Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to electrolyte repletion for patients hospitalized with cardiac and non-cardiac conditions?
My approach to electrolyte monitoring and repletion emphasizes a patient-specific risk assessment rather than adherence to arbitrary numeric thresholds. The routine, reflexive repletion of potassium, magnesium, and phosphorus in unselected medical inpatients is an overused practice with limited supp...
What is your approach to electrolyte repletion for patients hospitalized with cardiac and non-cardiac conditions?
My approach to electrolyte monitoring and repletion emphasizes a patient-specific risk assessment rather than adherence to arbitrary numeric thresholds. The routine, reflexive repletion of potassium, magnesium, and phosphorus in unselected medical inpatients is an overused practice with limited supp...
Have any studies shown that testosterone replacement therapy lowers the incidence of prostate cancer in hypogonadal men, or is the evidence still largely neutral?
This is a broad question to which I will give a broad answer.For men with hypogonadism (symptoms and signs of androgen deficiency, reproducibly low serum testosterone with an accurate, reliable assay) and no reversible cause, the epidemiological data overall do not show evidence of increased risk of...
In patients with iron deficiency due to history of gastric bypass or IBD, would you consider oral iron therapy if the iron deficiency anemia is mild?
Oral iron can often be effective in iron deficiency, as long as absorption is intact. If you are concerned about absorption, performing an oral iron challenge can be useful in allowing you to avoid long trials of oral iron that will be ineffective. Simply check an iron panel at baseline, then admini...
How have you developed your approach to delivering a new serious diagnosis such as cancer, diabetes, or a chronic progressive condition in the primary care setting, where the relationship is longitudinal and the follow-up is yours to carry?
I think the Primary Care physician is in a unique position to deliver difficult news to their patient. Given our long-term relationship with the patient and often with their family, there is an element of trust and familiarity that can provide a measure of stability and security in the midst of the ...
How would you approach anticoagulation for a patient with acute bilateral pulmonary emboli related to malignancy, but with a concomitant cavitary lung mass experiencing episodic, small-volume hemoptysis?
This is an interesting question to which we need to apply the art of medicine, weighing the risks and benefits of treatment. The major fatal events in this exact scenario are: Recurrent PE from undertreatment. Sudden massive hemoptysis after aggressive anticoagulation. The physician's management s...
How do you counsel patients on use of creatine monohydrate supplementation during a hospitalization for acute rhabdomyolysis from intense physical training?
I was a primary care doctor for the military for a few years. We regularly saw patients presenting with rhabdomyolysis from intense physical training. A standard question for all that present with this is whether supplements are being used. While there isn't a direct linkage to say that the use of c...
What is your approach to volume resuscitation in patients who are third spacing fluids?
In patients with significant third-spacing (e.g., due to capillary leak in sepsis, severe pancreatitis, hypoalbuminemia, etc), we prefer balanced crystalloids (e.g., Lactated Ringer’s) as the first-line fluid for initial resuscitation in hypovolemic or septic shock with third-spacing. Typical initia...
When do you consider giving IV albumin for severe hypoalbuminemia with third-spacing of fluid outside of standard indications (i.e., large-volume paracentesis, HRS, SBP, shock, etc.)?
On the wards, I do not treat the albumin number. Severe hypoalbuminemia with third spacing, by itself, is not an indication for IV albumin. The consistent signal from the literature is that albumin should not be used simply to raise serum levels or to “pull fluid back in” as an adjunct to diuretics....
How do you approach the discussion regarding loss of muscle mass with GLP-1 agonists in your non-geriatric population where the negative repercussions may not be as obvious?
We start by having the discussion PRIOR to starting the medication. We educate that this is not a GLP-1 phenomenon but a result of weight loss. We reinforce this at every dose change and at every follow-up, emphasizing protein and strength training. We use a body composition analysis scale to help p...