Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to IV fluid management for the treatment of hypercalcemia of malignancy?
At this point, I believe one can use either saline or lactated Ringer's. There is some evidence that low-chloride-containing solutions have advantages in general, which may well be the case, but we need more data on that. The amount of calcium in LR is very small and should not make a difference (1....
Do you always perform salivary gland biopsy to confirm the diagnosis In patients with suspected seronegative Sjogren's syndrome?
I often struggle with the decision of obtaining a biopsy in suspected Sjogren's in a person who is seronegative, when the main issue is dryness, and the main reason is that I wonder if it will make a difference in management. When I was a Rheumatology fellow, I was taught to give Hydroxychloroquine ...
What is the next best osteoporosis treatment option for patients who completed 2 years of teriparatide, but has contraindication to bisphosphosnate therapy (e.g. history of atypical femur fracture)?
I have successfully treated several patients with bisphosphonate-induced subtrochanteric femoral fractures with Forteo. However, before initiating another antiresorptive therapy, I first want to be sure that the Forteo at the desired effect on bone remodeling by increasing both bone formation and bo...
How do you approach managing patients with diabetic kidney disease and proteinuria who develop hypoglycemia after initiation of a SGLT2 inhibitor?
I would first determine if there are other medications the patient is on that reduce the blood glucose. Hypoglycemia with SGLT-2 inhibitors is usually due to something else. Another medication is most likely. Could be very poor dietary intake. Could lower the dose if not on the lowest available dose...
Given recent data from the REPRIEVE trial, how will you adapt your practice with regards to prescribing statins to patients living with HIV?
This randomized controlled trial (Randomized Trial to Prevent Vascular Events) found that, for people living with HIV between the ages of 40 and 75 years who were taking pitavastatin calcium, the risk of major adverse cardiovascular events was lowered by 35% and the risk of cardiovascular death was ...
When do you recommend limited or targeted respiratory pathogen testing versus a full respiratory pathogen panel in a patient presenting with URI symptoms?
I think we’re asking the wrong group of people. How infectious disease physicians use respiratory pathogen panels is not the same as how emergency medicine or urgent care clinicians use them. For stewards of diagnostics, especially ID providers, the test often doesn’t change management. In many sett...
What is your approach to the management of unprovoked distal DVTs?
The management of distal deep vein thrombosis (DVT)—[involving the peroneal, posterior tibial, anterior tibial, or the muscular calf veins (gastrocnemius and soleus); proximal DVT, by contrast, refers to thrombosis in the popliteal, femoral, or iliac veins]—is evolving in step with broader changes i...
How do you counsel someone about metformin use for type 2 diabetes mellitus who is also on a GLP-1 agonist and achieved goal HbA1c, but prefers not to be on metformin anymore?
I am all for this! I realize metformin is still "first line" technically, but so many patients are having a robust response to GLP-1as that I think this may change. Given that GLP-1as have a lower risk of hypoglycemia plus the cardiovascular benefits, I think monotherapy is very appropriate. Also, A...
What is your approach to IV fluid resuscitation during a sickle cell vaso-occlusive crisis?
My approach to IV fluid resuscitation in vaso-occlusive crisis is cautious and individualized. Adequate hydration is important to prevent further sickling, but I avoid aggressive fluid loading because of the risks of pulmonary edema and acute chest syndrome. I typically use isotonic balanced crystal...
In patients with moderate calcific mitral stenosis, possible HFpEF and dyspnea on exertion, how would you differentiate the etiology of the symptoms?
I would consider a dobutamine stress echocardiogram to evaluate the flow across the valve as well as diastolic parameters. If this does not answer the question, an exercise right heart catheterization could be helpful and could also look into concomitant pulmonary hypertension as a cause of dyspnea....