Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
With OpenBiome no longer in operation, what is your current approach for obtaining FMT for inpatients with acute severe/fulminant C. difficile infection unresponsive to antibiotics?
Consider Rebyota by enema or flex sig, similar to what you had done with standard FMT.
Do you consider use of oral antibiotics for complicated polymicrobial intra-abdominal infections?
Depends on how you're defining "complicated" IAI. Source control is key (I like this review: Source Control and Antibiotics in Intra-Abdominal Infections), especially if there's a fistula or anastomotic leak; but once an abscess is <5cm, if I have oral options that the patient can tolerate/dosed app...
Do you provide empiric doxycycline for Lyme Disease to asymptomatic patients after a tick bite who haven't developed Erythema migrans or are not sure it was an Ixodes tick?
I would base post-exposure prophylaxis upon local prevalence (unless the patient has a recent notable travel history). For example, Lyme disease is very rare in California due to the Ixodes tick's intermediate host being the Western Fence Lizard (long story short, something in their blood kills the ...
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?” ...
In patients with MASLD, would you consider management with off-label metformin, pioglitazone (despite weight gain risk), GLP-1 RA, or simply intensify lifestyle and monitor?
In 2025, we should be assessing if patients are developing F2-F3 fibrosis especially with the use of non-invasive assessments (FIB-4 score, transient elastography, or MRI elastography), and then offering either Semaglutide or Resmetirom for these individuals w/ F2-F3, which are the only FDA approved...
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...