Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to counseling an octogenarian on the risks and benefits of LHC in the context of NSTEMI complicated by new-onset heart failure and AKI on CKD?
This is a complex though not uncommon clinical scenario to which my approach would depend on many factors beyond those provided in the vignette. Among these (not an exhaustive list and not necessarily in order of importance): Is this a type I or type II NSTEMI? Is there evidence of ongoing ischemia ...
Can subclinical hypothyroidism cause myxedema coma?
While the patient's signs and symptoms mimic myxedema coma, he does not have, by definition, "myxedema" (severe hypothyroidism). The patient's normal FT4 can't be explained by his taking his levothyroxine that morning, given the 7-day half-life of levothyroxine. If he hadn't been taking his medicati...
How do you differentiate active vasculitis from pregnancy complications such as pre-eclampsia and HELLP in a patient with AAV?
Differentiating preeclampsia from autoimmune kidney disease in patients with rheumatic disease is often challenging due to the obvious overlap in clinical and serologic features. While most discussions about preeclampsia versus flare focus on SLE patients given that SLE is more common in women of re...
What are some considerations to make when managing a patient on peritoneal dialysis who develops acute pancreatitis?
A few points are noteworthy in this regard: It is unclear whether there is a causal association between peritoneal dialysis and the development of pancreatitis. Recall that the pancreas sits retroperitoneally and is therefore not in direct contact with the peritoneal dialysate. Development of pancre...
How long would you wait for outflow to improve before consulting surgery in a peritoneal dialysis patient with an outflow obstruction who is prescribed laxatives for catheter migration?
Any PD patient with outflow dysfunction that does not improve with laxatives should undergo abdominal x-ray to evaluate the position of the PD catheter. If the PD catheter is outside of its expected position within the mid-pelvis, there may be ongoing issues of catheter dysfunction if the catheter i...
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...