Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you routinely check an Allen's test before placing a radial arterial line?
If for whatever reason, both radials cannot safely be cannulated, the next best site would be femoral. If either femoral sites are not accessible, brachial and axillary would be the less than ideal. You are correct, the data regarding Allen’s test utilization is not robust.
Is there a difference in treatment of status epilepticus from alcohol withdrawal vs other causes?
Alcohol status is best managed by using short half-life like Ativan (lorazepam) and valium (diazepam) with long half-life benzos like Librium (chlordiazepoxide) unlike other status which responds to Phosphynition/levetiracetam and lorazepam.
In a patient with low titer +anti-SAE antibody and known ILD, but no other clinical features of dermatomyositis, how would you approach further testing or would you treat the patient as dermatomyositis associated ILD?
When someone with ILD has an isolated biomarker without other clinical features associated with that biomarker, I have to ask myself these questions: first, is the biomarker simply a false positive because I have tested a plethora of biomarkers and second, is ILD the initial or only manifestation as...
Would you recommend imaging of the brain and lungs to investigate potential disseminated disease in a recent heart transplant patient with a skin nodule that grew Rhizopus?
Yes. For any immune-compromised individual with Mucor on the skin or another organ, I look at the brain and the lungs.
Do you routinely start anticoagulation for a patient with newly diagnosed hepatocellular carcinoma presenting with a portal venous thrombosis?
No. Anti-coagulation is generally not indicated. Anti-coagulation is usually only indicated for acute PVT causing symptoms. This is more common with underlying thrombophilia. PVT is very common in cirrhosis and anti-coagulation is not required. PV thrombus from tumor similarly is common and anti-coa...
For how long would you treat a patient with dematiaceous fungi growing on a native heart valve discovered at the time of valve replacement?
The first step is to determine whether the positive culture may be a contaminant, as it very well could be. Every valve sent for culture should have also been sent for histopathological examination. In a patient with fungal endocarditis, one should expect to find evidence of acute inflammation and t...
How do you approach conversations regarding discontinuation of transfusions in patients with advanced hematologic malignancies who are otherwise appropriate for hospice?
While not an expert in leukemia care or MDS, the answer is nuanced (both in the care of patients and to hospice agencies). Some hospice programs will make exceptions to blood transfusions depending on how frequent - so it is always good to ask. From a clinical perspective, important to consider whet...
How long do you wait before arranging AVF placement in patients with AKI who remain dialysis dependent?
About 35-45% of dialysis-requiring AKI patients discharged from the hospital on dialysis will recover sufficient renal function to stop dialysis. The majority of patients who recover kidney function do so within the first 60 days after discharge. Elderly patients and those with poor pre-AKI kidney f...
How would you plan a post-op, distal rectal adenocarcinoma s/p neo-adjuvant chemotherapy and APR with minimal treatment response?
The PROSPECT trial evaluated the omission of radiotherapy from preoperative management for cases that presented with a disease that could be resected with a sphincter-sparing TME. In addition, if the disease responded poorly to preoperative FOLFOX, then patients on that arm were required to receive ...
Do you use intrapleural tPA/dornase in loculated effusions that are not due to infection?
The use of tPA ONLY has been reported in patients with a complicated pleural fluid collection, not due to infection (Heimes et al., PMID 28616283). The dose was 6 mg in 50 mL of normal saline instilled via a pleural chest tube. However, lower doses have been used (Thomas et al., PMID 25742001).