Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to achieving hypernatremia in a patient on CRRT for whom increasing the rate of a post-filter 3% sodium chloride infusion is insufficient?
Good question. First, we can always increase the rate of the 3% saline more. Eventually, the increased amount of salt will lead to an increase in serum sodium concentration. It has to be a gradual process though to make sure one does not overshoot. Second, if the patient does not require more dialys...
How do you manage arthritis resulting from deferiprone in transfusion dependent thalassemia?
The precise pathophysiology of deferiprone associated arthropathy is not well understood but some reports have suggested that there may be some deposition of iron in the synovial membranes, and some subchondral bone damage. Unfortunately, there is no specific treatment for this arthritis, other than...
Would you recommend a CT venogram or MR venogram in patients with concern for venous sinus thrombosis?
Either modality is suitable for assessing CVST. However, I typically prefer CTV. It's easier to obtain and has a quick scan time, which reduces the chances of motion artifacts. MRV provides better resolution, but it requires a screening form and has a longer scan time, which may lead to motion artif...
How do you manage patients with embolic stroke of an undetermined source and a papillary fibroelastoma found on an echocardiogram?
The definitive treatment is surgical, and the only way of knowing for certain that the lesion is a fibroelastoma is to perform surgery and obtain pathology. If a patient is not a candidate for heart surgery, anticoagulation could be tried.
Do you typically load DAPT in patients with ICAD?
If the ICAD lesion is symptomatic and the patient is aspirin-naive, I administer a one-time loading dose of 325 mg of aspirin, followed by 81 mg after that. I do not administer a loading dose of the P2Y12-inhibiting agent (such as clopidogrel, ticagrelor, etc.). I continue DAPT for 3 months then tra...
Are there certain sedatives or anti-epileptic meds to avoid in patients with IDD?
They are very interesting questions and I think “do no harm” relates to the issue of using any medication, whether it's an anti-epileptic drug or something for pain, or anything. Any medication can have an impact. When you think about someone with an intellectual or developmental disability (IDD) w...
What workup do you perform for elevated B12 levels in an adult who is not taking supplements?
There is no convincing evidence of the harmful effects of elevated serum B12 per se, so I have not vigorously pursued this lab finding. If excessive supplements are consumed, B12 is innocuously excreted in the urine once tissue receptors are saturated. Nonetheless, this question raises some interest...
Is there a correlation between spleen size and degree of thrombocytopenia?
In a normal individual, approximately 1/3 of total body platelets are sequestered in the spleen at any given time. As the size of the spleen increases, so too does the proportion of platelets in the spleen increase. This is due to the total volume of the spleen, not just longitudinal measurement. It...
Can romosozumab be used in patients on dialysis?
This is an interesting question given the common finding of osteoporosis among patients undergoing hemodialysis. There have been several individual case reports suggesting that treatment with romosozumab in this patient population can be safe and effective. The largest study (no control group) of wh...
Do you hospitalize patients with newly diagnosed lupus nephritis and nephrotic syndrome if you are able to provide pulse steroids outpatient and follow them closely?
Usually not. I suspect it all depends upon one's ancillary support situation. We are able to do in-house labs, give immediate in-house IV pulse steroids, and I can call interventional radiology and get an ASAP renal biopsy. If there were complications, such as infection, thrombosis, need for dialysi...