Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What are your preferred treatment options for patients with chronic non-healing leg ulcers?
In addition to all the typical things (decreasing edema with meds, compression, etc + treating superinfection, critical colonization, or debriding eschars), there is some evidence for pentoxifylline 400 mg TID or 800 BID in ulcerations of any etiology. There is also newer evidence for using topical ...
How do you approach balancing the risks and benefits of elective surgery with patients who have multiple co-morbidities (e.g., frailty, chronic kidney disease, and COPD), when standard risk calculators do not capture the full complexity of their condition?
This is definitely a concern, and tools/calculators can only take us so far. I have come across scenarios where, the e.g., pulmonary respiratory failure calculator provided a low score, and based on the history, I thought the patient was at high risk. A few weeks later, before the surgery, the patie...
How do you approach balancing the risks and benefits of elective surgery with patients who have multiple co-morbidities (e.g., frailty, chronic kidney disease, and COPD), when standard risk calculators do not capture the full complexity of their condition?
This is definitely a concern, and tools/calculators can only take us so far. I have come across scenarios where, the e.g., pulmonary respiratory failure calculator provided a low score, and based on the history, I thought the patient was at high risk. A few weeks later, before the surgery, the patie...
Would you consider anti-fibrinolytics for heavy menses in patients with a history of VTE?
A recent review article provided reassuring evidence about the combined use of antifibrinolytics and estrogen in women with heavy menstrual bleeding (Meschino et al., PMID 40680937); however, it did not specifically provide data in women with a prior history of VTE. In this case, I would first ensur...
How would you counsel a woman with a strong family history of thrombosis about oral contraceptives?
This can be a complex question for which there are likely no specific data or guidelines upon which to base a recommendation. ASH has published guidelines on thrombophilia testing in VTE (Middeldorp et al., PMID 37195076). They specifically recommend against testing prior to COC prescription. The ra...
Do you routinely prescribe dry powdered inhalers over metered dose inhalers for the purpose of addressing carbon emissions?
Appreciate this question because we often forget just how inextricable the link is between human health and climate health. More specifically, carbon emissions from inhalers worsen the respiratory conditions they are intended to treat. Inhaler prescriptions filled by CMS beneficiaries in 2022 were e...
Do you have a preference between an ACEI and ARB when initiating therapy for a patient with diabetic kidney disease, albuminuria, and hypertension?
Why would you use an ACEi over an ARB these days? Cough is a LOT more common than stated. I see patients all the time who have a ticket, an annoyance that goes away on an ARB. Also, I don't see a $ argument, nor am I aware that ACEi have even been shown to be superior to ARB for reno protection. Als...
Do you routinely check N-telopeptide levels in patients who you suspect might have immobilization induced hypercalcemia?
No, I do not check N-telopeptide level in patients with suspected immobilization-induced hypercalcemia. Although N-telopeptide is a sensitive marker of bone resorption, elevated N-telopeptide is not specific to immobilization-induced hypercalcemia and can be elevated in other clinical conditions cha...
What is your preferred laboratory test to assess treatment response or infection resolution in patients with bacterial pneumonia?
I don't generally check a laboratory test to assess resolution. I go more by their improved clinical status and seeing them get back to baseline oxygen status. If I am trending a WBC or procal, I do like to see it trend down, but it's not the only lab I hang my hat on to decide if someone has resolv...
What is your preferred laboratory test to assess treatment response or infection resolution in patients with bacterial pneumonia?
I don't generally check a laboratory test to assess resolution. I go more by their improved clinical status and seeing them get back to baseline oxygen status. If I am trending a WBC or procal, I do like to see it trend down, but it's not the only lab I hang my hat on to decide if someone has resolv...