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Samantha Wang

Jun 22, 2020 • 10 tweets • 4 min read • Read on X

@LindseyShipley8

1/9: A woman presents with diarrhea x 2 weeks that woke her from sleep. I love this fantastic framework for chronic diarrhea by @LindseyShipley8

https://twitter.com/LindseyShipley8/status/1251179121364828160

2/9 We reviewed her admission EKG. What do you notice?

3/9 #MedTwitter: What’s your ddx for low EKG voltage? Think back to physiology. The space between EKG leads &❤️ can be filled with: 𝗳𝗹𝘂𝗶𝗱 (pleural/pericardial effusion), 𝗮𝗶𝗿 (PTX, COPD), 𝗳𝗮𝘁, 𝗶𝘀𝗰𝗵𝗲𝗺𝗶𝗮 (dead tissue) or 𝗶𝗻𝗳𝗶𝗹𝘁𝗿𝗮𝘁𝗶𝘃𝗲 processes.

4/9 But is this all just noise? Remember, she came in for diarrhea! 💩

@cardionerds

5/9 The woman was skinny. Her previous TTE showed LVH. Residency taught me to always consider amyloidosis when we see low EKG voltage but LVH on echo. @cardionerds @Ron_Witteles @AmitGoyalMD

6/9 In the US, amyloidosis primarily exists in 2 flavors: AL (associated w/ plasma cell neoplasms) or ATTR (hereditary or wild type). To begin our work up, we sent off SPIE+FLC, which returned w/ a monoclonal λ light chain band.

𝗕𝘂𝘁 𝘄𝗮𝗶𝘁, 𝗱𝗶𝗱𝗻’𝘁 𝘀𝗵𝗲 𝗰𝗼𝗺𝗲 𝗶𝗻 𝘄𝗶𝘁𝗵 𝗱𝗶𝗮𝗿𝗿𝗵𝗲𝗮? Signal or noise?

8/9 She underwent a colonoscopy for her diarrhea which showed 𝘩𝘦𝘢𝘷𝘺 amyloid deposition. Her bone marrow biopsy showed a 5% clonal population of plasma cells. Final diagnosis: AL amyloidosis and lamda monotypic plasma cell neoplasm

9/9 Takeaways:
1. Always review a patients admission EKG regardless of chief complaint
2. If you see low voltage on EKG + LVH on echo, think amyloidosis
3. Sometimes signal and noise are part of the same tune.

@StanfordChiefs

#MedStudentTwitter #AdviceforNewDocs #Amyloidosis @StanfordChiefs @DxRxEdu @sargsyanz @StanCVFellows

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More from @DrSamanthaWang

Samantha Wang

@DrSamanthaWang

Sep 24, 2020

1/15 #MedTwitter: You're admitting a 64YO male with ESRD on HD for hyperkalemia after missing dialysis. A troponin was checked & returned at 0.78 (nl<0.055 ng/mL), similar to his baseline. He is w/osymptoms and EKG is w/o dynamic changes. What would you call this #tropbump?

2/15 Have you ever been taught to think about troponin as being cardiac vs. non-cardiac in origin? Though this may be a nice framework, it’s simply untrue: if you’re measuring cardiac troponin I (cTnI), it is expressed only on myocardium(not skeletal muscle, unlike troponin T).

3/15 The lexicon to describe troponins is confusing!

"𝘛𝘳𝘰𝘱𝘰𝘯𝘪𝘯𝘦𝘮𝘪𝘢" is frequently used but is not very helpful. It is NOT a diagnosis or etiology, and should probably be abandoned as a term altogether.

Read 16 tweets

Samantha Wang

@DrSamanthaWang

Aug 28, 2020

#MedTwitter: It is switch weekend/Friday! How do you like to sign-out your patient list to the oncoming physician?

I was once a proponent for the email sign out: putting words to paper (or screen) helped me organize my thoughts. And frankly, was more convenient.

But recently, I signed out to my colleague via phone and 💙 it!

We ended-up talking not only about the patients on our list, but past experiences on similar undifferentiated/challenging cases, and our emotional/psychological well-being during present times.

I now prefer signing out via 📞 and encourage you to try it as it:

Read 5 tweets

Samantha Wang

@DrSamanthaWang

Aug 12, 2020

1/15: #MedTwitter: You are admitting a 50-year-old man with a hx GI bleed for a PE. You start a heparin drip. What do you titrate the drip to?

2/15: At my institution, heparin anti-Xa levels (HAL) are recommended, but we routinely draw both aPTT and HAL. I’ve always wondered WHY?

There’s also the page: “The aPTT is supra-therapeutic but the HAL is therapeutic, which should we use?”

Let’s de-mystify this!

3/15: First, let’s understand unfractionated heparin (UFH).

UFH is a negatively charged, heterogenous mix of oligosaccharides. Heparin MUST bind antithrombin (AT) to have an anticoagulant effect. AT then inhibits Xa, thrombin (II), and other proteases.

pubmed.ncbi.nlm.nih.gov/27384570/

Read 16 tweets

Samantha Wang

@DrSamanthaWang

Aug 4, 2020

1/14 #MedTwitter: The ED pages you for an admission: a 24-year-old male with a history of IVDU presenting with fever. How do you take his drug history?

@cuttingforstone

2/14 As a resident, I fell into A + B, until @cuttingforstone taught me you need to know a lot more to appropriately Dx and Tx your patient. My mnemonic?

𝗗𝗥𝗨𝗚: Drug, Route, User, Goods.

3/14 Buckle up for a deep dive into why a detailed drug history matters!

Read 15 tweets

Samantha Wang

@DrSamanthaWang

Jun 19, 2020

1/8 We’ve all had that moment as learners when we think we’ve detected a key physical exam finding, and upon returning with the attending: that rash, cool extremity, or tremor has gone away.

@VillarPrados

2/8 @VillarPrados told me a great catch he made his intern year. He was admitting a gentleman with syncope. He heard a loud systolic murmur during cardiac auscultation and ordered an echocardiogram.

@VillarPrados

3/8 He presented the patient and this exam finding to his attending hours later. When they arrived at bedside to examine the patient, the murmur disappeared! At this point, @VillarPrados is feeling meek and second guessing himself. 😳

Read 9 tweets

Samantha Wang

@DrSamanthaWang

May 28, 2020

1/5 Myths in Medicine:
1.Docusate is an effective laxative
2.Oral iron requires TID dosing
3.HCQ for treatment of #COVID19
4. 𝗖𝗵𝗮𝗹𝗸 𝘁𝗮𝗹𝗸𝘀 𝗮𝗿𝗲 𝗲𝗮𝘀𝘆 𝗮𝗻𝗱 𝗲𝗳𝗳𝗼𝗿𝘁𝗹𝗲𝘀𝘀

2/5 The best #chalktalks are succinct, spontaneous, and seemingly breezy. But that does not mean they don’t require hard work! Anything that looks easy and effortless actually took hours of preparation and repetition. #PrepandReps