Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you consider the use of tocilizumab in patients with COVID pneumonia who have had an improvement in supplemental O2 requirements but have significantly elevated inflammatory markers after day two of remdesivir and dexamethasone?
I don’t use tocilizumab if the clinical condition is improving.
What is your approach to differentiating tender spots (as in fibromyalgia) and enthesitis (as in axSpA)?
The tender points in fibromyalgia are not limited to tendon insertion sites but are much more generalized, such as in the middle of the muscles of the neck, shoulders and back. Often tender points in fibromyalgia are found at the costochondral junction and at the lateral epicondyle or other tendons ...
How do you decide between ceftolozane/tazobactam and ceftazidime/avibactam for empiric treatment of an infection due to difficult-to-treat Pseudomonas aeruginosa while awaiting additional susceptibilities?
Either is generally acceptable. The choice of empiric therapy in this circumstance may be dependent on additional information, if available. As an example, a patient with cystic fibrosis may have recent microbiological data that could guide the decision. Such information, however, is not often avail...
Do you start immunosuppression for enlarging pulmonary nodules without symptoms, impaired pulmonary function, or extra-pulmonary disease in a patient with sarcoidosis?
First consider whether further diagnostic workup is necessary, to increase your confidence that enlarging nodules, changing pulmonary function, or extrapulmonary disease is due to sarcoidosis. Sarcoidosis patients have an increased risk of cancer in the early peri-diagnostic period, likely due to th...
What is the role of anticoagulation in patients with septic thrombophlebitis?
The role of heparin anticoagulation in septic thrombophlebitis is controversial. There are limited to no randomized trials to document outcomes. A systematic review (Falagas et al., PMID 17222406) supported this practice, and the Infectious Disease Society also supports this practice. The role of or...
What is the role of anticoagulation in patients with septic thrombophlebitis?
The role of heparin anticoagulation in septic thrombophlebitis is controversial. There are limited to no randomized trials to document outcomes. A systematic review (Falagas et al., PMID 17222406) supported this practice, and the Infectious Disease Society also supports this practice. The role of or...
Is there a role for biologic therapies in asthma-COPD overlap syndrome with evidence of type 2 inflammation?
While there are ongoing studies regarding the potential role of biologics in COPD care, to date, the data remains unclear. The whole issue of COPD/ asthma overlap syndrome remains controversial and I know of no clear data defining a role of biologics. However, I would suggest that the stronger the a...
Do you use standard dose or "meningitis dosing" of antibiotics when treating epidural abscesses, in the absence of CNS symptoms?
Not always. While I will use meningitis dosing for initial therapy, I have no qualms about using cefazolin for MSSA (and several recent publications support this), nor using ceftriaxone 2g/d for streptococcal infection. And frequently after the initial 3-4 weeks on IV, I transition to oral doxycycli...
When do you consider attributing isolated psychosis to an acute ischemic stroke?
Though relatively rare, systematic reviews have found post-stroke psychosis to occur in just under 5% of patients. When considering attributing psychosis to an acute stroke, there are several things it can be helpful to consider: Differential diagnosis: Making sure to rule out more common etio...
Do you routinely use milrinone to augment RV function in patients with massive pulmonary emboli on vasoactive support?
Recent data in experimental acute PE suggest that levosimendan and milrinone showed similar and beneficial hemodynamic profiles – reducing RV afterload and improving RV function without increasing RV mechanical work. (Dobutamine increased CO, but at the cost of an increase in RV afterload and RV mec...