Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
For patients with central hypothyroidism and a clear etiology (such as recent head irradiation), do you recommend brain imaging prior to starting thyroid hormone replacement therapy?
Levothyroxine does not cause tumor growth, and therefore you do not need to image before starting therapy. However, in general, it takes a long time for central hypothyroidism to develop after radiation, therefore in the presence of an early reduction in FT4 you must consider the possibility of the ...
What is the best treatment for radiation recall skin reaction of the breast?
History and distribution suggest radiation recall effect. If no agent which precipitated recall, can be ascertained then have done symptomatic management with a topical agent and follow up to see course (it subsides or gets better with time).
What workup do you recommend for patients with symptoms suggestive of saphenous neuropathy?
In most cases of isolated saphenous neuropathy, the etiology is pretty straightforward, as it usually occurs after surgery or injury/trauma at the medial knee. Another common cause of more distal saphenous neuropathy is saphenous vein harvesting for CABG surgery (less common nowadays). When there is...
How do you counsel patients with postmedian sternotomy plexopathy?
Brachial plexopathy after median sternotomy is not very common. Its frequency varies in different studies but it's most likely between 0.5-5%. The most likely mechanism is traction of the anterior rami of the C8>T1 roots, often associated with a fracture or upward displacement of the first rib. A re...
Is there a role for inpatient EMG/NCS in patients who present with rhabdomyolysis with unclear etiology?
Great question. This is something we are frequently asked to do, but frankly, it is useless most of the time or perhaps it doesn't add any information to what we already know. When a person presents with myalgia, muscle weakness, and very high CK levels (defined as well over 10 times the upper limit...
In a patient with bisphosphonate induced bilateral atypical femur fractures, how would you approach timing of alternative osteoporosis treatments and surgical management?
Unfortunately, this is still a very common problem. Although the information that oral bisphosphonates should likely be limited to 5 years duration has been available for many years, my large orthopaedic practice continues to see 2-4 atypical femur fractures per month and often the patient has been ...
Would you treat a sputum culture positive for Aspergillus niger despite an atypical CT chest and a negative serum galactomannan in an immunosuppressed patient who is too high risk for bronchoscopy?
What is your daily correction goal for those patients being treated for hyponatremia?
This is easily a short answer or 10,000 words. I choose the former. I try to limit it to 6 mmol/l/day, will tolerate 7. But a lot depends on where you start. A starting PNa of 100 is a lot different than a PNa of 120 as the relative osmotic shift will be greater at lower PNa.
Is there a minimum work-up necessary in patients with an ANA greater than 1:160 and no clinical symptoms suggestive of lupus (i.e., specific antibodies, UA)?
My personal practice has been to get the "ANA subtypes" and a UA for prot/Cr ratio, but I do this with the idea of needing to have a complete picture. Clinical symptoms are still king.
In which clinical scenarios do you use prolonged intermittent renal replacement therapy (PIRRT)?
I have not been using PIRRT. We talked about it at the height of COVID when we thought we were going to run out of CVVH solutions. However it never needed to be instituted. Other than that scenario, I think we can tweak the settings of the CVVH machine enough to provide aggressive renal replacement ...