The typical pattern on HRCT in 50-60% of RA-ILD patients is a UIP pattern followed by NSIP, OP, and even LIP is some cases. An experienced clinician with the hel...
What immunosuppressant will you choose in a patient with necrotizing myopathy partially responding to IV steroids and IVIG with a history of non Hodgkins lymphoma?
The decision should be taken in collaboration with the patient’s oncologist; however, Rituximab would be a reasonable choice to add given that IMNM generally responds well to it (particularly anti-SRP) and that it has a favorable safety profile concerning malignancy.
Which patients with rectal cancer who have not received neoadjuvant treatment do you offer adjuvant radiation to?
In order to answer this question, we may need to step back and first review the indications for radiation treatment in the neoadjuvant setting.Neoadjuvant concurrent chemoradiation or short course radiation treatment is considered to be part of the standard treatment (recommended by guidelines) for ...
In hospitalized patients with significant lower extremity edema, how can you integrate bedside POCUS findings with clinical assessment to guide the decision to start empiric anticoagulation for suspected DVT before formal imaging?
Great question! Especially if the significant lower extremity edema is asymmetric, it sounds like your clinical suspicion would be quite high. When you order a "duplex" study, the sonographer is using 2D ultrasound (aka B mode... white dots on black screen) + Doppler ultrasound (color and spectral)....
In hospitalized patients with significant lower extremity edema, how can you integrate bedside POCUS findings with clinical assessment to guide the decision to start empiric anticoagulation for suspected DVT before formal imaging?
Great question! Especially if the significant lower extremity edema is asymmetric, it sounds like your clinical suspicion would be quite high. When you order a "duplex" study, the sonographer is using 2D ultrasound (aka B mode... white dots on black screen) + Doppler ultrasound (color and spectral)....
What is the clinical significance of a low titer RNP, negative Sm, but Sm/RNP that is very high titer?
Important question as I've seen clinicians incorrectly interpret anti-Sm-RNP as anti-Smith antibody.The different autoantibodies (RNP, Smith, Sm/RNP) react to different antigens as follows: Anti-RNP can react to multiple components (antigens) of the U1 small nuclear RNP particle (snRNP), Anti-Smith ...