Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you manage hyperalgesia in patients with sickle cell disease?
In addition to the obvious, such as PCA narcotics, Lyrica/Neurontin, and Toradol, I have success with IV Tylenol, Zyprexa, po L-Arginine (Morris et al., PMID 23645695) as well as Dexmedetomidine (Precedex), steroids (NEJM: Griffin et al., PMID 8107739) and acupuncture [Johnson et al., Alternative an...
How do you distinguish between primary and tertiary hyperparathyroidism in a patient with ESRD?
Almost all patients with hypercalcemia, hyperparathyroidism, and ESRD are going to have tertiary HPTH and not primary. Imaging will show diffuse hyperplasia and multiple nodules in tertiary and in the rare case of primary would expect to see a solitary nodule without hyperplasia of the other glands....
What are the clinical indications and major limitations of lipoprotein apheresis?
LDL apheresis is a procedure that selectively removes apo B-containing lipoproteins (so primarily LDL particles) from the circulation. Very simply - venous blood is withdrawn via IV, plasma separated by the machine (liposorber, FDA approved in the US), passed through a column which binds the apo B c...
What is the approach to use of ACE inhibitors for suspected scleroderma renal crisis in patients with only mildly elevated BP and renal artery stenosis?
I recommend using a short-acting ACEi, like captopril, to treat scleroderma renal crisis. You can start at 6.25mg TID and rapidly titrate up the dose to achieve blood pressure goals. The presence of renal artery stenosis (RAS) would not dissuade me from using an ACEi, if there is evidence of thrombo...
How do you manage patients with systemic sclerosis and chronic thrombotic microangiopathy on renal biopsy, but no other evidence of scleroderma renal crisis?
Very good question. Disclaimer 1st - I am not a nephrologist or nephropathologist so this really requires putting many heads together! Thrombotic microangiopathies (TMA) are clinical syndromes defined by the presence of hemolytic anemia, thrombocytopenia, and organ damage from micro thrombosis in ca...
Would you recommend a TIPS procedure in the management of hepatorenal syndrome for a patient with no history of hepatic encephalopathy?
In the right patient, yes. TIPS will help with ascites and likely with renal function. I believe it is underused.
Is there a role for repeat surveillance blood cultures in patients with prosthetic valve endocarditis without associated cardiac abscess after a 6 week course of antibiotic treatment without surgical intervention?
Compared to NVE, PVE is associated with high morbidity and in-hospital mortality (10-30%). Patients with PVIE who are medically managed have either no surgical indication or have surgical contraindications. 2023 ESC guidelines supported repeating the blood cultures within the first week of finishing...
Do you routinely ask for removal of a indwelling central line (PICC or tunneled catheter) in a patient with pseudomonal bacteremia from known source with otherwise appropriate clinical improvement on anti-pseudomonal antibiotic therapy?
No
What is your approach to assessing whether oral/nasal ulcerations are features of systemic lupus erythematosus versus from another etiology?
Mucosal ulcerations due to lupus erythematosus (LE) are more complicated than many of us think. So, this question and answer are not as straightforward as many think. First, the subtitle to this question is misleading. I would not use the word "blister," a lay term that I usually reserve for vesicle...
How would you approach evaluation of a patient with persistent elevated ACE (angiotensin converting enzyme) level without evidence of cutaneous, ocular, or pulmonary granulomatous disease?
An ACE level was previously commonly used in sarcoidosis, often as a diagnostic tool. However, due to its low specificity, it has fallen out of favor. In cases where an ACE is elevated but an evaluation for sarcoidosis has turned up negative, consider other causes for an elevated ACE. Any disease th...