What are the key components of a hospitalist consult for an orthopedic patient with potential comorbid conditions such as hypertension, diabetes, or cardiovascular disease, arriving to the floor post-operative, requiring medical management of their health while inpatient?

Hospitalist Consult for Post-Operative Orthopedic Patients

Primary Objective

Your role as the hospitalist is to optimize the patient's medical condition within the context of their surgical illness, recommend medication changes, identify complications early, and ensure appropriate postoperative monitoring—not to "clear for surgery" but to provide comprehensive medical management. 1

Essential Initial Assessment Components

Comprehensive History Taking

Document the following specific elements immediately upon consult:

• Active cardiac conditions: Unstable coronary syndromes, recent MI (within 30 days), decompensated heart failure (NYHA class IV or new-onset), unstable angina (CCS class III-IV) 1
• Significant arrhythmias: High-grade AV block, Mobitz II or third-degree heart block, symptomatic ventricular arrhythmias, atrial fibrillation with uncontrolled ventricular rate (>100 bpm at rest), newly recognized ventricular tachycardia 1
• Severe valvular disease: Aortic stenosis (mean gradient >40 mmHg, valve area <1.0 cm², or symptomatic), symptomatic mitral stenosis 1
• Pacemaker or ICD history and orthostatic intolerance 1
• Functional capacity: Determine if patient can climb a flight of stairs or walk on level ground at 4 mph (≥4 METs)—poor functional capacity (<4 METs) increases perioperative risk 1
• Complete medication list: Include dosages, herbal supplements, over-the-counter medications, and document use of alcohol, tobacco, and illicit drugs 1

Critical Comorbidity Assessment

Evaluate and document these specific high-risk conditions:

Cardiovascular Disease

• Peripheral vascular disease and cerebrovascular disease: Their presence heightens suspicion for occult coronary artery disease 1
• Hypertension management: Continue antihypertensive medications through the morning of surgery and restart promptly postoperatively; grade 3 hypertension (≥180/110 mmHg) may warrant delay for optimization 1
• Heart failure: Optimize beta-blockers and other HF medications preoperatively; avoid IV beta-blockers to prevent uncontrolled hypotension 1

Diabetes Mellitus

• Insulin therapy increases cardiac morbidity risk 1
• Screen for diabetic complications: Nephropathy, neuropathy, retinopathy 2
• Implement hospital-specific perioperative glucose protocols; fragile patients require adjusted doses or infusions of short-acting insulin based on frequent blood glucose monitoring 1, 2

Pulmonary Disease

• COPD or restrictive lung disease increases risk of respiratory complications, hypoxemia, hypercapnia, and acidosis 1
• Assess functional capacity, response to bronchodilators, and consider arterial blood gas if carbon dioxide retention suspected 1
• If infection present, initiate appropriate antibiotics; consider steroids and bronchodilators while monitoring for arrhythmia or myocardial ischemia from beta-agonists 1

Renal Impairment

• 40% of orthopedic patients (especially hip fracture) have renal dysfunction; review renal function before prescribing opioids or other renally-cleared medications 2

Physical Examination Priorities

Focus on these specific findings:

• Jugular venous pressure: Elevated JVP or positive hepatojugular reflux indicates volume overload or heart failure 1
• Carotid and peripheral pulses: Abnormalities suggest vascular disease and occult coronary artery disease 1
• Cardiac auscultation: Third heart sound (S3) at apex suggests failing left ventricle; murmurs require assessment for significant valvular disease, particularly aortic stenosis 1
• Pulmonary examination: Assess for wheezing, crackles, or signs of infection 1

Postoperative Medical Management Plan

Medication Management

Make these specific decisions:

• Continue ACE inhibitors/ARBs through the perioperative period; no evidence supports withholding them in orthopedic surgery 2
• Continue beta-blockers in patients already taking them; avoid abrupt discontinuation 1
• Restart home medications promptly postoperatively, particularly antihypertensives 1
• Review polypharmacy: 20% of patients >70 years take >5 medications; 80% of adverse drug reactions are potentially avoidable 2

Pain Management Strategy

• Implement multimodal analgesia including regular acetaminophen and cautious opioid use 2
• Consider regional anesthesia techniques (femoral nerve block, fascia iliaca block) for superior pain control 2
• Establish discharge opioid plan to minimize excessive prescribing 1

Monitoring for Common Postoperative Complications

Actively surveil for these specific complications:

Acute Kidney Injury

• Monitor creatinine and urine output closely, especially in patients with pre-existing renal dysfunction or diabetes 3

Cardiovascular Events

• Monitor for myocardial ischemia, arrhythmias, and heart failure exacerbation, particularly in high-risk patients 3, 4

Pulmonary Complications

• Embolic complications (fat embolism, venous thromboembolism) are unique to orthopedic surgery, particularly joint arthroplasty 4
• Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) 4

Postoperative Anemia

• 40% of hip fracture patients are anemic preoperatively; transfuse if Hb <9 g/dL or <10 g/dL with cardiac history 2

Delirium

• Screen systematically using validated tools; elderly orthopedic patients on opioids and sedatives are particularly vulnerable 3, 4

Postoperative Fever

• Evaluate systematically for infectious and non-infectious causes 3

Gastrointestinal Complications

• Monitor for ileus, constipation (opioid-related), and stress ulceration 3

Risk Stratification for ICU-Level Care

Identify patients requiring higher-level monitoring based on these independent predictors (p<0.001):

• Congestive heart failure history (OR 24.26) 5
• Estimated blood loss >1000 mL (OR 17.36) 5
• COPD (OR 13.90) 5
• Intraoperative vasopressor use (OR 8.10) 5
• Revision hip arthroplasty (OR 2.71) 5
• BMI >35 kg/m² (OR 2.70) 5

Communication and Documentation

Ensure these specific actions:

• Direct communication with surgeon, anesthesiologist, patient, and family regarding findings and recommendations 1
• Never use phrases like "cleared for surgery"—provide comprehensive assessment addressing all relevant cardiovascular and medical aspects 1
• Document clearly in the medical record all findings, recommendations, and medication changes 1
• Plan long-term follow-up: Use this perioperative evaluation as an opportunity to initiate therapies that reduce long-term cardiovascular risk 1

Critical Pitfalls to Avoid

• Do not order redundant preoperative tests unless results will change management, surgical procedure, monitoring level, or timing of surgery 1
• Do not delay urgent orthopedic surgery (e.g., hip fracture) for "optimization" of chronic conditions—delay beyond 48 hours increases mortality 2
• Do not withhold ACE inhibitors/ARBs perioperatively in orthopedic patients 2
• Do not use IV beta-blockers routinely due to risk of uncontrolled hypotension 1
• Do not underestimate risk in elderly patients with multiple comorbidities—they require close surveillance despite being on general surgical floors 6