Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to the management of shrinking lung syndrome in SLE?
No consensus exists on the best way to diagnose shrinking lung syndrome (SLS). Interestingly, I rarely see this anymore. Possibly due to better treatments and universal use of hydroxychloroquine (HCQ)? We are not even sure how and why it occurs. Could it be a myopathy of the diaphragms or a result o...
How do you manage headaches in stroke patients?
In general, I treat headaches based on phenotype. If they have associated migraine features then I treat them with migraine medications. If tension type then I address all the headache hygiene components. If cervicogenic then physical therapy for these. Always screen for and counsel on medication ov...
How do you dose apixaban in patients with CrCl <30 mL/minute?
Patients with chronic kidney disease are challenging to treat with anticoagulation as they have an increased risk of both venous thromboembolism and bleeding. Treatment should be individualized after weighing the risks and benefits of anticoagulation as well as the indication for anticoagulation. Th...
Do you recommend any specific testing for patients with recurrent nephrolithiasis and suspected absorptive hypercalciuria?
I would consider genetic testing in this situation, although it would not alter my recommendations for diet and thiazide diuretic treatment. I would also look for primary hyperparathyroidism. Counterintuitively, parathyroid hormone increases absorption of urinary calcium; that’s why HPT patients are...
How do you manage MAT for opioid use disorder in lung transplant patients during the peri/postoperative period?
There is currently no evidence regarding mOUD in lung transplants. Available research represents generally a weak quality of evidence regarding opioid use for pain control before and after lung transplant. Non-opioid analgesic interventions, including thoracic epidural anesthesia and intercostal ner...
How do you choose between spironolactone and finerenone for patients with proteinuric diabetic kidney disease and heart failure?
Although finerenone may be easier to use due to its lower incidence of sexual side effects and hyperkalemia, it is more expensive than spironolactone and may be more difficult to prescribe. Many prescription drug plans require prior authorization for finerenone and documentation that the patient has...
Should platelet transfusions be considered for anti-platelet agent reversal in patients with major bleeding?
Patients on plavix and/or aspirin are at risk for bleeding whether in relation to surgery or bleeding from the gi tract. Much like the management of patients on anticoagulation temporary reversal of antiplatelet drugs is only achieved by normalizing platelet function. This is the same principle used...
How do you manage concurrent non-life-threatening hemoptysis and acute pulmonary embolism?
Hemoptysis can occur with PE when there is pulmonary infarction. However, the majority of pulm embolism cases have pleuritic chest pain without infarction. Significant hemoptysis is very rare in these cases and anticoagulation is nearly always safe. When hemoptysis continues or the volume is concern...
What is your protocol for transitioning to oral anticoagulation post-thrombolysis for pulmonary embolism?
My answer has multiple parts."Thrombolysis" is not all the same. As studied in stroke treatment, alteplase causes marked fibrinogen depletion and coagulopathy (prolonged PT, aPTT), whereas tenecteplase doesn't so much (Huang et al., PMID 26514192).So, if alteplase was used (systemic or reduced cathe...
Do you recommend early oral nutrition when managing diabetic ketoacidosis?
There are many benefits to starting enteral feedings in patients undergoing treatment for DKA. Once insulin is being infused, the use of enteral nutrition will help suppress ongoing ketosis. Also, restarting nutrition will help prevent weight loss during recovery. Of course, some patients have condi...