Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When pursuing complex PCI of the RCA (especially when lesion preparation is required), when do you consider placing a transvenous pacemaker in anticipation of conduction abnormalities?
There are a few options when using roto for the RCA or a dominant LCX. Upfront TVP if you want to play it safe. Pretreatment with aminophylline 100-250 mg 10 minutes. Test run without pre-treatment and having atropine and/or TVP nearby at the ready. Which you choose depends on gut instinct and how...
What criteria do you utilize in deciding when to treat or not treat frequent VPC’s?
Symptoms (burden and severity) PVC burden (>15-20% may lead to a cardiomyopathy) Presence of LV dysfunction Interference with bi-ventricular pacing PVCs triggering VT or VF
When would you consider AV nodal ablation in CRT-non-responders with persistent atrial fibrillation?
AV node ablation is the most definitive method for rate control. In this scenario where the patient already has CRT and is a nonresponder, what I do next depends on age of the patient, how symptomatic the patient is, whether the rates are elevated causing the CRT pacing percentage to be suboptimal a...
What is your approach to further work-up and management of neutropenia in patients with SLE/RA overlap?
This is an interesting situation that comes up in the routine evaluation of patients with rheumatoid arthritis and other autoimmune syndromes. The normocellular bone marrow suggests a peripheral destruction, in general, and raises some concerns for antibodies directed against neutrophils. These are ...
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...
Do you recommend patients temporarily hold cilostazol prior to and after a kidney biopsy?
Kidney biopsy is considered a high-risk bleeding procedure by SIR (Society of Interventional Radiology).Cilostazol is a PDE inhibitor leading to the inhibition of platelet aggregation. The Drug has a half-life of 10 hours. In the past, it was recommended to stop the drug at least 24 hours before a p...
Do you prescribe linezolid to patients who are concomitantly on an SSRI?
Yes, cautiously, especially when LZD is the best or only option. Recent Eur J Clin Pharmacol July 2023 meta-analysis involving 84 publications found an observed rate of < .01%; another study Shi et al., PMID 37301313 found a similar rate (1/1743 persons, 0.06%). Holding an SSRI for a day or two prio...
What strategies do you employ to minimize the risk of cardiovascular collapse when intubating a patient with severe pulmonary hypertension?
Intubating patients with pulmonary hypertension is a challenging medical and critical care situation. Generally, I try to apply principles of right ventricular optimization of care before I proceed with endotracheal intubation. Intubating patients with pulmonary hypertension is a challenging medical...
What therapies do you recommend for patients with limited life expectancy (<3 months) but whose depression is significantly reducing their quality of life?
I agree with Dr. @Dr. First Last that the first thing we need to do is to make sure that the patient actually meets the criteria for depression rather than demotivation or demoralization. If the patient is depressed, using Ritalin may have an effect in a very short amount of time, although there isn...
What is your approach to scheduling and then weaning nebulizers in patients admitted with acutely exacerbated asthma or COPD?
In hospitalized patients with acute asthma or COPD exacerbations, my approach to nebulizers is front-loaded and reassessment-driven. I start by gauging the severity and the patient’s ability to use an inhaler. pMDI with a spacer is preferred for most patients, but nebulizers are reasonable early on ...