Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When can abdominal surgery be safely performed for presumptive ovarian cancer in a patient with recent pulmonary emboli?
In general, the standard approach is to try to wait as long as possible after the thrombotic event, at the very least three months. This may not be possible, we then reduce that time interval to one month. Given the urgent nature of the surgical intervention, one approach is to wait one month and co...
Do you diagnose obstruction by the criteria of FEV1/FVC < 70% or < LLN?
Using lower limit of normal for FEV1/FVC ratio may reduce misclassification of airway obstruction but despite years of discussion and arguments it remains unclear whether it is a better approach. The simplicity of the fixed ratio approach to me remains a very important consideration and it is the ap...
What is the indication for phlebotomy in compound heterozygous hemochromatosis?
The indication for phlebotomy is proven or strongly suspected iron overload. The likelihood of expression in these individuals is low. An elevated ferritin is often due to reasons other than iron overload such as fatty liver or alcohol intake. I usually do a liver ultrasound in this circumstance. If...
In SIADH due to malignancy, do you prefer to use free water restriction or salt tablets?
Fluid restriction is usually the first line measure in chronic SIADH. Salt tablets only work at high doses, as SIADH is a water, not a salt problem, and you improve sodium only minimally. Tolvaptan is a very powerful drug, but, as per the package insert, must be started in an inpatient setting. Addi...
How would you work up and manage persistent lymphopenia in an asymptomatic patient?
Simple answer: refer to an immunologist, as this degree of lymphopenia is quite likely to represent a serious immunodeficiency. I would also send a next generation sequencing panel of immunodeficiency/immunoregulatory genes to be in process while awaiting the immunology consultation. Long answer (fr...
Is there utility in monitoring IgE levels in patients with IgG4-RD?
Serum IgE levels are associated with disease extent/severity and risk of relapse in patients with IgG4-RD. In some patients (although this is not true for all patients), IgE decreases following treatment and increases with disease flares. However, some patients who have extreme IgE elevations at bas...
Do you stop tolvaptan below a certain eGFR in a patient with autosomal dominant polycystic kidney disease?
In general, the practical guidelines support continuing tolvaptan until dialysis or transplant (Chebib and Torres, PMID 33705818). There are situations where I will discontinue sooner, either due to apparent lack of benefit, due to precipitous, unexpectedly rapid decline or accelerated decline, or, ...
Given that there are a fair number of myocarditis cases without a troponin elevation, how do you clinically approach the diagnosis of myocarditis?
If clinical suspicion for myocarditis is not based on elevated troponin there needs to be some objective evidence for it. These would be CRP/sed rate/cardiac MR/biopsy. Unlikely to pursue the last step if the first three are all normal.
How would you approach a patient with axial spondyloarthritis who develops new-onset proteinuria?
I would approach the workup for proteinuria based on the differential diagnosis with leading etiologies including, acute illness, diabetes, nephrotic syndrome (minimal change disease, FSGS, membranous neuropathy), drug-induced proteinuria, vasculitis, and of course IgA neuropathy. Standard studies i...
How would you manage a patient pre-operatively with a prolonged PTT that does not correct on mixing, with lupus anticoagulant testing that is abnormal by LA-PTT only?
Not all reagents/assays exhibit the same sensitivity (aka responsiveness) to lupus anticoagulants (LAC). In this case, there is evidence of LAC based on one assay, LA APTT. Often we see prolongation/inhibition in other assays e.g. APTT, but the phospholipid neutralization (PNP) step is not always di...