Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Have you used Karius to aid in the diagnosis of a non-resolving pneumonia, with negative bronchoscopy, biopsy, and other infectious work up in an immunocompetent patient?
Culture-negative hospital-acquired pneumonia is approximately 50%. Positive cultures are complicated by having to correlate results clinically as organisms may contaminate specimens (even if from a protected brush) and include an organism that doesn't even cause pneumonia, such as Enterococcus spp. ...
What would be your index of suspicion for AL amyloidosis with cardiac involvement in a patient with MGUS to prompt further imaging (and which modality would be preferred)?
In short, we will usually be concerned for potential underlying AL cardiomyopathy (AL-CM) in a patient with MGUS if they have symptoms/signs of heart failure. NT Pro BNP is very sensitive for detecting cardiac involvement of amyloid (Zhang et al., PMID 33283202) and troponin can also help. While the...
Would testing for ATTR cardiac amyloidosis be considered in an older patient with bilateral carpal tunnel surgeries and multiple spinal stenosis surgeries, but no obvious cardiac symptoms?
I would not look for ATTR-CM in the absence of cardiac findings such as abnormal echo (increased LV thickness) or conduction abnormalities that are suggestive. Only 10% of patients with bilateral CTS have ATTR-CM. I would do an echo if not done and review ECG. As much as we are concerned about under...
What is the role for iothalamate clearance testing for glomerular filtration estimation in patients with chronic kidney disease?
No role in my opinion. There is a false security for wanting and knowing an "exact" GFR. The eGFR reporting mandate is more a public health issue than useful for individual decision-making. AND iothalamate clearance as a measure of GFR has its own flaw (we did plenty of them in our prior studies wit...
Do you routinely use 3% sodium chloride and desmopressin to correct hypovolemic hyponatremia in an asymptomatic patient with serum sodium of less than 120 mEq/L?
The challenge with hypovolemic hyponatremia lies in the fact that, upon correcting volume depletion, the kidney's capacity to excrete dilute urine returns, potentially leading to a rapid excretion of large volumes of dilute urine. In the case of an asymptomatic patient with a sodium level of 120 mEq...
Do you avoid terlipressin for patients with hepatorenal syndrome who have a serum sodium level less than 125 mEq/L?
This is a good question and I'll admit I don't have much first-hand experience using terlipressin. However, terlipressin is relatively (6X) selective for V1 vs V2 receptors and is used for its vasoconstrictor actions in HRS. Although there are reports (mostly retrospective and uncontrolled case seri...
What is the maximum diuretic regimen recommended in patients with end-stage kidney disease who have residual renal function and volume overload?
Studies in peritoneal dialysis have shown both the safety and benefit of high-dose furosemide. One study randomly assigned 61 incident CAPD patients to either furosemide 250 mg every day or no furosemide at the time of CAPD training and they were followed prospectively. Baseline 24-hour urine volume...
How do you approach DMARD therapy in patients with rheumatoid arthritis and chronic hepatitis B?
Patients with hepatitis B core positivity, surface antigen positivity, and positive PCR for viral DNA, should be treated with entecavir prior to starting any DMARD. Given the DNA PCR is positive too, that indicates active viral replication and they may need treatment for a while before starting anyt...
When do you consider repeating CSF studies in a patient with suspected viral encephalitis but overall initially unrevealing CSF?
Definitely not an expert on this topic, but this situation does come up, particularly for HSV encephalitis! One question worth asking your lab is what kind of assay are they using to run this test. If it's a dedicated HSV PCR assay (e.g., Simplexa), then the sensitivity is going to be quite robust, ...
What is the duration of steroids that you prescribe for organizing pneumonia?
The recommended duration of corticosteroid therapy for organizing pneumonia is typically 6-12 months, as supported by clinical studies and expert guidelines: Reference 1: American Journal of Respiratory and Critical Care Medicine suggests prolonged steroid therapy, often lasting 6-12 months, to redu...