Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
For patients with high-risk stress test features with ischemic EKG changes and mild to no symptoms, what would be your threshold to directly admit them for coronary angiography, or pursue outpatient elective coronary angiogram?
The key is whether there is a stable clinical history. In the absence of any symptoms suggesting a change in clinical trajectory, the evaluation should be done without a direct admission particularly in order to allow patients to plan rather than create a sense of emergency. Unprovoked symptoms that...
How long post operatively do you wait before transitioning from parenteral anticoagulation to oral anticoagulants after pulmonary thromboendarterectomy for CTEPH?
It depends. In straightforward cases, we are pretty aggressive with starting anticoagulation to prevent re-thrombosis after pulmonary thromboendarterectomy. These patients are started on parenteral anticoagulation (with IV heparin) on POD #0, usually within several hours after arriving in the ICU if...
What is the preferred approach to managing non-occlusive or partially occlusive venous sinus thrombosis?
I would recommend a DOAC, particularly apixaban, with follow-up imaging in 3 months.
How long do you wait before starting a non-selective beta blocker in patients with newly reduced LVEF and recent cocaine use?
Cocaine use is a well-known cause of cardiovascular complications, including acute coronary syndromes, arrhythmias, and cardiomyopathy leading to reduced left ventricular ejection fraction (LVEF). The use of beta-blockers in this context is often debated due to concerns about unopposed alpha-adrener...
What is your approach to starting antiretroviral therapy in a patient living with HIV who is diagnosed with cryptococcal meningitis?
For newly HIV-diagnosed persons with cryptococcal meningitis, the current guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV recommend deferral of ART initiation until after the first 4-6 weeks of cryptococcal meningitis treatment, due to findi...
Is there a role for biologics to help patients with ABPA who are steroid responsive and have removed their allergen insult, but continue to have an elevated serum IgE and incomplete resolution of symptoms return to their baseline functional status?
We have a fairly large number of ABPA patients on Omalizumab. It works great. One of the issues we frequently encounter is that ABPA patients sometimes have too high of IGE counts for the approved highest Omalizumab dosage. In these patients, we initially treat them with standard prednisone therap...
How would you manage a patient with CKD4 due to lupus nephritis of unknown class who develops AKI requiring hemodialysis and nephrotic range proteinuria and is found to have atrophic kidneys on imaging?
The decision to biopsy a kidney is not based just on size. The operator should look at the kidney size compared to the height of the patient and the echogenicity on ultrasound.If the patient is short with a normal/near-normal echogenicity, even a <9cm kidney can yield useful information. This is rel...
Do you favor timely bronchoscopy for diagnostics over close surveillance in mildly symptomatic patients with CT findings suspicious for NTM infection who are not able to expectorate?
Yes, I do favor FOB to obtain BAL in symptomatic patients with suspected NTM.
Do you reduce the steroid regimen for patients with acute interstitial nephritis who have a high risk for developing side effects from glucocorticoid therapy?
No, generally not. AIN needs adequate treatment that isn't that long anyway. You could not treat and just stop the offending drug, but the long-term outcome is worse. I think you just need to treat and then taper.
Would you anticoagulate an SMV thrombosis caused by malignant obstruction in the setting of metastatic colorectal cancer?
Superior Mesenteric Vein Thrombosis is a rare phenomenon, within the category of Splanchnic thrombosis. While portal vein thrombosis is most often associated with cirrhosis (though also seen in many patients without cirrhosis), SMV thrombosis is more commonly seen in the context of either local prov...