Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your go-to non-invasive test for the evaluation of angina in the primary care setting?
Great question, but not a simple answer! In my experience, there is no "go-to" noninvasive test for the evaluation of angina in the primary care setting. That is because each noninvasive test has its own strengths and pitfalls, which must be judiciously applied in the selection process for the indiv...
How do you approach laboratory evaluation in patients with fatigue?
First search for evidence by history and physical examination for any evidence of inflammation. If there is tailor the lab workup rather than ordering tests as screening tools. ESR and CRP to start with. Anything more without a reasonable a priori likelihood of the targeted diagnosis is just asking ...
What would be your approach to percutaneous intervention for acute plaque rupture and cardiogenic shock for a patient with cirrhosis and severe thrombocytopenia?
This is a risk benefit ratio question and the benefits of PCI far outweigh the bleeding (and paradoxically, thrombotic) risk. ASA and ADP antagonists last the lifespan of the platelet for the most part, so after the early stage of DAPT with ASA and a potent P2Y12 inhibitor, d/c’ing ASA may reduce ov...
How do you approach patients who identify so strongly with being sick or with a particular diagnostic label that it makes up a significant portion of their identity?
In many cases, the point at which this question is being asked is one at which the train has already left the station, and sickness as a way of life/career has set in. Unfortunately, with functional somatic syndromes, there is data suggesting that self-rated quality of life and functioning are lower...
How many days prior to elective major surgery do you recommend holding oral GLP 1 R agonist therapy?
Zero. Or, I suppose, if you're having surgery early in the morning, one.This has gone back and forth, but the most recent guidance from the ASA (with other societies concurring) has been that most patients can continue their GLP medications as normal preoperatively, with higher-risk people being rec...
Do you recommend medical therapy for extensive atraumatic osteonecrosis of the femoral head to mitigate pain or prevent femoral head collapse?
This is a good question. Extensive atraumatic ON of the femoral head will probably not respond to any medical therapy; eventually, the patient will need a replacement. However, ON that is from a systemic insult (drugs, alcohol) is often bilateral so if the other hip is less affected or not affected,...
Do you routinely order a pre-operative TTE in patients with apparently compensated CHF, but who have not had an echocardiogram in some time?
In a patient with compensated CHF (with stable symptoms), I do not routinely order pre-operative echocardiograms for evaluation of ejection fraction. There are some situations in which it may be helpful for perioperative risk assessment, counseling, and management.The 2024 ACC/AHA (American College ...
How do you evaluate persistent resting sinus tachycardia (heart rate >100 bpm) in a hospitalized patient whose acute illness has otherwise stabilized?
This is a great question and something that we see rather frequently in the hospital. 2 guiding principles to frame this question: Sinus tachycardia (ST) is a symptom, not a diagnosis. It's a physiological response to an underlying condition. Which means we need to diagnose the condition, not focus ...
Is there a role for functional medicine approaches in psychiatric treatment?
Functional medicine is a pretty broad term that encompasses stressors underlying biological, hormonal, nutritional, and environmental impacts on a person’s health. While I am a big fan of trying to get to the root causes of health conditions, including mental health conditions, and think in terms of...
How do you approach osteoporosis screening in men?
While osteoporosis is more prevalent in postmenopausal women, it is often under-recognized in men. The risk of mortality after hip fracture is higher in men, and that risk may extend over 10 years after injury. Men who sustain a wrist fracture are more likely to have severe osteoporosis and a higher...