Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
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...
What is your approach to the management of asymptomatic bacteriuria in an elderly patient without clear urinary symptoms but with cognitive changes and falls?
Asymptomatic bacteruria does not cause altered mental status. Data suggests that when we attribute acute changes to it, we will be wrong about 85% of the time, thereby missing the true etiology. It is a difficult thing to educate staff of senior living facilities and families who have been told it w...
In what clinical circumstances do you use repository corticotropin injections in the management of a glomerulonephritis?
Personally, I have never used ACTH gel, but two specific disease states come to mind: steroid-resistant FSGS and membranous nephropathy. In one study, the partial remission rate for steroid-resistant FSGS was 29%, and for post-transplant recurrence of FSGS, 55%. For MN, the complete remission rate w...
How would you approach anticoagulation for a patient with acute bilateral pulmonary emboli related to malignancy, but with a concomitant cavitary lung mass experiencing episodic, small-volume hemoptysis?
This is an interesting question to which we need to apply the art of medicine, weighing the risks and benefits of treatment. The major fatal events in this exact scenario are: Recurrent PE from undertreatment. Sudden massive hemoptysis after aggressive anticoagulation. The physician's management s...
Does your hospital or institution have an Antimicrobial Stewardship Program (ASP), which oversees ID physicians, and if so, does the ASP have the authority to refuse an antibiotic prescribed by an ID consultant?
We have ASP and the ID docs have a very collegial relation with our PharmD who are both ID pharmacists. They are very helpful and they do not block the ID consultants. When ID consultant recommends something that should not be done due to drug interaction for instance The pharmacist will call explai...
Is there evidence that certain PPIs provide superior clinical efficacy compared to others in real-world practice?
While there are some differences between PPIs in terms of metabolism, bioavailability, and duration of acid suppression, generally speaking, in clinical practice, the efficacy of different PPIs is comparable. With that said, some differences include dexlansoprazole's dual-release nature which genera...
What is your approach to the use of GLP-1 agonists in older adults with diabetes with or at risk of sarcopenia?
This is an important question to keep an eye on, given the broadening use and effectiveness of GLP-1 agonists for various conditions, especially diabetes, and for weight loss. Unfortunately, as is so often the case, major clinical trials in this area do not reflect the heterogeneity of older adults ...
What is your preferred analgesic in patients with small bowel obstruction or ileus?
I typically use IV Tylenol ATC if fully obstructed, and IV Toradol if no other contraindications to NSAIDs (and they often are quite prerenal or losing a lot of fluid from an NG tube, so I often don't feel comfortable with more than a couple doses, and if I think they are going to the OR, I do not u...
What dietary advice do you give patients with hyperlipidemia who want to try and manage it with lifestyle changes first?
The first place I usually start with when it comes to patients seeking lifestyle changes for hyperlipedemia is to point them towards dietary changes. My go to diet for this is the PORTFOLIO diet. A researched diet that has been shown in multiple trials to reduce LDL and was even shown to be non-infe...
What dietary advice do you give patients with hyperlipidemia who want to try and manage it with lifestyle changes first?
The first place I usually start with when it comes to patients seeking lifestyle changes for hyperlipedemia is to point them towards dietary changes. My go to diet for this is the PORTFOLIO diet. A researched diet that has been shown in multiple trials to reduce LDL and was even shown to be non-infe...