Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you use MRSA nares PCR to influence antibiotic selection for non-respiratory infections?
BLUF: Yes, I use a MRSA nares PCR for early de-escalation in the stable patient with a non-purulent, non-respiratory infection. Mergenhagen et al., PMID 31573026 retrospectively examined nearly half a million clinical cultures and compared them to MRSA nares results. Among all infections, the NPVs w...
Do you routinely check digoxin levels, and if so, when would you consider using Digibind in chronic digoxin use patients?
The subanalysis of the DIG trial gave some insight into the value of keeping digoxin levels below 1.0. If HF patients, I tend to look at the levels for that reason. I rarely use digoxin for AF as there is little evidence of benefit with some evidence of harm. Re: use of digibind, I limit this if t...
In older adults with chronic mild hyponatremia (Na 128–132) attributed to SSRIs but good psychiatric response, do you tolerate persistent hyponatremia, reduce the dose, or switch agents?
In my practice, I generally tolerate mild hyponatremia, Na>130, if asymptomatic and mood symptoms have good control. If there’s moderate hyponatremia, Na 125-130, I generally consider either changing the dose or the agent. If severe, Na<125, I would change the agent and likely avoid the entire class...
What medications are preferred and contraindicated for insomnia in patients with a recent stroke or traumatic brain injury?
In acute brain injury (ABI), which includes stroke and traumatic brain injury the focus is often on neurorehabilitation. The presumption here is that the patient is medically and neurologically stable. For example, not having a stroke in evolution, uncontrolled gastrointestinal bleeding, or similar....
For older adults undergoing intermediate-risk non-cardiac surgery, do you routinely check pre-operative pro-BNP levels for risk stratification based on emerging data and updated Canadian guidelines?
Pre-operative NT-proBNP and BNP levels have been featured, not just in the cited Canadian guidelines but also in the 2024 update of the AHA/ACC preoperative evaluation guidelines. (Thompson et al., PMID 39316661). Those guidelines recommend evaluating a pre-op NT-proBNP level if the results will cha...
For older adults undergoing intermediate-risk non-cardiac surgery, do you routinely check pre-operative pro-BNP levels for risk stratification based on emerging data and updated Canadian guidelines?
Pre-operative NT-proBNP and BNP levels have been featured, not just in the cited Canadian guidelines but also in the 2024 update of the AHA/ACC preoperative evaluation guidelines. (Thompson et al., PMID 39316661). Those guidelines recommend evaluating a pre-op NT-proBNP level if the results will cha...
Should asymptomatic esophageal candidiasis identified incidentally on endoscopy be treated?
Yes, in our practice, we do treat asymptomatic esophageal candidiasis when found incidentally on endoscopy. A few things to consider: 1) While patients may be asymptomatic at the time of the endoscopy, untreated disease can lead to the future development of complications/symptoms, such as odynophagi...
What is your approach to perioperative risk stratification and optimization in patients with cirrhosis?
The VOCAL-Penn score is one piece of information that I use for risk stratification in patients with cirrhosis. I usually treat symptomatic decompensated cirrhosis first (hepatic encephalopathy, ascites, hepatic hydrothorax, hepatorenal syndrome, variceal bleeding), because the risk scores usually c...
How do you approach managing perioperative anxiety in Mohs patients?
Great question. Music, stress balls, having your team engage in conversations with the patient, and other distraction techniques are helpful. Some patients may need medications such as Halcion to help with anxiety but this should be given after the patient signs consent and has a verified driver aft...
How do you approach the choice of pharmacological therapy when treating insomnia in older adults in the outpatient setting with a high falling risk?
My approach is to first see if there are non-pharmacologic options to help with sleep - are there behavioral factors to target (e.g., caffeine or alcohol use; inappropriate sleep scheduling or daytime napping), medications that could disrupt sleep-wake schedules, or untreated sleep or mood disorders...