Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is the appropriate cardiac work-up and management for an otherwise healthy individual who has experienced immersion pulmonary edema while scuba diving?
Immersion pulmonary edema (IPE) is rare in the general population, but does occur in approximately 1% of triathletes and more frequently among military recruits (Kumar and Thompson, PMID 30403902). IPE is due to acute increases in pulmonary capillary wedge pressure (PCWP), which can flood the alveol...
How do you approach rising PSA following radical prostatectomy and early salvage radiation therapy?
There are several factors that I will take into consideration, including the patient's overall health, the interval from treatment to relapse, the PSA doubling time (rather than a PSA threshold), whether or not they're castrate resistant and whether or not they now have overt metastatic disease. Pat...
When and how should we use biomarkers (i.e., CRP, stool calprotectin, mAb levels) to guide or optimize medical management of Crohn’s disease or ulcerative colitis?
The principal clinical applications of biomarkers in IBD are as follows: Assessment of severity and prognosis during a flareup. Monitoring the efficacy of treatment. Determining the probability of postoperative recurrence of Crohn’s disease (i.e., the high negative predictive value of FPC for anasto...
In patients with an acute gout flare who have stage 3–4 CKD or are on anticoagulation, what is your preferred first-line treatment?
This is a challenge. Intra-articular steroids may be the best option. Colchicine is an extremely complicated issue. A single dose of colchicine at 0.3 or 0.15 mg might be considered. Systemic steroids probably should be avoided because they reduce resistance to infection in an already compromised in...
When do you use a carbapenem empirically to treat a patient with Acinetobacter infection?
Significant rates of Acinetobacter resistance to multiple classes of antimicrobial agents are a global concern. Mechanisms of resistance include bacterial production of beta-lactamases (i.e., carbapenemases), changes in porin channels, and alterations of target or cellular function due to mutations ...
When do you use a carbapenem empirically to treat a patient with Acinetobacter infection?
Significant rates of Acinetobacter resistance to multiple classes of antimicrobial agents are a global concern. Mechanisms of resistance include bacterial production of beta-lactamases (i.e., carbapenemases), changes in porin channels, and alterations of target or cellular function due to mutations ...
Do you have a standard approach to using POCUS to evaluate acute abdominal pain?
I don't have a standard framework for evaluating acute abdominal pain because my approach as a hospitalist depends very much on the history and available data. This is usually very different from the ED context, though we not infrequently have patients develop acute abdominal pain during hospitaliza...
Do you have a standard approach to using POCUS to evaluate acute abdominal pain?
I don't have a standard framework for evaluating acute abdominal pain because my approach as a hospitalist depends very much on the history and available data. This is usually very different from the ED context, though we not infrequently have patients develop acute abdominal pain during hospitaliza...
Do you recommend fluid restriction in addition to other management strategies for patients with hyponatremia due to SIADH?
Fluid restriction is the mainstay of therapy in patients with SIADH. To correct hyponatremia due to SIADH, electrolyte-free water intake must be less than urinary electrolyte-free water excretion assuming no significant non-renal fluid losses. The degree of fluid restriction may be lessened by the u...
How would you approach the consideration of continuing or ceasing colonoscopy for colon cancer screening in a relatively fit man in his 80s without a history of polyps on prior colonoscopies?
For someone in his 80s who has received good screening and never had polyps, continuing colonoscopy brings little benefit. The risks and difficulties from the procedure become greater with age, so, for most older adults, stopping routine screening is usually the better option for geriatric care. Whe...