Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How long do you wait before foley or IV placement in patients who have recieved TNK or TPA?
If foley is needed, especially if going to IR, etc., we place it before if possible, but often place it during infusion or even after if needed.
How do you manage patients with post spinal tap headaches?
There are two tracks of treatment to consider in these patients. The conservative path would be laying supine as much as possible or bed rest, aggressive hydration including intravenously, and caffeine consumption. This should be the first step and tried for 24 to 48 hours before considering procedu...
What is the normal range of spinal tap opening pressure?
Normal range is variable based upon supine versus sitting up, diurnal variations, etc., but the most important thing is what is considered "Low" and "High". For any patient, despite of age and BMI, supine opening pressure above 250 mm of water is considered high, and <6 mm of water is considered low...
Would you give TNK or IVT to a patient with proximal occlusion and an NIHSS of 0-3 (non-disabling)?
For non-disabling stroke symptoms with an NIHSS 0-5, current AHA Guidelines recommend against IV thrombolysis. (Technically, TNK has not yet made it into the AHA Guidelines, but that's not the topic here). Of course, what is considered disabling is always a debate, but the PRISMS trial defined it as...
Would you give IV thrombolysis to a patient presenting with acute disabling stroke symptoms after a TAVI procedure?
Maybe. If a stroke occurs after a TAVR, it is usually embolic. Theoretically, these patients might be candidates for intravenous thrombolysis, but there are two important reservations. First, patients usually receive full dose of heparin during the procedure, and are loaded with dual antiplatelets i...
Do you typically use NOACs or Lovenox in patients with stroke due to hypercoagulability from malignancy?
We can extrapolate from studies of venous thromboembolism associated with cancer. Apixaban (at VTE treatment dose) has been compared to dalteparin in an open-label RCT in the CARAVAGGIO trial and edoxaban was compared to dalteparin in an open-label RCT in the Hokusai VTE Cancer trial. Both painters ...
How do you approach treatment of myoclonic status epilepticus from anoxic brain injury?
Personal experience - I would treat with lorazepam if the myclonus makes the patient acidotic, else I would not treat it.
How do you approach ictal-interictal continuum in patients with presumed toxic/metabolic etiology?
This is a common conundrum in the EEG reading room. If during the routine EEG I get a sense that the GPDs are clearly state-dependent (i.e., more frequent in the alert state, taper off in the quiet state) and they have clear triphasic morphology, I may not do anything further aside from the recommen...
How do you approach the management of EBV Meningoencephalitis (CSF pleocytosis and CSF PCR positive for EBV)?
You have to be extremely careful before making this diagnosis. It is known that positive CSF PCR for EBV can be a "bystander" when there is actually another cause of encephalitis that shouldn't be missed. Therefore, one has to make sure that extensive PCR and/or antibody testing in the CSF has been ...
When are steroids indicated in the treatment of strep pneumo meningitis?
Yes, I recommend a four-day regimen of dexamethasone 0.4-0.6 mg per kilogram daily given before or with the first dose of antibiotics. Delaying the administration of corticosteroids would reduce the desired anti-inflammatory effects. van de Beek et al., PMID 14998499 Brouwer et al., PMID 26362566...