Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When do you consider switching a generic formulation of an antiseizure medication to the brand formulation?
This rarely, if ever, happens. The easiest way to think of the difference is not to think of brand versus generic. Think of brand as the first generic (G1), and all the rest are later generics (G1, G2, etc.). Since the active ingredient is identical amongst all formulations, the only difference is w...
When do you consider extended steroid tapers for acute asthma or COPD exacerbations?
The data doesn't support extended tapers - 5 days of 40 pred equivalent are non-inferior, and extended courses can cause harm, including increases in mortality. I only use extended tapers for patients who have, in the past have rapid symptom recrudescence with the typical shorter course. Typically, ...
When do you consider extended steroid tapers for acute asthma or COPD exacerbations?
The data doesn't support extended tapers - 5 days of 40 pred equivalent are non-inferior, and extended courses can cause harm, including increases in mortality. I only use extended tapers for patients who have, in the past have rapid symptom recrudescence with the typical shorter course. Typically, ...
Do you routinely repeat imaging for PE after anticoagulation treatment to establish a new baseline?
We only do imaging if the patient is symptomatic still after a few weeks or has persistent chest pain or clinical signs of pulmonary hypertension. Rarely I have seen recurrent or progressive thromboembolic disease on anticoagulation. Another possible reason if the patient needs to go to surgery in t...
What screening tools or signs do you use to predict if a cancer patient is near end-of-life?
For most of us, long-time practicing oncologists, all we have to do to determine that one of our patients is at the end of their life is to be in the same room with them. No special computer programs or calculators are needed. Just look closely at the patient's current weight, their level of conscio...
How do you decide when to initiate buprenorphine for chronic pain?
Typically, I initiate buprenorphine for chronic pain in two scenarios: The patient's providers are no longer willing to prescribe full-agonist opioids. This typically happens when there is concern about misuse. Buprenorphine is a good option for these patients because of its partial agonism, making...
How do you decide when to initiate buprenorphine for chronic pain?
Typically, I initiate buprenorphine for chronic pain in two scenarios: The patient's providers are no longer willing to prescribe full-agonist opioids. This typically happens when there is concern about misuse. Buprenorphine is a good option for these patients because of its partial agonism, making...
What is the optimal number of days to hold apixaban prior to a kidney biopsy or tunneled dialysis catheter placement?
If the patient has normal or mild renal impairment (≥30 mL/min), I will hold apixaban for 2 days prior to the procedure. If the patient has moderate to severe renal impairment (<30 mL/min), I will hold apixaban for 3 to 4 days prior to the procedure.
What is your approach to managing patients with hypertensive crisis and avoiding brisk reductions in blood pressure and subsequent ischemic acute kidney injury?
This is an important topic in which terminology and associated definitions are critical because they directly influence management. Historically, hypertensive crisis has served as an umbrella term encompassing both hypertensive emergency and hypertensive urgency. However, accumulating evidence has d...
Do you consider testing and treating IDA in unexplained thrombocytopenia?
Iron deficiency often causes thrombocytosis, and in fact, probably is the most common cause of reactive thrombocytosis encountered in clinical practice. With very severe iron deficiency, thrombocytopenia can be seen. I have seen it in rare patients presenting with hemoglobin levels about 3 gm/dL or ...