Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach the work up of pulmonary artery aneurysm in the absence of other clinical features of Behcet’s?
While Behçet’s disease (BD) is one of the most well-recognized causes of pulmonary artery aneurysms (PAA), it may not be the most common one globally. In scenarios where a careful history, exam, and vascular imaging don’t reveal other BD-compatible findings, other conditions can be more likely. It i...
Do you routinely obtain baseline vascular imaging (CTA, MRA, PET) in patients with suspected GCA, but negative temporal artery biopsy?
Vascular imaging is particularly helpful in patients with large vessel giant cell arteritis. This patient subset may present with persistent constitutional symptoms, refractory polymyalgia rheumatica, fever of unknown origin, or with vascular signs/symptoms (for example arm claudication). These pati...
How do you clinically distinguish between group I and group III PH in patients with CTD-ILD?
The distinction between pulmonary hypertension (PH) of the group 1 (pulmonary arterial hypertension (PAH)) and group 3 (pulmonary hypertension (PH) due to lung disease and/or hypoxia) is essential since the management is different. In group 1 PH we stratify the risk and treat with a variety of PAH-s...
What is your approach to the management of asymptomatic intracranial atherosclerosis discovered during the workup of an acute stroke?
I would maximize the treatment of vascular risk factors such as hypertension, elevated cholesterol, and diabetes. The patient will be taking an antithrombotic medication for the acute stroke so that will also reduce the risk of stroke related to ICAD.
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 ...