Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Would you give pentoxiphylline and vitamin E during HBO for vaginal necrosis?
My usual approach to treating radiation injuries in the pelvis would be to start with Vitamin E (Vit E) and pentoxifylline (PTX) for less severe radiation-related injuries, but in cases with ulceration and/or necrosis or bleeding requiring transfusion to proceed directly to hyperbaric oxygen (HBO). ...
Do you perform spontaneous breathing trials on higher levels of PEEP with extubation to positive pressure ventilation in patients intubated for obesity hypoventilation syndrome?
Yes. But like anything patient selection is key and the rationale for the use of higher levels of PEEP (e.g. improve oxygenation vs prevention of atelectasis for simplicity sake) factors into the decision (as do co-morbidities -heart failure, pulm HTN, etc). The literature nor weaning guideline do ...
How do you manage patients with status dystonicus?
Many times, severe, seemingly uncontrollable generalized dystonia can occur in patients with or without a prior history of dystonia. In cases of severe encephalopathy, often treating the encephalopathy is the best overall approach, with medications specifically targeting the movement disorder used s...
Would you attempt a brain MRI in patients who present to the ER with subacute presentation of obstructive hydrocephalus?
I think an MRI is warranted to characterize the cause of the hydrocephalus in almost all cases, especially in the setting of a mass. The MRI can help identify the nature of the mass and the absolute size, and help with the differential diagnosis. It will also help you identify the mass as a solitary...
Would you consider dual antiplatelet therapy for stroke prevention for ICAD in patients with a history of SAH?
It depends on the strength of the indication for DAPT and the cause of SAH. It is important to keep things in perspective: the absolute risk reduction from DAPT for secondary stroke prevention in the POINT, CHANCE, and THALES trials was small (on the order of 1-3% absolute risk reduction) for minor ...
For patients with acute ischemic stroke and BP >185/110, at what point do you consider persistently elevated BP too refractory to safely give thrombolysis?
Elevated BP is only very rarely truly refractory. I have never encountered a situation where I could not lower the BP in a timely fashion. So, directly, if the patient is appropriate for intravenous thrombolysis, I generally treat BP (give IV medications) in one IV and give thrombolysis in the other...
In patients with embolic stroke and a PFO, how often do you go beyond venous Doppler of the lower extremities to screen for DVT (e.g. MRV or CTV abdomen and pelvis)?
No other testing; treat with anticoagulants long term or until PFO fixed & no venous clots.
Do you typically recommend anti-epileptic medication in patients with acute multi-compartmental intracranial hemorrhage?
In the absence of seizures, data/recommendations support the use of prophylactic anti-seizure medications (for 7 days only) if the multi-compartmental hemorrhages were caused by trauma. If the multi-compartment hemorrhages were due to an aneurysm rupture, then it might be prudent to use ant-seizure...
Under which clinical scenarios do you consider an inpatient EMG?
From my personal practice, inpatient EMG requests most often come at the behest of the neurology inpatient or neurology consult team, and very seldom, if ever, come from other primary teams. As such, having an initial neurological evaluation to "vet" the requests' appropriateness for inpatient versu...
How do you target therapy before the EEG is connected in a patient who comes to the ED in super refractory generalized convulsive status epilepticus once the convulsions resolve?
I infer from the context of your follow-up question that the patient was most likely intubated and started on an appropriate sedative drip. I have typically seen burst-suppression maintained for 48 hours, longer if the patient had failed such a duration in the past. Typically targeted therapy will i...