@alemdanarrativa @PulmCrit @vitorborin_ Absolutely agree with @alemdanarrativa and @PulmCrit on this one! Clinical medicine is often a stew of fuzzy logic.
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David Snider
242 posts
David Snider
@DavidGSnider
General internal medicine resident @ University of Manitoba
Winnipeg, Manitoba Katılım Aralık 2019
607 Takip Edilen56 Takipçiler
@PulmCrit @vitorborin_ I find it rather bizarre that someone can claim to practice medicine and, at the same time, demand high quality unquestionable evidence for every single intervention, when in reality most of our interventions do not have it. Medicine is an art, not an algorithm.
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I'm sorry but CRP can be useful when admitting undifferentiated ICU patients (where history & exam are often minimal, eg 2/2 delirium)
If you're getting involved >24 hours after admission it's easy to look down at the docs who were frantically sorting out an undifferentiated pt
Brad Spellberg@BradSpellberg
We all know how hard it is to put down zombies. It’s time to World War Z the zombie tests, ESR and CRP!
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🩸Hematology for The Non-Hematology🩸
(A practical educational series for internal medicine trainees and physicians)
Episode 5: Profuse bleeding? Which blood product to grab: PLT, Cryo, FFP, or PCC? 😱 The answer’s easier than you think
Listen up - 🧵
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Motor neuronopathy
Pure motor syndromes. The body of the motor neurons are affected. Usually asymmetric and distal predominant, accompanied by atrophy, fasciculations, decreased/absent reflexes (can also have upper motor neuron signs) and normal sensory exam.
10/x
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Polyradiculoneuropathy
Proximal and distal weakness and sensory loss in the four limbs. Can be distal>proximal; distal=proximal or distal<proximal.
7/x
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TiTrATE transforms the dizzy consult from chaos to clarity.
Use it consistently and pattern recognition will follow.
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😵💫 Does the differential for dizziness make your head spin? Need help finding your balance in the world of vertigo?
Let's break down how to approach the confusing consults for “dizziness” 👇
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Ref:
Rajiv S et al, Compare A Fib in Young vs Elderly: Review, Card Res & Pract, 2013
Kralev S et al, Incidence of CAD in pts w/ A Fib at 1st coronary angio. PLoS One. 2011.
Al-Makhamreh HK et al, Prevalence of CAD among pts w/ A Fib in Jo-Fib Study. Medicina. 2021
15/15
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Votes are in... this is a GREAT example of COLLIDER bias which I will explain in this 🧵
I agree with the votes that A fib is NOT an independent harbinger of CAD (in general).
That said, we can't ignore the possibility of CAD either.
Here's why... 👇
1/15
Cory Rohlfsen@CoryRohlfsen
Is new onset A fib a harbinger of CAD? @CardioNerds #MedEd #MedTwitter
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this is a blueprint for delirium in older adults
but you can do this for any common illness
If repeated daily in morning reports around the country, care would get so much better and we wouldn't have an evidence-to-bedside gap of 10-20 years
instead we get zebras
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if the person stabilizes (which I hope for my patient!) then talk about hospital discharge planning
Can talk about how MediCal is only payer to cover long term caregiver support
Discuss post acute care options as @DavidCGrabowski & I summarized
pubmed.ncbi.nlm.nih.gov/33617438/
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I rather try not to answer Q3).
I say "We will think about it at that point. Let's focus on whether A works for the next week".
Usually, it is more helpful. They look more relieved.
It is better to give a concrete plan with a specific time frame.
3/3
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In a family meeting, patient/family asks lots of questions about the future.
1) "What if A doesn't work? "
2) "We will do B or C "
3) "What if B (or C) doesn't work?"
If you start answering this Q 3), you will get stuck, because more Qs will come. It won't end.
1/
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A parting shot: these authors suggest in this paper that we spend too much time, teaching modal presentations of diseases, and not enough time teaching the full spectrum of presentations of common diseases, which would have higher utility
amjmed.com/article/S0002-…
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You’ve heard the saying “ uncommon presentations of common diseases are more common than common presentations of uncommon diseases.”
Here is a picture that explains the adage followed by a more in-depth explanation
#clinicalreasoning #medicaldecisionmaking
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@VelezNephHepato @MaartenVHemelen Dr. Velez, Any chance I could get a copy of this paper sent to my email umsnided@myumanitoba.ca. Unfortunately, it’s pay walled. Thanks!
