Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you decide whether to empirically cover Pseudomonas for pneumonia in hospitalized patients?
The decision to empirically cover Pseudomonas aeruginosa in pneumonia among hospitalized patients depends on the pneumonia type (community-acquired pneumonia, CAP vs. hospital-acquired pneumonia, HAP), disease severity, etiology, and specific risk factors. For Community-Acquired Pneumonia (CAP) Pa...
Do you routinely prescribe oral antifungals for seborrheic dermatitis?
The most common indication when I have prescribed an oral anti fungal is when the seborrheic dermatitis extends beyond the scalp, such as on the sternum and/or face (petaloid), and has failed topicals. With that much widespread distribution, adequate application of topical treatments can be very cha...
Do you ever use amantadine or modafinil to aid in the rehabilitation of patients with ischemic strokes?
No randomized controlled trials of amantadine or modafinil for the treatment of disorders of consciousness (DoC) after ischemic strokes have been completed. A retrospective study of ICU patients with DoC after ischemic stroke found that amantadine, modafinil, or a combination may be useful in improv...
For atrial fibrillation patients with high risk of CVA who cannot tolerate full dose AC due to bleeding, do you consider low dose/extended dosing anticoagulation even if they do not meet age/GFR criteria for a dose reduction, if Watchman is not readily available as an option?
Most drugs, including anticoagulants, have a dose-response. Therefore, one could argue that even though DOACs were not studied at low doses, except in defined sub-groups such as the very elderly, using such a dose in other situations may have some benefit. The problem is that without data, we simply...
Do you routinely check PSA before starting finasteride?
I tend to grab a PSA prior to starting higher doses of finasteride for BPH treatment, given these patients are older and may have a different risk profile for prostate cancer. I am less inclined to grab a PSA prior to starting it for younger patients using lower doses of finasteride for male pattern...
How do you treat patients with stroke thought to be secondary to Lambl excrescence?
Pathophysiologically, these occur through sheer stress to the valvular endocardium causing small areas to be denuded followed by fibrin deposition and microthrombi formation on the endocardial injury, which can embolize. Histopathologically, they have similarities to fibroelastomas (which are larger...
Do you prefer a loading dose of 300mg or 600mg plavix for patients presenting with NSTEMI or unstable angina about to undergo LHC?
Interesting question! As a rule of thumb, 600mg loads faster than 300mg. Therefore, it is more important when you anticipate your ballooning/stenting happening sooner rather than later (within minutes/hours). Per guidelines, Plavix is preferred over prasugrel/brilinta for stable angina (which was no...
What medications are preferred and contraindicated for insomnia in patients with a recent stroke or traumatic brain injury?
In acute brain injury (ABI), which includes stroke and traumatic brain injury the focus is often on neurorehabilitation. The presumption here is that the patient is medically and neurologically stable. For example, not having a stroke in evolution, uncontrolled gastrointestinal bleeding, or similar....
Do you use lactulose in acute liver failure, particularly in patients on continuous renal replacement therapy (CRRT) for ammonia or toxin clearance?
Generally lactulose should be avoided in the situation given limited benefit as well a tendency for ileus in ALF and potential for lactulose to cause bowel distention.
What do you think about chronic suppressive therapy for HSV-2 in a patient with positive antibodies but no prior clinical outbreak?
The first challenge is often the reliability of the test result. HSV-2 serologies and their interpretation can be challenging. A strongly positive result for HSV2, i.e., an EIA or similar index value well above the minimal cut-off, usually is reliable. Lesser values often are false positives, even t...