Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your protocol for transitioning to oral anticoagulation post-thrombolysis for pulmonary embolism?
My answer has multiple parts."Thrombolysis" is not all the same. As studied in stroke treatment, alteplase causes marked fibrinogen depletion and coagulopathy (prolonged PT, aPTT), whereas tenecteplase doesn't so much (Huang et al., PMID 26514192).So, if alteplase was used (systemic or reduced cathe...
Do you recommend early oral nutrition when managing diabetic ketoacidosis?
There are many benefits to starting enteral feedings in patients undergoing treatment for DKA. Once insulin is being infused, the use of enteral nutrition will help suppress ongoing ketosis. Also, restarting nutrition will help prevent weight loss during recovery. Of course, some patients have condi...
Do you get volumetric MRI in all patients with cognitive difficulties?
Yes, I find MRI very useful in assessing patterns of atrophy, as well as the degree of vascular changes in the brain. It can help confirm suspected diagnoses such as frontotemporal dementia or Alzheimer's disease.
When would you consider proceeding with antiarrhythmic drug load concurrently with DCCV as opposed to DCCV alone in patients with new-onset atrial fibrillation?
There is no expert consensus. If we are dealing with a first episode of AF, and we know that the arrhythmia has a short duration and the anatomic substrate is not severe, I would proceed with cardioversion alone. After all, we learned from AFFIRM that many patients randomized to "rate control" after...
Are there instances when you recommend against a kidney biopsy in a patient with a single kidney who otherwise has indications for a biopsy, consents, and has no medical contraindications for the procedure?
I don't think so. These days the risks of having to do nephrectomy after kidney biopsy is very small and having a single kidney is a weak argument for not doing kidney biopsies. In my practice, a patient with a single kidney would get biopsied by interventional radiology to minimize the risk as much...
How do you approach consults regarding clearance of patients with chronic kidney disease for surgery?
I make sure that kidney function is stable and the medications are appropriate for the surgery/NPO status. Sometimes, I will adjust dosages or hold meds until after surgery. If it is CTS/cardiac cath, then I try to assess the risk for AKI and AKI-requiring dialysis using various scoring systems. It ...
Would you administer IV thrombolysis in a patient presenting with disabling stroke symptoms while on anti-amyloid therapy?
I agree with @Dr. First Last. There seems to be one case of catastrophic bleeding in the published literature. However, such events can occur with thrombolysis alone or in the context of other cerebrovascular conditions such as CAA, vascular malformations, and even severe WMH. While it's important t...
When would you initiate chronic therapeutic phlebotomy in a patient with erythrocytosis secondary to a high hemoglobin-oxygen affinity hemoglobinopathy?
The large majority of patients with high oxygen affinity hemoglobinopathy do not require therapeutic phlebotomy. There is a subset of patients who develop symptoms (generally these are non-specific such as headache) or complications such as thrombosis. There seems to be no correlation between hemato...
What is a reasonable inpatient imaging modality alternative to evaluate for infective endocarditis in a morbidly obese patient with poor acoustic windows on TTE and persistent bacteremia if TEE is not feasible or contraindicated?
This is an excellent question. Retrospectively gated cardiac CTA especially with the newer generations (Siemens Somatom force or Naetom alpha) are probably your best alternative. This would need careful planning and tube setting adjustments depending on the patient's body habitus as scattered and no...
How do you manage a patient with inclusion body myositis?
IBM is a slowly progressive disease with no proven treatment to date, unfortunately. The goals of care are to delay decline and maintain remaining muscle strength. The cornerstone of treatment is physical/occupational therapy. Blood flow restriction seems to anecdotally help some patients, pending t...