Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What are first-line choices for vasopressors/inotropes to use in hypotensive patients with Eisenmenger Syndrome?
The answer is that it all depends on the etiology... However, a common issue with Eisenmenger syndrome (ES) is that routine pharmacological treatments that cause peripheral vasodilatation may worsen the right to left shunting and further shock. My first patient with ES was a gentleman recovering fro...
What is your approach to the management of chronic GI bleeding from AVMs in an elderly patient on DOAC for atrial fibrillation?
I would definitely strongly consider the left atrial appendage occlusion device in these patients. While usually these devices (such as Watchman) do require anticoagulation for about 45 days until the device has an endothelial layer form on it (we usually confirm with a CT scan or TEE), there are so...
Do you recommend, based on current evidence, avoiding antimotility agents in patients with non-fulminant C. difficile infection who have no evidence of ileus?
I generally avoid their use based on the notions that diarrhea may contribute to the elimination of non-invasive GI pathogens and that impairment of intestinal motility could increase the risk of complications, such as toxic megacolon.The data and recommendations have not progressed beyond the follo...
In patients with suspected RCVS, is there a role for preventative CCB if headache has resolved/now asymptomatic?
In short, the use of CCBs in RCVS is only for the prevention of thunderclap headache (TCH) recurrence. Since their purpose is to prevent TCH recurrence, they are often used when the patient is asymptomatic as well (i.e., even after the index TCH has resolved). They do have no impact on eventual clin...
How does VExUS evaluation differ in a patient with a transjugular intrahepatic portosystemic shunt (TIPS)?
This is a very interesting question, and I don't think I have ever tried to look at VExUS in a patient with a TIPS before! Although, based on what I understand about this study, I would be cautious about relying on the original VExUS algorithm that incorporates hepatic vein, portal vein, and intrare...
In what clinical scenario would you consider the use of budesonide over prednisone as part of the pharmacologic management of autoimmune hepatitis?
Primarily in patients where the side effects of prednisone will or are too difficult to tolerate (diabetics, weight gain, metabolic syndrome, psychiatric disease, etc). I like to try prednisone first because of its ability to elucidate a biochemical response, fairly rapidly, so we know what we are d...
What is your approach to screening a cancer survivor for iron overload, and what is your treatment of choice?
We check the ferritin level after completion of chemotherapy. If ferritin is >1,000 ng/ml, we recheck the level as it can be falsely elevated with inflammation/infection. If ferritin is >1,000, we obtain a liver MRI with iron quantification. If liver iron concentration (LIC) is > 5 mg/g dry weight, ...
In a hospitalized older adult with significant pain and delirium, in which delirium may be due either to underlying pain or use of pain medications such as narcotics, how do you approach clinical management of delirium?
This is such a common and challenging scenario! Older adults experiencing delirium often cannot identify/vocalize the need for PRN medications. If there is high clinical suspicion for sub-optimally controlled pain being a contributor to the delirium, a strategy could be scheduling low-dose pain medi...
How do you decide when to give antibiotics for an older adult receiving comfort-focused care who develops signs of a symptomatic infection?
In an older adult receiving comfort-focused care, the decision to use antibiotics should be guided by goals of care and likelihood of symptom relief, rather than by the presence of infection alone. The main question is whether antibiotics are likely to meaningfully improve distressing symptoms such ...
At what point would you consider stopping antidepressant treatment of late life depression after remission?
My first step here would be to answer some clarifying questions: What is the patient's current prognosis? (If the patient has a limited life expectancy- weeks to small order months- then I would certainly consider deprescribing with more ease.) Are there any foreseeable anticipated triggers for depr...