Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach caring for patients admitted with decompensated CHF, but who also exhibit hypotension and do not have overt signs of hypervolemia on exam?
This is a case where you might be concerned about the patient sliding into cardiogenic shock. Remember that in the context of chronic heart failure, cardiogenic shock tends to present more insidiously because these patients are typically compensated at low or borderline low cardiac output (Abraham e...
Do you use daptomycin interchangeably with staphylococcal beta-lactams for ease of dosing on discharge for patients with serious MSSA infections (endocarditis, bacteremias, etc)?
I don’t use daptomycin interchangeably with antistaphylococcal beta-lactams for serious MSSA infections, and I think doing so routinely is a mistake. For invasive diseases like endocarditis, prolonged or complicated bacteremia, and deep-seated foci of infection, the outcome data consistently favor b...
Should platelet transfusions be considered for anti-platelet agent reversal in patients with major bleeding?
Patients on plavix and/or aspirin are at risk for bleeding whether in relation to surgery or bleeding from the gi tract. Much like the management of patients on anticoagulation temporary reversal of antiplatelet drugs is only achieved by normalizing platelet function. This is the same principle used...
How do you approach anti-seizure medication management when it was started by another team for a seizure-naive patient before/after craniotomy for a tumor?
I would refer you to Dr. @Dr. First Last's answer to a similar question (https://www.themednet.org/question/15031) which beautifully summarizes data and guidelines. I usually counsel patients that everyone regardless of their medical history has a certain risk of seizure under physical stressors, th...
What is the rationale/evidence to support doing 4 puffs of albuterol vs. 2 puffs for a reversibility study?
The rationale per ATS in 2005 is that 4 puffs of albuterol is higher on the dose-response curve and thus would potentially avoid getting a suboptimal (< 12%, < 200 mL) response from 2 puffs. Having said that, there was a study of this issue in 240 pediatric patients showing non-inferiority of 2 puff...
How do you counsel patients with depression about the role exercise may play in alleviating depressive symptoms?
I’m a big fan of exercise for all of my patients, to the point where I have my 5th-degree black belt diploma on the wall of my office next to my undergrad, PhD, and MD diplomas. I tell patients, “That’s up there to say to try and fit in exercise as realistically as your schedule allows, in a way you...
What is your approach to management of tremors in a kidney transplant recipient who is taking a CNI for immunosuppression?
This can be a really vesing problem for patients. My approach is somewhat dependent upon the severity of the tremors. I will sometimes try some low dose propranolol, 10 mg po BID-TID, or more often I will try converting from a the shorting acting forms of tacrolimus (Q12 hour formulations) to the lo...
How do you approach the management of older adult patients with coronary artery disease on aspirin who have developed intermittent diverticular bleeds?
This is a tough clinical scenario that comes up often in older adults. You will often have subspecialists involved and will need to adapt your approach to their management and communication styles. Generalists can add value here by looking at the whole picture and figuring out what matters most to t...
Do shorter door-to-balloon (D2B) times impact outcomes in STEMI, if it's already less than 90 minutes, and to what degree (i.e., 30 vs 60 minutes would have a more significant impact)?
No. Shorter door-to-balloon times have not been shown to improve survival or outcomes in STEMI. The reason is that the other variable is the time from the onset of chest pain to presentation to a medical facility. This time is beyond the control of the medical system. For example, a patient waits 4 ...
In patients with lupus nephritis, and MAHA with positive anti-phospholipid autoantibodies, what are the considerations to use or not use anti-coagulation therapy?
I support anticoagulation and C5 inhibition for such patients if they are not adequately responding.