Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to electrolyte repletion for patients hospitalized with cardiac and non-cardiac conditions?
My approach to electrolyte monitoring and repletion emphasizes a patient-specific risk assessment rather than adherence to arbitrary numeric thresholds. The routine, reflexive repletion of potassium, magnesium, and phosphorus in unselected medical inpatients is an overused practice with limited supp...
What therapies do you recommend for patients with limited life expectancy (<3 months) but whose depression is significantly reducing their quality of life?
I agree with Dr. @Dr. First Last that the first thing we need to do is to make sure that the patient actually meets the criteria for depression rather than demotivation or demoralization. If the patient is depressed, using Ritalin may have an effect in a very short amount of time, although there isn...
What is your approach to scheduling and then weaning nebulizers in patients admitted with acutely exacerbated asthma or COPD?
In hospitalized patients with acute asthma or COPD exacerbations, my approach to nebulizers is front-loaded and reassessment-driven. I start by gauging the severity and the patient’s ability to use an inhaler. pMDI with a spacer is preferred for most patients, but nebulizers are reasonable early on ...
When screening for malignancy, do you order CT with contrast (or) both with and without contrast?
I think the best way to think about this is to assess what each scan shows. A CT with oral and IV contrast is very good for assessing details between soft tissues and blood vessels. A CT without contrast is better for assessing for renal stones and for fractures, especially small insufficiency fract...
Should an ischemic evaluation be considered in the diagnostic work-up for new-onset diastolic heart failure/HFpEF in patients without clear anginal symptoms?
The ischemic phenotype is a well-recognized class among HFpEF patients. For men, this usually manifests as macrovascular disease with epicardial CAD, and for females, the more common manifestation is microvascular disease with CMD. Therefore, ischemic evaluation should be considered as part of the w...
Would you recommend a GLP-1 agonist as an option to reduce the risk of dementia in patients with a strong family history?
I'm recommending GLP-1 for many things right now, but I haven't yet independently recommended it just to reduce the risk of dementia. However, if microvascular disease can contribute to vascular dementia, then there may be a benefit to better controlling diabetes with this drug.
What therapeutic approaches have you found effective for athletes with anorexia nervosa whose eating disorder symptoms are intertwined with sport-driven weight pressures?
The gold standard for treatment of anorexia nervosa and all eating disorders is a team-based approach, including the individual, psychiatrist, counselor, primary care or sports medicine physician, dietician, appropriate family members, and, in the case of elite athletes, sometimes their coaches. Rap...
How do you approach the management of post-concussion syndrome with symptoms including vertigo, headaches, persistent fatigue, and/or mood symptoms?
Each persistent post-concussion symptom that you listed has interventions that can be helpful. For vertigo, I recommend referral to vestibular therapy. I also use our behavioral health providers very regularly in the PPCS population. Because a concussion is a neuro-psychiatric condition, therapy is ...
How do you integrate HIV (+) serostatus into a patient's ASCVD if they would not otherwise qualify for a statin either for primary or secondary prophylaxis?
HIV (+) serostatus is a significant risk-enhancer for the development of cardiovascular disease and should be taken into account when making treatment decisions regarding statin initiation, even if the patient's viral load is low or not detectable. In a patient >40 years old and with a risk >5%, wou...
Is there a role for routine stress testing in intermediate-high risk CAD patients with a significantly elevated coronary calcium score who are otherwise asymptomatic?
Current data does not support stress testing in asymptomatic intermediate risk individuals in general and those with incidental CAC also do not have an indication for the test. ASCVD risk factor modification suffices.