#193 Venous Congestion & VEXUS Interview with Dr. Ross Prager

Why is venous congestion not the same as volume overload? How can looking at IVC as well as doppler on the hepatic vein, portal vein, and/or intrarenal vein help? Can venous congestion explain someone's delirium? Or be at play in septic shock? What are the limitations of the VEXUS score?🔹 Sponsor: Oakstone CMEUse the code "CORE30" for 30% off: https://www.coreimpodcast.com/MKSAP 🔹Transcript and Shownotes(00:00) | Volume overload vs. Venous Congestion(05:49) | Venous Congestion and AKI, mortality, possible delirium(10:10) | Measuring Venous Congestion and the Role of VEXUS(15:05) | Common Mistakes and Best Practices of VEXUS score(23:13) | Assessing Fluid Tolerance and Risks with Venous Doppler in Acute Care(25:29) | Fluid vs. Vasopressor Strategy Guided by Venous Assessment Tags: CoreIM, Internal Medicine, Critical Care, Nephrology, Cardiology, Fluid Management, POCUS, Ultrasound, Doppler, Hospital Medicine, Clinical Reasoning, Medical EducationFind the best disability insurance for you: https://www.patternlife.com/disability-insurance?campid=497840Our Sponsors:* Check out Branch Basics: https://branchbasics.com/COREIM and use the code CoreIM for 15% * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com* Check out Uncommon Goods for 15% off: https://uncommongoods.com/COREIM* Check out Washington Red Raspberries: https://redrazz.orgAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy

SGLT-2i vs. GLP-1? vs Metformin? How do you balance the cost and coverage of first-line options like metformin, SGLT-2, and GLP-1s? How do you choose between SGLT-2 and GLP-1s for comorbidities like CAD or CKD? And how do you weigh their side effects and practical use?🔹 Sponsor:Use the code "CORE30" for 30% off: https://www.coreimpodcast.com/MKSAP🔹 Transcript and Show NotesTimestamps:(01:43) | Case 1: Managing Uncontrolled Diabetes in a 47-Year-Old Male(07:15) | Understanding Cost and Insurance Barriers in Diabetes Care(09:26) | Case 2: Addressing Weight Gain and Financial Stress in a 52-Year-Old Male(14:16) | Case 3: Managing Coronary Artery Disease and CKD in a 66-Year-Old Male(19:41) | Case 4: Severe Obesity and Pain Management in a 59-Year-Old Female(24:19) | Case 5: High A1C and Vascular Comorbidities in a 67-Year-Old Female (35:34) | Weighing Side Effects and Practical Use of GLP-1 and SGLT2 InhibitorsTags: CoreIM, Primary Care, Endocrinology, Diabetes Mellitus, Type 2 Diabetes, Type 1 Diabetes, Metformin, GLP-1, SGLT2, Insulin, CGM, A1C, DKA, Medical Education, Clinical Reasoning, Hospital MedicineFind the best disability insurance for you: https://www.patternlife.com/disability-insurance?campid=497840Our Sponsors:* Check out Branch Basics: https://branchbasics.com/COREIM and use the code CoreIM for 15% * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com* Check out Uncommon Goods for 15% off: https://uncommongoods.com/COREIM* Check out Washington Red Raspberries: https://redrazz.orgAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy

What really works when treating HRS? Vasoconstrictors like terlipressin vs. norepinephrine vs. midodrine: how do we decide which to use? Do you give albumin? When do you give Lasix or another diuretic? When is the better choice transplant, dialysis, or even palliative care?🔹 Sponsor: Oakstone CMEUse the code "CORE25" for 25% off: https://www.coreimpodcast.com/MKSAP🔹 Transcript & Show NotesTimestamps: (00:12) | Introduction and Overview of Hepatorenal Treatment (03:38) | Vasoconstrictors Focus: Terlipressin, Norepinephrine, and Midodrine (12:32) | Finding the Right Dose of Albumin and Knowing When to Stop (15:06) | Volume Management: Balancing MAP, Diuretics, and Creatinine (21:42) | Understanding the High Mortality of HRS-AKI (32:30) | Transplant, Dialysis, or Palliation CareTags: CoreIM, Internal Medicine, Primary Care, Medical Education, IMCore, Physician Assistant, Nurse Practitioner, Medical Student, Hepatorenal Syndrome, HRS-AKI, Cirrhosis, Nephrology, Liver DiseaseFind the best disability insurance for you: https://www.patternlife.com/disability-insurance?campid=497840Our Sponsors:* Check out Branch Basics: https://branchbasics.com/COREIM and use the code CoreIM for 15% * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com* Check out Uncommon Goods for 15% off: https://uncommongoods.com/COREIM* Check out Washington Red Raspberries: https://redrazz.orgAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy

