In this episode of Hospital Medicine Unplugged, we cut through inpatient hyponatremia—how to triage by symptoms and acuity, push 3% safely, prevent overcorrection, and fix the cause.

We open with the do-firsts: confirm it’s true hypotonic hyponatremia (check measured serum osmolality; correct Na for glucose), assess duration (<48 h vs >48 h), and stratify symptoms. Severe symptoms (seizure, coma, cardiorespiratory distress) or moderate symptoms with high-risk context (post-op, intracranial disease) → treat now. Place in a monitored setting; q2–4 h Na checks.

Hypertonic saline—how to do it without hurting anyone

Clamp the overcorrection

Etiology playbook (hypotonic only)

Severity & pace—what changes with chronicity

Monitoring that prevents ODS

Math you’ll actually use (only if needed)

Common pitfalls (and fixes)

We close with the system moves: a “Hyponatremia Bundle” that (1) hardwires osmolality/urine studies before therapy; (2) defaults to 3% bolus + guardrails with q2–4 h sodium checks; (3) includes DDAVP and D5W standing orders; (4) prompts SIADH second-line options (urea/vaptan) when fluid restriction fails; (5) flags high-risk for ODS to apply the 8-mEq/24-h cap; and (6) nudges endocrine/nephrology when etiology is unclear or correction is tricky.

Fast, guideline-driven, and bedside-ready—everything your team needs to rescue the brain, respect the caps, and fix the cause.

In this episode of Hospital Medicine Unplugged, we demystify inpatient cellulitis—who to admit, what to cover, and when to stop.

We open with the right patients: nonpurulent, warm, tender, spreading erythema—and the red flags for a bed (systemic toxicity, rapid progression, immunocompromise, failed outpatient therapy, hand/face, or NSTI concern). Use bedside ultrasound to unmask abscess; skip routine blood cultures unless severe, immunocompromised, or unusual exposure. Mark borders and reassess at 24–48 hours.

Therapy that works:

IV-to-PO and duration: switch when improving and tolerating PO; 5 days total for uncomplicated responders, extend to 7–10 days if slow or complicated. Step-down choices: cephalexin/amoxicillin for nonpurulent; doxycycline/TMP-SMX/clindamycin for MRSA—with a β-lactam if streptococcus still likely.

Adjuncts that matter: elevate, treat toe-web tinea, start compression for chronic edema, optimize glucose; consider brief NSAIDs or steroids only after NSTI is excluded.

System moves: default order set (cefazolin-first, MRSA gated), auto 5-day stop with “extend if not improving,” ultrasound-to-drainage pathway for purulence, and a discharge bundle (oral step-down, compression, antifungal, return precautions).

Guideline-aligned, bedside-ready—tight care without overkill.

In this episode of Hospital Medicine Unplugged, we get practical about inpatient pyelonephritis—how to stop sepsis, protect kidneys, and prevent complications.

We open at the door: recognize sepsis, two IV lines + fluids, draw urine and blood cultures (don’t delay antibiotics for tough sticks), check creatinine and lactate, and assess for obstruction/retention.

Then hit bugs fast—empiric IV antibiotics tailored to local resistance and risk of MDR:

De-escalate promptly once susceptibilities return.

Duration & step-down—short when you can, longer when you must:

Imaging that changes management (not everyone needs it):

Source control saves lives:

Special situations you’ll see:

Monitoring & checkpoints: expect defervescence by 48–72 h; if not, re-culture, re-image, reassess source control and spectrum. Remove or exchange indwelling catheters when feasible.

Concise, guideline-driven, ward-ready—empiric IV early, culture-guided de-escalation, short courses when safe, image only when it changes care, and never miss obstruction.

In this episode of Hospital Medicine Unplugged, we tackle Clostridioides difficile infection (CDI) on the wards—fast, practical, guideline-driven care from test ordering to recurrence prevention.

We open with the first moves: test only the right patient—≥3 unformed stools in 24 h (or ileus/toxic megacolon). Use a two-step algorithm: GDH + toxin EIA up front; NAAT as the tiebreaker if discordant. No “test of cure.” While labs cook, fix the basics: stop the inciting antibiotic if you can (or narrow), review meds (especially PPIs), start IV fluids/electrolytes, and avoid antimotility agents in severe/fulminant disease. Early nutrition, VTE prophylaxis, and pain control (skip NSAIDs in bad colitis).

Then the therapy that actually changes outcomes—start early, pick right:

Fulminant CDI (hypotension/shock, ileus, megacolon):

Risk tools & who gets extras: clock the high-recurrence patients (≥65, severe CDI, immunocompromise, IBD, CKD, episode within 6 months, on concomitant antibiotics). For them, consider bezlotoxumab 10 mg/kg IV once during treatment to cut recurrence.

