Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What do you recommend as a first-line antidepressant in patients with major depressive disorder and migraines?
In my clinical practice, I have found SNRI medication, particularly extended-release venlafaxine (dosed from 37.5 mg to 225 mg), to be helpful for patients with both comorbidities. Other medication classes I have seen used to good effect include TCAs (amitriptyline, nortriptyline) and some SSRIs (se...
What is your approach to acute pain management in hospitalized patients who receive long-acting injectable naltrexone for alcohol use disorder?
Maximize non-opioid therapies (NSAIDs, Tylenol, ketamine or lidocaine infusions if appropriate/available, nerve blocks). If opioids are still needed, the basic answer is that I would treat pain with higher doses of opioids. I would tailor my approach to the cause of the pain, though. If a patient w...
How do you manage resistant infections that persist after stopping antibiotic therapy in patients with non-CF bronchiectasis?
It depends on what is meant by resistant infections; if this means multi-drug resistant bacteria that remain present after treatment ends and when symptoms have returned to baseline, there are many things to consider. First, has the person had many exacerbations before? Or do they have minimal sympt...
How do you counsel patients who experience diarrhea from mycophenolate mofetil (Cellcept)?
I have them stop the drug, and when their bowels are back to normal (usually just a couple of days), I resume with 1 tablet bid of mycophenolate mofetil (MMF, CellCept), then a few days later go up to 1 tab tid, a few days later 2 tabs bid... etc. I instruct them to go down to the most recent dose ...
How does trimethoprim-sulfamethoxazole's efficacy against S. pyogenes influence your empirical treatment of skin infections in regions with high resistance rates?
Recommendations against using trimethoprim-sulfamethoxazole (TMP/SMX) for group A strep (GAS) skin and soft tissue infections (SSTIs) likely stemmed from a misconception that GAS is inherently resistant to the drug. Older studies reporting resistance used media containing a high thymidine concentrat...
How do you decide when to obtain a brain CT and/or MRI in hospitalized patients with altered mental status?
Always, unless the patient can be quickly awakened by glucose, etc., or it DNR, so I guess this means often.
Do you obtain routine blood cultures in a non-immunocompromised patient with community-acquired pneumonia who does not meet criteria for severe CAP?
Fabre et al., PMID 31942949, categorizes "non-severe community-acquired pneumonia" as low yield for bacteremia and therefore less critical and potentially wasteful/poor stewardship to obtain blood cultures, however do note that severe community-acquired pneumonia (CAP) falls into a moderate pre-test...
Do you obtain routine blood cultures in a non-immunocompromised patient with community-acquired pneumonia who does not meet criteria for severe CAP?
Fabre et al., PMID 31942949, categorizes "non-severe community-acquired pneumonia" as low yield for bacteremia and therefore less critical and potentially wasteful/poor stewardship to obtain blood cultures, however do note that severe community-acquired pneumonia (CAP) falls into a moderate pre-test...
Do you interpret failure to develop hypernatremia with prolonged water deprivation (such as for 12 hours) as evidence against diabetes insipidus even if the urine osmolality is just below normal?
This test indicates that this patient has fairly good urinary concentrating ability, but does not meet most criteria for "normal" since the osmoles did not go over 600. Since diabetes insipidus is a spectrum disorder, this result does not completely rule out the possibility of very mild diabetes ins...
Do you add empiric anti-MRSA coverage to the initial antibiotic regimen for a patient admitted with community-acquired pneumonia who has risk factors for MRSA but a negative MRSA nasal screen?
Thank you for this excellent and highly relevant clinical question. I approach this scenario by blending robust evidence-based medicine with fundamental principles of diagnostic reasoning. The short answer is generally no, you probably do not need to add empiric anti-MRSA coverage for a standard CAP...