Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you manage MPN patients with acquired VWD in the perioperative setting?
The greatest risk of a very high platelet is bleeding not thrombosis, and it is fair to say that this appears to apply to myeloproliferative (MPN) thrombocytosis as opposed to reactive thrombocytosis (there is no correlation between the platelet count and thrombosis with either cause of thrombocytos...
Should checking a urinalysis with reflex to culture be part of the standard work up for fever in an ICU patient with a urinary catheter?
Yes, as part of a broad workup for infectious and non-infectious causes of fever, and with many caveats. Patients in the ICU are at high risk for diagnosis with CAUTI, yet as I think you are applying, this is a difficult diagnosis to make given the inability of many patients to give a history (or fo...
How often do you check urine osmolality and urine electrolytes when treating hospitalized patients with hyponatremia?
Correction of hypovolemia with isotonic saline may result in overly rapid correction of hypovolemic hyponatremia once the stimulus for ADH secretion is removed, resulting in the excretion of a very dilute urine. Therefore, urinary electrolytes and osmolality should be closely monitored every 3-4 hou...
Do you use any urinary staining techniques when performing urine microscopy for patients with acute kidney injury?
No. Not at this time. At one point, about 10 years ago, we did have Wright stain to stain for eosinophilluria but it seemed too labor-intensive and not that helpful, so we stopped using it.
Can defibrotide be given safely for VOD in patients with refractory thrombocytopenia to platelet transfusions?
The short answer is "yes."The slightly longer answer is: “Yes, and in patients with veno-occlusive disease (VOD), the use of defibrotide is potentially life-saving (Richardson et al., PMID 26825712).” In the cited study, which led to its FDA approval for this indication, there was no significant dif...
Have you considered priming CRRT machines with renal replacement solutions during the current crystalloid solution shortage?
Yes. We are doing it. I don't see any problems from this practice.
What clinical sign or symptom do you consider to be the most specific for Cushing syndrome?
Cushing's syndrome is a rare disease. The following symptoms and signs are suggestive. Symptoms: weight gain, especially in the middle, muscle weakness, and easy bruising Signs: Moon facies Central obesity with relatively thin arms and legs Pad of fat behind the neck (Buffalo hump), thin skin, pur...
Do you use a phosphate binder to manage inpatient hyperphosphatemia in patients with AKI who have no history of CKD?
I agree there is uncertainty about optimal serum phosphate concentrations in patients, and essentially no data in AKI. However, increases in Phos do result in an increased risk of metastatic calcification, and increases FGF23 and PTH, even in AKI and these changes clearly have increased risks, thus,...
In which patients do you recommend craniectomy-watch after acute stroke?
The ideal candidates are younger patients with full MCA distribution stroke. One issue to be mindful of is that the “watch” part should be focused on watching to confirm the radiographic size of the stroke and the presence of cerebral edema. I would caution against watching for clinical deterioratio...
With the recent trials such as SELECT and STEP-HFpEF demonstrating benefits of GLP1-agonists in terms of CV risk reduction and improved exercise function, have you begun to incorporate this class of medications into routine CV health maintenance for patients with HFpEF and/or pre-existing CAD?
I would strongly support the use of this medication. The biggest challenge is insurance coverage. When would it be approved by insurance and how many hoops we will need to jump before they approve it?