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As a Cardiology fellow, we get a lot of consults for systolic heart failure.

Here is my approach/work-up for this consult (Part 3).

*Not to use as medical advice, just tips, and always discuss with your fellow/attending*

-thread 🧵-

#MedTwitter #MedEd #Cardiotwitter #IMG
- Dyspnea: earliest and most common
- Orthopnea: more with advanced disease (90% sensitive and specific), can develop PND and Cheyne-Stokes
- Fatigue/exercise intolerance
- Anorexia, abdominal pain, bloating with advanced right-sided heart failure
Physical Examination:
- Well-compensated: no symptoms
- Volume overloaded: weight gain, elevated JVP, +Hepatojugular reflex (>4 cm)
- Pedal edema (can be non-specific if venous insufficiency, nephrotic syndrome, hepatic dysfunction, use of Ca2+ blocker, or TZD)
Read 9 tweets
How do we diagnose Cushing's? We have 3 screening tests:

1. 24-hour Urinary Free cortisol
2. dexamethasone suppression test
3. Late night salivary cortisol

Late night salivary cortisol is THE BEST first test for Cushing's. Let's explore why the other two have their problems:
When can't we trust the dexamethasone suppression test?
1⃣.changes in Cortisol Binding Globulin (CBG)
⏫ CBG- increased estrogen (pregnancy, oral contraceptives, hormone replacement therapy), SERM
⏬ CBG- cirrhosis, nephrotic syndrome, critical illness
When can't we trust the dex suppression test?

2⃣ changes to dex metabolism
⏫ dex metabolism (CYP3A4 inducer)- anti seizure meds, pioglitazone, alcohol
⏬ dex metabolism- antidepressants (fluoxetine), diltiazem, cimetidine
ALWAYS measure a morning dex level with the cortisol!
Read 8 tweets
As a Cardiology fellow, we get a lot of consults for systolic heart failure.

Here is my approach/work-up for this consult (Part 2).

*Not to use as medical advice, just tips, and always discuss with your fellow/attending*

-thread 🧵-

#MedTwitter #MedEd #Cardiotwitter #IMG

- If the LHC is negative for obstructive epicardial disease, you have to play detective and determine the cause for non-ischemic cardiomyopathy

- Remember ~50% of cases will be non-ischemic cardiomyopathy. It may be challenging to determine the exact cause!
Differentials (Laundry List):
1) Idiopathic
2) Familial
3) Hypertrophic
4) Restrictive
5) Arrhythmia
6) Valvular Heart Disease
7) Hypertension
8) Amyloidosis
9) Sarcoidosis
10) Infectious (Chagas, Lyme, HIV, Adenovirus)
11) Toxins (alcohol, cocaine)
Read 10 tweets
A @Dr_BellaR inspired #MedEd #MedTwitter thread on delirium.

Useful stuff for clinical practice, rather than sodium and chloride ions doing things. 🧵
Delirium is a functional impairment of the brain across multiple cognitive domains. Often there’s a physical health insult somewhere in the body, and a ‘by-product’ of it/the body fighting it is that the ‘mind’ is knocked for 6 🏏.
It is far more likely to happen if the brain is already ‘vulnerable’. Decreased neurophysiological reserve if you will. An older brain with structural damage on CT/MRI (old strokes, atrophy, encephalomalacia etc).
Read 12 tweets
As a Cardiology fellow, we get a lot of consults for systolic heart failure.

Here is my approach/work-up for this consult (Part 1).

*Not to use as medical advice, just tips, and always discuss with your fellow/attending*

-thread 🧵-

#MedTwitter #MedEd #Cardiotwitter #IMG
What is Systolic Heart Failure?

- It is an impaired myocardial performance & progressive maladaptive neurohormonal activation of the cardiovascular + renal systems

- This leads to circulatory insufficiency & congestion

- Most common indication for hospitalization > 65 years
- LVEF < 40% with chamber dilation and decreased stroke volume

- Different modalities can vary in measuring EF (can use TTE, TEE, LV gram during LHC, MRI)

- Cardiac remodeling with myocyte hypertrophy, fibrosis, apoptosis, necrosis
Read 10 tweets
A 25-YO♂️ in Nigeria 2 years earlier: recurrent itchy swellings on his hands and forearms, appearing every week or so for the past few months.

