Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you routinely perform a pre-extubation bronchoscopy for secretion clearance during the index hospitalization in patients following lung transplantation?
Yes, this is routinely done on post-op day 1 and frequently repeated if the patient is not extubated on the first post-operative day after lung transplantation. This is typically necessary and done early in the post-op phase to clear out blood or debris from the airway that often accumulates in the ...
Is there a role for routine LP in HIV patients with disseminated histoplasmosis even in the absence of CNS signs/symptoms?
I would not recommend routine LP in the absence of CNS symptoms as it is unlikely to change the management of the infection in someone who has disseminated disease. Prolonged therapy will still be used and as opposed to Cryptococcal meningitis where intracranial pressure management is critical, ther...
Would you start octreotide in a patient with suspected sulfonyurea overdose but without frank hypoglycemia?
The data in the literature supports treating with Octreotide once hypoglycemia is present. Otherwise, a watchful, waiting period would be employed. It is reasonable to have a low threshold for its use once indicated, given how prolonged and profound the hypoglycemia can be in this situation.
How soon after starting treatment would you repeat imaging in patients with Takayasu to monitor response and ensure you have the correct diagnosis?
The optimal imaging frequency and imaging modality with which to monitor disease activity in TAK are not well defined. I would highlight some general concepts that I find helpful in determining the best monitoring strategy for a given patient. 1. Imaging interval should generally be shorter in patie...
Have you used Karius to aid in the diagnosis of a non-resolving pneumonia, with negative bronchoscopy, biopsy, and other infectious work up in an immunocompetent patient?
Culture-negative hospital-acquired pneumonia is approximately 50%. Positive cultures are complicated by having to correlate results clinically as organisms may contaminate specimens (even if from a protected brush) and include an organism that doesn't even cause pneumonia, such as Enterococcus spp. ...
What would be your index of suspicion for AL amyloidosis with cardiac involvement in a patient with MGUS to prompt further imaging (and which modality would be preferred)?
In short, we will usually be concerned for potential underlying AL cardiomyopathy (AL-CM) in a patient with MGUS if they have symptoms/signs of heart failure. NT Pro BNP is very sensitive for detecting cardiac involvement of amyloid (Zhang et al., PMID 33283202) and troponin can also help. While the...
Would testing for ATTR cardiac amyloidosis be considered in an older patient with bilateral carpal tunnel surgeries and multiple spinal stenosis surgeries, but no obvious cardiac symptoms?
I would not look for ATTR-CM in the absence of cardiac findings such as abnormal echo (increased LV thickness) or conduction abnormalities that are suggestive. Only 10% of patients with bilateral CTS have ATTR-CM. I would do an echo if not done and review ECG. As much as we are concerned about under...
What is the role for iothalamate clearance testing for glomerular filtration estimation in patients with chronic kidney disease?
No role in my opinion. There is a false security for wanting and knowing an "exact" GFR. The eGFR reporting mandate is more a public health issue than useful for individual decision-making. AND iothalamate clearance as a measure of GFR has its own flaw (we did plenty of them in our prior studies wit...
Do you routinely use 3% sodium chloride and desmopressin to correct hypovolemic hyponatremia in an asymptomatic patient with serum sodium of less than 120 mEq/L?
The challenge with hypovolemic hyponatremia lies in the fact that, upon correcting volume depletion, the kidney's capacity to excrete dilute urine returns, potentially leading to a rapid excretion of large volumes of dilute urine. In the case of an asymptomatic patient with a sodium level of 120 mEq...
Do you avoid terlipressin for patients with hepatorenal syndrome who have a serum sodium level less than 125 mEq/L?
This is a good question and I'll admit I don't have much first-hand experience using terlipressin. However, terlipressin is relatively (6X) selective for V1 vs V2 receptors and is used for its vasoconstrictor actions in HRS. Although there are reports (mostly retrospective and uncontrolled case seri...