Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
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...
What is the recommended follow-up/surveillance schedule following organ preservation treatment approach for cT1-2N0 rectal cancer?
Patients with stage I rectal cancer treated with organ preservation require close surveillance to rule out tumor regrowth and local recurrence that may be salvaged with radical surgery. The highest risk of recurrence is within 2 years after completion of neoadjuvant therapy and patients should be fo...
Can cardioversion be safely performed for recurrent atrial fibrillation in patients who have undergone left atrial appendage clipping during CABG, if they are not on chronic anticoagulation anymore?
Based upon the LAAOS III trial, we know that patients with left atrial appendage ligation at the time of cardiac surgery have a lower risk of stroke compared to those who did not when anticoagulation is continued in both groups. The data is much less clear for complete cessation of anticoagulation a...
Is active cocaine or methamphetamine use a contraindication to implanting defibrillators?
As a general principle, I do not think that a potentially life-saving intervention should be withheld in patients with substance use disorders (including tobacco, alcohol, cocaine, methamphetamine, or even IV drugs) unless the risk of the intervention outweighs the anticipated benefit. Further, I be...
Would you consider opting for beta blocker withdrawal to improve exercise capacity in patients with heart failure with preserved ejection fraction and chronotropic incompetence?
The short version of my answer is Yes, however, I will provide more insight into this: When considering beta-blocker withdrawal to improve exercise capacity in patients with HFpEF and chronotropic incompetence, the evidence and guidelines are nuanced. A prospective, randomized, controlled trial "Pre...
When would you consider switching to or adding on a PCSK9 inhibitor to lipid-lowering therapy following hospital discharge for acute coronary syndrome, in light of the results of the VICTORION-INCEPTION trial, provided LDL is still not at goal?
I don’t think the trial really changed my mind on this. I never really worried about not having ACS patients in the original phase 3 trials, so I had already been using inclisiran when I could in recent ACS patients. I would never switch from a statin to a PCSK9i. Statins are cheap, effective, and w...