Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you recommend IV sodium bicarbonate for patients with rhabdomyolysis and AKI without metabolic alkalosis or hypocalcemia?
The primary goal of IV fluids and urine alkalinization in patients with rhabdomyolysis is to prevent AKI, not to treat established AKI. The most important factor in preventing AKI is early and vigorous fluid administration (aiming to achieve a brisk diuresis of 200-400 ml/hr), while the choice of IV...
What is your approach to managing sclerosing mesenteritis (mesenteric panniculitis)?
I have seen and followed dozens of patients with this diagnosis. As noted above, it is important foremost to be sure of the diagnosis. Mesenteric panniculitis can be part of the IgG4 associated spectrum and so a biopsy is useful if it can be done safely. The other disease in the differential is carc...
What baseline work-up or "staging" do you do in patients with a new diagnosis of Sjogren's (i.e., PFT, cryoglobulins, complement, RF, UA)?
The baseline workup I like to do in patients newly diagnosed with Sjogren's are the following lab tests with rationale: ANA (almost all patients have a high titer ANA that is positive - typically it is a speckled pattern Extractable nuclear antigen (ENA) testing looking for SSA (anti-Ro antibody) +/...
Would you consider empiric anticoagulation in patients with an acute stroke for whom you have high suspicion for cardioembolic source, but have not yet confirmed LV thrombus, atrial fibrillation, etc.?
In practice, I would rarely consider empiric anticoagulation after an acute ischemic stroke without a confirmed cardioembolic source. I would not consider this approach for suspected LV thrombus, as transthoracic echocardiography is routinely available in the inpatient setting and can quickly confir...
Do you use combination therapy for persistent MSSA bacteremia?
I don’t think I’ve ever come across a situation where the problem wasn’t source control…
How do you calculate QTc intervals in patients being admitted for AAD drug loading who remain in atrial fibrillation or atrial flutter?
We measure 10 R-R intervals and the corresponding 10 QT intervals, average each of them, and then calculate the QTc. Bazett’s formula is commonly used, but is probably less accurate than other correcting formulae, particularly for patients actively in atrial fibrillation. We often use the Framingham...
Do you treat Stenotrophomonas maltophilia bacteremia with combination therapy and if so, what is your preferred combination of antibacterials?
Yes, I would use two agents, at least up front, as recommended in the 2024 IDSA guidelines (Tamma et al, PMID 39108079). The guidelines suggest two of the following agents should be used, unless the combination of ceftazidime-avibactam plus aztreonam is used instead: cefiderocol, TMP/SMX, levofloxac...
How do you approach the risk/benefit discussion for IV iron in a patient with concomitant severe iron deficiency and elevated hematocrit due to supra-physiologic testosterone supplementation?
I only administer iron if symptomatic (pagophagia, RLS, etc). I have not seen iron deficiency with testosterone prior to phlebotomy. When it is required, I literally walk both sides of the aisle. If a non-phlebotomized patient presented with ID, I would work it up like any other. If I have to treat,...
Do you have any tips for best practices or resources for interacting with adult protective services when reporting elder mistreatment?
Interacting with Adult Protective Services can sometimes feel like a one-way valve: we make a report, provide information, and don't hear back. I've come to learn that in many jurisdictions, APS is prohibited from sharing information with the reporter, and they actually want to have more/better inte...
What strategies have you found most effective for those attempting vaping cessation?
Clinicians are finding increasing success with Varencline and Nicotine Replacement Therapy (NRT) for vaping cessation. When combined with behavioral counseling, these treatments are more likely to achieve sustained abstinence than medication alone. For adolescents in particular, it is important to i...