Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you determine the severity of restrictive lung disease?
My interpretation of the latest ATS/ERS guidelines is that FEV1 should be used for "any spirometric abnormality" including restriction or mixed disorders, which is unchanged from the 2005 ERS Guidelines.That said, I tend to use FVC when grading pure restrictive disorders, habituated as a result of F...
Would you stop an ACE inhibitor/ARB or instead initiate a potassium binder to manage hyperkalemia in a patient with proteinuric CKD stage 5 who is on an ACEi/ARB?
This depends on where in CKD 5 the patient is, to some extent. Would also make sure to modify diet if possible and make sure on an appropriate dose of a loop diuretic. If very close to starting dialysis or getting a txp, I might reduce dose or stop, especially if a K-binder is expensive for the pati...
How do you counsel patients/families whose goals of care are clearly aligned with a comfort-focused, end-of-life approach, but who are hesitant to formally enroll in hospice?
Hospice sounds like a 4-letter word to a lot of families! I find it important to distinguish the philosophy of comfort care vs. the benefit package associated with enrolling in hospice. Some people are able to be provided end-of-life comfort care without electing the hospice benefit, and that is fin...
How do you counsel patients/families whose goals of care are clearly aligned with a comfort-focused, end-of-life approach, but who are hesitant to formally enroll in hospice?
Hospice sounds like a 4-letter word to a lot of families! I find it important to distinguish the philosophy of comfort care vs. the benefit package associated with enrolling in hospice. Some people are able to be provided end-of-life comfort care without electing the hospice benefit, and that is fin...
How do you approach a situation where you disagree with a consultant's recommendation for your patient, particularly when the consultant has more disease-specific expertise, but you have a fuller picture of the patient's overall clinical trajectory?
Thank you for this question. If a consultant provides a recommendation that I disagree with, I try to understand their perspective and rationale. Most of the time, it ends up in a direct phone call to talk through the clinical scenario, listen with intention to understand their perspective, and shar...
How do you approach a situation where you disagree with a consultant's recommendation for your patient, particularly when the consultant has more disease-specific expertise, but you have a fuller picture of the patient's overall clinical trajectory?
Thank you for this question. If a consultant provides a recommendation that I disagree with, I try to understand their perspective and rationale. Most of the time, it ends up in a direct phone call to talk through the clinical scenario, listen with intention to understand their perspective, and shar...
What is your approach to patients with persistent low libido despite normal testosterone levels after use of exogenous testosterone replacement therapy?
The key point is understanding a man’s mental health and relationship status. I will always screen for depression and strongly encourage sex therapy. My unvalidated but effective screening question is asking when their last vacation was and how their libido and erections were. It’s surprising how ma...
Are there still clinical situations in which you deliberately treat patients with a DOAC besides apixaban?
Thank you for your question. Apixaban has been my preferred agent for a long time for patients requiring therapeutic anticoagulation. Apixaban’s lower bleeding risk was shown prior to and now has additional evidence to support this with the COBRRA trial. The risk is also ameliorated by the safety in...
Are there still clinical situations in which you deliberately treat patients with a DOAC besides apixaban?
Thank you for your question. Apixaban has been my preferred agent for a long time for patients requiring therapeutic anticoagulation. Apixaban’s lower bleeding risk was shown prior to and now has additional evidence to support this with the COBRRA trial. The risk is also ameliorated by the safety in...
Do you add empiric anti-MRSA coverage to the initial antibiotic regimen for a patient admitted with community-acquired pneumonia who has risk factors for MRSA but a negative MRSA nasal screen?
Thank you for this excellent and highly relevant clinical question. I approach this scenario by blending robust evidence-based medicine with fundamental principles of diagnostic reasoning. The short answer is generally no, you probably do not need to add empiric anti-MRSA coverage for a standard CAP...