Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Would you biopsy calcified lung nodules and or lymphadenopathy that have shown stability over a 2-year period, in a bid to rule out sarcoidosis?
No. Certainly not without a comprehensive occupational and other exposure history. Follow "the rules" for the assessment of any sarcoidosis suspect. Do a physical exam to look for extrapulmonary signs of sarcoidosis. Order an eye exam to assess for ocular sarcoidosis. Obtain baseline MTB testing and...
Would you recommend anticoagulation prophylaxis for a pediatric patient admitted with COVID-19?
COVID-19 disease in children seems to be less severe than adults based on the current literature and our personal experience at Children's Hospitals. Among adults, the coagulopathy is beginning to be described with elevated inflammatory markers and other markers of coagulation activation, including ...
What specific strategies have you found most effective in your academic program for inspiring internal medicine residents to consider nephrology as a career?
Probably the best tool we have is having residents rotate with us. Nephrology is a mandatory rotation at RUSH Internal Medicine, and frankly, we are excellent teachers, so that sparks interest that may not have happened if they did not rotate. I cannot believe that all IM programs do not require nep...
For older adults undergoing intermediate-risk non-cardiac surgery, do you routinely check pre-operative pro-BNP levels for risk stratification based on emerging data and updated Canadian guidelines?
Pre-operative NT-proBNP and BNP levels have been featured, not just in the cited Canadian guidelines but also in the 2024 update of the AHA/ACC preoperative evaluation guidelines. (Thompson et al., PMID 39316661). Those guidelines recommend evaluating a pre-op NT-proBNP level if the results will cha...
For older adults undergoing intermediate-risk non-cardiac surgery, do you routinely check pre-operative pro-BNP levels for risk stratification based on emerging data and updated Canadian guidelines?
Pre-operative NT-proBNP and BNP levels have been featured, not just in the cited Canadian guidelines but also in the 2024 update of the AHA/ACC preoperative evaluation guidelines. (Thompson et al., PMID 39316661). Those guidelines recommend evaluating a pre-op NT-proBNP level if the results will cha...
How do you approach managing intolerable vivid dreams as a side effect of SSRIs?
There are several distinct options I go over with patients who have this side effect. It often self-resolves, but can take a few (up to 6) months to resolve, and there is no guarantee. If the patient is willing to tough it out, I often have them do nothing. But, we are talking about it being an int...
How do you balance the risks and benefits of stimulant treatment in patients with poorly controlled hypertension?
The short answer is that there are no clear cutoffs to clearly guide management, and often decisions are guided by shared decision making with patients and relevant specialties (psychiatry, primary care, cardiology).Clinical factors which may prompt you to stop or reduce stimulants: Elevated BP that...
How do you decide on switching to a different preventative anti-CGRP treatment in migraine patients who are experiencing reduced effectiveness with their current treatment?
The CGRP antibodies and gepants are my preventive treatments of choice. In fact, I hardly ever prescribe anything else anymore preventively, including botulinum toxin. Tolerability issues I hardly ever encounter with the antibodies, but sometimes I do with the gepants, in particular fat...
Would you stop current immunosuppressive therapy or delay starting immunosuppressive therapy in a patient with aplastic anemia who has been infected with COVID-19?
This is an interesting question. Based on personal communication (Italy, Germany, Israel), we have not seen increased risk for pediatric patients with hematological diseases and COVID-19. There was one case reported in China, but it was inconclusive (nearly 50 y.o. patient with aplastic anemia—seeme...
What factors do you consider for patients on an individual basis when establishing a post-cardiac arrest MAP goal after ROSC is achieved, considering some may benefit from higher MAP goals for optimal cerebral perfusion?
I generally aim for a MAP of 70. However, I am more concerned with ensuring end organ perfusion and will track urine output, lactate, mental status, and LFTs in addition to the physical exam (cool vs warm and absence of mottling). MAP goal adjustment should also be considered in instances with a wid...