Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you work up incidentally found papilledema in the emergency room?
The term "papilledema" should be reserved for optic disc swelling due to increased intracranial pressure - but I assume that this question is asking what to do if the fundus examination looks abnormal (blurred disc margins perhaps) when there are no visual symptoms or symptoms of increased intracran...
When do you consider nerve blocks for headache management in patients admitted to the neuro-intensive care unit with subarachnoid hemorrhage?
For aneurysmal SAH, I try different medication combinations for the first 5-7 days. After this time frame, if headache pain is still severe and/or the patient uses opioid meds too frequently, I request an occipital nerve block from our pain management team. In my experience, about two-thirds of pati...
How do you medically manage uncontrolled Graves' disease in a patient awaiting surgery who is intolerant to methimazole and PTU and refusing RAI?
Although this seems like a difficult situation, one must remember that in the past, patients were prepared for surgery with beta-blockers + KI, with excellent outcomes.Feek et al., PMID 6892650Therefore, I do not think you need to treat this patient with lithium, risking lithium toxicity, to prepare...
Do you repeat a lumbar puncture in a patient living with HIV diagnosed with and treated for neurosyphilis and if so, when?
This is a complex issue, and there isn't a one-size-fits-all approach. There are no hard and fast guidelines in place. If the initial CSF abnormalities include only reactive CSF VDRL, along with modest protein elevation and mononuclear pleocytosis (both of which are consistent with HIV infection), a...
What role do anti-seizure medication levels, such as levetiracetam, serve in seizure-free patients?
In patients with epilepsy who are being treated with antiseizure medication, the change in doses has to be driven by clinical data, mainly by seizure recurrence and/or adverse events. If a patient has been seizure-free and is not having adverse events, there is no need to check for blood levels, as ...
Do you take into consideration a patient's serum albumin level in your decision to use ertapenem?
A 2023 IDSA guidance recommended against the use of ertapenem in critically ill patients as well those with hypoalbuminemia. The latter is based on PK data indicating rapid clearance of the free fraction of the drug, which has approximately 90% protein binding, resulting in lack of attainment of an ...
How do you approach the management of patients on lamotrigine who develop a minor rash?
Lamictal rash can be dangerous but if we stop or switch lamictal for any rash during treatment we can run out of options soon. Get a good history and pictures, if possible. How long have they been on lamictal and was there a recent dose change or did the pharmacy change their generic brand? Have an...
Would you start anticoagulation in a patient with RCC and related (tumor) thrombus with extension to renal vein and further?
Tumor thrombus is an intraluminal extension of tumor mass, rather than a true thrombus. There is no evidence that anticoagulation improves outcomes in tumor thrombus (Marcoux et al., Blood 2019). Primary management is surgical resection, typically as part of radical nephrectomy for localized RCC or ...
What suspected myositis manifestations drive you to start empiric therapy before the work-up is complete?
When evaluating a patient with myositis, I would consider starting immediate therapy when 1) my suspicion of myositis is high (i.e. characteristic rashes, compatible constellation of symptoms, very high CPK) and 2) the symptoms are severe. It would be the severity of the symptoms that would drive ho...
What is your approach to elevated CK in patients without clinical or serologic evidence of immune mediated myopathy?
Thanks for your great question: This is especially important because we are much more likely to see patients sent for "elevated" CPK than patients with myositis.Unfortunately, I think that the answer to the approach depends a lot the circumstances, including (1) how elevated is the CPK, and (2) how ...