Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you interpret failure to develop hypernatremia with prolonged water deprivation (such as for 12 hours) as evidence against diabetes insipidus even if the urine osmolality is just below normal?
This test indicates that this patient has fairly good urinary concentrating ability, but does not meet most criteria for "normal" since the osmoles did not go over 600. Since diabetes insipidus is a spectrum disorder, this result does not completely rule out the possibility of very mild diabetes ins...
Do you add empiric anti-MRSA coverage to the initial antibiotic regimen for a patient admitted with community-acquired pneumonia who has risk factors for MRSA but a negative MRSA nasal screen?
Thank you for this excellent and highly relevant clinical question. I approach this scenario by blending robust evidence-based medicine with fundamental principles of diagnostic reasoning. The short answer is generally no, you probably do not need to add empiric anti-MRSA coverage for a standard CAP...
What is your approach to the management of asymptomatic bacteriuria in an elderly patient without clear urinary symptoms but with cognitive changes and falls?
Asymptomatic bacteruria does not cause altered mental status. Data suggests that when we attribute acute changes to it, we will be wrong about 85% of the time, thereby missing the true etiology. It is a difficult thing to educate staff of senior living facilities and families who have been told it w...
What is your approach to perioperative risk stratification and optimization of patients with ESRD on HD?
When evaluating a patient with end-stage renal disease (ESRD) on maintenance hemodialysis for surgery, my approach to perioperative risk stratification centers on three major areas: cardiovascular risk assessment, optimization of dialysis-related factors, and careful perioperative medication and met...
Would you start ASA and/or statin therapy on an asymptomatic patient noted to have incidental pathologic Q waves on EKG, assuming no prior history of ischemic heart disease?
I would start with a thorough H and P and comprehensive risk evaluation with necessary screening including blood work, at least a stress echocardiogram if not a full echocardiogram in addition, and also offer Calcium scoring. Given more details are not given regarding the patient's age and functiona...
Do you recommend prolonging hospitalization for a patient with severe substance use disorder to facilitate discharge directly to inpatient rehab?
In general, it is not recommended to prolong hospitalization solely to facilitate direct transfer to residential substance use treatment if the patient is otherwise medically stable for discharge. This is the case once withdrawal has been adequately managed, coexisting medical and psychiatric condit...
What would be your transfusion strategy for a patient with decompensated cirrhosis presenting with concomitant acute upper GI bleed and acute MI?
I would be guided by the patient's vital signs, response to crystalloids, and clinical findings for red cell transfusion decisions, more so than any hemoglobin/hematocrit determination. I would avoid plasma transfusion for INR/prothrombin time abnormalities unless the viscoelastic testing demonstrat...
For older adults undergoing intermediate-risk non-cardiac surgery, do you routinely check pre-operative pro-BNP levels for risk stratification based on emerging data and updated Canadian guidelines?
Pre-operative NT-proBNP and BNP levels have been featured, not just in the cited Canadian guidelines but also in the 2024 update of the AHA/ACC preoperative evaluation guidelines. (Thompson et al., PMID 39316661). Those guidelines recommend evaluating a pre-op NT-proBNP level if the results will cha...
For older adults undergoing intermediate-risk non-cardiac surgery, do you routinely check pre-operative pro-BNP levels for risk stratification based on emerging data and updated Canadian guidelines?
Pre-operative NT-proBNP and BNP levels have been featured, not just in the cited Canadian guidelines but also in the 2024 update of the AHA/ACC preoperative evaluation guidelines. (Thompson et al., PMID 39316661). Those guidelines recommend evaluating a pre-op NT-proBNP level if the results will cha...
What is your approach to treatment in a patient with radiographic UIP but pathologic evidence of both fibrotic NSIP and UIP?
Depends on the underlying etiology and progression. I will most likely use antifibrotics, particularly for IPF or progressive fibrosis, but include immune suppression for autoimmune-related ILD.