Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you treat CTD-associated organizing pneumonia?
I agree with what Dr. @Dr. First Last has said. To answer your question specifically, organizing pneumonia is slightly different to other forms of ILD. OP tend to have much better response to steroids in general. As with most other ILD patterns, CTD-OP has slightly worse prognosis than COP. So I am ...
How do you counsel patients with ALS on the benefits of enteral nutrition?
I agree with Drs. @Dr. First Last and @Dr. First Last but what I find frequently is that patients are reluctant to have PEG because of a number of psychological factors; fear of the surgery, fear of having a tube, fear of disease progression, fear that it will keep them alive indefinitely as in the ...
When do you recommend genetic testing in patients with neuropathy?
I would do genetic testing in any chronic progressive polyneuropathy that defies explanation after routine lab testing and is associated with at least one of the following features: positive family history early onset (<35-40) abnormal foot appearance-pes cavus, hammertoes motor predominant symptom...
What workup do you recommend on patients with suspected ischemic cranial nerve six palsy?
The conventional wisdom is that 90% of isolated ischemic (or "vasculopathic") 6th nerve palsies recover in 6 months or less. Diagnostic certainty of this etiology is increased if the patient is hypertensive, diabetic, or maybe has hyperlipidemia or tobacco use. The real problem for the non-ophthalmi...
How would you manage cognitive changes in a patient with memory impairment and significant brain atrophy with no diagnostic testing consistent with Alzheimer's disease?
It would depend on the clinical history, pattern of atrophy, and diagnostic biomarkers. If I had a patient with a typical clinical history of AD with progressive episodic memory loss substantiated by neuropsychological testing, IADL impairment, and hippocampal atrophy on imaging, I probably would no...
How frequently do you recommend flushing a peritoneal dialysis catheter for patients with ESKD who are hospitalized and are not currently undergoing peritoneal dialysis?
I'm not aware of any data to guide my response, just experience and "gut". It is our practice to flush unused peritoneal catheters on a weekly basis.
Is the adage “If GCS <8, intubate” still relevant for non-TBI patients?
It's a challenging area. NICO does lead credence to withholding intubation among patients that are comatose from acute poisoning with improvements in "composite end point of in-hospital death, length of ICU stay, and length of hospital stay."Practically speaking, I've never liked hard and fast rules...
When would you consider biopsy for an incidentally noted, PET negative, solid, solitary pulmonary nodule that is >8mm in size?
No, probably not. The whole point of a PET scan is to use it for its negative predictive value (which is very high for a nodule that is solid, and large enough). I'd like to know just how large it is because smaller nodules (e.g. just at or above the 8 mm size threshold we all perseverate on) can be...
What would be the main indications for opting for biosimilars over an original biologic, outside of insurance barriers?
A timely question, as we head to 2023! The only reason to use biosimilars is for the broad purpose of resource stewardship. There isn't a medical reason to prefer a biosimilar over a reference product (or vice versa), because if a product were found to have a significantly different therapeutic effe...
What steroid regimen do you use in patients with both septic shock and ARDS?
Personally, I have used Hydrocortisone 50mg q6h for patients with refractory shock, regardless of the presence of absence of ARDS. I have not been an adopter of Steroids in ARDS.