Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Is there a good rationale for using vasopressors/induced hypertension in a patient with fluctuating neurologic deficits from symptomatic intracranial stenosis?
I have raised blood pressure in patients with fluctuating stroke deficits, especially in patients with intracranial hypertension, with apparently good results. We usually try fluids first, but pressors are sometimes necessary. This makes sense from the known autoregulation curves, which are shifted ...
Do you recommend parathyroid adenoma resection or ablation for patients with primary hyperparathyroidism and recurrent nephrolithiasis who are found to have a single gland adenoma on parathyroid ultrasound and nuclear medicine imaging?
Yes. My two indications for ablation/resection of a proven parathyroid adenoma are (1) metabolically active calcium-based kidney stone disease and/or (2) osteopenia/porosis as identified by bone scan. I think there is strong evidence that primary hyperparathyroidism can cause either or both. In the ...
Do you administer calcium to patients with K > 6.5 without EKG changes?
No. But our ER does as a reflex and I don't have a problem with that. It used to drive me nuts bc it sent the wrong message, as though Ca lowers [K] level (of course it does not, it just decreases cardiac effect). But you don't know how fast they are being seen, how fast they will get treated, so I ...
When attempting PEEP titration, how long do you wait after decrements or increments to assess for a change in driving pressure?
This depends on the patient level of consciousness and whether or not they are paralyzed.
What is your approach to interpreting urine studies in patients hospitalized for hyponatremia who have recently received intravenous fluids containing sodium chloride?
Regardless of whether or not the patient receives intravenous saline infusion, a low urinary sodium concentration is still suggestive of reduced tissue perfusion (hypovolemia, CHF, cirrhosis).
When treating pancreatic body/tail lesions that result in significant dose spread to the spleen, what is your threshold to offer pneumococcal, hemophilus influenza, and meningococcal vaccines?
A really great question, and one that we don’t necessarily have a lot of data for guidance. There are some guidelines out there, though, that I think can be helpful to consider. The first is the recent guideline from ASCO on the vaccination of adults with cancer (Kamboj et al., PMID 38498792). In li...
Do you use the peri-operative management of biologics and DMARDs guidelines, which were mainly based on total hip and knee replacement surgeries, for all peri-operative surgical management?
The American College of Rheumatology Perioperative Guidelines focused on patients undergoing hip or knee arthroplasty. These guidelines can be a helpful starting place when thinking about medication management in patients undergoing other surgeries, but my recommendations for perioperative managemen...
How do you approach the timing of DMARD initiation in patients with active RA who are on treatment for latent TB?
As the patient is already treated for latent TB, if they have not initiated DMARD therapy for RA, I would follow the guidelines and start conventional DMARD therapy. If the patient requires additional therapy because of insufficient response, I would choose a non-TNF inhibitor as the risk for TB rea...
Is omalizumab an option for a patient needing a specific antibiotic with an IgE-mediated reaction who continues to have reactions during a desensitization?
Omalizumab is FDA-approved for Asthma, Chronic spontaneous urticaria, chronic rhinosinusitis with nasal polyposis, and food allergy. It is a monoclonal antibody directed at IgE which will deplete circulating IgE and thus specific IgE on the mast cell and basophils will decrease. There is also likely...
Would you recommend normal saline for pre- and post-LHC hydration in patients with CKD stage III to IV with reduced LV systolic function, and if so, what is a reasonable amount of volume?
The POSEIDON trial, or Prevention of Contrast Renal Injury with Different Hydration Strategies, was a randomized controlled trial that found a personalized hydration strategy can reduce the risk of contrast-induced acute kidney injury (CI-AKI) in patients undergoing cardiac catheterization. The tria...