Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Is there a role for monitoring serum ANCAs to assess ANCA associated vasculitis disease activity?
This is (and remains) a somewhat controversial question. ANCA titers do appear to rise in anticipation of disease flares and patients with persistent titers appear to have more flares. This is especially true for PR3 ANCAs. However, the proximity of flares to rising ANCA titers is not terribly close...
Do you take any special considerations when working up a pregnant patient for secondary causes of hypertension?
Pregnancy does affect the approach to secondary causes of hypertension evaluation. Because of the relatively high prevalence of pre-eclampsia (3-5% of pregnancies), hypertension occurring after the 20th week of gestation with new proteinuria often does not require additional workup. Patients could b...
How do you determine when ongoing outpatient treatment is no longer beneficial, and it may be appropriate to transition a patient to another provider?
To answer this question, I’d want to first set aside the issue of patient abandonment by taking it for granted that any transition would occur in a manner consistent with ethical and legal guidelines (for example, but not exclusively, those set out by the AMA, the literature, and in murky or content...
When giving albumin challenge, for acute kidney injury with suspected hepatorenal syndrome, do you administer a single dose daily or split the dose of albumin?
The main concern about albumin infusions is the potential risk for pulmonary edema (China et al., PMID 33657293). Therefore, I prefer to have albumin administered in divided doses of 25 grams at a time with a max daily dose of up to 100 grams, and I tend to stop IV albumin if the serum albumin level...
What approaches have you found most helpful for concurrent severe major depressive disorder and alcohol use disorder?
I'm a strong believer in AA for alcoholics, to address the addiction and also the depression, as the social support offered there can be very helpful. A person agreeing to "work the steps" with a sponsor has more in-depth character restructuring and available support than most therapists can provide...
Should all patients with suspected giant cell arteritis get a PET scan to look for large vessel disease?
PET-CT and PET-MRI can be very useful diagnostic modalities in GCA, but I do not recommend universal screening with PET scanning. The upcoming ACR/VF sponsored vasculitis guidelines will likely recommend obtaining non-invasive vascular imaging to evaluate for large vessel involvement, but the recom...
How do you weigh the risks and benefits of GLP-1 RAs in patients over age 65 specifically in regards to loss of muscle mass and osteoporosis?
This is indeed a crucial question: rapid weight loss is accompanied not only by a loss of adipose tissue but also by a loss of lean mass, including muscle and bone tissue. This must therefore be taken into account when making decisions, particularly in patients with osteoporosis, frailty, sarcopenic...
How do you evaluate the etiology of hyponatremia in a patient with ESRD and baseline oliguria/anuria?
In patients with ESRD and baseline oliguria or anuria, hyponatremia has to be approached differently because many of the usual diagnostic and monitoring tools (urine sodium, urine osmolality, urine output) are either unavailable or misleading. The key shift is to think in terms of total body water v...
How do you evaluate the etiology of hyponatremia in a patient with ESRD and baseline oliguria/anuria?
In patients with ESRD and baseline oliguria or anuria, hyponatremia has to be approached differently because many of the usual diagnostic and monitoring tools (urine sodium, urine osmolality, urine output) are either unavailable or misleading. The key shift is to think in terms of total body water v...
Are there any contraindications using nurtec in patients with headaches in the setting of recent RCVS?
I would be comfortable using Nurtec in a patient with a recent RCVS diagnosis. I am comfortable using triptans in patients with a prior stroke or MI with proper patient counseling unless they have critical/severe artery stenosis. I have had cluster headache patients who continue sumatriptan injectio...