Discover and read the best of Twitter Threads about #5goodminutes

Most recents (8)

1/ In which #UncleBob spends #5goodminutes discussing the strengths and weaknesses of guidelines - stimulate by the CAP discussion on twitter.

The idea of guidelines is to provide a guide for using evidence in diagnosis and management decisions.
@BradSpellberg @ABsteward
Let's first start with some excellent guidelines:
1. Pts with HFrEF should have an ACE-I or ARB
2. Pts with known CAD should take an aspirin daily
3. Pts with anemia & CKD should be treated to a Hgb of ~11.5 and no higher
4. Pts with stable anemia do not need tx until Hgb < 7
We would hope for a guideline for no more than 5 days of antibiotics in CAP patients stable after 3 days. Why? Because we have evidence of efficacy and less harm!
Read 12 tweets
DIURETIC RESISTANCE (an #UncleBob #5goodminutes tweetorial)

1/ 54 yo man w/ LVEF 30%. D/C from hospital 6 weeks - optivolemic
On Lisinopril 20 mg daily, Carvedilol 25 mg bid, Furosemide 80 mg bid

He now has dyspnea & peripheral edema &15 lb gain
h/t @dhekidney & @kidney_boy

On history he tells you that the furosemide no longer produces a significant diuresis like it did when he first returned home. By understanding some renal physiology and some pharmokinetics, we can develop a systematic approach to this patient.

Normal creatinine on labs

4 possibilities for wt gain on furosemide. Two we can discern by history alone.
1. Dietary indiscretion - too much salt in the diet - but that usually does not slow response to loop diuretics
2. NSAID use - they will definitely decrease urine output
Our pt denies both
Read 18 tweets
Hypokalemic quadriparesis (or severe hypokalemia)
39 yo Egyptian admitted with quadriparesis &K = 1.3
Spend #5goodminutes reading how #KashlakChief conceptualizes &teaches this electrolyte disorder. hope @thecurbsiders and @CPSolvers enjoy & @kidney_boy appropriately critiques
Step 1 determine the acid-base status. Patients can get severe hypokalemia and have normal gap acidosis, normal acid-base or metabolic alkalosis. I am not certain about increased anion gap acidosis, but suspect that some DKA patients have severe hypokalemia.
Let's first understand the normal gap acidosis hypokalemia. There are two major possibilities - distal RTA (Type 1) or diarrhea. We diagnose distal RTA when we have a normal gap acidosis and an elevated urine pH.
Read 16 tweets
Pathergy - several colleagues mentioned this key concept. Search for a precise definition, we use the term to group skin lesions that worsen w/debridement or even just minor trauma.
#KashlakChief presents #5goodminutes & @thecurbsiders & @CPSolvers @uabimres
As the presentation unfolded on Wednesday, the first big clue was that the lesions occurred after seemingly minor scrapes, and then worsened with debridement. The cause of the skin lesions became more complex after we learned that the patient had ESRD on dialysis.
The lesions actually looked similar to calciphylaxis. Two findings (prior to biopsy) made that diagnosis less likely. Her Ca 7.5 (alb 2.2) and Phos 4.5 did not give that high a calcium-phosphate product. Then her CT of the lesions did not show calcium.
Read 7 tweets
#5goodminutes with #KashlakChief
Great case conference, your job = diff dx Questions encouraged.
@thecurbsiders @CPSolvers
60+ woman w/ worsening forearm pain. Fell 1 month ago - forearms developed open sores. Debridement worsened the sores X 2. Antibiotics did not help. Now transferred to your hospital quite sick needing BP support.
Both forearms have large necrotic lesions. She has a new lesion on her abdomen. PMH - ESRD, DM2, CAD, Increased BP - on appropriate meds.
Will answer questions as best I can. Answer with brief tweetorial tomorrow
Read 3 tweets
Spend #5goodminutes thinking about refeeding syndrome with #KashlakChief. Refeeding syndrome actually occurs either with decreased glucose intake or total insulin lack. Who gets this syndrome? I have seen it mostly in alcoholics who eschew food.
Patients with eating disorders (especially anorexia nervosa) or diseases that restrict oral intake (esophageal cancer or stricture or Schatzki ring as examples. You can also get the syndrome from newly diagnosed type I diabetes.
In all these situations, when the 2 components necessary for glycolysis are present (glucose and insulin) the body proceeds. Because these patients have decreased phosphate stores (glycolysis produces ATP) this further decreases serum phosphate levels.
Read 7 tweets
Reciprocal creatinine plots (AKA 1/creatinine vs time) - why internists should understand this concept.
#5goodminutes #KashlakChief @thecurbsiders I hope @kidney_boy will comment and correct any errors
First, this is not a perfect concept, but it is useful for 3 reason. The concept follows from the observation that for most patients, GFR decreases linearly.
Since the creatinine clearance formula has creatinine in the denominator, we can use 1/creatinine as a substitute for estimated GFR. Thus these plots show us the usually relentless progression to ESRD in most patients with significant CKD.
Read 12 tweets
1/ #5goodminutes #KashlakChief has some tweetorial thoughts to add to:
Episode 2 – Hyponatremia – The Clinical Problem Solvers…
attn @DxRxEdu @CPSolvers @thecurbsiders Please ask for explanations if any of these points are confusing.
2/ Prior to giving saline to hyponatremic patients, please check urine osms. If they are very low (and the serum sodium is very low), you run the danger of overly fast correction and hence demyelination. If the urine osms suggest SIADH, then saline can lower Na significantly
3/ The best explanation for ineffective arterial volume comes from Schrier - here is my blog post from 10 years ago -
Read 8 tweets

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