Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to scheduling and then weaning nebulizers in patients admitted with acutely exacerbated asthma or COPD?
In hospitalized patients with acute asthma or COPD exacerbations, my approach to nebulizers is front-loaded and reassessment-driven. I start by gauging the severity and the patient’s ability to use an inhaler. pMDI with a spacer is preferred for most patients, but nebulizers are reasonable early on ...
When screening for malignancy, do you order CT with contrast (or) both with and without contrast?
I think the best way to think about this is to assess what each scan shows. A CT with oral and IV contrast is very good for assessing details between soft tissues and blood vessels. A CT without contrast is better for assessing for renal stones and for fractures, especially small insufficiency fract...
Would you recommend a GLP-1 agonist as an option to reduce the risk of dementia in patients with a strong family history?
I'm recommending GLP-1 for many things right now, but I haven't yet independently recommended it just to reduce the risk of dementia. However, if microvascular disease can contribute to vascular dementia, then there may be a benefit to better controlling diabetes with this drug.
How do you approach the management of post-concussion syndrome with symptoms including vertigo, headaches, persistent fatigue, and/or mood symptoms?
Each persistent post-concussion symptom that you listed has interventions that can be helpful. For vertigo, I recommend referral to vestibular therapy. I also use our behavioral health providers very regularly in the PPCS population. Because a concussion is a neuro-psychiatric condition, therapy is ...
How do you integrate HIV (+) serostatus into a patient's ASCVD if they would not otherwise qualify for a statin either for primary or secondary prophylaxis?
HIV (+) serostatus is a significant risk-enhancer for the development of cardiovascular disease and should be taken into account when making treatment decisions regarding statin initiation, even if the patient's viral load is low or not detectable. In a patient >40 years old and with a risk >5%, wou...
Considering only cerebrovascular indications, are there circumstances in which you would use aspirin along with a DOAC in patients with atrial fibrillation and stroke?
I will use aspirin 81 mg and a DOAC together in patients who "fail" (I hate that term) the DOAC. The combination was used in patients in the original DOAC trials, so it is not unreasonable. Not my first choice, but can be done. It is worth noting that the evidence does not support doing this upfront...
How do you workup patients with neuropathy suspected to be secondary to sarcoid?
To answer this question, the attached paper with consensus criteria for the diagnosis of neurosarcoidosis, published in 2018, should be reviewed, Stern et al., PMID 30167654.Based on this paper, a diagnosis of probable or definite neurosarcoidosis requires unequivocal evidence of non-caseating granu...
Is there an upper threshold of pCO₂ that can cause symptomatic hypercapnia (e.g. AMS) despite metabolic compensation and normal pH?
Hi - I'm not sure about an upper threshold of pCO2 and AMS. However, even with normal pH, elevated pCO2 can cause significant increases in cerebral blood flow. Pollock et al., PMID 19406361 studied MR perfusion imaging and found that patients with a mean pCO2 of ~ 54mmHg had more than double the cer...
What treatment combination approach would you recommend for mucous membrane pemphigoid?
First, it is important to know the extent and severity of the disease (oral, ocular, esophageal); the type of inflammatory infiltrate on histopathology (neutrophils, eosinophils, or cell-poor); and the results of salt split skin and antibody titers on monkey esophagus and/or target antigens (collage...
Are you more permissive of perioperative interruption of anticoagulation for VTE depending on the location and relative chronicity of the thrombus?
Yes - in general, I try to balance the relative urgency/importance of the procedure or surgery v. the thrombotic risk to the patient of a period of time off of anticoagulation. Location and chronicity both can feed into determining thrombotic risk. An upper extremity DVT, in general, has a lower rec...