Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When an older adult with multiple comorbidities develops a new, significant functional decline after a hospitalization, how do you decide whether to pursue further diagnostic workup versus accept it as post-hospitalization deconditioning and focus on rehabilitation?
I try to characterize the nature of the functional decline in a descriptive sense - what has become difficult and why, what are the patient and caregivers experiencing? I think through a differential diagnosis for that, and then I look at the totality of diagnosed problems from the hospitalization a...
When an older adult with multiple comorbidities develops a new, significant functional decline after a hospitalization, how do you decide whether to pursue further diagnostic workup versus accept it as post-hospitalization deconditioning and focus on rehabilitation?
I try to characterize the nature of the functional decline in a descriptive sense - what has become difficult and why, what are the patient and caregivers experiencing? I think through a differential diagnosis for that, and then I look at the totality of diagnosed problems from the hospitalization a...
What typical lab tests do you send off for evaluation of neuropathy?
Not too much has changed in over a decade regarding the recommendations on how we should approach initial laboratory testing in patients presenting with a neuropathy syndrome. Specifically for cases of distal symmetric polyneuropathy, the AAN practice parameter (reaffirmed in 2022) by England, et al...
What framework or risk assessment tool is most effective in determining surgical or palliative management of acute hip fracture after a fall in an elderly patient with co-morbidities and poor functional status?
I have found the NSQIP calculator to be the most useful in situations of acute hip fractures in elderly patients. In particular, it looks at more than just cardiac risk perioperatively - it examines functional, pulmonary, and ICU risks. They incorporate a number of co-morbidities and functional stat...
Would you perform a diagnostic paracentesis for first-time ascites in a patient with established CHF or pulmonary hypertension, but without apparent liver or other intra-abdominal disease?
Great question. Yes, we should perform a diagnostic paracentesis for first-time ascites, even in patients with established CHF or pulmonary hypertension, unless there is an obvious alternative explanation and the procedure is unsafe or technically not feasible. After the etiology is established, rep...
How do you approach initial anticoagulant selection in hemodynamically stable hospitalized patients with newly diagnosed pulmonary embolism?
Low-molecular-weight heparin demonstrates the greatest benefit in patients with cancer-associated pulmonary embolism, intermediate-risk PE, and those requiring outpatient management. While LMWH shows superior efficacy and safety compared to unfractionated heparin across most patient populations, cer...
When do you start steroids for radiation pneumonitis?
Great question on a relevant clinical topic. It's very important to remember that pneumonitis is a diagnosis of exclusion. Sometimes, if the timing is right and the patient's presentation is typical, there is a tendency to move quickly to the conclusion that the symptoms are caused by pneumonitis. R...
What is your approach to patients with chronic hypoxemic respiratory failure who have apparent higher oxygen needs during hospitalization but no clear acute/decompensated respiratory illness?
Will work them up completely for infection, PE, COPD exacerbation, heart failure/cardiac etiology. If no convincing reason for decompensation and they are stable, I will have them do a 6 min RT walk test to determine oxygen needs and have them follow up with PCP or pulmonary for further PFTs or othe...
Would you supplement iron for low iron studies in absence of anemia?
The answer is absolutely and positively. Iron deficiency causes symptoms independent of anemia which include fatigue, brain fog, restless legs syndrome, and pagophagia and other forms of pica. You simply cannot dignify waiting for overt iron deficiency to develop in someone with symptomatic iron def...
How do you decide which patients with upper GI bleeds should be monitored on telemetry?
Telemetry use has some standard indications in GI bleeding, specifically for patients with hemodynamic instability and significant cardiac comorbidities. Such situations include unresolved hypotension, >4 units transfused, known arrhythmia, and severe HFrEF. In these cases, I’m worried about someone...