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For the #OBGYN community please watch the free AAGL #COVIDー19 webinar w/ global gyn surgeons from Seattle to Italy & S.Korea. Sobering glimpse for what’s to come nationwide. I have summarized international takeaways below:
S.Korea has implemented many strategies that’s helping to effectively #FlattenTheCurve:

1. National coordinated/organized response:
-“United we stand, divided we fall”
2. Testing:
-Relatively cheap (<$200)
-Results available in 4-6 hours, -Convenience-drive thru testing launched quickly
-Fast Isolation and Treatment

3. Tracking (controversial)
-All confirmed cases using surveillance cameras, car license plates & credit cards
Read 19 tweets
1/ #COVID19 #Tweetorial, calling #MedStudentTwitter / #medtwitter to help search the literature as we refine treatment protocols @YaleMedicine @The_BMC @Pranay_md @KaminskiMed for the benefit of all.

Background: We need to tackle antiviral and hyperinflammation pathoimmunology
2/ Given no known efficient therapy, chloroquine was investigated given its prior described inhibition of several coronaviruses. This became a backbone of therapy ( Chloroquine is not readily available in the US at this time.
3/ Hydroxychloroquine (in vitro) was shown to reach 3x the potency of chloroquine ( More readily available in the US. Retinal toxicity of HCQ at the very short intervals we use for COVID19 is unlikely. Trials in South Korea and China are ongoing.
Read 11 tweets
Saddened as had been anticipating this along with many. Cancelling the conference during this unprecedented time is the right thing to do.

Through it all, I couldn't have asked for a better leadership team & the larger @SocietyHospMed community for their support! 1/

As stated with the evolving circumstances out of our control with COVID-19 there were risks to our community as it would have gathered, communities we connect with on our travels, and our home communities and hospitals – cancelling was the best way to mitigate these risks. 2/
It has been difficult to process especially with the original trends just over a week ago that showed this conference to have record attendance which is a testament to the engaged community, innovative ideas, amazing core content that was diverse & inclusive. 3/
Read 8 tweets
Teaching Rounds

Diarrhea - Part 1

3 Misleading Mimics
2 Key Questions

Join us #medtwitter & #medstudenttwitter
Diarrhea = increase in stool water content.

We tend to use the term loosely (Ha! 😉) so your patient may be referring to another change in bowel habits when they say diarrhea.

How do we know?

The Bristol Stool Chart!
🙏🙏 @Dietitianbytes
3 Misleading Mimics...

1. Constipation + overflow

2. Stool incontinence

3. Hyperdefecation
This amazing @COREIMpodcast case is a great example -

I've been fooled by all 3...multiple times.
Read 18 tweets
Teaching Rounds Day 4

Anemia - Part 2

Slow loss
The Bone Marrow Factory

Check out part 1 here

Join us #medtwitter & #medstudenttwitter
Ok, let's get out bearings..

1. Is there an approach to anemia?
I don't think so - we need a time course.

2. If you don't have a prior HgB, use the clues below to tease out between acute and chronic anemia.

3. Acute anemia =
Hemolysis or
Acute marrow disease
With me?

Cool - 👊

Let's take on chronic anemia and bring this schema to life.

Let's go!
Read 22 tweets
Teaching Rounds Day 3

Anemia - Part 1

Neighbors and Time Zones...

Join us #medtwitter & #medstudenttwitter
It's nearly impossible to have an approach to anemia.

Yup, impossible.

It's as tough as having an approach to altered mental status?

Wait, what?

Wasn't that the VERY first @cpsovlers episode?
And...what about this schema??
Well, we lied.
Sort of.

That's an approach to ACUTE altered mental status.

Not just any old altered mental status....
Read 22 tweets
Teaching Rounds Day 1/15

Venn Diagrams from a practical lens...
(or "VAN" diagrams as @DxRxEdu calls them!)

How do we actually use them?

