Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When would you consider long-term cardiac monitoring to look for atrial fibrillation in patients with mitral stenosis given their baseline elevated risk for atrial fibrillation and thrombosis?
This is a thought-provoking question. Not only is Afib a risk factor for strokes but these strokes can be particularly devastating. While screening for subclinical Afib in large populations is described, there is little data to show that this leads to clinical benefits (1, 2). The benefit of detecti...
What is your approach to the diagnosis of acute kidney injury suspected secondary to renal infarction from thromboembolic disease?
Renal infarction should be suspected in a patient with acute flank/abdominal pain, hematuria, and elevated LDH with normal AST and ALT, especially in the setting of atrial fibrillation, left ventricular thrombus, dilated cardiomyopathy, prosthetic heart valve, renal artery injury/dissection or hyper...
How do you typically manage a patient with a single positive blood culture from two sets growing Candida species in a stable patient without prosthetic devices or material?
Candidemia is defined as the presence of Candida species in the blood, and even a single positive blood culture specimen is considered significant and warrants treatment as candidemia. Initial management should include: Initiating antifungal therapy with an echinochandin (micafungin, capsofungin, o...
How would you approach management of a patient with seropositive RA and UIP-ILD, with concern for active lung disease?
There is a potential benefit of adding additional immunosuppression for an RA patient with a UIP pattern on HRCT. My go-to-drugs are either abatacept or rituximab. While MMF is a standard first-line medication for many forms of ARD-ILD, it was tried for RA joint disease many years ago and the study ...
How long would you wait before performing a kidney biopsy in a patient with possible AIN whose creatinine has plateaued, but not improved, after discontinuing the suspected offending agent?
If the kidney function has not resolved one week after withdrawal of the suspected offending agent, I would request a biopsy.
For elderly patients (i.e. older than 80) with only one documented episode of paroxysmal atrial fibrillation following a stress event (such as acute illness/steroid administration) and a CHADsVASc score greater than 1, how would you counsel them on the risks/benefits of anticoagulation and subsequent monitoring for afib recurrence?
If it were an isolated event, I would advocate continued monitoring for recurrence before starting an anticoagulant with the understanding that the risk of AF recurrence is relatively high.
Would you initiate antifibrotic therapy in a patient with CTD-ILD experiencing worsening symptoms and declining lung function, despite no clear evidence of fibrosis on CT scans?
If the predominant findings on CT were ground glass opacities and/or nodules without any evidence of fibrosis on CT, I would not start with an antifibrotic and, instead, would start with immunosuppression as a first-line agent. Based on the American College of Rheumatology (ACR) and American Thoraci...
How do you approach the management of older adult patients with dementia who repeatedly aspirate with oral intake but whose family/HCP may be unwilling to accept the aspiration risk associated with comfort eating?
This is a challenging situation where clinicians play a crucial role in providing education to families and caregivers. However, before we provide education, it’s important to assess the knowledge of families and caregivers around dysphagia and aspiration in persons with dementia (e.g., “What have o...
What is your risk/benefit analysis when deciding on the appropriateness and timing for discontinuation of systemic anticoagulation in patients who underwent ablation for paroxysmal atrial fibrillation with CHADS2VASc score >2?
I typically do not discontinue oral anticoagulation in post-ablation patients with paroxysmal atrial fibrillation and a CHA₂DS₂-VASc score of >2. Catheter ablation is not considered a "cure" for atrial fibrillation; therefore, there is always a risk of recurrent arrhythmia. The patient may be asympt...
In which subset of patients with concussion do you recommend further brain imaging?
I recommend further imaging of a concussion patient in a subset of patients. If the patient had a seizure with the head injury or any sign of declining mentation within the first few hours, they should have a CT head emergently. If it is within 1 week from injury and they report steadily worsening e...