Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
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...
Do you avoid SSRIs in patients with a history of RCVS?
SSRIs are on a long list of medications associated with RCVS. The condition is relatively rare, and a very low percentage of patients have recurrences. If there is a strong indication for antidepressants, I would treat them with appropriate warnings.
How do you evaluate patients with suspected pseudo-dementia?
I am very careful about diagnosing a functional cause for cognitive impairment. I typically get vitamin B12 and TSH levels, and also get a neuropsychological evaluation. They are usually able to pick up underlying behavioral disorders or poor effort. If unrevealing, and there are no obvious risk fac...
How do you approach the workup and management of patients with suspected functional neurologic disorders?
This is not really an answerable question. I would re-frame the question, because it really depends on the kinds of symptoms they have and the neurologic exam that is performed. I disagree with neurologists who say that "functional neurologic disorders" are a diagnosis of exclusion. That is absolute...
Would you avoid the use of keppra in patients with TBI due to concerns for worsening agitation?
I suspect that this practice of prophylactic antiepileptic medications for TBI patients will go away over time. History has shown us time and time again that we over-medicate patients.