Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you use steroids in patients with respiratory failure who are infected with both influenza and COVID-19?
Yes, along with Remdesivir, Tamiflu, Bactrim, and supportive care. If there is active GGO on CAT scan, steroids are usually beneficial. Start high and then taper to the lowest necessary for about a 10-day course.
Do you rule out TB in patients with AIDS and lobar pneumonia?
Depends: +Ve Risk Factors: Travel/contact Hx, recent Quantiferon Conversion, changing CXR, Night sweats Unexplained low-grade temps Then, yes. Otherwise, no.
Does your approach to treating latent tuberculosis differ in a patient on anti-fibrotic therapy?
With the increasingly common indication of progressive pulmonary fibrosis in the setting of CT-ILD, RA, and scleroderma, it is conceivable that patients being started on antifibrotic therapy may be on anti-TNF alpha or other immunosuppressive agents. Specifically with anti-TNF alpha agents such as R...
Do you check EPO levels in patients with anemia of chronic kidney disease?
No, I never check EPO levels in patients with anemia of CKD since they're uninterpretable. Patients with CKD have inadequate EPO synthesis for their degree of anemia, so their EPO levels may be greater than normal yet still not sufficient to correct the anemia. We now understand the role of inflamma...
Are you using the microbial cell-free DNA “Karius” test to aid in the diagnosis of an atypical pulmonary infection such as PJP or NTM?
No, not at this time. Intriguing, but not sure we know enough yet.
Do you consider use of convalescent plasma early in disease course in COVID-19 induced ARDS in mechanically ventilated patients?
At this time, I have not adopted the use of convalescence plasma in COVID-19-induced ARDS. I have read the Belgian study but I believe more evidence from other similar studies is needed before we accept it as standard of care. I have not seen any COVID-19-induced ARDS for almost 18 months.
How would you approach treating a patient with active rheumatoid arthritis and a history of treated lymphoma that is currently in remission?
I would individualize treatment in each patient depending on degree of RA activity, type of lymphoma and length of time of remission with shared decision-making between myself, patient and oncologist. For moderate to high degree of activity of RA, in general, rituximab in keeping with the ACR 2021 g...
How do you interpret the results of oligoclonal bands ordered to evaluate for demyelinating disease in patients with brain MRI lesions of unclear etiology?
While the presence of oligoclonal bands (OCBs) has been incorporated in the updated diagnostic criteria as a surrogate for dissemination in time, OCBs should not be used in isolation to make the diagnosis of multiple sclerosis. There are several systemic and peripheral immune diseases, including inf...
How do you approach patients with RA and severe bronchiectasis with associated findings of UIP?
Usual Interstitial Pneumonia or UIP is among the most serious forms of RA-associated lung disease. Clinical studies have demonstrated that its prognosis is similar to idiopathic pulmonary fibrosis (IPF). UIP is extremely challenging to treat and we have learned from experience that our DMARDs and bi...
How do you manage patients with a prior intracerebral hemorrhage from probable cerebral amyloid angiopathy who develop new small vessel ischemic infarcts?
In this situation, I would consider using cilostazol since it has both antihypertensive and antiplatelet properties. However, the safety profile is unclear in patients with amyloid angiopathy.