Join us #medtwitter & #medstudenttwitter
If you are in a position to use a Venn Diagram, that probably means you've crystalized the fundamental aspects of your patient's condition.

In other words, your problem representation is fairly advanced and you've identified the salient features.

Nice job!!👊👊👊
Ok...for real do we actually use this tool?

It's virtually impossible to run the DDx of both "A" and "B" at the SAME time...

That's the definition of cognitive overload.
Read 7 tweets
February Teaching Rounds - Recap

Part 1 of 2.

Because #spacedlearning is an endless journey...

Join us #medtwitter & #medstudenttwitter
Day 2 - Upper GI bleed

1. 4 common pathways to a working Dx of an overt upper GI bleed

2. 3 common diagnosis...

3. 2 KEY questions!

More here -
Day 3 - H20 toxicity

1. Hyponatremia = excess H20 = H20 toxicity.
The is true is most, but not all cases

2. Why do we care?
When neurons swell they don't work well...

3. @jackpenner's @CPSolvers video & schema

More here -
Read 5 tweets
I had a pretty scary experience last night as a patient that I wanted to share. This story may hit home for #allergy #foodallergy #celiac friends and I hope will be enlightening for my #medtwitter #medstudenttwitter friends! 1/
So my family ordered takeout from a restaurant that I’ve eaten safely at dozens of times in the past. Unfortunately 2 bites into my food, I started to feel nauseous and my lips start tingling.

For anyone with food allergies, you know that’s the start of something bad. 2/
That uncomfortable feeling progressed into full blown anaphylaxis very quickly.

Ive made it 28 yrs, never had to use my EpiPen before & I made the huge mistake of not having it with me. I am INCREDIBLY thankful that my partner keeps one for me at all times just in case. 3/
Read 17 tweets
1/ Welcome to the next installment of @NEJM #CPS summaries!

For full case:

40yo F w/ hx of treated immature teratoma & HBV infection p/w chronic, progressive diffuse pain and weight loss

Me when I get to share clinical pearls 👇🏾
2/ 🌟Initial DDx 🌟
#medstudenttwitter: I often find it tempting to jump straight into listing possible Dx.

Often have to remind myself to be systematic. For this patient:

Up next: how does the PMHx ("background") affect our analysis of this presentation ("foreground")
3/ 📚 History:
Teratoma: tx w/ 4 cycles of bleomycin, etoposide & cisplatin → TAH-BSO

HBV: tx w/ tenofovir

Immigrated from Vietnam 20 years ago

🧠Clinical reasoning: when evaluating "background" I ask myself 3 questions 👇🏾
Read 10 tweets
Teaching Rounds Day 11/15


Beyond the Mechanism & Back to the Bedside

Join us, #medtwitter & #medstudenttwitter
I fondly remember learning about hypoxemia in medical school and breaking it down by mechanism

1. Low FiO2
2. Hypoventilation
3. Impaired diffusion
4. Shunt
5. V/Q mismatch - the go-to answer every time!
This was a great way to understand hypoxemia, but I haven't found myself using this approach clinically.
Read 12 tweets
1/ Do you mentor or are you: a learner wanting to improve exam scores? Dx the reason for low test scores in today’s #MedEdMethodsMonday!

Inspired by @thecurbsiders ep193 featuring @Missydoc0128

#MedEd #MedThread #MedEdPearl #MedTweetorial #FacDev #Medtwitter #medstudenttwitter
2/ Self-Regulated Learning Microanalytic Assessment and Training (SRL-MAT) - a tool that can identify 6 test-taking problems, described by Dr. Andrews @williamkellymd @GenesseyFlint & Dr. Dezee from @USUhealthsci in @AcadMedJournal
3/ The tool is used between a mentor & learner in a 60-min session.

The learner 1st reads & thinks aloud while going through a vignette appropriate for their level, with the actual question and answers covered.

They then talk through a Question Review Form:
Read 9 tweets
Teaching Rounds Day 3/15

H2O toxicity...

