Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach a patient with high titer ANA and a new diagnosis of ITP, but no other signs or symptoms suggestive of active rheumatologic disease?
I would certainly treat the ITP with hematology involvement if necessary but would continue to monitor for lupus or similar CTDs. I have seen patients present with an ITP-like picture for years before lupus declared itself eventually. It may take years. I would also check a UA for proteinuria. This ...
How do you decide when to implement a "renal diet" (i.e., restricting electrolyte and/or fluid intake) in hospitalized patients with renal impairment?
I think about this from several perspectives: First, what's the severity of the renal impairment? Generally, I consider electrolyte abnormalities like hyperkalemia and hyperphosphatemia more likely to occur when the eGFR is <60 (for hyperphosphatemia, it might be more evident when the eGFR drops bel...
Do you commonly arrange home nocturnal oxygen at discharge for hospitalized patients with incidental nocturnal hypoxemia vs recommend an outpatient sleep study?
• No outcome trial supports empiric home O2 for isolated nocturnal hypoxemia. The evidence base for long-term oxygen therapy (NOTT, MRC, LOTT) is built on daytime resting hypoxemia in COPD (PaO2 ≤55 mmHg, or ≤59 with cor pulmonale/polycythemia). There's no equivalent mortality/morbidity benefit show...
How do you approach the decision to consult Cardiology and pursue an ischemic workup for an isolated troponin elevation attributable to a non-cardiac acute illness such as sepsis or acute respiratory failure?
This decision is much more complex than can be adequately addressed in this response, based on the information given. The demographics and clinical risk factors of the patient are important in this decision, as well as the comfort of the clinician/primary care physician caring for the patient. Does ...
What is your approach to the management of shrinking lung syndrome in SLE?
No consensus exists on the best way to diagnose shrinking lung syndrome (SLS). Interestingly, I rarely see this anymore. Possibly due to better treatments and universal use of hydroxychloroquine (HCQ)? We are not even sure how and why it occurs. Could it be a myopathy of the diaphragms or a result o...
Do you prefer a loading dose of 300mg or 600mg plavix for patients presenting with NSTEMI or unstable angina about to undergo LHC?
Interesting question! As a rule of thumb, 600mg loads faster than 300mg. Therefore, it is more important when you anticipate your ballooning/stenting happening sooner rather than later (within minutes/hours). Per guidelines, Plavix is preferred over prasugrel/brilinta for stable angina (which was no...
What is your approach to management and surveillance in low grade traumatic blunt ICA injury?
For blunt cerebrovascular injury (BCVI), I use the Biffl scale to evaluate the extent of vessel trauma. The extracranial neck vessels, such as the cervical ICA or VA, are most commonly affected. The Biffl classification consists of five categories, with Grade 1 representing a low-grade injury. This ...
What is your approach to using pegloticase in patients with congestive heart failure?
Clinical trial data show developing CHF exacerbation in 2% of patients while on Pegloticase treatment, while real-world data show higher numbers (6.4%), so careful patient selection and stabilization of CHF are necessary before starting treatment, and need close monitoring while receiving treatment....
For patients who do not have access to biologic therapies, what are some csDMARD combination pearls or tips that you have that have particular efficacy in different rheumatologic diseases?
I normally use MTX in RA. I initially aim for 15mg of MTX per week, then split the dose and maximize to 20-25mg/week. In some patients, I use SQ MTX if they have GI problems or are very obese. The addition of HCQ with MTX is better than MTX alone in some patients. I have rarely used SSZ+MTX+HCQ but ...
How do you approach the decision to initiate or continue bisphosphonate therapy in an older patient with significant esophageal disease or swallowing dysfunction?
Unless there are indications to turn first to non-bisphosphonate therapies, I would first consider whether the patient would be a candidate for IV bisphosphonate therapy. Many patients, even those without esophageal disease or dysphagia, find the convenience of an annual outpatient infusion appealin...