Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When considering deprescribing antihypertensives in older patients, how do you approach prioritization of which antihypertensives to target first?
When deprescribing antihypertensives in older adults, my approach is individualized, goal-concordant, and iterative with close monitoring after each step. Every patient is a little different, so there isn't one class of antihypertensives I always deprescribe first. My general rule of thumb is that w...
What resources do you find helpful for patients with MSK concerns who may not have access to physical therapy or who cannot afford it?
This is an excellent question and important because every MSK concern needs some form of exercise intervention for maximum benefit/recovery. In some (most?) EMR systems, general, basic home exercise programs (HEP) are available for patients. This is a convenient way to get patients started. Rarely, ...
What is the next best osteoporosis treatment option for patients who completed 2 years of teriparatide, but has contraindication to bisphosphosnate therapy (e.g. history of atypical femur fracture)?
I have successfully treated several patients with bisphosphonate-induced subtrochanteric femoral fractures with Forteo. However, before initiating another antiresorptive therapy, I first want to be sure that the Forteo at the desired effect on bone remodeling by increasing both bone formation and bo...
Do you have any concerns about lower extremity compression (e.g., compression stockings, intermittent pneumatic compression, etc.) worsening ascites in a patient with portal hypertension?
This is an interesting question, and I have to admit, not one I've thought about regularly. When I think of lower extremity compression and the contraindications, portal hypertension and ascites are not contraindications that immediately come to mind. I do understand the reasoning behind the questio...
Do you have any concerns about lower extremity compression (e.g., compression stockings, intermittent pneumatic compression, etc.) worsening ascites in a patient with portal hypertension?
This is an interesting question, and I have to admit, not one I've thought about regularly. When I think of lower extremity compression and the contraindications, portal hypertension and ascites are not contraindications that immediately come to mind. I do understand the reasoning behind the questio...
What are the best techniques to reduce POCUS artifact and increase the diagnostic accuracy of lung ultrasound?
It is important to first clarify that essentially all of lung ultrasound is artifact, and this is a great illustration of how artifact can actually help us to make a diagnosis rather than obscuring it. When we see B-lines, for example, that is an artifact that does not represent a similarly appearin...
What are the best techniques to reduce POCUS artifact and increase the diagnostic accuracy of lung ultrasound?
It is important to first clarify that essentially all of lung ultrasound is artifact, and this is a great illustration of how artifact can actually help us to make a diagnosis rather than obscuring it. When we see B-lines, for example, that is an artifact that does not represent a similarly appearin...
What additional screening/management, if any, would you recommend to a patient whose annual mammogram showed heterogeneously or extremely dense breast tissue?
As of now, the USPSTF has stated that there is insufficient evidence to support adjunct screening modalities in women with dense breast tissue (category C or D). The other issue to consider is that some insurance does not cover adjunct screening since it is not considered "screening" per se. That sa...
How can I incorporate neuromuscular ultrasound into my practice with limited prior experience?
I think it's awesome when anybody is willing to implement a new tool into their established clinical workflow. My suggestion, if you are already an EMGer, would be to start small and simple with a focus on upper extremity focal neuropathy and practice, practice, practice.Carpal tunnel syndrome and u...
How do you manage perioperative anticoagulation for a patient with a history of recent, surgically provoked VTE?
In most cases, bridging is rarely indicated because the bleeding risk usually outweighs the risk of VTE recurrence during a short (1–2 day) interruption of anticoagulation. However, after a recent VTE (defined as <3 months), the estimated risk of VTE recurrence is high (>15–20% per year) (still low ...