What's in the #eye (A) & in the blood (B)?
#Ophthalmology #parasitology #microbiology ImageImage
Identification of:
📌an adult worm in the eye
📌the microfilariae on a blood smear

LOA LOA FILARIASIS is a skin and eye disease caused by the nematode worm Loa loa.

#parasites #MedEd #MedTwitter ImageImage
Loa loa is one of three parasitic filarial nematodes that cause subcutaneous filariasis in humans.
The other two are Mansonella streptocerca and Onchocerca volvulus (causes river blindness).

#Doctor #MedStudentTwitter #oftalmologia
Read 4 tweets
As healthcare workers, our responsibility is to improve the well-being of our patients.

In order to take care of others, at the highest level, we need to prioritize our health & wellness.

Here are 4 areas I try to focus on:

-thread 🧵-

#MedTwitter #MedEd #Cardiotwitter #IMG
1) Healthy Eating
2) Sleeping
3) Physical Activity
4) Stress Management

The limiting resources during residency, fellowship, & even attending life are time and energy. As a fellow, I am working on trying to improve these 4 aspects.

Lets dive in:
1) Healthy Eating:

- This is critical because in the healthcare setting, we are expected to do physical work (walk around and see patients) & mental work (medical analysis, clinical decision-making)

- As we know, the brain consumes around 20% glucose and requires energy
Read 11 tweets
A 17-MO♀️, Morocco: fever, pallor, epistaxis, gingival petechiae, lower limbsedema, & hepatosplenomegaly.

Pancytopenia, hypoalbunemia.
Triglyceridemia, ferritinemia, LDH & fibrinogen:⬆️
Direct Coombs test:➕

🔬myelogram: ?

#parasitology #haematology #Pediatrics
Myelogram revealed the presence of leishmania bodies and figures of hemophagocytosis.

#Pathologists #microbiology #IDtwitter
The patient was put on liposomal amphotericin B and corticosteroid therapy with good clinical and biological evolution.

#MedTwitter #Doctor
Read 9 tweets
As a Cardiology fellow, we get a lot of consults for atrial fibrillation.

Here is my approach/work-up for this consult.

*Not to use as medical advice, just tips, and always discuss with your fellow/attending*

-thread 🧵-

#MedTwitter #MedEd #Cardiotwitter #IMG
- Most common sustained cardiac arrhythmia (1/3 of hospitalizations for cardiac disturbances)

- Degeneration of organized atrial electrical activity into a rapid, chaotic pattern.

- Increases risk of stroke, heart failure, and mortality; higher incidence M >W
Classification System:

1) Paroxysmal: Self-limiting
2) Persistent: > 7 days
3) Long-standing persistent > 12 months
4) Permanent: No longer pursuing restoration of NSR
5) Valvular: Rheumatic MS, Prosthetic Valve, or Mitral valve repair
6) Non-Valvular
Read 12 tweets
1/Ready for a throwdown? MMA fights get a lot of attention, but MMA (middle meningeal art) & dural blood supply doesn’t get the attention it deserves.

A #tweetorial on dural vascular #anatomy

#neurosurgery #neurorad #Neurointervention #radres #medtwitter #neurotwitter #meded
2/Everyone knows about the blood supply to the brain. Circle of Willis anatomy is king and loved by everyone, while the vascular anatomy of the blood supply to the dura is the poor, wicked step child of vascular anatomy that is often forgotten
3/But dural vascular anatomy & supply are important, especially now that MMA embolizations are common for chronic recurrent subdurals. It also important for understanding dural arteriovenous fistulas as well.
Read 17 tweets
A 63-year old man, kidney transplantation: fever and a painful ulcer on the lateral side of the tongue.

🔬: showed invasion of X?
#OralPath #maxillofacial #nephrology
🔬 showed invasion of Cryptococcus neoformans.

A tongue swab:➕for HSV-1.

