Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach weakly positive PL-7 antibody in a patient who initially presented with muscle weakness, rhabdomyolysis and non specific muscular edema on MRI that resolved with IV fluids?
During an episode of rhabdomyolysis, muscle MRI isn't reliable since it would be positive regardless of the underlying cause. So, monitoring the trajectory of CPK levels and serial muscle exams to evaluate for weakness would offer a more reliable assessment for true myositis. Positive antibody resul...
What are alternate approaches to medical therapy and/or interventions to consider in patients with refractory, severe coronary vasospasm despite short-acting nitrates, calcium channel blockers, L-arginine, and clonidine?
Angina caused by coronary vasospasm is relatively rare. I have come across very few cases of severe coronary vasospasm in my 15 years of career. The most common thread seems to be smoking and drug abuse (amphetamines, cocaine). Smoking cessation and stopping drug abuse are the most important interve...
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 ...