Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach for patients with a history of nephrolithiasis who are being evaluated for living kidney donation?
We have a protocol that guides us on the work-up in this situation. If they have a remote history of stones, then we do a Litholink and if they have a urinary milieu that is risky for stone disease they are counseled on fluid intake and dietary changes. If they have symptomatic stones, they are rule...
What laboratory workup do you perform in patients with symptoms consistent with erythromelalgia?
The usual CBC with differential, as well as CRP, ANA, ESR, and Rheumatoid Factor.
In what clinical scenarios do you utilize post-cardiac arrest targeted temperature management (TTM)?
There still is a role for TTM in post-cardiac arrest patients. The Targeted Temperature Management After Cardiac Arrest: A Systematic Review was a systematic review of six randomized clinical trials with a total of 3870 participants that were examined. Of these, 2,767 participants were treated with ...
How do you determine timing and frequency of stability scans for a patient with spontaneous, non-aneurysmal intracerebral hemorrhage?
We typically obtain a follow-up “stability scan” about 6 hours from the index scan. The AHA guidelines do not mention a specific timeframe. Situations, where we would consider sooner repeat imaging, would be clinical deterioration (increase in NIHSS by 4 or more points or decline in GCS by 2 or more...
What is your approach to management of pulmonary fibrosis in patients with a history of microscopic polyangiitis who do not have other active organ involvement?
ILD is an important organ manifestation in AAV, typically seen in patients with MPO-ANCA where ~20% of patients have ILD which often precedes the diagnosis of AAV. The most common radiographic pattern is UIP. ILD has been associated with a higher risk of mortality in AAV in multiple series including...
For patients with candida species osteomyelitis who have undergone extensive surgical debridement, do you routinely still recommend 6-12 months of antifungal therapy or opt for a shorter duration?
After removal of hardware, if present, and debridement of infected bone, my practice is to treat Candida osteomyelitis with an intravenous echinocandin for two weeks followed an oral azole, to which the fungus is susceptible, for at least six months. If full debridement is not possible, such as vert...
What is the utility of MRI for identifying disease activity in myositis patients when physical exam and labs are inconclusive?
Agree with @Dr. First Last, however, I want to caution about sensitivity and specificity of muscle MRI for a particular situation you are suggesting i.e., to evaluate if patient has active or inactive disease, has not been studied or proven. The muscle MRI, in general, has good sensitivity and speci...
Do you ever use ocular ultrasound in evaluation of papilledema?
As a neuro-ophthalmologist, I never use ultrasound to make a diagnosis of papilledema. I do use it to reveal optic nerve head drusen that also cause axoplasmic flow stasis and can mimic papilledema. A high quality set of fundus photos is very useful for determining the presence of optic disc edema.
What infections should we rule out in patients who develop diarrhea on immunotherapy?
Immunotherapy is known to be associated with immune-mediated diarrhea and colitis (IMDC). However, it remains unclear whether cancer patients undergoing immunotherapy are at a heightened risk for Clostridioides difficile colitis infection (CDI). A retrospective study focusing on patients treated wit...
Do you recommend CT perfusion in patients presenting with symptoms of acute stroke before 6 hours?
Routine CTP is not required in the <6 hours according to the AHA/ASA guidelines. The TENSION large core data would also support not requiring CTP in the early window.In the >6-24 hour period, the MR CLEAN-LATE trial, which was based on patients with CTA collaterals selection, showed favorable outcom...