Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach patients who are inappropriately worried/fixated on a test result that is flagged as abnormal but not clinically significant?
I emphasize that the reference range intentionally excludes normal individuals who are a little different from the average person, and that the reference range is just a numerical exercise and general guidance, not something that was ordained by higher powers. I don't use the analogy for patients, b...
For atrial fibrillation patients with high risk of CVA who cannot tolerate full dose AC due to bleeding, do you consider low dose/extended dosing anticoagulation even if they do not meet age/GFR criteria for a dose reduction, if Watchman is not readily available as an option?
Most drugs, including anticoagulants, have a dose-response. Therefore, one could argue that even though DOACs were not studied at low doses, except in defined sub-groups such as the very elderly, using such a dose in other situations may have some benefit. The problem is that without data, we simply...
What weight neutral language do you recommend to be used for charting in patients with obesity to avoid further medical stigmatization?
This is an interesting question which I have seen tackled in multiple ways by different providers, which I believe are all valid. There is a more common method of noting obesity as a condition rather than a characteristic of the patient. For example, "A patient with PMHx of Obesity" rather than "An ...
What clinical tools and/or thresholds do you use to determine driving risk among older patients with mild cognitive impairment?
I like to use the Clinical Assessment of Driver-Related Skills (CADReS). It reminds me to assess multiple domains, and reminds me which part of the MOCA is more pertinent to driving-related skills. If I have concerns, depending on the extent of my concern, I will either then file a concern with the ...
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
How do you decide when data patients bring to you for review/interpretation from a direct-to-consumer CGM is clinically useful and has it changed any of your management decisions in metabolically at-risk patients?
This is a tough question, as there is obviously published data for FDA-approved CGM devices, as published below: CGM Device Comparison | American Association of Clinical Endocrinology However, for those provided by independent companies, it would depend on whether or not they have independent third-...
What is your preferred anticoagulation/antiplatelet regimen for younger patients presenting with ACS, found to have an acute thrombotic event requiring aspiration thrombectomy without need for stent deployment?
Spontaneous in situ thrombosis of a coronary is rare, especially in the absence of a plaque rupture event. Malignancy-related coronary thrombotic occlusion, even with DOAC semi-compliance, is pathophysiologically difficult to understand, because coronary arteries are relatively high-flow areas, fili...
For septic patients with borderline heart failure, how do you individualize the decision about additional fluid boluses after the initial resuscitation?
For septic patients with borderline heart failure, the decision about additional fluid boluses after the initial resuscitation requires careful observation and monitoring. My approach has been to administer 500 cc-1 liter of fluid, and then assess volume status (physical exam, JVP, or POCUS, which i...
Have you used Karius to work up fevers in the hospital when the source remains unknown?
This is a tricky question because Karius is an expensive test, which many experts believe should not be used for its negative predictive value (and I have anecdotally seen negative results where infection was still present, and infections/organisms detected of very unclear significance). I like to u...