Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach the bronchoscopic evaluation of a cavitary lesion of the lung?
I think transbronchial biopsy is very helpful in the diagnosis of a cavitary lesion of the lung. I usually send it both for pathology and culture. I also believe it should be dealt with in a multidisciplinary approach and biopsy should be offered to those whose diagnoses are not clear or straightfor...
Do you treat Candida spp isolated from a bronchoalveolar lavage?
I would only treat if there was evidence of Candida infection from another source/location (at the same time).
How do you approach evaluation and management of a patient with recurrent monoarticular inflammatory arthritis of unclear etiology?
Routine testing will not identify Lyme disease although the WBC count is higher than usual. If the antibiotic does not target B burgdorferi recurrence might mean inappropriate therapy previously. WBC count WAAAY too high for mere trauma or internal derangement. Anything else to suggest psoriasis? Lo...
What is your blood pressure or mean arterial pressure goal in a critically ill patient with acute kidney injury?
The current surviving sepsis guidelines recommend targeting a mean arterial pressure (MAP) of 65 mm Hg with no benefit of targeting a higher MAP in septic shock patients.
Do you avoid performing urine microscopy in patients with AKI who have COVID-19 given concern for potential aerosolization?
No. The risk is very low to non-existent. At the beginning of the epidemic we were doing that but the evidence now is not supporting that practice.
Are there clinical scenarios in which you would start empiric treatment for pulmonary TB without microbiologic confirmation?
Yes, there are a few situations. One of them being pauci-bacillary TB in which you catch TB very early on its course hence your micro/cultures will be negative. CT will demonstrate micronodules. This is a diagnosis of exclusion and requires the right clinical setting (high-risk patient, from an ende...
When do you recommend hyperacute MRI for patients with wake-up stroke?
Wake-up stroke patients with arrival within 4.5 hours of symptom discovery may be eligible for tPA or tenecteplase if the acute MRI shows a DWI lesion but little or no FLAIR lesion.
Is there a role for using continuous glucose monitors for perioperative glucose monitoring in patients with diabetes?
Use of continuous glucose monitors is becoming more widely accepted for outpatients with diabetes to manage their glucose. Many hospitals now allow patients to continue to use their CGM when admitted, though most require some hospital monitoring as well. During the early phases of COVID, ICUs starti...
When would be your threshold to consider obtaining an exercise RHC for undifferentiated dyspnea to help diagnose HFpEF?
When to Consider Exercise Right Heart Catheterization (RHC) for Diagnosing HFpEF in Patients with Undifferentiated Dyspnea: Persistent, Unexplained Dyspnea: Clinical Context: Exercise RHC is indicated in patients with persistent dyspnea not explained by common conditions such as chronic obstructiv...
In light of the NOAH-AFNET6 and ARTESiA trials, how would you approach the decision regarding anticoagulation for patients with incidentally-detected AF <24 hrs on pacemakers/defibrillators?
Finding the right answer for subclinical atrial fibrillation is sometimes hard to tease out the subtleties. The 2023 ACC/AHA/HRS atrial fibrillation guidelines were published in Jan 2024 (Joglar et al., PMID 38033089) and a section (6.4.1) is dedicated to patients with CIED without prior atrial fibr...