Say what?

H2O toxicity.

The Story and The Schema.
Join us, #medtwitter & #medstudenttwitter
The Story...

What is H20 toxicity?
It’s when the blood has too much H2O.

What exactly is too much?
Enough that neurons swell and
don't work well.

The symptoms of this mysterious condition?
When severe, patients can have a seizure, and other marked neurologic symptoms.

More commonly, patients have symptoms from the underlying cause, and not so much the H20 toxicity.
Read 17 tweets
Alright #medtwitter, #medstudenttwitter, & #CriticalCare, today’s #tweetorial is on the ever challenging and misinterpreted lactate!

So, what does lactate most appropriately represent?

If you’re like me, you had lactate = anaerobic respiration = hypoxia drilled into your head.

First, is this real? And then, most importantly, is this clinically relevant?

To unravel this mystery-we need to know where lactate comes from!

Lactate is made in the cytoplasm according to this reaction:…

Read 20 tweets
#Tweetorial time! Today's topic: insulin!

We all know that insulin release is stimulated by glucose. So, let's start with a question.

You give a patient the same amount of glucose, either orally or via IV. Does one method cause a more robust insulin response than the other?
The insulin response is much greater to the oral glucose, even though both cause the same increase in blood sugar (Lindgren et al., 2011)! To understand why, we need to explore the wild world of incretins. But first, let's circle back to insulin!
#highyield review: Insulin is a peptide with an alpha and beta chain connected by three disulfide bonds. The most important insulin-dependent glucose transporter is GLUT-4, expressed on adipose tissue and striated muscle. But, many tissues don't need insulin to uptake glucose!
Read 17 tweets
This week's #tweetorialsinpsychiatry is on suicide risk assessment in the ED (or indeed anywhere) and is predominantly aimed at non-psychiatrists and psychiatrists in training. I hope it is of help. #psychtwitter #medtwitter #medstudenttwitter #suicide #depression #psychosis
For additional reading around this tweetorial I recommend the following guide from the Oxford Centre for Suicide Research:…
There are ~6000 suicides/yr in the UK (~47k in the US) of which ~90% have a psychiatric disorder. Depression accounts for 60%, Half have seen their GP within 3 months and 20% in the week before death.
Read 26 tweets
Enjoying our renal block right now. Thought I would try my hand at a #tweetorial for review and because this little pearl has been blowing my mind.

Why are people with nephrogenic diabetes inspidius, who are peeing lots, sometimes given a thiazide diuretic for treatment?
The answer is that while a thiazide diuretic would make you or I pee more, it will make someone with NDI pee less--so much less that it can be used to treat the polyuria that comes along with NDI.

To understand how, let's review the pathophys of NDI and the MOA of thiazides.
NDI is characterized by insensitivity of the kidney to ADH, aka vasopressin, the hormone that is secreted by the posterior pituitary and responsible for concentrating the urine.
Read 15 tweets

I dove into the FEC data, and it's pretty clear:

Grassroots health professional donors far prefer Sanders and Warren to Biden and Buttigieg. 1/
For doctors, donations went mostly to Warren and Sanders, with Sanders slightly receiving more.

Buttigieg received a substantial portion.

Biden received very little.

#MedTwitter #MedStudentTwitter
@darakass @DrDooleyMD @AbdulElSayed @DrSriram @DoctorsforPete @Docs_4_Bernie To me this corroborates the polls which show that while medical trade groups/guilds/professional societies might not support policies like #MedicareForAll, grassroots doctors feel differently. 3/
Read 11 tweets
#medtwitter #tweetorial on one of my favorite, elegant little mechanisms. This is something every #resident and #medstudenttwitter will see ALL the time! Bonus inclusion: a simple way to think about macro/micro-cytosis.

So, why is basically everyone in the hospital anemic?


- it is useful to remember that the venous blood “drawn” for a lab test is composed of many parts: plasma, RBCs and WBCs.

