Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your typical approach to the use of beta blockers in the setting of recent cocaine use amongst patients presenting with cocaine-related MI, arrhythmias, or new-onset heart failure?
I favor using or continuing non-selective beta-blockers in patients presenting with acute cardiac manifestations of recent cocaine use. My preferred agent in this setting is carvedilol.
What is your go-to strategy for non-opioid management of chronic low back pain in patients with limited access to physical therapy or behavioral health?
The short answer is that if pain fails to improve after three months of conservative management, patients should be referred to a board-certified pain physician for further evaluation and treatment. The long answer is that chronic pain management is a highly complex, multidisciplinary field that can...
Do you treat cerebral vein thrombosis with parenchymal hemorrhage using full dose heparin protocol rather than the high risk protocol?
I just want to clarify the question a bit. I will assume that you mean cerebral venous sinus thrombosis with cerebral vein thrombosis here. IV heparin is considered a standard treatment for cerebral venous sinus thrombus, but not necessarily cerebral vein thrombosis. Heparin for isolated cortical ve...
What is your strategy for treating persistent headaches in the aftermath of subarachnoid hemorrhage?
In the immediate aftermath of a subarachnoid hemorrhage, regardless of whether the aneurysm has been secured or not, the following strategies can be employed to manage headaches: Headache Cocktail: This may consist of magnesium infusions, Benadryl, and an antiemetic like Compazine. Magnesium infusi...
Do normal methylmalonic acid levels absolutely rule out vitamin B12 deficiency?
An elevated MMA is a good indicator of B-12 deficiency but a normal level does not argue strongly against B-12 deficiency. Normal MMA levels have been reported in 10-25% of patients with known B-12 deficiency (B-12 levels below 100). Testing for an elevated homocysteine level might help but this tes...
Can tamoxifen be safely prescribed for breast cancer patients with cirrhosis?
Tamoxifen would definitely not be my preferred endocrine agent in a patient with cirrhosis. I have had many cases of tamoxifen-induced liver injury. The incidence of MASH due to tamoxifen is really underreported in the literature. In a case of pre-existing MASH or other liver disease, I switch to an...
How do you manage pregnant individuals with newly diagnosed idiopathic intracranial hypertension?
Pregnancy in IIH is managed the same as if the patient did not have IIH with one caveat. IIH patients should stay within the recommended weight gain their obstetrician targets. Pregnancy is not a cause of IIH, but the excessive weight gain that can occur can trigger or worsen IIH. Labor and delivery...
How do you decide between oral vs nasal route of entry for bronchoscopy with BAL with moderate sedation?
I trained in the early 90s. Where I trained the nasal route of entry was preferred. My experience is that patients cough less, require less sedation, and the scope is easier to guide and direct from the "stable" base of a nasal insertion. With proper nasal preparation complications related to nasal ...
How would you approach chronic Achilles tendonitis that persists despite rest and physical therapy?
When situations like this arise, the first step is to re-evaluate the duration of symptoms and ensure the full trial of conservative management (rest, ice/heat, NSAID/Tylenol, PT) has been done. Oftentimes, it takes months to fully recover, even with these measures. If the symptoms persist despite a...
What factors would lead you to extend the duration of antithyroid drug therapy in a patient with Graves' disease who is clinically euthyroid at 12 months but has risk factors for recurrence?
One should never discontinue methimazole after an arbitrary period of time without checking anti-TSH receptor antibody levels. If they are positive or even “normal” but not undetectable, the patient will inevitably have a recurrence of their hyperthyroidism relatively quickly (Laurberg et al., PMID ...