Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you recommend noninvasive testing or coronary angiography as the initial test for pre-kidney transplant evaluation of an asymptomatic patient older than 50 years of age with ESKD secondary to diabetic nephropathy and no known history of CAD?
There is no evidence that revascularization of asymptomatic patients reduces the risk of transplant. obviously patient should have all relevant risk factors treated. the problem with routine angiography is that inevitably any lesion found is treated with stenting which actually exposes the patient t...
Following cardiac MRI, what imaging modality would you consider to further evaluate mild aortic regurgitation (regurgitant fraction on cardiac MRI of 26%) and mild to moderate mitral regurgitation secondary to mild bi-leaflet mitral valve prolapse (RF 30%) with low-normal LVEF and incomplete RBBB?
Consider an exercise echo if the patient is asymptomatic and continue to follow with echo-Doppler.
How would you approach initiating belimumab in a patient with serologic evidence of prior hepatitis B infection?
The patient in question is a patient who has serologic evidence of resolved hepatitis B infection. Of note, testing for hepatitis B is not a formal recommendation before starting belimumab. However, it is also important to point out that testing positive for hepatitis B was an exclusion criterion in...
Do you recommend sending an autoimmune work up for patients with recurrent nephrolithiasis and 24 hour urine chemistries consistent with distal renal tubular acidosis?
I do not think there is a "right" answer to this question. First, I would want more evidence of distal renal tubular acidosis than urine chemistries. Specifically, I would do a urinary acidification test. If positive for distal RTA, and there is no other suggestion in the history or physical examina...
What criteria do you use on echocardiogram and PFT to determine who needs further evaluation for CTD-associated pulmonary hypertension?
PFTs are often obtained in patients with systemic sclerosis to evaluate for interstitial lung disease. Low DLCO on PFTs can signify an increased probability of PH, but it is by no means specific. Echocardiograms are readily available, offer additional information about possible causes of PH (e.g. LV...
Do you start patients on a B complex multivitamin if they are on CRRT and have not previous been on renal replacement therapy?
This is a good question. I personally don’t routinely recommend Vitamin supplements for patients on CRRT, but wouldn’t argue with someone who does. It is known that critically ill patients, which includes most CRRT patients, often have deficiencies in micronutrients, including water-soluble vitamins...
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...