Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When home BP readings are consistently lower than office measurements, how do you decide whether to intensify, maintain, or de-escalate antihypertensive therapy?
If the home readings can be confirmed to be appropriately measured (i.e., in a hard-backed chair with arm support and checking multiple repeated readings), then I will adjust BP medications to target the average home BP of <130/80 (going lower toward 120/80, if tolerated). However, I have had patien...
What is your medication of choice when considering outpatient alcohol withdrawal management (diazepam vs chlordiazepoxide vs lorazepam)?
While benzodiazepines such as chlordiazepoxide, diazepam, and lorazepam remain the mainstay of treatment for acute alcohol withdrawal syndrome (AWS), their use in the outpatient setting is generally inappropriate for patients with Alcohol Use Disorder (AUD)—except in narrowly defined, low-risk scena...
Should long-acting subcutaneous insulin be started upfront in addition to regular insulin infusion for patients with diabetic ketoacidosis?
Current ADA guidelines suggest patients with uncomplicated mild or moderate DKA may be treated with subcutaneous rapid-acting insulin analogs every 1-2 hours as an effective alternative to IV insulin, but still only recommend IV short-acting insulin by continuous infusion for moderate-severe DKA. Ho...
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 assess and counsel women with chronic post-lumpectomy or mastectomy pain?
Post-surgical breast pain is not uncommon. Estimates suggest that 25-60% of patients having breast surgery experience persistent pain, with symptoms lasting from months to years following breast cancer diagnosis and treatment (Langford et al., PMID 25439318; Gartner et al., PMID 19903919).Initial as...
How do you manage anticoagulation/antiplatelet therapies with strong indications for uninterrupted therapy in setting of urgent procedures?
If anticoagulation is absolutely contraindicated because of the bleeding risk of the procedure, then "bridging" will usually make the most sense, most of the time, with low molecular weight heparin such as enoxaparin. If dual antiplatelet agents are contraindicated, particularly in the first month a...
What is your preferred fill volume, dialysis solution, and dwell time for patients with suspected peritoneal dialysis associated peritonitis who arrive to the hospital with a dry abdomen?
I agree with Dr. @Dr. First Last's approach with one addition: prior to instilling the fluid for 2 hours, I would do a quick flush of the abdomen- fill and drain immediately- to remove the cells that accumulated while the abdomen was dry, and thereby avoid "muddying" the waters (pun intended).
Do you routinely observe inpatients for 24 hours after transitioning from IV empiric antibiotics to an oral regimen prior to discharge when the source of infection is unclear?
To be sure, this is a big question with much nuance and should be broken down into component parts. To begin with, the lack of a source is not, in and of itself, a clear justification for continued hospitalization. What should drive the decision for discharge is established clinical stability and an...
How do you approach prescribing statins in patients with an ASCVD <7.5% but have a strong family history and/or elevated LDL (but <190)?
When considering statin therapy for patients with an ASCVD risk of less than 7.5%, but with a strong family history of cardiovascular disease or elevated LDL cholesterol levels, the decision is nuanced. Here’s how I approach this situation: Shared Decision-Making: Involve patients in the discussion...
Would you consider recommending parathyroidectomy for primary hyperparathyroidism patients with high calcium and PTH levels, even without traditional criteria, based on recent studies showing reduced anxiety and depression?
It depends on several factors. If the patient is suitable for surgery without any major significant risk factors then I would definitely proceed especially with a surgeon who has a lot of experience with parathyroidectomy.