Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What strategies do you employ to prevent post-intubation hypotension in a profoundly hypoxic patient given a paralytic for intubation?
There are a few strategies I use. I choose an induction agent such as Etomidate or a ketamine which has minimal hemodynamic effects. If BP is soft to start with, I use IV fluid small bolus, use a vasopressor such as phenylephrine push if needed before sedation.
What is the ideal period to wait until curative surgery for patients with acute pulmonary embolism and solid malignancy?
This is a very important and practical question. As with most clinical circumstances, there is no evidence-based recommendation. The approach will vary with individual situations. For example: 1) Incidentally discovered subsegmental PE: my bias would be to proceed with curative surgery after one mon...
What is your approach to the evaluation and management of a suspected intrapulmonary hematoma?
I usually observe and they do tend to resolve over time.
Would you consider deferring chest tube placement in a clinically stable patient with a small empyema without signs of systemic infection?
Firstly, diagnosing empyema means the fluid has already been diagnostically tested by thoracentesis. If all the fluid was removed on the diagnostic tap, I would continue and complete the course of antibiotics with close follow-up. The duration of Antibiotics ranges from 4-6 weeks. If a significant a...
What agents do you utilize for mucociliary clearance during the index hospitalization of patients post lung transplant?
Early post-operatively bronchoscopy is the mainstay for the removal of secretions which may be quite thick and obstructive related to the sloughing of pseudomembranes (ischemic epithelium). We will transition from bronchoscopy to hypertonic saline (3% or 5%) nebulized BID with bronchodilators prior ...
How would you approach a fit older (>70 years) with grade I-II, bulky, follicular lymphoma causing ureteral obstruction and renal failure?
You could also consider focal radiotherapy as we know follicular lymphoma is often very radiosensitive (and can respond quickly to RT). Depending on the trajectory of the AKI and dysfunction, I would discuss with my urology colleagues to see if there is any role for ureteral stenting to see if kidne...
What is your approach to differentiating primary from secondary hyperparathyroidism in recurrent kidney stone formers who also have chronic kidney disease, an elevated PTH, and hypercalcemia?
You have asked a complicated question. It is certainly possible for both conditions to coexist simultaneously. It would be unusual for primary hyperparathyroidism to cause secondary hyperparathyroidism, although recurrent obstructive uropathy from stones would be a possible etiology. Similarly, seco...
What are your management strategies for patients with nephrolithiasis and hypercalciuria who have a severe sulfa drug allergy and are unable to tolerate thiazide diuretics?
This is a difficult situation. Assuming the nephrolithiasis is calcium-based, I think the patient has to lean more heavily on dietary control. Dietary sodium restriction will decrease hypercalciuria. A further increase in fluid consumption will dilute the urinary calcium concentration. We are fortun...
How do you approach using DMARDs for patients with CPP arthritis who have frequent flares?
As far as I know, none of these agents are proven to prevent CPPD flares. Colchicine for acute flares. If someone is aware of evidence that any of these other choices work, I would be glad to hear about them. I have a patient with Gittleman's syndrome who had severe CPPD with almost constant flares....
Why are gout flares common in hospitalized patients undergoing diuresis but not commonly observed in cancer patients with hyperuricemia resulting from tumor lysis syndrome?
Tumor lysis syndrome (TLS) occurs with the release of uric acid, potassium, phosphorus and calcium into the bloodstream in response to cytolytic therapy administered in the setting of treatment for acute leukemia, B-cell lymphoma and rarely for solid neoplasms. Kidney injury results from the precipi...