Clinical Hospital Medicine: General Internal Medicine and Perioperative Care
The hospitalist's core skill is risk stratification and recognizing which stable-looking patient is actually decompensating. Understand the major perioperative frameworks: the Revised Cardiac Risk Index (RCRI), functional-capacity assessment in metabolic equivalents (METs), and the current emphasis on avoiding unnecessary testing. Know that routine stress testing before noncardiac surgery is not recommended for most patients; testing is reserved for those with poor or unknown functional capacity plus elevated risk who would have management changed by the result. Master perioperative medication management: continue beta-blockers (do not start acutely), hold ACE inhibitors/ARBs in the immediate perioperative window when hypotension is a concern, bridge anticoagulation only in selected high-thrombotic-risk situations, and manage perioperative hyperglycemia with sliding-scale or basal-bolus insulin.
Traps
Questions love to test the postoperative complications: delirium, aspiration, VTE prophylaxis timing, and postoperative fever timing (immediate = atelectasis; days 1-3 = pneumonia/UTI; days 3-5 = surgical site; >5 days = abscess or drug fever). Watch for the patient with decompensated cirrhosis or severe aortic stenosis being sent for elective surgery - both warrant delay or cardiology/anesthesia input.
Rule of thumb
If the patient can climb two flights of stairs without symptoms, functional capacity is adequate (≥4 METs) and routine cardiac stress testing adds little. If they cannot, and surgery is high-risk, engage the care team rather than reflexively ordering a stress test.