Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Which images do you routinely request when ordering a HRCT chest?
The images I tend to request depends in part on the clinical scenario. In general, I find it helpful to obtain a traditional "ILD protocol" when I meet an ILD patient for the first time, especially when the diagnosis is unclear. This includes both prone and supine images with 1-1.5 mm cuts, in addit...
For patients with newly diagnosed VTE on IV heparin planned for transition to DOAC, would you start at the loading or maintenance DOAC dose?
Agree with Dr. @Dr. First Last. In the clinical trials that led to rivaroxaban and apixaban approval, many patients had 2 days of injected anticoagulant first to arrive at successful outcomes leading to DOAC approval. I suggest IV heparin until hemodynamically normal (for PE), sq LMWH for a dose or ...
Do you recommend getting a muscle biopsy in a patient with suspected IMNM with statin exposure, weakness, elevated CK, and positive HMGCR antibody?
A patient with a typical clinical presentation of IMNM (muscle weakness, high levels of CPK) and positive anti-HMGCR antibodies leaves no question regarding the diagnosis, and muscle biopsy would not change management. I would reserve muscle biopsy for atypical cases (for example, positive anti-HMGC...
Do you obtain an echocardiogram as a part of risk stratification in all patients hospitalized with an acute pulmonary embolism?
I agree with Dr. @Dr. First Last! The echo offers a “functional view” that we can’t obtain by CTA, as well as the opportunity to diagnose clot-in-transit. However, if a formal echo cannot be quickly obtained, a bedside echo may offer key information. All critical care and ED clinicians should have a...
Would you recommend starting an SGLT2 inhibitor in a proteinuric CKD patient with chronic asymptomatic bacteriuria?
In spite of the biological plausibility that SGLT2 inhibitors are associated with increased risk for UTI, population-based cohort studies, like the one of Dave et al in diabetic patients, did not show a higher risk of severe or minor UTI with SGLT2 inhibitor users and other antidiabetic drugs. The d...
How do you decide whether to include a basal rate when initiating a PCA?
This is a difficult question for which there is no good data to guide one's practice. The best book on this and other opiate questions is Mary Lynn McPherson's "Demystifying Opiate Conversion Calculations". I am relatively conservative on using continuous infusions (also called basal rates). My reas...
For patients presenting with ACS and severe aortic stenosis with critical left main disease, would you consider BAV prior to PCI to the left main?
This sounds like a CABG AVR case on the surface; if inoperable or at prohibitive surgical risk, CHIP of the LNA lesion, followed by same setting or elective setting TAVR remains an option. CFA access with a large bore sheath (for CHIP/IABP or IMPELLA) will allow for an easy transition exchange for t...
How do you manage a patient with giant cell arteritis treated with weekly tocilizumab and low dose glucocorticoid who develops sudden vision loss?
Fortunately, this scenario is a rare event, as most patients treated with ongoing tocilizumab (TCZ) and prednisone are at a far lower risk for developing new visual loss due to giant cell arteritis (GCA). A recent paper by Amsler et al., PMID 33752737 reviewing the risk for visual loss in patients b...
How do you manage critically ill poor risk mixed germ cell tumor patients presenting de novo with extensive lung metastases and severe respiratory failure?
A few things. I would make sure the patient gets early brain imaging. I usually talk to the patient and family obviously about the severity of the condition, but also that ICU/intubation/ECMO might be needed over the course of treatment 1. I usually take the 3-day EP approach stop and watch for abou...
Would you recommend switching to DAPT for patients on anticoagulation who develop symptoms of a TIA secondary to ICAD?
It is important to remember that there is more to stroke secondary prevention than antithrombotics. Our use of DAPT in ICAD comes from the SAMMPRIS trial, in which patients in the control group did better than expected compared to historical controls with ICAD in the WASID trial. Recall however, tha...