Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach towards management of symptomatic broncholithiasis?
The broncholithiasis location relative to the airway can be outside the airway which is called peribronchial, inside the airway which is called endobronchial, or extends from inside to outside the bronchial wall which is called transbronchial broncholithiasis. Surgery is indicated in peribranchial b...
Do you use continuous or intermittent bronchodilator therapy in severe airway obstruction?
I use only intermittent.
What is your approach to monitoring for recovery in a patient with non-oliguric AKI requiring dialysis?
In my opinion, the best test to monitor the recovery of renal function in an AKI patient is a daily measurement of serum creatinine. Decreasing serum creatinine is the most reliable marker to indicate recovery of kidney function after AKI. The main confounder would be simultaneous loss of muscle mas...
Do you recommend using dextrose based solutions to induce osmotic diuresis for euvolemic patients with acute kidney injury in the setting of a hemolytic condition?
The incidence of hemolysis (especially after blood transfusion) has been so low that to my knowledge there have been no good studies about the treatment of AKI with osmotic diuretics in this setting. Older literature has always used Mannitol to induce osmotic diuresis, but whether that improved the ...
Would you perform dialysis on a patient with altered mental status in the setting of an elevated blood urea nitrogen level attributed to a tube feeding diet?
Uremia is symptomatic azotemia, I don't see how you don't dialyze that patient. The idea behind tube feeds is nutrition, that you need amino acids to make protein, but if the BUN is rising, clearly you are catabolizing some of them, and I would check with the dietician to make sure the patient isn't...
Do you hold CRRT for a period of time before performing a diuretic challenge in a patient with whom you are assessing for the ability to wean off of continuous dialysis?
You may want to sit down for this answer, I think the diuretic challenge is overrated and if I’m not mistaken, it was really developed to see if a patient may need to start RRT for Aki, not come off it. I would hardly use it on a patient with aki on Crrt for a decision. It isn’t rocket science to de...
Would you consider adding an SGLT2 inhibitor to augment diuresis in patients with worsening renal function presenting with acute decompensated heart failure and AKI on CKD?
SGLT2 inhibitors can provide another avenue in providing the much-needed diuresis our decompensated patients have. AKI often accompanies this decompensation. SGLT2 inhibitors can be used safely at times with GFR> 25. I would consider adding it to my regimen of aggressive diuresis to provide aggressi...
What burden of PVCs/NSVT in an inpatient post-MI cardiomyopathy patient would prompt an EP study-guided ICD implantation prior to discharge?
This is an interesting scenario which is best addressed by the results of the MUSTT trial. In that study patients with ischemic cardiomyopathy who had ejection fraction of </=40% and manifested NSVT (3 beats to < 30 seconds) underwent EP study and if they were inducible for sustained VT then they we...
How would you approach a patient with GCA who develops necrotizing fasciitis and then flares because they are off of tocilizumab?
While recurrent necrotizing fasciitis is exceedingly rare, patients with necrotizing fasciitis may be at higher risk for other infections. Therefore, a careful risk/benefit analysis is warranted in such a case, similar to other cases of serious infections in patients on immunosuppression. The specif...
Does your approach to extubating obese patients differ from your approach in non-obese patients?
If the patient has OSA/OHs I often extubate directly to CPAP OR bipap especially if they have high compliance to OSA cpap therapy and are "used to the mask". But if high levels of secretions, NIV can make clearance of secretions more difficult. Thus, individualize therapy is indicated.