Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you consider the use of antifibrotics at presentation in patients with a radiographic UIP pattern of pulmonary fibrosis in the presence of positive serologies without any symptoms of CTD who have not yet demonstrated evidence of a progressive phenotype?
I really like this question, because it succinctly encapsulates several areas of clinical uncertainty that we are routinely forced to address in our ILD clinics! Let’s unravel some of the subtleties here. For starters, if the radiographic pattern is convincingly that of UIP, our patient will technic...
Do you prefer starting a SGLT2i before steroids in patients with IgA nephropathy and proteinuria > 1.0 gram/day who are unable to tolerate ACEi/ARB due to hypotension?
I do try to start almost all of my IgAN patients on ACE-I/ARB and SGLT2i to help decrease proteinuria. The decision to start steroids or any other immunosuppressive treatment does not always have to wait for 6 months of conservative treatment and if still with residual proteinuria, then consider imm...
How would you approach a young patient with bilateral lower extremity muscle weakness and positive anti-Smith, dsDNA, RNP, Raynaud’s, and pericardial effusion but normal muscle enzymes?
The timeline of weakness may be helpful, but another possible cause of weakness in the setting of normal CK would be an inflammatory demyelinating polyneuropathy (can be acute or chronic). EMG and NCS would be helpful in evaluating this.
Is there a good rationale for using vasopressors/induced hypertension in a patient with fluctuating neurologic deficits from symptomatic intracranial stenosis?
I have raised blood pressure in patients with fluctuating stroke deficits, especially in patients with intracranial hypertension, with apparently good results. We usually try fluids first, but pressors are sometimes necessary. This makes sense from the known autoregulation curves, which are shifted ...
Do you recommend parathyroid adenoma resection or ablation for patients with primary hyperparathyroidism and recurrent nephrolithiasis who are found to have a single gland adenoma on parathyroid ultrasound and nuclear medicine imaging?
Yes. My two indications for ablation/resection of a proven parathyroid adenoma are (1) metabolically active calcium-based kidney stone disease and/or (2) osteopenia/porosis as identified by bone scan. I think there is strong evidence that primary hyperparathyroidism can cause either or both. In the ...
Do you administer calcium to patients with K > 6.5 without EKG changes?
No. But our ER does as a reflex and I don't have a problem with that. It used to drive me nuts bc it sent the wrong message, as though Ca lowers [K] level (of course it does not, it just decreases cardiac effect). But you don't know how fast they are being seen, how fast they will get treated, so I ...
When attempting PEEP titration, how long do you wait after decrements or increments to assess for a change in driving pressure?
This depends on the patient level of consciousness and whether or not they are paralyzed.
What is your approach to interpreting urine studies in patients hospitalized for hyponatremia who have recently received intravenous fluids containing sodium chloride?
Regardless of whether or not the patient receives intravenous saline infusion, a low urinary sodium concentration is still suggestive of reduced tissue perfusion (hypovolemia, CHF, cirrhosis).
When treating pancreatic body/tail lesions that result in significant dose spread to the spleen, what is your threshold to offer pneumococcal, hemophilus influenza, and meningococcal vaccines?
A really great question, and one that we don’t necessarily have a lot of data for guidance. There are some guidelines out there, though, that I think can be helpful to consider. The first is the recent guideline from ASCO on the vaccination of adults with cancer (Kamboj et al., PMID 38498792). In li...
Do you use the peri-operative management of biologics and DMARDs guidelines, which were mainly based on total hip and knee replacement surgeries, for all peri-operative surgical management?
The American College of Rheumatology Perioperative Guidelines focused on patients undergoing hip or knee arthroplasty. These guidelines can be a helpful starting place when thinking about medication management in patients undergoing other surgeries, but my recommendations for perioperative managemen...