Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
In patients with lupus nephritis on maintenance therapy, is there additional benefit in utilizing 2 grams vs 3 grams of mycophenolate mofetil (MMF) daily?
I agree with @Dr. First Last's answer. A few nuances to add: In my patients of African Ancestry, I always start with 1.5 gm bid if tolerated as they tend to need a higher dose (probably related to lower enterohepatic circulation, more rapid mycophenolic acid clearance, and other metabolic mechanism...
Are there clinical circumstances in which there is a role for steroids in treatment of calcified neurocysticercosis associated with perilesional edema and seizures?
Yes. Steroids would be routinely used if his perilesional edema. The question presumes that all of the intracranial lesions are calcified but there can be intraparenchymal cysts in different stages of dying or calcification.
How would you treat a de novo CLL with WBC of 1,000,000 and no overt signs of leukostasis?
This is an interesting question. I haven't seen anyone with a WBC count this high except when they had other factors influencing the count such as dehydration or systemic infection such as c diff and it was a reactive process in addition to CLL. It would be interesting to know what else was going on...
How do you treat sarcoidosis associated hypercalcemia in a patient with adenopathy and no other signs of systemic involvement?
This may seem like a straightforward query, but like many issues surrounding sarcoidosis, it is actually deceptively complex. For a more complete discussion, I refer the readers to an excellent review by Lower and Saidenberg-Kermanac’h (2019). In and of itself, asymptomatic “mild” hypercalcemia does...
Do you always comment on VA and KCO when reading PFT's when gas transfer is ordered?
I do not. I look at the VA to see if it meets ATS criteria ( [1] >=90% of largest VC in the session; or >=85% and within 200cc or 5% of the largest VC; [2] breath hold of 10 +/- 2 sec; [3] >=85% of inh ventilation inhaled in <4sec)
How do you approach patients with recurrent TGA in the emergency room?
I generally observe the patient in the hospital if the symptoms are still present or have resolved within 24 hours. I obtain an MRI to look for hippocampal lesions or evidence of stroke, CTA head and neck. If I see a patient days, weeks, or months after the event, I do an outpatient workup or an MRI...
Do you discontinue proning due to a perceived lack of response to intervention in a patient with ARDS?
Yes, I do.
Do you increase sedation or consider the use of neuromuscular blockade to prevent potential self-induced lung injury in patients with high respiratory drive?
My approach to patients with high respiratory drive is variable based on the disease process, the patient's physiology, and the stage of evolution of the disease. Optimization of ventilation parameters (inspiratory flow rate, flow pattern, cycle time, trigger settings) to promote synchrony is a firs...
Would you continue Rituximab infusions in a patient with GPA and renal involvement who has been in remission on Avacopan and Rituximab, but had PRES post Rituximab infusion?
PRES (Posterior reversible encephalopathy syndrome) is a potential complication reported with rituximab (RTX) use, not only in rheumatology but also in the oncology literature. It usually resolves, however, there are reports of potential mortality, and of course, morbidity while it is ongoing.If PRE...
Do you routinely isolate and test for TB in a patient incidentally found to have a miliary pattern of nodules on chest CT?
The short answer is yes. CDC recommends applying airborne isolation for any "suspected" case of TB. So if you suspect, you should isolate until you rule out with 3 negative AFB or have an alternative diagnosis. Keep in mind pretest probability and risk factors for that patient with the miliary patte...