Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Is there a role for using continuous glucose monitors for perioperative glucose monitoring in patients with diabetes?
Use of continuous glucose monitors is becoming more widely accepted for outpatients with diabetes to manage their glucose. Many hospitals now allow patients to continue to use their CGM when admitted, though most require some hospital monitoring as well. During the early phases of COVID, ICUs starti...
When would be your threshold to consider obtaining an exercise RHC for undifferentiated dyspnea to help diagnose HFpEF?
When to Consider Exercise Right Heart Catheterization (RHC) for Diagnosing HFpEF in Patients with Undifferentiated Dyspnea: Persistent, Unexplained Dyspnea: Clinical Context: Exercise RHC is indicated in patients with persistent dyspnea not explained by common conditions such as chronic obstructiv...
In light of the NOAH-AFNET6 and ARTESiA trials, how would you approach the decision regarding anticoagulation for patients with incidentally-detected AF <24 hrs on pacemakers/defibrillators?
Finding the right answer for subclinical atrial fibrillation is sometimes hard to tease out the subtleties. The 2023 ACC/AHA/HRS atrial fibrillation guidelines were published in Jan 2024 (Joglar et al., PMID 38033089) and a section (6.4.1) is dedicated to patients with CIED without prior atrial fibr...
How do you manage significant asymptomatic indirect hyperbilirubinemia in patients with hemolytic diseases (SCD, HS, etc.)?
Hello, Indirect bilirubin is from hemolysis, not cholestasis (a few exceptions from rare syndromes), so not associated with stones, and would not expect ursodiol to help. It's a marker of how bad the sickling is - along with LDH, reticulocyte count, and MCHC (which measures cell density, i.e., irrev...
What is your approach to the workup for an underlying systemic condition in a patient presenting with retinal vasculitis?
Retinal vasculitis is a frequently misunderstood condition. My colleagues and I have written about it on several occasions such as in Current Opinion in Rheumatology, 2016. Retinal vasculitis is often diagnosed by an ophthalmologist on the basis of vascular leakage in a test called a fluorescein ang...
Do you administer immunosuppression to patients with idiopathic NSIP who have normal lung function and mild to moderate respiratory symptoms?
I think it depends on whether or not it clinically seems that the idiopathic NSIP is driving the mild to moderate respiratory symptoms. If there are no other clear causes of the respiratory symptoms (pulmonary hypertension, cardiovascular disease, airways disease, etc.) and the HRCT imaging findings...
Are there any instances when you would not perform 3 consecutive daily dialysis sessions when initiating a patient on hemodialysis?
In-patient - Friday, Saturday, and Sunday (we are not fully staffed on Sundays). Out-patient - I see no reason to do three days in a row. There is nothing magical about starting dialysis. Patients were surviving without it before you started it, there is no rush. Updated answer: YES - I would no...
Do you consider tracheostomy for the management of continued hypercapnea despite compliance with PAP in patients with OHS and OSA?
I would try AVAPS such as trelegy machine first before considering Tracheotomy. In most circumstances with good compliance, it helps with the hypercapnic failure.
In a patient with anaphylaxis and loss of consciousness from stinging insect, suspected to be yellow jacket, the sIgE was significantly positive to all vespids, but honeybee and paper wasp were only 0.44, would you evaluate further with skin testing to wasp and decide on including wasp in treatment based on skin testing being positive or include it with just the low IgE level?
The wasp IgE may be cross-reactive with YJ, and if the YJ is more than 5 times higher than Polistes IgE then this is almost certainly the case, which would suggest that Polistes VIT is not necessary. However, there is no available test to prove the cross-reactivity, so given the severity of the reac...
How do you approach the workup of clinically diagnosed cutaneous vasculitis in healthy young individuals without systemic symptoms?
As with all of medicine this answer depends on the presentation. A thorough review of systems and exam is needed to stratify workup. If we are talking about classic LCV below the knee in an otherwise healthy person, with no other concerning s/sx (as sounds like you are asking), I do generally confir...