Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
For which patients with calciphylaxis would you recommend a parathyroidectomy?
In those with refractory hyperparathyroidism (typically PTH above 800-1000 pg/mL) despite medical therapies like cinacalcet.
When should one consider obtaining a cardiac MRI in ischemic stroke patients?
This is a terrific question. Cardiac MRI is increasingly utilized in the diagnostic evaluation of ischemic stroke and can uncover clinically covert cardiovascular disease. The clinical utility in ischemic stroke is most in patients with concern for LV thrombus (low EF or recent anterior ST elevation...
How do you complete brain death testing in patients who cannot tolerate apnea testing and are unable to transport for ancillary testing?
The short answer is that you cannot. Brain death diagnosis requires the presence of 3 conditions: persistent coma, absence of brainstem reflexes, and lack of ability to breathe independently. If portions of the clinical exam or apnea test cannot be performed, ancillary testing is necessary to make t...
Should you consider thromboprophylaxis, even for low-dose lenalidomide maintenance, post-autologous transplantation?
In the event there are no adverse contraindications for the use of thromboprophylaxis, yes, I recommend the use of a minimum of 81 mg of aspirin daily with a low dose of lenalidomide. In this meta-analysis (Chakraborty et al., PMID 31913498), the risk of venous thromboembolism was low with a low dos...
What postural change in FVC is suggestive of respiratory muscle weakness?
In our practice, an assisted ventilation clinic which is enriched with patients who have diagnosed neuromuscular disease and/or chronic respiratory failure of unclear etiology, we often use 12% or 200cc simply by analogy to the criteria we use to assess bronchodilator responsiveness during PFTs. Alt...
What is your approach to management of intradialytic hypotension and autonomic dysfunction in a patient with ESKD?
Decreasing dialysate temperature to 35.5 to 36 degrees has, in my experience, caused a marked decrease in intradialytic hypotension. We use midodrine in some instances. The decreased dialysate temperature is systemwide in all cases in our units.
What is a reasonable length of time for systemic anticoagulation in patients presenting with MI in the setting of coronary artery aneurysm with large thrombus formation?
This is a great question. I would make the following points in reply: The present standard of care for antithrombotic therapy after a type 1 acute myocardial infarction, with coronary thrombosis, is dual antiplatelet therapy for one year (preferentially including a potent P2Y12 inhibitor). Current e...
How do you workup splenomegaly related to possible hematologic etiology in the absence of abnormal blood counts, adenopathy or severe constitutional symptoms?
The presence of splenomegaly is an important finding found either on physical exams or by imaging. As noted in the question, the initial work up includes physical exam looking for lymphadenopathy. In addition, laboratory evaluation, including absolute white count, and differential may help explain w...
Is there any evidence for amyloid/amyloidosis causing a spurious/false PSA reading?
This is an excellent question.Our group has been involved with amyloid/radiation effects in patients with Alzheimer’s disease Turn our initial run-up and through our most recent reviews, I have not seen any significant publications nor have I seen clinical situations that this addresses, although am...
Excluding CLL, in which patients would you screen for hypogammaglobulinemia?
Patients I screen for hypogammaglobulinemia include those with: gammaglobulin gap (total protein-albumin) less than two; advanced multiple myeloma or mantle cell lymphoma; patients who have received CAR T cells or bispecific antibodies against BCMA or CD20.