Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What further work-up (if any) should be considered in patients with pituitary microadenoma and stigmata of Cushing's disease but low ACTH and repeatedly normal plasma, urinary, and salivary cortisol levels?
I would obtain history of alcohol intake, depression and anxiety, and will assess the pituitary adrenal axis by overnight dexamethasone suppression test.
Is it possible to have undetectable cortisol levels in secondary adrenal insufficiency?
Yes, you can certainly have undetectable cortisol in central AI. Low IGF-1 and low-normal FT4 would suggest hypopituitarism. Do you have a testosterone level? I would perform a GH stimulation test. An abnormal test would confirm pituitary pathology. Before this, however, I would carefully investigat...
Based on results from the VOYAGER PAD trial, when would you consider the primary use of rivaroxaban with aspirin +/- clopidogrel as opposed to conventional aspirin +/- clopidogrel in patients undergoing lower extremity revascularization?
Based on the results of the VOYAGER PAD trial, I would consider using rivaroxaban with ASA before undergoing revascularization.
What workup do you initiate for thoracic outlet syndrome?
This is a long and complicated topic and I would propose to read the Consensus reporting standards for thoracic outlet syndrome published in 2016 by the Society for Vascular Surgery (see below). I will summarize a few key points from the article: Diagnosis of neurogenic TOS is basically CLINICAL, an...
What management do you recommend in patients with backpack palsy?
Backpack palsy is a well-known brachial plexus injury, often affecting the upper/middle trunks, resulting from carrying heavy loads on the shoulders and upper back. I used to believe that it is typically a stretch injury causing transient neurapraxia (demyelination) with minimal axonal loss and an o...
What is the preferred imaging modality to evaluate subaortic membranes in patients with aortic valve disease?
Transesophageal echocardiography is the preferred modality for evaluating subaortic membranes, especially if transthoracic echo is equivocal.
How would you interpret a positive single specific markers like SSA or SSB in setting of working up an connective tissue disease, especially when ANA is negative?
Ha! Good question. And this is an issue I literally just talked about with our residents during an autoimmune labs lecture that I give. If you have a negative ANA by IFA (immunofluorescence assay), the sensitivity of such a test is extremely high (99%) as hundreds of antinuclear antibodies are scree...
How do you manage drug-drug interactions between oral anticoagulants and the ARSI agents such as apalutamide and enzalutamide?
Commonly used oral anticoagulants, such as apixaban, rivaroxaban, and warfarin are substrates of hepatic cytochrome P450 enzymes (CYP). Co-administration of an AR signaling inhibitor (ARSI) variably affects the concentration of those drugs depending on the effect on the type of CYP enzymes. For exam...
How often would you repeat testing in a patient suspected of Cyclic Cushing's?
24-hour urine-free cortisol and MN saliva cortisol are preferred tests over ON dex suppression. The exact frequency depends on the severity of the symptoms, generally about every 3 months.
In patients with secondary osteoporosis due to primary hyperparathyroidism, should parathyroidectomy be recommended in the setting of recent prior bisphosphonate use?
I would recommend parathyroid surgery in a person with confirmed primary hyperparathyroidism and osteoporosis as the bone density will increase in most patients after surgery. Many of the patients with osteoporosis may have received bisphosphonates. In rare situations, a patient may have received a ...