Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
For patients with microscopic hematuria, do you prefer a lab submitted urinalysis sample undergoes automated urine analysis or microscopic analysis by laboratory staff for quantification of red blood cells?
If quantification is really the question here, and not RBC casts or acanthocytes, I don't know if it really matters, I use both the dipstick blood and the microscopic data for that. A bigger problem is discordance, dipstick blood and minimal cells, which on an exam is pigmenturia but in real life is...
Can you use apixaban or rivaroxaban in case of dabigatran failure?
It depends on the indication of anticoagulation, co-morbidities, etc. In the absence of any direct data, in general, failure in the setting of venous thrombosis or atrial fibrillation it would seem reasonable to consider transition to an agent with a different mechanism of action.
Do you personally review all imaging you order or rely judiciously on radiologist interpretation?
In my practice, I do like to review the images and the reports for all the studies I order. While I trust my radiology colleagues, I find reviewing the images myself helps both my patients and my own understanding of the disease process. For operative patients, I like to look when the study is initi...
In what situations/patient population would you consider placing an implantable cardiac monitor in favor of external monitors for long-term dynamic monitoring of atrial fibrillation?
This is an excellent question and I think we need the remainder of the publication to make our best estimates (specifically Table 1 and the n for results, including % ablated - couldn't find online or any pictures of slide data on Twitter). The online MONITOR-AF late-breaking trial abstract is avail...
What is your approach to the management of patients with isolated cervical adenopathy related to sarcoidosis?
Establishing a diagnosis of sarcoidosis solely on the basis of isolated cervical adenopathy can present a challenge. Although thoracic adenopathy—alone or in combination with other extra-nodal clinical features—is part of the classic illness script for sarcoidosis, peripheral adenopathy as the exclu...
What is your approach to continuing or altering therapy when inheriting a patient with combined biologic immunosuppression that is in excess of guidelines?
This is by far the hardest task assigned for a practicing rheumatologist. Inheriting a patient on a regimen you did not develop and are uncomfortable continuing poses a daunting challenge: you are challenging the patient’s relationship with the previous rheumatologist, the control of the patient’s d...
How do you approach a persistently elevated mean platelet volume and immature platelet fraction in an otherwise healthy patient with a normal platelet count?
I am trying to understand the circumstances where this question might arise. Nowadays, when patients can readily see CBC results before their clinicians, they might notice the H or L designations and ask. In general, I would not think twice about "slightly out of range" CBC parameters in a single me...
For patients undergoing TNT for rectal cancer with planned operative management, what is the optimal sequencing and timing of workup imaging and procedures?
I think the question that is posed does not really make sense as written. One should not be making decisions about management (i.e. TNT) before the staging evaluation is complete. If a patient presents with a newly diagnosed rectal cancer, the first thing to do is to stage to find out whether the pr...
What is your preferred method for diagnosing adenine phosphoribosyltransferase (APRT) deficiency in a patient with recurrent kidney stones and abnormal crystalluria?
Genetic testing using a panel that includes APRT is the most reliable and straightforward thing to do. There is not a laboratory in the United States currently that can measure urinary or blood dihydroxy adenine. You can send a blood spot to the University of California San Diego lab for enzymatic a...
What is your approach to pacemaker lead thromboses in terms of threshold for lead extraction and initiation of systemic anticoagulation?
This is a question that often comes up. In general, most thrombi found on chronic pacing leads incidentally noted on an echo in our experience are not problematic. However, the bigger question is whether the mass noted is indeed a thrombus versus some vegetation related to an infection. In one publi...