Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach the management of a patient with symptomatic iron deficiency anemia who is intolerant of iron?
Oral iron will not work. I would bet my last dollar there was no anaphylaxis but rather an imprudently treated minor infusion reaction which is the cause of ostensible “anaphylaxis” over 99% of the time. You can’t verify that it was real because I can assure you: It was not. They did not do a trypt...
Do you routinely refer young patients with iron deficiency anemia for GI evaluation?
The answer is no, I do not. However, if after iron repletion deficiency persists, then I do. But as for pregnancy, unless there has been a precipitous and proven drop, I would definitely not do a GI workup during pregnancy.
How would you manage symptomatic iron deficiency in patients with PV on frequent phlebotomies?
While iron deficiency by itself is not harmful, if someone has symptomatic iron deficiency, you could consider them intolerant to phlebotomies, and start a cytoreductive agent. Then, over time they can replete their iron stores. In some patients who are very symptomatic from their iron deficiency, I...
How do you view the balance between opting for percutaneous coronary intervention and prioritizing optimal medical therapy as the initial treatment choice for patients with stable angina?
This is the holy grail of Cardiovascular practice on how to marry the prevalent scientific data to clinical practice. In my opinion, an astute history and in-depth analysis of patient symptoms (angina and ischemia with their varied clinical presentations) hold the key to individualized patient care....
Which images do you routinely request when ordering a HRCT chest?
The images I tend to request depends in part on the clinical scenario. In general, I find it helpful to obtain a traditional "ILD protocol" when I meet an ILD patient for the first time, especially when the diagnosis is unclear. This includes both prone and supine images with 1-1.5 mm cuts, in addit...
For patients with newly diagnosed VTE on IV heparin planned for transition to DOAC, would you start at the loading or maintenance DOAC dose?
Agree with Dr. @Dr. First Last. In the clinical trials that led to rivaroxaban and apixaban approval, many patients had 2 days of injected anticoagulant first to arrive at successful outcomes leading to DOAC approval. I suggest IV heparin until hemodynamically normal (for PE), sq LMWH for a dose or ...
Do you recommend getting a muscle biopsy in a patient with suspected IMNM with statin exposure, weakness, elevated CK, and positive HMGCR antibody?
A patient with a typical clinical presentation of IMNM (muscle weakness, high levels of CPK) and positive anti-HMGCR antibodies leaves no question regarding the diagnosis, and muscle biopsy would not change management. I would reserve muscle biopsy for atypical cases (for example, positive anti-HMGC...
Do you obtain an echocardiogram as a part of risk stratification in all patients hospitalized with an acute pulmonary embolism?
I agree with Dr. @Dr. First Last! The echo offers a “functional view” that we can’t obtain by CTA, as well as the opportunity to diagnose clot-in-transit. However, if a formal echo cannot be quickly obtained, a bedside echo may offer key information. All critical care and ED clinicians should have a...
Would you recommend starting an SGLT2 inhibitor in a proteinuric CKD patient with chronic asymptomatic bacteriuria?
In spite of the biological plausibility that SGLT2 inhibitors are associated with increased risk for UTI, population-based cohort studies, like the one of Dave et al in diabetic patients, did not show a higher risk of severe or minor UTI with SGLT2 inhibitor users and other antidiabetic drugs. The d...
How do you decide whether to include a basal rate when initiating a PCA?
This is a difficult question for which there is no good data to guide one's practice. The best book on this and other opiate questions is Mary Lynn McPherson's "Demystifying Opiate Conversion Calculations". I am relatively conservative on using continuous infusions (also called basal rates). My reas...