Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you avoid SSRIs in patients with a history of RCVS?
SSRIs are on a long list of medications associated with RCVS. The condition is relatively rare, and a very low percentage of patients have recurrences. If there is a strong indication for antidepressants, I would treat them with appropriate warnings.
How do you evaluate patients with suspected pseudo-dementia?
I am very careful about diagnosing a functional cause for cognitive impairment. I typically get vitamin B12 and TSH levels, and also get a neuropsychological evaluation. They are usually able to pick up underlying behavioral disorders or poor effort. If unrevealing, and there are no obvious risk fac...
How do you approach the workup and management of patients with suspected functional neurologic disorders?
This is not really an answerable question. I would re-frame the question, because it really depends on the kinds of symptoms they have and the neurologic exam that is performed. I disagree with neurologists who say that "functional neurologic disorders" are a diagnosis of exclusion. That is absolute...
Would you avoid the use of keppra in patients with TBI due to concerns for worsening agitation?
I suspect that this practice of prophylactic antiepileptic medications for TBI patients will go away over time. History has shown us time and time again that we over-medicate patients.
Is an early chest tube and tPA/Dornase therapy for a loculated and complex pleural effusion that is not an empyema or hemothorax helpful in reducing the rate of developing trapped lung?
We always keep a low threshold for adding TPA/DNase therapy, if chest tube output starts decreasing, while the radiological infiltrate is not resolving concurrently. The fact to keep in mind is that NO diagnostic workup is 100% sensitive for diagnosing infectious triggers/organizing paranamonic pro...
When do you recommend lumbar puncture in patients with concern for memory loss?
Rapidly progressive memory loss/dementia- because you obviously want to exclude diagnoses like CJD, infectious/autoimmune/paraneoplastic encephalitis, lymphoma or other malignancy, etc. When you need to know the patient's "brain amyloid status". E.g. a) Patients with amnestic MCI and atypical cour...
How long would you treat a patient with recent history of TAVR presenting with E faecalis bacteremia with unclear source with TEE showing thickened valves but no obvious vegetation?
Treatment duration depends on other additional factors.TEE showed leaflet thickening- a non-specific finding, not a feature per Duke's major imaging criteria. Another feature to consider would be an associated new-onset valvular insufficiency that might increase the likelihood of IE. In such cases, ...
What considerations do you take when managing a patient with end stage kidney disease on peritoneal dialysis who is planning on undergoing PEG tube placement?
This is a somewhat difficult question to address, as there is more opinion and conventional “wisdom” than there is data. Let me begin with the “easy” part: notwithstanding reports of caregivers confusing the PD catheter for the PEG tube and instilling enteral feeding solutions intraperitoneally, pla...
When do you recommend testing for APOL1 variants in patients with proteinuric chronic kidney disease?
As yet, despite APOL1 being a clear risk factor for kidney disease and ESKD, there are no clear guidelines to assist in decision-making regarding genetic testing. This is mainly due to the fact that there are (as yet) no specific drugs for APOL1-mediated kidney disease. There is an RCT for inaxaplin...
Do you use mannitol when initiating patients on intermittent hemodialysis?
This is a very good question. Mannitol has been used for decades to try and reduce disequilibrium, cramping and intradialytic hypotension. Most of the studies are small and were not placebo controlled and were performed in prevalent patients. In 2019, a randomized controlled trial was done that did ...