Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What approaches have you found most helpful for concurrent severe major depressive disorder and alcohol use disorder?
I'm a strong believer in AA for alcoholics, to address the addiction and also the depression, as the social support offered there can be very helpful. A person agreeing to "work the steps" with a sponsor has more in-depth character restructuring and available support than most therapists can provide...
Should all patients with suspected giant cell arteritis get a PET scan to look for large vessel disease?
PET-CT and PET-MRI can be very useful diagnostic modalities in GCA, but I do not recommend universal screening with PET scanning. The upcoming ACR/VF sponsored vasculitis guidelines will likely recommend obtaining non-invasive vascular imaging to evaluate for large vessel involvement, but the recom...
How do you weigh the risks and benefits of GLP-1 RAs in patients over age 65 specifically in regards to loss of muscle mass and osteoporosis?
This is indeed a crucial question: rapid weight loss is accompanied not only by a loss of adipose tissue but also by a loss of lean mass, including muscle and bone tissue. This must therefore be taken into account when making decisions, particularly in patients with osteoporosis, frailty, sarcopenic...
How do you evaluate the etiology of hyponatremia in a patient with ESRD and baseline oliguria/anuria?
In patients with ESRD and baseline oliguria or anuria, hyponatremia has to be approached differently because many of the usual diagnostic and monitoring tools (urine sodium, urine osmolality, urine output) are either unavailable or misleading. The key shift is to think in terms of total body water v...
How do you evaluate the etiology of hyponatremia in a patient with ESRD and baseline oliguria/anuria?
In patients with ESRD and baseline oliguria or anuria, hyponatremia has to be approached differently because many of the usual diagnostic and monitoring tools (urine sodium, urine osmolality, urine output) are either unavailable or misleading. The key shift is to think in terms of total body water v...
Are there any contraindications using nurtec in patients with headaches in the setting of recent RCVS?
I would be comfortable using Nurtec in a patient with a recent RCVS diagnosis. I am comfortable using triptans in patients with a prior stroke or MI with proper patient counseling unless they have critical/severe artery stenosis. I have had cluster headache patients who continue sumatriptan injectio...
How do you approach patients who identify so strongly with being sick or with a particular diagnostic label that it makes up a significant portion of their identity?
In many cases, the point at which this question is being asked is one at which the train has already left the station, and sickness as a way of life/career has set in. Unfortunately, with functional somatic syndromes, there is data suggesting that self-rated quality of life and functioning are lower...
How do you calculate QTc intervals in patients being admitted for AAD drug loading who remain in atrial fibrillation or atrial flutter?
We measure 10 R-R intervals and the corresponding 10 QT intervals, average each of them, and then calculate the QTc. Bazett’s formula is commonly used, but is probably less accurate than other correcting formulae, particularly for patients actively in atrial fibrillation. We often use the Framingham...
How often do you rely on using the C1 inhibitor functional assay versus the quantitative level alone to diagnose HAE?
We have seen a significant increase in lab costs billed to well-insured patients for some of the more "esoteric", detailed testing associated with immune/inflammatory disorders such as HAE. The cheapest screen is a C4 level, which, if normal during an active angioedema episode, makes C1 inhibitor de...
Do you make any dose adjustments for patients with ESKD who are on apixaban and do not otherwise meet criteria for reduced dosing?
I do most of the time but it depends on the indication and patient's weight and age. For soft indications, I usually give 2.5 mg bid, but if there is a significant risk (stroke, clots, etc), I will give a full dose of 5 mg bid.