Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your risk/benefit analysis when deciding on the appropriateness and timing for discontinuation of systemic anticoagulation in patients who underwent ablation for paroxysmal atrial fibrillation with CHADS2VASc score >2?
I typically do not discontinue oral anticoagulation in post-ablation patients with paroxysmal atrial fibrillation and a CHA₂DS₂-VASc score of >2. Catheter ablation is not considered a "cure" for atrial fibrillation; therefore, there is always a risk of recurrent arrhythmia. The patient may be asympt...
Do you pursue stress testing before discharge for a patient admitted with chest pain who has negative serial high-sensitivity troponins and a low HEART score?
Always test an admission for chest pain. Do not put so much faith in analytic scoring .
When do you consider extended steroid tapers for acute asthma or COPD exacerbations?
The data doesn't support extended tapers - 5 days of 40 pred equivalent are non-inferior, and extended courses can cause harm, including increases in mortality. I only use extended tapers for patients who have, in the past have rapid symptom recrudescence with the typical shorter course. Typically, ...
When do you consider extended steroid tapers for acute asthma or COPD exacerbations?
The data doesn't support extended tapers - 5 days of 40 pred equivalent are non-inferior, and extended courses can cause harm, including increases in mortality. I only use extended tapers for patients who have, in the past have rapid symptom recrudescence with the typical shorter course. Typically, ...
In older adults with mild cognitive impairment, do you ever prescribe cholinesterase inhibitors and/or memantine?
This is a great question, and of course, "do you ever" will get you in trouble every time! Let me start by saying that, in general, I do not prescribe these drugs for MCI. Cholinesterase inhibitors are clearly indicated for the mild-moderate stage of some kinds of dementia (some people would include...
What is your approach to managing incidental hypertension without evidence of end-organ damage in hospitalized patients?
Approaches to managing inpatient HTN without evidence of end-organ dysfunction have evolved over the years. I worked with some attendings who felt strongly about treating. There was a great JAMA IM article that explored this very question for non-cardiac patients. Link here: Rastogi et al., PMID 333...
When do you consider giving IV albumin for severe hypoalbuminemia with third-spacing of fluid outside of standard indications (i.e., large-volume paracentesis, HRS, SBP, shock, etc.)?
On the wards, I do not treat the albumin number. Severe hypoalbuminemia with third spacing, by itself, is not an indication for IV albumin. The consistent signal from the literature is that albumin should not be used simply to raise serum levels or to “pull fluid back in” as an adjunct to diuretics....
How should you manage a COVID-19 infected/suspected patient who is receiving chemotherapy and cannot interrupt or delay their cancer treatment?
This is difficult to answer specifically without further details. There certainly is accumulating evidence that patients with cancer, especially those receiving immunosuppressive chemotherapy, are at greater risk of COVID-19 infection if exposed, and a greater risk of serious and life-threatening co...
In adults ≥80 years with TSH 6–10 mIU/L and minimal symptoms, do you initiate levothyroxine, monitor, or avoid treatment entirely?
I tend to check free T4 in this situation. Aging is associated with some elevation in TSH value up to 10 mIU/L with normal free T4, and in those patients, levothyroxine is not needed. In some patients, I have seen it rise above 10 with normal free T4. Supplementing levothyroxine to lower serum TSH w...
What is a reasonable imaging modality for older patients with pAfib already on systemic anticoagulation outpatient but presenting with suspected cardioembolic stroke and TTE without evidence of LV thrombus?
Gold standard is TEE.