Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
For patients with acute renal failure and possible urinary retention, do you obtain a bedside bladder POCUS exam before ordering renal imaging or placing a Foley catheter?
Bedside Bladder Ultrasound has a strong role in the evaluation of acute urinary retention (AUR) as a possible cause for acute renal failure. Practice varies, as does the evidence base, but most POCUS experts recommend ultrasounding both the bladder (to assess for post-void residual volume) and both ...
What adjunctive therapies beyond an antisecretory agent (e.g., PPI, H2RA, etc.) do you find most helpful in managing the acute symptoms of PUD?
A meta-analysis of studies indicates that overall healing rates for duodenal ulcers with sucralfate range from 60% to 90% at 4-6 weeks of treatment. This data confirms sucralfate's effectiveness for its primary approved indication. The data for gastric ulcers is more nuanced and somewhat contradicto...
What is your process of discontinuing testosterone you prescribe to a patient?
First of all, it’s really rare that I discontinue. Proper counseling is critical, as starting TRT will result in loss of the natural ability to produce testosterone—when many men hear this, they will decide either not to start or to consider SERM therapy with clomiphene/enclomiphene. And that’s also...
How would you manage cardiac sarcoid with intolerance/contraindications to methotrexate, azathioprine, and mycophenolate/mycophenolic acid and that has proven refractory to adalimumab and infliximab as determined by PET?
In an article by the Yale group, Gallegos et al., PMID 33997256 give a nice summary of the literature cited options for managing cardiac sarcoidosis (Non-steroidal treatment of cardiac sarcoidosis: A systematic review.Options cited here that have not been discussed include cyclophosphamide, cyclospo...
How are you incorporating the newer RCT data suggesting no mortality benefit to indefinite beta-blocker therapy for patients who are several years out from an MI with preserved LVEF and no angina or arrhythmia?
I have been de-prescribing after counseling once the patient is a couple of years out. This reduces symptoms, pill burden, drug interactions, etc., so I see an active benefit even if the patient seems to be tolerating medication. Obviously, they would have no other indication for BB, mainly arrhythm...
How do you decide when to initiate antibiotics for superimposed bacterial pneumonia in patients with influenza?
Antibiotic therapy should not be routinely prescribed for patients with influenza and should instead be reserved for those with a specific clinical concern for secondary bacterial pneumonia. This diagnosis is best identified by clinical trajectory. Key triggers include initial improvement followed b...
How do you decide when to initiate antibiotics for superimposed bacterial pneumonia in patients with influenza?
Antibiotic therapy should not be routinely prescribed for patients with influenza and should instead be reserved for those with a specific clinical concern for secondary bacterial pneumonia. This diagnosis is best identified by clinical trajectory. Key triggers include initial improvement followed b...
What are best practices for taking care of lung cancer patients during the COVID-19 pandemic?
This is a great question, and as always there is no one size fits all. For patients on active treatment for lung cancer such as chemoimmunotherapy, I continue to stress the importance of hand washing, social distancing, and to work on reducing wait times in the waiting room to limit exposure, etc. I...
When giving albumin challenge, for acute kidney injury with suspected hepatorenal syndrome, do you administer a single dose daily or split the dose of albumin?
The main concern about albumin infusions is the potential risk for pulmonary edema (China et al., PMID 33657293). Therefore, I prefer to have albumin administered in divided doses of 25 grams at a time with a max daily dose of up to 100 grams, and I tend to stop IV albumin if the serum albumin level...
What is your approach to preventing exercise-associated hyponatremia?
Exercise-associated hyponatremia is typically due to fluid intake in excess of fluid loss. Therefore, athletes should avoid overconsumption of fluids. Rather, athletes should drink according to thirst. In addition, it is important to recognize that electrolyte-containing sport drinks does not provid...