Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to a situation where DILI is suspected secondary to an important medication (e.g., anticoagulation, antibiotics, etc.), but the diagnosis is uncertain and the liver injury is relatively mild?
If the drug suspected to induce liver injury causes symptoms and ALT is >3 times the upper limit of normal (ULN), I would stop the drug and find an alternative. Even if no symptoms are present, I would stop if ALT is >5 times ULN. Any level increase of ALT below the above parameters would still requ...
What is your approach to a situation where DILI is suspected secondary to an important medication (e.g., anticoagulation, antibiotics, etc.), but the diagnosis is uncertain and the liver injury is relatively mild?
If the drug suspected to induce liver injury causes symptoms and ALT is >3 times the upper limit of normal (ULN), I would stop the drug and find an alternative. Even if no symptoms are present, I would stop if ALT is >5 times ULN. Any level increase of ALT below the above parameters would still requ...
How do you decide when to act upon TFT derangements in hospitalized patients (e.g., start/adjust thyroid replacement therapy) vs attribute to NTIS (formerly euthyroid sick syndrome) and advise repeat TFTs as an outpatient?
It is not always easy to discern, but typically in NTIS, T3, T4, and TSH are all low or normal (TSH may be slightly elevated but not markedly elevated). True hypothyroid (requiring new medication or adjustments of existing medications) typically has a high TSH and low Free T4, and the patient may ha...
What is your approach to screening for cognitive impairment in hospitalized older adults?
Upon admission to the hospital, all older adults should undergo a brief cognitive screening. This initial step helps establish a baseline and can identify previously unrecognized cognitive issues. Several tools are well-suited for this purpose; we use minicog as the screening tool at our hospital. ...
What is your approach to screening for cognitive impairment in hospitalized older adults?
Upon admission to the hospital, all older adults should undergo a brief cognitive screening. This initial step helps establish a baseline and can identify previously unrecognized cognitive issues. Several tools are well-suited for this purpose; we use minicog as the screening tool at our hospital. ...
Are there instances when you would recommend obtaining a 24 hour urine protein measurement in place of spot urine protein studies in patients with acute kidney injury and proteinuria?
I would look at the urinalysis and if there was dipstick proteinuria, I would get a spot protein creatinine ratio (PCR) and a simultaneous albumin creatinine ratio (ACR), just to get some idea if I am dealing with a glomerular or tubular cause of AKI. These tests are not reliable from a quantity sta...
Has the TRAVERSE trial, which showed testosterone therapy was noninferior to placebo for MACE but raised signals for pulmonary embolism and atrial fibrillation, changed how you counsel middle-aged men who specifically cite cardiovascular safety when requesting TRT?
Results from the TRAVERSE trial have made my discussions a bit more streamlined, but I have always used a handout discussing known risks of TRT, such as infertility, testis atrophy, and erythrocytosis, and associated risks based on poor literature dating back to 2011. This trial confirmed what most ...
What is your approach to peri-operative risk stratification and optimization in patients with cirrhosis?
The VOCAL-Penn score is one piece of information that I use for risk stratification in patients with cirrhosis. I usually treat symptomatic decompensated cirrhosis first (hepatic encephalopathy, ascites, hepatic hydrothorax, hepatorenal syndrome, variceal bleeding), because the risk scores usually c...
How have you integrated the new HPV self-swab collection into your routine cervical cancer screening, particularly in those with prior abnormal results?
Unfortunately, the new HPV self-swab collection is not currently available in my institution, but I would definitely incorporate this into my routine cervical cancer screening if it were an option! I think the HPV self-swab option is ideal for patients who are either not amenable to a pelvic exam or...
What is your approach to managing high-volume, thick tracheal secretions in a patient with a tracheostomy when there is no clear evidence of pulmonary infection?
Managing airway secretions in patients with chronic tracheostomies can be very challenging, and secretion volume varies considerably in some patients from day to day or even hour to hour, often inexplicably. The tube itself is an irritant, as is frequent suctioning, so virtually every patient with a...