Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach a patient with sarcoidosis who cannot tolerate steroids and who is developing ILD?
As with most questions about sarcoidosis, clear understanding of the relevant clinical context should first be established. While interstitial lung disease (ILD) is a common manifestation of sarcoidosis, it often can be safely monitored without treatment, and so radiologically identified sarcoid ILD...
How would you manage cardiac sarcoid with intolerance/contraindications to methotrexate, azathioprine, and mycophenolate/mycophenolic acid and that has proven refractory to adalimumab and infliximab as determined by PET?
I think it would be important to know the doses of the medications 'failed'. Similarly to allopurinol dosing and gout prophylaxis 'failures', I find most patients I see for consultation with this story are not on high enough doses, need combo therapy, or are not on the medication long enough. Meth...
What is your approach to distinguishing a Jarisch-Herxheimer reaction from a delayed anaphylactoid reaction?
As with most things in medicine, this is context-dependent. The Jarisch-Herxheimer reaction is a systemic inflammatory response to the death of bacteria (most commonly associated with spirochetes and in particular, syphilis), typically in the hours following antibiotic administration. This response ...
What is your approach to distinguishing a Jarisch-Herxheimer reaction from a delayed anaphylactoid reaction?
As with most things in medicine, this is context-dependent. The Jarisch-Herxheimer reaction is a systemic inflammatory response to the death of bacteria (most commonly associated with spirochetes and in particular, syphilis), typically in the hours following antibiotic administration. This response ...
When do you consider using disulfiram in patients with alcohol use disorder?
Yes, there is a select population who benefit greatly from Antabuse: motivated professionals, monitoring programs for impaired professionals, and court-mandated cases. Informed consent would include complete disclosure related to dietary limitations/risks for severe drug interaction up to 2 weeks po...
How would you approach treatment in a patient with refractory Coccidioidal meningitis who has previously been treated with IV amphotericin B?
The previous receipt of amphotericin B is irrelevant. Shortly after its introduction in the mid-1950s, it was recognized that it was ineffective in the treatment of coccidioidal meningitis when given intravenously and that intrathecal administration was necessary (Winn, PMID 14065439). The introduct...
What are some alternatives to dexamethasone for brain edema in patients who are allergic, have an intolerance, or refuse the medication?
Dexamethasone is one of the most frequently prescribed medications in neuro-oncology clinics. Dexamethasone is often favored over other corticosteroids owing to its lower mineralocorticoid effects and high potency as well as essentially 1:1 oral to IV ratio meaning that we use similar IV and oral do...
What is your preferred first line management of alcohol use disorder with concomitant depression?
The presence of comorbid depression doesn't significantly change the way I think about pharmacotherapy for AUD. I would still consider disulfiram, naltrexone (PO and IM), and acamprosate as equivalent first-line agents. It's worth noting that distinguishing between major depressive disorder and subs...
How do you approach screening for occult cardiac or tracheal involvement in a patient with relapsing polychondritis?
Hello! Dynamic CT and echo, if you have suspicion of vasculitis (physical exam, sx), a CTA can help. Happy to discuss your case.
When would you consider long-term cardiac monitoring to look for atrial fibrillation in patients with mitral stenosis given their baseline elevated risk for atrial fibrillation and thrombosis?
This is a thought-provoking question. Not only is Afib a risk factor for strokes but these strokes can be particularly devastating. While screening for subclinical Afib in large populations is described, there is little data to show that this leads to clinical benefits (1, 2). The benefit of detecti...