Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Should bare metal stents be favored over drug eluting stents for pregnant patients presenting with acute coronary syndrome?
This is a great question. There is limited data that supports the safe use of DES in pregnant patients requiring revascularization (Regitz-Zagrosek et al., PMID 30165544). New-generation DES has a lower risk of stent thrombosis with shorter or even very short duration (28 days) of dual antiplatelet ...
When do you discontinue contact precautions in patients known to be colonized with ESBL-producing Enterobacterales?
There is no widely accepted guideline regarding the timing of discontinuation of isolation for ESBL-producing organisms. However, according to the article “Duration of Contact Precautions for Acute-Care Settings” published by ICHE in 2018, Maintaining contact precautions for ESBL-E and CRE for the d...
Are there factors that would prompt you to consider the use of methylene blue in refractory septic shock?
I usually don't consider using it unless all other options are exhausted. Although there is date that shows decrease in pressor needs, there is no data that shows any clinical improvements, and specifically no improvement in mortality. It is not part of my algorithm for refractory shock.
Do you use dual anti-platelet therapy inpatients with low NIHSS who have had bilateral brainstem strokes?
I usually look at the stroke mechanism in making my decisions about DAPT rather than just relying on the NIHSS alone. If the mechanism is ICAD, branch atherosclerotic disease, SVD (with infarct extension), embolism from the aortic arch plaque, subclavian artery heterogenous plaque, extra-cranial ver...
What leads you to suspect that a foot drop is secondary to a myopathy rather than a neuropathic process?
Factors suggesting that a foot drop is due to a myopathy include: Clinical factors (slow progression (myopathy but also seen in CMT) versus acute or sub-acute onset (usually neurogenic), absence of sensory findings, absence of pes cavus, signs of facial or shoulder girdle weakness (FSHD can cause f...
What is your approach to managing ILD associated with inflammatory bowel disease?
We must first convince ourselves that the "ILD" relates to the underlying IBD. Patients may be on an immunomodulating regimen that increases the risk of opportunistic infections. The regimen itself may cause diffuse pneumonitis. Environmental/occupational exposures may also play a role. Armed with c...
In massive transfusion protocol from suspected hemorrhage, is it worth obtaining a TEG to guide transfusion?
There really is no evidence (except expert opinion) on massive transfusion protocols and outcomes. There are a few trials showing that TEG or other viscoelastic tests reduce transfusion and even improve survival or other important outcomes in hemorrhage. So given the choice, if rapid point of care T...
Given recent trials for the management of atrial fibrillation with an early ablation strategy (for example, EAST-AFNET 4, EARLY-AF, PROGRESSIVE-AF, STOP-AF), what is your approach to determining the appropriate timing for ablation in patients with atrial fibrillation?
I agree with Dr. @Dr. First Last. I also usually start with an antiarrhythmic drug and then offer ablation if the drug is not tolerated or is ineffectual. This is a shared decision-making process - some patients want nothing to do with drugs and prefer ablation and others want to try multiple drugs ...
How do you manage hemodialysis for an ESKD patient presenting with severe hyponatremia and a serum sodium more than 10 mEq/L below the lowest available dialysate sodium concentration?
There are multiple ways of dealing with this situation. One option is not to dialyze if not urgent and let the sodium come up before starting dialysis. The most exact way of dealing with the situation is to do hemofiltration either continuously or intermittently with a concomitant D5W infusion adjus...
What is your approach to managing concurrent severe SIADH and large-volume malignant ascites when aggressive volume removal appears to exacerbate both symptoms and hyponatremia?
A challenging situation. I would approach it in a few steps: Ensure adequate solute intake since solute load determines free water clearance in SIADH. Loss of solute from repeated large-volume paracenteses can add a component of hypovolemic hyponatremia, and people with cancer and large ascites tend...