Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Is an early chest tube and tPA/Dornase therapy for a loculated and complex pleural effusion that is not an empyema or hemothorax helpful in reducing the rate of developing trapped lung?
We always keep a low threshold for adding TPA/DNase therapy, if chest tube output starts decreasing, while the radiological infiltrate is not resolving concurrently. The fact to keep in mind is that NO diagnostic workup is 100% sensitive for diagnosing infectious triggers/organizing paranamonic pro...
When do you recommend lumbar puncture in patients with concern for memory loss?
Rapidly progressive memory loss/dementia- because you obviously want to exclude diagnoses like CJD, infectious/autoimmune/paraneoplastic encephalitis, lymphoma or other malignancy, etc. When you need to know the patient's "brain amyloid status". E.g. a) Patients with amnestic MCI and atypical cour...
How long would you treat a patient with recent history of TAVR presenting with E faecalis bacteremia with unclear source with TEE showing thickened valves but no obvious vegetation?
Treatment duration depends on other additional factors.TEE showed leaflet thickening- a non-specific finding, not a feature per Duke's major imaging criteria. Another feature to consider would be an associated new-onset valvular insufficiency that might increase the likelihood of IE. In such cases, ...
What considerations do you take when managing a patient with end stage kidney disease on peritoneal dialysis who is planning on undergoing PEG tube placement?
This is a somewhat difficult question to address, as there is more opinion and conventional “wisdom” than there is data. Let me begin with the “easy” part: notwithstanding reports of caregivers confusing the PD catheter for the PEG tube and instilling enteral feeding solutions intraperitoneally, pla...
When do you recommend testing for APOL1 variants in patients with proteinuric chronic kidney disease?
As yet, despite APOL1 being a clear risk factor for kidney disease and ESKD, there are no clear guidelines to assist in decision-making regarding genetic testing. This is mainly due to the fact that there are (as yet) no specific drugs for APOL1-mediated kidney disease. There is an RCT for inaxaplin...
Do you use mannitol when initiating patients on intermittent hemodialysis?
This is a very good question. Mannitol has been used for decades to try and reduce disequilibrium, cramping and intradialytic hypotension. Most of the studies are small and were not placebo controlled and were performed in prevalent patients. In 2019, a randomized controlled trial was done that did ...
Would you anticoagulate a patient with splenic infarctions in the setting of CMV viremia?
Based on my general knowledge/experience, I would consider CMV viremia as temporary, short-lived risk factor for a thrombotic event on a part of other inflammatory conditions, and outside of other indications for anticoagulation (e.g., atrial fibrillation, etc), my inclination would be to conclude ...
How often do you check carnitine levels in your patients with end stage kidney disease on hemodialysis?
About 10 years ago I used to check carnitine levels in ESRD patients with intradialytic hypotension commonly. If low then I would treat with levocarnitine. At some point I gave up on the practice not because it was not working but because it was hard to determine if it was working or not. I am aware...
What form of surveillance do you recommend for esophageal adenocarcinoma s/p NACRT and resection at what frequency?
We pretty much follow the NCCN guidelines. H&P every 3 months x 2 years, every 4-6 months out to five years, and our thoracic surgeons tend to continue annual follow-up after that. CBC and chemistries at each visit. NCCN points out that the value of CEA is unknown, but we tend to check them. Imaging...
Do you perform PEEP titration while patients are proned?
Once a patient is proned- we don't use the PEEP: FIO2 ratio tables because you want to continue optimal recruitment. So we monitor driving pressures and maintain PEEP for optimal driving pressures. Also remember as the chest wall compliance decreases with proning, for a given plateau pressure, your ...