Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When would you consider elective hospitalization for parenteral treatment for new daily persistent headache?
New daily persistent headaches can have a tension-type headache phenotype or a migraine phenotype. If presenting with a severe daily headache and a migraine phenotype I will treat it as status migrainosus since there is no consistent way to differentiate migrainous NDPH from a status migrainosus las...
Would you recommend desmopressin for a patient with ESKD receiving thrice weekly hemodialysis who is hospitalized for a persistent gastrointestinal bleed not amenable to usual interventional treatment strategies?
Yes. I always give desmopressin in patients with uncontrolled bleeding and uremia to fix the bleeding time abnormality. In this situation, the benefits should out way the possible harms.
What are reasonable alternatives to invasive angiography for CAV surveillance in patients who are a few years out from cardiac transplant with impaired renal function?
In our practice, we move to PET-CT on Year 3 if the prior 2 angiograms with IVUS did not show accelerating disease. The issue with CAV is that there is not much to do about it reactively. The best you can do, is switch to an mTORi regimen early and optimize lipids. IVUS is useful for that reason. Be...
Do patients with central adrenal insufficiency on maintenance hydrocortisone therapy require doubling of their corticosteroid during chemotherapy cycles?
I would follow the same sick day rules. If the patient is not feeling well with nausea, diarrhea, or worsening fatigue, the same rules of doubling the GC dose would apply. In cases of severe vomiting and not being able to keep the double dose of GC, parenteral GC injection and going to the ED for fl...
Would you consider stepping down from an echinocandin to azole therapy prior to the end of an initial six-week course for fluconazole-susceptible Candida albicans endocarditis in the absence of valve surgery?
I would not step down to fluconazole prior to completing a six-week course of echinocandin therapy. Fluconazole has poor activity against Candida biofilms in contrast to the echinocandins. Fluconazole monotherapy has also been associated with poor outcomes in endocarditis. Admittedly, most of our un...
What is your approach to management and surveillance in low grade traumatic blunt ICA injury?
For blunt cerebrovascular injury (BCVI), I use the Biffl scale to evaluate the extent of vessel trauma. The extracranial neck vessels, such as the cervical ICA or VA, are most commonly affected. The Biffl classification consists of five categories, with Grade 1 representing a low-grade injury. This ...
Is there a role for chronic suppressive oral or inhaled therapy for recurrent Burkholderia cepacia pneumonia causing frequent hospitalizations in a patient with severe bronchiectasis with or without underlying cystic fibrosis?
In certain cases, certainly, suppression may be the optimal role but in conjunction with modification to the immunosuppression. Generally, the immunosuppression will need to be lowered to allow for cellular immunity to combat the infection. Other factors include whether the gemovar is a more aggress...
How do you decide the right time for MitraClip intervention in patients with symptomatic heart failure and severe mitral regurgitation who are on maximally tolerated GDMT?
When evaluating these patients, it is always important to consider a multidisciplinary approach inclusive of general cardiologists, imaging experts for MR quantification, and most importantly, heart failure and electrophysiology colleagues. I ensure that the patient is seen by our HF colleagues to t...
Which class(es) of antihypertensives do you recommend for first-line therapy for hypertension in severe aortic stenosis?
Most beneficial data on ACE inhibitors.B blockers are to be avoided if associated AR but prior apparent contradiction is no longer valid and some benefit in outcomes based on their effects. Exact Aortic Stenosis substrate and comorbidities to determine which drugs to benefit. ARB's role is probably ...
What treatment would you offer a patient with extensive lymphangioma circumscriptum intermittently covering the entire abdomen?
I would consider sirolimus (rapamycin) to shrink the lesion to a size that could be surgically excised.