Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
For stroke patients with ablated paroxysmal atrial fibrillation without known recurrence and ICAD, would you recommend dual antiplatelet therapy or anticoagulation with or without an antiplatelet agent?
Ablation treats cardiopulmonary symptoms, but it has not been adequately tested against anticoagulation for AFib-related stroke. Anecdotally, at least once a month, I will see a patient with an acute embolic-appearing stroke after their cardiologist has stopped their anticoagulation because they wer...
How do you use NT-proBNP in patients with chronic kidney disease or end-stage kidney disease, given that these conditions can affect NT-proBNP levels?
NT-proBNP is most useful for (a) diagnostic uncertainty in patients who present with dyspnea, and (b) prognostication in heart failure. It is released as a result of ventricular wall stress. In CKD, the clearance of NT-proBNP is impaired, leading to elevated levels. In late-stage CKD and ESRD, volum...
What is the expected timeframe for the development of radiation myelitis and therapies that have helped with neurologic symptoms?
The incidence and the timeframe of the development of radiation myelopathy are influenced by total radiation dose, radiation dose per fraction, time between courses of radiation, and associated chemotherapy or immunotherapy. Older age, the presence of diabetes, and previous exposure to radiation are...
How do you counsel eligible patients on lung cancer screening who are hesitant because of the cancer risk from CT scans?
This is simple. The risk of lung cancer in patients who have smoked for >20 years is orders of magnitude higher than the theoretical risk of medical X-ray-induced cancers from low-dose CT (LDCT) screening. A typical LDCT scan exposes patients to approximately 1.5 mSv of radiation, equivalent to abou...
What techniques do you use in the lab to reduce the amount of contrast that needs to be used in patients with CKD?
Avoid LV angiogram. Use ECHO instead to assess LV function.
When do you consider scheduled or more frequent POC blood glucose checks in hospitalized patients who are either not eating or otherwise at high risk for hypoglycemia?
Standard q6h (before meals + bedtime) monitoring is insufficient for patients who are NPO or at high risk for hypoglycemia. Evidence supports more frequent or scheduled monitoring in the following scenarios: 1. NPO/not eating Every 4–6 hours is recommended for NPO patients on basal insulin alone (E...
How would you treat a patient with osteoarthritis of just one joint of the hand?
People do this in various ways - some people treat the joint with a large margin, others may treat the whole hand.I originally started by treating the affected joint, but pretty soon I after I switched and started treating the whole hand - pain is subjective and though it may appear localized, there...
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...
What is your approach to acute pain management in hospitalized patients who receive long-acting injectable naltrexone for alcohol use disorder?
Maximize non-opioid therapies (NSAIDs, Tylenol, ketamine or lidocaine infusions if appropriate/available, nerve blocks). If opioids are still needed, the basic answer is that I would treat pain with higher doses of opioids. I would tailor my approach to the cause of the pain, though. If a patient w...