Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you counsel someone about metformin use for type 2 diabetes mellitus who is also on a GLP-1 agonist and achieved goal HbA1c, but prefers not to be on metformin anymore?
I am all for this! I realize metformin is still "first line" technically, but so many patients are having a robust response to GLP-1as that I think this may change. Given that GLP-1as have a lower risk of hypoglycemia plus the cardiovascular benefits, I think monotherapy is very appropriate. Also, A...
What is your approach to IV fluid resuscitation during a sickle cell vaso-occlusive crisis?
My approach to IV fluid resuscitation in vaso-occlusive crisis is cautious and individualized. Adequate hydration is important to prevent further sickling, but I avoid aggressive fluid loading because of the risks of pulmonary edema and acute chest syndrome. I typically use isotonic balanced crystal...
In patients with moderate calcific mitral stenosis, possible HFpEF and dyspnea on exertion, how would you differentiate the etiology of the symptoms?
I would consider a dobutamine stress echocardiogram to evaluate the flow across the valve as well as diastolic parameters. If this does not answer the question, an exercise right heart catheterization could be helpful and could also look into concomitant pulmonary hypertension as a cause of dyspnea....
Do you use premedications (acetaminophen, diphenhydramine) before pRBC and plt transfusions to prevent febrile nonhemolytic transfusion reactions and allergic reactions?
I do not routinely premedicate patients. There is a recent meta-analysis that shows no benefit. I only premedicate those who have had a prior transfusion reaction. Old studies showed this was a common practice but those studies were performed before universal leukoreduction and other strategies aimi...
Is there a role for anti-fibrinolytic agents in patients with hyperfibrinolytic disseminated intravascular coagulation?
DIC is a complex clinicopathologic syndrome. There are no randomized trials to support evidence-based practice. The following principles apply: 1) antifibrinolytics should not be used in patients with organ failure or those that are asymptomatic. One could justify their use in this group of patients...
What outpatient therapies do you recommend for continuous or severe pain from migraine that is refractory to acute therapies?
I assume that what we are dealing with here is what we call a migraine status or status migrainosus. This refers to a migraine headache that has continued well beyond its usual duration, for which we often use the arbitrary three-day mark. We base this mark on the erroneous assumption that migraine ...
Do you routinely continue dual antibiotic coverage or de-escalate to monotherapy based on peritoneal fluid culture sensitivities in patients with relapsing pseudomonas aeruginosa peritoneal dialysis peritonitis after peritoneal catheter removal?
If the peritoneal dialysis catheter has been removed then I would de-escalate to monotherapy based on the fluid culture sensitivities. Monitor clinical response and obtain new fluid samples for analysis if any concern for persistent infection.
Would you start treatment for MAC in a patient with nodular bronchiectatic disease who has demonstrated radiographic progression but remains asymptomatic and smear-negative?
My default answer would be yes; this is a sign of progressive disease that will get worse without treatment. Having said that many things could be considered while making the decision, including patient preferences. First is there another cause? Does the patient have an exacerbation of bronchiectasi...
Would you offer TPO-RAs to a steroid-refractory chronic ITP patient with history of stroke?
Yes, if needed, though with a bit of trepidation, and it probably wouldn't be my first choice. Second-line chronic ITP treatment can include TPO-RA, rituximab, or splenectomy, and no one treatment is clearly better than the others (Neunert et al., PMID 31794604). Both splenectomy and TPO-RAs have in...
What would be your approach to managing severe ANCA-associated vasculitis in a patient who is also septic from a bacterial infection?
It is prudent to evaluate if the ANCA-associated vasculitis is being triggered by the underlying bacterial infection. Certain clues on the kidney biopsy including diffuse exudative as well as diffuse crescentic [of same age] pattern of injury on light microscopy, intense C3 staining on immunofluores...