Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you counsel newly diagnosed patients with ALS on dietary recommendations?
I counsel all my newly diagnosed ALS patients about the importance of weight maintenance. Weight loss is an established risk factor for accelerated ALS progression according to several studies (Janse van Mantgem et al., PMID 32576612 and Jawaid et al., PMID 20500116). Therefore, we always aim to mai...
How would you manage patients with exposed bone due to injured gingiva after recent chemoradiation?
Pentoxifylline and vitamin E
How would you approach additional workup and management of a patient with active Crohn’s disease, who has multiple lung and brain nodules, with lung pathology demonstrating necrotizing granulomatous inflammation and brain biopsy with granulomatous inflammation and medium-large vessel vasculitis?
This is a great question and a challenging case. Further workup would depend on the clinical presentation and the risk factors of this particular patient, however, I will outline some broad considerations centered around questions I would consider in a similar case. Has Crohn's disease been definit...
Do you consider pulmonary hypertension related to sarcoidosis to be an indication to start steroids?
Pulmonary hypertension (PH) associated with sarcoidosis presents a complex clinical challenge. The decision to use corticosteroids in sarcoidosis-associated pulmonary hypertension depends on several factors: Underlying Cause of PH: It's crucial to determine whether the pulmonary hypertension is dir...
When would you add a third antibacterial agent in addition to macrolide and ethambutol for treatment of a patient with HIV and disseminated MAC?
Add 3rd agent for patients failing or not on ART regimen when diagnosed with disseminated MAC Optimize failing ART. For treatment-naïve or not on ART, start ART ASAP after MAC therapy All our samples are sent to National Jewish Health in Denver, CO, right away for drug resistance testing If no clin...
Is it safe to combine mycophenolate and adalimumab for management of pulmonary sarcoidosis in a patient that could not tolerate methotrexate?
Combination therapy is often required in patients with sarcoidosis. Combination of adalimumab with other immunosuppressants, such as methotrexate, leflunomide, azathioprine, or mycophenolate, can be used, with close monitoring of labs (CBC, CMP) and for infections.
How is transferrin saturation a reliable indicator for any parameter if serum iron is not reliable?
The question is a very good question. The Fe/TIBC must be drawn on an overnight fast including any vitamin pills containing iron. Otherwise, the serum iron is speciously elevated which in turn speciously elevates the TSAT. If those conditions are met, the TSAT is as good as the transferrin receptor ...
Should oral combined contraceptives be held prior to overnight dexamethasone suppression test to rule out Cushings?
Yes, they should be stopped for one month due to an increase in cortisol levels secondary to oral estrogen-increasing CBG. However, many women will still suppress while on OCP. Therefore, an alternative approach is to do the test while on OCP and to repeat it off OCP if the test is abnormal.
What is your approach to withdrawal of ventilatory support at the end of life?
This is a great question with a complex answer. Both options are reasonable and in my practice, I gear compassionate extubation practices towards the patient and family wishes. In conjunction with our Palliative Care team, we have an algorithm for providing medications to ensure the patient's will n...
Do you administer prophylactic antibiotics to prevent VAP following intubation in patients with acute brain injury?
I currently do not, though this trial is interesting and the results are compelling. I think the risk of one dose of CTX is low. No clear evidence of resistance. I think moving forward, I would have a low threshold for administering one dose of ceftriaxone following intubation in my TBI patients. Ho...