Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How would you manage anticoagulation in a patient with acute MI or PE with prolonged aPTT due to congenital factor XII deficiency?
You can monitor anti Xa levels.
What is your approach to a patient who has a cardiac PET scan suggestive of sarcoid but no other supporting evidence of a diagnosis of sarcoid?
The diagnosis of cardiac sarcoidosis (CS) can be challenging, as non-necrotizing granulomatous inflammation is frequently patchy, and as a result, may not be present on endomyocardial biopsy even in the setting of active cardiac disease. Many institutions, including ours, attempt to avoid endomyocar...
Would you add cholecalciferol or ergocalciferol to calcitriol therapy in patients with post operative hypoparathyroidism who have low 25 OH vitamin D levels?
Yes, if a person with hypoparathyroidism has a low 25(OH) D level, on calcitriol, I would do several things; first, figure out why it is low; and second, check a serum calcium and phosphorus level. If the calcium is low and the phosphorus is elevated, I would try using cholecalciferol 1000 IU daily ...
What is your perioperative approach to holding and restarting hydroxyurea in patients with essential thrombocythemia?
I would like to rephrase the question since as written, the assumption is that hydroxyurea is a preferred therapy for ET, when any careful reading of the literature will show that there is no proven rationale for using chemotherapy of any sort routinely in ET. There is no association between the pla...
When is it considered inappropriate to omit pathological mediastinal lymph node staging for non-small cell lung cancer?
This is a very good question often debated by thoracic radiation oncologists with their thoracic surgery colleagues and can get complicated. The best way to look at it, in my opinion, is to understand the sensitivity and specificity of FDG PET/CT to detect true mediastinal nodal disease. For example...
Have you applied the POET trial to clinical practice?
I do transition to oral therapy after clinical stability, resolution of systemic inflammatory response and blood culture negativity have been achieved. I have long operated on the principle that it doesn’t matter how (IV or oral administration) the antibiotic gets into the bloodstream as long as it ...
Would you recommend genetic testing to determine if there is a potential underlying primary process in a patient with congenital solitary kidney who is presumed to have secondary FSGS?
I do recommend genetic testing more frequently especially at our institution in which the cost to the patient is minimal to none. I would imagine very rarely one finds a positive genetic test result but one never knows what we find until we do the testing.
When do you re-image patients with a diagnosis of venous sinus thrombosis?
My practice is to perform early reimaging, typically at around 2 weeks, before transitioning from parenteral anticoagulation to oral anticoagulation. This early reassessment is important as recanalization processes begin early and are linked to clinical outcomes. Subsequent imaging at 6 months is al...
Which patients presenting with spontaneous ICH should be considered for a diagnostic cerebral angiogram/DSA?
Given the ease of obtaining CT angiograms, the majority of patients both with and without a history of hypertension are routinely getting CTA's. This has truly led to a minimization of the need for diagnostic cerebral angiograms. While the diagnostic performance of noninvasive neuroimaging is not cl...
How do you prescribe ketamine for treatment of refractory status epilepticus, and what is its efficacy?
For cases of RSE, I usually turn to ketamine if I encounter hypotension with propofol or if I'm not achieving the desired EEG response. My typical approach involves administering a 100 mg bolus followed by a continuous infusion of 100 mg/hr. For more detailed information, you can refer to this artic...