Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How often do you check fibrinogen levels and when do you administer FFP for patients with AKI requiring plasma exchange?
There is no single universal protocol for monitoring fibrinogen and giving FFP during TPE; the best approach really depends on the patient's bleeding risk. Because fibrinogen recovers slowly, daily albumin-only TPE can drop levels significantly, which has led to the traditional practice of checking ...
Do you recommend additional spinal MRI’s for an asymptomatic Chiari I malformation?
Age does not matter; the severity of the Chiari does. Although subjective, I would image the spine if I thought the foramen magnum was crowded enough to potentially cause a syrinx. I am not a big believer in "a high incidence" of tethered cord in the Chiari I population, so this concern would play i...
How soon after an acute upper GI bleed do you restart therapeutic anticoagulation in a patient with atrial fibrillation and a high thromboembolic risk (CHA₂DS₂-VASc ≥4)?
In real-world inpatient practice: ~72 hours after endoscopic control for high-stroke-risk AF with stable hemoglobin and no rebleeding. Extending hold to 5–7 days if the lesion is high risk or the bleed was severe.
Is your approach to managing immune related adverse events altered at all in light of COVID-19?
First of all, I wish to thank @Dr. First Last from Johns Hopkins/Sibley for his advice addressing this critical topic.We are all witnessing a rapidly evolving crisis that none of us have been prepared for and it is the right thing to quickly consider as best as we can how the COVID-19 pandemic shoul...
What are some tips for visual estimation of ejection fraction when trying to difference between low-normal (50-55%) and mildly reduced (45-50%)?
Differentiating between a low-normal (50–55%) and a mildly reduced (45–50%) ejection fraction (EF) is inherently difficult with visual estimation alone because the difference is subtle. When evaluating point-of-care ultrasound, it is important to consider the limitations of the device you are using....
For patients on immune checkpoint inhibitors presenting with chest pain, dyspnea, fatigue, and troponin elevation, would you recommend early initiation of high dose steroids for empiric treatment of ICI myocarditis while pursuing workup with coronary angiogram, echocardiogram, and/or cardiac MRI, or wait until alternative etiologies have been ruled out?
This question raises an important point that the clinical presentation of ICI-associated myocarditis often overlaps with other cardiovascular disorders, including acute coronary syndrome, chronic CAD, congestive heart failure, and other nonischemic cardiomyopathies. Therefore, prompt initiation of w...
When would you consider tapering glucocorticoids in a patient with ICI-associated myocarditis?
Once troponins start to decrease, I start the steroid taper and follow troponin levels. If they rise, I slow the taper. I also get serial ECGs, esp if there were arrhythmia manifestations of myocarditis. Don't forget to assess for the need for PJP prophylaxis with Bactrim or pentamidine and PPI sinc...
Do you recommend vitamin K2 supplements in patients with osteoporosis?
The answer, as with most vitamin supplementations, cannot be answered with high-level evidence to support a "yes or no". A bit of background and then a brief review of available evidence.Vitamin K is thought to be important for bone health because it activates several proteins involved in bone forma...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
How do you recommend educating patients with a diagnosis of PCOS with the new name change to PMOS?
This is a great question. For many years, I have been talking to people about how the presence or absence of ovarian cysts didn't really mean anything in their PCOS diagnosis. So, to me, the new name makes a lot more sense. I talk to people about the underlying issue in PMOS which is the underlying ...