Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you decide when an older patient's weight loss warrants an extensive workup versus a more focused or watchful approach?
I always start with the standard cut off of 5% of normal body weight in 6-12 months. If this cut-off is met, then I probe about intentional or unintentional. Many older adults are not eating enough protein (they need more than the RDA recommendation) -- I encourage 1-1.3 (sometimes 1.5) g/kg protein...
In what clinical scenarios do you utilize opioids in patients with restless leg syndrome?
I would say in refractory RLS, i.e., the patient has failed all the options below: Iron supplementation if ferritin <50, Gabapentin/pregabalin, Dopamine agonists, and Non-pharmacological options (like the vibrating pad). *I don't love carbidopa/levodopa for RLS. It very often causes augmentation.
Do you recommend routinely monitoring pancreatic markers such as amylase and lipase while receiving GLP1 R agonist or dual agonist therapies to determine their risk of pancreatitis?
Absolutely not. We know that changes in amylase and lipase levels on these drugs are very common. For example, if you look at the supplementary data across the SUSTAIN series of phase 3 trials with subcutaneous semaglutide, the average person had about a 15-30% rise in their amylase/lipase. Further,...
How does the presence of myositis alter your interpretation of cardiac enzymes when evaluating acute chest pain?
Troponin T and CK-MB are not reliable for cardiac issues in myositis as regenerating muscles produce these enzymes. This is especially true if the patient has an active disease with weakness and CK elevation. Troponin I is not much affected by muscle enzymes and should be used as a parameter to eval...
Would you consider using steroids in patients with respiratory failure caused by aspiration pneumonitis?
For aspiration pneumonitis alone, typically no. If there are other indications for steroids, for example, acute COPD or asthma exacerbation, then I would. I would also focus on addressing the aspiration to prevent future events. I have also seen providers use antibiotics if aspiration pneumonia vers...
How, if at all, do you incorporate techniques such as mindfulness into your discussions with patients who have chronic pain, particularly if they are on long-term opioids?
I do use the Oregon Pain Management website with my chronic pain patients, and if they select the mindfulness tile, I go over this with them and refer them to our embedded behavioral health provider. I also teach the "square breathing" technique quite often to anxious patients with or without pain, ...
How long do you treat Staphylococcus aureus pyomyositis with antibiotics?
I agree, and certainly evaluating for bacteremia that can be associated with these types of infections, which would alter the duration of therapy.
What is your approach to IV fluid management for the treatment of hypercalcemia of malignancy?
At this point, I believe one can use either saline or lactated Ringer's. There is some evidence that low-chloride-containing solutions have advantages in general, which may well be the case, but we need more data on that. The amount of calcium in LR is very small and should not make a difference (1....
What is your approach to IV fluid management for the treatment of hypercalcemia of malignancy?
At this point, I believe one can use either saline or lactated Ringer's. There is some evidence that low-chloride-containing solutions have advantages in general, which may well be the case, but we need more data on that. The amount of calcium in LR is very small and should not make a difference (1....
What class(es) of antihypertensives should be considered next for refractory hypertension in a patient compliant with high doses of Entresto, chlorthalidone, amlodipine, clonidine, and spironolactone if they previously did not have any improvement on beta blocker or hydralazine and work-up for secondary causes were unremarkable?
Minoxidil remains a rarely used but potent option.