Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you add fludrocortisone to hydrocortisone when starting stress dose steroids in a patient with septic shock?
In septic shock, vasoplegia is mostly believed to be related to widespread inflammation that giving hydrocortisone is supposed to address, and current guideline suggests hydrocortisone only is sufficient. However, it makes sense to add fludrocortisone since most of these patients present with undefi...
In patients with intrinsic acute kidney injury of unknown etiology and with pending kidney biopsy results, are there instances when you would recommend a trial of glucocorticoids?
I usually don't if I know I will have preliminary results of the biopsy within 24-36 hours. I do sometimes when it is not possible to do the biopsy in a timely manner. I don't think a 1-2 day delay would make a major difference in the amount of kidney damage.
Do you treat patients with HIV-AIDS and positive cryptococcal antigenemia but negative CSF cryptococcal antigen with standard meningitis treatment given the potential for the postzone effect?
Hello, What was his CD4 and HIV VL results? What were the LP results exactly: what were the cell count, protein, and glucose levels? Did he have symptoms consistent with meningitis, and what did the head CT show? These patients can sometimes have cryptococcal pneumonia and not meningitis, by the way...
For patients on CRRT with worsening hyperkalemia despite high replacement fluid rate using a 0 mEq/L potassium bath, do recommend using an additional CRRT machine with separate dialysis access for improved clearance?
I think this situation would be unusual. I would first try to optimize everything about the dose of the CRRT. If hyperkalemia persists despite the optimization for a number of hours (it will require a few hours of the change before one sees an effect), the options are: Switch to intermittent hemo w...
When would you consider using hypertonic saline for patients with refractory acute decompensated heart failure and diuretic resistance?
In patients with acute decompensated heart failure (ADHF) and diuretic resistance, hypertonic saline combined with furosemide has shown potential in improving clinical outcomes. This combination can decrease mortality, reduce hospital stay and readmission rates, and enhance diuretic effectiveness by...
Is there benefit to performing CVVH instead of intermittent hemodialysis for a patient with AKI secondary to rhabdomyolysis who requires renal replacement therapy?
My CRRT threshold is low, but a patient with AKI and rhabdo will have continuous K and Phos release from dead cells so I prefer a continuous therapy. This depends on the degree of rhabdo and the degree of AKI, but would lean towards CRRT for a moderate to bad rhabdo, same for TLS and same with acute...
Do you intensify the dialysis prescription for patients with end stage kidney disease who develop uremic pericarditis despite regular dialysis sessions?
This was what we did 30 years ago, it did not work. I remember as a fellow there were two explanations for pericarditis in a renal patient, uremic pericarditis if they had not started RRT and something else ("viral etc) if they were on RRT. This was based on the assumption that RRT was good enough t...
Would you treat a hemochromatosis carrier with IV iron if they have iron deficiency anemia in conjunction with elevated ferritin?
This scenario, with numbers like these, suggests another underlying issue. A carrier of hemochromatosis cannot typically have a ferritin level of >900 due to hemochromatosis. The TSAT of <10% corroborates this statement. If this patient is real, they likely have an underlying inflammatory disorder ...
What is your approach to monitoring patients with cardiac sarcoid while tapering immunosuppression?
Monitoring of patients with cardiac sarcoidosis (CS) is critical to optimizing therapy and improving outcomes. Once a decision has been made to institute immunosuppressive therapy, it is important that the efficacy of therapy is demonstrated and that the duration of therapy is guided by the response...
Is there a role for systemic therapy for a patient with scleroderma sine sclerosis, with esophageal strictures and Raynaud’s syndrome, but no pulmonary involvement?
We don't have any evidence that immunosuppression (assuming that is what you are referring to) would play a role in the treatment of the esophageal disease or the Raynaud phenomenon. Also, we don't have any data to suggest that this would have any overall long-term "disease-modifying" effects. So in...