Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How soon after a fracture would it be safe to start anti-resorptive therapy?
This is an important question. There is no definitive answer, and there have been no clinical or preclinical studies that demonstrate delayed healing in the presence of bisphosphonates. Personally, I favor waiting a few weeks before we start. That also gives us time to do a proper metabolic workup. ...
What is your approach to secondary stroke prevention in patients with atrial fibrillation and intracranial stenosis (>70%)?
The patient clearly needs to be on an anticoagulant for stroke prevention with atrial fibrillation and I would choose apixaban. If an antiplatelet is added to the apixaban, the risk of a major bleeding side effect is significantly increased. It is uncertain if apixaban is effective in reducing the r...
Do you have safety concerns when prescribing GLP-1 medications in patients on corticosteroids or immunosuppressive therapy?
I think we need to be particularly careful when co-prescribing with systemic corticosteroids because of the risk of sarcopenia. We know that rapid weight loss is accompanied not only by a loss of fat tissue but also of muscle. Corticosteroids can also have myotoxicity and cause muscle atrophy. I the...
How do you utilize Diamox in patients with cerebral venous sinus thrombosis and vision symptoms who do not undergo thrombectomy/recanalization?
Diamox (acetazolamide) is often used to treat papilledema with associated visual loss in cases of CVST. While there is a theoretical risk of dehydration from acetazolamide with potential worsening of the thrombosis, 1) acetazolamide is a weak diuretic and 2) the risk of blinding visual loss usually ...
How do you approach laboratory evaluation in patients with fatigue?
First search for evidence by history and physical examination for any evidence of inflammation. If there is tailor the lab workup rather than ordering tests as screening tools. ESR and CRP to start with. Anything more without a reasonable a priori likelihood of the targeted diagnosis is just asking ...
What additional workup would you perform to evaluate a new onset of spontaneous hemarthrosis?
The workup that you've outlined is essentially complete. Would rule out any possible medication/supplement effects, Would consider the possibility of a vascular fragility syndrome (EDS) or other connective tissue disease, Would rule out vitamin C deficiency, If there is other bleeding that clinical...
How do you manage patients with chronic migraine as well as medication overuse headaches?
I agree with Dr. @Dr. First Last about the treatment for chronic migraine and MOH for patients on opiates and/or barbiturates. If they are taking frequent opiates, I prefer to have a pain management doctor detoxify them. In the past, I slowly decreased their medication while giving them long-acting ...
Do you still consider propranolol first-line for sinus tachycardia in thyroid storm, or have newer perspectives on beta-blocker risks altered your management?
Yes, but...Propranolol remains the first-line option for thyroid storm, but recent evidence supports that beta-1 selective agents (metoprolol, atenolol) are equally effective and may be preferred in certain clinical contexts. The choice between propranolol and cardioselective beta-blockers should be...
How do you manage/treat acute radiation-induced enteritis?
I have no problem with the excellent comments already made. However, I think it is important to add some comments. First - one needs to be sure that the patient truly has radiation enteritis. Many patients receiving abdominal radiation therapy have other issues that need to be explored first. For ex...
How would you determine the safety of anticoagulation in patients with evidence of cerebral microhemorrhages who present with acute stroke secondary to cardioembolism?
This question assumes that the patient already had an MRI showing microhemorrhages. The Boston criteria provide guidelines for the number of microbleeds, associated superficial siderosis, or major hemorrhage to make the diagnosis of cerebral amyloid angiopathy. I would also assume that at least some...