Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When do you consider starting hypertonic saline solution in patients with an acute ischemic stroke?
Hypertonic (3%) saline is infrequently used, and mainly applies to patients who have signs of significant midline shift or cerebral edema on CT or MRI with a depressed loss of consciousness. In stroke patients in the awake/alert state with a large stroke and risk for edema development in the next 24...
In patients with recurrent ischemic infarcts on the same side as an internal carotid artery lesion, is intervention warranted even if there is less than 50% obstruction?
If a carotid web is found, it would be reasonable to consider intervention to prevent thrombus formation and embolization. Grory et al., PMID 30621527
What is the utility of an oral calcium loading test to differentiate FHH from secondary hyperparathyroidism due to low calcium intake?
Both vitamin D deficiency and calcium deficiency can result in secondary hyperparathyroidism. Before entertaining the diagnosis of FHH, I would treat the patient with an adequate calcium intake of 1000 mg a day of elemental calcium preferably from dietary sources like dairy. Supplemental sources are...
Do you routinely check G6PD level prior to initiation of hydroxychloroquine?
No, we do not routinely check G6PD levels prior to initiation of hydroxychloroquine (HCQ). The American College of Rheumatology does not recommend routine testing for G6PD prior to initiation of hydroxychloroquine (HCQ), but interestingly, package inserts often recommend caution in these patients. O...
Is an EMG/NCS required to clinically diagnose Guillain barre syndrome?
GBS remains a primarily clinical diagnosis, characterized by rapidly progressive large fiber sensorimotor deficits with early arreflexia, supported by albuminocytologic dissociation in cerebrospinal fluid. EMG/NCS can be normal or non-specific in up to half of the patients in the first week and only...
How do you determine the timing of anticoagulation for patients with large MCA strokes secondary to atrial fibrillation?
Timing for anticoagulation initiation depends on the size of the stroke and whether a thrombus is present outside the cerebral vasculature. In general, between 4-14 days is standard practice, with early initiation in smaller strokes (to prevent recurrent stroke) and later in larger strokes (to preve...
How frequently do you monitor EKGs for patients newly initiated on lacosimide?
In patients who are over the age of 50, smokers, or others with a higher risk of heart disease, I get an EKG at baseline and then at a maintenance dose. During treatment, if the patient reports any new potential cardiac symptoms like palpitations, PVCs, SOB, etc, I will get another EKG.
How would you treat pemphigus foliaceous in an elderly patient intolerant to oral steroids?
It depends on the extent of the disease and the severity of symptoms. Home wet wraps, when they can be done, can be essentially as effective as oral steroids in many situations, but can be time intensive. I provide the patient with instructions and a pound jar of triamcinolone ointment. Be careful s...
What is your approach to managing asymptomatic ORN of the mandible?
Do nothing until you have to.
Is there a role for vascular intervention in patients with renal artery stenosis found during work up of resistant hypertension?
The ASTRAL, STAR, and CORAL trials all attempt to this question in different patient populations. A portion of CORAL participants met the diagnostic criteria for resistant hypertension. What I have taken away from the data is that renal artery intervention can be helpful in fibromuscular dysplasia i...