Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When do you consider using aspirin 81 mg PO BID for VTE prophylaxis over other agents in patients with a fracture, considering recent trial data?
Aspirin for VTE prophylaxis may be reasonable in selected low-risk patients, but many patients undergoing surgery for a fracture are at high risk for VTE. In addition to the METRC trial you cited, another relevant study informing my opinion on this is the CRISTAL trial.In METRC, the mean patient age...
How long do you treat Staphylococcus aureus pyomyositis with antibiotics?
I agree, and certainly evaluating for bacteremia that can be associated with these types of infections, which would alter the duration of therapy.
When do you consider using stimulants in patients with cognitive impairments secondary to traumatic brain injury?
Perhaps most importantly, prescribing medication to address cognitive difficulties conveys hope to TBI patients that even if they have suffered structural brain damage, they can improve. Though the improvement may be fairly small, it can have important implications for better general functioning. We...
How do you approach work up for underlying rheumatologic disease in patients referred for chronic urticaria?
Chronic urticaria (6 weeks or longer) is often a self-limited disorder seemingly idiopathic in etiology. There are certain autoimmune disease more prevalent in patients with chronic urticaria including systemic lupus erythematosus, Sjogren's syndrome, autoimmune thyroid disease, celiac sprue, and rh...
How do you address social determinants of health that impact patients (e.g., housing instability, food insecurity) but for which there are no immediate resources available?
This is a complicated answer that will vary from state to state, county to county, and overall, it is not a straightforward answer. I do wish we had better systems in the U.S. for managing the social determinants of health (SDOH), and I don't have all of the answers here. Housing instability, food i...
For which rituximab infusion reaction symptoms do you consider it safe to re-challenge in the office with adjusted rates and pre-medications?
When deciding whether it is safe to re-challenge with rituximab after an infusion reaction, the most important consideration is the type of reaction that the patient experienced. This will help to risk stratify and determine whether same day or future infusions of RTX should be used. Importantly, th...
Do you routinely adjust your interpretation of SLUMS and/or MOCA tests in patients depending on their level of education?
I have routinely adjusted the MOCA score based on their educational level. If their educational level is less than 8th grade, I use MOCA Basic for assessment. Personally, I have not used SLUMS for assessment, so I cannot comment on that.
How soon would you repeat PET/CT in a patient with cardiac sarcoid after starting treatment with infliximab?
Very good question. There is no consensus on this answer, and it is also important to consider the medical burden on a patient to repeat such involved testing. Our approach is to follow the resolution/improvement of patient-reported cardiac-related symptoms and follow less invasive testing such as E...
When do you consider using phenobarbital over symptom-driven alcohol withdrawal protocols for patients at low-to-moderate risk of withdrawal complications?
While traditional frameworks often reference "low" or "moderate" risk for alcohol withdrawal complications, in clinical practice we find it more useful to focus on the treatment setting and validated predictors of severe withdrawal rather than subjective risk labels. Phenobarbital is increasingly us...
How do you decide whether to start MAT for opioid use disorder during hospitalization?
There are several considerations when approaching patients about MOUD. In general, every patient should be offered MOUD during their hospitalization because every admission represents an opportunity towards substance recovery. With that said, I don’t entangle substance use treatment with their medic...