Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What prompts you to procure EEG and/or imaging in patients presenting with multiple simple febrile seizures?
History always plays a key role. Is the child developing normally, and how old is the child? Also, were all of the seizures truly simple, or were there other features that make me suspicious that this is actually a "lower seizure threshold" in a patient with underlying epilepsy? Fortunately, a sleep...
What is the recommended approach to treating severe constipation in patients on GLP1 R agonist therapy?
About half of the people taking these drugs will experience some of these GI side effects (diarrhea or constipation), at least transiently. When I prescribe these meds, I also “prescribe” daily fiber and adequate fluid intake. They should have smaller, frequent meals rather than large meals in one s...
How do you manage stroke-related abulia?
There is surprisingly little recent evidence-based guidance on this front. Most therapeutic options focus on agonism or potentiation of dopamine in the frontal-subcortical circuits. Depending on the center and provider, options include psychostimulants. Any type might do but I prefer methylphenidate...
What is your approach to managing pyoderma gangrenosum recalcitrant to oral steroids?
Pyoderma gangrenosum is notoriously difficult to treat. The first thing I'd recommend in a case refractory to steroids is to reconsider the diagnosis. Notably, a high percentage of PG is misdiagnosed, so lack of response may indicate that you are dealing with a mimicker (e.g., infection, neoplasm, v...
When would you consider a diagnosis of peritonitis in a patient with SLE?
As noted in the question, clinically significant peritonitis is unusual/rare in lupus patients. In 25 years, I have seen two patients I was convinced had lupus peritonitis. The common thread was that both of them had had at least one abdominal surgery for an acute abdomen. The patients were known to...
Do you recommend pre-emptive anti-epileptic treatment for patients with spontaneous ICH?
This question also applies to other scenarios such as ischemic stroke, brain tumors, and TBI. Many neurologists do not, but neurosurgeons often do. The evidence for this is very limited, so a reasonable answer is as follows. 1) Yes, if an EEG shows epileptiform discharges. 2) Evidence or not, modern...
Is it clinically necessary to provide supplemental oxygen to patients with mild, asymptomatic hypoxemia only during activity while they are recovering from an acute respiratory illness?
My practice is to withhold supplemental oxygen in patients with mild, asymptomatic hypoxemia during exertion when the underlying condition is expected to improve. I am not aware of strong evidence supporting the benefit in these cases, and I believe the potential harms generally outweigh any theoret...
What factors influence your choice between low-dose DOAC therapy and dual antiplatelet therapy for the first 3 months after percutaneous left atrial appendage occlusion?
Using the ADALA study and previous observational studies, the use of apixaban 2.5 mg BID appears to be at least as safe if not safer than the use of DAPT. As a result, in patients who are unable to tolerate full-dose anticoagulation, low-dose DOAC is my first line. However, if patients have cerebra...
For how long do you treat an early spinal hardware infection secondary to MSSA after operative washout and retention of hardware?
This infection is a key research interest of mine and one I'm deeply passionate about. I typically treat with a 12-week induction regimen, preferably using antibiofilm-active agents—an approach adapted from the DATIPO trial for prosthetic joint infections (PJI). I generally do not recommend routine ...
Do all patients referred for acute symptoms of TIA or minor stroke require additional imaging with CT/MR angiography, in addition to admission/observation?
Regardless of whether symptoms are minor, improve, or resolve, it is important to obtain vessel imaging to evaluate the underlying head and neck vasculature, as this may guide additional treatments (e.g., carotid revascularization, ICAD management, dissection management, carotid-web management, etc....