Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you manage significant asymptomatic indirect hyperbilirubinemia in patients with hemolytic diseases (SCD, HS, etc.)?
Hello, Indirect bilirubin is from hemolysis, not cholestasis (a few exceptions from rare syndromes), so not associated with stones, and would not expect ursodiol to help. It's a marker of how bad the sickling is - along with LDH, reticulocyte count, and MCHC (which measures cell density, i.e., irrev...
What is your approach to the workup for an underlying systemic condition in a patient presenting with retinal vasculitis?
Retinal vasculitis is a frequently misunderstood condition. My colleagues and I have written about it on several occasions such as in Current Opinion in Rheumatology, 2016. Retinal vasculitis is often diagnosed by an ophthalmologist on the basis of vascular leakage in a test called a fluorescein ang...
Do you administer immunosuppression to patients with idiopathic NSIP who have normal lung function and mild to moderate respiratory symptoms?
I think it depends on whether or not it clinically seems that the idiopathic NSIP is driving the mild to moderate respiratory symptoms. If there are no other clear causes of the respiratory symptoms (pulmonary hypertension, cardiovascular disease, airways disease, etc.) and the HRCT imaging findings...
Are there any instances when you would not perform 3 consecutive daily dialysis sessions when initiating a patient on hemodialysis?
In-patient - Friday, Saturday, and Sunday (we are not fully staffed on Sundays). Out-patient - I see no reason to do three days in a row. There is nothing magical about starting dialysis. Patients were surviving without it before you started it, there is no rush. Updated answer: YES - I would no...
Do you consider tracheostomy for the management of continued hypercapnea despite compliance with PAP in patients with OHS and OSA?
I would try AVAPS such as trelegy machine first before considering Tracheotomy. In most circumstances with good compliance, it helps with the hypercapnic failure.
In a patient with anaphylaxis and loss of consciousness from stinging insect, suspected to be yellow jacket, the sIgE was significantly positive to all vespids, but honeybee and paper wasp were only 0.44, would you evaluate further with skin testing to wasp and decide on including wasp in treatment based on skin testing being positive or include it with just the low IgE level?
The wasp IgE may be cross-reactive with YJ, and if the YJ is more than 5 times higher than Polistes IgE then this is almost certainly the case, which would suggest that Polistes VIT is not necessary. However, there is no available test to prove the cross-reactivity, so given the severity of the reac...
How do you approach the workup of clinically diagnosed cutaneous vasculitis in healthy young individuals without systemic symptoms?
As with all of medicine this answer depends on the presentation. A thorough review of systems and exam is needed to stratify workup. If we are talking about classic LCV below the knee in an otherwise healthy person, with no other concerning s/sx (as sounds like you are asking), I do generally confir...
How do you decide when to obtain genetic testing for suspected autoinflammatory conditions in adults?
We have identified an autoinflammatory disorder that occurs in people of the Southern Appalachian mountains known as "Melungeons." Several have been evaluated at NIH, and while they do not have any of the known markers the diagnosis of familial Mediterranean fever has been confirmed. Dr. Kastner tol...
How long after surgical repair of a pleuroperitoneal leak do you resume peritoneal dialysis?
This is a bit of a challenging question as I'm not aware of any data to help guide my response. It seems to me however that, since failure of the surgical repair would inevitably culminate in permanent shift to HD, one should allow ample time for healing to occur and thereby to achieve the best poss...
What would be the preferred treatment option for PMR if patient develops gastric perforation soon after initiation of steroids?
Of course Kevzara.