Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When should I consider anticoagulation in an unprovoked upper extremity superficial venous thrombosis?
I would consider anticoagulation when there are significant risk factors for extension to the deep vein system such as proximity to the deep veins, underlying thrombophilia (cancer in particular), symptoms, and large clot burden.
How would you approach a non-healing wound following lumpectomy for recurrent disease in a patient who underwent breast conservation therapy with radiation 10 years prior?
Can try HBO and plastic surgery closure at some point.
What are your recommendations for adult sickle cell patients who end up being admitted several times a year for pain crises despite hydroxyurea, crizanlizumab, voxelotor, etc?
This is the problem that vexes all people treating sickle cell disease. First, is to be sure that drug dosing is optimized. Both voxelotor and crizanlizumab can be added to hydroxyurea. All three drugs could be used together. Perhaps equally important as drug therapy is to cope as best as possible w...
What is your approach to abbreviated DAPT in post-PCI patients (ACS and non-ACS) with high bleeding risk?
Current guidelines suggest dual antiplatelet therapy (DAPT) for a minimum of 6 months after PCI for patients undergoing PCI for stable CAD (non-ACS) and 1 year of DAPT after PCI for patients undergoing PCI for ACS. Patients at higher bleeding risk (HBR) after PCI, however, may not be able to tolerat...
When is a kidney biopsy warranted in a patient with possible scleroderma renal crisis?
Scleroderma renal crisis (SRC) is a relatively early complication of Systemic sclerosis that almost invariably occurs within the first five years after the onset of the disease and may even be the initial manifestation of SSc. Abrupt onset of moderate to marked hypertension and acute kidney injury w...
Do patients on eculizumab or ravulizumab require repeat vaccination against meningococcal infection after a certain interval?
Yes, CDC recommends a booster Men B vaccine 1 year after completion of series and then every 2-3 years thereafter, and booster Men C every 5 years.
Would you recommend mycophenolate mofetil for patients with progressive IgA nephropathy who do not tolerate corticosteroids?
Multiple studies showed no benefit of immunosuppressive agents (MMF, CYC), so this study is standing alone with relatively small number and limited centers. Better to role those IgAN patients in current ongoing studies, yet, I won't blame trying MMF if appropriate conservative management is optimize...
What is your PTH threshold for referring an ESKD patient with secondary hyperparathyroidism on maximum medical therapy for parathyroidectomy?
I think PTX should be done pretty much never with PTH <800 and most of the time with values >2000. Why such a large range? The biggest consideration is symptoms; if present, my threshold approaches 800. However, ascribing symptoms to hPTH is problematic. Hypercalcemia is the most specific finding wi...
Would you be comfortable using a JAK inhibitor in a patient with baseline thrombocytosis?
Knowing the etiology of this patient's thrombocytosis is a critical piece of information required before determining whether a JAK- inhibitor drug could be safely prescribed. Mutations in JAK-2 are responsible for several myelodysplastic disorders, some of which present with thrombocytosis. Therefor...
What is your approach to initial work up for a young patient with bronchiectasis?
I assume we are talking about patients in their 20s, 30s-50s who have had a HRCT with radiological bronchiectasis. It will be good to know if they have had clinical implications and symptoms of cough, infections, and mucus production. It will be good to know about multiorgan involvement like sinuses...