Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you recommend any CRRT prescription changes for optimal clearance for patients with AKI who are on a reduced blood flow rate due to concurrent regional citrate anticoagulation?
In distinction to conventional HD, solute clearance in CRRT is limited by dialysate/replacement solution flow, not blood flow. So, no, I do not make changes in the CRRT just because of a decrease in blood flow rate.
Is there a risk of hepatitis C activation with rituximab in a patient who has a history of HCV treated with antivirals and who is in sustained viral response?
In general, the risk of HCV flare with immunosuppression in general including rituximab must be viewed as minimal for those who have achieved a sustained virologic response (Undetectable HCV RNA ≥12 weeks after treatment completion) and does not influence my therapeutic decision-making if the patien...
When would you consider a kidney biopsy in a patient with longstanding diabetes and hypertension (baseline creatinine 4-5, 4+ proteinuria) who was recently found to have dsDNA positivity?
Only if something changed clinically, urine protein abrupt increase, hematuria microscopic, increase in trajectory of creatinine, or symptoms suggestive of SLE. I feel bad when I biopsy a diabetic only to find diabetic nephropathy, but if you never find diabetic nephropathy, you aren't doing enough...
Should intervention be considered for an intermediate flow-limiting coronary lesion that does not correlate with perfusion defects on stress testing in a patient with atypical anginal symptoms?
This is a kind of question that gets into the realm of the "art of medicine". There are multiple questions within this single question. I will try to answer each of them. What is an angina and what is atypical angina: I have come across a wide variety of angina syndromes throughout my clinical expe...
How would you approach pursuing a kidney biopsy in a patient with suspected lupus nephritis who is on warfarin for antiphospholipid antibody syndrome?
This is a decision to be made carefully involving multiple specialists. Personally have had a bad experience with resuming anticoagulation after kidney biopsy. I have seen patients bleed even one week after doing the kidney biopsy when resuming anticoagulation. Can switch to a heparin drip before th...
Is there a BMI cutoff for which you would refer a patient needing a native kidney biopsy to interventional radiology?
I refer all my patients who require a kidney biopsy irrespective of BMI to our in-hospital Interventional Nephrology service. They evaluate the depth of the kidney from the skin surface with ultrasound and decide whether they will be able to obtain adequate renal tissue for diagnosis. If the kidney ...
Should one perform a subsequent screening CTA or MRA head for mycotic aneurysm after cardio-embolic strokes in a setting of endocarditis with initial unremarkable CTA or MRA head/neck?
If the initial CTA is unremarkable and there is no intracranial hemorrhage, I do not routinely obtain follow-up imaging. In my practice, CTA is preferred over MRA due to the lower sensitivity of non-contrast/TOF imaging in detecting small mycotic aneurysms. As mentioned above, CTA may also miss s...
Do you routinely use higher-dose VTE prophylaxis in patients admitted with traumatic orthopedic injuries undergoing surgery?
Yes, at my institution, we have two separate order sets. One is for moderate-risk medicine patients, which recommends enoxaparin 30-40 mg daily depending on renal function (heparin for ESRD and low-weight patients). The other is for high-risk patients, which includes all orthopedic and trauma patien...
How do you approach long-term blood pressure parameters in ischemic stroke patients with severe symptomatic intracranial stenosis?
Every patient is unique and I just try to be as low and slow as possible. 4-6 weeks seems to be where most people do well with others tolerating more (I'm able to get them to under 140 or even 120 during their hospitalization over a few days). In the acute setting, I've found it helpful to make sure...
In obese men presenting with gynecomastia, elevated estrogens, and hypogonadism, what clinical factors would push you to obtain testicular and/or adrenal imaging to rule out an estrogen-producing tumor?
It is not generally necessary or useful to measure serum estradiol in the evaluation of acute (tender and/or growing) gynecomastia. The widely available estradiol assays are generally immunoassays that are not accurate at the low estradiol concentrations in men. In addition, it is not uncommon to se...