Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Are you using the microbial cell-free DNA “Karius” test to aid in the diagnosis of an atypical pulmonary infection such as PJP or NTM?
No, not at this time. Intriguing, but not sure we know enough yet.
Do you consider use of convalescent plasma early in disease course in COVID-19 induced ARDS in mechanically ventilated patients?
At this time, I have not adopted the use of convalescence plasma in COVID-19-induced ARDS. I have read the Belgian study but I believe more evidence from other similar studies is needed before we accept it as standard of care. I have not seen any COVID-19-induced ARDS for almost 18 months.
How would you approach treating a patient with active rheumatoid arthritis and a history of treated lymphoma that is currently in remission?
I would individualize treatment in each patient depending on degree of RA activity, type of lymphoma and length of time of remission with shared decision-making between myself, patient and oncologist. For moderate to high degree of activity of RA, in general, rituximab in keeping with the ACR 2021 g...
How do you interpret the results of oligoclonal bands ordered to evaluate for demyelinating disease in patients with brain MRI lesions of unclear etiology?
While the presence of oligoclonal bands (OCBs) has been incorporated in the updated diagnostic criteria as a surrogate for dissemination in time, OCBs should not be used in isolation to make the diagnosis of multiple sclerosis. There are several systemic and peripheral immune diseases, including inf...
How do you approach patients with RA and severe bronchiectasis with associated findings of UIP?
Usual Interstitial Pneumonia or UIP is among the most serious forms of RA-associated lung disease. Clinical studies have demonstrated that its prognosis is similar to idiopathic pulmonary fibrosis (IPF). UIP is extremely challenging to treat and we have learned from experience that our DMARDs and bi...
How do you manage patients with a prior intracerebral hemorrhage from probable cerebral amyloid angiopathy who develop new small vessel ischemic infarcts?
In this situation, I would consider using cilostazol since it has both antihypertensive and antiplatelet properties. However, the safety profile is unclear in patients with amyloid angiopathy.
When do you consider immunosuppression in patients with Sjogren's neuropathy?
Only when disease activity is moderate-severe, impairing QoL, or rapidly progressive, ie mononeuritis multiplex/vasculitis, with significant risk of end-organ/tissue damage. Occasionally, autonomic neuropathy in SjD can be so debilitating to patient, and all other supportive treatments have failed, ...
What further work up do you recommend for patients with a chronic high anion gap metabolic acidosis with normal eGFR who have been ruled out for lactic acidosis, ketosis, toxic alcohols, and other usual culprits of high anion gap metabolic acidosis?
I take a good history for Tylenol for pyroglutamic acid, as that may not be a test you can do. If there is ANY GI history of a D-lactate level. Might as well get a salicylate level, it can be hidden in wintergreen oil and a few other things. Make sure it isn't pseudohypobicarbonatemia, seen with hy...
What is your approach to further workup and treatment of abdominal aortitis found on imaging in asymptomatic individuals with elevated inflammatory markers?
The differential diagnosis of abdominal aortitis would include giant cell arteritis (we do not know the age of this patient), Takayasu arteritis, IgG4-related disease, Behcet's disease or other systemic rheumatic diseases (RA, SLE, ANCA-associated vasculitis - although less likely since this individ...
What instances will you start outpatient steroids in patients with nephrotic syndrome of unknown etiology prior to obtaining a kidney biopsy?
It is Friday, your patient presents with classic acute nephrotic syndrome, your biopsy Friday won't have results (if not longer if you need EMs which you need for MCD) until Tuesday. I never think a few days of steroids is a big deal, so I can see doing it.