Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Does the presence and location of cerebral microbleeds affect your decision for antithrombotic treatment in patients with atrial fibrillation?
That is a great question. Agree, the data is observational and no firm conclusions can be made. My practice is to consider left atrial appendage occlusion in patients with suspected CAA. In patients with hypertensive microbleeds, both resuming anticoagulation and left atrial appendage occlusion are ...
What is the utility of granulocyte infusions in patients with neutropenia and severe infection?
Granulocyte transfusion is infrequently used for septic neutropenic patients given that the randomized trial (RING) that looked at this question did not show improved outcomes (with the caveat that the trial did not finish accrual (Price et al., PMID 26333778). Having said that, the criteria to cons...
How do you approach palliative conversations about what patients can expect when deciding to stop maintenance dialysis?
I typically include this discussion with my patients as part of the discussion of what options are available to address irreversible progressive CKD (eGFR<25). I find it best to present all options for ESKD management in a balanced format and I open the clinic visits to all family and friends to sup...
How do you manage patients with end stage kidney disease and recurrent ascites who do not have any evidence of cardiac or liver disease?
This is not a common scenario but we definitely see it. More aggressive dialysis is likely the best treatment if possible not only as far as fluid removal but also as far as clearance. Recommend 4 days per week dialysis. If fluid removal is not adequate then would do large volume peritoneal taps eve...
What would be your threshold to offer coronary angiography for patients presenting with atypical chest pain features and Wellens syndrome on EKG without a troponin elevation or dynamic EKG changes?
In three words- very low threshold. Wellens syndrome typically presents with T-wave inversion in V 2, 3, but can be across the precordium. The patient may be asymptomatic at the time of presentation, but Wellen probably represents a pre-infarction state representing proximal LAD thrombus. The propos...
What is your approach to initial assessment of disease extent in patients with Behcet's disease?
As Behcet's syndrome is a clinical diagnosis, the symptoms that a patient presents with dictates the initial assessment, for the most part. A lot of work up is needed to rule out other conditions that may mimic Behcet's syndrome, however, assuming that has been done, evaluation for eye involvement b...
How important do you feel HLAB51 testing is in diagnosing Behcet's disease?
The diagnosis of Behcet syndrome is based on clinical signs and symptoms. Laboratory testing and imaging studies are usually used to rule out conditions that may mimic Behcet rather than confirm the diagnosis. There is a strong genetic association between HLA-B51 and Behcet. About 50–80% of Behcet p...
What is your first treatment of choice in patients with dermatomyositis sine myositis?
Great question! For better or worse, there isn't a great one-size-fits-all answer since choosing the "best" agent means assessing the severity of the disease, assessing if there are extracutaneous manifestations that also need to be addressed (e.g., interstitial lung disease? inflammatory arthritis?...
Do you avoid intra-articular and bursa/tendon sheath corticosteroid injections in patients with a history of avascular necrosis?
I would give intra-articular or bursa injections of steroids/glucocorticoids in patients with either active ON or a history of GC induced ON. I do not believe the local injection will increase the risk of progression or incident ON, as long as it is not given more often than every 3-4 months.
Should the age at which patients transition from pediatric to adult care differ depending on the disease diagnosis?
First, a distinction needs to be made between transition (which is a long-term, ongoing process) and transfer of care (which is the act of going to one provider to another). Transition introduction should start early, with recommendations that age 12 is a good beginning to introduce the concepts of ...