Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to initial work up for a young patient with bronchiectasis?
I assume we are talking about patients in their 20s, 30s-50s who have had a HRCT with radiological bronchiectasis. It will be good to know if they have had clinical implications and symptoms of cough, infections, and mucus production. It will be good to know about multiorgan involvement like sinuses...
What is the best approach to manage iron overload secondary to both heterozygous HFE gene mutation and two heterozygous aceruloplasminemia gene mutations?
The question is good as both heterozygotes for HFE and double heterozygotes (I suspect the same applies for aceruloplasminemia) for HFE are usually invisible. That being said, not always. What I do, if the increased iron is not urgent (normal LFTs, ferritins <1,500), is get them to become blood dono...
What is your approach to management of elderly patients with cardiopulmonary comorbidities and severe pulmonary hypertension?
I generally follow the current ERS/ESC guidelines with regard to the treatment of patients with WHO group 1 PAH. I often will often start with a low dose of PDE5i and see them back within 4 weeks prior to increasing the dose. Similarly, I will see back within 4 weeks of adding an ERA to look for sid...
What is your approach to using nintedanib in patients on baseline immunosuppression?
Typically I start antifibrotic therapy in a few situations: The most common reason is ILD progression despite adequate immune suppression, defined as no extra-pulmonary disease activity (usually joint disease, but can tailor according to the patient's disease/situation, such as by presence of rash, ...
Should patients with co-existing moderate-severe valvular disease (particularly AS and MS) and malignancy requiring radiation therapy undergo more frequent surveillance surface echocardiograms?
The answer is yes, for some patients with baseline moderate to severe valvular heart disease receiving radiation, with the heart in the radiation field (i.e. left breast, lung, esophageal cancers), they should have more frequent surveillance echocardiograms.The 2020 ACC/AHA valve guidelines recommen...
How long would you continue prednisone in an ESKD patient with a failed kidney transplant who develops mild graft pain when steroids are tapered?
Typically when a patient develops pain over a failed allograft, we would try a PO pred pulse and a taper back down to 5mg daily. If, when the prednisone is low-dose or off completely, the pain recurs, you need to assess the risk/benefit for the patient of maintaining them on low dose steroid versus ...
When prescribing hydroxychloroquine, how do you explain the mechanism of action and how this translates into clinical benefit for the patient?
1. Explaining the mechanism of action of hydroxychloroquine (HCQ) when RXing it to a patient:- Time is limited in clinical practice, and there are SO MANY positive benefits of HCQ that I do not explain the MOA except with the statement:"HCQ calms down the immune system without actually suppressing t...
For patients maintained on antiplatelet monotherapy post-DAPT following PCI, what is your recommendation for holding antiplatelet therapy prior to non-cardiac surgery?
As clopidogrel recently has gained traction as a preferred long-term monotherapy to aspirin but is generally not allowed to be administered for a week prior to surgery I have “bridged” with 81 mg aspirin.
For patients presenting with spontaneous coronary artery dissection, what other non-cardiac/vascular work-up can be considered to further risk stratify them as a predictor for any future cardiovascular events?
Our general practice has been to do a CTA head to pelvis to evaluate for FMD and/or aneurysmal disease.
In patient s/p definitive chemoRT for vulvar cancer with complete response, how do you manage a non-healing vulvar defect if biopsy is negative for residual disease?
Hard and takes time. Vitamin E with trental and quit smoking.