Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you adjust your management strategy to address the unique needs of anuric end-stage kidney disease patients when treating diabetic ketoacidosis?
There is no osmotic diuresis, and they do not need IVFluid, the opposite is true they may appear intravascularly overloaded, and will respond to insulin alone, they do not need HD for this. They will not be K deficient, do not give K. Their potassium will likely respond to insulin alone, and should...
Under what circumstances do you consider valacyclovir for the management of VZV disease of the CNS?
If the patient has encephalitis would use IV acyclovir and only transition to high dose valcyclovir (2 g every 8 or every 6 hs depending on weight) after improvement. Although there is PK data to support these high doses, I would not use it initially. Immunosuppressed patients have a higher likeliho...
What would be your differential for a wrist monoarthritis in an elderly female with erosions on MRI after less than 3 months of symptoms?
I would put CPPD arthritis high on the differential, as the wrist is a common site for CPPD arthropathy in the elderly. In the right context, septic arthritis is a possibility, particularly if the patient is immunosuppressed. Indolent infections such as fungal or mycobacterial are possibilities. Les...
At what lab values (ferritin, TSAT%) would you offer IV iron therapy to patients with restless leg syndrome?
1. I am hopeful that practitioners will start understanding that ferritin alone is not enough to assess iron because of its acute phase reactivity. I like to order iron parameters after a 5-9 hour fast so the serum iron is not speciously elevated and get a ferritin and TSAT. If the ferritin is <30 a...
When can we consider deferring an insulin drip in patients with hypertriglyceridemia-induced pancreatitis?
Serum triglyceride levels >500 mg/dL (5.6 mmol/L) are required for hypertriglyceridemia to be considered the underlying etiology of acute pancreatitis (UpToDate).For patients with severe hypertriglyceridemic pancreatitis, such as those serum triglyceride levels >1000 mg/dL plus lipase >3 times the u...
Is there a role for anti-fibrinolytic agents in patients with hyperfibrinolytic disseminated intravascular coagulation?
DIC is a complex clinicopathologic syndrome. There are no randomized trials to support evidence-based practice. The following principles apply: 1) antifibrinolytics should not be used in patients with organ failure or those that are asymptomatic. One could justify their use in this group of patients...
Should methotrexate be stopped prior to radiation therapy if a patient has rheumatoid arthritis?
I have not stopped as dose of MTX for RA is low (7.5 mg) and there is data of CMF with RT for breast cancer with higher dose of MTX showing no significant increase in morbidity.
What is your approach to counseling severely frail older adults regarding their planning for invasive life-sustaining therapy?
My approach is pragmatic, evidence-based, and bi-directional. Patients/family make the decision, but I ensure they are fully informed about the pros and cons and provide them time to think through.
What strategies would you suggest to reduce patient-directed discharges in hospitalized patients with substance use disorder?
Hello, This is an interesting question and one that our team has a lot of experience with. I think it is, first and foremost, important to remember that the hospital is a hard place to be for anyone, and especially for people with substance use disorder. They are used to being mistreated in the hosp...
How do you decide when to check a PEth level in patients hospitalized with alcohol-associated disease?
In my practice as a hospitalist and addiction medicine specialist, I use PEth (phosphatidylethanol) as an adjunctive tool to assess alcohol exposure over the preceding 2 to 4 weeks. I most commonly order it when the alcohol use history is unclear, when a patient's clinical presentation is highly sug...