Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When diuretics or lactulose are newly started or uptitrated at discharge, what clinical factors make you schedule follow-up within 72–96 hours rather than the usual 7–14 days?
In reality, follow-up in 72-96 hours is quite difficult to achieve, so we do rely a bit on nursing check-ins as opposed to clinic follow-up. But clinical factors such as severity of VOL or HE, suspected compliance, out-of-hospital discharge setting (home vs shelter), support structure for patient, a...
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 approach a patient with sarcoidosis who cannot tolerate steroids and who is developing ILD?
As with most questions about sarcoidosis, clear understanding of the relevant clinical context should first be established. While interstitial lung disease (ILD) is a common manifestation of sarcoidosis, it often can be safely monitored without treatment, and so radiologically identified sarcoid ILD...
When telemetry or ECG shows a newly prolonged QTc (e.g., >500 ms) in an otherwise stable hospitalized patient, how aggressively do you modify medications, electrolytes, or monitoring?
A newly prolonged QT can be easy to overlook amid the complexity of inpatient hospitalization, and when identified, I generally add it to the problem list so it remains visible during the admission and in future care. Although prolonged QT is associated with torsades de pointes, sudden cardiac death...
How do you manage anticoagulation/antiplatelet therapies with strong indications for uninterrupted therapy in the 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...
Do you screen for interstitial lung disease in patients with newly diagnosed polymyositis or dermatomyositis in the absence of respiratory symptoms?
I do screen all newly diagnosed IIM patients with PFTs and chest CT. This has a double purpose: establishing a baseline of lung function and, screening for lung cancer. While the patient might not have lung symptoms on presentation, respiratory involvement can manifest later on the course of the d...
How has COVID-19 altered your recommendations for invasive mediastinal staging for NSCLC?
I just had this discussion with our chief of interventional pulmonolgy at MD Anderson. Some of his faculty are being asked to staff our COVID-19 patient floor. In addition, bronchoscopy procedures should be considered high-risk procedures, and are required to have at least 45 minutes in between proc...
What is the role for checking uric acid levels in evaluation of SIADH in hospitalized older adults?
Uric acid is typically not a first-line test for evaluation of hyponatremia. It's usually used when trying to differentiate between hypovolemic states (not SIADH by definition) and euvolemic states (including SIADH). The utility stems from how uric acid is handled in the nephron, i.e., it's reabsorb...
What is the role for checking uric acid levels in evaluation of SIADH in hospitalized older adults?
Uric acid is typically not a first-line test for evaluation of hyponatremia. It's usually used when trying to differentiate between hypovolemic states (not SIADH by definition) and euvolemic states (including SIADH). The utility stems from how uric acid is handled in the nephron, i.e., it's reabsorb...
How do you think about using contraction alkalosis as a mark of achieving goal diuresis?
Thank you for your insightful question. Residual congestion at discharge for patients treated for decompensated heart failure is associated with increased rates of readmission and mortality. While I do occasionally use the development of metabolic alkalosis as a marker of decongestion, a review of t...