Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your strategy for counseling patients who don't qualify for colorectal cancer (CRC) screening under the current guidelines but are concerned with its increasing incidence at a younger age?
When counseling patients who are concerned about increasing rates of colorectal cancer among younger patients but do not qualify for screening based on current guidelines, I take the following approach: I try and elicit if there is any specific reason for their concern (signs, symptoms, family hist...
How do you evaluate a suspicious, but negative pleural effusion when working up NSCLC and SCLC?
Good question and this came up in my practice very recently (NSCLC). Historically, clinical trials have required 2 negative taps for entry. The patient I had in clinic appeared to have a node negative, LLL lesion with a ton of atelectasis and had a bloody tap that was negative for malignancy. It did...
Do you recommend routine use of protamine for hemostasis at the end of a transfemoral TAVI?
Always, in order to guarantee hemostasis of the femoral site and minimize femoral access complications. Dose is weight based, anegdotically lots of institutions give half the recommended dose as they still see some of the positive effects. Warning: ask about history of allergy/anaphylaxis. Protramin...
In addition to ampicillin, is there any benefit to the addition of either gentamicin or Bactrim when treating a patient with listeria meningitis?
There has been a lot of misinformation in the literature for decades about the treatment of Listeria bacteremia and meningitis/encephalitis. Some of this arose based on publications of in vitro studies that claimed that "PCN and ampicillin are bacteriostatic against Listeria." This was based on dete...
What is your approach to diagnosis and evaluation of nonbacterial thrombotic endocarditis (Libman-Sacks)?
Nonbacterial thrombotic endocarditis (NBTE), also known as Libman-Sacks endocarditis, is a form of endocarditis characterized by the presence of sterile vegetations on cardiac valves. It is most commonly associated with systemic autoimmune conditions, notably systemic lupus erythematosus (SLE) and a...
For patients with microcytosis MCV 75-79 and normal Hb, low TIBC, and normal ferritin do you always rule out thalassemia?
Microcytosis is typical in thalassemia. With a normal ferritin and hemoglobin concentration, I would start screening by measuring HPLC, HbA2 levels that are high in beta-thalassemia carriers. (HbA2 can be normal with “mild” thalassemia alleles and for several other reasons.) Microcytosis without iro...
What is the target ferritin level for patients with hereditary hemochromatosis and signs of end-organ damage?
I believe the best marker to guide phlebotomy therapy for iron overload is the serum ferritin concentration. I use a target ferritin level of approximately 50 ng/ml. However, one could justify a ferritin level of <200 ng/ml from the literature of serum ferritin compared to body iron stores in HFE he...
Do you continue antiplatelet/anticoagulant therapy in patients with hemodynamically stable diverticular bleeding to improve localization and treatment of source of bleeding?
Usually the decision to stop antiplatelet/anticoagulant therapy is dependent on the indication for starting the therapy, the severity of the bleeding and hemodynamic status of the patient. Based on the current ACG guidelines, it is ok to continue antiplatelet/anticoagulant therapy for hemodynamicall...
Do you recommend careful correction of serum sodium to avoid osmotic demyelination syndrome in patients who are found to have isoosmolar hyponatremia in the setting of an elevated BUN level?
Urea is an ineffective osm and so if the blood is "isoosmolar" in the setting of hyponatremia but is isoosmolar because of an elevated BUN it may be isoosmolar numerically but not physiologically. I would ignore the BUN in making my decision. I would not ignore the BG though if it were elevated.
How do you decide between opting for semi-elective outpatient versus inpatient TAVR for patients with severe critical AS?
Most patients undergo semi-elective procedures, which are more favorable for hospital reimbursement and reduce the risk of acute kidney injury. However, in a small subset of patients (<20%) with critical aortic stenosis (AS) and severe symptoms, particularly syncope, inpatient management is required...