Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
In patients with diffuse scleroderma and symptomatic lower extremity venous insufficiency, would you recommend treatment with endovenous laser/ablation?
It all depends on the severity of scleroderma and the severity of the venous insufficiency. No one can give an answer to that without knowing those two things.
How do you evaluate a patient with MGUS and peripheral neuropathy?
When I see a patient with MGUS and peripheral neuropathy, I think about it in stages: Does the patient have an IgM-monoclonal gammopathy? If so, then I think about DADS-M. An EMG/NCS, anti-MAG antibody, PET scan, and bone marrow biopsy are generally all part of the workup. I try to do MYD88 testing...
Do you consider administration of nintedanib or pirfenidone via enteral tube in patients unable to take PO due to recurrent aspiration?
I have not ordered nintedanib or pirfenidone via enteral tube for any of my patients. However, in the past, I have looked into it due to some research interests and have discussed it with our local MSLs and our clinical pharmacist. Nintedanib is available only in capsule form and is not recommended ...
Can combined oral contraceptive use cause falsely elevated 24-hour urine-free cortisol?
UFC is an expression of free cortisol. It should not be affected by oral estrogen.
Are SCDs contraindicated in patients with acute DVTs?
SCDs can help prevent DVT but I'm not aware of any evidence of benefit when treating an established event. There are rare reports of pulmonary embolism following the application of SCDs in patients with asymptomatic DVTs. I don't think this constitutes an absolute contraindication, but in the absenc...
Would you treat an ESKD patient with renal artery stenosis in an attempt to improve blood pressure control and preserve residual renal function?
When a patient is dialyzing, the dialysis prescription and lifestyle factors, like salt and water intake, dominate blood pressure control. In both CORAL and ASTRAL trials, blood pressure control and residual renal function was not improved by renal artery intervention. For both of those reasons, I w...
Do you advise patients to hold DMARDs for conditions such as psoriasis or rheumatoid arthritis while actively undergoing radiation treatment?
Data in this setting is limited. I have usually not held DMARDs with RT unless treating with concurrent chemo RT or treating a site (pelvis) where myelosuppression caused by RT would further suppression immunity especially with biologics and methotrexate.
How do you approach anti-seizure medication management when it was started by another team for a seizure-naive patient before/after craniotomy for a tumor?
I would refer you to Dr. @Dr. First Last's answer to a similar question (https://www.themednet.org/question/15031) which beautifully summarizes data and guidelines. I usually counsel patients that everyone regardless of their medical history has a certain risk of seizure under physical stressors, th...
Would elevated bone mineral density/T-score be enough to make a diagnosis of osteopetrosis?
You should not make the diagnosis of osteopetrosis based on a high bone density. There are several causes for high bone density including the autosomal recessive genetic disorder sclerostosis which is caused by mutations in the STOST gene which prevents the production of functional sclerostin.
What is your approach to monitoring the neurologic status of a patient with a traumatic brain injury requiring burst suppression for status epilepticus?
As with any other patient in status epilepticus requiring burst suppression, the neurological exam becomes limited to pupillary light reactivity. Pharmacotherapy used in the management of status epilepticus does not negate pupillary response. Not being able to obtain frequent neurological exams on a...