Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Is there a role for repeat surveillance blood cultures in patients with prosthetic valve endocarditis without associated cardiac abscess after a 6 week course of antibiotic treatment without surgical intervention?
Compared to NVE, PVE is associated with high morbidity and in-hospital mortality (10-30%). Patients with PVIE who are medically managed have either no surgical indication or have surgical contraindications. 2023 ESC guidelines supported repeating the blood cultures within the first week of finishing...
Do you routinely ask for removal of a indwelling central line (PICC or tunneled catheter) in a patient with pseudomonal bacteremia from known source with otherwise appropriate clinical improvement on anti-pseudomonal antibiotic therapy?
No
What is your approach to assessing whether oral/nasal ulcerations are features of systemic lupus erythematosus versus from another etiology?
Mucosal ulcerations due to lupus erythematosus (LE) are more complicated than many of us think. So, this question and answer are not as straightforward as many think. First, the subtitle to this question is misleading. I would not use the word "blister," a lay term that I usually reserve for vesicle...
How would you approach evaluation of a patient with persistent elevated ACE (angiotensin converting enzyme) level without evidence of cutaneous, ocular, or pulmonary granulomatous disease?
An ACE level was previously commonly used in sarcoidosis, often as a diagnostic tool. However, due to its low specificity, it has fallen out of favor. In cases where an ACE is elevated but an evaluation for sarcoidosis has turned up negative, consider other causes for an elevated ACE. Any disease th...
How would you treat a sarcoid patient whose only manifestations are B symptoms and generalized lymphadenopathy?
Historically, the term “B symptoms” was developed to describe poor prognostic signs and symptoms in stratifying patients with lymphoma. Specifically, these were fever, drenching night sweats, and significant weight loss (>10% over six months) and portended worse prognosis. B symptoms, of course, can...
Can Milwaukee shoulder present with a large subacromial bursitis, or does it predominantly cause joint effusion/destruction?
This is an interesting question. Milwaukee shoulder is primarily considered an arthropathy due to basic calcium phosphate crystals (Halverson et al., PMID 2155593). So the effusion will be seen in the joint, but because of secondary damage to the capsule and rotator cuff, it will typically extend in...
In patients with lupus nephritis on maintenance therapy, is there additional benefit in utilizing 2 grams vs 3 grams of mycophenolate mofetil (MMF) daily?
I agree with @Dr. First Last's answer. A few nuances to add: In my patients of African Ancestry, I always start with 1.5 gm bid if tolerated as they tend to need a higher dose (probably related to lower enterohepatic circulation, more rapid mycophenolic acid clearance, and other metabolic mechanism...
Are there clinical circumstances in which there is a role for steroids in treatment of calcified neurocysticercosis associated with perilesional edema and seizures?
Yes. Steroids would be routinely used if his perilesional edema. The question presumes that all of the intracranial lesions are calcified but there can be intraparenchymal cysts in different stages of dying or calcification.
How would you treat a de novo CLL with WBC of 1,000,000 and no overt signs of leukostasis?
This is an interesting question. I haven't seen anyone with a WBC count this high except when they had other factors influencing the count such as dehydration or systemic infection such as c diff and it was a reactive process in addition to CLL. It would be interesting to know what else was going on...
How do you treat sarcoidosis associated hypercalcemia in a patient with adenopathy and no other signs of systemic involvement?
This may seem like a straightforward query, but like many issues surrounding sarcoidosis, it is actually deceptively complex. For a more complete discussion, I refer the readers to an excellent review by Lower and Saidenberg-Kermanac’h (2019). In and of itself, asymptomatic “mild” hypercalcemia does...