Six of the “Rules” Used Most Frequently With Residents/Fellows

Repetition is a Great Teacher

I just finished seven days of covering our inpatient cardiology consult service. Here are some of the “500 Rules” I used most frequently during that time. Most have been mentioned in previous posts, but repetition is a great way to learn.

1. “Furosemide (Lasix) is both diagnostic and therapeutic.” I call Lasix “Vitamin L” since so many cardiac patients benefit from it. “Both diagnostic and therapeutic” means that if you give a bolus and the patient “pees like a race horse”, they needed it. This is also why I prefer a diuretic bolus to a diuretic drip. You give the bolus and within 3 hours you can see whether it worked or not. If it did not work, the patient might not have needed it or might need a bigger dose. And you don’t have to wait a day to see if a drip worked. (1)

2. “Isaac Newton was onto something.” Gravity probably does exist. Therefore, don’t look for peripheral edema in a hospitalized patient, look for sacral edema. Similarly, you cannot tell that there is no lung vascular redistribution (an or increase in upper lung vessels) from a flat chest x-ray. You can only really see vascular redistribution when the patient is upright or semi-upright.

3. “If there’s fluid in the butt, there’s fluid in the gut.” Patients with sacral edema probably have bowel edema so don’t send them home with sacral edema and oral medications because they may not absorb their oral diuretic. Get rid of the sacral edema and then send them home. (1)

4. “Look at the chloride to assess diuresis.” Diuresis should produce a hypochloremic metabolic alkalosis, so look at the chloride level in heart failure patients coming to the emergency department to see if they are taking their diuretic or not. If they come in with a chloride over 100 mEq/L, consider the possibility that they are not taking their diuretic. (2) Also, use the chloride level in hospitalized patients as one indicator of when they are sufficiently diuresed. (3)

5. “Check the NT-pro-BNP in patients with pneumonia, especially, bilateral pneumonia.” Heart failure can present like pneumonia and look like pneumonia on chest x-ray. Heart failure produces a cough in many patients. The x-ray, especially in patients with lung disease, can look like multiple infiltrates. So, in the emergency department, or the clinic, check a BNP before diagnosing just pneumonia. And heart failure patients can have fever. Paul Dudley White, the famous Boston cardiologist, lamented way back in 1940 that clinicians didn’t know that heart failure can cause fever, (4) furthering confusion between heart failure and pneumonia.

6. “Yell at patients.“ Many older patients are deaf, but won’t admit it or won’t tell you when they cannot hear, so speak loudly so they can hear you. Also, speak slowly – because using medical terms is, for patients, like learning a new language. You can often understand a person in your non-primary language if they speak slowly, but not if they speak rapidly. And don’t use abbreviations with patients – it can make them feel embarrassed if they don’t understand.(5)

1. https://substack.com/home/post/p-143506159

2. https://substack.com/home/post/p-139246643

3. https://substack.com/home/post/p-140521393

4. Kinsey, D. White, PD. Fever in Congestive Heart Failure. Arch Intern Med (Chic). 1940;65(1):163-170.

5. https://substack.com/home/post/p-141396437

#medicalpractice #medicine #heartfailure #NT-pro-BNP #hypochloremia