Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
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...
Do you recommend continuing SGLT2 inhibitors in patients with diabetic kidney disease and congestive heart failure who have been taking the medication for several years and later develop end stage kidney disease?
The very premise on which SGLT2i is supposed to work does not exist, if the patient does not have meaningful GFR; in fact most would not use/start SGLT2i once eGFR is <20-25 range. Studies have excluded patients with advanced CKD and any benefit with low GFR seems very doubtful. Zinman et al., PMID...
Do you recommend the use of indwelling pleural catheters in the management of patients with hepatic hydrothorax requiring frequent drainage?
The use of an indwelling pleural catheter (IPC) in hepatic hydrothorax (HH) is a nuanced question. One must weigh the benefit of frequent drainage versus the morbidity associated with the catheter as well as the clinical context of the patient.There are somewhat limited data regarding the use of IPC...
How do you treat persistent headache after RCVS?
To my knowledge, there are no published studies to guide treatment decisions for headaches related to RCVS. Therefore, I would base treatment on the headache phenotype. In my experience, the most common phenotype is chronic migraine. Literature suggests that a prior migraine diagnosis is a risk fact...
How would you manage a patient with distal rectal adenocarcinoma involving the anal canal and a single non-bulky inguinal nodal metastasis?
Patients with low rectal cancer and inguinal involvement at presentation should obviously be treated with curative intent because inguinal lymph nodes are first echelon drainage from the low rectum and anal canal. Standard dose neoadjuvant chemoradiation and limited surgical excision of the involved...
Would you consider exploratory surgery in a young patient with normocalcemic hyperparathyroidism that meets one or more criteria for parathyroidectomy but has no localized pathology on advanced neck imaging?
If the patient has any complications that could be caused by primary hyperparathyroidism surgery would be appropriate done by a highly experienced parathyroid surgeon. It is not uncommon for imaging to be negative in patients with relatively mild parathyroid problems.
For patients with suspected complement-mediated TMA, are there specific clinical or laboratory parameters that can help guide the decision for starting empirical treatment (e.g., eculizumab) while awaiting the results of complement testing?
I just want to point out that hemolytic microangiopathy (as seen on the peripheral smear by our Hematology colleague) is paramountly important in determining the presence of TMA. Laboratory parameters may be misleading. I have seen even ADAMT13 levels very low in sepsis and DIC process. Therefore lo...