Recurrence playbook:

Infection prevention that actually prevents: enteric contact precautions (gown/gloves), soap-and-water hand hygiene on exit, and sporicidal (bleach) cleaning for rooms and gear. Educate patients on hygiene and what recurrence looks like.

Rescue moves & ICU cues: escalating lactate/organ failure, peritonitis, perforation, or toxic megacolon? Get surgery and critical care to the bedside. Subtotal colectomy with end ileostomy is standard; diverting loop ileostomy with colonic lavage in selected high-risk cases. In the ICU: hemodynamics, serial abdominal exams, frequent labs/imaging, multidisciplinary huddles.

Special situations you’ll see:

Monitoring & discharge that sticks: expect symptom improvement in 48–72 h; if not, reassess for ileus/megacolon or a missed diagnosis. Don’t re-test for cure—follow the clinical course. Discharge with a documented episode/severity, drug/dose/duration, recurrence-prevention plan (stewardship, PPI review, bezlotoxumab/FMT when indicated), clear return precautions, and early follow-up.

Concise, high-yield, and system-savvy—everything your team needs to deliver safer, more effective inpatient CDI management.

In this episode of Hospital Medicine Unplugged, we demystify PFO workup and closure after ischemic stroke—who to test, who to close, and how to run a tight inpatient pathway.

We open with the right patients: nonlacunar, embolic-appearing infarcts in adults 18–60 with no better cause on initial workup. Everyone gets vascular imaging, inpatient rhythm monitoring, DVT screening, and risk-factor assessment before we even say “PFO.”

Then the diagnostics that matter: start with TTE + agitated-saline bubble, but plan for TEE with bubble to define shunt size, tunnel length, and atrial septal aneurysm (ASA)—the anatomy that changes decisions. Transcranial Doppler is your most sensitive shunt detector and pairs well with TEE. We highlight how to do Valsalva right (timing counts) and why a clean aortic arch and carotids are as important as the septum.

Causality tools you’ll actually use: RoPE score to gauge how likely the PFO caused the stroke, and PASCAL to combine RoPE with anatomy so you can label a PFO “likely,” “possible,” or “unlikely” culprit. High RoPE + large shunt/ASA = the sweet spot for closure benefit.

Next, the shortlist for closure:

Therapy playbook: begin antiplatelet now; if DVT or another indication for anticoagulation exists, anticoagulate and rethink closure. When closing, we cover timing (typically 2–6 weeks post-stroke once stabilized), device expectations, and how to manage the peri-procedural window without pausing secondary prevention.

What closure buys you: lower recurrent ischemic stroke, especially with large shunts/ASA—at the cost of more peri-procedural atrial fibrillation (usually transient) and rare device issues. We give you the numbers you’ll quote on rounds and the talking points for shared decision-making.

Post-closure meds and follow-up: DAPT (aspirin + clopidogrel) for 1–3 months, then single antiplatelet long-term (device-specific nuance included). If a patient needs anticoagulation for another reason, use that instead of DAPT. Plan rhythm surveillance (30-day patch or equivalent) and echo to check for residual shunt.

Special situations you’ll actually encounter: concurrent DVT (paradoxical embolism), pregnancy, hypercoagulability, TIA without infarct (why evidence is thinner), migraine with aura (not an indication), and older adults with borderline benefit—how we navigate each.

We close with the system moves: a Heart–Brain pathway that bundles TEE/TCD orders, DVT ultrasound, extended rhythm monitoring, RoPE/PASCAL documentation, and default post-closure antithrombotics. Add a templated note for “PFO-likely” vs “PFO-unlikely” and track AF after closure as a quality metric.

Crisp, guideline-driven, and bedside-ready—everything your team needs to make smart, safe decisions about PFO diagnosis and closure in ischemic stroke.

In this in-depth episode of Hospital Medicine Unplugged, we tackle the evidence-based inpatient management of lower gastrointestinal bleeding (LGIB)—from first contact in the ED to secondary prevention at discharge.

We start with stabilization and triage: ABCs, two large-bore IVs, targeted labs, and a restrictive transfusion strategy—generally transfuse at Hb <7 g/dL (aim >7), or >9 g/dL if significant cardiovascular disease or ongoing instability. We cover how to separate brisk UGIB from true LGIB, when an NG lavage helps, and how to use (but not overtrust) tools like the Oakland score alongside clinical judgment and ICU criteria.

Diagnostics and timing—what actually changes outcomes: for stable patients, colonoscopy after adequate prep remains first-line for diagnosis and therapy, but routine “urgent” colonoscopy hasn’t shown better mortality, rebleeding, or LOS. In the unstable or unprepped patient, CT angiography leads for localization and can hand off directly to IR embolization. We map a clean pathway for when to escalate to surgery.

