Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Is there an upper threshold of pCO₂ that can cause symptomatic hypercapnia (e.g. AMS) despite metabolic compensation and normal pH?
Hi - I'm not sure about an upper threshold of pCO2 and AMS. However, even with normal pH, elevated pCO2 can cause significant increases in cerebral blood flow. Pollock et al., PMID 19406361 studied MR perfusion imaging and found that patients with a mean pCO2 of ~ 54mmHg had more than double the cer...
What treatment combination approach would you recommend for mucous membrane pemphigoid?
First, it is important to know the extent and severity of the disease (oral, ocular, esophageal); the type of inflammatory infiltrate on histopathology (neutrophils, eosinophils, or cell-poor); and the results of salt split skin and antibody titers on monkey esophagus and/or target antigens (collage...
Are you more permissive of perioperative interruption of anticoagulation for VTE depending on the location and relative chronicity of the thrombus?
Yes - in general, I try to balance the relative urgency/importance of the procedure or surgery v. the thrombotic risk to the patient of a period of time off of anticoagulation. Location and chronicity both can feed into determining thrombotic risk. An upper extremity DVT, in general, has a lower rec...
Are you more permissive of perioperative interruption of anticoagulation for VTE depending on the location and relative chronicity of the thrombus?
Yes - in general, I try to balance the relative urgency/importance of the procedure or surgery v. the thrombotic risk to the patient of a period of time off of anticoagulation. Location and chronicity both can feed into determining thrombotic risk. An upper extremity DVT, in general, has a lower rec...
Should CT coronary calcium score be avoided in dialysis patients in light of presumed high prevalence of CAC in this population?
The incidence of coronary calcifications in patients on dialysis exceeds 80% and is between 50-80% in patients with CKD. In addition, dialysis and ESRD cause two types of vascular calcification - in the medial and intimal layers, the latter being the one that correlates best with atherosclerotic pla...
Would you still consider adding clindamycin for streptococcal toxic shock syndrome in situations where the isolate is considered to be resistant?
I would not use clindamycin as clindamycin works by decreasing protein production specifically by binding to 50 S ribosomal subunit and disrupting the translation process. If I'm dealing with a toxin mediated pathology such as toxic shock, I prefer using linezolid.
When should you use caplacizumab in the treatment of acute TTP patients?
Whenever I encounter a patient with features of thrombotic microangiopathy and a normal coagulation panel (that rules out DIC), I consider the possibility they may have immune TTP.If my suspicion of immune TTP is high (e.g. history of autoimmune disease, possible relapse of immune TTP) and there is ...
Are there instances when you dose sodium zirconium cyclosilicate more than once daily for long term therapy for patients with end stage kidney disease and hyperkalemia?
Not for long-term therapy. I definitely use it more than once daily to lower serum potassium levels acutely, in patients who have clotted their access and are unable to dialyze for 1-2 days until they get decloted, etc. I would imagine that it would be safe to use long-term more than once daily exce...
For which stroke patients, if any, do you recommend implantable loop recorder for long-term cardiac monitoring and why?
Fantastic and pertinent question! I won't pretend that I have an answer, but do have a few thoughts that may help frame further discussion: We derive our evidence for the efficacy of anticoagulation in stroke prevention from older trials designed to answer that specific question (SPAF, etc.). In the...
How do you manage symptomatic ascites in a patient with SBP?
In my personal practice, the management of symptomatic ascites in the setting of concurrent SBP is a complex situation and can lead to potential complications. As SBP is a common precipitant of HRS in a cirrhotic patient with ascites, especially if hemodynamically unstable, my answer is IT DEPENDS o...