Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Does the overall conclusion of the CHANCE-2 trial make ticagrelor + ASA a worthwhile transition given the data showing cumulative hazard of stroke diverged during the first week and was subsequently similar, which suggests the benefit of ticagrelor over clopidogrel is seen predominantly soon after stroke?
Given the fact that clopidogrel costs 11 cents a day and ticagrelor costs almost $8/day and the fact that most patients will not be tested for slow CYP2c19 metabolizer (or have the results back in a timely fashion), it seems that the combination of ASA plus clopidogrel is the best option from a publ...
In a patient with a bleeding disorder, how would one approach anticoagulation during active COVID infection?
This is very dependent on what the bleeding disorder is, how severe it is, and what you think is the risk of clotting with this COVID infection in this individual. For example, if this is a mild-moderate type I VWD with very infrequent bleeding with a need for treatment, you could probably handle th...
How do you evaluate asymptomatic patients referred for benign intracranial hypertension?
"Benign intracranial hypertension" is not really the preferred term for pseudotumor cerebri or idiopathic intracranial hypertension (IIH) anymore, as the phenomenon can lead to permanent vision loss and thus cannot be considered truly benign. Having said that, if the patient has no symptoms (no blur...
Is rituximab for refractory ITP contraindicated in the setting of an active COVID infection, particularly in a patient with asymptomatic COVID?
Given that we would delay rituximab treatment for many active infections, I would recommend that we apply the same restrictions. I would hold the rituximab for ten days after covid test confirmation.
What is your work-up for acquired keratoderma?
The differential diagnosis for acquired keratoderma is broad and includes categories such as inflammatory skin disorders (such as pityriasis rubra pilaris, cutaneous T cell lymphoma, etc), infections (syphilis, crusted scabies, HIV, etc), medications (tyrosine kinase inhibitors, etc), nutritional de...
When do you use levocarnitine in patients on Depakote therapy for seizures?
No, unless they have elevated ammonia or LFt levels related to VPA. Hope this helps!
Do you ever do surveillance MR imaging in patients with stable exam and history of cardioembolic stroke?
I typically do not do an MRI unless a patient is having symptoms.
What is your approach to using medications that can cause bone marrow suppression in SLE patients who have persistent leukopenia?
I am so glad someone asked this question. I have heard some peers state that they are reluctant to use immunosuppressants in this situation. However, I do not agree with this. The whole reason our systemic lupus (SLE) patients have leukopenias is due to their autoimmunity (but make sure drugs, infe...
How do you approach anticoagulation in the setting of HIT and thrombocytopenia?
This is a very relevant but rather broad question. On a day-to-day basis, the decision on whether one is dealing with HIT vs other causes of thrombocytopenia can be complex. Applying the 4Ts score is easier in retrospect, but in real life patient management, the score has the potential to change alm...
How slowly do you taper a dopamine agonist to prevent dopamine agonist withdrawal syndrome (DAWS)?
Currently about to do this, myself, though mainly due to symptomatic orthostatic hypotension complicated by PDD/psychosis. I'll recommend cutting back a half tablet for one of the doses (probably first) for a week and then a 1/2 tablet for the 2nd dose for a week -- and so on until the med is fully ...