Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What are your management strategies for patients with nephrolithiasis and hypercalciuria who have a severe sulfa drug allergy and are unable to tolerate thiazide diuretics?
This is a difficult situation. Assuming the nephrolithiasis is calcium-based, I think the patient has to lean more heavily on dietary control. Dietary sodium restriction will decrease hypercalciuria. A further increase in fluid consumption will dilute the urinary calcium concentration. We are fortun...
How do you approach using DMARDs for patients with CPP arthritis who have frequent flares?
As far as I know, none of these agents are proven to prevent CPPD flares. Colchicine for acute flares. If someone is aware of evidence that any of these other choices work, I would be glad to hear about them. I have a patient with Gittleman's syndrome who had severe CPPD with almost constant flares....
Why are gout flares common in hospitalized patients undergoing diuresis but not commonly observed in cancer patients with hyperuricemia resulting from tumor lysis syndrome?
Tumor lysis syndrome (TLS) occurs with the release of uric acid, potassium, phosphorus and calcium into the bloodstream in response to cytolytic therapy administered in the setting of treatment for acute leukemia, B-cell lymphoma and rarely for solid neoplasms. Kidney injury results from the precipi...
Have you seen rheumatoid nodules or RA-ILD in patients with seronegative RA?
By definition, rheumatoid nodules are considered to be a highly specific manifestation of RA. Regarding the first part of the question, one should never see true rheumatoid nodules in someone who does not have seronegative RA. Though there are sporadic case reports of finding these nodules in people...
How do you approach the initiation and/or continuation of antiseizure medication in a patient who has experienced one lifetime seizure with a normal EEG and MRI with a comorbid health condition that is associated with an increased risk of epilepsy?
AAN Guideline (2015): Management of an Unprovoked First Seizure in AdultsAntiepileptic drug treatment after an unprovoked first seizure (Bao et al 2018)The 2015 AAN guidelines point to level B evidence that starting ASMs decreases the overall risk of recurrent seizure within 2 years. The Bao et al 2...
What is your preferred formulation of parenteral iron?
The question is not simple. The formulation I use the most is ferumoxytol because four insurance carriers allow a total dose infusion of 1020 mg in 20-30 minutes. This has been published twice (Auerbach et al., PMID 21922526 and Karki and Auerbach, PMID 31155744). Otherwise, it must be given as two ...
How do you approach the work up of pulmonary artery aneurysm in the absence of other clinical features of Behcet’s?
While Behçet’s disease (BD) is one of the most well-recognized causes of pulmonary artery aneurysms (PAA), it may not be the most common one globally. In scenarios where a careful history, exam, and vascular imaging don’t reveal other BD-compatible findings, other conditions can be more likely. It i...
Do you routinely obtain baseline vascular imaging (CTA, MRA, PET) in patients with suspected GCA, but negative temporal artery biopsy?
Vascular imaging is particularly helpful in patients with large vessel giant cell arteritis. This patient subset may present with persistent constitutional symptoms, refractory polymyalgia rheumatica, fever of unknown origin, or with vascular signs/symptoms (for example arm claudication). These pati...
How do you clinically distinguish between group I and group III PH in patients with CTD-ILD?
The distinction between pulmonary hypertension (PH) of the group 1 (pulmonary arterial hypertension (PAH)) and group 3 (pulmonary hypertension (PH) due to lung disease and/or hypoxia) is essential since the management is different. In group 1 PH we stratify the risk and treat with a variety of PAH-s...
What is your approach to the management of asymptomatic intracranial atherosclerosis discovered during the workup of an acute stroke?
I would maximize the treatment of vascular risk factors such as hypertension, elevated cholesterol, and diabetes. The patient will be taking an antithrombotic medication for the acute stroke so that will also reduce the risk of stroke related to ICAD.