Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach for a symptomatic inpatient with locally advanced NSCLC who cannot have a PET?
These are tough cases. While we ideally aspire to have full (and congruent) staging information, this is not always possible.There are therefore competing pressures. Factors that favor AP/PA, 3 Gy fractions include 1) the need to initiate treatment rapidly given symptomatic burden and 2) the desire ...
What is your approach to platelet transfusion in heparin induced thrombocytopenia?
In general, I avoid giving platelets in intensely prothrombotic disorders, except in the circumstance of severe bleeding. Severe thrombocytopenia is uncommon in HIT, though DIC may occur in some patients. However, bleeding is relatively uncommon and platelets not generally necessary.
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,...