Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is the goal oxygen saturation for patients with COPD and pulmonary hypertension?
Although an oxygen saturation target of 88–92% is commonly used in patients with COPD to reduce the risk of oxygen-induced hypercapnia, a higher saturation goal is appropriate in patients with pulmonary hypertension associated with COPD. In this population, we generally aim for an oxygen saturation ...
What is your diagnostic and therapeutic approach to hospitalized patients with persistent hypotension (MAP <65) of uncertain etiology, but no evidence of hypoperfusion or shock physiology?
Clinical concern for MAPs <65 mmHg has become ingrained due to extensive literature on septic shock, but there is little evidence to support intervening solely at this threshold in patients without evidence of hypoperfusion. My initial approach to hypotension is therefore diagnostic: confirm it is r...
Do you typically load DAPT in patients with ICAD?
If the ICAD lesion is symptomatic and the patient is aspirin-naive, I administer a one-time loading dose of 325 mg of aspirin, followed by 81 mg after that. I do not administer a loading dose of the P2Y12-inhibiting agent (such as clopidogrel, ticagrelor, etc.). I continue DAPT for 3 months then tra...
What is your approach when a patient has concomitant acute decompensated heart failure and rapid atrial fibrillation?
Is the patient stable? If not stable, then I would move towards immediate cardioversion. If stable (good BP) but poor oxygenation, then diuretic with consideration of metoprolol, digoxin, or amiodarone. If unable to tolerate BB due to lower BP, then would lean towards amiodarone or digoxin. Anticoa...
How long after initiating mycophenolate do you wait before tapering prednisone off in patients with myositis-associated ILD?
Taper Pred after 6 weeks MMF tapering to prednisone 20 mg/day and hold this dose for 6-8 weeks monitoring for relapses. If no relapse, taper to Prednisone 10 mg/day.
What key principles of consultative/peri-operative medicine would you emphasize for early-career internists/hospitalists serving in this role without much prior experience?
For completing a preoperative risk assessment: Take a systematic approach, hitting the high-yield systems/topics: Cardiac, pulmonary, DVT/PE prophylaxis, delirium, Diabetes/endocrine, Anticoagulants/antiplatelet agents, medications, clinical frailty, and other applicable to your patient (e.g., live...
What key principles of consultative/peri-operative medicine would you emphasize for early-career internists/hospitalists serving in this role without much prior experience?
For completing a preoperative risk assessment: Take a systematic approach, hitting the high-yield systems/topics: Cardiac, pulmonary, DVT/PE prophylaxis, delirium, Diabetes/endocrine, Anticoagulants/antiplatelet agents, medications, clinical frailty, and other applicable to your patient (e.g., live...
What are your management strategies for patients with bradycardia post-kidney biopsy who received lidocaine for local anesthesia?
In the management of patients with bradycardia post-kidney biopsy who received lidocaine for local anesthesia, one must distinguish between vasovagal reaction and Local Anesthetic Systemic Toxicity (LAST). Vasovagal reaction is typically characterized by bradycardia with hypotension, lightheadedness...
Do you routinely check serum phosphorus levels after IV iron therapy?
Only before and after FCM. I hold subsequent doses if phosphorus low. There is no need to monitor with the other formulations. For people needing multiple doses of IV iron (IBD, bariatric surgery, heavy uterine bleeding, angiodysplasia), I avoid FCM.
Do you use standard dose or "meningitis dosing" of antibiotics when treating epidural abscesses, in the absence of CNS symptoms?
Not always. While I will use meningitis dosing for initial therapy, I have no qualms about using cefazolin for MSSA (and several recent publications support this), nor using ceftriaxone 2g/d for streptococcal infection. And frequently after the initial 3-4 weeks on IV, I transition to oral doxycycli...