Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is the specificity of dynamic air bronchograms for bacterial pneumonia?
Dynamic air bronchograms on lung ultrasound for bacterial pneumonia have a specificity estimate around 95% (Lichtenstein et al., PMID 19225063 and Haaksma et al., PMID 34582414). This high specificity reflects the presence of patent, transiently air-filled bronchi within consolidation characteristic...
In patients with type 2 diabetes and albuminuric CKD already on ACEi/ARB, are you initiating finerenone over spironolactone in the primary care setting?
There is a lot of activity in this space. Beyond ACE/ARB, I would opt for SGLT2i over mineralocorticoid receptor antagonist (MRA) or non-steroidal mineral corticoid antagonist (NSMA) given the benefit for cardiovascular disease outcome in addition to CKD. The major question is, “What about GLP-1s?” ...
How do you suggest using POCUS to detect or confirm a pneumothorax?
Great question - yes, there are mimickers of "lung point" (known as pseudo-lung point) such as pleural-based blebs, anatomical junction between heart/lung or between two lobes, focal adhesions - to name a few. On top of this, searching for a lung point in a deteriorating patient can delay interventi...
In an older adult hospitalized with recurrent falls, weight loss, without clear injuries, but with an inconsistent or difficult-to-reach caregiver, what findings would make you formally report suspected elder neglect and/or abuse?
I'm so glad that you're thinking about the possibility of abuse/neglect in this scenario! It's important to have it on our differential, or we'll always miss this diagnosis. First, it would be good to see if the patient can explain what is happening and provide contextual information that veers us a...
In an older adult hospitalized with recurrent falls, weight loss, without clear injuries, but with an inconsistent or difficult-to-reach caregiver, what findings would make you formally report suspected elder neglect and/or abuse?
I'm so glad that you're thinking about the possibility of abuse/neglect in this scenario! It's important to have it on our differential, or we'll always miss this diagnosis. First, it would be good to see if the patient can explain what is happening and provide contextual information that veers us a...
Do you prescribe empiric antibiotics to patients with CAP who test positive for a respiratory virus?
I do not start antibiotics when there is a detected viral etiology. And I tend to stop them if they were started. Obviously, this changes if the symptoms worsen and/or I suspect a bacterial superinfection. Another caveat would be in a patient with underlying COPD where Azithromycin may play a role i...
Do you prescribe empiric antibiotics to patients with CAP who test positive for a respiratory virus?
I do not start antibiotics when there is a detected viral etiology. And I tend to stop them if they were started. Obviously, this changes if the symptoms worsen and/or I suspect a bacterial superinfection. Another caveat would be in a patient with underlying COPD where Azithromycin may play a role i...
What is your preferred workup for patients who present with concern for autonomic neuropathy?
When patients report one or more symptoms suggestive of autonomic dysfunction, objective confirmation of impaired autonomic function is required. This may include the standard battery of autonomic tests included in the CASS score (tilt table testing, response of HR and BP to Valsalva maneuver, and ...
Which imaging features do you use when considering Normal Pressure Hydrocephalus to decide whether to proceed with large-volume LP or lumbar drain trial?
At our center, we follow the approach of the NPH clinic at the Imperial College Hospital in London.See this excellent review article for further details: Carswell, PMID 36162853.
Given the long half-life of dexamethasone, what is an appropriate dose schedule?
After a discussion years ago with my fellowship-trained Neuro-oncologist friend (from Neurology track), I use dexamethasone only ever on a qam schedule. It doesn’t disrupt the sleep as much, there’s no waking for doses, the schedule is easy for patients and families to remember. In seven years of pr...