Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you transition to oral antibiotics to treat uncomplicated Staphylococcus aureus bacteremia after patients have improved with intravenous antibiotic therapy?
I agree with Dr. @Dr. First Last, further these are tissue drugs more than bloodstream drugs. That’s why they don’t work well in bacteremia.
What is the preferred treatment regimen for cardiovascular syphilis, specifically syphilitic ostial coronary artery disease?
The standard treatment with benzathine pen G 2.4 MU IM, 1-3 doses at weekly intervals, depending on likely duration of syphilis, should be sufficient. Most likely there is no need for especially high dose penicillin therapy. I can understand a theoretical rationale for it, for urgent or potentially ...
What type of visual disturbance qualifies as a visual aura?
Visual aura should be a time-limited neurologic event (5 minutes to 60 minutes) with or without migraine headache. It can contain positive (e.g., flashes of light) and/or negative (e.g., scotoma) visual phenomena. It is often toward one side of the visual field but is binocular (comes from both eyes...
Between mean arterial pressure (MAP) and blood pressure (BP), which do you use when prescribing hemodialysis to instruct a hold on additional ultrafiltration should the value become too low?
I believe the data on systolic blood pressure and outcomes is better than the other values of blood pressure measurement. As such I use the systolic blood pressure mainly to decide on ultrafiltration, medications and other therapy. Of course patient symptoms are also very important.
Do you typically obtain an EEG in patients undergoing workup for cognitive dysfunction?
I do not obtain an EEG unless something in the patient's history leads me to suspect seizures.
How do you transition patients between different long-acting injectable antipsychotics?
When it is time for the next dose of LAI #1, administer LAI #2 instead. Use an equivalent dose to produce equivalent dopamine receptor activity. To determine the equivalent dose, consider the maximum recommended dose of #1 to be equivalent to the maximum recommended dose of #2. With all the sophisti...
Do you preferentially avoid use of piperacillin-tazobactam for empiric anti-pseudomonal coverage in hospitalized patients due to risk of nephrotoxicity?
The bulk of published data indicates that the onset of nephrotoxicity in patients receiving piperacillin-tazobactam plus vancomycin seldom occurs before 3 days of the combination. Thus, I do not object to initiation of this combination empiric therapy, but, as in all cases, therapy must be reevaluat...
What would be your threshold to recommend TEE guided DCCV in a patient who has remained in atrial fibrillation in the post-operative period following CABG, who has achieved adequate amiodarone loading dose?
If not anticoagulated for a sufficient period of time, TEE would be mandatory prior to electrical cardioversion.
How do you approach RA management in a patient who develops a new solid tumor while on therapy?
Risk-benefit ratios need to be individually assessed. There are several aspects to take into account: Choice of DMARD - Data on impact of various DMARDS on cancer recurrence or progression is scarce, especially for patients with active cancer. In general, there are few concerns for conventional DMA...
Would you recommend TNK or DAPT in patients with stroke-like symptoms and NIHSS less than 5 presenting within 4.5 hours?
I agree with Dr. @Dr. First Last. The decision in patients with minor stroke rests on whether the symptoms are disabling, which in general, is based on a discussion with the patient and their family to understand how the deficit could impact the patient's career or hobbies. For disabling deficit, I ...