Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you decide when to initiate or restart diuretics in a cirrhotic patient with ascites if they are receiving a therapeutic paracentesis?
This question has two parts, one with a straightforward answer, the other with a much more nuanced answer, if I understand it correctly. Any patient receiving a therapeutic paracentesis should start/restart diuretics afterwards. Per the 2021 AASLD guidelines, one of the statements reads “LVP is the ...
How do you approach the management of patients who require nutritional restoration in the setting of a presumed functional GI disorder recalcitrant to behavioral medicine and pharmacologic therapies?
It certainly is a very good question if indeed the patient has functional disease; then, for sure, they need more than just my help. They probably need the help of a nutritionist, but even more so, they need perhaps psychiatric medication and the treatment of a behavioral therapist or psychological ...
How soon after an acute upper GI bleed do you restart therapeutic anticoagulation in a patient with atrial fibrillation and a high thromboembolic risk (CHA₂DS₂-VASc ≥4)?
In real-world inpatient practice: ~72 hours after endoscopic control for high-stroke-risk AF with stable hemoglobin and no rebleeding. Extending hold to 5–7 days if the lesion is high risk or the bleed was severe.
When telemetry or ECG shows a newly prolonged QTc (e.g., >500 ms) in an otherwise stable hospitalized patient, how aggressively do you modify medications, electrolytes, or monitoring?
A newly prolonged QT can be easy to overlook amid the complexity of inpatient hospitalization, and when identified, I generally add it to the problem list so it remains visible during the admission and in future care. Although prolonged QT is associated with torsades de pointes, sudden cardiac death...
Would you recommend discontinuing testosterone replacement in a male patient in his 60s with newly diagnosed favorable intermediate-risk prostate cancer who is declining surgery and will receive definitive radiation?
Historically, we (as a field) have viewed TRT as the opposite of ADT and therefore inherently problematic. I am not convinced this is logical. ADT has RCT evidence to support it, whereas withdrawing TRT has not been as cleanly studied. Let's say we stop TRT, and this drops their testosterone to 150 ...
Is your approach to managing immune related adverse events altered at all in light of COVID-19?
First of all, I wish to thank @Dr. First Last from Johns Hopkins/Sibley for his advice addressing this critical topic.We are all witnessing a rapidly evolving crisis that none of us have been prepared for and it is the right thing to quickly consider as best as we can how the COVID-19 pandemic shoul...
What is the role for checking uric acid levels in evaluation of SIADH in hospitalized older adults?
Uric acid is typically not a first-line test for evaluation of hyponatremia. It's usually used when trying to differentiate between hypovolemic states (not SIADH by definition) and euvolemic states (including SIADH). The utility stems from how uric acid is handled in the nephron, i.e., it's reabsorb...
What is the role for checking uric acid levels in evaluation of SIADH in hospitalized older adults?
Uric acid is typically not a first-line test for evaluation of hyponatremia. It's usually used when trying to differentiate between hypovolemic states (not SIADH by definition) and euvolemic states (including SIADH). The utility stems from how uric acid is handled in the nephron, i.e., it's reabsorb...
When do you consider scheduled or more frequent POC blood glucose checks in hospitalized patients who are either not eating or otherwise at high risk for hypoglycemia?
Standard q6h (before meals + bedtime) monitoring is insufficient for patients who are NPO or at high risk for hypoglycemia. Evidence supports more frequent or scheduled monitoring in the following scenarios:NPO/ not eating Every 4–6 hours is recommended for NPO patients on basal insulin alone (Endoc...
How would you manage persistent Norovirus diarrheal infections in a kidney transplant patient that are not responding to a decrease in the patient’s maintenance immunosuppressive regimen?
This is a difficult situation and does not have a strong evidence based response. First, I would really make sure they are not on mycophenolate as this is really the main problem with chronic Norovirus for most patients. Next, I would see if there are any available clinical trials that the patient m...