Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Does your approach to cervical cancer screening change in developmentally delayed patients who are not and have never been sexually active compared to non-developmentally delayed patients?
Any screening is only accomplished with a shared decision-making conversation. Screening for cervical cancer can feel very invasive for many people. I talk to the patients and their families/guardians about the risk/benefits of having a pelvic exam and doing cervical cancer screening. In light of th...
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
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...
How do you approach titration or transitioning to Cobenfy in patients currently on an antipsychotic?
Antipsychotics with significant anticholinergic activity, such as olanzapine and clozapine, can add to the effects of trospium contained in xanomeline-trospium combination. Product labeling reads "Concomitant use of COBENFY with other antimuscarinic drugs that produce anticholinergic adverse reactio...
For opiate-related ileus in the postoperative setting, at what point do you consider trialing methylnaltrexone?
I personally have never used this particular PAMORA for post-op ileus. Despite some promising phase 2 trials indicating potential benefit, several Phase 3 RCTs evaluating this drug specifically for post-operative ileus showed no benefit in preventing nausea/vomiting or speeding up time to discharge ...
For opiate-related ileus in the postoperative setting, at what point do you consider trialing methylnaltrexone?
I personally have never used this particular PAMORA for post-op ileus. Despite some promising phase 2 trials indicating potential benefit, several Phase 3 RCTs evaluating this drug specifically for post-operative ileus showed no benefit in preventing nausea/vomiting or speeding up time to discharge ...
Would you biopsy calcified lung nodules and or lymphadenopathy that have shown stability over a 2-year period, in a bid to rule out sarcoidosis?
No. Certainly not without a comprehensive occupational and other exposure history. Follow "the rules" for the assessment of any sarcoidosis suspect. Do a physical exam to look for extrapulmonary signs of sarcoidosis. Order an eye exam to assess for ocular sarcoidosis. Obtain baseline MTB testing and...
How soon after a fracture would it be safe to start anti-resorptive therapy?
This is an important question. There is no definitive answer, and there have been no clinical or preclinical studies that demonstrate delayed healing in the presence of bisphosphonates. Personally, I favor waiting a few weeks before we start. That also gives us time to do a proper metabolic workup. ...
When do you check vitamin D levels in patients with depressive symptoms?
I routinely check 25-OH D in all my patients. Given that half the population is deficient and that we now know the role of vitamin D not only for bones but in mood, cognition, and immunity. We need to be aware of deficiencies and replete if low. Moreover, ideal levels are 60-80, not just over 29 as ...