Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
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 ...
How much weight would you place on a low titer Ku antibody in a patient with mild CPK elevation but no weakness on exam and no other features of CTD overlap syndrome?
Not much as we know autoantibodies can be false positive especially at low titre. I do not treat patients with just autoantibody without any clinical feature. If this patient has anti-Ku antibody with elevated CK, I would just monitor the patient regularly for development of new clinical symptoms/si...
How do you approach differentiating segmental arterial mediolysis from abdominal vasculitis?
This can be quite challenging. Patients with SAM tend not to have increased inflammatory markers to the degree that patients with abdominal vasculitis do. In addition, I rarely have found a SAM patient being systemically ill like we commonly do see patients with systemic vasculitis involving the abd...
How do you manage dyschezia and tenesmus following TNT with short course RT?
Specifically for the management of moderate to severe tenesmus and pelvic pain/cramping, I’ve found that combinations of steroids, bentyl, and gabapentin are very effective. Another consideration, if sequencing short course RT prior to chemotherapy, is to delay chemotherapy for 2-4 weeks after short...
Do you favor the use of Fick or thermodiluation to measure cardiac output in patients with interstitial lung disease with suspected pulmonary hypertension?
Unless the patient has a left to right shunt or a metabolic cart is used to calculate direct Fick, thermodilution cardiac output (TDCO) is the preferred method of cardiac output measurement in all patients with pulmonary hypertension. This is supported by current guidelines. It's important to take t...
Is an elevated CRP an expected finding in an otherwise healthy patient with hemoglobin S - alpha thalassemia?
If you Google "CRP levels in sickle cell disease", you will find a number of articles reporting that CRP levels are chronically elevated in many patients with SCD. This undoubtedly reflects the chronic inflammatory state that is part of the clinical milieu of SCD. Patients with Sickle - alpha thalas...
How would you treat systemic polyarteritis nodosa with orchitis, mononeuritis and glomerulonephritis in a person who is being treated for HiV with low level viremia?
Difficult situation but there is a clear need to make decisions and balance somewhat unquantifiable risks. It is always good to remember that polyarteritis nodosa is quite rare. One should ensure the diagnosis is confirmed with, preferably, both a positive biopsy of one of the affected areas and neg...
Do you recommend starting an antiplatelet for primary prophylaxis in post splenectomy thrombocytosis given there is some increased risk of venous thrombosis?
I do not recommend routinely initiating prophylactic antiplatelet therapy for post splenectomy thrombocytosis. First, in patients without a myeloproliferative neoplasm (MPN), the increase in platelet number post splenectomy is both delayed and mild, and there is no correlation between reactive throm...
How would you manage polymyalgia rheumatica refractory to prednisone, methotrexate and tocilizumab?
Interesting situation. With PMR, the first question I continue to ask myself is - do I have the right diagnosis? This disease is always rewarding to treat whether you get the thrill of starting steroids to be the hero or starting therapy and having to reassess. You report that there are no signs of ...