Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
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...
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)....
In clinical practice, are you using single-dose liposomal amphotericin B for treatment of cryptococcal meningitis for patients living with HIV?
I have practiced in Dallas, Texas, at Parkland Hospital for nearly 20 years; unfortunately, we see at least 50 patients a year with cryptococcal meningitis and HIV. We have been using the standardized approach from the US DHHS guidelines that recommend at least a 14-day course of therapy of Ambisome...
Do you routinely perform a pre-extubation bronchoscopy for secretion clearance during the index hospitalization in patients following lung transplantation?
Yes, this is routinely done on post-op day 1 and frequently repeated if the patient is not extubated on the first post-operative day after lung transplantation. This is typically necessary and done early in the post-op phase to clear out blood or debris from the airway that often accumulates in the ...
Is there a role for routine LP in HIV patients with disseminated histoplasmosis even in the absence of CNS signs/symptoms?
I would not recommend routine LP in the absence of CNS symptoms as it is unlikely to change the management of the infection in someone who has disseminated disease. Prolonged therapy will still be used and as opposed to Cryptococcal meningitis where intracranial pressure management is critical, ther...
Would you start octreotide in a patient with suspected sulfonyurea overdose but without frank hypoglycemia?
The data in the literature supports treating with Octreotide once hypoglycemia is present. Otherwise, a watchful, waiting period would be employed. It is reasonable to have a low threshold for its use once indicated, given how prolonged and profound the hypoglycemia can be in this situation.