Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you determine which atrial fibrillation patients with a high thromboembolic risk and a contraindication for oral anticoagulation should undergo left atrial appendage occlusion?
If the contraindication is absolute, all high risk patients need to be informed about the availability of LAAO devices. If the patient cannot take an anticoagulant or antiplatelet for a short period after implant, an epicardial approach could be considered.
How soon after starting treatment for Takayasu arteritis do you decide on the need for any vascular interventions to manage chronic damage?
To answer this question, several elements need to be considered. As a rule of thumb, in TAK and large vessel vasculitis in general, it is recommended to perform vascular surgery at the time of disease remission to prevent complications during the surgical procedure and in the immediate postoperative...
What is the likelihood of recovery of parathyroid gland function for patients who underwent total thyroidectomy, found to have embedded parathyroid glands intra-operatively and then subsequently had them re-implanted into neck muscle?
Recovery of parathyroid function after total thyroidectomy in which parathyroid tissue was found embedded in the thyroid depends upon many factors. How many glands were found in the thyroid? Was the surgery extensive, and thus perhaps led to compromise of the vascular supply of the parathyroid gland...
For patients hospitalized with volume overload who improve after IV diuresis but have no prior outpatient diuretic regimen, do you routinely start a scheduled oral diuretic at discharge?
I do routinely start a scheduled oral diuretic at discharge, because to me, if the patient requires hospitalization for IV diuresis for a new diagnosis of heart failure, they will need a maintenance oral diuretic regimen to avoid readmission. How to choose an appropriate dose for the patient in fron...
How do you explain progression free survival to patients?
This is a really, really important question. I'd argue we often greatly undervalue the importance of communication with our patients and the impact the quality of our communication has on what they understand about their illness. I remember once having a long conversation with a patient where I outl...
Are you covering the tracheostomy site with a surgical mask due to COVID-19 to protect the therapist?
I have not routinely used masks over tracheostomy tubes, but it seems like a good idea in the current environment. Our staff, including physicians, nurses, and therapists, do use masks while taking care of these patients, including during suctioning of tracheal secretions.
For patients over 70 with elevated ASCVD risk but no prior cardiovascular events, do you ever recommend continuing or initiating low-dose aspirin?
Yes, I might still recommend low-dose ASA for primary prevention for someone over 70 if the patient is very functional.
How do you weigh the benefit of urinary catheter placement for strict I/O measurement with the risk of avoidable CAUTI?
Our hospital's approach, which is consistent with CDC guidance, limits urinary catheters (UC) for I/O measurement to critically ill patients. We clarify that the information from the UC should be used at least q1-2 hours, otherwise it can be obtained in other ways (noninvasive collection, bladder sc...
How would you approach an asymptomatic older female patient with eosinophilia to 17,000, present for years, and normal eosinophilia workup including marrow and negative FLIP1?
Interesting case. Eos have been in the 17K range for years? Was it incidentally noted? Could just be idiopathic HES. I would worry about cardiac infiltration in an older patient, but if there have never been cardiac issues and no evidence of a myeloid variant, I would probably defer to the patient a...
What is your approach during DCCV if you have an obese patient with atrial fibrillation refractory to up to 3, 360 J shocks?
To some degree it depends on what happened with the first three shocks, (I would have applied pressure to shorten the AP diameter for the second and/or third). If the patient converted but it didn't stick, I would consider AAD loading followed by a repeat procedure. If the patient did not appear to...