Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
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.
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...
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,...
In older adults with chronic mild hyponatremia (Na 128–132) attributed to SSRIs but good psychiatric response, do you tolerate persistent hyponatremia, reduce the dose, or switch agents?
In my practice, I generally tolerate mild hyponatremia, Na>130, if asymptomatic and mood symptoms have good control. If there’s moderate hyponatremia, Na 125-130, I generally consider either changing the dose or the agent. If severe, Na<125, I would change the agent and likely avoid the entire class...
How do you approach the choice of pharmacological therapy when treating insomnia in older adults in the outpatient setting with a high falling risk?
My approach is to first see if there are non-pharmacologic options to help with sleep - are there behavioral factors to target (e.g., caffeine or alcohol use; inappropriate sleep scheduling or daytime napping), medications that could disrupt sleep-wake schedules, or untreated sleep or mood disorders...
What is your calcium level threshold for initiating targeted calcium lowering therapies for patients with an acute kidney injury believed secondary to renal vasoconstriction and volume depletion?
Treatment of hypercalcemia should be based on the severity of the symptoms rather than any arbitrary calcium level threshold. Therefore, if the AKI is due to hypercalcemia-induced renal vasoconstriction and volume depletion, then the hypercalcemia should be treated.