Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Would you administer IV thrombolysis in a patient presenting with disabling stroke symptoms while on anti-amyloid therapy?
I agree with @Dr. First Last. There seems to be one case of catastrophic bleeding in the published literature. However, such events can occur with thrombolysis alone or in the context of other cerebrovascular conditions such as CAA, vascular malformations, and even severe WMH. While it's important t...
When would you initiate chronic therapeutic phlebotomy in a patient with erythrocytosis secondary to a high hemoglobin-oxygen affinity hemoglobinopathy?
The large majority of patients with high oxygen affinity hemoglobinopathy do not require therapeutic phlebotomy. There is a subset of patients who develop symptoms (generally these are non-specific such as headache) or complications such as thrombosis. There seems to be no correlation between hemato...
What is a reasonable inpatient imaging modality alternative to evaluate for infective endocarditis in a morbidly obese patient with poor acoustic windows on TTE and persistent bacteremia if TEE is not feasible or contraindicated?
This is an excellent question. Retrospectively gated cardiac CTA especially with the newer generations (Siemens Somatom force or Naetom alpha) are probably your best alternative. This would need careful planning and tube setting adjustments depending on the patient's body habitus as scattered and no...
How do you manage a patient with inclusion body myositis?
IBM is a slowly progressive disease with no proven treatment to date, unfortunately. The goals of care are to delay decline and maintain remaining muscle strength. The cornerstone of treatment is physical/occupational therapy. Blood flow restriction seems to anecdotally help some patients, pending t...
In a patient with cryptogenic stroke while on antecedent aspirin 81 mg, how do you decide between single antiplatelet therapy, dual antiplatelet therapy, or antiplatelet agent combined with anticoagulation such as rivaroxaban 2.5 mg BID?
This question assumes that a thorough workup has been completed, and the patient does not have paroxysmal a fib, a PFO, an intracranial stenosis, a hypercoagulable state, or vasculitis. This workup is the most important issue. If all is negative, and the stroke is relatively minor (NIHSS less than o...
How would you best evaluate and manage a patient with hemiplegic migraine and a history of ischemic stroke?
Without further information, I would say that these two conditions, hemiplegic migraine and ischemic stroke, have nothing to do with each other. Hemiplegic migraine should be evaluated and managed as migraine with gepants ideal for abortive treatment and CGRP antibodies for preventive treatment if n...
What do you do for patients who have received accidental extra dosages of long-acting injectable antipsychotics?
Close monitoring, any EPS, one repeat EKG in a few days, reporting this to the family so that they are aware of the patient getting an extra dose, and cutting down or stopping any oral anti-psychotics to mitigate risk are some of the things I would do. There is no clear protocol on this, unfortunate...
Do you use combination antibiotic therapy for treatment of bacterial endocarditis due to gram-negative bacilli?
The approach towards different might differ depending on whether the culprit organism belongs to the HACEK group or the nonHACEK group. The mortality rates per literature were approximately 2% for HACEK and 20-30% for the nonHACEK group. Combination therapy is usually not recommended for HACEK endoc...
How frequently, and in which situations do you use quantitative EEG for the detection and/or monitoring of delayed cerebral ischemia after aneurysmal SAH?
Almost never.
At what point should aspirin therapy for stable cardiovascular disease be discontinued in patients with a diagnosis of chronic cerebral microbleeds or possible Cerebral Amyloid Angiopathy?
I would continue low aspirin indefinitely.