Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to the management of persistent hydropneumothorax due to a non expandable lung?
This depends on the clinical scenario and really, relating to patient factors. For instance, if a patient is young without many co-morbidities and the non-expandable lung is related to a 'benign' etiology (i.e. empyema that has resolved and is now a transudative effusion), then surgical consultation...
Based on findings of the INCREASE trial, are you routinely prescribing inhaled treprostinil to patients with group 3 pulmonary hypertension secondary to interstitial lung disease?
As a brief background, the INCREASE trial (Waxman et al., PMID 33440084) was a randomized trial in patients with pulmonary hypertension due to interstitial lung disease (PH-ILD) assessing the effect of inhaled treprostinil versus placebo on change in 6-minute walk distance at 16 weeks. The study enr...
What antidepressants are recommended for management of depression or anxiety in patients with spinal cord injuries?
Some general considerations first: Acute or chronic injury? Associated TBI? Is uncomplicated depression/anxiety the main feature or significant anger and agitation? Is some cognitive rehabilitation needed? Is some motor system rehabilitation needed? On a vent? Difficult to wean? Acute? Think about a...
Do you add gentamicin when treating prosthetic valve endocarditis secondary to viridans group Streptococcus with a penicillin-intermediate isolate (MIC >0.125 - <0.5)?
No, we do not treat patients with such infections with a combination of penicillin and gentamicin. For these infections, we treat with ceftriaxone alone. Monotherapy with ceftriaxone is a more reasonable option than a combination of penicillin and gentamicin because we have every reason to consider ...
What are your preferred strategies to manage mild to moderate rectal ulceration causing tenesmus and discomfort after chemoradiation for rectal adenocarcinoma?
Radiation-induced proctitis or tenesmus -- important to determine if the cause is external or internal to anal verge. Also important to rule out rectal fissures as this typically requires a different approach (Analpram cream and high fiber diet, +/- GI evaluation). If the cause is internal to anal v...
What is your process for considering alternative imaging modalities for cardiac imaging when POCUS is limited by patient conditions, such as emphysema or body habitus?
When POCUS is limited, a multi-faceted process that considers the clinical question, patient characteristics, the strengths and limitations of available imaging techniques, and the available resources should be implemented. The most important question is what you are specifically trying to evaluate....
Do you ever use amantadine or modafinil to aid in the rehabilitation of patients with ischemic strokes?
No randomized controlled trials of amantadine or modafinil for the treatment of disorders of consciousness (DoC) after ischemic strokes have been completed. A retrospective study of ICU patients with DoC after ischemic stroke found that amantadine, modafinil, or a combination may be useful in improv...
What is your approach to a patient with a low alkaline phosphatase?
This is a wonderful and increasingly relevant question as it is not uncommon for someone to have a low alkaline phosphatase and be told it is not important since alkaline phosphatase is only important if it is elevated. Causes for this abnormality include protein deficiency, Wilson’s disease, and hy...
How would you approach antithrombotic therapy in patients with acute ischemic infarcts and a non-occlusive intracranial thrombus?
I agree with the previous answer and can expand on a few key management nuances involving stroke size, symptom severity, and etiology. For stroke size, I typically initiate anticoagulation (heparin drip) if less than one-third of the affected territory is involved, extrapolating from tPA guidelines....
What has been your stepwise approach to oxygenation, including when to consider the use of inhaled nitric oxide or epoprostenol, in refractory hypoxemia due to cardiogenic pulmonary edema in patients who are otherwise not ECMO candidates?
Stepwise Approach to Oxygenation in Refractory Hypoxemia Due to Cardiogenic Pulmonary Edema: Initial Stabilization and Oxygen Therapy: Start with supplemental oxygen to maintain SpOâ‚‚ > 90%. Use noninvasive ventilation (NIV), such as CPAP or BiPAP, to provide positive end-expiratory pressure (PEE...