Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
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...
Are there instances when you would pursue a kidney biopsy in a pregnant patient instead of waiting to perform the procedure post-delivery?
Prior to 20 weeks, consideration of a biopsy shouldn't be different than how we would think about biopsy in a non-pregnant individual. The pregnancy is still pre-viable, and so knowing a diagnosis and treating the disease with the goal of improving the kidney function, and thus the pregnancy, makes ...
How do you decide when to refer patients with obstructive hypertrophic cardiomyopathy for alcohol septal ablation versus septal myectomy?
If a patient with obstructive HCM remains severely symptomatic despite being on maximal standard-of-care medical therapy, (beta blockers, non-dihydropyridine calcium channel blockers, addition of disopyramide for combination therapy, or a cardiac myosin inhibitor if appropriate), septal reduction th...
Do you recommend a kidney biopsy for patients who develop acute kidney injury after starting sacituzumab?
For all novel agents, I think that it is prudent - if there are no contraindications to the renal biopsy - to proceed with a biopsy. A renal biopsy is helpful in clarifying the etiology of the AKI and may have implications regarding whether the medication can be safely continued - depending on what ...
Are contact precautions effective at preventing MRSA transmission in healthcare settings?
I have a major axe to grind here. Whenever this has been looked at it seems that the answer is that, outside of an outbreak situation for example, so long as people wash their hands, this adds nothing but waste of medical equipment. See the following articles: CID review: Diekema et al., PMID 377385...
How do you approach the diagnosis of erythronychia?
Erythronychia has a broad differential including inflammatory diseases (lichen planus), infectious diseases (verruca), and benign (onychopapilloma, glomus tumor), and malignant tumors (SCC, amelanotic melanoma). I approach erythronychia with history and physical examination including measuring width...
In a life-time non-smoker with stage IV lung adenocarcinoma presenting in visceral crisis, what therapy would you recommend to avoid organ failure while awaiting mutational status?
I would offer cytotoxic platinum doublet chemotherapy and omit immunotherapy based on emerging data that TKI adverse events are often worse after prior immunotherapy exposure (Calles et al., PMID 32421452). The choice and dose of cytotoxic doublet will depend on the individual circumstances of each ...
Are there concerns with using sulfasalazine in SLE?
A very practical question:1. Yes, there is a concern theoretically; but you can use SSZ in lupus patients in certain circumstances.Sulfonamides are divided up into antibiotic (abx) sulfonamides (like trimethoprim-sulfamethoxazole, TMP-SMX) and non-abx sulfonamides (e.g. furosemide, hydrochlorothiazi...