The cryptococcal antigen test on serum: ➕


#mycology #Pathologists #microbiology
A CT-scan of the lungs showed extensive ground glass lesions & a lesion of 4.7 cm in the left upper lobe.

Bronchoalveolar lavage:➕for Cryptococcus neoformans & Pneumocystis jirovecii.


#IDtwitter #MedTwitter
Read 8 tweets
1/n A🧵. I finally paid off my medical school loans this week. I made payments simultaneously with the LRP. Here is why the @NIH_LRP is a great career move for PhD scientists and especially for physicians who generally have crushing loans... #loans #MedEd
2/n *Let yourself be #mentored* When I was finishing cardiology fellowship training, I swore I was NEVER going back to research! My Chair convinced me (“…just one last ride, can do it”). Listen to those who know you and see something. @Keith_R_M @JustinLathia
3/n *Accept roadblocks*. I was offered an amazing job in private practice paying 7x my salary. No shame in that. I applied for 12 grants and 1 was awarded. My 1st K08 was rejected. In my darkest hour at 12:31 hrs on a Saturday AM @NIH_LRP emailed. Someone believed in my work
Read 14 tweets
During my Internal Medicine training, I wrote 100s of discharge (d/c) summaries.

In my PGY4 chief year, I was an outpatient attending and reviewed many d/c summaries.

Here are some tips and tricks for your d/c summaries.

-thread 🧵-

#MedTwitter #MedEd #Cardiotwitter #IMG
First of all, why do d/c summaries matter?

- They matter because effective transitions of care (inpatient to PCP setting) can lead to better clinical outcomes and decreased hospital (re)-admissions.

- It is a conversation through words between the primary team and PCP
1) Reason for Presentation to the ER:

- Similar to the H&P, this is important for the PCP to know.

- It can be a few words, "chest pain, abdominal pain, uncontrolled hypertension."

- As a PCP, I would think: "Could this presentation been prevented?"
Read 11 tweets
Saline is a powerful surgical instrument. #neurosurgery #bleed #meded #clinicalpearl
Credit to this neurosurgeon Image
Craniotomy for Evacuation of acute subdural hematoma causing compression on brain. See primer on SDH from Netter. Image
Read 3 tweets
Here’s a fun ICU puzzle: what is causing this crazy spiking pattern on the ECG waveform of both an intra-aortic balloon pump & ICU monitor?

A #MedEd 🧵 on an important clinical artifact & the triboelectric effect that we’ll need to go back in time 2500 years to understand!

1/ ImageImage
Before we get to the cool physics behind this important clinical artifact, what device could attached to the patient that’s causing these crazy spikes on the EKG?

The answer is: CRRT machine

In fact, any machine that uses a *roller pump* can cause this artifact.

A roller pump squeezes tubing to generate flow. Here’s the roller pump on the CRRT machine that was causing this weird EKG artifact 👇

Read 11 tweets
Basic cardiac #POCUS views image acquisition flash cards.
Courtesy of Philips Healthcare
#MedEd #Nephpearls #echofirst
Read 10 tweets
During my Internal Medicine training, I wrote 100s of History and Physicals (H&Ps).

Now as a Cardiology fellow, I read every single H&P for a new consult.

Here are some tips and tricks for effective H&Ps.

-thread 🧵-

#MedTwitter #MedEd #Cardiotwitter #IMG
1) Chief Concern:
- This should be the 1st thing listed at the top of the note
- This answers the question, "What made the patient decide to seek medical care?"
- It can be brief, such as abdominal/chest pain or nausea/vomiting
- It is the introduction for the patient's story
2) HPI:
- Tell the story in the patient's words
- It doesn't have to be a novel!
- Usually 4-6 sentences of what the patient is feeling can thoroughly explain the context
- Include pertinent descriptions of the chief concern; i.e. duration, severity, quality of their symptoms
Read 11 tweets
Autoinflammatory syndromes by Dr Dan Kastner at #ACR22 !


