Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your preferred laboratory test to assess treatment response or infection resolution in patients with bacterial pneumonia?
I don't generally check a laboratory test to assess resolution. I go more by their improved clinical status and seeing them get back to baseline oxygen status. If I am trending a WBC or procal, I do like to see it trend down, but it's not the only lab I hang my hat on to decide if someone has resolv...
What is your preferred laboratory test to assess treatment response or infection resolution in patients with bacterial pneumonia?
I don't generally check a laboratory test to assess resolution. I go more by their improved clinical status and seeing them get back to baseline oxygen status. If I am trending a WBC or procal, I do like to see it trend down, but it's not the only lab I hang my hat on to decide if someone has resolv...
What adjunctive therapies to you recommend for symptom control in acute opioid withdrawal beyond full/partial opioid agonists?
Here are some general recommendations below. I recommend asking the patient what symptoms are most bothersome or what they anticipate to be the most bothersome when prescribing adjuncts. I routinely recommend APAP/ibuprofen, and then usually prescribe something for anxiety and nausea. Tizanidine can...
What is your approach to monitoring blood parasite smears in an immunocompetent patient with babesiosis?
In an immunocompetent person the response rate to the treatment of acute babesiosis is extremely high and if a person is clinically improving follow-up smears are probably unnecessary. However, I generally check one at 48 hours to confirm a decrease in parasite burden. If that is favorable and the p...
How do you manage persistent rectal bleeding in the setting of rectal adenocarcinoma in a treatment-naive patient?
For a locally advanced rectal adenocarcinoma in the era of TNT, treatment of the tumor with either chemoradiation or chemotherapy upfront is reasonable, and both choices are known to palliate colorectal cancers effectively. With more severe bleeding, we often consider starting with chemoradiation th...
In an older adults with dementia-related behavioral symptoms refractory to nonpharmacological management in whom you are starting SSRI, do you ever consider a short course of antipsychotic medication to overlap with the initiation of SSRI while waiting for therapeutic effect?
The American Geriatric Society recommends that antipsychotics may be considered when behaviors do not respond to non-pharmacological management and the patient is at risk of harming themselves or others. Thereby, it may be reasonable to overlap short-term antipsychotic with SSRI initiation in older ...
What is your approach to medication selection and titration for post-operative pain?
My general approach to postoperative pain management is a stepwise multimodal strategy that prioritizes opioid-sparing therapy while tailoring medication choices to patient-specific and surgical factors. In practice, I try to balance three things: the expected pain mechanism related to the surgery, ...
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...