Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you ever use POCUS to evaluate for fecal impaction or stool burden in a patient with abdominal pain?
I have used POCUS in the evaluation of abdominal pain suspected of being constipation. I generally find it easiest to assess this in the right upper quadrant near the gallbladder, where you can often get a decent view of the ascending/transverse colon. If there is significant stool in the colon at t...
Do you ever use POCUS to evaluate for fecal impaction or stool burden in a patient with abdominal pain?
I have used POCUS in the evaluation of abdominal pain suspected of being constipation. I generally find it easiest to assess this in the right upper quadrant near the gallbladder, where you can often get a decent view of the ascending/transverse colon. If there is significant stool in the colon at t...
How do you consider the clinical relevance of elevated serum B12 levels as a marker of underlying hepatic disease?
Elevated B12 levels have shown significant relevance and significance to many underlying conditions, particularly a high correlation with underlying liver disease. About 1 in 5 to 1 in 4 B12 levels >1000 pg/ml had a significant correlation. It is a prognosticator, in my opinion, and the literature s...
How do you consider the clinical relevance of elevated serum B12 levels as a marker of underlying hepatic disease?
Elevated B12 levels have shown significant relevance and significance to many underlying conditions, particularly a high correlation with underlying liver disease. About 1 in 5 to 1 in 4 B12 levels >1000 pg/ml had a significant correlation. It is a prognosticator, in my opinion, and the literature s...
What is your approach to isolated alkaline phosphatase without other laboratory abnormalities?
Assuming none of the other LFTs are abnormal, I would get a GGT. If GGT is elevated --> likely a hepatobiliary issue. Would consider age, medical history, and risk factors. If persistently elevated, could consider RUQ US + MRCP. Conditions like PSC or PBC are frequently discovered due to asymptomati...
How do you differentiate cognitive impairment from normal age-related cognitive decline?
Dr. @Dr. First Last's answer is right on target. I have a couple of additional tips when taking a history. First: normal cognitive decline would include certain features and not others. Normal aging typically leads to slower processing, more effort with multitasking and learning something new, and m...
What are the current clinical practices for TEE to guide cardioversion and anticoagulation duration post-cardioversion for Afib/flutter in patients following left atrial appendage closure?
Right now, there is not a great deal of data to guide us to answer this question. In general, the safest thing from a stroke prevention standpoint would be to adhere to the same guidelines that we would for patients without left atrial appendage occlusion devices. However, of course, most of these p...
Is it reasonable to consider the use of DOACs for LV thrombus management instead of coumadin?
I have no qualms whatsoever at using a DOAC instead of Vitamin K antagonist in this situation, provided that the patient doesn't have a mechanical valve. Endothelium is endothelium, so mechanistically I don't see much of a difference between using a DOAC to prevent/treat an LAA thrombus versus an LV...
How do you decide when to initiate or restart diuretics in a cirrhotic patient with ascites if they are receiving a therapeutic paracentesis?
This question has two parts, one with a straightforward answer, the other with a much more nuanced answer, if I understand it correctly. Any patient receiving a therapeutic paracentesis should start/restart diuretics afterwards. Per the 2021 AASLD guidelines, one of the statements reads “LVP is the ...
How do you decide when to initiate or restart diuretics in a cirrhotic patient with ascites if they are receiving a therapeutic paracentesis?
This question has two parts, one with a straightforward answer, the other with a much more nuanced answer, if I understand it correctly. Any patient receiving a therapeutic paracentesis should start/restart diuretics afterwards. Per the 2021 AASLD guidelines, one of the statements reads “LVP is the ...