Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How would you approach the workup of unilateral chorea with a normal MRI?
I would first rule out Sydenham chorea by checking ASO titers, DNase B titers, ESR, and CRP, and performing an echocardiogram and EKG. I would also recommend an MR angiogram if not already done for Moya-Moya. Following that, I would check copper levels, ceruloplasmin, serum amino acids, serum lactat...
Do you routinely discontinue atypical coverage in community-acquired pneumonia when PCR testing (i.e., respiratory pathogen panel) is negative for atypical organisms?
In community-acquired pneumonia (CAP), here is how I approach the decision to discontinue atypical coverage (e.g., azithromycin or doxycycline) when respiratory pathogen panel PCR testing is negative for atypical organisms (most commonly, Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneum...
What is your approach to differentiating RA-ILD from medication toxicity (I.e. from methotrexate)?
RA-ILD occurs in about 7-10% of patient with RA. It is more common in males and in those with a history of smoking. Most are seropositive. The typical pattern on HRCT in 50-60% of RA-ILD patients is a UIP pattern followed by NSIP, OP, and even LIP is some cases. An experienced clinician with the hel...
Do you typically give GI prophylaxis when providing patients with steroid taper for status migrainosus?
I usually do a 3-6 day taper with prednisone, dexamethasone, or medrol dose pack for status migrainous. Occasionally, I have done a 12-day taper if the status migrainous is prolonged. I have not used GI prophylaxis.
What immunosuppressant will you choose in a patient with necrotizing myopathy partially responding to IV steroids and IVIG with a history of non Hodgkins lymphoma?
The decision should be taken in collaboration with the patient’s oncologist; however, Rituximab would be a reasonable choice to add given that IMNM generally responds well to it (particularly anti-SRP) and that it has a favorable safety profile concerning malignancy.
Which patients with rectal cancer who have not received neoadjuvant treatment do you offer adjuvant radiation to?
In order to answer this question, we may need to step back and first review the indications for radiation treatment in the neoadjuvant setting.Neoadjuvant concurrent chemoradiation or short course radiation treatment is considered to be part of the standard treatment (recommended by guidelines) for ...
In hospitalized patients with significant lower extremity edema, how can you integrate bedside POCUS findings with clinical assessment to guide the decision to start empiric anticoagulation for suspected DVT before formal imaging?
Great question! Especially if the significant lower extremity edema is asymmetric, it sounds like your clinical suspicion would be quite high. When you order a "duplex" study, the sonographer is using 2D ultrasound (aka B mode... white dots on black screen) + Doppler ultrasound (color and spectral)....
In hospitalized patients with significant lower extremity edema, how can you integrate bedside POCUS findings with clinical assessment to guide the decision to start empiric anticoagulation for suspected DVT before formal imaging?
Great question! Especially if the significant lower extremity edema is asymmetric, it sounds like your clinical suspicion would be quite high. When you order a "duplex" study, the sonographer is using 2D ultrasound (aka B mode... white dots on black screen) + Doppler ultrasound (color and spectral)....
What is the clinical significance of a low titer RNP, negative Sm, but Sm/RNP that is very high titer?
Important question as I've seen clinicians incorrectly interpret anti-Sm-RNP as anti-Smith antibody.The different autoantibodies (RNP, Smith, Sm/RNP) react to different antigens as follows: Anti-RNP can react to multiple components (antigens) of the U1 small nuclear RNP particle (snRNP), Anti-Smith ...
In clinical practice, are you using single-dose liposomal amphotericin B for treatment of cryptococcal meningitis for patients living with HIV?
I have practiced in Dallas, Texas, at Parkland Hospital for nearly 20 years; unfortunately, we see at least 50 patients a year with cryptococcal meningitis and HIV. We have been using the standardized approach from the US DHHS guidelines that recommend at least a 14-day course of therapy of Ambisome...