Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you balance the risks versus benefits of starting a statin in a patient with MASLD and a persistent but mild elevation in their AST/ALT?
I no longer hesitate to start a statin despite mild ast/alt elevation. I might just check lfts again in a few months, but if there is a clear indication for the statin we go ahead and do it.
How do stroke-risk considerations affect your use of atypical antipsychotics for patients with dementia?
Antipsychotics carry a number of risks, including a warning of sudden death in elderly demented patients. If nothing else works for a behavioral problem, you have to use an antipsychotic. Also, for frank paranoia, which is not only causing distress to parents but also to the environment, treatment w...
Do you start bisphosphonates after tapering off menopausal hormone therapy to prevent the rapid decline of bone mineral density?
Women lose one T-score unit (10-12%) of bone mass on average during menopause. Estrogen, as a part of menopausal hormone therapy (MHT), is approved by the FDA to prevent osteoporosis, but not for its treatment. Upon MHT discontinuation, women will experience a period of rapid bone loss, for which st...
How do you differentiate cognitive impairment from normal age-related cognitive decline?
It can be tricky to differentiate normal aging from true cognitive impairment. I think the key ingredients are objective cognitive testing and bringing in a trusted informant. When a patient or a carepartner expresses a memory concern, or you wonder about memory during a routine evaluation, the firs...
How do you manage perioperative anticoagulation for a patient with a history of recent, surgically provoked VTE?
In most cases, bridging is rarely indicated because the bleeding risk usually outweighs the risk of VTE recurrence during a short (1–2 day) interruption of anticoagulation. However, after a recent VTE (defined as <3 months), the estimated risk of VTE recurrence is high (>15–20% per year) (still low ...
How do you think about using contraction alkalosis as a mark of achieving goal diuresis?
Thank you for your insightful question. Residual congestion at discharge for patients treated for decompensated heart failure is associated with increased rates of readmission and mortality. While I do occasionally use the development of metabolic alkalosis as a marker of decongestion, a review of t...
Do you recommend checking urine sodium 2 hours after loop diuretic administration to determine the need for dose adjustment in a patient with acute decompensated heart failure?
I know that is maybe a more physiologic way, but I can tell if it is working just by the urine output. The urine output is not going to increase following a loop diuretic without a natriuresis. And what good id an increased urine Na if the volume of urine is insufficient? If I am diuresing in decom...
How do you approach the management of aortic stenosis in an elderly, frail patient with multiple comorbidities who is symptomatic but considered high risk for surgical aortic valve replacement?
In an older patient with severe aortic stenosis (AS) who is not a candidate for surgery, there are 3 treatment options – TAVR, balloon aortic valvuloplasty (BAV), and medical management.In the original PARTNER trial, 358 patients with severe AS who, in the judgement of at least 2 cardiac surgeons, w...
Is there a role for routine EEG in the diagnostic evaluation of critically ill comatose patients or should these patients always receive long-term continuous video EEG monitoring?
We looked into this and found that in a non-comatose patient with no history of clinical seizures, the lack of epileptiform abnormalities on initial 30 minutes of EEG recording is associated with <5% risk for electrographic seizures suggesting that a routine EEG can be sufficient in that group (Stru...
Do you think repeated routine EEG is sufficient for cardiac arrest patients or should we be always using continuous EEG?
For most patients with cardiac arrest, cEEG has not been shown to offer improved outcomes over serial routine EEGs. In cases where there are EEG patterns that suggest seizures may be occurring, such as rhythmic or periodic patterns other than low-frequency GPDs, or repetitive evolving patterns, we t...