Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you select an SSRI and dosing strategy for older adults newly being treated for depression?
SSRIs are preferred based on tolerability, drug interaction potential, and comorbidities. Start at low doses (e.g., sertraline 25 mg daily) and titrate gradually to therapeutic levels over 1–2 weeks, monitoring closely for adverse effects. Among SSRIs, sertraline and escitalopram are particularly r...
Do you favor aggressive airway clearance regimens or bronchoscopy for clearing occluding mucous plugs in patients who are not in respiratory distress?
The first step is to determine the cause of the secretion issue. Is this acute or chronic? The underlying disorder that predisposes to abnormal mucus or ineffective cough? How much difficulty is this creating with ventilation and or oxygenation (ir level of urgency?). Since there is no respiratory d...
Do you integrate firearm violence prevention into your annual wellness visits?
Do you recommend providing supplemental oxygen for patients with a pneumothorax in the absence of hypoxemia?
I was certainly always taught that one should give supplemental oxygen to patients to decrease the size of the pneumothorax. This is based on the "nitrogen wash-out" theory, essentially, you're trying to get the partial pressure of nitrogen down in the alveoli so that it will be resorbed from the pn...
What factors should be considered when deciding whether to omit radiation in pediatric/AYA patients receiving N+AVD, particularly regarding long-term outcomes and second malignancy risks?
Based on the early data from S1826, it appears that radiation can be omitted if end-of-therapy scans (after 6 cycles of therapy) show metabolic remission of disease. The ability to limit RT to 1% of patients is encouraging for potential reduction in late effects such as cardiovascular disease and SM...
In patients with confirmed hypercortisolism with a high/normal unsuppressed ACTH who have both a pituitary adenoma and adrenal adenoma identified on imaging, can you reliably use DHEA-S to determine the source of cortisol production?
There is a difference between high-normal and unsuppressed ACTH. If ACTH is high-normal, this is ACTH-dependent Cushing. However, you can have mild adrenal Cushing without fully suppressed ACTH (e.g., ACTH in the 10-20 pg/ml range and sometimes even above 20). I don't think you can rely on DHEAS in ...
When starting stress dose steroids for patient with primary adrenal insufficiency, how do you decide whether to start hydrocortisone 100 mg every 8 hours versus 50 mg every 6 hours?
Stress doses of steroids in patients with primary adrenal insufficiency depend on the anticipated stress. The dose of steroids can be doubled or tripled depending on the stress. For example, in cases of maximal stress such as major surgery, the dose can be similar to the dose used for an adrenal cri...
When starting stress dose steroids for patient with primary adrenal insufficiency, how do you decide whether to start hydrocortisone 100 mg every 8 hours versus 50 mg every 6 hours?
Stress doses of steroids in patients with primary adrenal insufficiency depend on the anticipated stress. The dose of steroids can be doubled or tripled depending on the stress. For example, in cases of maximal stress such as major surgery, the dose can be similar to the dose used for an adrenal cri...
How do you consider and approach transition to hospice in a patient with HFrEF who does not appear to tolerate GDMT?
I approach this situation similarly to any illness that has reached end-stage or is approaching end-stage. First, I determine the patient's goals of care. By this, I mean, what does the patient value? If time is getting short, how do they want to spend their time? Where and with whom? How do they de...
How do you consider and approach transition to hospice in a patient with HFrEF who does not appear to tolerate GDMT?
I approach this situation similarly to any illness that has reached end-stage or is approaching end-stage. First, I determine the patient's goals of care. By this, I mean, what does the patient value? If time is getting short, how do they want to spend their time? Where and with whom? How do they de...