Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to preventing exercise-associated hyponatremia?
Exercise-associated hyponatremia is typically due to fluid intake in excess of fluid loss. Therefore, athletes should avoid overconsumption of fluids. Rather, athletes should drink according to thirst. In addition, it is important to recognize that electrolyte-containing sport drinks does not provid...
How do you interpret the presence of GAD antibody in a middle-aged patient with diabetes when all other type 1 diabetes antibodies are absent?
It depends on patient's clinical course of diabetes, controlled on orals vs insulin, BMI, family history DM. For a brittle DM patient, high GAD titer could indicate DM1 or LADA. For stable DM patients, the recommendation is to have 2 positive antibodies to diagnose DM1.
How do you evaluate livedo reticularis (not livideo racemosa)?
Livedo reticularis appears as an interrupted vascular network on the lower limbs. One does not need to warm up the affected area in order to make this diagnosis. The response to heat usually occurs in cutis marmorata that is found in children. Livedo reticularis when it is acquired in teenage and la...
Do you prefer scopolamine patches, glycopyrrolate, or other treatment regimens to manage oropharyngeal secretions at the end of life?
Terminal respiratory secretions, the “death rattle,” may occur during the dying process. Noisy breathing may upset family members, but can also be a normal part of dying. It is important to stop non-essential IV fluids that may contribute to volume overload and pulmonary edema. The head of the bed m...
How do you treat patients with Linear IgA that are deficient in G6PD?
Quite a unique clinical situation! One in which the diagnosis is rather rare, but with an added wrinkle where the most classic textbook therapy, dapsone, cannot be used.A few case reports have shown that omalizumab and dupilumab have been reported to effectively treat LABD: Almuhanna et al., PMID 37...
Would you consider giving thrombolytic therapy for patients with acute vision loss concerning for CRAO based on history and within the window before any ophthalmological assessment and confirmation?
We have utilized a prior study to give tPA or tenecteplase within 4.5 hours of onset for CRAO. I would not do so, however, without an ophthalmology evaluation to confirm the likely diagnosis and to exclude an alternative diagnosis such as a retinal detachment.
Do you treat prosthetic joint infections after a two-stage revision arthroplasty with oral antibiotics for the full duration of therapy, assuming a susceptible oral option is available?
This is a hard one-I definitely think the data is there for PO, but until the IDSA recommendations change and the culture of practice changes it is hard to make the switch to doing a full regimen PO! I also think the accountability of IV antibiotics is useful -with the visiting nurse, weekly labs, i...
What are some immunosuppression regimens to consider in a patient with refractory cardiac sarcoidosis?
Unfortunately, there is no high quality data at this point to directly answer this question but here are some options. For patients who have only been treated with oral steroids, I would first consider the addition of weekly methotrexate at a dose of between 10 - 20 mg WEEKLY with supplemental folic...
When would you consider referring a patient with suspected cardiac sarcoidosis based on PET and MRI for endomyocardial biopsy given degree of patchy involvement, as opposed to initiating empiric immunosuppressive therapies?
I would avoid initiating empiric immunosuppressive therapies without a firm diagnosis of sarcoidosis. I will mention however that the latest Japanese Circulation Society criteria for the diagnosis of sarcoidosis do include criterion for the non-invasive diagnosis of likely cardiac sarcoidosis based ...
Do you utilize soluble IL-2 receptor or ACE levels as serum biomarkers to monitor disease activity in pulmonary sarcoidosis?
I use ACE levels to monitor disease activity in patients who demonstrate elevated ACE levels at diagnosis of confirmed sarcoidosis and for which there is no other explanation for elevation of ACE. ACE normalizes with treatment and will increase again if/when the disease relapses. The literature indi...