Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you suggest incorporating POCUS into the evaluation of SSTIs, and do you use this as a means to guide initial antibiotic selection?
I routinely incorporate POCUS into my SSTI evaluation because it reliably distinguishes simple cellulitis from purulent infection, which directly guides my initial management. A quick bedside scan allows me to rule out a drainable abscess. If the scan shows only cobblestoning without a fluid collect...
How do you suggest incorporating POCUS into the evaluation of SSTIs, and do you use this as a means to guide initial antibiotic selection?
I routinely incorporate POCUS into my SSTI evaluation because it reliably distinguishes simple cellulitis from purulent infection, which directly guides my initial management. A quick bedside scan allows me to rule out a drainable abscess. If the scan shows only cobblestoning without a fluid collect...
How do you treat a patient with a gram-negative infection with resistance to imipenem but sensitivity to meropenem and negative for Carbapenem resistant organism by xpert Carba-R-assay?
The finding of meropenem susceptible, imipenem resistant GNR can be explained in Pseudomonas aeruginosa by efflux pump overexpression and porin (particularly OprD) loss. The opposite pattern in P. aeruginosa - imipenem susceptible, meropenem resistant – has often been attributed to overexpression of...
When would you consider prescribing a wakefulness promoting agent for excessive daytime sleepiness from insufficient sleep?
I would never consider prescribing an alerting medication for someone with insufficient sleep. Behaviorally insufficient sleep is a diagnosis in and of itself. The treatment for excessive daytime sleepiness in the case of insufficient sleep is changing behavior to allow for more time in bed. I would...
How effective have you found acupuncture for treatment of chronic migraine?
I would prefer to educate a patient interested in acupuncture for severe headaches about all the other treatments that are available. However, if they would still like to pursue acupuncture, I would support them, just like Dr. @Dr. First Last would say. Some patients can get better, although it is n...
Do you recommend IV sodium bicarbonate for patients with rhabdomyolysis and AKI without metabolic alkalosis or hypocalcemia?
The primary goal of IV fluids and urine alkalinization in patients with rhabdomyolysis is to prevent AKI, not to treat established AKI. The most important factor in preventing AKI is early and vigorous fluid administration (aiming to achieve a brisk diuresis of 200-400 ml/hr), while the choice of IV...
How do you approach the use and titration of Cobenfy in patients with treatment refractory schizophrenia not responding to clozapine?
It depends on what medications they are on. If they are on clozapine and you want to cross-titrate, then it will depend on the dose of clozapine and how fast you want to take it off, as we do not want cholinergic rebound. Let's say they are on clozapine 300 mg po qhs, then you can start Cobenfy at t...
How do you approach incidental image findings with unclear clinical significance?
I approach them as findings, regardless of how they were acquired they need to be managed. In primary care one of the biggest drivers of malpractice cases is failure to act on a finding, just because it wasn't something you were directly looking for does not protect you. So manage the finding. Work ...
What would be your next diagnostic test of choice for a patient with findings concerning for silent ischemia on noninvasive functional testing in the absence of chest pain?
There are a lot of unanswered questions just from the information given. Why was the test done in the first place if truly asymptomatic? If not having chest discomfort, were they having an anginal equivalent - such as a new complaint of shortness of breath with exertion not previously present? What ...
How do you approach DMARD therapy in a patient with lupus and recurrent pericarditis?
Both asymptomatic pericardial effusions and symptomatic pericarditis are common in systemic lupus erythematosus (SLE) patients. I will limit my answer to symptomatic pericarditis per the question.The first thing to be sure of is that the symptoms are truly due to pericarditis. The full differential ...