Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach incidental image findings with unclear clinical significance?
I approach them as findings, regardless of how they were acquired they need to be managed. In primary care one of the biggest drivers of malpractice cases is failure to act on a finding, just because it wasn't something you were directly looking for does not protect you. So manage the finding. Work ...
What would be your next diagnostic test of choice for a patient with findings concerning for silent ischemia on noninvasive functional testing in the absence of chest pain?
There are a lot of unanswered questions just from the information given. Why was the test done in the first place if truly asymptomatic? If not having chest discomfort, were they having an anginal equivalent - such as a new complaint of shortness of breath with exertion not previously present? What ...
How do you approach DMARD therapy in a patient with lupus and recurrent pericarditis?
Both asymptomatic pericardial effusions and symptomatic pericarditis are common in systemic lupus erythematosus (SLE) patients. I will limit my answer to symptomatic pericarditis per the question.The first thing to be sure of is that the symptoms are truly due to pericarditis. The full differential ...
How do you approach a patient at intermediate ASCVD risk who has been referred to you because of an abnormal coronary CTA (obstructive lesion ~90%) but an excellent exercise capacity on treadmill without angina and a negative MPI?
Unless the reported lesion involves proximal LAD or LM (MPI can look normal if balanced ischemia), I would then treat medically (ISCHEMIA trial, ACC/AHA stable CAD guidelines).
When do you consider using a paramedian approach for a lumbar puncture?
I consider the paramedian approach for lumbar puncture in several clinical scenarios: When patients are unable to adequately flex their spine. When midline interspaces are narrow (<1 cm). When ultrasound reveals densely calcified spinal ligaments—a common finding in elderly patients that can obscure...
Do you find 14.3.3 eta or vectra DA helpful in clinical practice?
These blood tests were developed to help diagnose and monitor rheumatoid arthritis.14-3-3 eta is an interesting protein that may have pro-inflammatory properties and could be helpful in diagnosing RA (Maksymowych et al., PMID 25128504), confirmed in a recent meta-analysis to have reasonable diagnost...
Besides treadmill, what other exercises may be considered for post-exercise ABIs, and are their diagnostic parameters identical to standard post-exercise ABIs?
2 minutes of Toe-raises has been demonstrated to be an acceptable alternative to exercise ABI's.
What serologic biomarkers do you send to assess for sarcoidosis at baseline and/or during flares, in patients where it may correlate with disease activity?
Elevated ACE, dihydroxy vitamin D, and soluble IL2r levels have been shown to correlate with disease activity, but it is important to keep in mind that the sensitivity and specificity are variable and they should never be used in isolation to diagnosis or assess disease activity in sarcoidosis. The ...
What is your approach to distinguishing a Jarisch-Herxheimer reaction from a delayed anaphylactoid reaction?
As with most things in medicine, this is context-dependent. The Jarisch-Herxheimer reaction is a systemic inflammatory response to the death of bacteria (most commonly associated with spirochetes and in particular, syphilis), typically in the hours following antibiotic administration. This response ...
What is your approach to distinguishing a Jarisch-Herxheimer reaction from a delayed anaphylactoid reaction?
As with most things in medicine, this is context-dependent. The Jarisch-Herxheimer reaction is a systemic inflammatory response to the death of bacteria (most commonly associated with spirochetes and in particular, syphilis), typically in the hours following antibiotic administration. This response ...