Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What parasites do you screen for in your workup of HES?
In my practice, if GI symptoms (particularly diarrhea), then culture for stool ova and parasites (broad screen). If there are no GI symptoms, then only screening for Strongyloides with a blood test for Strongyloides antibody. If there is a recent travel history or a patient immigrated from areas wi...
Would you consider an ICD for secondary prevention in an otherwise previously healthy adult found to have severe LV systolic dysfunction admitted s/p VF/VT arrest due to profound hypokalemia and hypomagnesemia, or defer implantation given resolution of arrhythmias after correcting electrolyte abnormalities?
I would need to have much more information. For example, does this person have CAD and/or a definable etiology for the cardiomyopathy? Does he/she/they have a family history or genetic profile that might influence the decision. Importantly, I would not dismiss a secondary ICD in this person based on...
What is the upper limit of blood glucose target in hyperglycemic critically ill patients?
I don't think there's much data that argues that setting the upper limit between 180 and 200 will make much of a mortality difference. The SCCM guidelines center around initiation of insulin infusions, and doesn't seem to say that we should start insulin infusions for BG>180, but tolerate it up to 2...
How do you approach management of recurrent idiopathic pleuropericarditis?
The first line is colchicine and NSAIDs until the pain resolves, CRP normalizes, etc… After this, if the CRP tracks with the symptoms, fluid reaccumulation, and/or cMRI evidence of the pericarditis, I find il-1 inhibitors work very well.
Would the diagnostic yield for ABIs or peripheral arterial duplex doppler in a patient with metal rods in both legs be similar or acceptable in comparison to those tests in a patient without metal rods?
Ankle-brachial index(ABI) relies on the compression of upper and lower extremity arteries with blood pressure cuffs and measuring the ratio of blood pressure between them. While I am not aware of specific studies in those with metallic rod fixation, ABI measurements should have similar utility as lo...
How do you use IVC collapsibility on POCUS to inform decisions for managing hypotension?
If a hypotensive patient is lying flat and spontaneously ventilating with a >50% collapse of the IVC (IVCmax - IVCmin/IVCmax x 100%) during a 'sniff' test then I would consider them 'volume tolerant'. They may not be responsive to IVF but it is unlikely that additional IVF will be harmful. Absolute ...
What is a reasonable class of antihypertensive to start in patients with HCM who remain hypertensive and symptomatic in spite of maximal doses of beta blockade or calcium channel blockers?
My answer is based on the experience and not the research data per se in HCM: I will add low-dose HCTZ (12.5 mg daily). It won't cause dehydration or hypokalemia and might do wonders in managing HTN in these patients. One of the cheapest and most effective! Or I would consider Spironolactone instea...
How do you approach interpreting a low titer dsDNA (such as crithidia 1:40 to 1:80) in the setting of a moderately elevated ANA without other specific features of SLE?
Serologies are not a diagnosis nor are they diagnostic. This patient does not NOW have lupus. Are there first-degree relatives with SLE? Does this patient have any other autoimmune disorders like Hashimoto thyroiditis? What to do? Follow-up and education. Routine follow-up and welcome phone calls to...
Is methacholine challenge on its way out?
I have not needed to order the challenge test for a long time now. I see the need for this test is declining.
What is your approach to anticoagulation in a patient with AKI and cirrhosis who has frequent filter clotting on CRRT?
A meta-analysis (Qi et al., PMID 37186766) compared 348 patients from 9 studies receiving RCA to 127 patients from 5 studies receiving heparin anticoagulation. Among the RCA recipients, the incidence of citrate accumulation, metabolic acidosis, and metabolic alkalosis was 5.3%, 26.4%, and 1.8%, resp...