Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your institutional approach to a restrictive “neutropenic diet”?
Simple answer: never. The "neutropenic diet" has no efficacy and may actually be nutritionally AND microbially inferior to normal diet. This has been shown by multiple studies. I like the title of the review, "Things We Do For No Reason: Neutropenic Diet." Ma et al., PMID 35356218. Radhakrishnan et ...
What criteria does your institution use to indicate patient is ready for PEG tube removal?
The short answer is we typically advise patients that if they can maintain an oral diet (using the tube for flushes only) for 2 weeks and demonstrate no weight loss they are typically ready for tube removal. Our patients though are followed through the course of their treatment by a dietician, and t...
Do you give IV fluids to avoid renal compromise in patients with inflammatory myositis with a CK over a certain threshold?
No, because myositis is a chronic disease, CK rises slowly and typically doesn't affect kidneys (unlike rhabdomyolysis, which leads to an acute rise in CK to very high levels). However, when CK is too high like > 20,000 to 30,000 rarely in cases of necrotizing myopathy or cases of metabolic myopathy...
Do you give intrapleural lytics for complicated effusion/empyema in patients on systemic anticoagulation?
Like some people's relationship status, it's complicated. Since 2011, when the MIST II trial (1) was published by Rahman and colleagues, intrapleural tissue plasminogen activator (tpa) and DNase have been given intrapleurally to facilitate source control for pleural infection by breaking up loculati...
What steroid regimen do you employ prior to extubating a patient who does not have a suitable cuff leak?
Before deciding on steroids, there are many factors to be considered. Patient height and weight, ET tube size and medical history. For example, a person who is 5’ 0” with a size 8 ETT intubated for 2 days might not have a leak but be perfectly safe to extubate without steroids. Alternatively, someon...
What is your approach to volume resuscitation in patients with obvious septic shock but also with a component of suspected cardiogenic shock?
I think it comes down to clinical decision-making at bedside with the help of a combination of modalities. POCUS to evaluate the IVC size and collapsibility is one option we commonly use and is quick and easy to obtain. Additionally, in situations of unclear shock state, our practice is to float a P...
What patient related factors and hemodynamic parameters would lead you to avoid transbronchial biopsies in patients with pulmonary hypertension?
I try to avoid if INR is > 1.7 or platelet count is less than 30,000 in patients who have Grp I PAH.
Do you perform a clamp trial before removing a chest tube for pneumothorax?
Yes, almost always but depending on the indication for chest tube placement commonly encountered as below. A) If the chest tube is placed for pneumothorax, clamping a chest tube before removal is essentially simulating the same scenario when the chest tube is out. It is much better to clamp than to ...
Would you start an amiodarone load for new onset atrial fibrillation with RVR intermittently in normal sinus rhythm to further suppress AF recurrence in the acute setting?
The answer to this question really depends on the clinical scenario. Does the patient have a structurally normal heart? Is this a post-op setting where the AF is expected to settle down with time? Age of patient? Co-morbidities? Candidacy for less toxic drugs or ablation? If this were a post-op pati...
What is your stepwise approach to initiating GDMT in the inpatient setting for newly diagnosed HFrEF?
The decision to preferentially initiate one of the 4 first line GDMT agents (BB, RAASi, SGLT2i, MRA) other the other, is to a large extend determined by patient characteristics, such as BP (can start all medications at low doses if BP permits), HR (prefer BB if tachycardic), presence of AKI (delay i...