Random New Attending Questions

[Disinence2]

Hello!

Survived my 1st 6 months of being an attending but had a list of random questions for the community.

1) Say you get a patient with Syncope/Near syncope that already has pacer/ICD, and there are absolutely no events after its interrogated. If they don't have any other of the "high risk" criteria, normal vital, normal labs, no murmur, normal oxygen do you still admit them? Most of these people have CHF, or other cardiac issues that led to putting the device in, that makes me hesitant to discharge, but I still think most of these people are probably just dry, overdiuresed, or vasovagal

2) How do you approach a patient with Health Care associated PNA, but actually looks really good and can probably go home. The sick patients who are admitted get loaded up with antibiotics. What would you discharge the patient on, or do you keep most of these? I figure levaquin and 24-48 hour outpt follow up, with strict return precautions should cover most things.

3) The dialysis patient that "Just Doesn't Feel Right", Normally I order a big work up on these people because they are usually sick or they have abnormal vitals and are an easy admit, but I have had a few where everything comes back looking absolutely normal. I work at a place where hospitalists will happily admit anything you give them with little fuss or push back so I usually just admit these people for "General Weakness" or something to that effect, but was wondering if other people just kick them out. This is my default for old people with general weakness, and normal everything else.

Any other tips that the more experienced docs wish they would have known would be appreciated.

Thanks

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[Arcan57]

1) I'll send them home since I have proof that their syncopy wasn't caused by a malignant arrhythmia which is the main intellectual underpinning of my admitting their non-cyborg brethren.

2) I'm not sure the last time I saw a HCAP that looked good.

3) Never underestimate the mockery that ESRD pts make of your ability to risk stratify. If they leave it's only after I've talked to their nephrologist, communicated plan in depth to family, and have two sets of negative cardiac markers with a non-ischemic EKG. I'll also toss on a lactate and blood cultures. At least at my shop they are the number 1 population for presenting with early or partially treated sepsis.

 

[RustedFox]

1.) Send home after discussion with cardiologist.

2.) Admit.

3.) Admit as above.

 

[Daiphon]

Hello!

Survived my 1st 6 months of being an attending but had a list of random questions for the community.

1) Say you get a patient with Syncope/Near syncope that already has pacer/ICD, and there are absolutely no events after its interrogated. If they don't have any other of the "high risk" criteria, normal vital, normal labs, no murmur, normal oxygen do you still admit them? Most of these people have CHF, or other cardiac issues that led to putting the device in, that makes me hesitant to discharge, but I still think most of these people are probably just dry, overdiuresed, or vasovagal

2) How do you approach a patient with Health Care associated PNA, but actually looks really good and can probably go home. The sick patients who are admitted get loaded up with antibiotics. What would you discharge the patient on, or do you keep most of these? I figure levaquin and 24-48 hour outpt follow up, with strict return precautions should cover most things.

3) The dialysis patient that "Just Doesn't Feel Right", Normally I order a big work up on these people because they are usually sick or they have abnormal vitals and are an easy admit, but I have had a few where everything comes back looking absolutely normal. I work at a place where hospitalists will happily admit anything you give them with little fuss or push back so I usually just admit these people for "General Weakness" or something to that effect, but was wondering if other people just kick them out. This is my default for old people with general weakness, and normal everything else.

Any other tips that the more experienced docs wish they would have known would be appreciated.

Thanks

Agree with above for #'s 1 & 2.

I'll add this for #3: it's a HD patient, meaning that they either don't feel good after dialysis or it'll be at least a day until they are dialyzed.

If the former, need to worry about over aggressive fluid shifts & possibility of silent MI due to transient hypoTN. Also, even if just volume down, near syncopal HD patients are at higher risk of bleeds if they fall (platelet dysfunction + heparin in the circuit). If nothing else, obs for judicious fluids & serial enzymes.

If the latter, then you've gotta worry about the silent MI again (increased workload due to increased volume) as well as the K issue... 23h for serial enzmes, monitoring, and HD.

Don't overthink these patients.

-d

 

[goodoldalky]

1. Discharge.

2. Admit for broad spectrum abx pending culture data.

3. If you've done serial (2h) ECGs / trops in the ED, +/- cultures, and everything really is normal, there's nothing wrong with sending these people home for outpatient follow-up with return precautions. Really depends on the patient though.

 

[RuralEDDoc]

I suspect this echos some people above, but my two cents:
1. Normal vitals, well appearing, etc, call Cards and dc home.
2. Are you calling this hospital acquired pneumonia because they were in the hospital within the last three months? If so, then it depends on what's going on. If someone had a routine ortho surgery two months ago and now has a run of the mill mild pneumonia, is not hypoxic, and well appearing, then dc home. If this is a pneumonia bounce back, a chronically ill patient, diabetic, from a nursing home, etc., then admit till the cows come home.
3. With normal workup, and without some weird spidey-sense of doom, I'll likely discharge home. Can't imaging admitting these patients with normal EKG (rather, unchanged from baseline), stable delta-trop, normal CBC and lactic acid, and normal physical exam. Talk to the Nephrologist first. Even places with poor specialty back up (like where I work), Nephrology is usually available for their patients. This isn't CYA, its making sure the doc know about their patient and is following up on them. Strict return precautions, of course.

 

[TheBlueBlazer]

I echo #3 talking to their nephrologist. They may say "they do this all the time, I'm not sure why someone sent them to the ED, I'll have someone call them tomorrow" or "wow this is weird, you should bring them in" both of which have a substantial affect on your likelihood ratios of badness. Follow both of these scenarios up by talking to the patient. If you tell them everything is negative, they might not be wanting to stay, and you can document the "upon shared decision making with the patient, and discussion of risks and alternatives, they chose to..." that looks good on the chart and is the best thing for them in the setting of "nothing wrong" as well as making the sale of things easier with hospitalist if they give you pushback - "they don't feel safe going home". They may end up being fine with going home, and "just came in to get checked out." While many/most of these patients are ticking time bombs, some of the folks that have been on dialysis a while have been through some stuff, and you couldn't kill if you tried.

 

[DrQuinn]

1) discharge. we admit mostly for cardiac stuff. guessing its not a PE or blah blah that's causing their syncope. they got the pacemaker so fi they pass out again they're good to go.

2) agre,e never seen an HCAP that looked great. no real good outpatinet abx to send home on.

3) long discussion with pt and nephrologist, to see tomorrow kinda thing.

good questions though.
Q

 

[BAM!]

#2 -- An acute rehab patient may meet HCAP criteria by virtue of the fact that they live in acute rehab. Something to this effect is what you're talking about, right? If they look good and you feel comfortable sending them home, then you could imagine it's likely caused by a community acquired PNA bug and not a multi-drug resistant pathogen. In which case, levaquin or ceftriaxone + azithro depending on local sensitivities should be fine.