Discover and read the best of Twitter Threads about #kashlakchief
Most recents (11)
1/
#KashlakChief present #5goodminutes on cardiac prevention:
New AHA/ACC CVD Primary Prevention Guideline medscape.com/viewarticle/91… via @Medscape
Much good advice in this guideline for @thecurbsiders
#KashlakChief present #5goodminutes on cardiac prevention:
New AHA/ACC CVD Primary Prevention Guideline medscape.com/viewarticle/91… via @Medscape
Much good advice in this guideline for @thecurbsiders
2/
They do emphasize risk prediction and still use their old model. I prefer changing to the model discussed in our podcast - Improving Estimation of Cardiovascular Risk @AnnalsofIM @ACPinternists bit.ly/2ugxkbq
They guideline does suggest shared decision making here.
They do emphasize risk prediction and still use their old model. I prefer changing to the model discussed in our podcast - Improving Estimation of Cardiovascular Risk @AnnalsofIM @ACPinternists bit.ly/2ugxkbq
They guideline does suggest shared decision making here.
3/
When the decision is a difficult one they endorse coronary artery calcium scoring for risk stratification - interesting and a topic for a future podcast.
When the decision is a difficult one they endorse coronary artery calcium scoring for risk stratification - interesting and a topic for a future podcast.
1/
#5goodminutes provides the answer to #KashlakChief presenting: Patient with 5 lb weight loss, recurrent esophageal strictures, & painful esophagitis. Labs creat 2.2 (up from 1.3), Ca++ 12.8.
ANSWER: milk alkali
@thecurbsiders @CPSolvers
#5goodminutes provides the answer to #KashlakChief presenting: Patient with 5 lb weight loss, recurrent esophageal strictures, & painful esophagitis. Labs creat 2.2 (up from 1.3), Ca++ 12.8.
ANSWER: milk alkali
@thecurbsiders @CPSolvers
2/
After presentation, I asked if the patient was taking Tums. The student had gotten the history of excess calcium carbonate intake.
The next day after withholding CaCO3, the calcium lowered to 10 and creatinine was already decreasing.
Here are some references:
After presentation, I asked if the patient was taking Tums. The student had gotten the history of excess calcium carbonate intake.
The next day after withholding CaCO3, the calcium lowered to 10 and creatinine was already decreasing.
Here are some references:
3/
Hypercalcemia and Milk‐Alkali Syndrome journalofhospitalmedicine.com/jhospmed/artic… A case report we wrote 9 years ago
Dx Schema - Hypercalcemia clinicalproblemsolving.com/dx-schema-hype… via @CPSolvers
Hypercalcemia and Milk‐Alkali Syndrome journalofhospitalmedicine.com/jhospmed/artic… A case report we wrote 9 years ago
Dx Schema - Hypercalcemia clinicalproblemsolving.com/dx-schema-hype… via @CPSolvers
1/
#KashlakChief goes a bit deeper into the loop diuretic discussion started yesterday. Spend #5goodminutes considering these ideas. Some postulated that the oral diuretics on the last day would increase LOS and it could not be done. Check this out @thecurbsiders
#KashlakChief goes a bit deeper into the loop diuretic discussion started yesterday. Spend #5goodminutes considering these ideas. Some postulated that the oral diuretics on the last day would increase LOS and it could not be done. Check this out @thecurbsiders
2/
Most such patients need massive diuresis. You should have a good idea of pending d/c a couple days in advance. We switch to oral once d/c is approaching to be certain that we have the proper oral loop diuretic. Since we have some data that it decreases readmissions ...
Most such patients need massive diuresis. You should have a good idea of pending d/c a couple days in advance. We switch to oral once d/c is approaching to be certain that we have the proper oral loop diuretic. Since we have some data that it decreases readmissions ...
3/
Another comment was concerned about the cost of torsemide. Check out GoodRX - goodrx.com/torsemide - only three times as expensive as generic furosemide if you purchase at the right place (and almost everyone has a WalMart). 30 cents per 20mg pill is not bad.
Another comment was concerned about the cost of torsemide. Check out GoodRX - goodrx.com/torsemide - only three times as expensive as generic furosemide if you purchase at the right place (and almost everyone has a WalMart). 30 cents per 20mg pill is not bad.
1/ #KashlakChief spends more than #5goodminutes exploring normal anion gap metabolic acidosis (NAGMA) due to CKD.
We see many CKD patients on sodium bicarbonate tablets or sodium citrate. This tweetorial will start with why we treat NAGMA. @thecurbsiders
We see many CKD patients on sodium bicarbonate tablets or sodium citrate. This tweetorial will start with why we treat NAGMA. @thecurbsiders
2/ Following we will explain the physiologic causes of NAGMA. Finally, we will discuss treatment dosing.
3/ Current guidelines recommend treating NAGMA with a goal bicarbonate of 22. Three benefits - decrease bone disease, improve nutritional status, delay progression of CKD to ESRD.
1/ How to decipher today's abnormal FBP:
82 yo woman admitted 4 GI bleed (esophageal ulcer) Transfused & volume repleted.
4 days later BMP 142/3.4/112/17/5/0.8
Admission
142/4.2/101/25/45/1.3
#KashlakChief asks
Why is the bicarb 17?
@CPSolvers & @thecurbsiders
82 yo woman admitted 4 GI bleed (esophageal ulcer) Transfused & volume repleted.
4 days later BMP 142/3.4/112/17/5/0.8
Admission
142/4.2/101/25/45/1.3
#KashlakChief asks
Why is the bicarb 17?
@CPSolvers & @thecurbsiders
2/
She has a bicarbonate of 17 with an anion gap of 13. Her albumin was normal.
Initial assumption - normal gap metabolic acidosis.
Two possibilities - losing base or inability to buffer daily acid
She has a bicarbonate of 17 with an anion gap of 13. Her albumin was normal.
Initial assumption - normal gap metabolic acidosis.
Two possibilities - losing base or inability to buffer daily acid
3/
Losing base occurs when we have GI losses. The patient had no diarrhea, no previous Gi surgery, thus this seemed extremely unlikely. Patients with normal renal function need liters of diarrhea to develop this much lowering of their bicarbonate.
Losing base occurs when we have GI losses. The patient had no diarrhea, no previous Gi surgery, thus this seemed extremely unlikely. Patients with normal renal function need liters of diarrhea to develop this much lowering of their bicarbonate.
1/
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
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
2/
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.
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.
3/
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.
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.
1/
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
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
2/
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.
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.
3/
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.
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.
1/
#5goodminutes with #KashlakChief
Great case conference, your job = diff dx Questions encouraged.
@thecurbsiders @CPSolvers
#5goodminutes with #KashlakChief
Great case conference, your job = diff dx Questions encouraged.
@thecurbsiders @CPSolvers
2/
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.
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.
3/
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
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
1/
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.
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.
2/
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.
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.
3/
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.
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.
1/
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
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
2/
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.
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.
3/
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.
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.
1/ #5goodminutes #KashlakChief has some tweetorial thoughts to add to:
Episode 2 – Hyponatremia – The Clinical Problem Solvers clinicalproblemsolving.com/2018/12/09/epi…
attn @DxRxEdu @CPSolvers @thecurbsiders Please ask for explanations if any of these points are confusing.
Episode 2 – Hyponatremia – The Clinical Problem Solvers clinicalproblemsolving.com/2018/12/09/epi…
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 - medrants.com/archives/3480
