Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you recommend parathyroid imaging testing for patients with recurrent nephrolithiasis who are incidentally found to have an elevated PTH but who do not have hypercalciuria, hypercalcemia, hypovitaminosis D, or chronic kidney disease?
Yes, but with caveats. The “yes” is because hyperparathyroidism is a surgically curable disease if done by an experienced parathyroid surgeon. The caveat is if previous stone analyses have not shown a substantial calcium phosphate component, the stone formation may be due to other causes and unaffec...
How do you differentiate demoralization from depression during cancer treatment?
Certainly a key question in all referrals for "depression" in psycho-oncology. The two syndromes have areas of overlap and are not mutually exclusive. Clinical depression in cancer looks much like it would in any other context, though non-specific physical symptoms that can be caused by the cancer/t...
Do you hold anticoagulation prior to performing bronchoalveolar lavage?
Can do BAL on anticoagulation. Anticoagulation does not increase the risk of bleeding for BAL.
How do you determine which patients with ANCA associated vasculitis may be good candidates for reduced dose glucocorticoid tapering?
This is an important question. Currently there are several groups of patients that benefit from reduced dose glucocorticoids: The largest group are patients who are receiving avacopan for remission induction. The ADVOCATE trial demonstrated that avacopan can markedly reduce the dose of glucocorticoi...
How do you read a PFT with restrictive type spirometry but normal lung volumes?
Non-specific pattern. Initially, NEJM papers showed that these patients develop obstructive patterns in the long term but follow-up papers have shown that patients can stay in that pattern (non-specific) or develop restrictive or obstructive patterns.
Does your evaluation of a young person with spontaneous upper extremity DVT vary as compared to lower extremity DVT?
The workup for a young adult with an upper extremity DVT differs for me in two ways: Venous thoracic outlet syndrome must be suspected and a careful history of repetitive overhead movements must be obtained. Consulting your vascular surgery team in these cases to ensure the anatomy does not put the...
What is your approach to immunosuppression in patients with preserved kidney function who are found to have nephrotic syndrome of unknown etiology and cannot safely undergo a kidney biopsy?
This is a difficult scenario. Would definitely try to get a biopsy at a Higher level of care perhaps by Interventional Nephrology. Would obtain a comprehensive laboratory workup including kidney function, serum albumin level, random and 24-hour urine collection for albuminuria and proteinuria, Hepat...
Is there a role for dual antibiotic treatment with ethambutol and macrolide only, as opposed to three-drug antibiotic therapy, in the treatment of treatment-naive pulmonary MAC without cavitary disease?
That is a great question, as the role of rifampin (or rifabutin) regarding its relative contribution to the treatment of MAC is not overly clear. Historic data that is a few decades old raised the possibility of better activity when a rifamycin is combined with ethambutol (at least in vitro and furt...
Do you use delayed-release budesonide over prednisone or methylprednisolone for the treatment of IgA nephropathy, considering the available safety and efficacy data?
The two agents (TRF-budesonide and systemic glucocorticoids, the latter of which include prednisone and methylprednisolone) have never been compared head-to-head, and so direct comparisons are unavailable. I try to present both options to patients, and in particular, I will focus on the side effect ...
How long after a motor vehicle accident would you expect symptoms including memory loss, hypersomnia, and mood changes to be attributable to the accident?
I would love to have the answer to this. I can tell you what the Headache Classification Committee of the International Headache Society says:Post-traumatic headache (PTHA) is defined as a secondary headache that develops within 7 days after head trauma (or after regaining consciousness following he...