Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you stop ACEi or ARB medications in patients with ESKD who are on hemodialysis and have issues with chronic hyperkalemia?
I don't. I don't think it contributes much to the hyperkalemia. I usually try to correct the potassium using modifications of the potassium bath, dietary changes and if still high potassium binders.
How would you approach a patient with anti-scl70 ab positive sine scleroderma complicated by ILD who also has seropositive RA with active arthritis?
This scenario can be looked at in different ways. For example, does this patient have scleroderma that explains the ILD and seropositive RA to explain the arthritis? Or, does this patient have seropositive RA which explains both the arthritis and the ILD? I favor the latter explanation. In this scen...
Do you recommend obtaining both a parathyroid ultrasound and a parathyroid nuclear medicine scan when evaluating a patient with recurrent calcium based nephrolithiasis who is found to have an elevated PTH level, hypercalcemia, and hypercalciuria?
Yes. The scenario you describe is typical for primary hyperparathyroidism. Appropriate treatment includes removing the parathyroid adenoma. However, finding a parathyroid adenoma can be difficult. An enlarged one may be no more than a few millimeters in diameter. Our radiology staff recommends both ...
Is history of radiation an absolute contraindication to using parathyroid hormone (PTH) analogues?
Hx of prior radiation was never a contraindication, it was a warning due to the known increase in osteosarcoma in patients who had prior radiation. A contraindication requires proof of harm. There was no data that radiation plus a PTH anabolic increased the risk of osteosarcoma. With the review of 1...
How do you approach use of DMARDs and/or biologics for inflammatory arthritis in patients with a history of seizure disorder on anti-epileptic medications?
Polypharmacy should always be a worry in our treatment of rheumatoid arthritis. Fortunately, the biologics, reflecting their immunoglobulin framework, are rarely a concern for drug-drug interactions. This is in contrast to small molecule inhibitors such as methotrexate, leflunomide, and the jak inhi...
Do you continue TNF inhibitors in patients with a new diagnosis of CLL?
If the patient does not require any treatments for CLL that are potentially immunosuppressive, I would continue TNF-inhibitor therapy in this setting. It is always helpful to discuss the case with the patient's hematologist/oncologist to make sure everyone is comfortable with the plan.
Would you start ASA and/or statin therapy on an asymptomatic patient noted to have incidental pathologic Q waves on EKG, assuming no prior history of ischemic heart disease?
I would start with a thorough H and P and comprehensive risk evaluation with necessary screening including blood work, at least a stress echocardiogram if not a full echocardiogram in addition, and also offer Calcium scoring. Given more details are not given regarding the patient's age and functiona...
How do you approach peri-operative management of anti-resorptive therapies such as denosumab in patients undergoing joint replacement?
This is a very practical question. I think it is fine to continue the denosumab on a regular 6-month schedule for patients undergoing joint replacement. The reduction in bone turnover should not affect the implant. In fact, with denosumab, there is a small anabolic effect with each treatment that mi...
Would you evaluate for thrombophilia in patients with incidental splenic infarcts in the setting of known cirrhosis, portal hypertension, and splenomegaly?
When approaching splenic infarction, one question is to attempt to discern if the infarction is due to venous thrombosis (e.g., in the splenic vein) and subsequent congestion or due to arterial thrombosis (e.g. in the splenic artery), which is much more common. Talking with an expert diagnostic radi...
What is the preferred management plan for patients diagnosed with a concussion in the acute setting?
For acute concussion, if sports related, they should be removed from play immediately and not allowed to return for the duration of the game. For any cause of concussion, it is generally accepted to avoid NSAIDs and use acetaminophen for the first 24 hours if needed for headache. After the initial 2...