Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
In light of recent measles outbreaks in the US, would you recommend an MMR booster for immunocompetent patients born before 1957?
I would not recommend a measles vaccine for a person born before 1957. This year has been chosen because people before born before 1957 have a very very high likelihood of having had measles because virtually all children got this highly contagious disease. On the other hand, there is no harm to get...
How do you approach managing patients with diabetic kidney disease and proteinuria who develop hypoglycemia after initiation of a SGLT2 inhibitor?
I would first determine if there are other medications the patient is on that reduce the blood glucose. Hypoglycemia with SGLT-2 inhibitors is usually due to something else. Another medication is most likely. Could be very poor dietary intake. Could lower the dose if not on the lowest available dose...
Is there any benefit in maintaining statin or aspirin therapy in patients >75 years old with stable, multivessel ischemic heart disease in light of challenges encountered with polypharmacy?
This is a great geriatric cardiology question because it acknowledges that guidelines may not apply in an older patient with multiple medical problems and a complex medication regimen. The question further implies that treatment should be individualized and patient-centered. I agree with the questio...
Do you routinely recommend diagnostic endoscopy for patients with persistent enterococcus bacteremia despite receiving adequate antimicrobial therapy and no clear nidus?
It depends. Did you do an echocardiogram to rule out endocarditis? Urine cultures were negative? Gallbladder ultrasound was negative? CT of the abdomen and pelvis with contrast was negative?Any other symptomatology that accompanied the recurrent episodes of enterococcus bacteremia that could help us...
How often do you check fibrinogen levels and when do you administer FFP for patients with AKI requiring plasma exchange?
There is no single universal protocol for monitoring fibrinogen and giving FFP during TPE; the best approach really depends on the patient's bleeding risk. Because fibrinogen recovers slowly, daily albumin-only TPE can drop levels significantly, which has led to the traditional practice of checking ...
Do you recommend additional spinal MRI’s for an asymptomatic Chiari I malformation?
Age does not matter; the severity of the Chiari does. Although subjective, I would image the spine if I thought the foramen magnum was crowded enough to potentially cause a syrinx. I am not a big believer in "a high incidence" of tethered cord in the Chiari I population, so this concern would play i...
What are some tips for visual estimation of ejection fraction when trying to difference between low-normal (50-55%) and mildly reduced (45-50%)?
Differentiating between a low-normal (50–55%) and a mildly reduced (45–50%) ejection fraction (EF) is inherently difficult with visual estimation alone because the difference is subtle. When evaluating point-of-care ultrasound, it is important to consider the limitations of the device you are using....
For patients on immune checkpoint inhibitors presenting with chest pain, dyspnea, fatigue, and troponin elevation, would you recommend early initiation of high dose steroids for empiric treatment of ICI myocarditis while pursuing workup with coronary angiogram, echocardiogram, and/or cardiac MRI, or wait until alternative etiologies have been ruled out?
This question raises an important point that the clinical presentation of ICI-associated myocarditis often overlaps with other cardiovascular disorders, including acute coronary syndrome, chronic CAD, congestive heart failure, and other nonischemic cardiomyopathies. Therefore, prompt initiation of w...
When would you consider tapering glucocorticoids in a patient with ICI-associated myocarditis?
Once troponins start to decrease, I start the steroid taper and follow troponin levels. If they rise, I slow the taper. I also get serial ECGs, esp if there were arrhythmia manifestations of myocarditis. Don't forget to assess for the need for PJP prophylaxis with Bactrim or pentamidine and PPI sinc...
How do you recommend educating patients with a diagnosis of PCOS with the new name change to PMOS?
This is a great question. For many years, I have been talking to people about how the presence or absence of ovarian cysts didn't really mean anything in their PCOS diagnosis. So, to me, the new name makes a lot more sense. I talk to people about the underlying issue in PMOS which is the underlying ...