Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is the maximum diuretic regimen recommended in patients with end-stage kidney disease who have residual renal function and volume overload?
Studies in peritoneal dialysis have shown both the safety and benefit of high-dose furosemide. One study randomly assigned 61 incident CAPD patients to either furosemide 250 mg every day or no furosemide at the time of CAPD training and they were followed prospectively. Baseline 24-hour urine volume...
How do you approach DMARD therapy in patients with rheumatoid arthritis and chronic hepatitis B?
Patients with hepatitis B core positivity, surface antigen positivity, and positive PCR for viral DNA, should be treated with entecavir prior to starting any DMARD. Given the DNA PCR is positive too, that indicates active viral replication and they may need treatment for a while before starting anyt...
When do you consider repeating CSF studies in a patient with suspected viral encephalitis but overall initially unrevealing CSF?
Definitely not an expert on this topic, but this situation does come up, particularly for HSV encephalitis! One question worth asking your lab is what kind of assay are they using to run this test. If it's a dedicated HSV PCR assay (e.g., Simplexa), then the sensitivity is going to be quite robust, ...
What is the duration of steroids that you prescribe for organizing pneumonia?
The recommended duration of corticosteroid therapy for organizing pneumonia is typically 6-12 months, as supported by clinical studies and expert guidelines: Reference 1: American Journal of Respiratory and Critical Care Medicine suggests prolonged steroid therapy, often lasting 6-12 months, to redu...
What prompts you to procure EEG and/or imaging in patients presenting with multiple simple febrile seizures?
History always plays a key role. Is the child developing normally, and how old is the child? Also, were all of the seizures truly simple, or were there other features that make me suspicious that this is actually a "lower seizure threshold" in a patient with underlying epilepsy? Fortunately, a sleep...
What is the recommended approach to treating severe constipation in patients on GLP1 R agonist therapy?
About half of the people taking these drugs will experience some of these GI side effects (diarrhea or constipation), at least transiently. When I prescribe these meds, I also “prescribe” daily fiber and adequate fluid intake. They should have smaller, frequent meals rather than large meals in one s...
How do you manage stroke-related abulia?
There is surprisingly little recent evidence-based guidance on this front. Most therapeutic options focus on agonism or potentiation of dopamine in the frontal-subcortical circuits. Depending on the center and provider, options include psychostimulants. Any type might do but I prefer methylphenidate...
What is your approach to managing pyoderma gangrenosum recalcitrant to oral steroids?
Pyoderma gangrenosum is notoriously difficult to treat. The first thing I'd recommend in a case refractory to steroids is to reconsider the diagnosis. Notably, a high percentage of PG is misdiagnosed, so lack of response may indicate that you are dealing with a mimicker (e.g., infection, neoplasm, v...
When would you consider a diagnosis of peritonitis in a patient with SLE?
As noted in the question, clinically significant peritonitis is unusual/rare in lupus patients. In 25 years, I have seen two patients I was convinced had lupus peritonitis. The common thread was that both of them had had at least one abdominal surgery for an acute abdomen. The patients were known to...
Do you recommend pre-emptive anti-epileptic treatment for patients with spontaneous ICH?
This question also applies to other scenarios such as ischemic stroke, brain tumors, and TBI. Many neurologists do not, but neurosurgeons often do. The evidence for this is very limited, so a reasonable answer is as follows. 1) Yes, if an EEG shows epileptiform discharges. 2) Evidence or not, modern...