Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to intractable hiccups of uncertain etiology in hospitalized patients?
Most cases I have seen are more persistent than intractable hiccups. Similar to intractable hiccups, it would involve looking for anything reversible: GERD, gastric distention or paresis, medication effects, or metabolic abnormalities. I typically start with reassurance that the hiccups will resolve...
What workup do you recommend for otherwise healthy migraine patients that develop dizziness with episodes?
The workup should exclude other potential causes of vertigo including CNS disorders, and Meniere's disease, with neurology examination, MRI brain, videonystagmography, or electronystagmography. An article also evaluated vestibular migraine versus migraine without vertigo and found in several studies...
What is your preferred analgesic in patients with small bowel obstruction or ileus?
I typically use IV Tylenol ATC if fully obstructed, and IV Toradol if no other contraindications to NSAIDs (and they often are quite prerenal or losing a lot of fluid from an NG tube, so I often don't feel comfortable with more than a couple doses, and if I think they are going to the OR, I do not u...
In a frail older adult with moderate-to-severe lower urinary tract symptoms, when do you start a beta-3 agonist like vibegron over an anticholinergic?
In a frail older adult with OAB-predominant moderate-to-severe LUTS, I generally start a β3 agonist (vibegron or mirabegron) as the first-line pharmacologic option once behavioral interventions are insufficient. Behavioral therapies may include fluid management, bladder retraining, pelvic floor exer...
How do you approach balancing the treatment of urinary incontinence with anticholinergic medications with the use of cholinesterase inhibitors in dementia?
This is a great question and speaks to the importance of shared decision-making and understanding the context of individual patients. Ultimately, it would be best to avoid anticholinergic medications in our patients living with dementia. Medications with anticholinergic properties increase the risk ...
How do you weigh the risk of urinary catheter or fecal management system placement with that of soiling sacral wounds?
This question is an important question that arises for many of our bed-bound and poorly mobile patients, as sacral wounds commonly develop due to pressure injury. They become very challenging to treat due to fecal and urinary contamination, which can lead to further infection. Fecal and urinary dive...
How many total days of antibiotics do you prescribe for uncomplicated non-purulent cellulitis in hospitalized patients who show clear clinical improvement within 48–72 hours?
Thanks for the question. Five days total, with transition to oral antibiotics upon clinical improvement to complete this course. Notably, my health system (via our EMR-based clinical decision support tool) recommends penicillin (IV) or amoxicillin (PO) as first-line treatment for nonpurulent celluli...
How soon after excising a keloid do you inject kenalog?
I ran into this issue in clinic a few months ago when I started doing keloid excisions on patients' ears - there's some decent data in the following article for doing immediate kenalog injections without impairing wound healing.Burusapat et al., PMID 34367855
How do you manage Fanconi’s syndrome and polyuria related to ifosfamide?
Treatment of ifosfamide-induced Fanconi syndrome and polyuria is primarily supportive. First, the benefits and risks of discontinuation of ifosfamide should be discussed with the oncologist. Treatment of Fanconi syndrome is aimed at repletion of potassium, bicarbonate, and phosphate. Calcitriol is a...
When stopping denosumab and transitioning to PO bisphosphonate, do you wait for 6 months after the last denosumab injection to start PO bisphosphonate?
Some background: In patients discontinuing denosumab without subsequent antiresorptive therapy, BMD rapidly reverts back to baseline with an elevation in vertebral fracture risk (with an enhanced risk of multiple vertebral fractures). Thus, sequential treatment regimens following denosumab have been...