Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Is there any role of sympathectomy in Raynaud’s disease?
Sympathectomy was once considered to be the treatment of last resort for severe, refractory Raynaud's. Though severe Raynaud's remains a challenging disorder to manage, nowadays, sympathectomy rarely if ever enters the therapeutic discussion. Though most patients with Raynaud's phenomenon observed a...
What is your approach to therapy for pulmonary sarcoidosis resistant to methotrexate?
The first question I ask myself in any situation dealing with "refractory" sarcoidosis is "Am I sure active inflammation from sarcoidosis is the cause of their symptoms?". Oftentimes, I will see patients referred for refractory disease who end up having other causes of their symptoms. If I am confid...
How do you approach evaluation of hypocomplementemia in a patient with arthralgias and a history of Hodgkin's lymphoma treated in the past?
There are both acquired disorders - more common - of the complement system and inherited disorders - less common - of the complement system. Although rheumatologists commonly deal with autoimmune/acquired disorders of the immune system, they should be aware that certain inherited deficiencies of the...
How do you approach differentiating infectious vs inflammatory tenosynovitis?
Infectious tenosynovitis is boggy and very tender. Inflammatory tenosynovitis is less tender.
What is your approach to determining if an SPEP abnormality is causal or coincidental in peripheral neuropathy work up?
Because the answer to this question is long and complex, I would refer to a nice recently published review of the topic in Continuum (AAN) which provides a detailed discussion and nice algorithms to investigate the monoclonal gammopathy and determine a possible relationship to the neuropathy (or lac...
What is the preferred timing for removal of a peritoneal dialysis catheter in a patient who has transitioned to hemodialysis?
I think that depends on the reason for the transfer to HD. If it is absolutely certain that the patient will not return to PD- for example, despite maximal prescription PD unequivocally cannot deliver sufficient solute clearance or provide sufficient UF- then the catheter may be removed immediately....
Is there utility in obtaining pericardial fluid autoimmune labs such as ANA or RF in patients with recurrent idiopathic pericardial effusions, but no other clinical or serologic evidence of rheumatic disease?
There seems not to be a consensus literature on this topic, so my answer is based on common sense rather than science. The first step is a detailed history (including family history) and physical examination looking for evidence of inflammatory joint disease with/without other findings that might fo...
When would it be reasonable to consider enhanced external counter-pulsation therapy in patients with refractory angina despite maximally tolerated anti-anginal therapy?
I would exhaust all options for coronary revascularization first.
Do you use anti-DFS70 Ab to help reduce the posttest probability of ANA-positive patients having a systemic autoimmune disease if other autoantibodies are negative?
I agree with Dr. Dixit that any lab test, especially an autoantibody test, has to be taken in context with the clinical features and other lab features. Our laboratory does not run this test as part of our serologic profiles. It may be reassuring to the clinician and patient that it is likely they d...
How do you diagnose and treat patients with cervicogenic headache?
I struggle with cervicogenic headaches. Conceptually, it is a secondary headache disorder with headache attributed to a disorder of the cervical spine and its component bony, disc, and/or soft tissue elements. The ICHD-3 criteria help make this causal attribution. If a headache begins in relation to...