Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you take patients off anticoagulation for tandem and ovoid or tandem and ring procedures?
We don't take them off anti coagulant for intracaviatry alone unless using a hybrid applicator
How would you approach diagnosis of residual ovarian tissue in a patient with ER positive breast cancer, history of BSO, and a rising estradiol level on tamoxifen?
Diagnosing elevated estrogen levels in a patient who has undergone BSO is difficult, since the symptoms are typically very non-specific (e.g., improvement in hot flashes, change in mood). There are multiple potential reasons for elevated estrogen levels following BSO, including an adrenal tumor that...
Have you adopted the use of low dose morphine for treatment of cough in patients with IPF?
Yes, I selectively use low-dose morphine for the treatment of chronic cough (lasting more than 8 weeks) in certain patients with idiopathic pulmonary fibrosis (IPF).This includes individuals who demonstrate somewhat preserved lung function (specifically, a forced vital capacity [FVC] of 45% or more ...
Do you consider extensive clot burden as a factor in determining whether patients with submassive PE may be appropriate for thrombolytic therapy?
I don't either. I think it is fairly clear that mortality in PE correlates to hemodynamic effect and RV function, rather than clot burden (see Hariharan et al., PMID 27742425; Furlan et al., PMID 22993221), likely related to acute pulmonary hypertension caused by endogenous elaboration of such media...
What aspects on history and physical exam could help differentiate genetic muscular dystrophy from immune-mediated myopathy?
Great question, and one that comes up all the time in clinical practice. Unfortunately, the question gets a little bit complicated because of the heterogeneity of the musculodystrophies, metabolic myopathies, and neuropathies that can mimic myositis (not to mention the phenotypic variation between t...
Do you routinely check an Allen's test before placing a radial arterial line?
If for whatever reason, both radials cannot safely be cannulated, the next best site would be femoral. If either femoral sites are not accessible, brachial and axillary would be the less than ideal. You are correct, the data regarding Allen’s test utilization is not robust.
Is there a difference in treatment of status epilepticus from alcohol withdrawal vs other causes?
Alcohol status is best managed by using short half-life like Ativan (lorazepam) and valium (diazepam) with long half-life benzos like Librium (chlordiazepoxide) unlike other status which responds to Phosphynition/levetiracetam and lorazepam.
Would you recommend imaging of the brain and lungs to investigate potential disseminated disease in a recent heart transplant patient with a skin nodule that grew Rhizopus?
Yes. For any immune-compromised individual with Mucor on the skin or another organ, I look at the brain and the lungs.
Do you routinely start anticoagulation for a patient with newly diagnosed hepatocellular carcinoma presenting with a portal venous thrombosis?
No. Anti-coagulation is generally not indicated. Anti-coagulation is usually only indicated for acute PVT causing symptoms. This is more common with underlying thrombophilia. PVT is very common in cirrhosis and anti-coagulation is not required. PV thrombus from tumor similarly is common and anti-coa...
For how long would you treat a patient with dematiaceous fungi growing on a native heart valve discovered at the time of valve replacement?
The first step is to determine whether the positive culture may be a contaminant, as it very well could be. Every valve sent for culture should have also been sent for histopathological examination. In a patient with fungal endocarditis, one should expect to find evidence of acute inflammation and t...