Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you decide when to check a PEth level in patients hospitalized with alcohol-associated disease?
In my practice as a hospitalist and addiction medicine specialist, I use PEth (phosphatidylethanol) as an adjunctive tool to assess alcohol exposure over the preceding 2 to 4 weeks. I most commonly order it when the alcohol use history is unclear, when a patient's clinical presentation is highly sug...
How do you weigh the risks and benefits of ongoing hospitalization in elderly patients with protracted delirium but without clear acutely reversible cause?
Even when no clearly reversible cause of delirium has been identified, clinicians should maintain a high index of suspicion for a missed diagnostic or therapeutic opportunity, recognizing that an initially "negative" evaluation may have overlooked factors such as polypharmacy, occult infection, unco...
How do you distinguish normal post-operative pain and swelling in an extremity from a post-operative complication such as hemorrhage, surgical site infection, etc.?
That is a good question. I would first ask the patient if their pain (and/or swelling) is any different (or worse). A change in the pain (or the recurrence of pain) could be a sign of a postoperative complication. Swelling beyond the first postoperative day, especially with erythema/warmth, could in...
How do you distinguish normal post-operative pain and swelling in an extremity from a post-operative complication such as hemorrhage, surgical site infection, etc.?
That is a good question. I would first ask the patient if their pain (and/or swelling) is any different (or worse). A change in the pain (or the recurrence of pain) could be a sign of a postoperative complication. Swelling beyond the first postoperative day, especially with erythema/warmth, could in...
After major non-cardiac surgery in high-risk older adults, do you routinely check post-operative troponins to screen for myocardial injury?
I do not routinely check postoperative troponins on every older adult after major non-cardiac surgery, but I do use them selectively in patients who are at high risk for perioperative cardiovascular complications. My practice has evolved as our understanding of myocardial injury after non-cardiac su...
How do you decide when and how often to reach out to patients with serious mental illness who are disengaging from care due to psychosocial stressors?
Outreach is always determined on a case-by-case basis, so it's difficult to give a definitive answer on this. Important factors to consider are the person's functional status, potential risk for harm without care, their decision-making ability, and the intensity of stressors. Obviously, those who ar...
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.
In patients who are on 3 of the 4 pillars of HF therapy for HFrEF, would you add the 4th pillar if they are no longer in symptomatic HF and LVEF normalizes?
This is a great question, and a data-free zone. The way I see it, the LV recovered with 3 pillars, and assuming the EF is normal and patient asymptomatic, I'm not sure what benefit is derived from the fourth pillar. I would not add it as there is no data that in patients with HFimpEF already on 3 pi...
When do you usually introduce conversations regarding tracheostomy placement in patients with refractory status epilepticus, or other conditions where one may anticipate delayed awakening?
It depends on the underlying pathology and how long the patient is expected to have impaired airway reflexes requiring prolonged mechanical ventilation. In the Setpoint 2 trial, among patients with severe stroke receiving mechanical ventilation, a strategy of early tracheostomy (</= 5 days), compare...
What is your approach to evaluating post-operative hypotension?
Postoperative hypotension secondary to anesthesia could very well be a case of retrospective diagnosis and, to some extent, diagnosis of exclusion.When a patient is hypotensive in the postoperative period, confirming true hypotension with a manual BP and looking for signs of reduced end-organ perfus...