Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How would you manage anti-platelet therapy in patients presenting with ischemic stroke and have a history of von Willebrand disease?
I follow the ASH ISTH NHF WFH 2021 guidelines, recommendation 3: "In patients with VWD and cardiovascular disease who require treatment with antiplatelet agents or anticoagulant therapy, the panel suggests giving the necessary antiplatelet or anticoagulant therapy over no treatment (conditional reco...
Do you routinely start full dose anticoagulation in new onset atrial fibrillation in the ICU?
Yes. (Based on CHADS2 + Absence of absolute contraindications, i.e., active uncontrolled bleeding or coagulopathy.)
What is your threshold to start stress dose steroids in the management of patients with septic shock?
Absent long-term use at baseline, I do not routinely start stress dose steroids for patients with septic shock. I reserve steroids for patients with a persistent vasopressor requirement despite adequate volume resuscitation and treatment of the underlying source of infection.
What is your approach to BK hemorrhagic cystitis not responding to cidofovir?
BK hemorrhagic cystitis can range from completely asymptomatic infection (with positive BK viremia and viruria by PCR) or grade 0 to massive macroscopic hematuria requiring instrumentation for clot evacuation and urinary obstruction requiring bilateral nephrostomy tubes for urine diversion (grade 4)...
For a patient with PE undergoing procedures like port placement in the first month, how do you manage anticoagulation?
Due to their convenience, efficacy, and safety, I think direct oral anticoagulants (DOC) are the agents of choice for most cases of PE, DVT, or chronic prophylaxis. As per the package insert for Apixaban, for moderate or high risk invasive procedures, stop 48 hrs in advance, and for low risk, stop 2...
Do you recommend testing for G6PD deficiency in those with whom rasburicase for tumor lysis syndrome is indicated?
G6PD deficiency is a contraindication to the use of rasburicase and should be tested for prior to the use of this drug.
What is your approach to managing hypocalcemia following a parathyroidectomy in patients with end stage kidney disease?
The hungry bone syndrome can be tricky and insidious. I have seen patients go home after a pth-ectomy without evidence of it and then a few days later show up in the ED with symptoms of hypocalcemia. Hemodialysis may mask it (as well as treat it) by supplying a large IV calcium load. If you dialyze ...
What is your daily correction goal for those patients being treated for hypernatremia?
There is no correction per se. Although, older guidelines recommend a correction of no more than 8-10 mEq/dL in 24 hours. The theoretical risk of correcting hypernatremia too fast is the development of cerebral edema. However, a recent study (Chauhan et al., PMID 30948456) showed no evidence of cere...
What is your approach to the use of desmopressin prior to performing a kidney biopsy to potentially prevent procedural associated bleeding?
I do not routinely request a bleeding time or administer desmopressin prior to performing a percutaneous kidney biopsy. The bleeding time is very operator dependent and therefore could be prolonged even when platelet function is normal. I ask patients to hold aspirin one week before performing a kid...
Is there a platelet count threshold when you would avoid performing a kidney biopsy in patients with thrombocytopenia?
The kidney biopsy is considered a high-risk procedure. The society of Interventional Radiology recommends: INR less than 1.5 and platelet more than 50,000.We follow these recommendations!Patel et al., PMID 22513394