Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to treatment of patients with fulminant C difficile infection who required ileostomy creation or colectomy?
Great question. If the entire colon has been removed, I do not see a role for oral vancomycin.
For patients with spinal hardware infections, in what circumstances do you recommend 12 weeks over 6 weeks of antimicrobial therapy?
Extrapolating from PJI data, I tend to treat longer, but not always IV if there is an oral option after initial IV therapy. A big blurry line is when do oral antibiotics stop being for treatment and start being suppressive? Anyone I'm considering for long term suppressive antibiotics, really gets a ...
Do you recommend combined baseline cortisol and DHEA-S testing to improve the efficiency and accuracy of adrenal insufficiency diagnosis?
Yes, especially in the absence of recent glucocorticoid exposure, which can lower DHEAS levels and make it less helpful. Han et al., PMID 39657727 recently published a comprehensive manuscript on this topic.
Would you consider treating hypercalcemia with CRRT and regional citrate anticoagulation for a dialysis dependent patient who does not respond to bisphosphonate therapy and low calcium dialysate bath?
Although CRRT with citrate anticoagulation may be effective in treating significant hypercalcemia, this is only a temporary solution if the underlying etiology of hypercalcemia persists. The underlying cause of hypercalcemia should be addressed, if possible. If the underlying etiology cannot be easi...
What are your management strategies for patients with recurrent uric acid nephrolithiasis and chronic kidney disease who have persistent hypocitraturia and acidic urine pH?
This is a good question. The primary goal is to correct the urine pH to at least 6 and preferably 6.5, regardless of renal function. Hypocitraturia is not a critical issue in uric acid stones disease, though it will likely respond to therapies listed below. Concurrent chronic kidney disease does not...
How do you approach mitral valve endocarditis associated with a large vegetation size and severe mitral regurgitation, but without any heart failure, hemodynamic instability or valve destruction?
This is a great question and it poses the risk-benefit of the situation nicely. This stems off the 2012 NEJM (Kang et al., PMID 22738096) paper linked in the question, comparing Early (<48 hr) vs Conventional/Abx treatment for large vegetation (>10 mm) without major stroke yet. Summary: this was pre...
When would you suspect metabolic myopathy and what is your approach to initial workup?
Great question and really important to rheumatology practice. As always, a history and physical exam is the best initial diagnostic tool. It’s a little bit difficult because of the sheer number and heterogeneity of non-autoimmune myopathies that clinicians may encounter, but a few general principles...
What is your approach to using ketamine for agitation in the ED setting?
The use of ketamine for agitation in the ED setting is not without controversy. Some clinicians feel that it is an essential tool for the management of agitation, while others feel that the potential risks outweigh the benefits. If ketamine is going to be used to treat agitation, appropriate patient...
When would you consider using Ibutilide for rapid pharmacologic cardioversion of atrial fibrillation?
Someone already on anti-coagulation for paroxysmal or persistent atrial fibrillation. As well as someone with very recent onset atrial fibrillation/flutter in less than 24 hours. (Some may like less than 12 hours others less than 48 hours) Someone I planned on electrical cardioversion that day, how...
Do you send CSF or serum ACE levels in the workup of neurosarcoidosis?
Unfortunately, serum and/or CSF ACE levels are just not sensitive or specific enough to guide the diagnosis or treatment of sarcoidosis, particularly neurosarcoid. Rather, imaging characteristics, specific organ system involvement, and biopsy results are much more useful in my practice.Bradshaw et a...