Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When starting stress dose steroids for patient with primary adrenal insufficiency, how do you decide whether to start hydrocortisone 100 mg every 8 hours versus 50 mg every 6 hours?
Stress doses of steroids in patients with primary adrenal insufficiency depend on the anticipated stress. The dose of steroids can be doubled or tripled depending on the stress. For example, in cases of maximal stress such as major surgery, the dose can be similar to the dose used for an adrenal cri...
When starting stress dose steroids for patient with primary adrenal insufficiency, how do you decide whether to start hydrocortisone 100 mg every 8 hours versus 50 mg every 6 hours?
Stress doses of steroids in patients with primary adrenal insufficiency depend on the anticipated stress. The dose of steroids can be doubled or tripled depending on the stress. For example, in cases of maximal stress such as major surgery, the dose can be similar to the dose used for an adrenal cri...
How do you consider and approach transition to hospice in a patient with HFrEF who does not appear to tolerate GDMT?
I approach this situation similarly to any illness that has reached end-stage or is approaching end-stage. First, I determine the patient's goals of care. By this, I mean, what does the patient value? If time is getting short, how do they want to spend their time? Where and with whom? How do they de...
How do you consider and approach transition to hospice in a patient with HFrEF who does not appear to tolerate GDMT?
I approach this situation similarly to any illness that has reached end-stage or is approaching end-stage. First, I determine the patient's goals of care. By this, I mean, what does the patient value? If time is getting short, how do they want to spend their time? Where and with whom? How do they de...
Do you favor 24 hour urinary metabolites over random urine collection when screening for MCAS?
In my practice, I currently use 24-hour urine metabolites. The 24-hour urine collection has been extensively validated and its use is supported by the literature (see review: Butterfield et al, PMID 35346887).That being said, a spot urine collection is now available and this is far more convenient f...
How would you work up a mildly neutropenic patient (ANC >800) with family history of neutropenia and personal history of occasional mouth sore?
The first question is whether to evaluate the neutropenia at all. With ANCs >800 and only occasional mouth sores, is a diagnosis necessary, and should the term “neutropenia” be used at all? If the family’s origin is in a part of the world where the Duffy null phenotype is common (e.g. Africa, parts ...
Would you pursue a colonoscopy for a patient in their 20s with constipation and rectal bleeding if they had a first-degree relative who died young from a "carcinoid tumor"?
Carcinoid tumor is relatively uncommon in someone who is relatively healthy and young. I would make sure to consider all the more common diagnoses and workup before considering carcinoid tumor. Moreover, carcinoid tumor is associated with diarrhea rather than constipation. Neuroendocrine tumor of th...
What is a reasonable hemoglobin goal for patients with chronic anemia presenting with acute MI?
The diversity of acute myocardial infarction (AMI) does not allow a monolithic answer to this question. The recent MINT study—an important contribution presented at AHA 2023 and published in NEJM—highlights this complexity. Although MINT, which randomized anemic patients with AMI to liberal versus r...
What is a reasonable hemoglobin goal for patients with chronic anemia presenting with acute MI?
The diversity of acute myocardial infarction (AMI) does not allow a monolithic answer to this question. The recent MINT study—an important contribution presented at AHA 2023 and published in NEJM—highlights this complexity. Although MINT, which randomized anemic patients with AMI to liberal versus r...
Do you diagnose MCAS if a patient is concurrently on drugs known to cause non-specific mast cell degranulation?
Yes, MCAS may be diagnosed if a patient is on drugs known to cause non-specific mast cell activation.The reason for this answer requires a better understanding of MCAS criteria and etiology. In 2022, an expert consortium proposed revisions to the classification of mast cell activation disorders. (Va...