HRS-AKI vs. other causes of AKI in cirrhosis: What do serum or urine sodium clues, albumin challenges, and shifting diagnostic criteria actually reveal about getting the diagnosis right?🔹 Sponsor: Oakstone CMEUse the code "CORE25" for 25% off: https://www.coreimpodcast.com/MKSAP🔹 Transcript & Show NotesTimestamps: (00:57) | Understanding the Pathophysiology of HRS (03:42) | How Portal Hypertension Traps the Kidneys (10:32) | Sorting the Differential of AKI in Cirrhosis Beyond HRS (18:28) | Hyponatremia and Urine Sodium in Advanced Cirrhosis (24:04) | Official Diagnosis and Evolving Criteria of HRS (29:30) | Albumin: When It Helps and When to Hold Back (34:00) | Recap and Future DirectionsTags: CoreIM, Internal Medicine, Primary Care, Medical Education, IMCore, Physician Assistant, Nurse Practitioner, Medical Student, Nephrology, renal, hepatology, Portal Hypertension, Liver DiseaseFind the best disability insurance for you: https://www.patternlife.com/disability-insurance?campid=497840Our Sponsors:* Check out Branch Basics: https://branchbasics.com/COREIM and use the code CoreIM for 15% * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com* Check out Uncommon Goods for 15% off: https://uncommongoods.com/COREIM* Check out Washington Red Raspberries: https://redrazz.orgAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy

Who’s really at risk for fractures, and how should we be treating them? Most fragility fractures occur in patients without osteoporosis. Should we rethink who gets treated? And could just one or two IV infusions (spread years apart) of zoledronate prevent fractures for years? Have the concerns about bisphosphonates been overblown?Find out all the nuances on this episode of Beyond Journal Club, a series brought to you by Core IM in collaboration with NEJM Group.🔹 Sponsor: Oakstone CMEUse the code "CORE25" for 25% off: https://www.coreimpodcast.com/MKSAP🔹 Transcript & Show NotesTimestamps:(00:59) | Diagnosing Osteoporosis and Hidden Fracture Risk(05:38) | Evolution of Bisphosphonate Use in Osteoporosis Treatment(07:51) | Current Use of Bisphosphonates: Benefits, Risks, and Side Effects(10:31) | Exploring Non-Bisphosphonate Options for Fracture Prevention(11:44) | Teriparatide and Alternative Osteoporosis Medications(14:53) | Inside the Latest Bisphosphonate Clinical Trial(18:07) | Key Findings from the Zoledronate Fracture Prevention Study(22:38) | Public Health Impact of Fracture Prevention Strategies(24:24) | Final Takeaways and Expert Perspectives on Osteoporosis CareTags:  CoreIM, Internal Medicine, Primary Care, Medical Education, IMCore, Physician Assistant, Nurse Practitioner, Medical Student, Osteoporosis, Fragility Fractures, Zoledronate, Bone HealthFind the best disability insurance for you: https://www.patternlife.com/disability-insurance?campid=497840Our Sponsors:* Check out Branch Basics: https://branchbasics.com/COREIM and use the code CoreIM for 15% * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com* Check out Uncommon Goods for 15% off: https://uncommongoods.com/COREIM* Check out Washington Red Raspberries: https://redrazz.orgAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy

Medications for orthostatic hypotension! When to initiate treatment, how to use them safely, and what to do when new issues arise during treatment. How do those change if someone has autonomic failure? What do you do when your patient has hypertension AND also has orthostatic hypotension?🔹 Sponsor: Oakstone CME’Use the code "CORE25" for 25% off: https://www.coreimpodcast.com/MKSAP🔹 Transcript & Show Notes Timestamps (+/- 1-2 mins):(00:28) | Case Recap: Beyond Non-Pharm Strategies(03:07) | Midodrine: Timing, Testing, & Supine Hypertension(06:23) | Fludrocortisone: Benefits vs. Risks(09:01) | Droxidopa: Evidence, Side Effects, Access Issues(10:11) | Pyridostigmine & NSAIDs: Secondary Options(12:31) | Balancing Hypertension and Orthostatic Hypotension(14:29) | Functional Hypotension & Risk Stratification(18:45) | Symptomatic Patients: What to Stop, What to Continue(20:19) | Autonomic Disease: Supine & Nocturnal Hypertension(21:47) | Bed Elevation, Compression, & Non-Pharm PearlsTags: Internal Medicine, Geriatrics, Autonomic Dysfunction, Hypertension, Syncope, Falls, Patient Safety, Medical Education, physician assistant, nurse practitioner, hospitalist, primary care, neurologyFind the best disability insurance for you: https://www.patternlife.com/disability-insurance?campid=497840Our Sponsors:* Check out Branch Basics: https://branchbasics.com/COREIM and use the code CoreIM for 15% * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com* Check out Uncommon Goods for 15% off: https://uncommongoods.com/COREIM* Check out Washington Red Raspberries: https://redrazz.orgAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy

