Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you recommend thiamine for patients presenting with acute symptoms of TGA?
Thiamine might be considered, especially if the patient has features of Wernicke-Korsakoff syndrome. However, if the patient has TGA, no drug treatment is needed since the amnesia resolves on its own.
How do you approach management of ILD in the presence of weakly positive RF and ANA but no other objective systemic findings of connective tissue disease?
This issue comes up frequently in our combined ILD/Rheumatology clinic and my pulmonary colleagues are typically looking at me for an answer as to whether I think the biomarkers are relevant to the patient's ILD. Low-level ANAs and RFs are not uncommon in the general population and can result in ove...
What adjustments do you make to a hemodialysis prescription for a patient with a recent stroke?
There are multiple considerations in the setting of a CVA in a patient requiring hemodialysis. One is addressing potentially high intracerebral pressure (ICP). A slow reduction in BUN to avoid osmotic-related brain cell swelling and an associated rise in ICP may be addressed in a variety of ways. Lo...
What are your management strategies for patients with end stage kidney disease on hemodialysis who develop hypercalcemia of immobility?
I have seen this situation from time to time. First, I would make sure the patient is not getting any calcium or vitamin D-containing products. Then would try to use a lower calcium bath. Unfortunately, many units are unable to lower the calcium bath below 2.0 mEq/L currently and a lot of time that ...
How would you approach the staging and treatment of extranodal marginal zone lymphoma of left and right lacrimal gland?
This entity is described in literature as "ocular adnexal lymphoma". I usually screen those patients for Chlamydia infection and would empirically consider a 3-week course of doxycycline especially if the disease is indolent behaving clinically and there is prior serologic evidence of Chlamydia infe...
What blood pressure targets do you enforce in the first 24-48 hours in a patient who develops an intracranial hemorrhage after mechanical thrombectomy?
Typically post-thrombectomy you encounter hemorrhagic transformation of an ischemic infarct. In this setting, I adjust the SBP goal to the classification of hemorrhagic transformation (HI-1, HI-2, PH-1 or PH-2). HI-1: No specific parameter; SBP goal adjusted according to TICI score. HI-2: SBP 120-...
When would you initiate exchange transfusion in babesiosis and significant hemolysis?
There are no studies that answer this question. Some people have extrapolated from the use of exchange transfusions for severe malaria to consider using this treatment with babesiosis, another intraerythrocytic protozoan infection. Unfortunately, though there are some studies on malaria, the results...
What criteria are used to choose a specific dose of aspirin in ischemic stroke?
In my training and current practice, most stroke specialists have adjusted from the standard 81 mg aspirin dose (one-size-fits-all) to weight-based dosing. A meta-analysis of RCTs (Rothwell et al., PMID 30017552) suggests that low-dose aspirin may not suffice for stroke prophylaxis for patients who ...
What is your preferred initial imaging choice for a patient suspected of having renal artery stenosis who does not have any contraindications to imaging contrast media?
If the suspicion is for atherosclerotic-related renal artery stenosis (>55 years old, history of systemic atherosclerosis, tobacco use), then I start with a renal duplex ultrasound. Importantly, I do not get a renal duplex ultrasound on all patients with resistant hypertension. If the suspicion is f...
How do you adjust your management strategy to address the unique needs of anuric end-stage kidney disease patients when treating diabetic ketoacidosis?
There is no osmotic diuresis, and they do not need IVFluid, the opposite is true they may appear intravascularly overloaded, and will respond to insulin alone, they do not need HD for this. They will not be K deficient, do not give K. Their potassium will likely respond to insulin alone, and should...