Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Would you recommend starting tolvaptan at 7.5 mg per day, which is half the typical starting dose, to reduce the risk of overcorrection in an inpatient with SIADH and a serum sodium level of 122 mEq/L?
If it is for SIADH, I always start with 7.5 mg. See this, my fellow and I put together years ago. Dosing in SIADH: A Tale of Two Tolvaptans If it is for CHF, I would start with 15 mg as those patients are so pre-renal, their distal delivery is so impaired, and tolvaptan is limited by that. I haven't...
Can the tracheostomy be reversed after completion of chemoradiation for laryngeal cancers?
Yes, if there has been a CR. Wait 3 months. PET. If negative, plug trach for 2 weeks. If all is well, pull trach.
How do you evaluate and manage acute alcohol withdrawal when symptom-driven protocols are confounded/unreliable?
Often, if someone has an underlying condition that may artifactually elevate their symptom monitor scores (such as essential tremor in CIWA-Ar or tachycardia from cancer or sepsis in mMINDS), I will do any of the following: Increase the threshold for the symptom-triggered med by a few points (if th...
How do you counsel patients/families whose goals of care are clearly aligned with a comfort-focused, end-of-life approach, but who are hesitant to formally enroll in hospice?
Hospice sounds like a 4-letter word to a lot of families! I find it important to distinguish the philosophy of comfort care vs. the benefit package associated with enrolling in hospice. Some people are able to be provided end-of-life comfort care without electing the hospice benefit, and that is fin...
How do you counsel patients/families whose goals of care are clearly aligned with a comfort-focused, end-of-life approach, but who are hesitant to formally enroll in hospice?
Hospice sounds like a 4-letter word to a lot of families! I find it important to distinguish the philosophy of comfort care vs. the benefit package associated with enrolling in hospice. Some people are able to be provided end-of-life comfort care without electing the hospice benefit, and that is fin...
How do you titrate opioids for pain and breathlessness in patients with a DNR/DNI code status, but who otherwise still wish to pursue life-prolonging treatments?
Carefully! But let's be very clear about this situation: the DNR/DNI status shouldn't really affect your management if the patient wants full treatment otherwise. In fact, even if someone opts for a hospice care plan and does not want full treatment nor resuscitation, we can still have the same gene...
How do you titrate opioids for pain and breathlessness in patients with a DNR/DNI code status, but who otherwise still wish to pursue life-prolonging treatments?
Carefully! But let's be very clear about this situation: the DNR/DNI status shouldn't really affect your management if the patient wants full treatment otherwise. In fact, even if someone opts for a hospice care plan and does not want full treatment nor resuscitation, we can still have the same gene...
Is there a maximum duration for raloxifene use?
There is relatively scant data on long-term raloxifene use in patients with osteoporosis, but generally, there are no recommendations for a drug holiday. The primary endpoint in the pivotal registration trial, MORE, was incidence of vertebral fracture, and the difference between the raloxifene and p...
Would you use a parathyroid hormone analog for treatment of osteoporosis in a patient with mildly elevated AlkPhos of unclear etiology?
I would be hesitant to administer an anabolic in this setting without first delineating the reason for an elevated AlkPase. I would suggest starting with sorting out the source of the AlkPase (i.e., bone, liver, or gut with measuring bone-specific AlkPase, G-GGT levels, and possibly a liver ultrasou...
How do you approach the significance of +RNP III antibody in a patient with positive ANA but no other signs or symptoms of systemic sclerosis?
RNA polymerase III is a specific autoantibody for a subset of systemic sclerosis associated with severe diffuse cutaneous scleroderma, renal crisis, GAVE, and a strong association with malignancy. If this antibody is identified in the absence of Raynaud's or other symptoms of scleroderma, its signif...