Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you handle hypogammaglobulinemia detected in patients prior to maintenance rituximab infusion?
That is a good question. Adding on to Dr. @Dr. First Last's response, rituximab has been shown to cause hypogammaglobulinemia that can persist or worsen with ongoing therapy. In a study published by Barmettler and colleagues, 133 patients out of a cohort of 8633 patients had serum IgG levels checked...
What is a reasonable length of time to pass before considering TEE guided DCCV for atrial fibrillation in a patient with a suspected acute cardioembolic stroke and concerns for tachycardia-mediated cardiomyopathy?
There are many issues to consider before proceeding with DCCV. We need to make sure the patient is neurologically stable following the stroke and can be anticoagulated. We seek the opinion of a knowledgeable stroke neurologist in that regard. As soon as anticoagulation can be initiated with a DOAC t...
Under what circumstances would you hold an ACE inhibitor or ARB prior to surgery in a patient with CKD?
I suppose if it was a high risk for hypotension or fluid shift, I may hold it. I'd rather be a bit hypertensive than under-perfused. If they are being used for reno protection, getting off them for a short period will have no influence.
What is your medication of choice when considering outpatient alcohol withdrawal management (diazepam vs chlordiazepoxide vs lorazepam)?
While benzodiazepines such as chlordiazepoxide, diazepam, and lorazepam remain the mainstay of treatment for acute alcohol withdrawal syndrome (AWS), their use in the outpatient setting is generally inappropriate for patients with Alcohol Use Disorder (AUD)—except in narrowly defined, low-risk scena...
Should long-acting subcutaneous insulin be started upfront in addition to regular insulin infusion for patients with diabetic ketoacidosis?
Current ADA guidelines suggest patients with uncomplicated mild or moderate DKA may be treated with subcutaneous rapid-acting insulin analogs every 1-2 hours as an effective alternative to IV insulin, but still only recommend IV short-acting insulin by continuous infusion for moderate-severe DKA. Ho...
How do you assess and counsel women with chronic post-lumpectomy or mastectomy pain?
Post-surgical breast pain is not uncommon. Estimates suggest that 25-60% of patients having breast surgery experience persistent pain, with symptoms lasting from months to years following breast cancer diagnosis and treatment (Langford et al., PMID 25439318; Gartner et al., PMID 19903919).Initial as...
How do you manage anticoagulation/antiplatelet therapies with strong indications for uninterrupted therapy in setting of urgent procedures?
If anticoagulation is absolutely contraindicated because of the bleeding risk of the procedure, then "bridging" will usually make the most sense, most of the time, with low molecular weight heparin such as enoxaparin. If dual antiplatelet agents are contraindicated, particularly in the first month a...
What is your preferred fill volume, dialysis solution, and dwell time for patients with suspected peritoneal dialysis associated peritonitis who arrive to the hospital with a dry abdomen?
I agree with Dr. @Dr. First Last's approach with one addition: prior to instilling the fluid for 2 hours, I would do a quick flush of the abdomen- fill and drain immediately- to remove the cells that accumulated while the abdomen was dry, and thereby avoid "muddying" the waters (pun intended).
Do you routinely observe inpatients for 24 hours after transitioning from IV empiric antibiotics to an oral regimen prior to discharge when the source of infection is unclear?
To be sure, this is a big question with much nuance and should be broken down into component parts. To begin with, the lack of a source is not, in and of itself, a clear justification for continued hospitalization. What should drive the decision for discharge is established clinical stability and an...
Would you consider recommending parathyroidectomy for primary hyperparathyroidism patients with high calcium and PTH levels, even without traditional criteria, based on recent studies showing reduced anxiety and depression?
Let the patient decide.