Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Which patients with cirrhosis and portal hypertension are ideal candidates to undergo TIPS to reduce perioperative risk in anticipation of an elective surgery?
A pre-operatively placed TIPS may have a role in preventing hepatic decompensation and post-surgical complications in carefully selected patients undergoing elective abdominal surgery. The data to support TIPS pre-operatively is limited, given the varying surgical contexts and the generally poor pro...
In patients with inflammatory bowel disease with low rectal cancer with planned proctocolectomy, would you consider creation of a pouch?
This is a very difficult case- are you speaking of Ulcerative Colitis or Crohn's disease? If UC - can consider pouch but really depends on the stage of the primary rectal cancer. If neoadjuvant chemoradiation is given, the likelihood of an ileoanal J-pouch functioning appropriately is low. Generally...
How would you approach new-onset large vessel vasculitis in a young patient with Crohn's disease?
Patients with Crohn's Disease (or IBD) can develop features of large vessel vasculitis or even other forms of vasculitis. The first consideration in a young patient would be determining the type of vasculitis--whether there is a distribution and clinical picture suggestive of TAK. It is important to...
How do you approach caring for patients admitted with decompensated CHF, but who also exhibit hypotension and do not have overt signs of hypervolemia on exam?
This is a case where you might be concerned about the patient sliding into cardiogenic shock. Remember that in the context of chronic heart failure, cardiogenic shock tends to present more insidiously because these patients are typically compensated at low or borderline low cardiac output (Abraham e...
How do you approach caring for patients admitted with decompensated CHF, but who also exhibit hypotension and do not have overt signs of hypervolemia on exam?
This is a case where you might be concerned about the patient sliding into cardiogenic shock. Remember that in the context of chronic heart failure, cardiogenic shock tends to present more insidiously because these patients are typically compensated at low or borderline low cardiac output (Abraham e...
What are your thoughts on trending beta-hydroxybutyrate once a diagnosis of DKA is already established?
Beta-hydroxybutyrate (BOHB) ≥3.0 mmol/L is highly sensitive and specific for diagnosing DKA and can be measured through serum or point-of-care testing. However, its role in monitoring treatment response and determining resolution remains debated. The American Diabetes Association recommends continui...
When do you consider changing a patient's levothyroxine dose during hospitalization due to abnormal TFTs, but without clinical evidence of thyrotoxicosis or hypothyroidism?
Thank you for your question. I think this is something we commonly get in the hospital, and we often overreact to it. This was a "Things We Do For No Reason" some time back, and I think they outline the issues well.When people are acutely ill, TSH testing is unreliable. The times when TSH testing is...
What are your preferred treatment options for patients with chronic non-healing leg ulcers?
In addition to all the typical things (decreasing edema with meds, compression, etc + treating superinfection, critical colonization, or debriding eschars), there is some evidence for pentoxifylline 400 mg TID or 800 BID in ulcerations of any etiology. There is also newer evidence for using topical ...
How do you approach balancing the risks and benefits of elective surgery with patients who have multiple co-morbidities (e.g., frailty, chronic kidney disease, and COPD), when standard risk calculators do not capture the full complexity of their condition?
This is definitely a concern, and tools/calculators can only take us so far. I have come across scenarios where, the e.g., pulmonary respiratory failure calculator provided a low score, and based on the history, I thought the patient was at high risk. A few weeks later, before the surgery, the patie...
How do you approach balancing the risks and benefits of elective surgery with patients who have multiple co-morbidities (e.g., frailty, chronic kidney disease, and COPD), when standard risk calculators do not capture the full complexity of their condition?
This is definitely a concern, and tools/calculators can only take us so far. I have come across scenarios where, the e.g., pulmonary respiratory failure calculator provided a low score, and based on the history, I thought the patient was at high risk. A few weeks later, before the surgery, the patie...