Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you balance the risks and benefits of stimulant treatment in patients with poorly controlled hypertension?
The short answer is that there are no clear cutoffs to clearly guide management, and often decisions are guided by shared decision making with patients and relevant specialties (psychiatry, primary care, cardiology).Clinical factors which may prompt you to stop or reduce stimulants: Elevated BP that...
When do you consider starting short-term DAPT in patients who present more than 24 hours after the onset of a high-risk TIA or minor stroke syndrome?
The literature states that DAPT is most effective when started within the first 24 hours after such an event, but is still effective as far as 72 hours later. So if the patient presents more than 24 hours later, but not later than 72 hours, I would still start it then but would want a CT scan first.
Would you accept the diagnosis of SLE on the basis of an AVISE CTD panel where the results just showed a positive EC4d or BC4d, positive ANA>1/80 + one clinical criteria such as multiple tender joints but did otherwise not fulfill criteria for SLE?
The answer is "Yes and No."@Dr. First Last: I am so glad you asked this question. I once observed a speaker give incorrect information on this topic with an answer of "yes."The quick answer, is that the AVISE Lupus Test (which uses EC4d and BC4d) result does NOT give a "yes" or "no" answer for someo...
How do you approach cardiac surveillance in an asymptomatic adult who received anthracycline-based chemotherapy for a childhood cancer and presents to you without an active survivorship program?
At our children's hospital, we are not allowed to follow patients >23 years old if they were not diagnosed and treated at our institution. However, we do offer a 1 time courtesy consultation in the survivor clinic. We request roadmaps and create a treatment summary for the patient, perform a history...
What is your preferred next step when you do not achieve daily diuresis goals with spot doses of IV furosemide in patients with decompensated heart failure?
When faced with a situation where the congested heart failure patient is not responding to initial spot (bolus) IV loop diuretic (typically furosemide), my initial step would be assurance that the appropriate dose is being used. We learned from the DOSE-AHF trial (Felker et al., PMID 21366472) that ...
What is your typical approach to the use of beta blockers in the setting of recent cocaine use amongst patients presenting with cocaine-related MI, arrhythmias, or new-onset heart failure?
I favor using or continuing non-selective beta-blockers in patients presenting with acute cardiac manifestations of recent cocaine use. My preferred agent in this setting is carvedilol.
What factors would lead you to extend the duration of antithyroid drug therapy in a patient with Graves' disease who is clinically euthyroid at 12 months but has risk factors for recurrence?
One should never discontinue methimazole after an arbitrary period of time without checking anti-TSH receptor antibody levels. If they are positive or even “normal” but not undetectable, the patient will inevitably have a recurrence of their hyperthyroidism relatively quickly (Laurberg et al., PMID ...
When would you consider elective hospitalization for parenteral treatment for new daily persistent headache?
New daily persistent headaches can have a tension-type headache phenotype or a migraine phenotype. If presenting with a severe daily headache and a migraine phenotype I will treat it as status migrainosus since there is no consistent way to differentiate migrainous NDPH from a status migrainosus las...
At what stage of the neuropathy workup do you screen for B6 toxicity?
In my experience, vitamin B6 deficiency due to poor oral intake is very uncommon. However, toxicity may occur with supplementation typically more than 2 gm/day, although chronic use of 50 mg/d may also be a cause. Vitamin B6 is present in many supplements and toxicity may cause direct damage to the ...
In what clinical scenarios do you utilize opioids in patients with restless leg syndrome?
I would say in refractory RLS, i.e., the patient has failed all the options below: Iron supplementation if ferritin <50, Gabapentin/pregabalin, Dopamine agonists, and Non-pharmacological options (like the vibrating pad). *I don't love carbidopa/levodopa for RLS. It very often causes augmentation.