Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
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 ...
In what clinical settings is acute ICH clot removal recommended?
Clot removal should be performed when there is a cerebellar hemorrhage with brainstem compression and/or hydrocephalus. Clot removal can be considered as a life saving measure if there is neurologic deterioration, midline shift, or depressed consciousness. There is still uncertainty about clot remov...
Which medications do you deem necessary to stop prior to measuring plasma renin and plasma aldosterone when evaluating a patient for possible primary aldosteronism?
The most important medications to stop before checking renin and aldo levels are spironolactone, amiloride, triamterene, finerenone, and eplerenone. Ideally, patients should be off these meds for at least 6 weeks before testing. A pathologic primary aldo can be detected while taking beta blockers or...
How do you approach treatment of a patient with active RA and a history of Lynch Syndrome?
The presence of hereditary polyposis coli and its predisposition to colon cancer should have little effect on the management of RA. Available data indicate that methotrexate has at best a neutral effect on predisposition to malignancy. There are data to suggest that the combination of methotrexate a...