Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you weigh the risk of urinary catheter or fecal management system placement with that of soiling sacral wounds?
This question is an important question that arises for many of our bed-bound and poorly mobile patients, as sacral wounds commonly develop due to pressure injury. They become very challenging to treat due to fecal and urinary contamination, which can lead to further infection. Fecal and urinary dive...
How many total days of antibiotics do you prescribe for uncomplicated non-purulent cellulitis in hospitalized patients who show clear clinical improvement within 48–72 hours?
Thanks for the question. Five days total, with transition to oral antibiotics upon clinical improvement to complete this course. Notably, my health system (via our EMR-based clinical decision support tool) recommends penicillin (IV) or amoxicillin (PO) as first-line treatment for nonpurulent celluli...
How do you manage Fanconi’s syndrome and polyuria related to ifosfamide?
Treatment of ifosfamide-induced Fanconi syndrome and polyuria is primarily supportive. First, the benefits and risks of discontinuation of ifosfamide should be discussed with the oncologist. Treatment of Fanconi syndrome is aimed at repletion of potassium, bicarbonate, and phosphate. Calcitriol is a...
What is your preferred method for confirming the diagnosis of primary aldosteronism in a patient with an elevated plasma aldosterone to renin ratio?
The endocrine guidelines on primary aldo diagnosis (1) allow for 3 confirmatory tests: 24-hour urine, fludrocortisone suppression testing, and response to saline infusion. At UAB, we use the 24-hour urine collection. Most of our patients do not need additional salt loading during the 24-hour collect...
How do you approach the management of a symptomatic Baker's cyst?
I have offered NSAIDs, PT, and ultrasound-guided aspiration and injection for management of a symptomatic Baker’s cyst in a patient with OA or mechanical pathology. I favor aspiration and injection of the knee joint as well as the cyst, though the literature does not necessitate injection of the joi...
How do you approach initiating a deprescribing conversation about a long-standing benzodiazepine in an older adult who has been on a stable dose for years and reports no side effects?
First, I try to understand what symptoms led to the initiation of the benzodiazepine, which can help me identify whether there is a safer alternative treatment. Then I make sure people understand why we want them to come off the benzodiazepine in the first place, since this is not common knowledge (...
When do you recommend limited or targeted respiratory pathogen testing versus a full respiratory pathogen panel in a patient presenting with URI symptoms?
I think we’re asking the wrong group of people. How infectious disease physicians use respiratory pathogen panels is not the same as how emergency medicine or urgent care clinicians use them. For stewards of diagnostics, especially ID providers, the test often doesn’t change management. In many sett...
In light of the NOAH-AFNET6 and ARTESiA trials, how would you approach the decision regarding anticoagulation for patients with incidentally-detected AF <24 hrs on pacemakers/defibrillators?
Finding the right answer for subclinical atrial fibrillation is sometimes hard to tease out the subtleties. The 2023 ACC/AHA/HRS atrial fibrillation guidelines were published in Jan 2024 (Joglar et al., PMID 38033089) and a section (6.4.1) is dedicated to patients with CIED without prior atrial fibr...
Do you treat patients with culture positive mycobacterium abscessus if they are asymptomatic and do not have progression on imaging?
If by "symptomatic," the assumption is that patients have a productive cough, malaise, fatigue, and weight loss, they should be treated per protocol. We usually proceed with "shared decision making" discussing the nuances of untreated versus treated scenarios.
How do you approach management of new onset ILD in a patient with RA who is otherwise well controlled on methotrexate or leflunomide?
We do not have any randomized controlled trials for DMARDs in RA-ILD. Most of the data is case series or retrospective analysis. Nonetheless, we can use current data to at least make clinical decisions until we receive more direction from high-quality clinical trials. We now know that in general met...