Acute Coronary Syndrome
Acute Coronary Syndrome (ACS) includes STEMI, NSTEMI, and unstable angina (UA). In the era of high sensitivity troponin, UA has become a slippery diagnosis but can still be diagnosed with a convincing story despite a negative troponin. The basics of acute management are discussed below. STEMI From an internist perspective, our job is to make […]
Altered Mental Status
Sometimes the cause of acute altered mental status (AMS) is obvious: the patient is septic from an apparent source, or having a hemorrhagic stroke clearly seen on CT. “Acute encephalopathy,” as we call it for billing purposes, is extremely common, and when things aren’t clear, I like to use the DMISTO mnemonic, to DeMISTOfy the […]
Type II Diabetes
With type II diabetes, keep it simple on the in-patient side. Non-Insulin Medications With room for thoughtful exceptions, when a patient is admitted to the hospital, stop the non-insulin medications. Insulin If the patient is already on insulin, and their blood sugar is relatively well controlled: Decrease the total dose by about 10%–20%. Make small […]
Hospital Culture
The High Stakes For Healthcare Workers Working in healthcare is challenging. Being a good doctor is difficult. Being a perfect doctor is impossible. The stakes are high. Healthcare workers are often stressed. I have never seen a hospital without some amount of intrapersonal conflict and drama. Some all-time favorite classics on an internal medicine service […]
Bacterial Infections
Managing patients with bacterial infections is part of the bread and butter of internal medicine. Sometimes the infectious source is obvious, but other times no infection is apparent, despite vitals and lab tests suggestive of sepsis. Still other times, there are multiple sources of infection. It is nice to have a framework for diagnosing and […]
Renal Failure
The kidneys tend to be innocent bystanders that suffer secondary to systemic illness or failure from another organ system. Acute kidney injury is extremely common in the hospital. The first question to ask yourself is whether or not the patient needs emergent dialysis. The answer is almost always No. Here is a helpful mnemonic to […]
Hypertension
Briefly, unless the patient has a specific condition that requires blood pressure management (acute stroke, aortic dissection, etc.) or a change in their clinical status, hypertension in the hospital should not be treated quickly. This runs counter to the old dogma that significantly elevated BP (systolic over 180), needs to be urgently lowered. I would […]
Sodium Abnormalities
It is very difficult to spend a week on a hospital medicine rotation without encountering an abnormal sodium value. Hypernatremia is easy to evaluate and manage, so we will start there. Hypernatremia First, correct the volume status. If you think the patient is volume down, start with a bolus or two of ringers (130 mEq/L […]
Presenting Patients
Oral patient presentations should be in the following order: CC HPI ROS PMH Medications Relevant PSH Relevant SH Relevant FH, if any Vitals PE Labs EKG Imaging Summary: Ideally this will make it clear how you are framing the case and should segue into your problem-based assessment and plan. Assessment and Plan, by problem. Image […]
Hyperkalemia
Unfortunately, the first symptom of hyperkalemia can be death due to arrhythmia. Severe hyperkalemia, especially with associated EKG changes, should be treated as an emergency. Our Toolkit to Lower the Potassium Level (While we simultaneously treat the underlying issue, which may be evaluation and treatment of kidney dysfunction, stopping implicated medications, and more.) Dilute with […]