Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
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 ...
How would you approach treatment in a patient with refractory Coccidioidal meningitis who has previously been treated with IV amphotericin B?
The previous receipt of amphotericin B is irrelevant. Shortly after its introduction in the mid-1950s, it was recognized that it was ineffective in the treatment of coccidioidal meningitis when given intravenously and that intrathecal administration was necessary (Winn, PMID 14065439). The introduct...
What are some alternatives to dexamethasone for brain edema in patients who are allergic, have an intolerance, or refuse the medication?
Dexamethasone is one of the most frequently prescribed medications in neuro-oncology clinics. Dexamethasone is often favored over other corticosteroids owing to its lower mineralocorticoid effects and high potency as well as essentially 1:1 oral to IV ratio meaning that we use similar IV and oral do...
What is your preferred first line management of alcohol use disorder with concomitant depression?
The presence of comorbid depression doesn't significantly change the way I think about pharmacotherapy for AUD. I would still consider disulfiram, naltrexone (PO and IM), and acamprosate as equivalent first-line agents. It's worth noting that distinguishing between major depressive disorder and subs...