Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How would you best evaluate and manage a patient with hemiplegic migraine and a history of ischemic stroke?
Without further information, I would say that these two conditions, hemiplegic migraine and ischemic stroke, have nothing to do with each other. Hemiplegic migraine should be evaluated and managed as migraine with gepants ideal for abortive treatment and CGRP antibodies for preventive treatment if n...
What do you do for patients who have received accidental extra dosages of long-acting injectable antipsychotics?
Close monitoring, any EPS, one repeat EKG in a few days, reporting this to the family so that they are aware of the patient getting an extra dose, and cutting down or stopping any oral anti-psychotics to mitigate risk are some of the things I would do. There is no clear protocol on this, unfortunate...
Do you use combination antibiotic therapy for treatment of bacterial endocarditis due to gram-negative bacilli?
The approach towards different might differ depending on whether the culprit organism belongs to the HACEK group or the nonHACEK group. The mortality rates per literature were approximately 2% for HACEK and 20-30% for the nonHACEK group. Combination therapy is usually not recommended for HACEK endoc...
How frequently, and in which situations do you use quantitative EEG for the detection and/or monitoring of delayed cerebral ischemia after aneurysmal SAH?
Almost never.
At what point should aspirin therapy for stable cardiovascular disease be discontinued in patients with a diagnosis of chronic cerebral microbleeds or possible Cerebral Amyloid Angiopathy?
I would continue low aspirin indefinitely.
How soon after an end stage kidney disease patient receives a MRI study with gadolinium contrast do you perform their next hemodialysis session?
Very contentious question. But as an author of the NKF and ARA position paper on this, I would follow our advice, no need to dialyze immediately after, but try to time the study with the next dialysis.Weinreb et al., PMID 33170103ASN Communities (for ASN members) had a VERY LONG post on this general...
What treatment options would you consider for a young patient with limited mobility, low bone mass and multiple vertebral compression fractures who is on dialysis for advanced kidney disease?
There are a lot of variables to this question. I would worry that the person may have a variant of OI (osteogenesis imperfecta) or some other collage problem and then add renal failure to the mix. I would try to establish the causes of each problem first such as steroid induced bone disease or a bon...
Following left main bifurcation stenting, do you routinely proceed with kissing balloon inflation of the side branch, either LCx or LAD?
It depends on the technique used; most crush based techniques require kissing balloon inflation.
Would you consider adding or switching to pirfenidone for a patient with progressing UIP (based on imaging and PFTs) who is currently on nintedanib?
Yes, I would consider it. There's some recent literature addressing this, which indicates switching may be associated with disease amelioration. Why might it work? Not super clear, perhaps biologic differences or maybe driven by better compliance. Smarter people than me could probably speak to the r...
How can hepatic venous pressure gradients in patients with cirrhosis be used to differentiate between cardiac cirrhosis and portopulmonary hypertension?
HVPG is a measure that quantifies the increase in sinusoidal resistance to blood flow and can be obtained in a minimally invasive way compared to portal venous sampling directly which may be more invasive. HVPG is the pressure difference between hepatic vein wedge pressure (HVWP) & hepatic vein free...