Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Are there scenarios in which you would advise using benzodiazepines for the treatment of hyperactive delirium?
The only situation that comes to mind is in patients who have active alcohol or benzodiazepine withdrawal as the etiology of their delirium. Outside of that, I do not use benzodiazepine therapy for delirium due to the risk of adverse effects (including prolonging the delirium) and lack of any data I...
How would you manage a patient with necrotizing pneumonia due to a susceptible Pseudomonas aeruginosa strain who continues to have significant purulent secretions and worsening imaging while receiving cefepime?
I agree, not enough information here to make a firm recommendation, but often times these necrotic pneumonias will undergo significant liquefactive necrosis, and all of that dead lung and purulence has to come out through the mouth. I tell patients that they may have a worse cough for a while, and t...
For patients with Hashimoto's thyroiditis, is there a commercially available blood test for detecting abnormalities in the type 1 deiodinase enzyme in order to identify patients who would potentially benefit from T4 and T3 combination therapy?
Most clinicians decide to use combination therapy based on a weak response to levothyroxine, with patients still complaining of symptoms related to hypothyroidism. The TSH should not be low before selecting dual replacement.
When (if ever) do you recommend taping a patient off of buprenorphine after sustained remission?
I rarely recommend tapering off buprenorphine after sustained remission for opioid use disorder (OUD) because typically, buprenorphine is well-tolerated, risks are minimal, tapering can be challenging, and the risk of overdose after tapering off MOUD is high.Instances when I would consider a taper a...
What is your preferred, first-line class of anti-anginals for MINOCA with proven epicardial coronary vasospasm?
We typically start with long-acting nitrates such as isosorbide mono or dinitrate, but often patients will have adverse effects to nitrates that make long-term use challenging. We have had good results with non-dihydropyridine calcium channel blockers, particularly diltiazem, both as short and long-...
What is your approach to deprescribing gabapentinoids so as to prevent withdrawal effects?
Prescriptions for gabapentinoids are increasingly common, particularly for off-label indications such as neuropathic pain (1). There is relatively limited evidence to guide deprescribing strategies for gabapentinoids, as demonstrated in a 2023 scoping review (2). Abrupt discontinuation of gabapentin...
What is your approach to deprescribing gabapentinoids so as to prevent withdrawal effects?
Prescriptions for gabapentinoids are increasingly common, particularly for off-label indications such as neuropathic pain (1). There is relatively limited evidence to guide deprescribing strategies for gabapentinoids, as demonstrated in a 2023 scoping review (2). Abrupt discontinuation of gabapentin...
How do you approach revascularization in patients over 75 years with NSTEMI, given recent evidence from the SENIOR-RITA trial that an invasive strategy does not significantly reduce cardiovascular events compared to a conservative strategy?
The Senior-Rita trial was a randomized trial of nstemi patients over the age of 75 randomized to conservative therapy versus an invasive strategy plus optimal medical therapy. Non-fatal MI was more common in the conservative strategy group but overall a primary outcome event occurred in 25-26% in bo...
For outpatients undergoing a kidney biopsy, do you routinely recommend an overnight admission for continued hemoglobin monitoring?
If I perform an uneventful kidney biopsy in the morning on a patient with well-controlled BP and normal hemoglobin, I can observe the patient all day. If vitals are stable and the repeat hemoglobin at 8 hours is stable, I would discharge the patient. However, if I did the biopsy later in the day or ...
How to you approach the risk/benefit discussion for hormone replacement therapy in perimenopausal women with significant vasomotor symptoms and borderline ASCVD risk?
Thank you for this question. It is a conversation of a bit complex nature to be had with the patient. Generally, I follow the steps of [1] educating the patient on the data on the use of HRT in setting of ASCVD in that HRT is indicated for treating moderate to severe perimenopausal symptoms up to 5 ...