Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When is follow-up imaging warranted in patients with anoxic brain injury?
Acutely, either MRI or CT can be used to assess for cerebral edema and impending herniation. However, MRI is much better to assess for extent of ischemic injury. Imaging can be helpful in prognostication as one part of the puzzle, but not in isolation, and prognostication based on imaging alone is p...
What is your approach for a patient with an acute ischemic stroke caused by an aortic thrombus?
It depends upon the risks, factors, and age of the patients. If they have hypercoagulable states then the patient needs anticoagulation otherwise, aortic atheroma is generally "white" clot which is made up of platelets and cholesterol and hence, treatment would be anti-platelets and cholesterol lowe...
Do you always perform temporal artery biopsy in patients with positive inflammatory markers and high clinical suspicion of GCA?
As with most clinical scenarios, the short answer is 'it depends'. If a patient has cranial symptoms, elevated inflammatory markers, and suspicion for GCA is high, I do refer for temporal artery biopsy to help confirm the diagnosis. This is in line with guidelines from the American College of Rheuma...
If a PET/CT scan is positive for mediastinal lymph node involvement, is a mediastinoscopy or EBUS still required for NSCLC staging?
The gold standard for mediastinal staging is still mediastinoscopy. You can have 15 to 20 percent false positive PET findings in mediastinum and for these patients surgery should not be excluded based on PET findings alone.
Is either ESR or CRP more sensitive or specific for the diagnosis of GCA?
I typically obtain both an ESR and a CRP in the workup of new onset or relapsing GCA. The CRP may be slightly more sensitive than the ESR based on Kermani et al., PMID 22119103 which demonstrated a sensitivity of 86.9% and 84.1% respectively for CRP and ESR, for a positive TAB. There is discordance ...
How do you treat post-IVIG headache that is not responsive to Tylenol or NSAIDs?
In my opinion, there is no one simple treatment for such headaches. We try slowing the infusion rate, premedicate with steroids, low dose Lasix, or premedicate with Nurtec. Usually, one of these methods helps minimize or eliminate the headaches.
How do you treat patients with symptoms of acute ischemic stroke who have an allergic reaction to alteplase?
For patients with an allergic reaction (i.e. perioral or lingual edema, difficulty breathing, or other serious reactions), our protocol is to stop tPA (and not resume), discuss with the ED attending whether there is a need for epinephrine 0.3 mg (1:1000 dilution) or intubation, monitor respiratory s...
Do you frequently encounter asterixis in patients with UTI associated encephalopathy?
Yes. The teaching that asterixis is only associated with hepatic encephalopathy is definitely false. The major metabolic triad that is associated with asterixis include liver failure, kidney failure (uremia), and hypercarbia. But don't forget toxic causes! Lots of medications (including AEDs) can co...
What DHE migraine protocol works best for acute treatment both in terms of dosage and timeframe?
Dihydroergotamine (DHE) is a non-specific ergot that acts on the serotonergic, dopaminergic, and adrenergic pathways. It is used as an acute migraine treatment that can be given parenterally or nasally. Oral does exist, but is not available in the USA. It may be used acutely as a rescue treatment du...
Do you always pursue stroke work up in patients diagnosed with transient global amnesia?
I do not routinely recommend imaging or EEG for clinically straight-forward patients with Transient Global Amnesia (TGA), although I suspect I am in the minority. When the diagnosis is in question, or when the symptoms have not resolved, then yes, I would do additional workup, including MRI and EEG....