Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How soon would you repeat PET/CT in a patient with cardiac sarcoid after starting treatment with infliximab?
Very good question. There is no consensus on this answer, and it is also important to consider the medical burden on a patient to repeat such involved testing. Our approach is to follow the resolution/improvement of patient-reported cardiac-related symptoms and follow less invasive testing such as E...
When do you consider using phenobarbital over symptom-driven alcohol withdrawal protocols for patients at low-to-moderate risk of withdrawal complications?
While traditional frameworks often reference "low" or "moderate" risk for alcohol withdrawal complications, in clinical practice we find it more useful to focus on the treatment setting and validated predictors of severe withdrawal rather than subjective risk labels. Phenobarbital is increasingly us...
How do you decide whether to start MAT for opioid use disorder during hospitalization?
There are several considerations when approaching patients about MOUD. In general, every patient should be offered MOUD during their hospitalization because every admission represents an opportunity towards substance recovery. With that said, I don’t entangle substance use treatment with their medic...
How do you decide on supportive care vs empiric antibiotics in a patient with suspected aspiration pneumonitis (i.e., witnessed macroaspiration event within the past 24 hours) but with features that could suggest pneumonia (e.g., acute respiratory distress, fever, leukocytosis, pulmonary infiltrates, etc.)?
Great question and one that comes up all the time for me. As the patient has more signs of true infection, such as those you mention with fever, leukocytosis, and respiratory distress, I am much more likely to start antibiotics. If the patient just has chest radiograph findings of opacities and some...
How do you decide on supportive care vs empiric antibiotics in a patient with suspected aspiration pneumonitis (i.e., witnessed macroaspiration event within the past 24 hours) but with features that could suggest pneumonia (e.g., acute respiratory distress, fever, leukocytosis, pulmonary infiltrates, etc.)?
Great question and one that comes up all the time for me. As the patient has more signs of true infection, such as those you mention with fever, leukocytosis, and respiratory distress, I am much more likely to start antibiotics. If the patient just has chest radiograph findings of opacities and some...
In the absence of clear guidelines, when would be a reasonable threshold to refer patients with resistant hypertension for renal denervation?
Recommendations surrounding renal denervation have now been added to the AHA 2025 guidelines.
What type of DES should you opt for if a patient has or is concerned about possible nickel allergy?
For a coronary stent, I would lean toward a Medtronic DES. There are published recommendations for nitinol with a durable polymer. That said, I cannot remember more than one case in 25 years where I thought that a metal allergy may have played a role in a patient receiving a stent and that was prior...
How do you approach managing clozapine in patients who are critically ill?
With COVID-19 disproportionately affecting those with mental illness we found an increasing number of medical admissions for those on clozapine. There are multiple domains of concern for those on clozapine who are medically ill. Clozapine levels have been shown to potentially double during periods o...
Would you consider treating empirically for AVP deficiency in a patient who had pituitary surgery 6 months earlier and complaints of polyuria/polydipsia with dilute urine (without performing water deprivation studies)?
In the appropriate clinical setting, like this, if you have documented inappropriately diluted urine, you can treat. The chance of resolution 6 months after surgery is very low. Always instruct the patient to have a daily polyuric phase to reduce the risk of hyponatremia.
Should GLP1 R agonists be used as first line glucose lowering agents in patients with ESKD and DM2?
This is a great question, but like all clinical questions the answer will be "it depends". A provider considering adding a new drug for DM2 in a patient with CKD5/dialysis would need to know several specifics about the patient. Let's say, the patient is not on any DM2 medication. Is this an older, t...