Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When do you consider benzodiazepine-sparing treatment protocols for acute alcohol withdrawal?
Benzodiazepine-sparing protocols for acute alcohol withdrawal should be considered cautiously and within the context of careful risk stratification. Benzodiazepines became the predominant treatment for alcohol withdrawal through historical adoption rather than through prospective, head-to-head trial...
How would you manage a CVST secondary to a traumatic brain injury with the presence of intracranial hemorrhage?
When dealing with CVST after TBI, the mechanism of injury is not the same as a spontaneous CVST. There is often direct injury to the vein or the area overlying it. Given that these patients often have other traumatic injuries, and given the lack of clear evidence to support one therapy or another, I...
How do you counsel your patients with diabetes that tighter glycemic control could be harmful as they age when they've been committed to a goal A1c% <7.0-7.5 for many years?
I counsel my elderly patients and their families that at a certain age, the risk of developing long-term sequela of diabetes (eye disease, kidney disease) becomes lower because those things take many years to develop. However, elderly people are more vulnerable to medication side effects, so we adju...
What is your approach to anticoagulation in patients with hypertrophic cardiomyopathy and an apical aneurysm?
Patients with hypertrophic cardiomyopathy and an apical aneurysm are at higher risk for sudden cardiac death (hence the 2a guideline recommendation for primary prevention ICD) and thromboembolism. Rowin et al., PMID 29122139 previously noted that non-anticoagulated HCM patients with apical aneurysms...
How do you recommend counseling patients on the prognosis of advanced cancer as a generalist who is not highly specialized in cancer literature or cancer-directed therapies?
Generalists can accurately prognosticate on the order of days to short months without specialized knowledge when caring for people with advanced cancer because the prognosis is often clinically obvious, and because most cancer-directed therapies take weeks to months to work (a patient may not live l...
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?
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 ...