Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When would you consider implantable loop recorders for athletes with nonspecific complaints of palpitations/dizziness, without known history of arrhythmias?
I first do a maximum ECG stress test to see if any arrhythmias could be induced with max exercise. One might also consider a 30-day MCOT monitoring session. The ECG exercise test would also give us some information about the BP response during and after exercise. And, of course, I would start with m...
When is an appropriate time to consider genetic testing for cardiomyopathies for athletes as part of risk stratification for sudden cardiac death, in light of heightened prevalence of cardiac remodeling confounded by exercise and athletic conditioning?
I'm assuming this question is referring to proactive genetic screening rather than evaluation of a patient with clinical signs of heart disease. Clinical screening with EKG, echo and history including family history is a much more effective method of risk stratification. UK Biobank exome sequencing...
When do you consider intrathecal baclofen pump in patients with acquired spasticity?
I am a neurologist in Minneapolis and have directed a spasticity clinic for over 20 years. We typically have at least 100 intrathecal baclofen patients. It is an excellent therapy for selected patients but requires dose adjustments and refills of the Medtronic synchromed pumps. Problems may occur wi...
Do you hold IV iron in the setting of active infection?
While there is no evidence of harm, there is enough conjecture about the danger to make it prudent to wait until infection is controlled. So yes, I do. Further because of the iron restricted erythropoiesis during infection, the efficacy is likely to be blunted.
How do you manage and/or prevent ruxolitinib withdrawal syndrome?
Generally, tapering over a week or two is the best way to prevent it. If immediate discontinuation is needed, can consider using steroids.
What are the perceived implications of broader genomic sequencing as it pertains to interpreting variants of unknown significance and germline predisposition mutations?
Engaging families in a discussion of genomic and or germline testing and the possible positive, negative and VUS results is critical to assisting their understanding of tumor sequencing and paired tumor-germline sequencing. Partnering with genetic counselors to ensure language is used that helps fam...
How do you manage refractory hyponatremia in patients on active therapy in small cell lung cancer?
The classic teaching is that if this is a paraneoplastic SIADH then treat the underlying cancer. If hyponatremia is worsening despite treatment, it might herald progression. I have used tolvaptan in the past as bridge but without effective treatment, this is likely not going to be very effective. Of...
In a patient with Type I von Willebrand disease with history of VTE and heavy menses, would tranexamic acid be a treatment option?
No, with thrombosis one would not inhibit the thrombolytic pathway. Would anticoagulate with Coumadin with low INR 1.5 to 2.
How do you manage hyponatremia in patients with renal cell carcinoma on cabozantinib and nivolumab?
Since ICPI can cause thyroiditis and adrenal insufficiency, the TSH and AM cortisol should be checked -- in addition to the usual evaluation for hyponatremia (serum and urine Osm, urine electrolytes, and an assessment of the patient's volume status). If adrenal insufficiency is present, the hyponatr...
How do you approach work-up for a patient suspected for monoclonal gammopathy of renal significance for whom renal biopsy is contraindicated?
Not very many reasons that a renal biopsy could not be done, but I would consider doing a bone marrow biopsy if the free light chain ratio was significantly abnormal, i.e. a ratio of 3 or greater. A reminder that in renal failure, both light chains may be elevated, but the ratio in benign processes ...