Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you counsel patients on the risks vs benefits of naltrexone for alcohol use disorder with persistently elevated liver enzymes?
Before answering this question, it is first important to point out that obtaining baseline liver function tests (LFTs) is not necessary before starting a patient on any formulation of naltrexone (oral or long-acting injectable XR). However, it is essential to consider if the patient has an underly...
How are you incorporating the newer RCT data suggesting no mortality benefit to indefinite beta-blocker therapy for patients who are several years out from an MI with preserved LVEF and no angina or arrhythmia?
I have been de-prescribing after counseling once the patient is a couple of years out. This reduces symptoms, pill burden, drug interactions, etc., so I see an active benefit even if the patient seems to be tolerating medication. Obviously, they would have no other indication for BB, mainly arrhythm...
How would you approach hormone replacement therapy for perimenopause in a patient with increased risk factors for VTE?
Like many medical choices, this decision involves weighing trade-offs—specifically, the risk of venous thromboembolism (VTE) versus the burden of severe menopausal symptoms. If we focus only on VTE risk (and set aside the trade-offs related to menopausal symptoms and the controversial issue of breas...
How do you counsel cancer patients when they ask if they should avoid sugar?
“We don’t have evidence to support any specific diet that can either worsen or improve outcomes. I encourage a healthy, well-balanced diet with my top priority being you maintaining your weight during treatment.” Particularly for my head and neck patients, getting in sufficient calories is of the ut...
Do you typically include exercise restrictions and/or alcohol intake restrictions in routine counseling for patients with atrial fibrillation?
I counsel on adopting a heart-healthy diet, exercising regularly, limiting alcohol (reasonable amounts of caffeine likely not a big deal), quitting smoking, managing stress, and ensuring quality sleep, especially treating sleep apnea. No exercise restrictions (unless they do extreme exercise; data m...
How do you pragmatically approach a conversation about "liver detox"/"liver cleansers" when patients bring up this topic?
It's important to keep an open mind with the use of these products, as often people will want to take them despite what you might say. Having some experience with the use of these products (or at least their ingredients) will give the patient a comfort level with freely discussing their use with you...
Is there a role for suppressive antibiotic therapy when it comes to chronic femoral/tibial osteomyelitis?
Suppressive antibiotic therapy would be considered if there is felt to be a nidus that cannot be removed. For example, if a patient has hardware in place that is infected with associated osteomyelitis, but is not a candidate for surgery due to advanced age perhaps. This patient can be considered for...
What is your approach for de-escalation of antiarrhythmics for patients with a history of ventricular arrhythmias?
This is an important question. The answer depends on several factors including the type of arrhythmia being treated, the patient's underlying condition, drug intolerance and expense, and patients' expectations. Unfortunately, there is very little published information on this topic but as a general ...
How do you select between antipsychotics in the treatment of delirium refractory to nonpharmacological management in hospitalized older adults with dementia?
I have learned that antipsychotic selection is very institution-based/variable.Traditionally, at the Brigham, we have preferred Seroquel because it is titratable and avoids issues if the patient has underlying Parkinson's. However, now that Zyprexa is available in IV form, house staff often prefer t...
What work-up and treatment do you recommend for exertional headaches?
Primary Exercise Headache Diagnostic Criteria per ICHD-3: At least two headache episodes fulfill criteria B and C Brought on by and occurring only during or after strenuous physical exercise Lasting <48 hours Not better accounted for by another ICHD-3 diagnosis Caveats: Migraine headache worsened o...