Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
In what clinical scenarios should we use the 2-day 2mg DST instead of the 1mg overnight DST for screening of Cushing syndrome?
The 2-day low-dose DST may be of some value in patients suspected to have nonneoplastic hypercortisolism (normal cortisol <1.4-1.8 ug/dL). The Dex/CRH test performs better in such patients, but the CRH is not available.
What are your criteria for deciding if a patient who had VF arrest in the setting of subacute myocarditis requires ICD or long term WCD?
This is a complex question with multiple variables. In general, if the patient had a VF arrest, then we are no longer talking about primary prevention, this would be a secondary prevention indication. For me, I would want to identify a reversible cause with reasonable expectation that the VF episode...
Are there certain subsets of ANCA vasculitis patients for whom you would consider life long maintenance therapy?
Overall the field is moving towards longer, and sometimes indefinite maintenance therapy. This is because multiple studies have demonstrated that relapse risk increases when maintenance therapy is stopped. I consider indefinite maintenance therapy for the following patients: 1. Frequent relapsers - ...
How would you manage a patient with antiphospholipid syndrome in the setting of severe steroid-refractory thrombocytopenia?
Dr. @Dr. First Last answered the question of severe thrombocytopenia in a patient with APS and an acute thrombotic stroke. I agree with his approach. However, this “between a rock and a hard place” clinical scenario does also appear not infrequently during the chronic management of patients with APS...
Do you avoid ESAs in patients with anemia and chronic kidney disease who also have Factor V Leiden?
I personally do not. I think it is better to get the hemoglobin in the 10-11 g/dL range and avoid having to give blood transfusions potentially than the slightly increased risk of hypercoagulability.
What is your approach to determining the need for continued isolation in the dialysis unit for an ESKD patient who had a positive hepatitis B surface antigen one year ago but who now has a negative HbsAg in the absence of treatment?
I have not encountered this situation before. Assuming that both checks are accurate and not the result of vaccination, then I would continue to isolate for another 6 months, repeat Hep BsAg and viral load. If still negative would take off isolation.
Do you consider hyperuricemia as a potential etiology of an anion gap metabolic acidosis in patients with elevated uric acid levels and no other readily explainable causes of acidosis?
Urate has a molecular weight of ~166 mg/mmole and the valence of the anion is -1. Hence, let us say we have severe hyperuricemia with 16 mg/dl. That will provide an "anion gape" of only 1! So, by itself, urate cannot increase the anion gap. Could hyperuricemia be a "biomarker" of other causes of met...
How would you manage a patient with radiation pneumonitis who remains symptomatic on steroids?
Engage your Pulmonology colleagues to assist in these difficult cases. Important to rule out other causes of persistent symptoms including infectious processes. Rebronch can be helpful for infectious work up and/or determining the nature of the inflammatory process that is ongoing (for example, the ...
When (if ever) do you check for anti-platelet antibodies for workup of thrombocytopenia?
Routinely available anti-platelet antibody tests have a sensitivity too high and specificity too low to be of much clinical use. A patient's response to first line therapy (steroids or IVIg) is most telling and if there is no response, a bone marrow is warranted as it would be atypical for ITP. Ther...
What is your approach to safely performing hemodialysis in a patient with a fistula who is hospitalized for altered mental status and unable to remain still?
First, I would try to delay performing dialysis if possible and give the patient a chance to be more alert. Second, if there is a way to perform dialysis safely through meds or very close supervision, then I would try to use the fistula for dialysis. If the above is not possible, then the patient wo...