Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?
Assuming that a thorough workup for other causes of fatigue (anemia, thyroid dysfunction, sleep apnea, etc.) has been performed and is negative, no single medication has been proven by a randomized placebo-controlled trial to help chronic fatigue in PASC. Anecdotally, my colleagues who treat PASC ha...
At what eGFR do you typically refer for vein mapping for a patient with advanced CKD who prefers hemodialysis when indicated?
This is a big "it depends". Depends on trajectory of GFR loss, likelihood of preemptive transplant, my best clinical guess of the likelihood of successful fistula vs need for graft, etc. But in general, if it seems like HD start would be within 4-6 months.
When do you consider scheduled antiemetics in hospitalized patients experiencing severe nausea?
The biggest problem I see is antiemetics given PRN when a patient has consistent nausea. The goal is to get above the nausea so that the patient begins to feel better. This is similar to how one treats pain. Thus, if a patient is taking an antiemetic more than once a day and has consistent nausea, I...
What is your approach to initiation of mirtazapine for appetite stimulation and depression in older adults, both in terms of starting dose and titration?
I consider initiation of mirtazapine for older adults who could benefit from at least two of the three potential effects of mirtazapine - improvement of mood, appetite, and/or sleep. I always start at a low dose of 7.5 mg nightly, potentially uptitrating to 15 mg nightly after a week or two if the m...
Can patients "age out" of screening colonoscopies if, on their last colonoscopy prior to turning 76, they had tubular adenomas?
How long ago was the last colonoscopy? How many adenomas? How old is the patient now? State of health and expected longevity? What does the patient want? Frankly, at this point, I think I’d probably be content with an annual FIT.
What is your preferred method for subclinical CAD screening prior to initiation of class IC antiarrhythmic drugs for atrial fibrillation?
Flecainide and propafenone are the IC agents in use for atrial fibrillation. Encainide and moricizine were predominantly used for ventricular arrhythmias and encainide was pulled a long time ago due to proarrhythmia concerns and I believe Ethmozine stopped being marked many years ago.The CAST trial ...
What is your approach when a female patient does not want a male MA/scribe present in the exam room but other staff are unavailable?
I think we need to respect a patient’s request for same sex providers. Some patients are shy. For some, it is religion-based. I would ask the scribe to stand behind the curtain while I am seeing the patient. Regarding the MA, I would ask the MA to leave the room during my full-body skin exam. If I n...
Is there a particular PVC/NSVT burden on inpatient telemetry in which you would consider discharging a patient with a LifeVest post-STEMI with newly reduced LVEF <35% while optimizing GDMT?
The PVC/NSVT burden is not part of the equation for post-STEMI LifeVest. The guidelines clearly state that if you have an EF of <35% and are within 40 days of an MI, or any revascularization within the past 90 days, the wearable defibrillator is a class IIb indication while optimizing GDMT. If the p...
How should we approach the recommendation of intermittent fasting for weight loss in patients with pre-existing cardiovascular conditions, given the observed association of increased CV mortality with eating durations of less than 8 hrs?
I will admit my prejudice on this topic. I don’t understand the biologic plausibility of shortening the time during which meals are consumed to 8 consecutive hours a day with no snacking for 16 hours a day (but without calorie restriction) in order to lose weight. This would be like saying “have bru...
How would you treat an asymptomatic patient with a positive Blastomyces antibody, evidence of prior granulomatous lung disease on imaging, and who may require immunosuppression in the future?
We practice in an area with a good bit of blastomycosis and rarely see a positive Blastomyces antibody, even in patients with culture-proven blastomycosis. The newer EIA antibody that MiraVista lab is doing may be more reliable. If the prior granulomatous lung disease has been worked up with negativ...