Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Can you explain the block and replace approach in the treatment of thyrotoxicosis, including when it is most appropriate to use and how it compares to other treatment options?
More than 20 years ago, Japanese researchers had data that suggest that remission rates for Graves' disease was much better with the block and replacement treatment with Methimazole/carbimazole and Levothyroxine. At least 3 US and European studies did NOT confirm this observation. I do occasionally ...
What is the next step in management of a thyroid nodule that was biopsied and classified as Bethesda III, but Afirma genetic testing reveals parathyroid signature?
This is not an uncommon clinical presentation of intrathyroidal parathyroid adenomas, diagnosed incidentally on molecular profiling of cytological indeterminate nodules (CIN). These adenomas most often have the imaging features of a TIRADS 4 thyroid nodule (with well-demarcated margins, solid, profo...
How would you approach management of a patient with rapidly progressive systemic sclerosis with worsening skin disease, myositis, arthritis, dysphagia and failure to thrive developing within 6 months?
This is a unique subset of patients with very aggressive disease and high risk for poor outcomes with myopathy, poor GI dysmotility, at risk for early PH. We tend to treat them aggressively. I would consider rapid escalation of immunosuppression such as MMF and consider IVIG up front as well, especi...
How do you manage cases of levodopa intolerance due to nausea or drowsiness?
This is a great question. Side effects from levodopa can be challenging to manage. First, when you start carbidopa-levodopa, ensure you uptitrate it slowly to limit side effects. Carbidopa is most effective in reducing side effects when it is at least 75 mg total daily dose, thus, the 10-100 tablet ...
What are some important considerations for use of ACE inhibition in scleroderma renal crisis patients who require dialysis?
Yes, captopril is dialyzable with about ~35% of the drug being removed during intermittent hemodialysis. It is not recommended to be used if an AN69 hemofilter is used for iHD, as it is associated with anaphylaxis with that particular filter. There does not appear to be any contraindications to usi...
How do you manage MPN patients with acquired VWD in the perioperative setting?
The greatest risk of a very high platelet is bleeding not thrombosis, and it is fair to say that this appears to apply to myeloproliferative (MPN) thrombocytosis as opposed to reactive thrombocytosis (there is no correlation between the platelet count and thrombosis with either cause of thrombocytos...
Should checking a urinalysis with reflex to culture be part of the standard work up for fever in an ICU patient with a urinary catheter?
Yes, as part of a broad workup for infectious and non-infectious causes of fever, and with many caveats. Patients in the ICU are at high risk for diagnosis with CAUTI, yet as I think you are applying, this is a difficult diagnosis to make given the inability of many patients to give a history (or fo...
How often do you check urine osmolality and urine electrolytes when treating hospitalized patients with hyponatremia?
Correction of hypovolemia with isotonic saline may result in overly rapid correction of hypovolemic hyponatremia once the stimulus for ADH secretion is removed, resulting in the excretion of a very dilute urine. Therefore, urinary electrolytes and osmolality should be closely monitored every 3-4 hou...
Do you use any urinary staining techniques when performing urine microscopy for patients with acute kidney injury?
No. Not at this time. At one point, about 10 years ago, we did have Wright stain to stain for eosinophilluria but it seemed too labor-intensive and not that helpful, so we stopped using it.
Can defibrotide be given safely for VOD in patients with refractory thrombocytopenia to platelet transfusions?
The short answer is "yes."The slightly longer answer is: “Yes, and in patients with veno-occlusive disease (VOD), the use of defibrotide is potentially life-saving (Richardson et al., PMID 26825712).” In the cited study, which led to its FDA approval for this indication, there was no significant dif...