Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Would you consider deferring chest tube placement in a clinically stable patient with a small empyema without signs of systemic infection?
Firstly, diagnosing empyema means the fluid has already been diagnostically tested by thoracentesis. If all the fluid was removed on the diagnostic tap, I would continue and complete the course of antibiotics with close follow-up. The duration of Antibiotics ranges from 4-6 weeks. If a significant a...
What agents do you utilize for mucociliary clearance during the index hospitalization of patients post lung transplant?
Early post-operatively bronchoscopy is the mainstay for the removal of secretions which may be quite thick and obstructive related to the sloughing of pseudomembranes (ischemic epithelium). We will transition from bronchoscopy to hypertonic saline (3% or 5%) nebulized BID with bronchodilators prior ...
How would you approach a fit older (>70 years) with grade I-II, bulky, follicular lymphoma causing ureteral obstruction and renal failure?
You could also consider focal radiotherapy as we know follicular lymphoma is often very radiosensitive (and can respond quickly to RT). Depending on the trajectory of the AKI and dysfunction, I would discuss with my urology colleagues to see if there is any role for ureteral stenting to see if kidne...
What is your approach to differentiating primary from secondary hyperparathyroidism in recurrent kidney stone formers who also have chronic kidney disease, an elevated PTH, and hypercalcemia?
You have asked a complicated question. It is certainly possible for both conditions to coexist simultaneously. It would be unusual for primary hyperparathyroidism to cause secondary hyperparathyroidism, although recurrent obstructive uropathy from stones would be a possible etiology. Similarly, seco...
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 ...