Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When do you consider immunosuppression in patients with Sjogren's neuropathy?
Only when disease activity is moderate-severe, impairing QoL, or rapidly progressive, ie mononeuritis multiplex/vasculitis, with significant risk of end-organ/tissue damage. Occasionally, autonomic neuropathy in SjD can be so debilitating to patient, and all other supportive treatments have failed, ...
What further work up do you recommend for patients with a chronic high anion gap metabolic acidosis with normal eGFR who have been ruled out for lactic acidosis, ketosis, toxic alcohols, and other usual culprits of high anion gap metabolic acidosis?
I take a good history for Tylenol for pyroglutamic acid, as that may not be a test you can do. If there is ANY GI history of a D-lactate level. Might as well get a salicylate level, it can be hidden in wintergreen oil and a few other things. Make sure it isn't pseudohypobicarbonatemia, seen with hy...
What is your approach to further workup and treatment of abdominal aortitis found on imaging in asymptomatic individuals with elevated inflammatory markers?
The differential diagnosis of abdominal aortitis would include giant cell arteritis (we do not know the age of this patient), Takayasu arteritis, IgG4-related disease, Behcet's disease or other systemic rheumatic diseases (RA, SLE, ANCA-associated vasculitis - although less likely since this individ...
What instances will you start outpatient steroids in patients with nephrotic syndrome of unknown etiology prior to obtaining a kidney biopsy?
It is Friday, your patient presents with classic acute nephrotic syndrome, your biopsy Friday won't have results (if not longer if you need EMs which you need for MCD) until Tuesday. I never think a few days of steroids is a big deal, so I can see doing it.
Are there instances when you recommend femoral vein dialysis catheter placement in patients newly started on hemodialysis in an effort to preserve upper extremity future fistula options?
I do not recommend tunneled femoral lines for patients who will need dialysis through the catheter for more than a week or so. Temporary femoral catheters are useful at times if unable to place tunneled line expeditiously.
Do you routinely use inhaled pulmonary vasodilators in the management of patients with ARDS with refractory hypoxemia?
No, as of right now it is not routinely used. There are some early animal models that suggest benefits, but other small clinical trials conducted over the last few years haven’t been able to show benefits. Some providers have inhaled iloprost or inhaled nitric as the last resort when nothing else se...
Is a larger bore percutaneous chest tube sufficient to adequately drain a hemothorax, or is a surgical chest tube required?
A pigtail is frequently sufficient for hemothorax. There are studies suggesting there was no obvious advantage of larger chest tubes over smaller size chest tubes in hemothorax. There are also studies to support the use of tPA in hemothorax to facilitate the drainage.
In patients with Afib on anticoagulation and concurrent intracranial atherosclerotic disease, would you consider adding an anti-platelet to anticoagulation if there are recurrent events that could be related to the ICAD?
This is a difficult clinical situation. If the new stroke was clearly in the vascular territory related to the ICAD, I would consider adding low-dose aspirin to the anticoagulant. I would also consider using the 2.5 mg dose of apixaban as the anticoagulant to reduce the risk of major bleeding associ...
Is it true that a ferritin above 200 essentially rules out iron deficiency?
No, I do not think that a ferritin >200 ug/L essentially "rules out" iron deficiency. Ferritin is an acute phase reactant and can be elevated in myriad conditions including kidney disease, autoimmune disorders, etc. The transferrin saturation (measure of serum iron/TIBC) is an important marker of ir...
Does PT/PTT elevation due to severe vitamin K deficiency protect against thrombosis?
Yes, most of us think that vitamin K deficiency increases the risk for bleeding rather than protecting against VTE.