Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you treat patients with hemiplegic migraine?
The is no agreed-upon treatment for hemiplegic migraine. I have often used NSAID’s acutely, occasionally triptans, and rarely steroids when nothing is working. The relatively new acute care gepants could be tried, but I have not done that as these patients are hard to find. I would consider adding a...
When do you consider use of ketamine in patients with migraine with aura?
Never. For the treatment of migraine, like for any other condition, we should rely on specific medications, that is, triptans or gepants for abortive treatment and gepants or CGRP antibodies for preventive treatment.
What is the differential for elevated T3 (with suppressed T4 and normal TSH) in a patient not taking any thyroid hormones?
This patient has a low to low normal TSH, with weight loss and fatigue so I would approach this as mild hyperthyroidism, or T3 thyrotoxicosis. Sertraline has been associated with abnormal TFTs, usually an elevated TSH and low T4, not with increased T3 levels. Assess the patient for any other sympto...
How long do you normally wait before considering any bronchoscopic procedure (EBUS-TBNA, Transbronchial biopsy) after an episode of acute PE in a patient needing these procedures?
This depends upon the indication for bronchoscopy and the risk stratification for an acute PE. Generally, anticoagulation can be stopped safely for a short period of time after 10 to 14 days of therapeutic coagulation in low-risk PE but for higher-risk patients or if the bronchoscopy is not urgent a...
Would you add voclosporin to mycophenolate for refractory proteinuria in a patient with low EF?
There are two major potential concerns in a lupus nephritis patient with systolic dysfunction and a left ventricular ejection fraction (LVEF) of only 30%: QTc prolongation potential worsening leading to acute cardiac death Exacerbation of hypertension leading to worse LVEF and CHF However, with prop...
How do you manage patients with suspected cholangiocarcinoma that presents with biliary obstruction but has repeated negative brushings/biopsies?
This is often encountered in patients with PSC. Patients present with jaundice and biliary stricture, rising CA 19-9, and repeat ERCP with brushing/biopsies have shown no evidence of malignancy (often showed abnormal cells). Brushings have high specificity if positive (99%) but very poor sensitivity...
When would you consider CT aortic valve calcium score over TEE to further delineate the severity of LFLG aortic stenosis?
If the concern is for classical low flow low gradient severe AS (LVEF < 50%, AVA < 1 cm2 by echocardiogram with peak velocity < 4 m/s or mean gradient < 40 mmHg coupled with low stroke volume index, < 35 ml/m2), would recommend dobutamine stress echocardiography to distinguish between pseudo severe ...
How would you approach immunomodulatory treatment for systemic lupus associated protein losing enteropathy (PLE) in a patient whose clinical course has been complicated by significant infection?
Lupus protein-losing enteropathy (LPLE) is a rare manifestation of systemic lupus erythematosus (SLE). Therefore, the medical evidence for the "best treatment" of LPLE is only based on anecdotal reports, case series, and retrospective reviews.Although the easy way out would be to say that a SQ or IV...
How would you approach treating a patient with Rheumatoid arthritis/Psoriatic arthritis and alcoholic cirrhosis?
The liver plays a central role in the clearance of nearly all small molecule (e.g. non-biologic) drugs. Thus, cirrhosis perturbs the clearance of these agents. Moreover, there generally is a potential deleterious effect on hepatocyte health, making these drugs unattractive from a safety perspective....
What are your top takeaways from CHEST 2023?
There were so many great presentations: My top 3 were the following. Pulmonary Hypertension: Expert Didactics and DiscussionThe Pulmonary Hypertension: Expert Didactics and Discussion course was a half-day discussion on pulmonary hypertension evaluation and management. This was a master class that ...