Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you counsel patients who are concerned that discontinuation of certain chronic medications may actually perpetuate suffering at the end of life?
Great question, and it’s very nuanced. I’ll share how I typically approach this based on my experience. In the end-of-life care setting, when I review a medication list, I go through every single one and ask: “What is the purpose of this medication in this particular case?” For example, anticoagul...
Should patients starting cyclophosphamide be screened routinely for latent tuberculosis (TB)?
Yes, I think patients starting Cyclophosphamide should be screened routinely for latent TB since CYC is a strong immunosuppressant and increases the risk of TB reactivation. The issue is that CYC is often being considered for life or organ-threatening situations, for which it may not be ideal to wai...
In middle-aged adults with TSH 5–10 mIU/L and no symptoms, would you start levothyroxine or monitor, and does your threshold change with cardiovascular risk factors?
In a middle-aged patient with a TSH between 5-10 and no symptoms, I would initially monitor their thyroid levels. I would consider checking a TPO antibody titer; if positive, the rate of transition to overt hypothyroidism is greater. I would also screen for other medical issues that could be impacte...
Do you routinely monitor urine toxicology for primary care patients prescribed tramadol for chronic pain?
I get a urine at least once per year for someone on a daily opioid agonist for a chronic pain syndrome. Tramadol carries the same risks as other opioid analgesics. For anyone on chronic opioid therapy, I also complete a controlled substance agreement, which I try to approach like an informed consent...
Do you ever recommend the use of a Creatine Monohydrate supplementation to your patients looking to improve physical fitness?
Yes. I do recommend Creatine Monohydrate for patients/athletes hoping to gain strength and muscle mass. The current data is favorable for short bursts of strength or speed, but there is some growing evidence that there may be some benefit for higher rep/longer exertion and possibly for cognitive hea...
Do you routinely order karius in evaluation of culture negative prosthetic valve endocarditis?
Don’t “routinely” order Karius test. Rarely, in culture-negative suspected endocarditis, especially if a prosthetic valve is present. Once for suspected culture-negative aortic graft infection. 3x for culture-negative meningitis. Likely to become more frequent but adoption very dependent on cost an...
What are your preferred non-benzodiazepine therapies for the hyperactive/agitated phase of methamphetamine withdrawal, both in the hospital and in the office?
In our outpatient substance use disorder practice, we tend to use lisdexamphetamine (Vyvanse) at fairly high doses off-label for patients with meth withdrawal. We establish a buddy system preferably with someone who lives with them, provide Suicide hotline phone number, describe reasons to transport...
What are your preferred non-benzodiazepine therapies for the hyperactive/agitated phase of methamphetamine withdrawal, both in the hospital and in the office?
In our outpatient substance use disorder practice, we tend to use lisdexamphetamine (Vyvanse) at fairly high doses off-label for patients with meth withdrawal. We establish a buddy system preferably with someone who lives with them, provide Suicide hotline phone number, describe reasons to transport...
What is your approach to managing incidental hypertension without evidence of end-organ damage in hospitalized patients?
Approaches to managing inpatient HTN without evidence of end-organ dysfunction have evolved over the years. I worked with some attendings who felt strongly about treating. There was a great JAMA IM article that explored this very question for non-cardiac patients. Link here: Rastogi et al., PMID 333...
Do you routinely treat patients with neurosyphilis with IM penicillin for 1-3 weeks after completing a full treatment course of IV penicillin?
The same question was asked almost exactly two years ago. Repeating the same reply with minor edits: This has been a topic of a debate among syphilis experts for decades. There are no data at all on whether there is benefit (e.g. in preventing later relapse) in adding low-dose but long-acting penici...