Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What factors would lead you to extend the duration of antithyroid drug therapy in a patient with Graves' disease who is clinically euthyroid at 12 months but has risk factors for recurrence?
One should never discontinue methimazole after an arbitrary period of time without checking anti-TSH receptor antibody levels. If they are positive or even “normal” but not undetectable, the patient will inevitably have a recurrence of their hyperthyroidism relatively quickly (Laurberg et al., PMID ...
What is your preferred mechanism for venting the left ventricle in patients on VA-ECMO?
Based on recent studies and evidence in the literature, my preferred approach for venting the left ventricle in patients on VA-ECMO would be guided by the individual patient's clinical scenario, with a cautious inclination towards using the intra-aortic balloon pump (IABP) over Impella. This prefere...
Would you recommend giving N-acetylcysteine in addition to holding diuretics in a patient with chronic kidney disease and mild hypervolemia who is planned to have a contrast study?
There are several meta-analyses showing conflicting evidence on the use of N-acetylcysteine to prevent contrast-associated AKI. However, the largest randomized trial (PRESERVE) did not show any benefit from using oral N-acetylcysteine in 4993 high-risk patients undergoing scheduled angiography (Weis...
What further evaluation do you pursue for patients who present with vague symptoms such as subjective fevers or intermittent night sweats, who have no pulmonary symptoms but have a positive IGRA?
Great question. Another scenario that is not uncommon is some degree of cough, sometimes for long periods of time, but no other symptoms. If their risk is higher for progression to active disease (e.g., immunocompromised; recent contact with an active case) I may do more than if the risk is low. My ...
How do you prescribe a steroid taper for radiation and checkpoint inhibitor related pneumonitis?
I subscribe to the philosophy of "hitting hard, tapering slowly" for cases of pneumonitis, either radiation pneumonitis, or checkpoint inhibitor-related pneumonitis (some of those cases probably have mixed origin, with contributions from radiation and/or checkpoint inhibitors). For severely symptoma...
Do you treat non-albicans strains of Candida on sputum culture or BAL in patients who are immunosuppressed?
I agree with these answers and do not treat either without biopsy.
Outside of their use in performance anxiety, have you tried or found benefit with a daily beta blocker for generalized anxiety?
In concert with a psychiatrist, I've used beta blockers for patients with a history of trauma and/or somatoform disorder to reduce sympathetic stimulation and bodily sensations that worsen anxiety. In one particularly challenging case, the near-immediate relief after taking propranolol was helpful i...
Do you ever favor cefazolin over ceftriaxone for bacteremia with susceptible E. coli?
No
How do you interpret small joint effusions seen on ultrasound without power doppler signal in the setting of compatible inflammatory symptoms (i.e morning stiffness)?
It certainly increases probability of Inflammatory arthritis, if aligns with clinical symptoms. I would check inflammatory markers, autoimmune serologies, infectious work up and all to determine type of arthritis and consider prednisone trial and likely consider immune suppressive regimen based on r...
For patients with SLE, is there an ANC level for which you would hold or adjust hydroxychloroquine in an asymptomatic patient?
Leukopenia most often as lymphocytopenia, of course, is not unusual in lupus. Total WBC less than 4000 is an ACR classification criteria for the disease as is ALC less than 1500 on two occasions. SLICC disease classification requires ALC less than 1000. Total WBC < 3000 generates SLEDAI points. On t...