Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What therapeutic approaches have you found effective for athletes with anorexia nervosa whose eating disorder symptoms are intertwined with sport-driven weight pressures?
The gold standard for treatment of anorexia nervosa and all eating disorders is a team-based approach, including the individual, psychiatrist, counselor, primary care or sports medicine physician, dietician, appropriate family members, and, in the case of elite athletes, sometimes their coaches. Rap...
How do you approach the management of post-concussion syndrome with symptoms including vertigo, headaches, persistent fatigue, and/or mood symptoms?
Each persistent post-concussion symptom that you listed has interventions that can be helpful. For vertigo, I recommend referral to vestibular therapy. I also use our behavioral health providers very regularly in the PPCS population. Because a concussion is a neuro-psychiatric condition, therapy is ...
How do you integrate HIV (+) serostatus into a patient's ASCVD if they would not otherwise qualify for a statin either for primary or secondary prophylaxis?
HIV (+) serostatus is a significant risk-enhancer for the development of cardiovascular disease and should be taken into account when making treatment decisions regarding statin initiation, even if the patient's viral load is low or not detectable. In a patient >40 years old and with a risk >5%, wou...
Is there a role for routine stress testing in intermediate-high risk CAD patients with a significantly elevated coronary calcium score who are otherwise asymptomatic?
Current data does not support stress testing in asymptomatic intermediate risk individuals in general and those with incidental CAC also do not have an indication for the test. ASCVD risk factor modification suffices.
How do you approach a patient with high titer ANA and a new diagnosis of ITP, but no other signs or symptoms suggestive of active rheumatologic disease?
I would certainly treat the ITP with hematology involvement if necessary but would continue to monitor for lupus or similar CTDs. I have seen patients present with an ITP-like picture for years before lupus declared itself eventually. It may take years. I would also check a UA for proteinuria. This ...
Considering only cerebrovascular indications, are there circumstances in which you would use aspirin along with a DOAC in patients with atrial fibrillation and stroke?
I will use aspirin 81 mg and a DOAC together in patients who "fail" (I hate that term) the DOAC. The combination was used in patients in the original DOAC trials, so it is not unreasonable. Not my first choice, but can be done. It is worth noting that the evidence does not support doing this upfront...
What is your approach to treatment of macrolide-sensitive localized bone/joint MAC disease?
Agree with the above answers. Obviously, no strong clinical studies on duration and outcomes. At NJH, we typically recommend: Aggressive debridement/resection, Treat with appropriate antimicrobial therapy (in macrolide-S MAC, then AZM/EMB/Rifamycin +/- IV AMK) for a minimum of 6 months total, but a...
How do you workup patients with neuropathy suspected to be secondary to sarcoid?
To answer this question, the attached paper with consensus criteria for the diagnosis of neurosarcoidosis, published in 2018, should be reviewed, Stern et al., PMID 30167654.Based on this paper, a diagnosis of probable or definite neurosarcoidosis requires unequivocal evidence of non-caseating granu...
Is there an upper threshold of pCO₂ that can cause symptomatic hypercapnia (e.g. AMS) despite metabolic compensation and normal pH?
Hi - I'm not sure about an upper threshold of pCO2 and AMS. However, even with normal pH, elevated pCO2 can cause significant increases in cerebral blood flow. Pollock et al., PMID 19406361 studied MR perfusion imaging and found that patients with a mean pCO2 of ~ 54mmHg had more than double the cer...
What treatment combination approach would you recommend for mucous membrane pemphigoid?
First, it is important to know the extent and severity of the disease (oral, ocular, esophageal); the type of inflammatory infiltrate on histopathology (neutrophils, eosinophils, or cell-poor); and the results of salt split skin and antibody titers on monkey esophagus and/or target antigens (collage...