Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What are your preferred strategies to manage mild to moderate rectal ulceration causing tenesmus and discomfort after chemoradiation for rectal adenocarcinoma?
Radiation-induced proctitis or tenesmus -- important to determine if the cause is external or internal to anal verge. Also important to rule out rectal fissures as this typically requires a different approach (Analpram cream and high fiber diet, +/- GI evaluation). If the cause is internal to anal v...
What is your process for considering alternative imaging modalities for cardiac imaging when POCUS is limited by patient conditions, such as emphysema or body habitus?
When POCUS is limited, a multi-faceted process that considers the clinical question, patient characteristics, the strengths and limitations of available imaging techniques, and the available resources should be implemented. The most important question is what you are specifically trying to evaluate....
What is your approach to a patient with a low alkaline phosphatase?
This is a wonderful and increasingly relevant question as it is not uncommon for someone to have a low alkaline phosphatase and be told it is not important since alkaline phosphatase is only important if it is elevated. Causes for this abnormality include protein deficiency, Wilson’s disease, and hy...
How would you approach antithrombotic therapy in patients with acute ischemic infarcts and a non-occlusive intracranial thrombus?
I agree with the previous answer and can expand on a few key management nuances involving stroke size, symptom severity, and etiology. For stroke size, I typically initiate anticoagulation (heparin drip) if less than one-third of the affected territory is involved, extrapolating from tPA guidelines....
What is your approach when cryptococcus serum or CSF antigen titers do not change despite treatment in HIV-positive patients with cryptococcal meningitis or invasive disease, but there is clinical improvement and cultures remain negative?
While cryptococcal antigen is an excellent diagnostic marker for this infection, with excellent sensitivity and specificity, it is not reliable for tracking response to therapy. An initially high CSF antigen level has been identified as a sign of poor prognosis in patients with AIDS, but multiple st...
What is your approach to managing post-operative dysphagia following C-spine surgery?
Dysphagia is relatively common after anterior C-spine surgery. (recently estimated at 10%, Shimizu et al., PMID 40461647). While I have less rigorous personal data, anecdotally, I agree with the conclusions of the authors that postoperative pain is a significant predictor. While I typically defer in...
What is the optimal frequency and duration of post-operative radiological surveillance following resection of a solitary fibrous tumor?
Partly depends on the subset of SFT. The classic variant is low-grade, indolent clinical behavior and can recur late (several years later) requiring (maybe less frequent) but long-term follow-up for 10 years or even beyond. The malignant SFTs have a shorter natural history and typical sarcoma follow...
Is there a role for DOAC use for patients with unprovoked PE, that have had recent sleeve gastrectomy with duodenal bypass?
Alterations in the gastrointestinal (GI) tract following bariatric surgery, as well as altered or reduced oral intake, have the potential to impair the absorption of both DOACs and VKAs in the acute setting. DOACs are absorbed in the upper GI tract, which is altered by the most common bariatric surg...
What is the role of surveillance imaging after first line therapy in patients with aggressive lymphomas?
Most relapses from complete remission in patients with diffuse large B-cell lymphoma are symptomatic. I am aware of no evidence that surveillance leads to the diagnosis of asymptomatic relapses that are more likely to respond to salvage therapy. My own concern about frequent surveillance is the adve...
Would you consider PPM implantation for patients during their hospital stay following TAVR if they were to develop lengthening PR intervals and widening LBBB QRS duration exceeding 150ms afterwards?
Would do an EP study to guide me further.