Therapeutics by etiology:

Medications that matter (and those that don’t): PPIs have no role in LGIB; tranexamic acid (HALT-IT) offers no benefit and potential harm. We give a practical, risk-balanced approach to antithrombotics: when to reverse, when aspirin should stop (primary) or continue (secondary), and why most anticoagulated patients should restart within ~7 days once safe.

We close with system moves that improve care—multidisciplinary pathways, 24/7 colonoscopy/CTA/IR access, and standardized algorithms that shorten time-to-diagnosis and reduce resource waste.

Concise, guideline-driven, practical medicine—no fluff, just the evidence for safer, more effective inpatient management of LGIB.

In this episode of Hospital Medicine Unplugged, we unpack the evidence-based inpatient management of upper gastrointestinal bleeding (UGIB)—from triage at the door to secondary prevention at discharge.

We open with stabilization: airway protection when mental status or torrential hematemesis threatens, two large-bore IVs, targeted labs (CBC, CMP, coagulation studies, type & cross), and a restrictive transfusion strategy (Hb <7 g/dL for most; <8 g/dL if CAD or ongoing massive bleed). We cover when to reverse coagulopathy and why platelets <50k with active bleeding warrant transfusion.

Next, risk tools that actually change what you do: Glasgow-Blatchford Score to decide ED discharge vs admission and to prioritize endoscopy; how AIMS65 and Rockall complement mortality prognostication.

Then the meds—started early:

• High-dose IV PPI (bolus + infusion, or guideline-supported intermittent high-dose) for suspected peptic ulcer bleeding.

Endoscopy timing and technique: perform within 24 hours in most, sooner (≈12 h) if unstable after resuscitation. For non-variceal bleeds, we highlight combination therapy (epinephrine plus thermal or clips) over epinephrine alone; when to reach for over-the-scope clips or hemostatic powder. For varices: band ligation for esophageal, cyanoacrylate for gastric.

Post-endoscopic care that prevents rebleeding: 72 hours of high-dose PPI, early enteral nutrition, and criteria for repeat endoscopy if rebleeding occurs. For variceal hemorrhage: continue vasoactives and antibiotics, start NSBBs, and plan serial EVL.

Rescue playbook: when to call IR for arterial embolization in refractory non-variceal bleeding; balloon tamponade as a bridge in uncontrolled variceal hemorrhage; early or salvage TIPS in high-risk cirrhotics who keep bleeding despite optimal therapy.

We round out with special situations—cirrhosis (infection risk, renal vulnerability), patients on anticoagulants/antiplatelets (who to reverse, and how/when to resume), and the elderly with multimorbidity. Plus the system moves: GI-bleed pathways, early GI/hepatology involvement, ICU vs ward triage, and why standardized order sets improve outcomes.

Concise, guideline-driven, practical medicine—no fluff, just the evidence for safer, more effective inpatient management of UGIB.

In this in-depth episode of Hospital Medicine Unplugged, we walk through the evidence-based hospital management of decompensated cirrhosis. From triage to discharge, we cover the full playbook hospitalists need on the wards.

We start with rapid assessment and risk stratification—how to find precipitating factors (infection, GI bleed, alcohol, meds/nephrotoxins), what to order up front (CBC, CMP, INR, cultures), and how to use MELD-Na and ACLF scores to guide level of care.

Next, we hit the time-critical moves:

Early diagnostic paracentesis for any new/worsening ascites—don’t delay. If SBP (PMN ≥250): ceftriaxone 2 g IV daily plus albumin 1.5 g/kg day 1 and 1 g/kg day 2.

Hepatic encephalopathy: lactulose titrated to 2–3 soft stools/day; add rifaximin for recurrence; always fix triggers (bleed, infection, constipation, electrolytes, sedatives).

Ascites/volume: Na <2 g/day; combined spironolactone:furosemide (≈100:40, titrate). Hold diuretics in AKI/hypovolemia. Large-volume paracentesis needs albumin 6–8 g/L removed (>5 L). Hyponatremia: optimize diuretics; fluid restrict only if Na <125 and unresponsive.

Variceal hemorrhage: cautious resuscitation (Hgb ~7), antibiotic prophylaxis (ceftriaxone), vasoactive therapy (octreotide/terlipressin), and urgent EGD with banding. Secondary prevention: nonselective β-blocker (carvedilol/propranolol) + repeat banding. Consider early TIPS in refractory/high-risk bleeds.

