Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your medication of choice when considering outpatient alcohol withdrawal management (diazepam vs chlordiazepoxide vs lorazepam)?
While benzodiazepines such as chlordiazepoxide, diazepam, and lorazepam remain the mainstay of treatment for acute alcohol withdrawal syndrome (AWS), their use in the outpatient setting is generally inappropriate for patients with Alcohol Use Disorder (AUD)—except in narrowly defined, low-risk scena...
In what scenario, if any, would medroxyprogesterone acetate be preferred over micronized progesterone given the latter's better side effect profile and lower rate of DVT/PE?
Medroxyprogesterone acetate (MPA) would be preferred over micronized progesterone primarily in the case of a woman with a peanut allergy, as micronized progesterone is suspended in peanut oil. In that case, however, some physicians would prescribe micronized progesterone via a compounding pharmacy t...
What factors do you consider before discharging an MGUS patient from hematology clinic to safely follow with outpatient PCP?
In general, I follow the risk stratification referenced in the Mayo Clinic's recent review, and I tend to think about a clinic discharge from hematology if they have low-risk MGUS, i.e., serum M protein <1.5 gm/dL, IgG subtype, normal FLC ratio (0.26-1.65).I then use the Lee Index to estimate the pa...
Would you initiate anti-arrhythmic drug therapy in patients who are asymptomatic and have normal LV function but with a PVC burden >20 percent?
In my younger days I've managed high-burden PVCs with minimal to no symptoms with a spectrum of strategies, including ablation (I've had a case of LVS PVC/VT ablation with late resolution akin to Candemir et al., PMID 30822513), BB, flecainide (case of resolved PVCs after medication holiday), and ob...
Do you take any special considerations when working up a pregnant patient for secondary causes of hypertension?
Pregnancy does affect the approach to secondary causes of hypertension evaluation. Because of the relatively high prevalence of pre-eclampsia (3-5% of pregnancies), hypertension occurring after the 20th week of gestation with new proteinuria often does not require additional workup. Patients could b...
What work-up and treatment do you recommend for exertional headaches?
Primary Exercise Headache Diagnostic Criteria per ICHD-3: At least two headache episodes fulfill criteria B and C Brought on by and occurring only during or after strenuous physical exercise Lasting <48 hours Not better accounted for by another ICHD-3 diagnosis Caveats: Migraine headache worsened o...
How do you decide when to test for Legionella in patients with pneumonia, given periodic outbreaks and risk for delayed diagnosis?
Legionella testing is really a question of pretest probability, not a reflex order on every CAP admission, and that distinction matters practically, since the ATS/IDSA 2019 CAP guideline explicitly moves away from routine testing toward a targeted strategy.The clearest indication is severity. Any pa...
What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?
Assuming that a thorough workup for other causes of fatigue (anemia, thyroid dysfunction, sleep apnea, etc.) has been performed and is negative, no single medication has been proven by a randomized placebo-controlled trial to help chronic fatigue in PASC. Anecdotally, my colleagues who treat PASC ha...
Do you have safety concerns when prescribing GLP-1 medications in patients on corticosteroids or immunosuppressive therapy?
I think we need to be particularly careful when co-prescribing with systemic corticosteroids because of the risk of sarcopenia. We know that rapid weight loss is accompanied not only by a loss of fat tissue but also of muscle. Corticosteroids can also have myotoxicity and cause muscle atrophy. I the...
For which stroke patients, if any, do you recommend implantable loop recorder for long-term cardiac monitoring and why?
Fantastic and pertinent question! I won't pretend that I have an answer, but do have a few thoughts that may help frame further discussion: We derive our evidence for the efficacy of anticoagulation in stroke prevention from older trials designed to answer that specific question (SPAF, etc.). In the...