Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How would you work up an elevated copper level without cytopenias in a patient with history of bariatric surgery not on supplements or using copper utensils?
Would make sure they are not on supplements as these are often recommended post bariatric surgery. Otherwise, not sure of a connection with bariatric surgery. Would check ceruloplasmin level to rule out Wilson's disease. A low copper level is more likely and can cause leucopenia and sideroblastic an...
How do you manage recurrent hemodialysis filter clotting in an in-center ESKD patient with heparin-induced thrombocytopenia?
I have actually not faced this situation recently. something that may be tried though: flush the lines more frequently with saline, giving patients dose of eliquis orally prior to treatment, other anticoagulant?
Do you recommend targeting a higher Kt/V in an ESKD patient on hemodialysis with pruritis and a Kt/V of 1.4?
I do not. I believe there is not good evidence to suggest more dialysis will help with ckd pruritis and in general slightly higher kt/v usually does not correlate well with actual clinical findings. A better study to be done would be to see if more frequent dialysis will help treat ckd pruritis.
Does your goal rate of correction in patients with chronic hypoosmolar hyponatremia differ based on the degree of hypoosmolarity?
Certainly the lower the PNa is, any increase in PNa will have a greater effect on serum osmolality, so yes the lower the PNa the more careful I am. I would suggest never to be complacent, but for instance if the PNa was 105 I would make sure not to increase it by more than 6 in 24 hours, but if it w...
Do you recommend continuing peritoneal dialysis in an ESKD patient on peritoneal dialysis who is diagnosed with encapsulating peritoneal sclerosis since abdominal symptoms may worsen when peritoneal dialysis is stopped?
It is generally accepted that after a diagnosis of encapsulating peritoneal sclerosis (EPS), most patients are transitioned off peritoneal dialysis (PD) and switched to hemodialysis as patients with EPS often have chronic abdominal pain and will often have difficulty with dialysis adequacy and ultra...
How would you approach a patient with elevated CPK in the 500-1000 range with no weakness on exam or myositis on MRI but with positive HMGCoA ab?
No treatment but follow closely for weakness and muscle enzyme further elevation. If CK starts to go up and doubles and triples, or weakness start, then start treatment as soon as possible.
In a patient with a history of HIT, how would you reintroduce Heparin?
When patients with even remote histories of HIT are re-exposed to heparin, there is a very high risk of heparin-PF4 antibody seroconversion (Warkentin and Anderson, PMID 27114458). I have seen two patients who suffered a fatal relapse of HIT (e.g., case one in Kodityal et al., PMID 12890149). Bivali...
Would a surgical decompression be indicated in a patient with amyloidosis and severe median neuropathy at the wrist?
Yes, of course, if the median neuropathy is symptomatic. I am not aware of any literature suggesting lower rates of success with carpal tunnel release surgery in patients with various amyloidosis subtypes compared to non-amyloid CTS.
Do you recommend obtaining a spot urine or 24-hour urine magnesium measurement when evaluating patients with persistent hypomagnesemia of unknown etiology?
I try to avoid 24-hour collections for just about everything short of stone evaluations (Litholink). They are hard to do properly and bad information is worse than no information. I would use a FeMg and from UpToDate a FEMg > 3% in the setting of hypoMg and nl renal function usually indicates urinar...
In which patients awaiting a kidney transplant do you evaluate for primary hyperoxaluria given the high risk of allograft dysfunction following transplantation?
Primary hyperoxaluria is often diagnosed in adolescents and young and is typically diagnosed prior to being referred for transplant. One might consider work-up in a young to middle-aged adult with a significant history of kidney stones that are not explained by other conditions.