Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How does the presence of gallbladder sludge vs stones on POCUS impact your suspicion for gallbladder disease as a cause of abdominal pain?
With all point-of-care ultrasound, so much depends on your pre-test probability before you acquire the image. If you are simply trying to identify biliary colic in a patient with a good history of the disease, then the presence of either sludge or stones is quite an effective test with bedside provi...
How exhaustive (especially considering cost) should an immunological workup be for patients with extensive, recurrent, or deep seated Staph aureus infections without obvious immunocompromise (e.g. cancer, diabetes, steroids) or recurrent breaks in skin integrity?
Obviously, children with recurrent Staph aureus infections should be evaluated for both CGD (chronic granulomatous disease) and IgM deficiency. However, the majority of adults with recurrent SA infections do not have a known systemic immunodeficiency. We should keep in mind that Staph aureus is an a...
How would you approach surveillance imaging for men with early-stage, hormone receptor-positive breast cancer after unilateral mastectomy?
As always, appreciate others' input. If you're referring to systemic imaging, I do not obtain surveillance systemic imaging as part of surveillance for any patient with early-stage hormone-positive breast cancer (male or female) unless there are symptoms or initial labs that suggest possible metasta...
How do you approach the medical evaluation of new onset psychosis in elderly patients?
The medical evaluation of new-onset psychosis begins with a thorough history (medical, neurologic, and psychiatric history), including a history of the present illness, medications, as well as the use of alcohol and recreational drugs. Obtaining information from family or others who know the patient...
Do you routinely repeat imaging for PE after anticoagulation treatment to establish a new baseline?
We only do imaging if the patient is symptomatic still after a few weeks or has persistent chest pain or clinical signs of pulmonary hypertension. Rarely I have seen recurrent or progressive thromboembolic disease on anticoagulation. Another possible reason if the patient needs to go to surgery in t...
At what point should you consider deactivating ICDs or implanted pacemakers in patients nearing the end of life but not imminently dying?
Great question. I’ll start with the second part first. This should be a unique point in your discussions. You should clarify whether or not they want the ICD turned off, even if they agree to comfort care measures. If they hesitate to turn the ICD off, take this as an opportunity to explore more. Wh...
Is there a role for use of GLP1 R agonist or dual agonist therapy for management of post bariatric hypoglycemia and dumping syndrome?
There is little systematically collected information in this area on which to base judgments. A case series of 5 post-bariatric surgical patients treated empirically with liraglutide described reduction of hypoglycemic events based on patient history. In an experimental study comparing several treat...
What is your approach to duration of fidaxomicin in a patient receiving treatment for first C difficile infection while also receiving concurrent antibiotics for an infection?
Yes, I would extend the duration of Fidaxomicin for at least 7 days past the completion of antibiotics. Additionally, I would consider resuming Fidaxomicin if a patient needs additional antibiotics within 2 weeks of having completed C diff treatment.
What is your approach to duration of fidaxomicin in a patient receiving treatment for first C difficile infection while also receiving concurrent antibiotics for an infection?
Yes, I would extend the duration of Fidaxomicin for at least 7 days past the completion of antibiotics. Additionally, I would consider resuming Fidaxomicin if a patient needs additional antibiotics within 2 weeks of having completed C diff treatment.
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 ...