Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you recommend, based on current evidence, avoiding antimotility agents in patients with non-fulminant C. difficile infection who have no evidence of ileus?
I generally avoid their use based on the notions that diarrhea may contribute to the elimination of non-invasive GI pathogens and that impairment of intestinal motility could increase the risk of complications, such as toxic megacolon.The data and recommendations have not progressed beyond the follo...
Do you ever favor cefazolin over ceftriaxone for bacteremia with susceptible E. coli?
No
How do you interpret small joint effusions seen on ultrasound without power doppler signal in the setting of compatible inflammatory symptoms (i.e morning stiffness)?
It certainly increases probability of Inflammatory arthritis, if aligns with clinical symptoms. I would check inflammatory markers, autoimmune serologies, infectious work up and all to determine type of arthritis and consider prednisone trial and likely consider immune suppressive regimen based on r...
For patients with SLE, is there an ANC level for which you would hold or adjust hydroxychloroquine in an asymptomatic patient?
Leukopenia most often as lymphocytopenia, of course, is not unusual in lupus. Total WBC less than 4000 is an ACR classification criteria for the disease as is ALC less than 1500 on two occasions. SLICC disease classification requires ALC less than 1000. Total WBC < 3000 generates SLEDAI points. On t...
Is there any benefit to checking serum viscosity in patients with autoimmune disease and headaches/migraines to see if aspirin or clopidogrel may be beneficial?
The serum viscosity test measures the time required for the serum to flow through a calibrated capillary tube under controlled pressure. Clinically significant elevations in viscosity (≥2.5 centipoise, normal range 1.4 - 1.8 cP) can cause symptoms and are most commonly seen in hyperviscosity syndrom...
What is the interpretation of an IGRA with positive TB wells and negative nil and negative mitogen wells?
We don't see positive controls in most clinical assays. They are run, of course, but hidden from view. The mitogen well is the positive control in the IGRAs. The mitogen used QuantiFERON-TB Gold is, I believe, PHA or phytohemagglutinin. PHA turns on T-cells to indiscriminately. If I remember my mito...
Do you counsel a mother to avoid certain food in her diet if she is still breast feeding and her child has confirmed IgE mediated food allergies?
Wangberg et al., PMID 33636342 surveyed a total of 133 breastfeeding mothers with allergic children. A total of 47.4% of mothers reported their healthcare provider encouraged them to continue breastfeeding without dietary restrictions, 17.3% were advised to continue breastfeeding but avoid eating th...
Do you routinely hold anticoagulation (including pharmacologic VTE prophylaxis) for bedside procedures such as paracentesis, thoracentesis, and central venous catheter placement?
We do not hold anticoagulation of any kind for paracentesis. I also do not hold anticoagulation of any kind of thoracentesis, though some places will still ask things like Plavix or DOAC to be held. We do hold ppx and anticoagulation for LP due to the risk of epidural hematoma. I do not hold for the...
Do you routinely hold anticoagulation (including pharmacologic VTE prophylaxis) for bedside procedures such as paracentesis, thoracentesis, and central venous catheter placement?
We do not hold anticoagulation of any kind for paracentesis. I also do not hold anticoagulation of any kind of thoracentesis, though some places will still ask things like Plavix or DOAC to be held. We do hold ppx and anticoagulation for LP due to the risk of epidural hematoma. I do not hold for the...
Do you recommend the use of albumin-adjusted calcium measurement formulas to accurately assess calcium levels?
It is a reasonable approach to correct serum calcium using albumin when hypocalcemia is present, especially in a hospital setting. I believe it is less useful for evaluating hypercalcemia.Although it is reasonable to use albumin to correct serum calcium in patients with hypocalcemia it may be worthw...