Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you manage orthostatic hypotension in patients with Parkinsonian syndromes?
Don’t forget to check for adjunctive medications including urinary alpha antagonists which can cause orthostatic hypotension. If possible, reduce doses of cardiac medications. If this is not possible, then consider small frequent meals, exercise, especially the lower extremity elevating the head of ...
Do you account for the effect of coffee on platelet aggregation studies?
Although recommendations from the International Society of Thrombosis and Haemostasis (ISTH) [1] suggest that individuals should avoid caffeine for at least 2 hours before blood is drawn for light transmission platelet aggregation studies, (and be fasting, be rested for 30 minutes, and avoid smoking...
How long after initiating mycophenolate do you wait before tapering prednisone off in patients with myositis-associated ILD?
Taper Pred after 6 weeks MMF tapering to prednisone 20 mg/day and hold this dose for 6-8 weeks monitoring for relapses. If no relapse, taper to Prednisone 10 mg/day.
How often do you recommend basic metabolic panel checks in a hospitalized ESKD patient on thrice weekly hemodialysis and for whom hyperkalemia is not of major concern?
The ease (usually no venipuncture), cost (miniscule relative to the overall cost of hospitalization), blood loss (not much) and utility (varying from little to significant depending on the clinical setting) indicate at least thrice weekly BMPs. A very ill, ICU patient will need a daily BMP while an ...
What is your approach to determining the safety, appropriateness, and timing of SPECT or PET MPI in patients admitted with NSTEMI and who remain chest pain-free and hemodynamically stable?
Patients with NSTEMI who are stable should have a coronary angiogram as soon as possible. If an angiogram is not available or may be higher risk due to renal failure then a stress test is reasonable but it should be also be done as soon as possible. The goal is to revascularize a vulnerable plaque b...
Would it be reasonable to begin considering GLP1 RAs or finerenone for patients with heart failure with recovered LVEF in light of recent trials such as SELECT and FINEARTS-HF showing some success in HFpEF and HFmrEF populations?
I reject the premise of the question. Patients with HFrEF who improve on medical therapy do not become HFpEF. The pathophysiology of these diseases are entirely distinct and it speaks to the limitation of EF as a categorical variable. HFrEF patients have cardiomyopathy that manifests over time as di...
When do you use seizure prophylaxis in patients on clozapine?
The topic of the use of anticonvulsants for primary prophylaxis of clozapine-induced seizures continues to be debated. The idea of prescribing anticonvulsants prophylactically for patients taking >600 mg/day of clozapine was suggested by Devinksy et al., PMID 2006003 in 1991. Clozapine-induced seizu...
How do you decide whether or not to pursue inpatient workup of an incidental liver mass?
When deciding whether to pursue inpatient evaluation of an incidentally discovered liver lesion, I ask two key questions:Is the lesion plausibly related to the clinical syndrome I’m treating now?Are there patient- or system-level barriers that would make outpatient follow-up unreliable or unsafe?Cli...
How frequently would you consider IV iron treatment for ongoing iron loss and severe iron deficiency anemia?
Absolutely. You first want to estimate and replace their iron deficit. For patients who are very anemic, they can start at 2-3 grams deficit. I usually don’t give more than 1500 g of iron dextran at one time, but I will have no concern about doing 1000 or 1500 mg weekly until I have replaced their d...
How would you approach the treatment of a patient with solid food esophageal dysphagia and GERD without a detectable esophageal stricture on upper endoscopy?
I would obtain a barium esophagram followed by high-resolution esophageal manometry and 48-hour esophageal pH testing.