Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you interpret small joint effusions seen on ultrasound without power doppler signal in the setting of compatible inflammatory symptoms (i.e morning stiffness)?
It certainly increases probability of Inflammatory arthritis, if aligns with clinical symptoms. I would check inflammatory markers, autoimmune serologies, infectious work up and all to determine type of arthritis and consider prednisone trial and likely consider immune suppressive regimen based on r...
For patients with SLE, is there an ANC level for which you would hold or adjust hydroxychloroquine in an asymptomatic patient?
Leukopenia most often as lymphocytopenia, of course, is not unusual in lupus. Total WBC less than 4000 is an ACR classification criteria for the disease as is ALC less than 1500 on two occasions. SLICC disease classification requires ALC less than 1000. Total WBC < 3000 generates SLEDAI points. On t...
Is there any benefit to checking serum viscosity in patients with autoimmune disease and headaches/migraines to see if aspirin or clopidogrel may be beneficial?
The serum viscosity test measures the time required for the serum to flow through a calibrated capillary tube under controlled pressure. Clinically significant elevations in viscosity (≥2.5 centipoise, normal range 1.4 - 1.8 cP) can cause symptoms and are most commonly seen in hyperviscosity syndrom...
What is the interpretation of an IGRA with positive TB wells and negative nil and negative mitogen wells?
We don't see positive controls in most clinical assays. They are run, of course, but hidden from view. The mitogen well is the positive control in the IGRAs. The mitogen used QuantiFERON-TB Gold is, I believe, PHA or phytohemagglutinin. PHA turns on T-cells to indiscriminately. If I remember my mito...
Do you counsel a mother to avoid certain food in her diet if she is still breast feeding and her child has confirmed IgE mediated food allergies?
Wangberg et al., PMID 33636342 surveyed a total of 133 breastfeeding mothers with allergic children. A total of 47.4% of mothers reported their healthcare provider encouraged them to continue breastfeeding without dietary restrictions, 17.3% were advised to continue breastfeeding but avoid eating th...
Do you recommend the use of albumin-adjusted calcium measurement formulas to accurately assess calcium levels?
It is a reasonable approach to correct serum calcium using albumin when hypocalcemia is present, especially in a hospital setting. I believe it is less useful for evaluating hypercalcemia.Although it is reasonable to use albumin to correct serum calcium in patients with hypocalcemia it may be worthw...
Would you consider using steroids in patients with respiratory failure caused by aspiration pneumonitis?
For aspiration pneumonitis alone, typically no. If there are other indications for steroids, for example, acute COPD or asthma exacerbation, then I would. I would also focus on addressing the aspiration to prevent future events. I have also seen providers use antibiotics if aspiration pneumonia vers...
What precautions should be taken when discharging a patient from the medical setting on new medication assisted therapy for alcohol use disorder?
Great question. This article absolutely adds to the argument for using medications for alcohol use disorder. The precautions would mostly explain side effects, just as you would for any new medication. A few specific considerations depend on the medication (I'll restrict this to four more common cho...
What recommendations do you have regarding the use of dronabinol to prevent cannabis withdrawal in an inpatient medical or psychiatric setting?
I routinely use dronabinol in patients who are heavy/daily cannabis users and are having a hard time as inpatients with any degree of withdrawal and cravings. It can be a good anxiolytic as well as antiemetic and orexigenic in this situation. Depending on their preferences, it can be scheduled with ...
How do you approach weaning patients off of buprenorphine?
I have found using injectable extended release buprenorphine (XR-BUP) as a good way to help patients taper off SL buprenorphine in a means much more tolerable than trying to taper SL buprenorphine. We published a case series on this approach (Ritvo et al., PMID 32925232) and subsequently another cas...