The Point of Care Podcast

Explore asterixis, often called the 'liver flap,' a critical neurological sign indicating toxic-metabolic encephalopathy. Learn why this 'negative myoclonus' isn't a tremor, how to spot its distinctive 'flapping' motion, and its diverse etiologies, from liver and kidney disease to hypoglycemia and medications. We demystify its strong historical link to hepatic issues and emphasize why this finding is key to a complete diagnostic assessment.

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Navigating hepatic encephalopathy can be complex, and the role of ammonia levels is often misunderstood. In this concise episode, we clarify why hepatic encephalopathy is fundamentally a clinical diagnosis, not one based solely on lab values, and reveal the crucial limitations of ammonia testing. Learn when ammonia levels are genuinely helpful - specifically in acute liver failure - and why relying on them for routine diagnosis or trending can lead clinicians astray, diverting focus from essential clinical assessment.

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Hepatic encephalopathy (HE) can feel like it comes out of nowhere: one day a patient is baseline, the next they’re confused after “just” constipation, a little dehydration, or a routine diuretic tweak.
In this episode, we unpack why seemingly benign stressors can flip a fragile gut–liver–brain system past its tipping point.

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In this episode, we break down why lactulose and rifaximin work specifically for HE: lactulose acidifies the colon to “trap” ammonia as ammonium (NH4⁺) and rapidly clears nitrogen substrates via catharsis, while rifaximin reshapes the gut microbiome and dampens gut-derived inflammatory signaling - benefits that don’t always correlate with serum ammonia levels. We also cover why other antibiotics fell out of favor, where polyethylene glycol fits, and how to think mechanistically about the best risk–reward strategy for preventing and treating HE.

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A comprehensive guide on how to complete a thorough history and physical (H+P) for patients presenting to the hospital with opioid withdrawal.

00:15 Admission Checklist for Opioid Withdrawal
00:40 Triage and Chart Check
02:01 Critical Considerations and Admission Orders
03:10 Initial Treatment Options for Opioid Withdrawal
05:32 Detailed HPI Intake Questions
07:33 Physical Exam Notes
08:35 Key Takeaways and Conclusion

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POCM Opioid Withdrawal Inpatient Admission
POCM Opioid Use Disorder and Withdrawal Clinical Review

13 Essential Facts for Managing Opioid Withdrawal in 2025