Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to patients with biopsy proven giant cell arteritis that continue to have symptoms after initiation of high dose glucocorticoid therapy?
First, let's define and discuss “high-dose” steroids. Oral therapy is typically 60-100 mg of prednisone daily, and IV is 500-1000 mg of methylprednisolone daily for three days, followed by oral prednisone. There has been no difference in long-term outcomes for vision loss or diplopia. The complicati...
Is there an age cutoff where you consider the risks of monoclonal antibody therapy outweigh any potential benefit(s) in early-onset dementia?
A brief discussion of dementia terminology is worthwhile to avoid confusion regarding diagnostic classification and treatment rationale. As is well known, there are many dementias, and the descriptor “early onset” can be used for childhood dementias, such as Rett syndrome, and also for disorders suc...
Do you escalate treatment in patients with myositis who achieve clinical remission but continue to have elevated CPK?
Typically, patients who are doing well and in remission can have low levels of CK abnormality, which needs to be monitored but not treated. Post myositis improvement, some patient's muscle membrane remains leaky or not perfect, leading to some low levels of elevated CK, which has no clinical signifi...
How do you manage gram-negative bacteremia in a patient with an aortic bypass graft, for whom there is low clinical suspicion for active graft infection?
This is a very nuanced question, and thus, there is no perfect answer. If there is low suspicion for graft infection and the bacteria is not commonly associated with biofilms (like a simple E. coli) and the bacteremia clears quickly, I would likely treat for a couple of weeks and monitor (and even c...
How do you approach the use of benzodiazepines in patients with chronic medical illnesses that may be susceptible to respiratory compromise (e.g., CHF, COPD, ILD)?
It’s a very good question and answers may vary among different specialty providers. Yes, a slow or gradual weaning of the benzodiazepines would be advisable. When they reach lower doses the taper should be even slower over weeks or longer. There is a risk for not weaning them off benzodiazepines inc...
What parameters would you use to monitor and interpret iron levels in a hemochromatosis patient where ferritin is unreliable due to underlying chronic inflammation?
The biggest question in these situations is whether the patient truly has iron overload vs. just high ferritin. If iron sat is not elevated, true iron overload is very unlikely. If both ferritin and iron sat are elevated, but they don't have a homozygous C282Y genotype, I make sure that the patient ...
Do you routinely use cefdinir for the treatment of common infections diagnosed in the outpatient setting such as CAP, uncomplicated UTIs?
Not routinely. More expensive than equally effective alternatives.
Are drug challenges after serum sickness-like reactions useful in delabeling the allergy?
Too unpredictable each time.
Do you have to extend treatment for acute Lyme disease if a patient is on high dose steroids for another indication?
I am unaware of any evidence to support longer-term therapy in such a setting. I am quite sure no such study has ever been done. Standard therapy for early Lyme disease is 10 days of appropriate antibiotics. Extending to 20 days would likely do no harm to the patient, but may not be necessary, and t...
What is your go-to strategy for non-opioid management of chronic low back pain in patients with limited access to physical therapy or behavioral health?
The short answer is that if pain fails to improve after three months of conservative management, patients should be referred to a board-certified pain physician for further evaluation and treatment. The long answer is that chronic pain management is a highly complex, multidisciplinary field that can...