Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Would you consider adding an SGLT2 inhibitor to augment diuresis in patients with worsening renal function presenting with acute decompensated heart failure and AKI on CKD?
SGLT2 inhibitors can provide another avenue in providing the much-needed diuresis our decompensated patients have. AKI often accompanies this decompensation. SGLT2 inhibitors can be used safely at times with GFR> 25. I would consider adding it to my regimen of aggressive diuresis to provide aggressi...
What burden of PVCs/NSVT in an inpatient post-MI cardiomyopathy patient would prompt an EP study-guided ICD implantation prior to discharge?
This is an interesting scenario which is best addressed by the results of the MUSTT trial. In that study patients with ischemic cardiomyopathy who had ejection fraction of </=40% and manifested NSVT (3 beats to < 30 seconds) underwent EP study and if they were inducible for sustained VT then they we...
How would you approach a patient with GCA who develops necrotizing fasciitis and then flares because they are off of tocilizumab?
While recurrent necrotizing fasciitis is exceedingly rare, patients with necrotizing fasciitis may be at higher risk for other infections. Therefore, a careful risk/benefit analysis is warranted in such a case, similar to other cases of serious infections in patients on immunosuppression. The specif...
Does your approach to extubating obese patients differ from your approach in non-obese patients?
If the patient has OSA/OHs I often extubate directly to CPAP OR bipap especially if they have high compliance to OSA cpap therapy and are "used to the mask". But if high levels of secretions, NIV can make clearance of secretions more difficult. Thus, individualize therapy is indicated.
What is your approach to counseling an octogenarian on the risks and benefits of LHC in the context of NSTEMI complicated by new-onset heart failure and AKI on CKD?
This is a complex though not uncommon clinical scenario to which my approach would depend on many factors beyond those provided in the vignette. Among these (not an exhaustive list and not necessarily in order of importance): Is this a type I or type II NSTEMI? Is there evidence of ongoing ischemia ...
Can subclinical hypothyroidism cause myxedema coma?
While the patient's signs and symptoms mimic myxedema coma, he does not have, by definition, "myxedema" (severe hypothyroidism). The patient's normal FT4 can't be explained by his taking his levothyroxine that morning, given the 7-day half-life of levothyroxine. If he hadn't been taking his medicati...
How do you differentiate active vasculitis from pregnancy complications such as pre-eclampsia and HELLP in a patient with AAV?
Differentiating preeclampsia from autoimmune kidney disease in patients with rheumatic disease is often challenging due to the obvious overlap in clinical and serologic features. While most discussions about preeclampsia versus flare focus on SLE patients given that SLE is more common in women of re...
What are some considerations to make when managing a patient on peritoneal dialysis who develops acute pancreatitis?
A few points are noteworthy in this regard: It is unclear whether there is a causal association between peritoneal dialysis and the development of pancreatitis. Recall that the pancreas sits retroperitoneally and is therefore not in direct contact with the peritoneal dialysate. Development of pancre...
How long would you wait for outflow to improve before consulting surgery in a peritoneal dialysis patient with an outflow obstruction who is prescribed laxatives for catheter migration?
Any PD patient with outflow dysfunction that does not improve with laxatives should undergo abdominal x-ray to evaluate the position of the PD catheter. If the PD catheter is outside of its expected position within the mid-pelvis, there may be ongoing issues of catheter dysfunction if the catheter i...
Do you add fludrocortisone to hydrocortisone when starting stress dose steroids in a patient with septic shock?
In septic shock, vasoplegia is mostly believed to be related to widespread inflammation that giving hydrocortisone is supposed to address, and current guideline suggests hydrocortisone only is sufficient. However, it makes sense to add fludrocortisone since most of these patients present with undefi...