Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What dietary advice do you give patients with hyperlipidemia who want to try and manage it with lifestyle changes first?
The first place I usually start with when it comes to patients seeking lifestyle changes for hyperlipedemia is to point them towards dietary changes. My go to diet for this is the PORTFOLIO diet. A researched diet that has been shown in multiple trials to reduce LDL and was even shown to be non-infe...
How do you approach initial steroid dosing in patients with eosinophilic fasciitis?
I usually start with a high dose at 60 mg daily for a few weeks, then add DMARDs like MTX.
In a patient with sicca symptoms and SS-B antibodies only, can a minor salivary gland lip biopsy with lymphoid aggregates, but also scattered areas of acute neutrophilic inflammation be consistent with Sjogren's Disease?
I agree with @Dr. First Last and cannot speculate on the neutrophils.I'd also like to point out that a French study showed that only 1% of isolated anti-SSB patients had Sjogren's disease, SjD (Jardel et al., PMID 28931060); all others had other autoimmune diseases, neoplasia, infection, and solitar...
When do you recommend neuropsychiatric testing in patients with post-concussive syndrome?
I typically ask the patient what scenarios they experience cognitive issues. The various examples they provide usually relate to difficulty following conversations, forgetfulness within their working memory, and concentration/focus. In the post-concussion patient, they typically have developed adjus...
For patients with MSSA bacteremia and planned oxacillin at home via OPAT due to start the day after discharge, would you consider discharging after a one-time dose of ceftriaxone or daptomycin?
In a patient with MSSA bacteremia, I would not be comfortable sending a patient home after one dose of ceftriaxone or daptomycin to continue outpatient anti-staph IV antibiotics. Staphylococcus aureus bacteremia causes distant seeding in more than 1/3 of cases and has a mortality rate ranging betwee...
How do you approach ADT in patients with high-risk prostate cancer who have risk factors for VTE, such as Factor V Leiden?
My default recommendation for patients with localized, high-risk prostate cancer is to recommend the use of long-term ADT. This intervention seems to offer a relatively large, clinically significant OS benefit for patients in the modern era receiving dose-escalated ADT. This benefit has been observe...
In what situations would you treat a rectal mass as cancer despite negative biopsies?
It is not uncommon to see a patient with rectal mass highly suspicious for malignancy by endoscopic evaluation but has a negative biopsy. Usually, this is due to superficial biopsy specimens. In our clinic, we usually get repeated endoscopic evaluation with biopsy as our first step. However, a small...
When, if ever, would you consider tapering patients started by another provider on low-dose, as-needed lorazepam for insomnia without a history of cognitive impairment or substance use disorders?
It is important to have a conversation with your patient about potential side effects and benefits of discontinuation of benzodiazepines, especially when it is used for an indication like insomnia. I have had this conversation with any of my patients who are using benzodiazepines. Benzodiazepines ar...
What are your thoughts about lion's mane supplementation to slow the decline or improve cognitive capacity for those at risk of dementia?
Lion's mane is the latest in the ever-evolving list of supplements that have a whiff of animal data, very small human trials, or frankly, anecdotal evidence. A decade ago, it was coconut oil; last week, it was lithium. There will always be suggestions of the benefit of this or that. Currently, there...
How do you counsel older adults regarding the use, dosing, and safety of CBD-containing products for insomnia?
When counseling older adults on CBD use for insomnia, I usually explain that evidence for safety and effectiveness is limited. Most products are not FDA-approved, and their labeling, purity, and dosing can be inconsistent. It’s important to review the patient’s comorbidities and medications closely,...