Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you start anticoagulation in a patient with infective endocarditis who also has atrial fibrillation and stroke?
In the acute phase, no. You have to get CTA or MRI/MRA with contrast to evaluate for hemorrhagic risk associated with mycotic aneurysms. Even without aneurysms, there is an increased risk of hemorrhage. I normally recommend aspirin in atrial fibrillation patients while the infection is being treated...
Is angioedema secondary to IV tPA considered an absolute contraindication for tPA in future?
In short, no. In general, the only absolute contraindications to alteplase and other forms of tPA are active bleeding or situations that could result in active uncontrollable bleeding; all other considerations are relative. Hemi-orolingual angioedema is thought to arise associated with activation of...
When do you start anticoagulation in a patient with cardioembolic CVA secondary to new onset atrial fibrillation with hemorrhagic conversion?
Those are great questions and there is no right answer. My general practice is to delay anticoagulation beyond the standard 3-14 days initiation period when there is hemorrhage. I would wait longer if the hemorrhage is parenchymal as opposed to petechial but in both cases, I performed follow up scan...
In what subset of traumatic brain injury/concussion patients would you consider use of N-Acetyl Cysteine?
There are some reports that N-Acetyl Cysteine (NAC) may help the patient with TBI for behavioral recovery and it has neuroprotective effects. I also used NAC and Alpha lipoic acid in patients with post-chemotherapy neuropathy as antioxidants. There are limited studies on how effective they are but t...
How do you approach the workup of a patient with incidentally found pachymeningitis?
In general, when we think about the meninges, we consider the leptomeninges and the pachymeninges separately, though many of the disorders of one can also cause disease in the other. We also consider whether the pachymeningitis is focal and nodular or diffuse. Common causes of pachymeningitis are in...
How do you treat refractory focal status epilepticus in patients with traumatic bilateral subdural hematomas?
It is important to know a few more facts: Are the subdural hematomas acute/relevant? Or are they chronic findings (remote symptomatic epilepsy)? If they are acute, are they significant enough to cause brain compression needing neuro-surgical intervention? Is this electrographic only (non-clinical) ...
What is the utility in repeating a temporal ultrasound (US) in a previously US diagnosed positive GCA patient who has received treatment and is presenting with recurrent GCA symptoms?
While TA ultrasound may have a role in the assessment of disease relapse, currently there is little evidence to understand its utility in this area. It is well known that the halo sign is steroid responsive and multiple studies have shown that the halo sign recedes within the first several weeks of ...
What is your approach to managing intradialytic cramping that recurs despite multiple dry weight adjustments in a patient with ESKD?
This is a great question and there is no easy answer. As always, try and make sure the patient is following fluid restriction in between treatments as having less fluid to remove during a session may reduce cramping. I also try gabapentin 100mg prior to treatment for cramping. If they treat early in...
What symptomatic management do you recommend in patients with post LP headaches?
In my clinical experience, the symptomatic/medical management of post lumbar puncture (LP) headache is challenging and of limited utility. In contrast, for the vast majority of cases, a large volume autologous epidural lumbar patch ("blood patch") is highly effective (and much appreciated by the pat...
How do you evaluate and treat patients with cerebral edema secondary to hyperammonemia?
The previous answer is a reasonable plan for the raised ICP. We need to remove ammonia - ammonia scavengers or dialysis are reasonable. If not liver cirrhosis, look for urea cycle issues even in adults, old GI surgical procedure that creates blind pouch with bacterial overgrowth, etc as other potent...