Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What clinical sign or symptom do you consider to be the most specific for Cushing syndrome?
Cushing's syndrome is a rare disease. The following symptoms and signs are suggestive. Symptoms: weight gain, especially in the middle, muscle weakness, and easy bruising Signs: Moon facies Central obesity with relatively thin arms and legs Pad of fat behind the neck (Buffalo hump), thin skin, pur...
Do you use a phosphate binder to manage inpatient hyperphosphatemia in patients with AKI who have no history of CKD?
I agree there is uncertainty about optimal serum phosphate concentrations in patients, and essentially no data in AKI. However, increases in Phos do result in an increased risk of metastatic calcification, and increases FGF23 and PTH, even in AKI and these changes clearly have increased risks, thus,...
In which patients do you recommend craniectomy-watch after acute stroke?
The ideal candidates are younger patients with full MCA distribution stroke. One issue to be mindful of is that the “watch” part should be focused on watching to confirm the radiographic size of the stroke and the presence of cerebral edema. I would caution against watching for clinical deterioratio...
With the recent trials such as SELECT and STEP-HFpEF demonstrating benefits of GLP1-agonists in terms of CV risk reduction and improved exercise function, have you begun to incorporate this class of medications into routine CV health maintenance for patients with HFpEF and/or pre-existing CAD?
I would strongly support the use of this medication. The biggest challenge is insurance coverage. When would it be approved by insurance and how many hoops we will need to jump before they approve it?
What would be the differential and initial workup for tongue fasciculation?
Tongue atrophy and fasciculations, unless very severe and obvious, can be difficult to determine by clinical exam alone. I have had multiple patients who were told that they have ALS after an inexperienced examiner saw them for an initial visit and thought they had tongue fasciculations without furt...
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...