- Hemoglobin (Hgb) is a direct measure of the actual Hgb molecule within the RBCs


- hematocrit (Hct) is the % volume of RBCs

So why can we “cheat” and just multiply the hemoglobin by 3 to get the hematocrit?

Well - in a healthy RBC, approximately 1/3 of its space is a hemoglobin molecule!

So, imagine each RBC as just a Hgb molecule wearing a coat! The Hgb is 1/3 of the space, the coat 2/3s!

Read 17 tweets
Hey #medtwitter and #medstudenttwitter! A while ago, I gave a #dermatology presentation on the intersection of derm and #trans health.

I learned a lot. So here's a #medthread on some of the takeaways I found most valuable.

Let's start with our transfeminine pts.

Derm can provide a number of facial feminization procedures (FFP): e.g. botox, soft-tissue augmentation.

These FFPs can be more affordable/less invasive than feminizing surgeries such as forehead or mandibular contouring.

Note: tho traditionally considered "cosmetic", these interventions have MATERIAL psychosocial benefits – studies show that facial feminization has a demonstrated positive impact on QoL + mental health outcomes.

Read 10 tweets
#tweetorial time for SUPER FAST, no WINTER or (difficult) MATH evaluation of Anion-Gap Metabolic Acidosis:


The metabolic seesaw:

(more BC)

dAG = delta Anion Gap
dBC = delta Bicarbonate.
Toward the Center = more bicarbonate

This will all make sense in a moment.

Scene: patient w/ anion-gap metabolic acidosis

Your ?: is their compensation appropriate? Do I need more labs? Who and what is a winter and why do they have a formula?!?!

Answers: seesaw only, a chemistry is all you need!

Read 12 tweets
A last-day-of-pediatrics-clerkship thread.

#BuckleUp #MedTwitter #MedStudenTtwitter #Pediatrics

When my sister was 3 years old, my mom brought her to her general pediatrician for a regular well check.
She was a healthy appearing, curious and impassioned 3 year old. I wasn’t there but I imagine her pediatrician had to use the kind of magic only pediatricians have to get her to sit still for the visit.
I imagine that maybe he and my mom chatted casually about life’s happenings as he proceeded with the physical exam. I imagine that the exam was made challenging by my sister who was probably squirreling around, excited about the lollipop or sticker that awaited.
Read 11 tweets

A #tweetorial for the #dermtwitter, #medtwitter, #medstudenttwitter, and #hospitalist crowd. 📸:@dermnetnz #medthread

Let's start with a question - What percentage of leg ulcers do you think is caused by venous stasis?
Roughly half (40-50%) of all leg ulcers are the result of venous stasis! Since 1% of the population will get stasis ulcers at some point, it's quite common, both in the inpatient & outpatient settings!

While some say they aren't painful, many of my patients would disagree....
Let's talk exam. These ulcers are predominantly on the lower legs, and often near the medial malleolus. They're usually chronic, so they may have a base covered by yellow fibrinous debris. They tend to be shallow, and given the pathophysiology, quite exudative.
Read 15 tweets
CUTANEOUS LUPUS – a #tweetorial/#medthread!!

We all learn about Systemic Lupus Erythematosus (SLE) in medical school, but did you know there are multiple forms #lupus can take in the #skin?

#Meded #FOAMed #dermtwitter #medtwitter #rheumtwitter #dermatologia pc: @dermnetnz
It wasn’t until #dermatology residency I learned about all the subtypes of cutaneous lupus (CLE)! I thought it was all just one disease: SLE. But in reality there are many forms of CLE, each with its own implications on systemic involvement and effect on the patient.
Let’s start with the 3 subtypes:
Acute, Subacute, and Chronic Cutaneous Lupus Erythematosus (ACLE, SCLE, CCLE). CCLE is aka Discoid.
Each subtype "overlaps" with SLE in a different way.

Eg: ACLE overlaps completely with SLE, so they all have SLE! 👇…
Read 17 tweets

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