Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Should we routinely include geriatric functional assessments to determine candidacy for TAVR?
Studies have shown that 40-50% of older patients with severe AS and high (≥8%) or prohibitive (≥15%) risk for perioperative mortality with surgical aortic valve replacement (based on the STS score) fail to survive with improved quality of life 1 year after undergoing TAVR. This suggests that TAVR ma...
In patients presenting to the hospital with atrial fibrillation of >/= 48 hours and are started on anticoagulation, provided they spontaneously convert with AV nodal blocking agents but then revert back into AF, would you need LAA imaging before a rhythm control strategy with AADs or cardioversion?
I would approach this the same way as if the patient had never spontaneously converted. There is a risk of stroke with chemical as well as electrical cardioversion, so should factor in CHA2DS2-VASc when making that decision. If CHA2DS2-VASc is 0 and no other high-risk features (rheumatic disease, HC...
What is the optimal antithrombotic management, if at all, in patients with incidentally identified findings of multiple silent embolic appearing cerebral infarcts?
It is important to confirm the pattern is embolic. If unsure, input from a specialized physician (such as vascular neurology or neuro-radiology, if available) can aid in confirming the diagnosis. Various white matter findings may mimic an embolic pattern, and distinguishing between unilateral...
What is your approach to treatment of airway involvement, such as recurrent bronchial stenosis, in relapsing polychondritis?
Depending on the location of airway involvement from the subglottic area to the trachea and central airways, options include cryo-spray ablation, balloon dilation, APC/Laser ablation (less favored), Kenalog injection and airway stenting. Typically, combined modalities are more effective than single ...
How do you approach PJP prophylaxis in patients with rheumatic disease on corticosteroids?
Here is a graphic I made covering PJP Prophylaxis with Dr. @Dr. First Last if anyone is interested! As noted, one can check absolute lymphocyte count (ALC) or CD4 count as factors to further risk stratify as well.
When do you pursue additional workup for incidental thrombocytosis in hospitalized patients?
Since most acutely ill patients will have lab evidence of acute illness, including thrombocytosis, I usually do not work it up during the hospital stay. But it should be stated in the discharge summary and followed up post-discharge.
Do you recommend vitamin C supplementation with PO iron in patients with iron deficiency?
Vitamin C supplementation is unnecessary. Taking the iron with a glass of orange juice away from food and especially coffee optimizes absorption. That being said vitamin C does no harm. See vonSiebenthal et al eClinical Works 2023 (Lancet publication), Benson et al, Lancet Haem 2025 or Auerbach et a...
How do you manage patients with embolic stroke of an undetermined source and a papillary fibroelastoma found on an echocardiogram?
The definitive treatment is surgical, and the only way of knowing for certain that the lesion is a fibroelastoma is to perform surgery and obtain pathology. If a patient is not a candidate for heart surgery, anticoagulation could be tried.
When do you send for genetic testing (e.g., SPINK1, PRSS1, CFTR) in a patient with recurrent or chronic pancreatitis without an obvious etiology and how does it impact your management?
I offer and discuss getting genetic testing in patients with idiopathic recurrent acute pancreatitis or chronic pancreatitis, more frequently in younger patients. Impact of testing can help identify undiagnosed CFTR patients, for whom further CF evaluation and management including options to try new...
In a patient with low titer +anti-SAE antibody and known ILD, but no other clinical features of dermatomyositis, how would you approach further testing or would you treat the patient as dermatomyositis associated ILD?
When someone with ILD has an isolated biomarker without other clinical features associated with that biomarker, I have to ask myself these questions: first, is the biomarker simply a false positive because I have tested a plethora of biomarkers and second, is ILD the initial or only manifestation as...