Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you recommend transfer to an institution with a PE response team for a patient with an intermediate risk PE?
This is an interesting and difficult question. It depends on the case of a high intermediate-risk submassive PE that we have. Whenever there is a debate on the approach, a relative contraindication for certain forms of anticoagulation, different approaches on a catheter-directed intervention, or a ...
What are the preferred inotropes/vasopressors agents for cardiogenic shock in situations with and without LVOT obstruction?
Randomized evidence to support an answer to this question is lacking. As the question recognizes, "cardiogenic shock" encompasses a diversity of anatomic and hemodynamic substrates of disease. Left ventricular outflow tract obstruction, which may be fixed or dynamic, a baseline feature or acutely ac...
Should thyroid hormone replacement be initiated in patients with very prolonged critical illness with associated low thyroid hormone levels?
There is no evidence that LT4 is of benefit in such patients.
What is your approach towards management of symptomatic broncholithiasis?
The broncholithiasis location relative to the airway can be outside the airway which is called peribronchial, inside the airway which is called endobronchial, or extends from inside to outside the bronchial wall which is called transbronchial broncholithiasis. Surgery is indicated in peribranchial b...
Do you use continuous or intermittent bronchodilator therapy in severe airway obstruction?
I use only intermittent.
What is the appropriate cardiac work-up and management for an otherwise healthy individual who has experienced immersion pulmonary edema while scuba diving?
Immersion pulmonary edema (IPE) is rare in the general population, but does occur in approximately 1% of triathletes and more frequently among military recruits (Kumar and Thompson, PMID 30403902). IPE is due to acute increases in pulmonary capillary wedge pressure (PCWP), which can flood the alveol...
What is your approach to monitoring for recovery in a patient with non-oliguric AKI requiring dialysis?
In my opinion, the best test to monitor the recovery of renal function in an AKI patient is a daily measurement of serum creatinine. Decreasing serum creatinine is the most reliable marker to indicate recovery of kidney function after AKI. The main confounder would be simultaneous loss of muscle mas...
Do you recommend using dextrose based solutions to induce osmotic diuresis for euvolemic patients with acute kidney injury in the setting of a hemolytic condition?
The incidence of hemolysis (especially after blood transfusion) has been so low that to my knowledge there have been no good studies about the treatment of AKI with osmotic diuretics in this setting. Older literature has always used Mannitol to induce osmotic diuresis, but whether that improved the ...
Would you perform dialysis on a patient with altered mental status in the setting of an elevated blood urea nitrogen level attributed to a tube feeding diet?
Uremia is symptomatic azotemia, I don't see how you don't dialyze that patient. The idea behind tube feeds is nutrition, that you need amino acids to make protein, but if the BUN is rising, clearly you are catabolizing some of them, and I would check with the dietician to make sure the patient isn't...
Do you hold CRRT for a period of time before performing a diuretic challenge in a patient with whom you are assessing for the ability to wean off of continuous dialysis?
You may want to sit down for this answer, I think the diuretic challenge is overrated and if I’m not mistaken, it was really developed to see if a patient may need to start RRT for Aki, not come off it. I would hardly use it on a patient with aki on Crrt for a decision. It isn’t rocket science to de...