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@MaartenVHemelen Hey Maarten, you might be interested in this review article addressing pathophysiology of hepatorenal syndrome. Let me know if are able to get the PDF pubmed.ncbi.nlm.nih.gov/38649221/
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Do you ever wonder how come vasoconstrictors revert renal vasoconstriction in #hepatorenal syndrome? Found it counterintuitive? Here is a 30 sec animation:
GIF
Metairie, LA 🇺🇸 English
A great HPI often makes for an excellent overall H&P!
So keep on working at making it as clear, concise, chronological, and relevant as possible!
Would love any feedback from #MedTwitter on this or other approaches you use!
/Fin
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Pro tips for early trainees for HPI writing and oral presentations:
- Go in forward chronological time (start from when pt was last well up until the present)
- OK to include previous objective data, such as labs + imaging, if avail from before the current presentation
1/
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If you've read this far, you are awesome 💪🏼💪🏼💪🏼💪🏼💪🏼💪🏼💪🏼💪🏼💪🏼💪🏼💪🏼💪🏼💪🏼💪🏼
Thank you 🙏🏻
#MedTwitter if you like it, share it ✅
20/20
#MedEd
GIF
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You are a young #medicine resident!
You are working in a heavy emergency when:
23,♂️,p/w acute breathlessness
You check his SpO2, it's👇🏻
You are worried and start him on supplemental 02, but he remains hypoxic😭
Read on for the diagnosis and a brief review!
1/20
#MedTwitter
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9/
Thanks for reading! I hope this helps you localize. And if you don't know #theroots check them out, great late 90's vibe...
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1/
Me: Lift up your leg.
Patient: I can't!
Me: Ok, look at it and then lift it.
Patient: (lifts leg) Woah!
Me: Voila!
A #tweetorial #neurotwitter #MedTwitter #neuromuscular #MedEd #neurology
Hint: It's not functional neurologic disorder (FND)
Another Hint:
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15/Waiting for 2 important RCTs to see if any of this leads to meaningful outcomes
⚡️ Hi-Lo: ajkd.org/article/S0272-…
⚡️ PHOSPHATE trial: clinicaltrials.gov/ct2/show/NCT03…
Shoutout to @WUNephrology stalwarts/mentors Drs. Slatopolsky,Delmez and others who did so much work in this area
🙏🙏
GIF
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1/ Rounding in our large HD unit past 3 wks & teaching @thehappykidneys @JCummingsMD about P @ sec hyperparathyroidism (secHPT), one of the frustrating topics in Neph. Little data but expert opinions have set goals for P and PTH that pts, MDs, dietitians try to achieve ...
GIF
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New thread approach is one post at a time or it just crashes. So apologies if things appear randomly sometimes. The rest of the posts will arrive in due course. Elon’s X can’t handle it
GIF
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10/10 SIADH encompasses several pathogenic mechanisms that result in ⬆️ AQP2-mediated 💧retention. While treatment modalities aimed to restrict💧, block AVP2R or ⬆️solute aquaresis may b used in most instances, understanding the underlying etiology may help effectively manage pts
New Orleans, LA 🇺🇸 English
1/n SIADH is the FSGS of electrolyte disorders. Why? because it represents a pattern of disorder of water regulation (⬆️uOsm, ⬆️uNa) that can be triggered by different mechanisms of disease, like FSGS is a pattern of injury that can be the result of various glomerular hits.
GIF
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15/15 hypoNa in cirrhosis can be challenging. For more, check out this review with @NephroMD pubmed.ncbi.nlm.nih.gov/35487602/ Fin
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1/n Hyponatremia in cirrhosis rounds: case 1: ESLD 2/2 ETOH. Admitted at OUH 2/2 abd distension/lethargy w/sNa 133. Kept on spirono + furosem + lactulose. Gradual ⬇️in sNa in 10 days. Transferred 4 ⬆️level of care. Arrives with sNa 125, sCr 0.8. Alert, jaundice, ascites, no edema
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#medtwitter We talk a lot about documentation💻 for the sake of insurance companies, other physicians, and even the patient (now that notes are shared) but we never talk about a very (the most?) important person you are communicating with in your notes.....
YOUR FUTURE SELF
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@ekgdx 18/ For those who love to read Instead of a thread, here I share the link:
ekgdx.com/blog/pacemaker…
Note: I made a mistake in the sequence of thread numbers (I apologize)
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1/ Today's 🧵 is about the #pacemaker basics.
The objective of this post is to clarify several doubts in a simple way. #CardioTwitter
I will explain it with simple steps and classic examples so you can understand better.
@ekgdx
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