Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you perform a kidney ultrasound in patients following a kidney biopsy to evaluate for post-procedural complications?
I agree with Dr. @Dr. First Last. There is a high incidence of hematoma formation post-kidney biopsy when evaluated by ultrasound (70%) or CT scan (90%). This will result in unnecessary ultrasounds leading to stress for patients and physicians. I usually get a hemoglobin level 4-8 hours after the bi...
What is your approach to weaning dialysis in a patient with AKI on CKD and CHF who now has resolved AKI but a history of recurrent episodes of decompensated heart failure?
My preference would be to keep them on dialysis. If the serum creatinine is really getting toward the normal range and urine output is good, I would just stop dialysis for a week and give them diuretics to see if they can do without dialysis. However in patients with creatinine levels in the higher ...
Are there instances when you would recommend against pursuing adrenal vein sampling in a patient with primary hyperaldosteronism and normal adrenal imaging?
Yes, it is not uncommon for patients to choose not to pursue an adrenalectomy. I do not get the adrenal vein sampling (AVS) until I've had a discussion about the risk/benefits of adrenalectomy. Sometimes, I'll have them visit the surgeon before attempting an AVS to get a full picture of the surgery ...
How do you think about deferring VTE prophylaxis versus implementing non-pharmacologic methods when chemical prophylaxis is contraindicated?
No good reason not to use mechanical/non-pharmacological methods for VTE prophylaxis. Modality may not be ideal, but it is a generally accepted alternative when you cannot use chemical/pharmacological agents.
How would you approach management of nodular scleritis in the setting of suspected GCA?
Scleritis is probably a rare but real association with GCA. The rarity is such that I would not ignore alternative causes of scleritis. For example, ANCA-associated vasculitis could mimic GCA and syphilis has also been reported as a masquerade. Scleritis is usually divided into 5 forms: nodular, dif...
Can giant cell arteritis present with a partial cranial neuropathy?
Giant cell arteritis (although giant cells on temporal artery biopsy are not a sine qua non) most typically presents to the neuro-ophthalmologist with ischemic optic neuropathy (usually anterior and sometimes posterior).Ophthalmoplegia is uncommon in GCA but has been attributed to oculomotor and abd...
Is there any role for prophylactic bronchial artery embolization in immunocompromised patients with invasive pulmonary aspergillosis?
Bronchial artery embolization is NOT without complications. Although the bleeding risk is very high in invasive pulmonary aspergillosis, empirical embolization is not well supported either by data or clinical practice. It probably should be a case-by-case decision.
What is your approach to managing patients who initially present with symptomatic intracranial large vessel occlusion but subsequently experience resolution of symptoms or become non-disabling before any intervention?
If a large vessel occlusion (LVO), such as ICA-terminus, M1, or Basilar, is present, I would treat it even if there has been a significant improvement in symptoms. As mentioned in the prior post, an occlusion in one of these areas will likely exhaust collateral reserves and become symptomatic again....
What factors would influence your decision to use or avoid heparin bridging in patients with mechanical heart valves resuming anticoagulation after intracerebral hemorrhage?
The main conclusion from the publication by Sakusic et al., PMID 39102615 was that withholding anticoagulation for the first seven days after ICH is safe in patients with mechanical heart valves and bridging with intravenous heparin to coumadin upon resumption of anticoagulation should be avoided. T...
When would you consider aspirin for long term management of unprovoked VTE after initial therapeutic anticoagulation?
The WARFASA trial randomly assigned patients with first unprovoked VTE who had completed 6-18 months of anticoagulation to 2 additional years of aspirin versus placebo. While the study demonstrated a 40% reduction in recurrent thrombotic events, the rates of VTE in those receiving aspirin were still...