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 aortic stenosis in an elderly, frail patient with multiple comorbidities who is symptomatic but considered high risk for surgical aortic valve replacement?
In an older patient with severe aortic stenosis (AS) who is not a candidate for surgery, there are 3 treatment options – TAVR, balloon aortic valvuloplasty (BAV), and medical management.In the original PARTNER trial, 358 patients with severe AS who, in the judgement of at least 2 cardiac surgeons, w...
Is there a role for routine EEG in the diagnostic evaluation of critically ill comatose patients or should these patients always receive long-term continuous video EEG monitoring?
We looked into this and found that in a non-comatose patient with no history of clinical seizures, the lack of epileptiform abnormalities on initial 30 minutes of EEG recording is associated with <5% risk for electrographic seizures suggesting that a routine EEG can be sufficient in that group (Stru...
Do you think repeated routine EEG is sufficient for cardiac arrest patients or should we be always using continuous EEG?
For most patients with cardiac arrest, cEEG has not been shown to offer improved outcomes over serial routine EEGs. In cases where there are EEG patterns that suggest seizures may be occurring, such as rhythmic or periodic patterns other than low-frequency GPDs, or repetitive evolving patterns, we t...
Would you recommend starting tolvaptan at 7.5 mg per day, which is half the typical starting dose, to reduce the risk of overcorrection in an inpatient with SIADH and a serum sodium level of 122 mEq/L?
If it is for SIADH, I always start with 7.5 mg. See this, my fellow and I put together years ago. Dosing in SIADH: A Tale of Two Tolvaptans If it is for CHF, I would start with 15 mg as those patients are so pre-renal, their distal delivery is so impaired, and tolvaptan is limited by that. I haven't...
Can the tracheostomy be reversed after completion of chemoradiation for laryngeal cancers?
Yes, if there has been a CR. Wait 3 months. PET. If negative, plug trach for 2 weeks. If all is well, pull trach.
How do you evaluate and manage acute alcohol withdrawal when symptom-driven protocols are confounded/unreliable?
Often, if someone has an underlying condition that may artifactually elevate their symptom monitor scores (such as essential tremor in CIWA-Ar or tachycardia from cancer or sepsis in mMINDS), I will do any of the following: Increase the threshold for the symptom-triggered med by a few points (if th...
How do you counsel patients/families whose goals of care are clearly aligned with a comfort-focused, end-of-life approach, but who are hesitant to formally enroll in hospice?
Hospice sounds like a 4-letter word to a lot of families! I find it important to distinguish the philosophy of comfort care vs. the benefit package associated with enrolling in hospice. Some people are able to be provided end-of-life comfort care without electing the hospice benefit, and that is fin...
How do you counsel patients/families whose goals of care are clearly aligned with a comfort-focused, end-of-life approach, but who are hesitant to formally enroll in hospice?
Hospice sounds like a 4-letter word to a lot of families! I find it important to distinguish the philosophy of comfort care vs. the benefit package associated with enrolling in hospice. Some people are able to be provided end-of-life comfort care without electing the hospice benefit, and that is fin...
How do you titrate opioids for pain and breathlessness in patients with a DNR/DNI code status, but who otherwise still wish to pursue life-prolonging treatments?
Carefully! But let's be very clear about this situation: the DNR/DNI status shouldn't really affect your management if the patient wants full treatment otherwise. In fact, even if someone opts for a hospice care plan and does not want full treatment nor resuscitation, we can still have the same gene...
How do you titrate opioids for pain and breathlessness in patients with a DNR/DNI code status, but who otherwise still wish to pursue life-prolonging treatments?
Carefully! But let's be very clear about this situation: the DNR/DNI status shouldn't really affect your management if the patient wants full treatment otherwise. In fact, even if someone opts for a hospice care plan and does not want full treatment nor resuscitation, we can still have the same gene...