Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When incidental microscopic hematuria is found on routine urinalysis, how do you decide on further workup versus repeat testing?
Would you biopsy calcified lung nodules and or lymphadenopathy that have shown stability over a 2-year period, in a bid to rule out sarcoidosis?
No. Certainly not without a comprehensive occupational and other exposure history. Follow "the rules" for the assessment of any sarcoidosis suspect. Do a physical exam to look for extrapulmonary signs of sarcoidosis. Order an eye exam to assess for ocular sarcoidosis. Obtain baseline MTB testing and...
Would you consider empiric anticoagulation in patients with an acute stroke for whom you have high suspicion for cardioembolic source, but have not yet confirmed LV thrombus, atrial fibrillation, etc.?
In practice, I would rarely consider empiric anticoagulation after an acute ischemic stroke without a confirmed cardioembolic source. I would not consider this approach for suspected LV thrombus, as transthoracic echocardiography is routinely available in the inpatient setting and can quickly confir...
Based on most current research regarding the more widespread use of class IC antiarrhythmic drugs, what are your prescribing practices in patients with coronary artery disease?
Fair question, as we know the definition of "structural heart disease" is unknown. In the trial, it was likely ischemia driving the poor outcomes, so I will get stress with imaging on everyone >50 years old (CAD risk). Given the common finding of "questionable" stent placement in the community, I wi...
In what situations would you recommend metformin in addition to aggressive lifestyle interventions for patients with prediabetes and obesity?
So based on studies such as the Diabetes Prevention Program and newer meta-analyses such as Comparison of the Efficacy of Metformin and Lifestyle Modification for the Primary Prevention of Type 2 Diabetes: A Meta-Analysis of Randomized Controlled Trials (Vajje et al., PMID 38021728). Lifestyle modif...
How would you approach management of retroperitoneal fibrosis causing ureteral compression that has already caused irreversible loss of kidney function?
I agree with my colleagues and will add some additional thoughts. While I agree that tissue diagnosis is helpful whenever it can be obtained (both to differentiate IgG4-related vs idiopathic RPF and to exclude other causes such as lymphoma, sarcoma, and Erdheim-Chester Disease), it is often the case...
In patients with persistent borderline hypotension recovering from sepsis or critical illness, do you use midodrine to avoid escalating to higher levels of care?
Although midodrine is a medication that can be used to avoid vasopressors, I think it is much more important to give isotonic fluids when the patient would benefit from fluids. It is also very important to determine the etiology of hypotension. Is hypotension related to sepsis? Hypovolemia? Bleeding...
How do you approach the treatment of patients with Ehlers-Danlos hypermobile type with chronic muscle spasms with minimal exertion?
You accept that EDS is a genetic connective tissue disorder and not a rheumatological issue. You check hormones and vitamins to ensure they are in range: especially Mg with the cramps. Some EDS patients find working with an EDS physical therapist is beneficial: the goal being to learn how to exercis...
How do you decide the maximum amount of volume to remove during a therapeutic thoracentesis?
Critically ill (hypotension/shock on pressors) that are not having hypoxia issues/increased FiO2 requirements, I would probably be cautious. Rest of the population, use clinical judgement based on the clinical response... Less likely to need a "hard" stop/limit.
How do you decide the maximum amount of volume to remove during a therapeutic thoracentesis?
Critically ill (hypotension/shock on pressors) that are not having hypoxia issues/increased FiO2 requirements, I would probably be cautious. Rest of the population, use clinical judgement based on the clinical response... Less likely to need a "hard" stop/limit.