Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Based on most current research regarding the more widespread use of class IC antiarrhythmic drugs, what are your prescribing practices in patients with coronary artery disease?
Fair question, as we know the definition of "structural heart disease" is unknown. In the trial, it was likely ischemia driving the poor outcomes, so I will get stress with imaging on everyone >50 years old (CAD risk). Given the common finding of "questionable" stent placement in the community, I wi...
In what situations would you recommend metformin in addition to aggressive lifestyle interventions for patients with prediabetes and obesity?
So based on studies such as the Diabetes Prevention Program and newer meta-analyses such as Comparison of the Efficacy of Metformin and Lifestyle Modification for the Primary Prevention of Type 2 Diabetes: A Meta-Analysis of Randomized Controlled Trials (Vajje et al., PMID 38021728). Lifestyle modif...
How would you approach management of retroperitoneal fibrosis causing ureteral compression that has already caused irreversible loss of kidney function?
I agree with my colleagues and will add some additional thoughts. While I agree that tissue diagnosis is helpful whenever it can be obtained (both to differentiate IgG4-related vs idiopathic RPF and to exclude other causes such as lymphoma, sarcoma, and Erdheim-Chester Disease), it is often the case...
In patients with persistent borderline hypotension recovering from sepsis or critical illness, do you use midodrine to avoid escalating to higher levels of care?
Although midodrine is a medication that can be used to avoid vasopressors, I think it is much more important to give isotonic fluids when the patient would benefit from fluids. It is also very important to determine the etiology of hypotension. Is hypotension related to sepsis? Hypovolemia? Bleeding...
When would you consider checking JC virus prior to initiating biologic therapy?
JC is a ubiquitous virus with sero-prevalence in the adult population of 60-70% in most studies. The concern is that in those who harbor latent JC are vulnerable to reactivation and ultimately the development of Progressive Multifocal Leukoencephalopathy (PML). The drug natalizumab used to treat MS ...
What do you think about using conventional thoracic imaging methods (e.g., X-ray, CT, etc.) to determine if a pleural effusion is of adequate size to consider thoracentesis?
Generally speaking, CT would be superior as it would allow you to see more volumetric characteristics of the effusion; XR would have a hard time discerning true size, presence of loculations, or trapped lung. The real winner for this application would be bedside ultrasound. This modality would give ...
What do you think about using conventional thoracic imaging methods (e.g., X-ray, CT, etc.) to determine if a pleural effusion is of adequate size to consider thoracentesis?
Generally speaking, CT would be superior as it would allow you to see more volumetric characteristics of the effusion; XR would have a hard time discerning true size, presence of loculations, or trapped lung. The real winner for this application would be bedside ultrasound. This modality would give ...
How do you balance the risks versus benefits of starting a statin in a patient with MASLD and a persistent but mild elevation in their AST/ALT?
I no longer hesitate to start a statin despite mild ast/alt elevation. I might just check lfts again in a few months, but if there is a clear indication for the statin we go ahead and do it.
How do stroke-risk considerations affect your use of atypical antipsychotics for patients with dementia?
Antipsychotics carry a number of risks, including a warning of sudden death in elderly demented patients. If nothing else works for a behavioral problem, you have to use an antipsychotic. Also, for frank paranoia, which is not only causing distress to parents but also to the environment, treatment w...
Do you recommend checking urine sodium 2 hours after loop diuretic administration to determine the need for dose adjustment in a patient with acute decompensated heart failure?
I know that is maybe a more physiologic way, but I can tell if it is working just by the urine output. The urine output is not going to increase following a loop diuretic without a natriuresis. And what good id an increased urine Na if the volume of urine is insufficient? If I am diuresing in decom...