Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach management of adult patients with CVID and sarcoid-like syndrome?
Common variable immunodeficiency syndrome (CVID) is the most common primary immunodeficiency, and is of course, characterized by recurrent infections. This can lead to bronchiectasis due to structural damage from these recurrent infections. However, patients can also have non-infectious manifestatio...
How often do you see bony erosions in patients with Lyme arthritis?
There are three ways that Lyme disease can result in joint involvement. The most common is diffuse arthralgias (not a true arthritis) associated with the acute infection. This is self-limited and does not harm the joint. The second is an inflammatory arthritis that is similar to other infected joint...
Given that high coronary calcium scores portend significantly increased cardiac mortality rates over 5-6 years, is there any data to support performing coronary angiography when the score is very high, e.g. over 1000, even in asymptomatic patients with no objective evidence of ischemia?
The question is; is coronary angiography necessary in asymptomatic folks with extensive CAD on EBCT? Will it tell us more than what we already know; that the patient has extensive CAD? Will it make an asymptomatic patient feel better? Will the information obtained from coronary angiography allow for...
Which patients, if any, treated according to PROSPECT for an early stage rectal cancer, would you offer surveillance if they achieved cCR after neoadjuvant chemotherapy?
Thanks for the important question. This is a nice but also challenging situation given, at this time, we do not have evidence for organ preservation with chemotherapy alone. Nonetheless, the PROSPECT trial did show approximately 20% of patients indeed achieved pathological compete response (was quit...
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...
How do you manage headaches in stroke patients?
In general, I treat headaches based on phenotype. If they have associated migraine features then I treat them with migraine medications. If tension type then I address all the headache hygiene components. If cervicogenic then physical therapy for these. Always screen for and counsel on medication ov...
How do you dose apixaban in patients with CrCl <30 mL/minute?
Patients with chronic kidney disease are challenging to treat with anticoagulation as they have an increased risk of both venous thromboembolism and bleeding. Treatment should be individualized after weighing the risks and benefits of anticoagulation as well as the indication for anticoagulation. Th...
Do you recommend any specific testing for patients with recurrent nephrolithiasis and suspected absorptive hypercalciuria?
I would consider genetic testing in this situation, although it would not alter my recommendations for diet and thiazide diuretic treatment. I would also look for primary hyperparathyroidism. Counterintuitively, parathyroid hormone increases absorption of urinary calcium; that’s why HPT patients are...
How do you manage MAT for opioid use disorder in lung transplant patients during the peri/postoperative period?
There is currently no evidence regarding mOUD in lung transplants. Available research represents generally a weak quality of evidence regarding opioid use for pain control before and after lung transplant. Non-opioid analgesic interventions, including thoracic epidural anesthesia and intercostal ner...
How do you choose between spironolactone and finerenone for patients with proteinuric diabetic kidney disease and heart failure?
Although finerenone may be easier to use due to its lower incidence of sexual side effects and hyperkalemia, it is more expensive than spironolactone and may be more difficult to prescribe. Many prescription drug plans require prior authorization for finerenone and documentation that the patient has...