Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How would you approach pursuing a kidney biopsy in a patient with suspected lupus nephritis who is on warfarin for antiphospholipid antibody syndrome?
This is a decision to be made carefully involving multiple specialists. Personally have had a bad experience with resuming anticoagulation after kidney biopsy. I have seen patients bleed even one week after doing the kidney biopsy when resuming anticoagulation. Can switch to a heparin drip before th...
Is there a BMI cutoff for which you would refer a patient needing a native kidney biopsy to interventional radiology?
I refer all my patients who require a kidney biopsy irrespective of BMI to our in-hospital Interventional Nephrology service. They evaluate the depth of the kidney from the skin surface with ultrasound and decide whether they will be able to obtain adequate renal tissue for diagnosis. If the kidney ...
Should one perform a subsequent screening CTA or MRA head for mycotic aneurysm after cardio-embolic strokes in a setting of endocarditis with initial unremarkable CTA or MRA head/neck?
If the initial CTA is unremarkable and there is no intracranial hemorrhage, I do not routinely obtain follow-up imaging. In my practice, CTA is preferred over MRA due to the lower sensitivity of non-contrast/TOF imaging in detecting small mycotic aneurysms. As mentioned above, CTA may also miss s...
Do you routinely use higher-dose VTE prophylaxis in patients admitted with traumatic orthopedic injuries undergoing surgery?
Yes, at my institution, we have two separate order sets. One is for moderate-risk medicine patients, which recommends enoxaparin 30-40 mg daily depending on renal function (heparin for ESRD and low-weight patients). The other is for high-risk patients, which includes all orthopedic and trauma patien...
How do you approach long-term blood pressure parameters in ischemic stroke patients with severe symptomatic intracranial stenosis?
Every patient is unique and I just try to be as low and slow as possible. 4-6 weeks seems to be where most people do well with others tolerating more (I'm able to get them to under 140 or even 120 during their hospitalization over a few days). In the acute setting, I've found it helpful to make sure...
In obese men presenting with gynecomastia, elevated estrogens, and hypogonadism, what clinical factors would push you to obtain testicular and/or adrenal imaging to rule out an estrogen-producing tumor?
It is not generally necessary or useful to measure serum estradiol in the evaluation of acute (tender and/or growing) gynecomastia. The widely available estradiol assays are generally immunoassays that are not accurate at the low estradiol concentrations in men. In addition, it is not uncommon to se...
When do you recommend starting a continuous opioid infusion for symptom control at the end of life?
If the RN who is at the bedside and administering intermittent opiate doses is reporting hourly administration/dosing needs, then an infusion may be warranted to optimize pain, comfort, and/or control of symptoms.
When do you recommend starting a continuous opioid infusion for symptom control at the end of life?
If the RN who is at the bedside and administering intermittent opiate doses is reporting hourly administration/dosing needs, then an infusion may be warranted to optimize pain, comfort, and/or control of symptoms.
What is your protocol for conscious sedation during T&O insertion?
I have used many forms of anesthesia for cervix HDR and all have some disadvantage. For the last couple of years I have moved to spinal anesthesia which has been ideal for our workflow. Patients receive a single dose of bupivicaine via CRNA/anesthesia team in our in brachy suite. The provides about ...
How do you approach a medically inoperable patient with clinically stage 2 grade 1 endometrioid endometrial carcinoma with heavy vaginal bleeding that is refractory to EBRT and requiring inpatient management with transfusions?
Tough case that requires some individualized care- I’d favor brachy if not resectable.