Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How should you manage a pediatric oncology patient who has an ANC > 500 and a normal chest x-ray but is confirmed to be infected with COVID-19 and is immunosuppressed from chemotherapy?
The treatment for pediatric patients with cancer who develop COVID-19 is very poorly defined. The risk of severe disease is unknown because although adults with cancer appear to have worse outcomes than those without, non-immunocompromised children seem to have few severe outcomes from the disease a...
Are there still clinical situations in which you deliberately treat patients with a DOAC besides apixaban?
Thank you for your question. Apixaban has been my preferred agent for a long time for patients requiring therapeutic anticoagulation. Apixaban’s lower bleeding risk was shown prior to and now has additional evidence to support this with the COBRRA trial. The risk is also ameliorated by the safety in...
Are there still clinical situations in which you deliberately treat patients with a DOAC besides apixaban?
Thank you for your question. Apixaban has been my preferred agent for a long time for patients requiring therapeutic anticoagulation. Apixaban’s lower bleeding risk was shown prior to and now has additional evidence to support this with the COBRRA trial. The risk is also ameliorated by the safety in...
When you identify new atrial fibrillation in a hospitalized patient that spontaneously converts to sinus rhythm within 24–48 hours, and the patient has a CHA₂DS₂-VASc score of 2–3, how do you decide whether to initiate anticoagulation and/or discharge with a wearable cardiac monitor?
This is a tough one. I think the easier part is who should get a wearable cardiac monitor? I think the answer is pretty much everyone since the recurrence rate is around 30% in one year - and if it recurs, it predisposes to strokes, and I'd likely provide anticoagulation per AHA/ACC based on CHA₂DS₂...
For patients admitted with acute decompensated heart failure, do you wait until the patient is euvolemic before ordering a TTE?
For patients with newly diagnosed CHF, I always get a TTE prior to discharge to establish a baseline study. It would help me identify valvular disease and pulmonary hypertension, or other structural problems. If a TTE would help you distinguish CHF from other volume overload conditions, then I would...
When do you consider PET/CT to evaluate for an occult source of infection in patients with persistent bacteremia if TTE/TEE does not show evidence of endocarditis?
Great question. Generally, I consider PET/CT to evaluate for an occult source of infection in patients with persistent bacteremia if TTE/TEE does not show evidence of endocarditis, in the following scenarios: Persistent bacteremia ≥72 hours. TEE was negative or nondiagnostic. No source identified o...
What are the current official guidelines regarding managing patients during COVID-19?
Here are some guidelines and FAQ from professional societies: NCCN: https://www.nccn.org/covid-19/default.aspx ASTRO FAQ: https://www.astro.org/Daily-Practice/COVID-19-Recommendations-and-Information/COVID-19-FAQs ASCO Coronavirus Resources: https://www.asco.org/asco-coronavirus-information
In a hospitalized patient with compensated cirrhosis or heavy alcohol use requiring analgesia, do you use acetaminophen and if so how do you approach dosing?
For compensated cirrhosis, acetaminophen could be used. It's a common practice to offer acetaminophen in these patients at max 2 g/day. Again, I would advise closely monitoring liver function. In patients with heavy alcohol use, acetaminophen could be used cautiously if the liver function is fine (w...
What is your approach to patients with chronic hypoxemic respiratory failure who have apparent higher oxygen needs during hospitalization but no clear acute/decompensated respiratory illness?
Will work them up completely for infection, PE, COPD exacerbation, heart failure/cardiac etiology. If no convincing reason for decompensation and they are stable, I will have them do a 6 min RT walk test to determine oxygen needs and have them follow up with PCP or pulmonary for further PFTs or othe...
At what point would you consider stopping antidepressant treatment of late life depression after remission?
My first step here would be to answer some clarifying questions: What is the patient's current prognosis? (If the patient has a limited life expectancy- weeks to small order months- then I would certainly consider deprescribing with more ease.) Are there any foreseeable anticipated triggers for depr...