Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your preferred choice of anticoagulant (VKA vs. DOAC) in patients with an LV thrombus and apical infarct?
Traditionally, warfarin is recommended. However, there has been recent evidence to suggest that DOACS are effective as well. In my practice, I have migrated to DOACS for ease of use. Many elderly patients are overwhelmed when they are discharged with 6 or 7 medications and add to that the complexity...
What is your preferred choice of anticoagulant (VKA vs. DOAC) in patients with an LV thrombus and apical infarct?
Traditionally, warfarin is recommended. However, there has been recent evidence to suggest that DOACS are effective as well. In my practice, I have migrated to DOACS for ease of use. Many elderly patients are overwhelmed when they are discharged with 6 or 7 medications and add to that the complexity...
Do you recommend getting a muscle biopsy in a patient with suspected IMNM with statin exposure, weakness, elevated CK, and positive HMGCR antibody?
A patient with a typical clinical presentation of IMNM (muscle weakness, high levels of CPK) and positive anti-HMGCR antibodies leaves no question regarding the diagnosis, and muscle biopsy would not change management. I would reserve muscle biopsy for atypical cases (for example, positive anti-HMGC...
Do you obtain an echocardiogram as a part of risk stratification in all patients hospitalized with an acute pulmonary embolism?
I agree with Dr. @Dr. First Last! The echo offers a “functional view” that we can’t obtain by CTA, as well as the opportunity to diagnose clot-in-transit. However, if a formal echo cannot be quickly obtained, a bedside echo may offer key information. All critical care and ED clinicians should have a...
Would you recommend starting an SGLT2 inhibitor in a proteinuric CKD patient with chronic asymptomatic bacteriuria?
In spite of the biological plausibility that SGLT2 inhibitors are associated with increased risk for UTI, population-based cohort studies, like the one of Dave et al in diabetic patients, did not show a higher risk of severe or minor UTI with SGLT2 inhibitor users and other antidiabetic drugs. The d...
How do you decide whether to include a basal rate when initiating a PCA?
This is a difficult question for which there is no good data to guide one's practice. The best book on this and other opiate questions is Mary Lynn McPherson's "Demystifying Opiate Conversion Calculations". I am relatively conservative on using continuous infusions (also called basal rates). My reas...
What is the interpretation of two IGRAs with negative mitogen wells, in the absence of immunosuppression?
If I understand this case correctly, the patient is actively ill and the patient's doctors are considering tuberculosis as a possible etiology of the patient's illness. In that scenario, IGRAs and PPDs have a limited to no role. Epidemiology, family history, and other possible exposures do. In your ...
In which subset of patients with concussion do you recommend further brain imaging?
I recommend further imaging of a concussion patient in a subset of patients. If the patient had a seizure with the head injury or any sign of declining mentation within the first few hours, they should have a CT head emergently. If it is within 1 week from injury and they report steadily worsening e...
For patients presenting with ACS and severe aortic stenosis with critical left main disease, would you consider BAV prior to PCI to the left main?
This sounds like a CABG AVR case on the surface; if inoperable or at prohibitive surgical risk, CHIP of the LNA lesion, followed by same setting or elective setting TAVR remains an option. CFA access with a large bore sheath (for CHIP/IABP or IMPELLA) will allow for an easy transition exchange for t...
How do you manage a patient with giant cell arteritis treated with weekly tocilizumab and low dose glucocorticoid who develops sudden vision loss?
Fortunately, this scenario is a rare event, as most patients treated with ongoing tocilizumab (TCZ) and prednisone are at a far lower risk for developing new visual loss due to giant cell arteritis (GCA). A recent paper by Amsler et al., PMID 33752737 reviewing the risk for visual loss in patients b...