Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
For patients with patellofemoral pain syndrome whose symptoms continue despite an adequate course of physical therapy, what adjunctive treatments (bracing, taping, injections, orthotics, or imaging) do you consider most helpful?
After an adequate course of physical therapy (under the guidance of a knowledgeable PT), I recommend imaging to determine if there is underlying pathology like chondromalacia, chondrosis/fissuring, an OCD lesion, or perhaps a tendinopathy or fat pad impingement. Starting with a plain film (AP, later...
How do you recommend mitigating the risks of using beta blocker and clonidine therapy in combination for management of hypertension?
Beta blockers vary in lipophilicity, which affects blood-brain barrier permeability. Propranolol and metoprolol readily cross the blood-brain barrier, while other beta-blockers like nebivolol do not. The CNS side effects of fatigue, depression, and insomnia are more likely to worsen if using a lipop...
How many days prior to elective major surgery do you recommend holding oral GLP 1 R agonist therapy?
Zero. Or, I suppose, if you're having surgery early in the morning, one.This has gone back and forth, but the most recent guidance from the ASA (with other societies concurring) has been that most patients can continue their GLP medications as normal preoperatively, with higher-risk people being rec...
How do you approach management of new onset ILD in a patient with RA who is otherwise well controlled on methotrexate or leflunomide?
We do not have any randomized controlled trials for DMARDs in RA-ILD. Most of the data is case series or retrospective analysis. Nonetheless, we can use current data to at least make clinical decisions until we receive more direction from high-quality clinical trials. We now know that in general met...
Do you recommend initiating treatment with an SGLT2 inhibitor or semaglutide first for a patient with obesity and heart failure with preserved ejection fraction?
Irrespective of body weight status, my first line of treatment for patients with HFpEF is with SGLT2 inhibitors if there are no contraindications (DELIVER trial and EMPEROR preserved trial). For patients with obesity (cardiometabolic) phenotype HFpEF, who qualify for GLP1 receptor agonists, I add on...
How do you approach caring for patients admitted with decompensated CHF, but who also exhibit hypotension and do not have overt signs of hypervolemia on exam?
This is a case where you might be concerned about the patient sliding into cardiogenic shock. Remember that in the context of chronic heart failure, cardiogenic shock tends to present more insidiously because these patients are typically compensated at low or borderline low cardiac output (Abraham e...
How do you approach caring for patients admitted with decompensated CHF, but who also exhibit hypotension and do not have overt signs of hypervolemia on exam?
This is a case where you might be concerned about the patient sliding into cardiogenic shock. Remember that in the context of chronic heart failure, cardiogenic shock tends to present more insidiously because these patients are typically compensated at low or borderline low cardiac output (Abraham e...
Should we routinely include geriatric functional assessments to determine candidacy for TAVR?
Studies have shown that 40-50% of older patients with severe AS and high (≥8%) or prohibitive (≥15%) risk for perioperative mortality with surgical aortic valve replacement (based on the STS score) fail to survive with improved quality of life 1 year after undergoing TAVR. This suggests that TAVR ma...
In patients presenting to the hospital with atrial fibrillation of >/= 48 hours and are started on anticoagulation, provided they spontaneously convert with AV nodal blocking agents but then revert back into AF, would you need LAA imaging before a rhythm control strategy with AADs or cardioversion?
I would approach this the same way as if the patient had never spontaneously converted. There is a risk of stroke with chemical as well as electrical cardioversion, so should factor in CHA2DS2-VASc when making that decision. If CHA2DS2-VASc is 0 and no other high-risk features (rheumatic disease, HC...
What is the optimal antithrombotic management, if at all, in patients with incidentally identified findings of multiple silent embolic appearing cerebral infarcts?
It is important to confirm the pattern is embolic. If unsure, input from a specialized physician (such as vascular neurology or neuro-radiology, if available) can aid in confirming the diagnosis. Various white matter findings may mimic an embolic pattern, and distinguishing between unilateral...