Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
How do you decide when data patients bring to you for review/interpretation from a direct-to-consumer CGM is clinically useful and has it changed any of your management decisions in metabolically at-risk patients?
This is a tough question, as there is obviously published data for FDA-approved CGM devices, as published below: CGM Device Comparison | American Association of Clinical Endocrinology However, for those provided by independent companies, it would depend on whether or not they have independent third-...
What is your preferred anticoagulation/antiplatelet regimen for younger patients presenting with ACS, found to have an acute thrombotic event requiring aspiration thrombectomy without need for stent deployment?
Spontaneous in situ thrombosis of a coronary is rare, especially in the absence of a plaque rupture event. Malignancy-related coronary thrombotic occlusion, even with DOAC semi-compliance, is pathophysiologically difficult to understand, because coronary arteries are relatively high-flow areas, fili...
For septic patients with borderline heart failure, how do you individualize the decision about additional fluid boluses after the initial resuscitation?
For septic patients with borderline heart failure, the decision about additional fluid boluses after the initial resuscitation requires careful observation and monitoring. My approach has been to administer 500 cc-1 liter of fluid, and then assess volume status (physical exam, JVP, or POCUS, which i...
Have you used Karius to work up fevers in the hospital when the source remains unknown?
This is a tricky question because Karius is an expensive test, which many experts believe should not be used for its negative predictive value (and I have anecdotally seen negative results where infection was still present, and infections/organisms detected of very unclear significance). I like to u...
Have you used POCUS with color power Doppler to assess blood pressure in a patient whose cuff readings are in doubt?
Thank you for bringing up this question, as it focuses on a POCUS topic I often think about. I will split my assessment into two categories: clinical utility and physiologic limitations, with a brief EBM note at the end. Clinical Utility While the referenced study suggests this technique is feasible...
Have you used POCUS with color power Doppler to assess blood pressure in a patient whose cuff readings are in doubt?
Thank you for bringing up this question, as it focuses on a POCUS topic I often think about. I will split my assessment into two categories: clinical utility and physiologic limitations, with a brief EBM note at the end. Clinical Utility While the referenced study suggests this technique is feasible...
What are your preferred second-line medications for trigeminal neuralgia?
My FIRST-LINE medication for trigeminal neuralgia is botulinum toxin. I write about its application in face pain, including trigeminal neuralgia, in Chapter 16 of my book, HEADACHES: Why You Have Them - What You Can Do About Them.
How do you work up patients who present with elevated myoglobin in the setting of normal creatinine kinase and exercise intolerance?
Myoglobin may originate either from cardiac or skeletal muscle; therefore, I would first try pinpointing the origin with troponins and CK fractions. I would work up the exercise intolerance with a non-ischemic forearm test to determine whether a flat lactate curve is present. In that case, I’d typic...