Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you differentiate demoralization from depression during cancer treatment?
Certainly a key question in all referrals for "depression" in psycho-oncology. The two syndromes have areas of overlap and are not mutually exclusive. Clinical depression in cancer looks much like it would in any other context, though non-specific physical symptoms that can be caused by the cancer/t...
Do you hold anticoagulation prior to performing bronchoalveolar lavage?
Can do BAL on anticoagulation. Anticoagulation does not increase the risk of bleeding for BAL.
How do you determine which patients with ANCA associated vasculitis may be good candidates for reduced dose glucocorticoid tapering?
This is an important question. Currently there are several groups of patients that benefit from reduced dose glucocorticoids: The largest group are patients who are receiving avacopan for remission induction. The ADVOCATE trial demonstrated that avacopan can markedly reduce the dose of glucocorticoi...
How do you read a PFT with restrictive type spirometry but normal lung volumes?
Non-specific pattern. Initially, NEJM papers showed that these patients develop obstructive patterns in the long term but follow-up papers have shown that patients can stay in that pattern (non-specific) or develop restrictive or obstructive patterns.
Does your evaluation of a young person with spontaneous upper extremity DVT vary as compared to lower extremity DVT?
The workup for a young adult with an upper extremity DVT differs for me in two ways: Venous thoracic outlet syndrome must be suspected and a careful history of repetitive overhead movements must be obtained. Consulting your vascular surgery team in these cases to ensure the anatomy does not put the...
What is your approach to immunosuppression in patients with preserved kidney function who are found to have nephrotic syndrome of unknown etiology and cannot safely undergo a kidney biopsy?
This is a difficult scenario. Would definitely try to get a biopsy at a Higher level of care perhaps by Interventional Nephrology. Would obtain a comprehensive laboratory workup including kidney function, serum albumin level, random and 24-hour urine collection for albuminuria and proteinuria, Hepat...
How long after a motor vehicle accident would you expect symptoms including memory loss, hypersomnia, and mood changes to be attributable to the accident?
I would love to have the answer to this. I can tell you what the Headache Classification Committee of the International Headache Society says:Post-traumatic headache (PTHA) is defined as a secondary headache that develops within 7 days after head trauma (or after regaining consciousness following he...
What workup is sufficient to determine if an aortic aneurysm is "mycotic/infectious" or not, in that you would not prescribe empiric antibiotic therapy?
It depends on your index of suspicion. If the clinical picture looks consistent with mycotic aneurysm, this is the one time where I have found karius testing to be helpful, particularly with nutritionally-variant strep species which can be tough to culture.
Do you recommend discontinuing IVIG for a newly diagnosed HMGCR+ statin induced necrotizing myopathy who developed a recent brachial DVT?
Really, the issue is if the DVT was provoked or not. If possibly not provoked then would decrease the dose of IVIG or give it over a long time frame. For example, if the patient is on 2 gm/kg over 2 days, I would do 2 gm/kg over 4 days. Or reduce the dose to 1 gm/kg over 2 days.
What additional workup would you recommend for a patient with a liver abscess caused by Fusobacterium and Aggregatibacter, who has had unrevealing endoscopies and no other abdominal masses on a CT scan?
When I trained, we called it actinobacillus, now apparently aggregatibacter. Part of the HACEK group - causes of periodontitis and endocarditis. Fusobacterium I also with dental disease, oral infections and bacteremia. So my main interest would be the teeth, head/neck and endocarditis. In my populat...