Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your loading dose goal and typical loading regimen for PO amiodarone in patients with atrial fibrillation?
I dose amiodarone differently when treating AF compared to when treating VT. For AF, assuming that the patient has been adequately anticoagulated since we are not dealing with a life-threatening arrhythmia, I generally do an initial loading of 400mg BID for 7 days and then cutting back to 200mg dail...
What is the recommended fungal workup in an immunocompromised patient after 5 days of persistent fever?
For any patient with fevers, I focus significantly on any symptoms that a patient might have, like headache, diarrhea, and sinus symptoms, and work up a differential diagnosis based on possible pathogens in this area. If I am not finding anything, I would obtain a CT chest/abd/pelvis, as both invasi...
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...
In patients on long-term proton pump inhibitors for GERD with stable symptoms, do you routinely attempt discontinuation or continue indefinitely given relapse risk?
This is a good question, as we see many patients who were placed on PPIs and continued indefinitely for GERD. As this question implies, this may not be necessary, and long-term PPI use comes with risks that include C. diff. There are additional studies that suggest fractures, CKD, and nutrient defic...