Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you recommend the use of portable high-efficiency particulate absolute air cleaners to former smokers with moderate to severe COPD?
This is a regional decision that is based upon ambient air pollution, such as wildfire smoke in the Southwest, and can be trialed before purchase to evaluate symptomatic efficacy. The CLEAN AIR STUDY (Hansel et al., PMID 34449285) did not validate improvement in total St George's Respiratory Questio...
Do you routinely order a pre-operative TTE in patients with apparently compensated CHF, but who have not had an echocardiogram in some time?
In a patient with compensated CHF (with stable symptoms), I do not routinely order pre-operative echocardiograms for evaluation of ejection fraction. There are some situations in which it may be helpful for perioperative risk assessment, counseling, and management.The 2024 ACC/AHA (American College ...
How long do you recommend patients hold aspirin for prior to and after undergoing a native kidney biopsy?
I usually recommend that patients hold aspirin (ASA) 7 days prior to and one day after undergoing a percutaneous native kidney biopsy. 30 mg of ASA irreversibly inhibits cyclooxygenase a key platelet enzyme for the synthesis of thromboxane and the effect lasts for approximately one week. This effect...
How do you reconcile the risk of contrast-induced nephropathy (CIN) with the diagnostic benefit of contrasted CT in patients with AKI/CKD?
Overall, the risk of contrast-induced nephropathy is much less than what we fear. In many studies, we underutilize CT because we're concerned about contrast-induced nephropathy. If there is a good reason to get the CT with contrast, then I think it should be done. And just monitor Cr.
What is your approach to iron supplementation in patients with an active infection?
In patients with active infections, I generally avoid intravenous iron due to the potential for promoting pathogen growth, a practice supported by cautions from nephrology and gastroenterology society guidelines. However, evidence for the risk of infection with IV iron is inconsistent, underpowered,...
What is your approach to iron supplementation in patients with an active infection?
In patients with active infections, I generally avoid intravenous iron due to the potential for promoting pathogen growth, a practice supported by cautions from nephrology and gastroenterology society guidelines. However, evidence for the risk of infection with IV iron is inconsistent, underpowered,...
What class(es) of antihypertensives should be considered next for refractory hypertension in a patient compliant with high doses of Entresto, chlorthalidone, amlodipine, clonidine, and spironolactone if they previously did not have any improvement on beta blocker or hydralazine and work-up for secondary causes were unremarkable?
Minoxidil remains a rarely used but potent option.
Is there a serum phosphorus level you would consider too low to safely perform hemodialysis?
I actually do. I have previously published reports of 2 patients who developed recurrent encephalopathy due to dialysis-induced hypophosphatemia. They were treated with adding phosphorus to the dialysis fluid and the episodes did not recur (Koganti & Sam, PMID 31940631). I definitely do not want the...
Do you perform pap smears as part of the surveillance of patients with a history of cervical or vaginal cancers who had radiation as part of their treatment?
I personally do not routinely perform pap testing for patients with a prior history of cervical or vaginal cancer who have had prior radiation. The main driver for me in this decision is that the results we receive from Pap testing often show abnormalities that are not reflective of recurrence or de...
How have you improved your serious illness conversation skills over the course of your career?
I surely hope that my communication skills have improved over the course of my career (in the same way that being a doctor has improved). However, improvement as a clinician doesn't just happen. One has to be intentional about it. Things that will help: Take a course. VitalTalk runs a number of edu...