Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How would you manage persistent Norovirus diarrheal infections in a kidney transplant patient that are not responding to a decrease in the patient’s maintenance immunosuppressive regimen?
This is a difficult situation and does not have a strong evidence based response. First, I would really make sure they are not on mycophenolate as this is really the main problem with chronic Norovirus for most patients. Next, I would see if there are any available clinical trials that the patient m...
How would you manage a patient with Crohn's disease on a biologic and presents with non-bloody diarrhea, normal-appearing mucosa on sigmoidoscopy but severe colitis on biopsy with a positive CMV stain?
A few key pieces of information help distinguish CMV colitis from other competing diagnoses in this frequently encountered conundrum. An experienced pathologist will usually be able to tell you: If the CMV immunohistochemistry stain has good controls and whether it is floridly positive or scant. Al...
What other conditions should you consider in someone with presumed Tolosa Hunt but without significant improvement on steroid therapy?
Sufficient workup should ideally be obtained before initiating steroids in order to exclude disorders that may have a similar presentation with quite a different approach to management. These investigations include but are not limited to the following: brain MRI with contrast + thin slices through t...
How do you manage anticoagulation in a patient with DVT from likely malignant mechanical obstruction?
This is a very difficult situation to manage. Would promptly initiate therapeutic anticoagulation as long as no increased risks for bleeding. The surgery to remove the uterine mass is likely urgent. I would confirm with gynecologic oncology (or the team planning on removing the mass) that it is not...
How do you approach a patient who develops a rest tremor after chemotherapy?
Like many questions in Neurology, this question can be simple or rather complex to answer. If the patient is felt to have a drug-induced tremor, withdrawal of the offending drug or drugs should be the first choice whenever possible. In the chemotherapy setting, a common scenario would be when a dopa...
Do you pursue a cardiac evaluation in all patients with an excised cutaneous myxoma?
I'm a dermatopathologist, not a clinician, but would note the following data points: Many things are called myxomas. Those associated with Carney complex, in which atrial myxomas also occur, are a specific variant, superficial angiomyxomas. They usually have inactivation of protein kinase regulator...
Is ABI (Ankle Brachial index) lower limb arterial doppler not recommended if patient already has arterial stents in the legs, and if so, what other imaging modality would you consider as first-line?
ABI is still helpful in follow-up of patients with arterial stents but only gives a sense of global perfusion to the distal limb and may not be helpful in patients with calcified non-compressible vessels, (e.g. CKD, diabetics), so a better assessment is arterial duplex that can visualize the entire ...
How do you choose between eculizumab and ravulizumab for patients with acute kidney injury from complement mediated thrombotic microangiopathy?
For atypical HUS (aka complement-mediated TMA), both eculizumab and ravalizumab are FDA-approved therapies and are technically equivalent.The main advantage of ravulizumab is that it is a re-engineered form of eculizumab that extends its half-life to 51.8 days vs 11.3 days for eculizumab.Of note, me...
What is the preferred antibiotic treatment regimen for vancomycin-resistant Enterococcus faecium endocarditis assuming susceptibility to both daptomycin and linezolid?
I would use dapto+ceftaroline or +ampicillin. Linezolid lacks cidal activity so less attractive for that reason.
Which steroid-sparing agent do you prefer to treat multi-organ Sweet's syndrome?
I have used methotrexate in combination with cyclosporine with some success but am most impressed with the effect of anakinra to control disease and allow discontinuation of corticosteroids. I would also recommend them in that order.