Hepatorenal syndrome: albumin plus vasoconstrictor (terlipressin where available; norepinephrine in ICU), avoid nephrotoxins, and start early transplant evaluation.

We then zoom out to supportive care and systems:

Nutrition first—no routine protein restriction; aim 30–35 kcal/kg and 1.2–1.5 g/kg protein with a late-evening snack. Replete thiamine/folate and fat-soluble vitamins when indicated. Use EMR order sets/care bundles to hard-wire best practices and reduce 30-day mortality.

Special populations get focused guidance: ICU/ACLF, pregnancy (protocol tweaks, but standard principles), advanced renal disease, and infection-prone patients—where decisions about vasoconstrictors, antibiotics, and procedures demand tailoring.

We close with transition and long-term care: concrete discharge plans (diuretics, lactulose targets, SBP prophylaxis), linkage to hepatology/transplant, alcohol cessation and viral therapy when appropriate, HCC surveillance every 6 months, vaccinations, and when to loop in palliative care.

No fluff—just a concise, guideline-driven path to safer inpatient cirrhosis management.

In this in-depth episode of Hospital Medicine Unplugged, we walk through evidence-based inpatient care for opioid use disorder (OUD)—from triage to transition of care—so hospitalists can start, continue, and optimize medications for opioid use disorder (MOUD) on the wards.

We start with bedside assessment and risk stratification—confirming OUD by history and DSM-5, using the Clinical Opiate Withdrawal Scale (COWS) to time inductions, and ordering high-yield labs (CBC, CMP, HIV/HBV/HCV, pregnancy when relevant) plus an ECG when methadone is on the table.

Next, the core moves:

Make MOUD the default. Continue pre-admission methadone/buprenorphine and offer initiation to all eligible inpatients. We contrast options:

• Buprenorphine: first-line for many; standard induction once in mild–moderate withdrawal, or micro-induction for fentanyl exposure/high tolerance or when full agonists are still required for pain.

Acute stabilization & withdrawal: Treat overdose quickly with titrated naloxone and observe for recurrence (fentanyl effect). For withdrawal, prioritize buprenorphine or methadone; use adjuncts (clonidine, antiemetics, NSAIDs, loperamide) to improve comfort.

Pain and peri-op care: Don’t stop MOUD. Expect higher opioid requirements; use multimodal analgesia and supplement with short-acting full agonists (e.g., hydromorphone) as needed. Avoid mixed agonist–antagonists that can precipitate withdrawal.

Addiction consult services amplify success. Where available, consult teams double in-hospital MOUD starts and improve linkage after discharge. Where not, hospitalists should still initiate MOUD using standardized order sets.

We then embed harm reduction and discharge planning:

• Naloxone for everyone at risk with overdose education.

Special sections tackle complex scenarios—pregnancy (methadone or buprenorphine are safe; avoid detox), adolescents/young adults, people leaving jail/prison, and advanced liver/renal disease—where protocols and dosing need tailoring.

We close with systems and policy: clearing up the legality of inpatient continuation/initiations, using EMR order sets, measuring outcomes/readmissions, and making the case that hospital-based MOUD is not just lifesaving—it’s cost-effective.

This episode delivers concise, guideline-driven, practical medicine—no fluff, just the evidence you need for safe, effective inpatient management of OUD.

In this in-depth episode of Hospital Medicine Unplugged, we discuss acute coronary syndromes (ACS)—why minutes matter, how to sort risk fast, and the exact moves from triage to discharge.

We frame the stakes (plaque rupture → thrombus → myocardium at risk), then run a time-zero checklist: 12-lead ECG within 10 minutes (repeat if nondiagnostic), high-sensitivity troponin on a 0/1–2-hour pathway, telemetry, and GRACE/TIMI to separate low/intermediate/high risk. Use bedside echo for wall-motion clues; consider CT-coronary angiography only in selected low–intermediate-risk uncertainty.

The treatment playbook:

• ABCs, two IVs, monitors; oxygen only if SpO₂ <90% or distress.

Reperfusion decisions:

• STEMI → primary PCI (door-to-balloon ≤90 min; ≤120 from first medical contact if transfer). If not feasible, give fibrinolysis (check contraindications) and transfer for early angiography/rescue PCI.

Complications to catch: VT/VF and AF, cardiogenic shock (culprit-only PCI; selective mechanical support), mechanical ruptures, and post-MI pericarditis (aspirin ± colchicine).

We land on discharge that sticks: a clear DAPT plan (with de-escalation for high bleeding risk), statin + ACEi/ARB (± MRA for LV dysfunction), rehab referral, smoking cessation, risk-factor targets, depression screening, and a 7–14-day follow-up with labs and ownership for med titration.

Lean, practical, 3 a.m.–ready.