Twenty Common Mistakes Made in Daily Clinical Practice

• 1.

  All patients with elevated blood troponin levels have had a myocardial infarction. An elevated troponin value informs the physician that the patient has had a myocardial injury. To call this myocardial injury, there has to be clinical evidence of myocardial ischemia. There are many clinical situations in which there are acute or chronic myocardial injuries with ischemia not present, and these latter injuries are not myocardial infarctions.¹

• 2.

  All patients admitted with a diagnosis of acute coronary syndrome should be placed on supplementary inspiratory oxygen. There are now a number of studies that have documented harm when a patient with acute coronary syndrome and normal oxygen saturation in the arterial blood are placed on supplemental inspiratory oxygen. If the patient’s arterial oxygen saturation is less than 90%, then supplemental inspiratory oxygen is appropriate.²

• 3.

  All patients complaining of a sore throat and who have erythema and an exudate on their pharynx should be treated with a course of antibiotics to prevent rheumatic fever. Most cases of pharyngitis are caused by a viral infection, including many with exudate on the tonsils or the pharynx. Antibiotic therapy in such a situation is a waste of money and may encourage the growth of antibiotic-resistant bacteria. A throat culture is appropriate in such patients with antibiotic therapy prescribed if the cultures grow Streptococcus pyogenes.³

• 4.

  Patients whose chest pain resolves with sublingual nitroglycerin have had an anginal episode secondary to coronary artery disease. Many patients with chest pain that is not secondary to myocardial ischemia will report resolution of the discomfort with sublingual nitroglycerin. In some instances this is the placebo effect at work. Esophageal spasm can cause discomfort that mimics angina and can be relieved with sublingual nitroglycerin.⁴

• 5.

  Patients with erythema and swelling of the skin of the distal lower extremity have cellulitis and should receive antibiotics. Chronic venous insufficiency is a common imitator of cellulitis and does not respond to antibiotic therapy.⁵

• 6.

  Patients who are hospitalized and receiving intravenous antibiotics for an infection should remain in hospital for 1 day following transition to oral antibiotics. Studies have demonstrated that it is safe to send patients home to continue antibiotic therapy orally as long as the patient has demonstrated clinical and laboratory evidence that the infection is resolving.⁶

• 7.

  Lower back pain is best treated with bed rest and oral benzodiazepines. Many physical maneuvers such as manipulation, massage, and acupuncture are as effective as bed rest and benzodiazepines at relieving back strain and discomfort.⁷

• 8.

  Patients with alcoholic cirrhosis and an upper gastrointestinal bleed most commonly have had a variceal bleed. This is not a true statement. The most common cause of gastrointestinal bleeding in a patient with alcoholic cirrhosis is gastritis.⁸

• 9.

  An echocardiogram is essential in performing preoperative cardiovascular clearance for elective or urgent surgery. American College of Cardiology/American Heart Association (ACC/AHA) guidelines do not recommend screening echocardiography for surgical clearance. Clinical history and physical examination are usually sufficient for this task.⁹

• 10.

  Prophylactic antibiotic therapy before dental work is no longer needed for any cardiac condition. A number of high-risk cardiac conditions still require prophylactic antibiotics prior to dental work; an example is the patient with a prosthetic heart valve.¹⁰

• 11.

  Patients with heart failure and an elevated blood creatinine test will invariably show an increase in the creatinine value following vigorous diuresis. Often the opposite occurs, and the creatinine falls, when the engorged kidney, related to the cardiorenal syndrome, improves in patients with heart failure. Vigorous diuresis will improve renal function.¹¹

• 12.

  Patients who faint should all have carotid ultrasound studies to search for significant arterial stenoses that should be stented. Most causes of syncope are related to sudden drops in systemic blood pressure and not to an arterial stenosis of the carotid circulation. For carotid disease to cause syncope, both carotids would need to underperfusing the brain at the same time, which would be highly unlikely. Physicians do not have to do carotid ultrasound testing as part of a syncope workup. Syncope (transient loss of consciousness) is most often a medical condition and rarely a primary neurologic disorder.¹²

• 13.

  All patients with asymptomatic bacteriuria require antibiotic treatment. There is an overuse of antibiotics in the United States that is leading to the emergence of antimicrobial resistance. Current guidelines from the Infectious Diseases Society of America (IDSA) discourage this practice,¹³ except in special circumstances.

• 14.

  Prolonged bed rest is therapeutic for most inpatients with a variety of illnesses. Prolonged bed rest is not therapeutic for most inpatients with a variety of illnesses. Recovery is often delayed, and there is an increased risk of veno-embolic disease, bed sores, depression, and general deconditioning.¹⁴

• 15.

  It is essential for all inpatients to have vital signs determined every 4 hours. Vital sign determination every 4 hours in most inpatients has never been shown to improve clinical outcomes and contributes greatly to patient dissatisfaction with their hospital course because of sleeplessness.¹⁵

• 16.

  Patients who are receiving a statin drug should not eat grapefruit. Grapefruit juice ingestion has been reported to interact with some drugs, including statins by inhibiting CYP3A4 and the p-glycoprotein transport system, which can inhibit statin metabolism. For example, atorvastatin, lovastatin, and simvastatin raise blood levels but only with high statin doses and even then, rarely posing a problem. Alternative statins that are not associated with the grapefruit juice-statin interaction include fluvastatin and pravastatin. Concurrent ingestion of grapefruit juice with statins should not pose a problem.¹⁶

• 17.

  Patients with severe liver disease, peripheral edema, and ascites should be treated with low-dose spironolactone to help control excess fluid retention. Spironolactone helps control excess fluid retention and can be used with in a wide dose range to achieve maximal benefit. High-dose therapy can be used, but always watch for hyperkalemia.¹⁷

• 18.

  Avoid administration of the influenza vaccine in patients with a history of egg allergy. Recent data would suggest that a history of egg allergy does not prohibit vaccination for influenza on an annual basis. This premise is supported by recommendations from the Centers for Disease Control and Prevention (CDC).¹⁸

• 19.

  Skin infections should always be cultured before starting antibiotic therapy. Skin infections do not need to be routinely cultured before starting antibiotic therapy because the skin has normal bacterial flora that would make it difficult to identify a specific pathogenic organism.¹⁹

• 20.

  Asymptomatic unifocal premature ventricular contractions found on physical examination or electrocardiography always require treatment with anti-arrhythmic therapy. Premature ventricular contractions are commonly found in normal subjects. In asymptomatic patients with premature ventricular contractions, there is no evidence that therapy with anti-arrhythmic therapy has any clinical benefit in prolonging life in patients. With bothersome palpitations related to premature ventricular contractions, treatment with a β-adrenergic blocker may be useful. In patients with frequent premature ventricular contractions, anti-arrhythmic therapy may be useful in preventing cardiomyopathy.²⁰

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-William H. Frishman, MD, MACP^a,b, Joseph S. Alpert, MD^c,d