Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How should a patient with perforated H. pylori negative gastric MALT be managed?
Generally, the treatment for H. Pylori neg gastric MALT of limited stage is radiotherapy, dose 24-30 gy. The question presumably concerns the influence of a history of perforation on that recommendation. Data are limited but radiation induced gastric or intestinal perforation when treating lymphoma ...
What is your approach to a patient who has an ischemic stroke while on clopidogrel despite strict compliance and normal results on clopidogrel response assay?
Not all recurrent infarcts are from a failure of anti-thrombotics, some patients with large artery atherosclerosis are not taking their statin (as evidenced by no change in LDL-C) or are not exercising (based on subanalysis of SAMMPRIS), other lacunar subtype patients have uncontrolled hypertension,...
What is your approach to treating severe manifestations of neuropsychiatric SLE in the setting of concomitant infection?
This is a scenario that most rheumatologists will face during their careers, and it always makes us nervous. We ask ourselves your exact question as we decide upon management.First, I cannot let this question go without making a statement about the term "neuropsychiatric SLE." I propose that this sh...
How do you approach infused prostacyclin therapy for critical digital ischemia?
This is a great question! Critical digital ischemia (CDI) associated with Raynaud phenomenon (RP) requires urgent measures to prevent digit loss. While, thankfully this is not very common, we come across it often enough in patients with structural vascular disease (occlusive vasculopathy) superimpos...
What is the maximum pRBC volume you can transfuse when performing a manual exchange transfusion in an adult-sized patient with sickle cell disease?
It depends on how much hemodynamic stress the patient can tolerate and the rate of the phlebotomy. The rate is usually 30 minutes for every 500 cc whole blood, but may need to slow down in smaller-sized patients (e.g. 50 kg or less), patients with history of pre-syncope or syncope with phlebotomy, a...
What is your preferred anticoagulant for acute portal vein thrombosis?
The most common reason for portal vein thrombosis is underlying portal hypertension from cirrhosis. Thus, treatment choice is limited by the underlying liver disease. If they have liver disease with prolonged baseline PT, coumadin should not be used. Likewise, if they have liver disease, I don't fee...
How do you prescribe Perampanel for use in patients with refractory status epilepticus?
LD: 6-12 mg MD: 12 mg/day Use not recommended in severe renal impairment (CrCl <30 ml/min). Consider dose reduction in mild to moderate hepatic impairment. Use is not recommended in severe hepatic impairment.
How do you approach management of newly diagnosed locally advanced NSCLC in patients who are intubated for respiratory failure due to their disease burden?
There are a few other approaches that can sometimes help: Interventional pulmonology can sometimes debulk tumor in the airway and/or place a stent. I've had some success with intrabronchial brachytherapy as well. I've had more success with 1-3 relatively large radiation fractions (4-6Gy). However,...
How would you approach treatment for fulminant RA-associated ILD?
Even though this hypothetical patient has tolerated methotrexate (MTX), I would probably stop it since MTX can directly scar lung parenchyma and continuation of it may confuse the clinical picture. The data for adverse lung toxicity with TNFi drugs is less clear, so I would consider maintaining it. ...
Would you hold osimertinib in a patient with a STEMI, and for how long?
Compared with other EGFR TKIs, osimertinib seems to have a higher risk for cardiac events including decreased LVEF and prolongation of QTc. In an interesting analysis utilizing the FDA Adverse Events Reporting System (FAERS), investigators found that, when compared with all drugs reported in this da...