Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
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...
How do you approach patients who identify so strongly with being sick or with a particular diagnostic label that it makes up a significant portion of their identity?
In many cases, the point at which this question is being asked is one at which the train has already left the station, and sickness as a way of life/career has set in. Unfortunately, with functional somatic syndromes, there is data suggesting that self-rated quality of life and functioning are lower...
How do you calculate QTc intervals in patients being admitted for AAD drug loading who remain in atrial fibrillation or atrial flutter?
We measure 10 R-R intervals and the corresponding 10 QT intervals, average each of them, and then calculate the QTc. Bazett’s formula is commonly used, but is probably less accurate than other correcting formulae, particularly for patients actively in atrial fibrillation. We often use the Framingham...
How often do you rely on using the C1 inhibitor functional assay versus the quantitative level alone to diagnose HAE?
We have seen a significant increase in lab costs billed to well-insured patients for some of the more "esoteric", detailed testing associated with immune/inflammatory disorders such as HAE. The cheapest screen is a C4 level, which, if normal during an active angioedema episode, makes C1 inhibitor de...
Do you make any dose adjustments for patients with ESKD who are on apixaban and do not otherwise meet criteria for reduced dosing?
I do most of the time but it depends on the indication and patient's weight and age. For soft indications, I usually give 2.5 mg bid, but if there is a significant risk (stroke, clots, etc), I will give a full dose of 5 mg bid.
In cases of intermediate-risk pulmonary embolism, what factors influence your decision to pursue catheter-directed thrombolysis?
"Intermediate-risk" is a complex term. Patients with intermediate-low risk are not prognostically the same as those with intermediate-high risk (i.e., with elevated cardiac biomarkers and RV dysfunction) (Santos et al., PMID 31017472), and my threshold to intervene on intermediate-high risk patients...
Do you recommend starting a statin in patients above 75 years old with diabetes but no known ASCVD?
The time to benefit (TTB) for statins in primary prevention of cardiovascular events is generally about 1.5 to 3 years. This means that adults aged 50 to 75 years typically need to take statins for at least 2.5 years to achieve a meaningful reduction in major adverse cardiovascular events (MACE), su...
Do you commonly observe acute erythrocytosis in patients with ILD flares being treated with supplemental oxygen and high-dose corticosteroids?
Assuming that this patient does not have erythrocytosis at baseline, my experience is that acute erythrocytosis is not typical. Erythrocytosis caused by hypoxemia typically has a lag of several weeks, even though EPO increases within 48 hours. You commonly see a moderate acute leukocytosis with high...
What is your clinical threshold for treating a potential monoclonal gammopathy of thrombotic significance?
I strongly advise against routine screening for monoclonal gammopathy in patients with thrombosis. The incidence of MGUS, particularly in older patients, is relatively high and so the signal-to-noise ratio in this setting will be very low. In a patient with recurrent thrombosis and thrombocytopenia ...