Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to scheduling and then weaning nebulizers in patients admitted with acutely exacerbated asthma or COPD?
In hospitalized patients with acute asthma or COPD exacerbations, my approach to nebulizers is front-loaded and reassessment-driven. I start by gauging the severity and the patient’s ability to use an inhaler. pMDI with a spacer is preferred for most patients, but nebulizers are reasonable early on ...
When screening for malignancy, do you order CT with contrast (or) both with and without contrast?
I think the best way to think about this is to assess what each scan shows. A CT with oral and IV contrast is very good for assessing details between soft tissues and blood vessels. A CT without contrast is better for assessing for renal stones and for fractures, especially small insufficiency fract...
Should an ischemic evaluation be considered in the diagnostic work-up for new-onset diastolic heart failure/HFpEF in patients without clear anginal symptoms?
The ischemic phenotype is a well-recognized class among HFpEF patients. For men, this usually manifests as macrovascular disease with epicardial CAD, and for females, the more common manifestation is microvascular disease with CMD. Therefore, ischemic evaluation should be considered as part of the w...
Would you recommend a GLP-1 agonist as an option to reduce the risk of dementia in patients with a strong family history?
I'm recommending GLP-1 for many things right now, but I haven't yet independently recommended it just to reduce the risk of dementia. However, if microvascular disease can contribute to vascular dementia, then there may be a benefit to better controlling diabetes with this drug.
How do you approach the management of post-concussion syndrome with symptoms including vertigo, headaches, persistent fatigue, and/or mood symptoms?
Each persistent post-concussion symptom that you listed has interventions that can be helpful. For vertigo, I recommend referral to vestibular therapy. I also use our behavioral health providers very regularly in the PPCS population. Because a concussion is a neuro-psychiatric condition, therapy is ...
How do you integrate HIV (+) serostatus into a patient's ASCVD if they would not otherwise qualify for a statin either for primary or secondary prophylaxis?
HIV (+) serostatus is a significant risk-enhancer for the development of cardiovascular disease and should be taken into account when making treatment decisions regarding statin initiation, even if the patient's viral load is low or not detectable. In a patient >40 years old and with a risk >5%, wou...
How do you approach a patient with high titer ANA and a new diagnosis of ITP, but no other signs or symptoms suggestive of active rheumatologic disease?
I would certainly treat the ITP with hematology involvement if necessary but would continue to monitor for lupus or similar CTDs. I have seen patients present with an ITP-like picture for years before lupus declared itself eventually. It may take years. I would also check a UA for proteinuria. This ...
Considering only cerebrovascular indications, are there circumstances in which you would use aspirin along with a DOAC in patients with atrial fibrillation and stroke?
I will use aspirin 81 mg and a DOAC together in patients who "fail" (I hate that term) the DOAC. The combination was used in patients in the original DOAC trials, so it is not unreasonable. Not my first choice, but can be done. It is worth noting that the evidence does not support doing this upfront...
What is your approach to treatment of macrolide-sensitive localized bone/joint MAC disease?
Agree with the above answers. Obviously, no strong clinical studies on duration and outcomes. At NJH, we typically recommend: Aggressive debridement/resection, Treat with appropriate antimicrobial therapy (in macrolide-S MAC, then AZM/EMB/Rifamycin +/- IV AMK) for a minimum of 6 months total, but a...
How do you workup patients with neuropathy suspected to be secondary to sarcoid?
To answer this question, the attached paper with consensus criteria for the diagnosis of neurosarcoidosis, published in 2018, should be reviewed, Stern et al., PMID 30167654.Based on this paper, a diagnosis of probable or definite neurosarcoidosis requires unequivocal evidence of non-caseating granu...