Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When you identify new atrial fibrillation in a hospitalized patient that spontaneously converts to sinus rhythm within 24–48 hours, and the patient has a CHA₂DS₂-VASc score of 2–3, how do you decide whether to initiate anticoagulation and/or discharge with a wearable cardiac monitor?
This is a tough one. I think the easier part is who should get a wearable cardiac monitor? I think the answer is pretty much everyone since the recurrence rate is around 30% in one year - and if it recurs, it predisposes to strokes, and I'd likely provide anticoagulation per AHA/ACC based on CHA₂DS₂...
How are you deciding between injectable and oral formulations of buprenorphine, given new studies suggesting injectable performs similarly in regards to safety and efficacy when compared to oral buprenorphine?
The study referenced here was a randomized trial evaluation of the initiation of buprenorphine in an emergency room setting, comparing long-acting injectable formulations with transmucosal formulations. It showed that both formulations are safe and effective even for patients with active/recent fent...
Do you recommend to exchange nephrostomy tubes when a patient is diagnosed with a urinary tract infection in the absence of any overt signs of infection at the exit site?
This patient has asymptomatic bacteriuria by definition - apparently with occasional symptomatic UTI. I would not change the tube because of the ASB like I would not change a urethral catheter in the setting of ASB. And as noted the patient has already demonstrated continued ASB after changing the t...
In an older man on tamsulosin for BPH who is presenting with recurrent falls, how do you manage the medication, in light of urinary symptom control and fall risk?
Tamsulosin carries the risk of orthostatic hypotension and falls, especially in older adults1. In the situation of an older adult man taking tamsulosin for BPH symptoms who is presenting with recurrent falls, I would first check orthostatic vitals and if positive, I would discuss this finding with t...
What is your response to the question, "Is this terminal?"
Thanks for this question, it's really important. This question comes up in two distinct scenarios: when a person is first diagnosed and when a person is nearing the end of her life. Let's talk about them in sequence. 1). At diagnosis: When a person is first diagnosed, this question is part of "getti...
What antibiotic prophylaxis do you recommend for a cirrhotic patient with an upper GI bleed, if any, in light of the recent meta-analysis published in JAMA Internal Medicine?
This study highlights the lack of high-quality data supporting the recommendation for antibiotic prophylaxis in cirrhosis patients with upper GI bleeding. At my institution, we usually recommend a short course of 3 to 5 days, though some clinicians extend it to 7 days. If there is ongoing bleeding, ...
How would you manage a patient who presents with hair loss that began after they started a GLP-1 inhibitor?
If it fits with telogen effluvium, I recommend monitoring. Many patients will improve after this initial shedding and will not have long-term shedding or long-term thinning. If there is any underlying androgenetic alopecia or pattern hair loss, then starting treatment as you normally would is also r...
In what scenario, if any, would medroxyprogesterone acetate be preferred over micronized progesterone given the latter's better side effect profile and lower rate of DVT/PE?
Medroxyprogesterone acetate (MPA) would be preferred over micronized progesterone primarily in the case of a woman with a peanut allergy, as micronized progesterone is suspended in peanut oil. In that case, however, some physicians would prescribe micronized progesterone via a compounding pharmacy t...
How do you approach the workup of pauci-immune glomerulonephritis?
When a kidney biopsy reveals a pauci-immune GN, the Ddx must extend well beyond classic AAV and infective endocarditis. For instance, anti-GBM disease should remain high on the list, as up to 25% of these patients present with a "dual-positive" ANCA, and the characteristic linear IgG staining on IF ...
What procedures do you recommend for patients interested in xanthelasma removal?
I have had success treating xanthelasma with both hyfrecation (particularly for very small lesions) and fully ablative laser (both CO2 and Erb-YAG).