Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What workup do you recommend for patients with symptoms suggestive of saphenous neuropathy?
In most cases of isolated saphenous neuropathy, the etiology is pretty straightforward, as it usually occurs after surgery or injury/trauma at the medial knee. Another common cause of more distal saphenous neuropathy is saphenous vein harvesting for CABG surgery (less common nowadays). When there is...
For patients with candida species osteomyelitis who have undergone extensive surgical debridement, do you routinely still recommend 6-12 months of antifungal therapy or opt for a shorter duration?
After removal of hardware, if present, and debridement of infected bone, my practice is to treat Candida osteomyelitis with an intravenous echinocandin for two weeks followed an oral azole, to which the fungus is susceptible, for at least six months. If full debridement is not possible, such as vert...
How soon after an acute upper GI bleed do you restart therapeutic anticoagulation in a patient with atrial fibrillation and a high thromboembolic risk (CHA₂DS₂-VASc ≥4)?
In real-world inpatient practice: ~72 hours after endoscopic control for high-stroke-risk AF with stable hemoglobin and no rebleeding. Extending hold to 5–7 days if the lesion is high risk or the bleed was severe.
Do you prefer using unfractionated heparin or low molecular weight heparin in stable patients presenting with NSTE ACS awaiting primary PCI (assuming normal renal function)?
I advocate for the use of LMWH. I see a surprising number of patients on unfractionated heparin with PTTs indicating either homeopathic (<35s) or supratherapeutic (>120s) levels of anticoagulation. The 2025 ACC/AHA Guideline for the Management of Patients With Acute Coronary Syndromes summarizes cli...
How do you interpret the presence of GAD antibody in a middle-aged patient with diabetes when all other type 1 diabetes antibodies are absent?
It depends on patient's clinical course of diabetes, controlled on orals vs insulin, BMI, family history DM. For a brittle DM patient, high GAD titer could indicate DM1 or LADA. For stable DM patients, the recommendation is to have 2 positive antibodies to diagnose DM1.
What is your preferred choice of anticoagulant (VKA vs. DOAC) in patients with an LV thrombus and apical infarct?
Traditionally, warfarin is recommended. However, there has been recent evidence to suggest that DOACS are effective as well. In my practice, I have migrated to DOACS for ease of use. Many elderly patients are overwhelmed when they are discharged with 6 or 7 medications and add to that the complexity...
What is your preferred choice of anticoagulant (VKA vs. DOAC) in patients with an LV thrombus and apical infarct?
Traditionally, warfarin is recommended. However, there has been recent evidence to suggest that DOACS are effective as well. In my practice, I have migrated to DOACS for ease of use. Many elderly patients are overwhelmed when they are discharged with 6 or 7 medications and add to that the complexity...
Would you consider amiodarone for the treatment of atrial fibrillation with RVR in patients who cannot tolerate beta blockers but have a high CHA2DS2-VASc score and are not on anticoagulation?
We typically do not due to risk of chemical cardioversion and precipitating an embolism.
What is your systolic blood pressure target for patients over 80 with frailty and multiple comorbidities?
The target of 150/90 mmHg for adults over 80 primarily comes from the HYVET study, which demonstrated benefit in reducing stroke and mortality in this age group. However, as with all decisions in geriatric care, treatment should be individualized and guided by the patient’s functional status and goa...
How do you decide when to treat hypocalcemia in hospitalized patients?
When I think about when to treat hypocalcemia in hospitalized patients, I anchor the decision on three things: symptoms, the absolute calcium level, and the trajectory. First, it’s important to confirm true hypocalcemia: either a serum calcium <8 mg/dL or an ionized calcium <1.1 mmol/L, and to consi...