Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you always comment on VA and KCO when reading PFT's when gas transfer is ordered?
I do not. I look at the VA to see if it meets ATS criteria ( [1] >=90% of largest VC in the session; or >=85% and within 200cc or 5% of the largest VC; [2] breath hold of 10 +/- 2 sec; [3] >=85% of inh ventilation inhaled in <4sec)
How do you approach patients with recurrent TGA in the emergency room?
I generally observe the patient in the hospital if the symptoms are still present or have resolved within 24 hours. I obtain an MRI to look for hippocampal lesions or evidence of stroke, CTA head and neck. If I see a patient days, weeks, or months after the event, I do an outpatient workup or an MRI...
Do you discontinue proning due to a perceived lack of response to intervention in a patient with ARDS?
Yes, I do.
Do you increase sedation or consider the use of neuromuscular blockade to prevent potential self-induced lung injury in patients with high respiratory drive?
My approach to patients with high respiratory drive is variable based on the disease process, the patient's physiology, and the stage of evolution of the disease. Optimization of ventilation parameters (inspiratory flow rate, flow pattern, cycle time, trigger settings) to promote synchrony is a firs...
Would you continue Rituximab infusions in a patient with GPA and renal involvement who has been in remission on Avacopan and Rituximab, but had PRES post Rituximab infusion?
PRES (Posterior reversible encephalopathy syndrome) is a potential complication reported with rituximab (RTX) use, not only in rheumatology but also in the oncology literature. It usually resolves, however, there are reports of potential mortality, and of course, morbidity while it is ongoing.If PRE...
Do you routinely isolate and test for TB in a patient incidentally found to have a miliary pattern of nodules on chest CT?
The short answer is yes. CDC recommends applying airborne isolation for any "suspected" case of TB. So if you suspect, you should isolate until you rule out with 3 negative AFB or have an alternative diagnosis. Keep in mind pretest probability and risk factors for that patient with the miliary patte...
Do you use steroids in patients with respiratory failure who are infected with both influenza and COVID-19?
Yes, along with Remdesivir, Tamiflu, Bactrim, and supportive care. If there is active GGO on CAT scan, steroids are usually beneficial. Start high and then taper to the lowest necessary for about a 10-day course.
Do you rule out TB in patients with AIDS and lobar pneumonia?
Depends: +Ve Risk Factors: Travel/contact Hx, recent Quantiferon Conversion, changing CXR, Night sweats Unexplained low-grade temps Then, yes. Otherwise, no.
Does your approach to treating latent tuberculosis differ in a patient on anti-fibrotic therapy?
With the increasingly common indication of progressive pulmonary fibrosis in the setting of CT-ILD, RA, and scleroderma, it is conceivable that patients being started on antifibrotic therapy may be on anti-TNF alpha or other immunosuppressive agents. Specifically with anti-TNF alpha agents such as R...
Do you check EPO levels in patients with anemia of chronic kidney disease?
No, I never check EPO levels in patients with anemia of CKD since they're uninterpretable. Patients with CKD have inadequate EPO synthesis for their degree of anemia, so their EPO levels may be greater than normal yet still not sufficient to correct the anemia. We now understand the role of inflamma...