Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you decide on switching to a different preventative anti-CGRP treatment in migraine patients who are experiencing reduced effectiveness with their current treatment?
On occasion, I have found that patients who were diagnosed with chronic migraine actually have EPH or CPH and respond to an indomethacin trial. Alternatively, those with less-than-ideal responses to CGRP antagonists or gepants, Botox injections can offer more relief. These patients tend to have a si...
How could POCUS be useful in the initial evaluation of a severely ill patient in whom infectious endocarditis is suspected?
I would broaden the question to incorporate principles of diagnostic reasoning: how does a given test, in this case, point-of-care ultrasound (POCUS), adjust the probability of infective endocarditis (IE) in a severely ill patient?IE is a difficult diagnosis, and clinicians should be cautious about ...
What is your threshold to offer trimethoprim-sulfamethoxazole for treatment of cyclosporiasis to an immunocompetent patient?
Most immunocompetent people with cyclosporiasis will clear the infection, and their symptoms will resolve within about a week. If diarrhea persists beyond a week and Cyclospora has been confirmed on testing, I'll treat with antibiotics. Diarrhea is a miserable symptom. If we can safely shorten the c...
How do you counsel patients who are interested in using kratom for chronic pain management?
I am not a pain management expert, but would recommend against use for chronic pain management. Risks outweigh in a significant order. It's not FDA-approved for any form of pain treatment. There is no dosage reference to use. The pain control one gets may be too low compared to the addictive risks, ...
What is your approach to GDMT uptitration (particularly dosing for ARBs/ARNIs/MRA) if there is further evidence of renal dysfunction, especially in situations with worsening AKI on CKD?
Titration of RAAS inhibitors in the setting of AKI on CKD is challenging. First, look at the patient: if they have an increase in Cr after an increase in the RAAS inhibitor but no/stable HF symptoms and appear euvolemic on examination, then I will decrease diuretic therapy and see if the Cr improves...
What are your thoughts on patients presenting with hyponatremia receiving IV fluids before urine studies are collected and the etiology is fully characterized?
Whenever possible, I try to obtain serum osmolality, urine osmolality, and urine sodium before giving IV fluids. A urine specimen requires only a small volume and can usually be collected at the same time as the initial bloodwork without meaningfully delaying care. That said, treatment should never ...
Do you recommend that your patients with COPD avoid gabapentin or pregabalin entirely, given the increased rate of exacerbations noted in patients on these medications?
No, I don't exclude gabapentin or pregabalin as therapeutic options for patients with COPD. The study of Rahman is a cohort study that suggests an interesting association but has limitations, including residual confounding variables and a lack of smoking information on the study population. The issu...
Have you used Karius to work up fevers in the hospital when the source remains unknown?
This is a tricky question because Karius is an expensive test, which many experts believe should not be used for its negative predictive value (and I have anecdotally seen negative results where infection was still present, and infections/organisms detected of very unclear significance). I like to u...
When do you consider starting an antiplatelet in a patient with stoke due to septic emboli?
If no ICH or microbleed on MRI and the patient has a strong indication for home antiplatelet, would continue single antiplatelet. Would NOT start for septic embolic stroke. Also avoid medical DVT prophylaxis for the first 1-2 days after endocarditis-related strokes. Initial vessel imaging with CTA o...
What are your discharge criteria for a patient admitted with acute alcohol intoxication and/or withdrawal?
Patients presenting with acute alcohol intoxication alone generally do not require hospitalization and can be discharged once clinically sober, medically stable, and able to tolerate oral intake. Consider admission to the hospital when there is concern for high-risk alcohol withdrawal, including pri...