GI Bleeding
Gastrointestinal hemorrhage can be lethal, but fortunately, the management is usually cognitively straightforward. Most patients do fine. Our job is to put blood into the patient faster than the blood is leaving the patient until a gastroenterologist, interventional radiologist, or surgeon can perform procedures to achieve a definitive diagnosis and management strategy. The treatment of […]
Insomnia
Patients Lose Sleep in the Hospital Pain, noise, acute illness, stress, unfamiliar environment/bed, procedures, blood draws, and other diagnostic tests are a few of the things that keep our patients awake. Inpatient insomnia can be frustrating to treat. For example, you get paged in the middle of the night by a nurse who wants help […]
Atrial Fibrillation
Atrial fibrillation is a very common arrhythmia in the hospital. Fortunately, it is usually easy to manage. In general, I treat a-fib with RVR in the following way: As you start to follow this algorithm, you should simultaneously try to identify the provoking factor for the atrial fibrillation (if new) or RVR. Is the patient […]
Alcohol Withdrawal
There are two conventional strategies to treat alcohol withdrawal: symptom-driven administration of benzodiazepines, and phenobarbital monotherapy. Patients with alcohol withdrawal syndrome (AWS) have relative GABA deficiency in their brains, and the mainstay of treatment is GABA agonism. Benzodiazepines (and barbiturates) are GABA agonists and are effective at treating alcohol withdrawal. To find the right dose […]
Ischemic Stroke
“Brain Attack” Every stroke is different, but the principles of stroke management are always the same. An ischemic stroke occurs when there is an issue with blood flow to some area of the brain. The neurologic impact is dependent on what part of the brain is affected. Considerations in Acute Stroke Revascularization The decision to […]
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 […]
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 […]