Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you treat refractory focal status epilepticus in patients with traumatic bilateral subdural hematomas?
It is important to know a few more facts: Are the subdural hematomas acute/relevant? Or are they chronic findings (remote symptomatic epilepsy)? If they are acute, are they significant enough to cause brain compression needing neuro-surgical intervention? Is this electrographic only (non-clinical) ...
What is the utility in repeating a temporal ultrasound (US) in a previously US diagnosed positive GCA patient who has received treatment and is presenting with recurrent GCA symptoms?
While TA ultrasound may have a role in the assessment of disease relapse, currently there is little evidence to understand its utility in this area. It is well known that the halo sign is steroid responsive and multiple studies have shown that the halo sign recedes within the first several weeks of ...
What is your approach to managing intradialytic cramping that recurs despite multiple dry weight adjustments in a patient with ESKD?
This is a great question and there is no easy answer. As always, try and make sure the patient is following fluid restriction in between treatments as having less fluid to remove during a session may reduce cramping. I also try gabapentin 100mg prior to treatment for cramping. If they treat early in...
What symptomatic management do you recommend in patients with post LP headaches?
In my clinical experience, the symptomatic/medical management of post lumbar puncture (LP) headache is challenging and of limited utility. In contrast, for the vast majority of cases, a large volume autologous epidural lumbar patch ("blood patch") is highly effective (and much appreciated by the pat...
How do you evaluate and treat patients with cerebral edema secondary to hyperammonemia?
The previous answer is a reasonable plan for the raised ICP. We need to remove ammonia - ammonia scavengers or dialysis are reasonable. If not liver cirrhosis, look for urea cycle issues even in adults, old GI surgical procedure that creates blind pouch with bacterial overgrowth, etc as other potent...
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 ...