Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to determining the safety, appropriateness, and timing of SPECT or PET MPI in patients admitted with NSTEMI and who remain chest pain-free and hemodynamically stable?
Patients with NSTEMI who are stable should have a coronary angiogram as soon as possible. If an angiogram is not available or may be higher risk due to renal failure then a stress test is reasonable but it should be also be done as soon as possible. The goal is to revascularize a vulnerable plaque b...
Would it be reasonable to begin considering GLP1 RAs or finerenone for patients with heart failure with recovered LVEF in light of recent trials such as SELECT and FINEARTS-HF showing some success in HFpEF and HFmrEF populations?
I reject the premise of the question. Patients with HFrEF who improve on medical therapy do not become HFpEF. The pathophysiology of these diseases are entirely distinct and it speaks to the limitation of EF as a categorical variable. HFrEF patients have cardiomyopathy that manifests over time as di...
When do you use seizure prophylaxis in patients on clozapine?
The topic of the use of anticonvulsants for primary prophylaxis of clozapine-induced seizures continues to be debated. The idea of prescribing anticonvulsants prophylactically for patients taking >600 mg/day of clozapine was suggested by Devinksy et al., PMID 2006003 in 1991. Clozapine-induced seizu...
How do you decide whether or not to pursue inpatient workup of an incidental liver mass?
When deciding whether to pursue inpatient evaluation of an incidentally discovered liver lesion, I ask two key questions:Is the lesion plausibly related to the clinical syndrome I’m treating now?Are there patient- or system-level barriers that would make outpatient follow-up unreliable or unsafe?Cli...
How frequently would you consider IV iron treatment for ongoing iron loss and severe iron deficiency anemia?
Absolutely. You first want to estimate and replace their iron deficit. For patients who are very anemic, they can start at 2-3 grams deficit. I usually don’t give more than 1500 g of iron dextran at one time, but I will have no concern about doing 1000 or 1500 mg weekly until I have replaced their d...
How would you approach the treatment of a patient with solid food esophageal dysphagia and GERD without a detectable esophageal stricture on upper endoscopy?
I would obtain a barium esophagram followed by high-resolution esophageal manometry and 48-hour esophageal pH testing.
What is your stepwise approach to treating constipation in a patient with symptoms such as abdominal pain, nausea, decreased appetite, etc?
For patients that are symptomatic, I favor more aggressive management, often starting with polyethylene glycol (preferred) or another osmotic agent as first line. I will also usually supplement this with some sort of management from "below" but will usually discuss with the patient and nursing wheth...
How do you manage patients with central sleep apnea due to heart failure with reduced ejection fraction?
I assume you are referring to CSA with Cheyne-Stokes respiration. Several possibilities, but first ask yourself what your treatment goal is. If the patient does NOT have symptoms (frequent awakenings, daytime sleepiness, etc.) I contend that you don't need to treat at all. We already know that there...
Are there situations where you would consider treating E faecalis or E faecium that grows from a respiratory culture?
Pretty much almost never! Enterococcus is not recognized as a pneumonia pathogen. In the setting of a lung abscess, I suppose you could consider treating it as part of a polymicrobial infection. In a heavily immunocompromised patient, it is possible that enterococcus might cause pneumonia—and it has...
What is your approach to discharge planning for a patient with chronic SIADH who is admitted with asymptomatic acute-on-chronic hyponatremia?
An acceptable baseline serum sodium level in chronic SIADH is based on both clinical status and risk of complications. Based on literature, in the absence of severe symptoms, the target is a gradual correction to a level that minimizes neurocognitive and physical impairment, typically aiming for a s...