Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
For patients admitted while taking chronic outpatient opioids, how do you decide whether to resume their baseline opioid regimen at discharge versus tapering or modifying therapy during hospitalization?
I'm not sure there's a single right answer here. My only recommendation is for patients who are on chronic outpatient opiates: please talk to their ambulatory clinician before making any significant changes. Their ambulatory doctor knows them over time and can give you advice regarding what's happen...
For patients admitted while taking chronic outpatient opioids, how do you decide whether to resume their baseline opioid regimen at discharge versus tapering or modifying therapy during hospitalization?
I'm not sure there's a single right answer here. My only recommendation is for patients who are on chronic outpatient opiates: please talk to their ambulatory clinician before making any significant changes. Their ambulatory doctor knows them over time and can give you advice regarding what's happen...
How do you approach the management of patients with mildly elevated mPAP (21-24 mmHg) and PVR (2-3 WU) who may be at risk of progression, given the recent changes in the hemodynamic definition of pulmonary hypertension?
The "new" definition of PH with a cutoff of 20 mmHg is a very sensible change, based on the study by Kovacs et al., PMID 19324955, which showed that a mean PAP of 20 mmHg is already two standard deviations above the mean PAP in normals. Thus, the cut off of 20 mmHg makes more sense than 25 mmHg.To a...
What is your general approach to an immunocompetent patient with chronic, non-infectious diarrhea?
If the diarrhea has lasted more than a few weeks and all infectious workup is negative, then I'll send serologies for IBD/celiac, especially if there is any weight loss. Where we practice in New York City, these patients almost always end up getting an EGD/colonoscopy.
What leads you to suspect that a foot drop is secondary to a myopathy rather than a neuropathic process?
Factors suggesting that a foot drop is due to a myopathy include: Clinical factors (slow progression (myopathy but also seen in CMT) versus acute or sub-acute onset (usually neurogenic), absence of sensory findings, absence of pes cavus, signs of facial or shoulder girdle weakness (FSHD can cause f...
How can hospitalists most effectively advocate for funding to support POCUS initiatives (e.g., curriculum, faculty development, equipment, etc.) at their institutions?
I have been delaying answering this question because it is complex and highly context-dependent. I think the most common approach taken is to present POCUS as value-added, utilizing some form of ROI analysis based on accumulating data on POCUS impact on LOS, readmissions, and hospital costs. My appr...
Are there mechanisms in place to distinguish SVT with aberrant conduction from VT on external cardiac monitoring devices?
Unfortunately, there is no easy answer to this question. Differentiation of aberrancy from ventricular tachycardia can be very difficult, even with high quality 12-lead ECGs. Standard rules can be applied but many features of VT such as precordial R-wave concordance, is not possible. The best idea i...
For patients with patellofemoral pain syndrome whose symptoms continue despite an adequate course of physical therapy, what adjunctive treatments (bracing, taping, injections, orthotics, or imaging) do you consider most helpful?
After an adequate course of physical therapy (under the guidance of a knowledgeable PT), I recommend imaging to determine if there is underlying pathology like chondromalacia, chondrosis/fissuring, an OCD lesion, or perhaps a tendinopathy or fat pad impingement. Starting with a plain film (AP, later...
Do you consider use of oral antibiotics for complicated polymicrobial intra-abdominal infections?
Depends on how you're defining "complicated" IAI. Source control is key (I like this review: Source Control and Antibiotics in Intra-Abdominal Infections), especially if there's a fistula or anastomotic leak; but once an abscess is <5cm, if I have oral options that the patient can tolerate/dosed app...
When do you add a thiazide-type diuretic to IV furosemide for a patient with acute decompensated heart failure who has had an inadequate diuretic response after 48 hours?
I think you hit the nail on the head - I start it after inadequate diuretic response for 48 hours to a high dose of IV furosemide (e.g., 80 mg IV TID dosing), and I want to avoid going to a furosemide drip, as this has implications for level of care in my hospital. If I suspect that the furosemide i...