Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you decide on switching to a different preventative anti-CGRP treatment in migraine patients who are experiencing reduced effectiveness with their current treatment?
The CGRP antibodies and gepants are my preventive treatments of choice. In fact, I hardly ever prescribe anything else anymore preventively, including botulinum toxin. Tolerability issues I hardly ever encounter with the antibodies, but sometimes I do with the gepants, in particular fat...
What typical lab tests do you send off for evaluation of neuropathy?
Not too much has changed in over a decade regarding the recommendations on how we should approach initial laboratory testing in patients presenting with a neuropathy syndrome. Specifically for cases of distal symmetric polyneuropathy, the AAN practice parameter (reaffirmed in 2022) by England, et al...
What framework or risk assessment tool is most effective in determining surgical or palliative management of acute hip fracture after a fall in an elderly patient with co-morbidities and poor functional status?
I have found the NSQIP calculator to be the most useful in situations of acute hip fractures in elderly patients. In particular, it looks at more than just cardiac risk perioperatively - it examines functional, pulmonary, and ICU risks. They incorporate a number of co-morbidities and functional stat...
How do you choose among SSRIs and dosing strategies for the management of behavioral and psychological symptoms of dementia?
The best supported SSRI for BPSD generally is citalopram. Much of this came out of the CitAD trials [1]. This primarily showed citalopram may be useful for hyperactive behaviors, irritation, but also for depression and anxiety [1, 2]. The effect and response to citalopram, though, may be affected by...
Would you perform a diagnostic paracentesis for first-time ascites in a patient with established CHF or pulmonary hypertension, but without apparent liver or other intra-abdominal disease?
Great question. Yes, we should perform a diagnostic paracentesis for first-time ascites, even in patients with established CHF or pulmonary hypertension, unless there is an obvious alternative explanation and the procedure is unsafe or technically not feasible. After the etiology is established, rep...
How do you approach initial anticoagulant selection in hemodynamically stable hospitalized patients with newly diagnosed pulmonary embolism?
Low-molecular-weight heparin demonstrates the greatest benefit in patients with cancer-associated pulmonary embolism, intermediate-risk PE, and those requiring outpatient management. While LMWH shows superior efficacy and safety compared to unfractionated heparin across most patient populations, cer...
When do you start steroids for radiation pneumonitis?
Great question on a relevant clinical topic. It's very important to remember that pneumonitis is a diagnosis of exclusion. Sometimes, if the timing is right and the patient's presentation is typical, there is a tendency to move quickly to the conclusion that the symptoms are caused by pneumonitis. R...
How many days prior to surgery do you recommend stopping SGLT2 inhibitors and when is it safe to resume therapy?
SGLT2-inhibitors have been known to precipitate episodes of diabetic ketoacidosis(DKA) with glucose levels far lower than are usually seen in DKA. This has been called euglycemic DKA. SGLT-2 inhibitors cause an increase in the glucagon to insulin ratio, which promotes ketosis, as well as fluid loss ...
How do you approach pharmacologic management of OCD in patients with comorbid bipolar disorder, particularly when considering SSRIs or clomipramine?
This is a great question! Depending on the study you read, anywhere from 10% to 25% of patients with bipolar disorder have comorbid OCD. The challenge, as you might imagine, is that treatment with SRIs in the absence of a mood stabilizer may run the risk of inducing a manic episode. A larger debate...
What is your approach to patients with chronic hypoxemic respiratory failure who have apparent higher oxygen needs during hospitalization but no clear acute/decompensated respiratory illness?
Will work them up completely for infection, PE, COPD exacerbation, heart failure/cardiac etiology. If no convincing reason for decompensation and they are stable, I will have them do a 6 min RT walk test to determine oxygen needs and have them follow up with PCP or pulmonary for further PFTs or othe...