Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Would you ever consider oral doxycycline for treatment of either gram-negative or gram-positive uncomplicated bacteremia?
I would not consider this a first or even second-line option due to the poor serum levels that are achieved. I supposed that this could be used for "mop up" therapy, but in such cases, it's almost as if you are using the doxy to treat yourself rather than the patient.
How does your approach to subsegmental PE differ from segmental PE both diagnostically and therapeutically?
My approach to subsegmental PE and segmental PE generally tends to be very similar. I am aware of the CHEST guidelines which indicate patients can safely be observed with subsegmental PE, but like a recent study showed (Rouleau et al., PMID 37531107), uptake of these guidelines is slow and many pati...
How do you manage patients with ice-pick headaches?
Ice-pick headaches, previously known as jabs & jolts and now often referred to as stabbing headaches, also manifest as stabbing face pain, which can be mistaken for trigeminal neuralgia due to lack of awareness. They can strike the head or the face suddenly, resembling lightning bolts. While common ...
How frequently do you check serum electrolytes for patients on CRRT?
When starting out CVVH and with unstable patients who have very abnormal electrolytes, as often as even every 6 hours. In patients who have been on stable dose of cvvh and electrolytes are within goal, even twice a day may be enough.
In patients presenting with classical findings of primary hyperparathyroidism (i.e mild hypercalcemia, high 24hr urine calcium, elevated 1,25 Vit D but normal PTH), can spontaneous normalization of calcium be explained by episodic hypersecretion of PTH?
PTH secretion is always about 70% basal, related to the mass of parathyroid tissue, and about 30% episodic. Patients with primary hyperparathyroidism can have superimposed secondary hyperparathyroidism. High urinary calcium suggests a negative calcium balance. PTH is not "normal" if calcium levels a...
What is the optimal management of pain and loss of function due to pathologic compression fractures?
I explain to my patients if they have an acute compression fracture that they are likely to experience pain for approximately 2-3 weeks that will gradually resolve. I often give them some type of pain relief using Tylenol or ibuprofen and if severe, a more potent analgesic for a short period of time...
When would you consider treatment with steroids in patients with diabetic radiculoplexus neuropathy?
Steroids (pulse IV methylprednisolone) are the only treatment for diabetic amyotrophy supported by randomized placebo controlled trial (Dyck PJB et al., Neurology 2006; 66(5, Suppl 2):A191.) The soonest the treatment is started after onset of symptoms, the best. I will treat most patients presenting...
What is your approach in differentiating IPAF (interstitial pneumonia with autoimmune features) versus "CTD ILD" in patients with serologic abnormalities but do not fulfill criteria for autoimmune disease?
Even for those of us who work in ILD clinics, this can be a challenging issue. The concept of IPAF (interstitial pneumonia with autoimmune features) was developed in 2015 jointly by the ATS and the ERS for study purposes and as such is somewhat helpful in the clinic. Much like classification criteri...
Have you incorporated the use of steroids for patients with severe community-acquired pneumonia?
Yes, the evidence is pointing toward starting steroids (hydrocortisone at 200mg total daily dose) early (in the first 24 hours) in patients with severe CAP who do NOT have influenza. In septic shock caused by CAP, steroid recs follow the septic shock guidelines. Dequin et al., PMID 36942789 showed t...
Do you consider late latent syphilis adequately treated if a patient receives a 10-14 day course of IV ceftriaxone for another indication?
This is a great question and not uncommon scenario. First, I would emphasize the importance of accurately staging the patient as 'late latent' and be sure there are no current signs or symptoms concerning for neurosyphilis, ocular, or otic (even before the IV CTX was given). Having said that, the bo...