Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When do you re-image patients with a diagnosis of venous sinus thrombosis?
My practice is to perform early reimaging, typically at around 2 weeks, before transitioning from parenteral anticoagulation to oral anticoagulation. This early reassessment is important as recanalization processes begin early and are linked to clinical outcomes. Subsequent imaging at 6 months is al...
Which patients presenting with spontaneous ICH should be considered for a diagnostic cerebral angiogram/DSA?
Given the ease of obtaining CT angiograms, the majority of patients both with and without a history of hypertension are routinely getting CTA's. This has truly led to a minimization of the need for diagnostic cerebral angiograms. While the diagnostic performance of noninvasive neuroimaging is not cl...
How do you prescribe ketamine for treatment of refractory status epilepticus, and what is its efficacy?
For cases of RSE, I usually turn to ketamine if I encounter hypotension with propofol or if I'm not achieving the desired EEG response. My typical approach involves administering a 100 mg bolus followed by a continuous infusion of 100 mg/hr. For more detailed information, you can refer to this artic...
Is there still a role for direct laryngoscopy in the intubation of patients in the ICU?
I believe you have to be proficient in many techniques in case you need alternatives when performing a procedure. This applies to DL. Video intubation has facilitated intubation greatly but the technique is different and if it fails the default is DL.
How do you manage diarrhea in a patient with CTD-ILD on MMF who was recently started on full dose nintedanib?
It is important to keep in mind that immunomodulator therapy is also frequently associated with gi toxicity (MMF, methotrexate, leflunomide, azathioprine, etc.). Given this, it is important to begin one therapy at a time in order to mitigate side effects and do understand which agent is responsible....
Do you prefer monitoring creatinine over cystatin C levels in patients with lymphoma and chronic kidney disease given the potential for cystatin C levels to be increased with certain malignancies?
My default is to monitor creatinine, not cystatin C, in all patients with malignancies except: if patients have had weight loss and down-trending creatinine, patients are at eGFR cutoffs for chemotherapy drug dosing, leading to concern for potential over/under-dosing, there is concern for pseudo-AKI...
Do you continue to prone patients with severe ARDS after initiation of VV-ECMO?
Not routinely - although we have occasionally proned VV ECMO patients at our center. Reasons for not proning include: Cannula dislodgement/displacement risk (although Roca et al, PMID 34461971 reviews the literature on proning with VV ECMO and the risk of major line complications is small). Generall...
Can joint replacement surgery be performed in someone with active Paget’s disease elsewhere?
Joint replacement surgery can be done in patients with Paget's disease. There should be no problem particularly if the patient has been treated to suppress disease activity. The best treatment is a 5 mg intravenous infusion of Recast which can suppress disease activity for 5 years or more.
What else do you consider in the differential diagnosis for pulmonary-renal syndromes if there is low clinical and serologic evidence of AAV, Goodpasture's or other rheumatologic disease (SLE, RA, APS, Scleroderma)?
Endocarditis can mimic vasculitis and can have pulmonary hemorrhage. You CANNOT miss that one. Sarcoidosis is I suppose a pulmonary renal syndrome. Renal vein thrombosis from MGN with a pulmonary embolus is I suppose a pulmonary-renal syndrome.
How do you counsel newly diagnosed patients with ALS on dietary recommendations?
I counsel all my newly diagnosed ALS patients about the importance of weight maintenance. Weight loss is an established risk factor for accelerated ALS progression according to several studies (Janse van Mantgem et al., PMID 32576612 and Jawaid et al., PMID 20500116). Therefore, we always aim to mai...