1/15 Disposition from the hospital can be confusing, so let's review two potential options that are often mixed up:
- SNF
- RCFE

#MedEd #MedStudentTwitter #MedTwitter #FOAMEd

@kelleychuang reminded me that prepping dispo should happen in advance, so let's review before Monday!
2/15 A SNF is a Skilled Nursing Facility. These facilities require INSURANCE. There are two durations of stays:
- Short-term (for skilled needs)
- Long-term (for custodial care)
3/15 Which of the following is NOT an example of a skilled need?
4/15 The answer is "Foley catheter care." Medicare defines a skilled need as one of the following nine things: medicareadvocacy.org/medicare-cover… Image
5/15 SNFs can also be broken down by their ability to handle patients with high risk of harm if they were to elope:
- Open
- Secured
- WanderGuard
6/15 Open SNFs can care for patients with capacity. A secured SNF is for a patient with dementia who has high elopement risk.
7/15 A WanderGuard SNF is for patients with dementia who have low elopement risk (an alarm will go off after they cross a threshold to allow staff to redirect them to their room).
8/15 If a patient with dementia is bedbound, do they have to be placed in a secured SNF?
9/15 The answer is "No." The value of a secured SNF is that they are able to prevent elopement! Now onto RCFEs.
10/15 Which subtype of SNF requires a DPOA to sign the patient in?
11/15 The answer is "Secured." For the other subtypes, as long as there is a reliable surrogate, the patient may go to the SNF.
12/15 RCFE stands for Residential Care for the Elderly. This encompasses Board and Cares (B&C) and Assisted Living Facilities (ALFs). These facilities require MONEY. There are two types:
- Open
- Secured (Memory Care)
13/15 RCFEs can provide a lot of services (notably, they almost never take patients with indwelling Foley catheters): caassistedliving.org/about-assisted… Image
14/15 @COREIMpodcast made this excellent infographic that nicely covers some of this: coreimpodcast.com/2020/06/10/snf… Image
15/15 This is a lot of info, but it is critical in being able to safely discharge patients from the hospital. Every state has different regulations, so learn them from your social workers and case managers. Here is a table that summarizes this thread. Feedback is welcome! Image

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More from @SatyaPatelMD

6 Sep
1/18 Chest pain is a frequently seen reason for admission. Here's my take on when to consider ACS in patients with chest pain!
#MedTwitter #CardioTwitter #MedEd #FOAMed #MedTweetorial @MedTweetorials
2/18 Our evaluation of ACS starts with 3 things:

1⃣ History
2⃣ EKG
3⃣ Troponin

The primary focus of this thread is going to be on the history (a heads up - the flowchart at the end will go a little bit out of order)!
3/18 When taking a chest pain history, we ask lots of questions about associated symptoms and alleviating/aggravating factors, mostly because we were taught to obtain and report this history. But is there a more focused way to approach this? Image
Read 18 tweets
30 Aug
1/5 How can you calculate the estimated DAILY risk of ischemic stroke (and other events) in patients with atrial fibrillation?

#MedTwitter #HemeTwitter #CardioTwitter #MathTwitter #FOAMed #MedEd

Note: the original post was deleted due to a mathematical error
2/5 While the CHADSVASc is helpful for annual estimation of ischemic stroke risk (and other events), what is the risk of DAILY risk? Turns out we can do some math to derive it from the annual risk estimation!
3/5 The math here doesn't EXACTLY reflect the daily risk of for patients because there are countless variables that we cannot control. @JessieCurrier17 describes the rationale using probability quite nicely. Image
Read 5 tweets
25 Aug
1/7 Considering how to manage community-acquired pneumonia (CAP)? Is it CURB-65 or should it be CARB-65? No idea what I am talking about? Let's talk about azotemia and uremia!

#MedTwitter #FOAMEd #MedEd #NephTwitter #IDTwitter
2/7 The CURB-65 score has been used for diagnosis and treatment of adults with community-acquired pneumonia (CAP). The most recent IDSA CAP guidelines in 2019 (pubmed.ncbi.nlm.nih.gov/31573350/) referenced the 2007 IDSA CAP criteria for defining severity
3/7 The original article that describes validation of the CURB scoring system (ncbi.nlm.nih.gov/pmc/articles/P…) does NOT use the word "uremia," but instead references an serum urea level cutoff.
Read 7 tweets
25 Jul
1/9 You admit a patient overnight with hyponatremia and you diagnose it as SIADH. But how are you going to manage it?

To review how to diagnose SIADH, check out the volume-based or ADH/RAAS-based approaches below.

#MedEd #FOAMed #MedTwitter #NephTwitter #Tweetorial
2/9 The cornerstone of treatment is to treat the underlying cause. Everything else is just a 🩹. It can sometimes be very hard to treat the underlying cause immediately (assuming you can identify it).
3/9 Free water restriction is going to help (to a certain degree), but make sure that it’s feasible for the patient (they often need to do this beyond hospitalization). Consider restricting 500 cc below their 24-hour urine output:
Read 9 tweets
22 Jul
1/8 A patient with compensated HFrEF (EF 35%) has positive orthostatics. He is not hypovolemic. What medication is reasonable to prescribe?
#MedTwitter #MedEd #FOAMed #NeuroTwitter #GeriTwitter
2/8
💥Fludrocortisone will increase ⬆️ RAAS and can cause volume overload, so you should avoid it here
💥 Caffeine and ibuprofen are last-line agents to manage orthostatic hypotension
💥 Midodrine is probably your best bet here
3/8 You prescribe midodrine 2.5 mg PO q8h and end up titrating it up to 5 mg PO q8h over the course of a few weeks. The patient shows you their BP log and you notice that their nighttime supine BPs are elevated. What do you do next?
Read 8 tweets
21 Jul
1/5 A 78 yo F with no prior medical history p/w progressive pill-rolling tremor, shuffling gait, and dizziness upon standing. She takes no meds. Orthostatics are ➕. What is the likely cause of her orthostatic hypotension?
#MedTwitter #MedEd #FOAMEd #GeriTwitter #NeuroTwitter
2/5 The answer is Parkinsonism! Parkinsonism is a synucleinopathy (the protein alpha-synuclein accumulates in neurons and glia) leading to autonomic dysfunction. Review this approach on orthostatic hypotension here: . Let's keep going.
3/5 She is diagnosed with Parkinsonism, and started on carbidopa-levodopa BID with improvement in symptoms. Her family has hired 24/7 caregivers who ensure her PO intake is adequate.
Read 5 tweets

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