Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How would you manage a patient who presents with hair loss that began after they started a GLP-1 inhibitor?
If it fits with telogen effluvium, I recommend monitoring. Many patients will improve after this initial shedding and will not have long-term shedding or long-term thinning. If there is any underlying androgenetic alopecia or pattern hair loss, then starting treatment as you normally would is also r...
What is your preferred method for confirming the diagnosis of primary aldosteronism in a patient with an elevated plasma aldosterone to renin ratio?
The endocrine guidelines on primary aldo diagnosis (1) allow for 3 confirmatory tests: 24-hour urine, fludrocortisone suppression testing, and response to saline infusion. At UAB, we use the 24-hour urine collection. Most of our patients do not need additional salt loading during the 24-hour collect...
In patients with MASLD, would you consider management with off-label metformin, pioglitazone (despite weight gain risk), GLP-1 RA, or simply intensify lifestyle and monitor?
In 2025, we should be assessing if patients are developing F2-F3 fibrosis especially with the use of non-invasive assessments (FIB-4 score, transient elastography, or MRI elastography), and then offering either Semaglutide or Resmetirom for these individuals w/ F2-F3, which are the only FDA approved...
What is the optimal number of days to hold apixaban prior to a kidney biopsy or tunneled dialysis catheter placement?
If the patient has normal or mild renal impairment (≥30 mL/min), I will hold apixaban for 2 days prior to the procedure. If the patient has moderate to severe renal impairment (<30 mL/min), I will hold apixaban for 3 to 4 days prior to the procedure.
How long after initiating mycophenolate do you wait before tapering prednisone off in patients with myositis-associated ILD?
Taper Pred after 6 weeks MMF tapering to prednisone 20 mg/day and hold this dose for 6-8 weeks monitoring for relapses. If no relapse, taper to Prednisone 10 mg/day.
Would you start treatment for MAC in a patient with nodular bronchiectatic disease who has demonstrated radiographic progression but remains asymptomatic and smear-negative?
My default answer would be yes; this is a sign of progressive disease that will get worse without treatment. Having said that many things could be considered while making the decision, including patient preferences. First is there another cause? Does the patient have an exacerbation of bronchiectasi...
How do you counsel patients who are interested in using kratom for chronic pain management?
I am not a pain management expert, but would recommend against use for chronic pain management. Risks outweigh in a significant order. It's not FDA-approved for any form of pain treatment. There is no dosage reference to use. The pain control one gets may be too low compared to the addictive risks, ...
How do you decide when to order an EEG to evaluate for non-convulsive status epilepticus in a patient admitted with acute encephalopathy?
This can be a challenging question to answer given the broad differential of acute encephalopathy and how available EEG is at your hospital. At centers with easily available EEG capabilities, the threshold to obtain an EEG will be lower. I will also assume this question is related to patients who ha...
When do you consider pharmacologic therapies such as sodium tablets, urea, vaptans, etc., vs conservative management for persistent asymptomatic hyponatremia in hospitalized patients?
For patients with SIADH, I consider active therapy in one of the following scenarios: Na remains <130, especially <125–128, despite 24–48 h of appropriate conservative management. Fluid restriction is not feasible (thirst, tube feeds, need for hydration, patient cannot adhere). The patient has recu...
What is your approach to managing patients with hypertensive crisis and avoiding brisk reductions in blood pressure and subsequent ischemic acute kidney injury?
This is an important topic in which terminology and associated definitions are critical because they directly influence management. Historically, hypertensive crisis has served as an umbrella term encompassing both hypertensive emergency and hypertensive urgency. However, accumulating evidence has d...