Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you counsel patients who are opposed to the recommendation of facility-based post-acute rehab?
This seems to happen most often with patients who have had bad experiences in the past at SNFs. Typically, I try to get a sense from PT and OT what would be required to make a home discharge safest; refer to home health PT/OT and nursing; enlist the family and do expectations management about what w...
Do you seek pathologic confirmation before proceeding with empiric immunosuppressive therapy in symptomatic patients with radiographic NSIP?
In general, getting lung biopsies is needed in a minority of people who have clear evidence of NSIP on HRCT. If there is any evidence to suggest a concomitant ARD, a biopsy will not typically be needed. In our combined ILD-Rheumatology clinic, we see these patients all the time and I can think of on...
How do you approach the workup of pauci-immune glomerulonephritis?
When a kidney biopsy reveals a pauci-immune GN, the Ddx must extend well beyond classic AAV and infective endocarditis. For instance, anti-GBM disease should remain high on the list, as up to 25% of these patients present with a "dual-positive" ANCA, and the characteristic linear IgG staining on IF ...
In older adults with mild cognitive impairment, do you ever prescribe cholinesterase inhibitors and/or memantine?
This is a great question, and of course, "do you ever" will get you in trouble every time! Let me start by saying that, in general, I do not prescribe these drugs for MCI. Cholinesterase inhibitors are clearly indicated for the mild-moderate stage of some kinds of dementia (some people would include...
What is the role for inpatient limited-montage EEG recording?
Unequivocal YES! For purposes of detecting severe seizures that cause brain injury (i.e., high seizure burden, status epilepticus), a reduced montage EEG is more than adequate, performs equivalently, and in fact BETTER because of the Clarity AI algorithm which continuously monitors, interprets, and ...
How do you counsel patients about the potential benefits of laxatives when they are experiencing overflow diarrhea and are concerned about it getting worse with these medications?
I'll preface this by saying I rarely see this, and I will approach this answer as if this patient were in palliative care. But I think I would start with education on the mechanism of this type of diarrhea and the rationale for using laxatives to improve the situation. I would also discuss that, aft...
How do you counsel patients about the potential benefits of laxatives when they are experiencing overflow diarrhea and are concerned about it getting worse with these medications?
I'll preface this by saying I rarely see this, and I will approach this answer as if this patient were in palliative care. But I think I would start with education on the mechanism of this type of diarrhea and the rationale for using laxatives to improve the situation. I would also discuss that, aft...
Do you change your pre-operative insulin dosing when patients are NPO for surgery, but also just recovering from newly resolved DKA?
For patients immediately recovered from DKA (e.g., within 72 hours), my first priority would be to delay any non-emergent surgery until the etiology of DKA has been evaluated and (if possible) addressed and the DKA has been definitively resolved with conversion off of continuous insulin and resumpti...
Do you change your pre-operative insulin dosing when patients are NPO for surgery, but also just recovering from newly resolved DKA?
For patients immediately recovered from DKA (e.g., within 72 hours), my first priority would be to delay any non-emergent surgery until the etiology of DKA has been evaluated and (if possible) addressed and the DKA has been definitively resolved with conversion off of continuous insulin and resumpti...
What is your approach to managing patients with suspected osmotic nephrosis from monthly IVIG infusions?
If the patient develops IVIG-induced osmotic nephrosis, the current IVIG therapy should be suspended, and treatment of the AKI is supportive. If IVIG needs to be restarted once the patient’s renal function recovers, there are several preventive strategies that can be tried. The patient should be swi...