Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Would you consider opting for beta blocker withdrawal to improve exercise capacity in patients with heart failure with preserved ejection fraction and chronotropic incompetence?
The short version of my answer is Yes, however, I will provide more insight into this: When considering beta-blocker withdrawal to improve exercise capacity in patients with HFpEF and chronotropic incompetence, the evidence and guidelines are nuanced. A prospective, randomized, controlled trial "Pre...
How do you approach making an acute pain IV opioid plan for a new adult SCD patient who doesn’t remember what has worked for them in the past?
I create an FYI at the initial clinic visit and go over the FYI with them so that we are both comfortable with the plan and the patient knows their plan. The first thing I would do is look through outside records, for example, if they are available in Care Everywhere. If that is not available, then ...
What is your approach to the diagnosis of acute kidney injury suspected secondary to renal infarction from thromboembolic disease?
Renal infarction should be suspected in a patient with acute flank/abdominal pain, hematuria, and elevated LDH with normal AST and ALT, especially in the setting of atrial fibrillation, left ventricular thrombus, dilated cardiomyopathy, prosthetic heart valve, renal artery injury/dissection or hyper...
Would you continue or stop anticoagulation for a DVT/PE in a patient with active cancer who has completed 6 months of therapy?
This is an important question that we didn’t really have a clear answer for… until this year when an NEJM RCT was published! Mahé et al., PMID 40162636 In this RCT, patients with cancer-associated VTE who completed 6 months of full-dose apixaban were randomized to half-dose apixaban vs. full-dos...
How do you decide when to implement a "renal diet" (i.e., restricting electrolyte and/or fluid intake) in hospitalized patients with renal impairment?
I think about this from several perspectives: First, what's the severity of the renal impairment? Generally, I consider electrolyte abnormalities like hyperkalemia and hyperphosphatemia more likely to occur when the eGFR is <60 (for hyperphosphatemia, it might be more evident when the eGFR drops bel...
How do you manage moderate chest wall pain after breast radiation if imaging studies are normal?
Pain in the breast or chest wall due to RT-induced myositis or fibrosis is generally mild and responds to nonsteroidal anti-inflammatory agents and stretching exercises. However, one should first determine whether there is a cause of pain separate from RT effects. One of the common sources of such c...
Do you use MRSA nares PCR to influence antibiotic selection for non-respiratory infections?
BLUF: Yes, I use a MRSA nares PCR for early de-escalation in the stable patient with a non-purulent, non-respiratory infection. Mergenhagen et al., PMID 31573026 retrospectively examined nearly half a million clinical cultures and compared them to MRSA nares results. Among all infections, the NPVs w...
How do you decide when to use streptococcal urine antigen as part of your workup for pneumonia?
Guidelines recommend only using it for severe CAP as defined by the ATS/IDSA guidelines.
What are the pearls and pitfalls of using AI to draft after-visit summaries for patients discharging from the hospital?
AI can be a valuable tool for creating discharge summaries and patient education instructions for the after-visit summary (AVS) because it helps translate complex medical information into clear, patient-friendly language and concise, easy-to-read communication for primary care physicians. The quoted...
How do you approach a situation where you disagree with a consultant's recommendation for your patient, particularly when the consultant has more disease-specific expertise, but you have a fuller picture of the patient's overall clinical trajectory?
Thank you for this question. If a consultant provides a recommendation that I disagree with, I try to understand their perspective and rationale. Most of the time, it ends up in a direct phone call to talk through the clinical scenario, listen with intention to understand their perspective, and shar...