Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is a reasonable class of antihypertensive to start in patients with HCM who remain hypertensive and symptomatic in spite of maximal doses of beta blockade or calcium channel blockers?
My answer is based on the experience and not the research data per se in HCM: I will add low-dose HCTZ (12.5 mg daily). It won't cause dehydration or hypokalemia and might do wonders in managing HTN in these patients. One of the cheapest and most effective! Or I would consider Spironolactone instea...
How do you approach interpreting a low titer dsDNA (such as crithidia 1:40 to 1:80) in the setting of a moderately elevated ANA without other specific features of SLE?
Serologies are not a diagnosis nor are they diagnostic. This patient does not NOW have lupus. Are there first-degree relatives with SLE? Does this patient have any other autoimmune disorders like Hashimoto thyroiditis? What to do? Follow-up and education. Routine follow-up and welcome phone calls to...
Is methacholine challenge on its way out?
I have not needed to order the challenge test for a long time now. I see the need for this test is declining.
What is your approach to anticoagulation in a patient with AKI and cirrhosis who has frequent filter clotting on CRRT?
A meta-analysis (Qi et al., PMID 37186766) compared 348 patients from 9 studies receiving RCA to 127 patients from 5 studies receiving heparin anticoagulation. Among the RCA recipients, the incidence of citrate accumulation, metabolic acidosis, and metabolic alkalosis was 5.3%, 26.4%, and 1.8%, resp...
What is your approach to secondary prophylaxis for C difficile infection during concomitant antibiotic use in a patient with a history of C difficile infection?
We have been restricting secondary prophylaxis to those patients with severe protein malnutrition, receiving immunosuppressive chemotherapy, generally at the extremes of age who require unavoidable systemic antibiotics that cannot be withdrawn. Based on the 2024 paper by Ronza Najjar-Debbiny et al.,...
How would you treat ESRD patients on hemodialysis with recurrent AV fistula thrombosis found with low protein C activity?
I assume that the patient described in the vignette has a negative family and personal history of VTE. PC (and PS) deficiencies are relatively common in ESRD patients. The low levels are thoughts to reflect a combination of true (acquired) reduction and the assay interference rather than true defici...
Does IVIG or subcutaneous Ig interfere with monoclonal antibody therapy (i.e. dupilumab, infliximab, rituximab, etc)?
I definitely agree with Dr. @Dr. First Last concerns. For what it’s worth, I use a lot of IVIG in combination with monoclonal medications in my myositis clinic, and have anecdotally noted multiple instances in which I feel that the efficacy of one of those monoclonals seems to have been worse when t...
How would you manage a patient with Takayasu arteritis controlled on TNFi who develops erythema nodosum that is only partially responsive to NSAIDs?
Erythema nodosum and pyoderma gangrenosum (as well as erythema induratum) are well recognized as cutaneous manifestations of TAK. Unfortunately, we do not know how often cutaneous and the vascular disease are decoupled from each other due to a lack of available data. Most case series document associ...
What is your approach to therapy in patients with progressive Scedosporium pulmonary infection who are not candidates for surgical debridement?
Scedosporium species are increasingly common clinical isolates in patients with bronchiectasis (both CF and NCFBE). There are precious few publications describing these infections in immune-competent hosts, but it seems that these infections tend to be symptomatic (rather than asymptomatic colonizat...
Do you recommend automatically starting CRRT anticoagulation when initiating CRRT if there are no medical contraindications to anticoagulation?
Great question. My practice is that we don't. However, I wonder if we should. In any case, it is not unreasonable not to give it at the beginning and start it if the patient clots daily or more often. I think bleeding episodes tend to be very dramatic at times and result in clouding our judgement a ...