Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach new-onset idiopathic intracranial hypertension (IIH) with someone who has history of systemic lupus erythematosus?
Since there is not a clinical recurrence of lupus, let's assume the disease is quiescent. The patient may have a clotting tendency so extra care should be taken in MRV interpretation. Does the MRV show the smooth-walled flow-related stenoses of intracranial hypertension or is it more consistent with...
How do you approach patient requests for medical time away from work or other accommodations (such as disability paperwork) when the patients have mild-moderate symptoms being managed in the outpatient setting?
This is a very important question as clinicians are often requested to provide certain assertions based on their role as the medical provider. In reviewing this, there are several areas to keep in mind: First, if you are the provider and are the one with the knowledge, then you should provide the r...
How would you approach management of a patient with seropositive RA and UIP-ILD, with concern for active lung disease?
There is a potential benefit of adding additional immunosuppression for an RA patient with a UIP pattern on HRCT. My go-to-drugs are either abatacept or rituximab. While MMF is a standard first-line medication for many forms of ARD-ILD, it was tried for RA joint disease many years ago and the study ...
When can we consider deferring an insulin drip in patients with hypertriglyceridemia-induced pancreatitis?
Serum triglyceride levels >500 mg/dL (5.6 mmol/L) are required for hypertriglyceridemia to be considered the underlying etiology of acute pancreatitis (UpToDate).For patients with severe hypertriglyceridemic pancreatitis, such as those serum triglyceride levels >1000 mg/dL plus lipase >3 times the u...
How would you manage an ESKD patient who complains of severe fatigue after hemodialysis, but does not experience intradialytic or post-dialysis hypotension and has not responded to dry weight adjustments?
Difficult but unfortunately not uncommon situation. My theory is that more frequent dialysis would be beneficial to avoid dramatic electrolyte and fluid shifts that occur with intermittent hemodialysis. Would see if peritoneal dialysis or home hemodialysis would be an option. If not, maybe 4 days pe...
What is your preferred approach to a patient with incidentally found low ceruloplasmin?
I repeat it, but also take a thorough history and physical with attention to a diagnosis of Wilson's disease. If repeat comes back less than 19 again, then 24 urine copper and liver US/fibroscan, and maybe optho exam.
In what clinical scenario would you consider the use of budesonide over prednisone as part of the pharmacologic management of autoimmune hepatitis?
Primarily in patients where the side effects of prednisone will or are too difficult to tolerate (diabetics, weight gain, metabolic syndrome, psychiatric disease, etc). I like to try prednisone first because of its ability to elucidate a biochemical response, fairly rapidly, so we know what we are d...
Is there a role for use of GLP-1/GIP receptor agonists in the management of substance use disorders, whether or not they meet other inclusion criteria for their use?
Currently, we lack the RCTs to understand the full impact of GLP-1s on SUD outcomes. Most evidence is pre-clinical, observational, suggesting potential reductions in cravings and alcohol use. A recent RCT, lab study of semaglutide in non-treatment-seeking adults with AUD showed decreased alcohol con...
Do you use combination therapy for persistent MSSA bacteremia?
I don’t think I’ve ever come across a situation where the problem wasn’t source control…
In a patient with selective IgM deficiency who is completely asymptomatic in terms of infections, what is your typical laboratory work up?
B cell phenotyping, lymphocyte subsets, IgG to diphtheria, tetanus and S pneumonia. Evaluate the humoral function, as it is important to know and possibly follow with time, but with an asymptomatic treatment is not warranted.