Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you routinely treat chronic sacral osteomyelitis when there is no plan for debridement or flap?
I would treat acute febrile cellulitis with a relatively brief course of antibiotics but not with a long course of IV antibiotics attempting to cure osteomyelitis, if surgical debridement is not performed.
In drawing blood cultures from a central line to evaluate for CLABSI, do you advise drawing separate blood cultures from each port in case of dual or triple lumen line?
You don't need to use the central line to draw those cultures. Using the line to draw blood can in it by itself pose risk of introducing a microorganisms. NHSN CLABSi definition does not call for blood culture to be done from a line.
What is your approach to management of CIED in a patient with community-acquired Staph aureus bacteremia who clears blood cultures quickly with negative follow up blood cultures within 72 hours of antimicrobial therapy and negative TEE?
The recent 2023 guidelines on AHS CIEDI defined definite CIED infection as 2 or more sets of blood cultures positive for staph aureus or CoNS + (positive TEE and/Or positive PET/CT). The guidelines stated that the organism isolated from blood cultures determines the likelihood of CIEDI, and coagulas...
Do you stop ACEi or ARB medications in patients with ESKD who are on hemodialysis and have issues with chronic hyperkalemia?
I don't. I don't think it contributes much to the hyperkalemia. I usually try to correct the potassium using modifications of the potassium bath, dietary changes and if still high potassium binders.
How would you approach a patient with anti-scl70 ab positive sine scleroderma complicated by ILD who also has seropositive RA with active arthritis?
This scenario can be looked at in different ways. For example, does this patient have scleroderma that explains the ILD and seropositive RA to explain the arthritis? Or, does this patient have seropositive RA which explains both the arthritis and the ILD? I favor the latter explanation. In this scen...
Do you recommend obtaining both a parathyroid ultrasound and a parathyroid nuclear medicine scan when evaluating a patient with recurrent calcium based nephrolithiasis who is found to have an elevated PTH level, hypercalcemia, and hypercalciuria?
Yes. The scenario you describe is typical for primary hyperparathyroidism. Appropriate treatment includes removing the parathyroid adenoma. However, finding a parathyroid adenoma can be difficult. An enlarged one may be no more than a few millimeters in diameter. Our radiology staff recommends both ...
Is history of radiation an absolute contraindication to using parathyroid hormone (PTH) analogues?
Hx of prior radiation was never a contraindication, it was a warning due to the known increase in osteosarcoma in patients who had prior radiation. A contraindication requires proof of harm. There was no data that radiation plus a PTH anabolic increased the risk of osteosarcoma. With the review of 1...
How do you approach use of DMARDs and/or biologics for inflammatory arthritis in patients with a history of seizure disorder on anti-epileptic medications?
Polypharmacy should always be a worry in our treatment of rheumatoid arthritis. Fortunately, the biologics, reflecting their immunoglobulin framework, are rarely a concern for drug-drug interactions. This is in contrast to small molecule inhibitors such as methotrexate, leflunomide, and the jak inhi...
Do you continue TNF inhibitors in patients with a new diagnosis of CLL?
If the patient does not require any treatments for CLL that are potentially immunosuppressive, I would continue TNF-inhibitor therapy in this setting. It is always helpful to discuss the case with the patient's hematologist/oncologist to make sure everyone is comfortable with the plan.
Would you start ASA and/or statin therapy on an asymptomatic patient noted to have incidental pathologic Q waves on EKG, assuming no prior history of ischemic heart disease?
I would start with a thorough H and P and comprehensive risk evaluation with necessary screening including blood work, at least a stress echocardiogram if not a full echocardiogram in addition, and also offer Calcium scoring. Given more details are not given regarding the patient's age and functiona...