🧬AR, pyrin mutation, evolutionary resistance to Y pestis

🌡️Fever 1-3 days
😣Peritonitis (severe)
🫁Pleurisy unilateral
✊Mono or oligoarthritis


⚕️ colchicine, anti IL1 💉

#MedTwitter #MedEd

No ethnic predisposition

🧬AD, TNGRSF1A- p55

🌡️Fever 4-6 weeks
♨️Migratory rash proximal -->distal
👁️ conjunctivitis, periorbital edema

Amyloidosis occasionally

❌response to colchicine
⚕️Steorids ✅ anti IL1✅

Northern europeans

🌡️3-7 days
😣 Serositis
♨️Diffuse MP rash
Cervical adenopathy
Aphthous ulcers

Read 5 tweets
🔥We will have a 1 year, and one of its kind Thrombosis Fellowship training program @ccfvascmed starting July 1, 2023. Our highly-acclaimed expert in thrombosis Dr. Marcelo Gomes is the PD. Applicants should be qualified in Vascular Medicine 🫀, hematology 🩸 or IM.
Training will be given by vascular internists, hematologist, cardiologists, clinical pathologists in thrombosis. Real mentorship & protected time for thrombosis research will also be given by @nih_nhlbi funded investigators . Thank you to @InariMedical for sponsorship !
This is a joint venture between @CleClinicHVTI @CCLRI #CleClinicCancer. Formal application available soon. Please DM me if interested. Please retweet. Our staff:….
Read 5 tweets
Abdominal Vein Milking demonstrating rostral blood flow of Caput Medusae via @bobvarkey

#foamed #meded

Compare to this example of caudal blood flow in SVC Stenosis…

See this great thread by @DrArunKValsan on abdominal vein physical exam pearls Image
Read 3 tweets
You use it, I use it, but how much do you really know about socialisation (or socialization for my friends across the Atlantic)?

Buckle up, it’s #MedEd #TheoryThursdays time!

🧵 Yellow background, black text reading "grab a coffee..
Some of you might be surprised I’m covering socialisation. Many don’t discuss socialisation as a theory or pay it the attention theory needs in MedEd

But it is a theory – in fact, socialisation is a **set of theories** that can help us explain how the status quo is reproduced
Socialisation theories are usually mid-range, as they explore connections between the status quo (+the values/ideas which constitute this), and the social processes (often interactions, shaped by variables such as gender/class/ethnicity) that bring people in line with these ideas
Read 25 tweets
As a Cardiology fellow, we get a lot of consults for syncope.

Here is my approach/work-up for this consult.

*Not to use as medical advice, just tips, and always discuss with your fellow/attending*

-thread 🧵-

#MedTwitter #MedEd #Cardiotwitter #IMG
First, what is syncope?:

- It is the sudden and transient loss of consciousness accompanied by postural tone with recovery; bimodal distribution with peak at age 20 and 80

- Due to transient reduction of cerebral blood flow (at least 6-8 seconds) w/ SBP < 60 mm Hg
What are the major causes?:

1) Reflex-Mediated ➡️ Most common (2/3 cases) with exaggerated / inappropriate reflex ➡️ PS tone

2) Dysautonomia ➡️Think Parkinson's, MS, Lewy body dementia, mult-system atrophy

3) Cardiac Syncope ➡️Arrhythmia versus mechanical obstruction
Read 10 tweets
As a Cardiology fellow, we get a lot of consults for chest pain.

Here is my approach/work-up for this consult.

*Not to use as medical advice, just tips, and always discuss with your fellow/attending*

-thread 🧵-

#MedTwitter #MedEd #Cardiotwitter #IMG
1) Vitals:
- This is the first thing I look at (especially HR & BP)
- Look at their temperature and O2 requirements as common pathology such infection/sepsis/pneumonia can cause a sinus tachycardia
- Many times patient with chest pain are hypertensive with BP > 180
2) EKG:
- One of the most important pieces of the puzzle
- Compare their EKG with a previous one (ideally baseline from clinic/not symptomatic)
- I look for: rate, rhythm, ST-T wave changes, new LBBB, T-wave inversions, septal Q-waves, LVH, R-wave progression, reciprocal changes
Read 13 tweets

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