Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach tapering immunosuppression in a patient with a history of Susac Syndrome who has stabilized on MMF and IVIG?
Susac's is a rare disease characterized by an occlusive retinal vasculopathy, eighth nerve disease including hearing loss and balance issues, and CNS disease with a predilection for involvement of the corpus callosum. I am not aware of any randomized controlled data to guide treatment for Susac's, b...
When do you consider ketamine to treat nonconvulsive status epilepticus?
Ketamine is a fine agent for the management of status epilepticus (SE) and some centers use it first line instead of propofol or midazolam. Mechanistically, it makes more sense as it controls the seizures through NMDA blockade, bypassing GABA receptors, which are downregulated in the setting of SE. ...
When would you consider using acetazolamide to augment diuresis in patients with ADHF?
The ADVOR trial suggested that the addition of acetazolamide to a loop diuretic "upfront" in congested patients with heart failure achieves greater decongestion at 72 hours and discharge. While most would not use such a combination in "all" patients, this strategy is optimal in those demonstrating s...
Do you regularly recommend an immunological workup for patients with suspected immunodeficiency or defer to immunology?
I defer after a very preliminary work-up based on the type of immunodeficiency expected. I try to direct the consult to a provider most likely to have expertise in the problem I suspect. Often, I suggest consulting with a provider at NIH.
When and how should we use biomarkers (i.e., CRP, stool calprotectin, mAb levels) to guide or optimize medical management of Crohn’s disease or ulcerative colitis?
The principal clinical applications of biomarkers in IBD are as follows: Assessment of severity and prognosis during a flareup. Monitoring the efficacy of treatment. Determining the probability of postoperative recurrence of Crohn’s disease (i.e., the high negative predictive value of FPC for anasto...
How would you manage recurrent migratory lower extremity thrombophlebitis that occurs despite being on therapeutic apixaban?
The differential diagnosis of Trousseau syndrome (migratory superficial thrombophlebitis) is relatively broad and includes both inflammatory states and undetected proximal DVTs. So I think the short answer about venogram is "maybe," based on how clear is the view by ultrasound. This isn't a typical ...
What is your preferred first-line agent for VTE prophylaxis in hospitalized medical patients with adequate renal function?
Lovenox. It can also be dose adjusted for poor renal clearance if needed; otherwise, Heparin.
What is your approach to evaluating amiodarone induced interstitial pneumonitis?
There are no definitive histopathological or radiological findings of amiodarone toxicity. For example, foamy lipid laden macrophages are reported but this reflects exposure, not injury, and these findings are present without interstitial lung disease related to amiodarone. High HUs have been report...
How do you decide when, if ever, to defer pharmacologic venous thromboembolism prophylaxis for hospitalized patients?
For the majority of patients who are not actively bleeding, I use pharmacological prophylaxis. I prefer heparin products, unless they have a history of HIT or religious preferences on porcine products. Even for patients planned for surgery, heparin can always be held or reversed. I prefer LMWH over ...
What is the utility of checking reverse T3 in clinical practice?
I have never routinely ordered it, only when forced to by certain rare patients who are reading Dr. Google or other information they find. They think it will change their plan, it never does.