Learn specific, practical ways to counsel patients on non-pharmacologic interventions. What is our goal with OH treatment? Is it the blood pressure number that matters? How do we avoid missing neurogenic causes of orthostatic hypotension (OH)? 🔹 Sponsor: Oakstone CME’Use the code "CORE30" for 30% off effective 11/1/25 through 1/31/26: https://www.coreimpodcast.com/MKSAP🔹 Transcript & Show NotesTimestamps:(00:05) | Case Presentation: Urinary Retention → Lightheadedness(02:37) | Defining Orthostatic Hypotension & Prevalence(04:10) | Why Diagnosis Is Harder Than It Seems(06:20) | How (and When) to Measure Orthostatic Vitals(10:06) | Role of Heart Rate in Narrowing the Differential(14:41) | Rethinking Treatment Goals: Function > Numbers(17:52) | Recognizing Orthostatic Intolerance Symptoms(22:14) | Non-Pharmacologic Strategies in the HospitalTags: Primary care, Internal Medicine, Physician Assistant, Nurse Practitioner, Geriatrics, Autonomic Dysfunction, Syncope, Falls, Patient Safety, Medical EducationFind the best disability insurance for you: https://www.patternlife.com/disability-insurance?campid=497840Our Sponsors:* Check out Branch Basics: https://branchbasics.com/COREIM and use the code CoreIM for 15% * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com* Check out Uncommon Goods for 15% off: https://uncommongoods.com/COREIM* Check out Washington Red Raspberries: https://redrazz.orgAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy

Next time you’re squinting at a chest tube, feel confident you know exactly what to look for and why. Hear it explained in a way that really sticks!🔹 Sponsor: Oakstone CME’s ACP MKSAP Audio CompanionUse the code "CORE30" for 30% off effective 11/1/25 through 1/31/26: https://www.coreimpodcast.com/MKSAP🔹 Transcript & Show NotesTimestamps:(02:50) | Xray vs. POCUS vs. CT for Pneumothorax Diagnosis(07:29) | Do All PTXs Need Chest Tubes?(11:55) | Explaining Pneumothorax to Patients(14:58) | Understanding the Pleural Drainage System(26:11) | Monitoring Air Leaks with the Water Seal Chamber(32:27) | Managing Persistent Air LeaksTags: CoreIM, Internal Medicine, Pulmonology, Critical Care, Medical Education, 3-Chamber Drainage System, Endobronchial Valves and PleurodesisFind the best disability insurance for you: https://www.patternlife.com/disability-insurance?campid=497840Our Sponsors:* Check out Branch Basics: https://branchbasics.com/COREIM and use the code CoreIM for 15% * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com* Check out Uncommon Goods for 15% off: https://uncommongoods.com/COREIM* Check out Washington Red Raspberries: https://redrazz.orgAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy

How do you work up neutropenia? When is neutropenia benign? When do neutrophils recover? How can you diagnose neutropenic fever in the first 15 minutes and start antibiotics in the first 60 minutes? Do you always add MRSA coverages? Only Pseudomonas coverage? When do you add fungal coverage?🔹 Sponsor: Oakstone CME’s ACP MKSAP Audio CompanionUse the code "CORE30" for 30% off effective 11/1/25 through 1/31/26: https://www.coreimpodcast.com/MKSAP🔹 Transcript & Show Notes Timestamps:(02:24) | Approach to Neutropenia & Duffy Null(11:38) | Dose and duration-dependent neutropenia vs. immune-mediated neutropenia(19:46) | When do neutrophils recover?(29:56) | Classifying Neutropenic Fever Syndromes(29:53) | Strategies for Managing Low-Risk Neutropenic Fever(33:02) | Antimicrobial Therapy and Duration in Febrile NeutropeniaTags: CoreIM, Internal Medicine, Oncology, Hematology, Medical Education, Physician Assistant, Nurse Practitioner, Neutropenic Fever Management, AntibioticsFind the best disability insurance for you: https://www.patternlife.com/disability-insurance?campid=497840Our Sponsors:* Check out Branch Basics: https://branchbasics.com/COREIM and use the code CoreIM for 15% * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com* Check out Uncommon Goods for 15% off: https://uncommongoods.com/COREIM* Check out Washington Red Raspberries: https://redrazz.orgAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy

Have a good laugh and reflect deeply with these three stories that hit the feels in different ways.If you'd love to hear more stories from Dr. Maria Rosasco, check out some of her other appearances on the podcast: July Stories and Handoffs & Contingency Planning.🔹 Sponsor: Oakstone CME’s ACP MKSAP Audio CompanionUse the code "CORE30" for 30% off effective 11/1/25 through 1/31/26: https://www.coreimpodcast.com/MKSAP🔹 Transcript and Show NotesTimestamps:(01:04) | Story 1: Sharing a Personal Story for Patient Care(03:42) | Story 2: Leading a Family Meeting(06:52) | Story 3: Early Days of the COVID-19 Pandemic(10:22) | What Rituals and Values Guide Your Path in MedicineTags: CoreIM, Internal Medicine, Primary Care, Medical Education, IMCore, Physician Assistant, Nurse Practitioner, Medical Student, Narrative Medicine, HumanitiesFind the best disability insurance for you: https://www.patternlife.com/disability-insurance?campid=497840Our Sponsors:* Check out Branch Basics: https://branchbasics.com/COREIM and use the code CoreIM for 15% * Check out FIGS and use my code FIGSRX for a great deal: https://wearfigs.com* Check out Uncommon Goods for 15% off: https://uncommongoods.com/COREIM* Check out Washington Red Raspberries: https://redrazz.orgAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy