Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How would you counsel a woman with a strong family history of thrombosis about oral contraceptives?
This can be a complex question for which there are likely no specific data or guidelines upon which to base a recommendation. ASH has published guidelines on thrombophilia testing in VTE (Middeldorp et al., PMID 37195076). They specifically recommend against testing prior to COC prescription. The ra...
In older adults with mild cognitive impairment, do you ever prescribe cholinesterase inhibitors and/or memantine?
This is a great question, and of course, "do you ever" will get you in trouble every time! Let me start by saying that, in general, I do not prescribe these drugs for MCI. Cholinesterase inhibitors are clearly indicated for the mild-moderate stage of some kinds of dementia (some people would include...
Do you routinely prescribe dry powdered inhalers over metered dose inhalers for the purpose of addressing carbon emissions?
Appreciate this question because we often forget just how inextricable the link is between human health and climate health. More specifically, carbon emissions from inhalers worsen the respiratory conditions they are intended to treat. Inhaler prescriptions filled by CMS beneficiaries in 2022 were e...
Do you have a preference between an ACEI and ARB when initiating therapy for a patient with diabetic kidney disease, albuminuria, and hypertension?
Why would you use an ACEi over an ARB these days? Cough is a LOT more common than stated. I see patients all the time who have a ticket, an annoyance that goes away on an ARB. Also, I don't see a $ argument, nor am I aware that ACEi have even been shown to be superior to ARB for reno protection. Als...
What are some practical tips in distinguishing between metabolic bone disease due to chronic kidney disease and osteoporosis?
The biggest difference between osteoporosis and CKD-MBD has to do with the underlying bone mineral laboratories. Generally, with osteoporosis, bone chemistries are relatively normal; there may be a decrease in Vit D. However, with CKD-MBD, there is usually an increase in PTH, potentially abnormaliti...
Do you use DOAC in patients with mild or moderate rheumatic mitral stenosis?
Although using DOACs in this population may be safe, these patients were excluded from the large DOAC trials. In addition, MS progresses, so what may be moderate disease today will progress rapidly in some patients. Thus, if anticoagulation is necessary and a VKA is a major issue for the patient, a ...
How do you counsel patients on the risks and benefits of antidepressant use during pregnancy?
I always frame the decision as being between the risks and benefits of the medication vs. the underlying condition. We are always aiming for the "minimum effective dose" but "effective" is just as important as "minimum." Medications are, of course, not the only way to treat psychiatric illness and a...
How do you evaluate and manage incidental urinary retention in hospitalized patients?
Another great question. First, we need to confirm the presence of urinary retention (>300 ml on postvoid residual [PVR] bladder scan is considered clinically significant to continue evaluating for common reversible causes, such as medications, structural abnormalities, presence of constipation, feca...
How do you evaluate and manage incidental urinary retention in hospitalized patients?
Another great question. First, we need to confirm the presence of urinary retention (>300 ml on postvoid residual [PVR] bladder scan is considered clinically significant to continue evaluating for common reversible causes, such as medications, structural abnormalities, presence of constipation, feca...
Do you routinely check N-telopeptide levels in patients who you suspect might have immobilization induced hypercalcemia?
No, I do not check N-telopeptide level in patients with suspected immobilization-induced hypercalcemia. Although N-telopeptide is a sensitive marker of bone resorption, elevated N-telopeptide is not specific to immobilization-induced hypercalcemia and can be elevated in other clinical conditions cha...