Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How would you manage and determine the duration of antibiotics for a patient with suspected chronic postoperative spinal implant infection, status post lumbar fusion, now presenting with loosened hardware on imaging, normal inflammatory markers, and no systemic infection symptoms?
Loosening can be identified as lucency around pedicle screws on standard radiography, commonly at the upper or lower ends of the surgical construct. It was graded on a scale of 0-3. High-grade loosening (grade 2 or 3) is associated with increased odds of requiring revision surgery. It can be mechani...
In patients presenting to the hospital with atrial fibrillation of >/= 48 hours and are started on anticoagulation, provided they spontaneously convert with AV nodal blocking agents but then revert back into AF, would you need LAA imaging before a rhythm control strategy with AADs or cardioversion?
I would approach this the same way as if the patient had never spontaneously converted. There is a risk of stroke with chemical as well as electrical cardioversion, so should factor in CHA2DS2-VASc when making that decision. If CHA2DS2-VASc is 0 and no other high-risk features (rheumatic disease, HC...
Do you recommend avoiding radial artery access for cardiac catheterization to preserve potential future dialysis access sites in patients with advanced CKD?
With Radial arterial catheterization ( RA-CA), structural damage to the artery manifests as intimal tears and medial dissection along the length of the vessel. Further, even though 2-30% of the arteries will thrombose, about 50% of these will recanalize at 1 month. In spite of this, endothelial func...
Is there a role for functional medicine approaches in psychiatric treatment?
Functional medicine is a pretty broad term that encompasses stressors underlying biological, hormonal, nutritional, and environmental impacts on a person’s health. While I am a big fan of trying to get to the root causes of health conditions, including mental health conditions, and think in terms of...
What practical next steps would you recommend once identifying loneliness in an older adult patient?
First, normalize and validate the experience, emphasizing that it is common and appreciating that the patient is willing to discuss this with you. Explaining that they can and deserve to feel better may help set the stage for the conversation. Listen with genuine attention. Clarify the type of lonel...
Do you routinely recommend a lumbar puncture for patients with suspected ocular or otic syphilis in the absence of additional CNS symptoms?
No, this isn’t necessary, assuming no other evidence of non-ocular/otic neurosyphilis. I recommend management as advised by CDC in the 2021 treatment guidelines (https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf, p. 40). An especially careful neurological exam is advised, includin...
What surveillance do you recommend for a patient with locally advanced rectal adenocarcinoma who had a complete clinical response to total neoadjuvant therapy and declines to undergo surgery?
It is important to watch these patients closely since ~15-20% will have local regrowth/recurrence that are salvageable (Dossa et al Lancet 2017). The OPRA trial, recently presented at ASCO 2020, included 324 patients treated with TNT regimens and WW if complete response. Organ preservation rates wer...
How do you decide whether to place an NGT or PEG tube in patients with dysphagia precluding adequate PO nutritional intake?
There are several factors that go into the decision of PEG tube vs continued nutrition via a nasogastric feeding tube(NGT). Anticipated time to recovery of oral pharyngial function (especially in the most common underlying illness, which is stroke). NGT can stay in place for up to 2 months without...
How do you decide whether to place an NGT or PEG tube in patients with dysphagia precluding adequate PO nutritional intake?
There are several factors that go into the decision of PEG tube vs continued nutrition via a nasogastric feeding tube(NGT). Anticipated time to recovery of oral pharyngial function (especially in the most common underlying illness, which is stroke). NGT can stay in place for up to 2 months without...
How routinely do you use POCUS to assess fluid responsiveness in patients with sepsis?
I do use this sometimes, but would recommend using it with caution and only as one piece to the puzzle - IVC ultrasound should never be used in isolation. My most recent example was a patient who initially appeared volume overloaded, then was found to have sepsis. When I looked at his IVC, it was ex...