Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How would you prioritize physiotherapy and cognitive behavioral therapy for functional movement disorders in a resource-limited setting where access to both might be constrained?
I have a dedicated clinic for people with functional movement disorder/functional neurologic disorder (FMD/FND) in New York City and even in a city like New York, it is difficult or actually impossible to refer patients for appropriate therapy.For some people with rather straightforward cases, a ref...
What is the clinical significance of positive anti-thyroid antibodies in a patient that is post-thyroidectomy?
Ordinarily, the persistence of anti thyroperoxidase antibodies (antiTPO) or antithyrogloblin (antiTG) antibodies is of no concern or clinical relevance. However, in the case of patients with differentiated thyroid cancer, in whom thyroglobulin (TG) testing is a cornerstone of follow up, persistent a...
How do you mitigate risk when performing bronchoscopy in hypoxic patients requiring high levels of supplemental oxygen?
The first question you have to ask yourself, is 'why am I doing this'? If the answer is not going to significantly alter management (i.e. removal of a foreign body, bronchus plug; or biopsy to alter drug therapy) then it would be wise to defer until the patient is more stable. If it is deemed the pr...
How would you manage hemodialysis for an ESKD patient who presents with a phosphorus of 1.6 mg/dl and potassium of 6.5 mEq/L without ECG changes?
Don’t panic. EKG changes correlate not with plasma K but with intra/extra cell K ratio, that ratio is what determines arrhythmias and muscle weakness, so while agreeing with dialysis with usual bath K (2.0?), check Hb and occult blood stools, review diet and recounsel, is the patient underdualized? ...
In light of recent measles outbreaks, have you adjusted your vaccination counseling or preventive strategies for adult immunocompromised patients?
Check measles antibody (once) in individuals working in public places, especially when working with kids.
How long do you continue antibiotics after cholecystostomy tube placement for acute cholecystitis?
The solution to questions regarding treatment duration invariably falls under the category of "it depends." For individuals with severe illnesses, particularly those with bacteremia, an extended treatment period ranging from 7-14 days might be needed. Conversely, for patients who show significant im...
Do you perform a kidney ultrasound in patients following a kidney biopsy to evaluate for post-procedural complications?
I agree with Dr. @Dr. First Last. There is a high incidence of hematoma formation post-kidney biopsy when evaluated by ultrasound (70%) or CT scan (90%). This will result in unnecessary ultrasounds leading to stress for patients and physicians. I usually get a hemoglobin level 4-8 hours after the bi...
What is your approach to weaning dialysis in a patient with AKI on CKD and CHF who now has resolved AKI but a history of recurrent episodes of decompensated heart failure?
My preference would be to keep them on dialysis. If the serum creatinine is really getting toward the normal range and urine output is good, I would just stop dialysis for a week and give them diuretics to see if they can do without dialysis. However in patients with creatinine levels in the higher ...
Are there instances when you would recommend against pursuing adrenal vein sampling in a patient with primary hyperaldosteronism and normal adrenal imaging?
Yes, it is not uncommon for patients to choose not to pursue an adrenalectomy. I do not get the adrenal vein sampling (AVS) until I've had a discussion about the risk/benefits of adrenalectomy. Sometimes, I'll have them visit the surgeon before attempting an AVS to get a full picture of the surgery ...
How do you think about deferring VTE prophylaxis versus implementing non-pharmacologic methods when chemical prophylaxis is contraindicated?
No good reason not to use mechanical/non-pharmacological methods for VTE prophylaxis. Modality may not be ideal, but it is a generally accepted alternative when you cannot use chemical/pharmacological agents.