Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What are your considerations for peri-operative anticoagulation in patients with a mechanical heart valve undergoing a major noncardiac surgery?
For a patient with a modern (e.g St Jude bi-leaflet) mechanical valve (with or without AF) and who does NOT have a h/o of stroke or TIA, the available evidence suggests that "bridging" may have more risk than benefit: See Kovacs et al., PMID 34108229 and Siegal et al., PMID 22912386. Based on this e...
What is your approach to evaluation of underlying autoimmune disease in patients with bilateral scleromalacia?
Scleromalacia perforans is an uncommon form of scleritis wherein there is scleral melt in an otherwise white/quiet appearing eye. The most common systemic association for scleromalacia perforans is with long standing rheumatoid arthritis. Other etiologies of scleritis should also be considered: syst...
Does testing for elevated serum homocysteine have any relevance in thrombophilia management?
Homocystine levels is part of a DVT workup. Although rare, it is a factor in DVT risk. The gene mutation in MTHFR contributes to the elevation and the mutation frequency is extremely high. However, elevation is almost never seen due to added and natural folate in the diet.
How should one manage a patient with leukocytosis and borderline detectable BCR-ABL without other clinical features of CML such as basophilia or splenomegaly?
Leukocytosis has many causes and I will assume within the context of this question that we can narrow the definition to neutrophilic leukocytosis, and that it has been persistent without evidence of an underlying infection, cancer, inflammatory disorder, significant obesity, exposure to a drug or to...
Is a biopsy of either skin or muscle always indicated in the diagnosis of dermatomyositis?
A biopsy of either skin or muscle is not always necessary and the need for each depends on each patient's presentation. A typical history and physical exam, along with MRI or EMG findings, or more importantly, a positive myositis specific antibody can be adequate to make the diagnosis of dermatomyos...
Have you seen patients who develop neuromuscular disorders following COVID-19 vaccination?
I have personally seen and managed post vaccine Bell's palsy and one patient with Brachial neuritis, both with improvement after few months.Mahajan et al., PMID 33890680
In what circumstances do you pursue labial salivary gland biopsy in an asymptomatic patient with high titer ANA and positive SSA?
I seldom, if ever, suggest a lip biopsy in the work-up of patients with Sjogren's syndrome. It is invasive, and even the histo-pathological interpretation is often open to question. I typically refer patients to an ophthalmologist for a diagnosis of keratoconjunctivitis sicca, if present, and if nec...
Which medications have the lowest risk of tuberculosis reactivation in patients with uncertain tuberculosis history and active rheumatologic disease?
Conventional synthetic DMARDs used in RA are at lower risk for reactivation of latent TB. Steroids do confer some risk of reactivation. The highest risk is the class of biologic DMARDs used to treat RA and many rheumatic diseases with the exception of rituximab.
What is your practice for work up and treatment of incidental splenic infarcts with or without splenomegaly in patients without sickle cell disease?
I obtain CBC/diff, CMP, and LDH in all patients. I assume a CT of the abdomen has already been done because that is what usually leads to the diagnosis of incidental infarcts. Of course, it is important to rule out intra-abdominal pathology which should be visible by CT. I obtain a thrombophilia scr...
For treatment of ITP, what would you add to dexamethasone to achieve the fastest recovery in a patient waiting for a procedure?
I usually use IVIG, particularly if the patient has responded in the past.