Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What postural change in FVC is suggestive of respiratory muscle weakness?
In our practice, an assisted ventilation clinic which is enriched with patients who have diagnosed neuromuscular disease and/or chronic respiratory failure of unclear etiology, we often use 12% or 200cc simply by analogy to the criteria we use to assess bronchodilator responsiveness during PFTs. Alt...
What is your approach to management of intradialytic hypotension and autonomic dysfunction in a patient with ESKD?
Decreasing dialysate temperature to 35.5 to 36 degrees has, in my experience, caused a marked decrease in intradialytic hypotension. We use midodrine in some instances. The decreased dialysate temperature is systemwide in all cases in our units.
What is a reasonable length of time for systemic anticoagulation in patients presenting with MI in the setting of coronary artery aneurysm with large thrombus formation?
This is a great question. I would make the following points in reply: The present standard of care for antithrombotic therapy after a type 1 acute myocardial infarction, with coronary thrombosis, is dual antiplatelet therapy for one year (preferentially including a potent P2Y12 inhibitor). Current e...
How do you workup splenomegaly related to possible hematologic etiology in the absence of abnormal blood counts, adenopathy or severe constitutional symptoms?
The presence of splenomegaly is an important finding found either on physical exams or by imaging. As noted in the question, the initial work up includes physical exam looking for lymphadenopathy. In addition, laboratory evaluation, including absolute white count, and differential may help explain w...
Is there any evidence for amyloid/amyloidosis causing a spurious/false PSA reading?
This is an excellent question.Our group has been involved with amyloid/radiation effects in patients with Alzheimer’s disease Turn our initial run-up and through our most recent reviews, I have not seen any significant publications nor have I seen clinical situations that this addresses, although am...
Excluding CLL, in which patients would you screen for hypogammaglobulinemia?
Patients I screen for hypogammaglobulinemia include those with: gammaglobulin gap (total protein-albumin) less than two; advanced multiple myeloma or mantle cell lymphoma; patients who have received CAR T cells or bispecific antibodies against BCMA or CD20.
What is your approach for patients with a history of nephrolithiasis who are being evaluated for living kidney donation?
We have a protocol that guides us on the work-up in this situation. If they have a remote history of stones, then we do a Litholink and if they have a urinary milieu that is risky for stone disease they are counseled on fluid intake and dietary changes. If they have symptomatic stones, they are rule...
What laboratory workup do you perform in patients with symptoms consistent with erythromelalgia?
The usual CBC with differential, as well as CRP, ANA, ESR, and Rheumatoid Factor.
In what clinical scenarios do you utilize post-cardiac arrest targeted temperature management (TTM)?
There still is a role for TTM in post-cardiac arrest patients. The Targeted Temperature Management After Cardiac Arrest: A Systematic Review was a systematic review of six randomized clinical trials with a total of 3870 participants that were examined. Of these, 2,767 participants were treated with ...
How do you determine timing and frequency of stability scans for a patient with spontaneous, non-aneurysmal intracerebral hemorrhage?
We typically obtain a follow-up “stability scan” about 6 hours from the index scan. The AHA guidelines do not mention a specific timeframe. Situations, where we would consider sooner repeat imaging, would be clinical deterioration (increase in NIHSS by 4 or more points or decline in GCS by 2 or more...