Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you prescribe a low-dose tricyclic antidepressant as a gut-brain neuromodulator for a patient with IBS that has not responded to dietary modification and first-line pharmacotherapy?
Yes, I do. In fact, I consider a tricyclic like imipramine (highest GI effects) to be first-line pharmacotherapy.
When do you consider using disulfiram in patients with alcohol use disorder?
Yes, there is a select population who benefit greatly from Antabuse: motivated professionals, monitoring programs for impaired professionals, and court-mandated cases. Informed consent would include complete disclosure related to dietary limitations/risks for severe drug interaction up to 2 weeks po...
What is the recommended follow-up/surveillance schedule following organ preservation treatment approach for cT1-2N0 rectal cancer?
Patients with stage I rectal cancer treated with organ preservation require close surveillance to rule out tumor regrowth and local recurrence that may be salvaged with radical surgery. The highest risk of recurrence is within 2 years after completion of neoadjuvant therapy and patients should be fo...
How do you evaluate persistent resting sinus tachycardia (heart rate >100 bpm) in a hospitalized patient whose acute illness has otherwise stabilized?
This is a great question and something that we see rather frequently in the hospital.2 guiding principles to frame this question:Sinus tachycardia (ST) is a symptom, not a diagnosis. It's a physiological response to an underlying condition. Which means we need to diagnose the condition, not focus on...
What is your treatment paradigm for rectal cancer in the setting of COVID-19?
We haven't changed our standard recommendation: short course radiation -> 3-4 months of FOLFOX. In a very timely manner, the RAPIDO ASCO abstract was released here in May. It showed that the patients who received short course radiation -> FOLFOX had improved pCR, less disease related treatment failu...
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...
Do you add empiric anti-MRSA coverage to the initial antibiotic regimen for a patient admitted with community-acquired pneumonia who has risk factors for MRSA but a negative MRSA nasal screen?
Thank you for this excellent and highly relevant clinical question. I approach this scenario by blending robust evidence-based medicine with fundamental principles of diagnostic reasoning. The short answer is generally no, you probably do not need to add empiric anti-MRSA coverage for a standard CAP...
Should asymptomatic esophageal candidiasis identified incidentally on endoscopy be treated?
Yes, in our practice, we do treat asymptomatic esophageal candidiasis when found incidentally on endoscopy. A few things to consider: 1) While patients may be asymptomatic at the time of the endoscopy, untreated disease can lead to the future development of complications/symptoms, such as odynophagi...
What is your approach to acute pain management in hospitalized patients who receive long-acting injectable naltrexone for alcohol use disorder?
Maximize non-opioid therapies (NSAIDs, Tylenol, ketamine or lidocaine infusions if appropriate/available, nerve blocks). If opioids are still needed, the basic answer is that I would treat pain with higher doses of opioids. I would tailor my approach to the cause of the pain, though. If a patient w...