Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How should you manage a pediatric oncology patient who has an ANC > 500 and a normal chest x-ray but is confirmed to be infected with COVID-19 and is immunosuppressed from chemotherapy?
The treatment for pediatric patients with cancer who develop COVID-19 is very poorly defined. The risk of severe disease is unknown because although adults with cancer appear to have worse outcomes than those without, non-immunocompromised children seem to have few severe outcomes from the disease a...
How do you pragmatically approach a conversation about "liver detox"/"liver cleansers" when patients bring up this topic?
It's important to keep an open mind with the use of these products, as often people will want to take them despite what you might say. Having some experience with the use of these products (or at least their ingredients) will give the patient a comfort level with freely discussing their use with you...
How do you approach a patient maintained on chronic methadone incidentally found to have a prolonged QTc?
If a patient without OUD on chronic methadone who has not previously had QTc issues, suddenly has a prolonged QTc, I look for other reversible causes such as hypokalemia, hypomagnesemia, new medications (such as recent antibiotics, Zofran), etc. From there, it's a nuanced and patient-centered risk/b...
How do you approach a patient maintained on chronic methadone incidentally found to have a prolonged QTc?
If a patient without OUD on chronic methadone who has not previously had QTc issues, suddenly has a prolonged QTc, I look for other reversible causes such as hypokalemia, hypomagnesemia, new medications (such as recent antibiotics, Zofran), etc. From there, it's a nuanced and patient-centered risk/b...
How do you choose among SSRIs and dosing strategies for the management of behavioral and psychological symptoms of dementia?
The best supported SSRI for BPSD generally is citalopram. Much of this came out of the CitAD trials [1]. This primarily showed citalopram may be useful for hyperactive behaviors, irritation, but also for depression and anxiety [1, 2]. The effect and response to citalopram, though, may be affected by...
How would you recommend using POCUS to evaluate jugular venous pressure?
I use it in essentially the exact same way I do with visualizing the JVP; put the patient at a 30-45 degree angle, and measure how far up the neck it goes. If you are able to easily visually estimate JVP, POCUS doesn't add much. However, in someone whose venous pulse is hard to see, POCUS has been h...
How would you recommend using POCUS to evaluate jugular venous pressure?
I use it in essentially the exact same way I do with visualizing the JVP; put the patient at a 30-45 degree angle, and measure how far up the neck it goes. If you are able to easily visually estimate JVP, POCUS doesn't add much. However, in someone whose venous pulse is hard to see, POCUS has been h...
How do you counsel patients who are opposed to the recommendation of facility-based post-acute rehab?
This seems to happen most often with patients who have had bad experiences in the past at SNFs. Typically, I try to get a sense from PT and OT what would be required to make a home discharge safest; refer to home health PT/OT and nursing; enlist the family and do expectations management about what w...
Do you seek pathologic confirmation before proceeding with empiric immunosuppressive therapy in symptomatic patients with radiographic NSIP?
In general, getting lung biopsies is needed in a minority of people who have clear evidence of NSIP on HRCT. If there is any evidence to suggest a concomitant ARD, a biopsy will not typically be needed. In our combined ILD-Rheumatology clinic, we see these patients all the time and I can think of on...
How do you approach the workup of pauci-immune glomerulonephritis?
When a kidney biopsy reveals a pauci-immune GN, the Ddx must extend well beyond classic AAV and infective endocarditis. For instance, anti-GBM disease should remain high on the list, as up to 25% of these patients present with a "dual-positive" ANCA, and the characteristic linear IgG staining on IF ...