Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Are there other scenarios besides prior history of TIA or stroke or LV dysfunction in which systemic anticoagulation for LV non-compaction would be considered?
There is limited data in this area, but LV non-compaction by itself is not always an indication for anticoagulation. In addition to prior history of TIA, stroke or LV dysfunction, other conditions that anticoagulation should be considered include a history of atrial fibrillation or LV thrombus. The ...
In ischemic stroke patients with low LDL levels (<30-50 mg/dl), would you consider lowering LDL levels to lower values without concern for any side effects?
If LDL levels are already below 70, I don’t target a lower goal. The SPARCL trial showed that reducing LDL to this range has an NNT of about 45 to prevent one stroke, which I find to be modest at best. From my perspective, lowering LDL further (<30-50 range) shifts the focus to treating a number rat...
How would you approach the management of a patient who develops an accelerated junctional rhythm who exhibits no symptoms and has no prior history of cardiac issues, aside from consulting a cardiologist?
There would be many clinical factors to consider before making a decision to treat to suppress such an arrhythmia including the age of the patient, presence of associated structural heart disease, symptoms associated with the arrhythmia, its rate and putative mechanism, and its pattern and persisten...
How would you approach the management of a patient who develops an accelerated junctional rhythm who exhibits no symptoms and has no prior history of cardiac issues, aside from consulting a cardiologist?
There would be many clinical factors to consider before making a decision to treat to suppress such an arrhythmia including the age of the patient, presence of associated structural heart disease, symptoms associated with the arrhythmia, its rate and putative mechanism, and its pattern and persisten...
How do you interpret the presence of GAD antibody in a middle-aged patient with diabetes when all other type 1 diabetes antibodies are absent?
It depends on patient's clinical course of diabetes, controlled on orals vs insulin, BMI, family history DM. For a brittle DM patient, high GAD titer could indicate DM1 or LADA. For stable DM patients, the recommendation is to have 2 positive antibodies to diagnose DM1.
How do you evaluate livedo reticularis (not livideo racemosa)?
Livedo reticularis appears as an interrupted vascular network on the lower limbs. One does not need to warm up the affected area in order to make this diagnosis. The response to heat usually occurs in cutis marmorata that is found in children. Livedo reticularis when it is acquired in teenage and la...
Do you prefer scopolamine patches, glycopyrrolate, or other treatment regimens to manage oropharyngeal secretions at the end of life?
Terminal respiratory secretions, the “death rattle,” may occur during the dying process. Noisy breathing may upset family members, but can also be a normal part of dying. It is important to stop non-essential IV fluids that may contribute to volume overload and pulmonary edema. The head of the bed m...
How do you treat patients with Linear IgA that are deficient in G6PD?
Quite a unique clinical situation! One in which the diagnosis is rather rare, but with an added wrinkle where the most classic textbook therapy, dapsone, cannot be used.A few case reports have shown that omalizumab and dupilumab have been reported to effectively treat LABD: Almuhanna et al., PMID 37...
Would you consider giving thrombolytic therapy for patients with acute vision loss concerning for CRAO based on history and within the window before any ophthalmological assessment and confirmation?
We have utilized a prior study to give tPA or tenecteplase within 4.5 hours of onset for CRAO. I would not do so, however, without an ophthalmology evaluation to confirm the likely diagnosis and to exclude an alternative diagnosis such as a retinal detachment.
Do you treat prosthetic joint infections after a two-stage revision arthroplasty with oral antibiotics for the full duration of therapy, assuming a susceptible oral option is available?
This is a hard one-I definitely think the data is there for PO, but until the IDSA recommendations change and the culture of practice changes it is hard to make the switch to doing a full regimen PO! I also think the accountability of IV antibiotics is useful -with the visiting nurse, weekly labs, i...