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Sep 18, 2020 8 tweets 2 min read Read on X
1/ Res report with our fellow Dr. Michelle Rengarajan this week featured a cool case with a lot of ✨pearls✨

28 year old man presents with acute quadriplegia.

What's on your ddx?
2/ BMP drawn and showed K of 1.3!

Your intern year prepared you for this aggressive K repletion moment.

His K improved quickly and weakness resolved! Pt's TSH of <0.01 makes the diagnosis of

*drum roll*

✴thyrotoxic period paralysis (TPP)!✴
3/ We are not done! What's causing the hyperthyroidism?

Review the axis to find 4 mechanisms:

1️⃣Autonomous hormone production by the thyroid (Graves vs. Toxic Nodule)

2️⃣Exogenous

3️⃣Release of preformed hormone

4️⃣Hypothalamic/pituitary stimulation of production Image
4/ We will focus on the top 3 since they cause a low TSH like our Pt. How do we find the etiology?

The T3/T4 ratio can be a helpful initial clue!

Which one of the following conditions often has a T3/T4 ratio greater than 20?

🤔🤔🤔🤔🤔🤔
5/ ANS: Graves!

The ratio is one hint, other key diagnostics include:
☢radioactive iodine scan
🧪TSI & TBII

Check out this great table for a refresher on how to distinguish the different causes of ⬆️ thyroid levels. Image
6/ TSI comes back ➕
You diagnose this Pt with Graves Dz!

Treatment options?

💊 methimazole (or PTU)
☢ radioactive iodine ablation***
🔪 thyroidectomy

*** ☢ suboptimal here. There is a risk of worsening hyperthyroidism in 1st 6mo ➡️ precipitate periodic paralysis
7/ take home messages:

🏠 hypokalemia periodic paralysis can be a presentation of hyperthyroidism!

🏠 4 key mechanisms for thyrotoxicosis

🏠 T3/T4 >20 , +ve TSI and diffuse uptake on RAIU are hallmarks of Graves dz

🏠 3 Tx options for Graves> Meds, RAI, surgery!
8/ Learn more by reviewing a CPC on a similar case!

nejm.org/doi/full/10.10…

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More from @mghmedres

Apr 8, 2021
1/ 34 y/o F with new AML dx on chemo (7+3) ANC 200. Counts are expected to continue to drop & not get better for at least another ~10d. Has been febrile 🌡️🔥 & on cefepime 2g q8 for the past 5 days💊💉. What do you do next?

#MedTwitter #OncTwitter #IDTwitter
2/ Former chief resident & leukemia doc @andrewbrunner from @MGHCancerCenter spoke about acute leukemias & #FebrileNeutropenia (F+N) ! Here are some #ConferenceTwearls

Definition:

Febrile: ≥ T 100.4 🌡️



Neutropenia: ANC ≤ 500 or an expected 📉 to an ANC of ≤ 500 in 48h
3/ It's 🔑to look for a source of possible infection. BCx for all comers! Additional w/u depends on the clinical context.

📸Low threshold to image/scope these pts since they may not present classically---> e.g. pt w perforated abdomen can present w soft abdomen on PE.
Read 7 tweets
Mar 17, 2021
1/36 y/o F hx of anxiety p/w a 2nd episode of transient chest pain w emotional stress & her admission EKG shows 4 mm ST elevations in leads V1-V3. Her 1st troponins check was high. She is currently chest-pain free & vitals are normal.

What do you do next?
#MedTwitter
2/ This is a picture of her EKG Image
3/ You look up and notice the STEMI pathway chart conveniently plastered above your workstation‼️

You recognize the patient's presentation is consistent with ACS and her ST elevations meet criteria for STEMI---> you appropriately escalate and decide to call "code STEMI" 🚨📞 Image
Read 8 tweets
Feb 9, 2021
1/ID docs are known for their smarts, amazing notes and for being.....NOSY! 👃🔍

Former chief resident & ID fellow @PierreAnkomah unravels the clinical reasoning behind

🕵️‍♀️Why ID docs ask so many Questions

Follow for #ConferenceTwearls!

#IDtwitter @mgh_id @MGHBWHIDFellows
2/ One of the core concepts of clinical reasoning in ID is to

🔍 name the syndrome (i.e acute febrile diarrheal illness)

while exploring the interaction between

🦠 Microbes

👤 Host

🌍 Environment Image
3/ see the example below that showcases the
🔍syndrome👤host 🌍environment

When it comes to 🦠 microbes, think of them in BUCKETS:
💥Viruses

💥Typical bacteria
💥Atypical bacteria
💥Mycobacteria

💥Fungi
💥Parasites

See an example w a ddx of ring enhancing brain lesions🧠 ImageImage
Read 4 tweets
Jan 19, 2021
1/ If there's some joint pain
In your neighborhood
Who you gonna call? 📞

🤯GOUT BUSTERS 👩‍⚕️

PGY-1 @Jen_LS_Hanberg gave a talk on
💊Urate-Lowering Therapy (ULT)💊

Let's review some pearls!
@MeganLockwoodMD @MGH_MSUS #MedTwitter #RheumTwitter #Nephtwitter #Gout Image
2/ Who gets ULT?

The strongest indication is for patients with:

✅2 or more flares annually

✅Radiographic damage due to gout

✅TOPHI Image
3/ What are your ULT options? Check out the awesome slide below.

Takeaways:
💊Start with allopurinol! It will give you the biggest bang for your buck
💊Your target UA level is 6⃣- titrate q2-4 weeks
💊Start prophylactic therapy at the same time (NSAID, colchicine, pred) Image
Read 6 tweets
Oct 4, 2020
1/ We have a special tweetorial by PGY-1 @kevincmillerMD !

We are here to talk about @DGlaucomflecken 's favorite organ: THE SPLEEN! ♥️Or rather, what happens in its absence!

Is having a splenectomy a risk factor for thrombosis ❓🤔

@MedTweetorials #MedTwitter
2/ First, the spleen is a complex, beautiful & underrated organ. There, we said it. 🤷

It’s so great that 15% of people have an extra accessory spleen

The spleen has 3 general components: A marginal zone & 2 pulps.
3/ ↔️Marginal Zone: Free-flowing transit space for immune cells, where antigens are captured by dendritic cells and B cells (i.e. as APCs) prior to migration to white pulp.

⚪️White Pulp: Physically exclusive lymphoid tissue where T and B cells mature 👶👧👩👵
Read 15 tweets
Sep 15, 2020
1/ The fall weather is getting us into the halloween spirit, and things are about to get bloody 👻❗

Let's review former chief resident and GI master @NnekaUfereMD's high yield pearls on:

🔴⚫ GI Bleeding ⚫🔴

@MGH_GI #MedTwitter #livertwitter
2/ What's the source?
Upper GI ⬆️ Vs. Lower GI ⬇️

⚫ MELENA
Usually ⬆️
Only 10% of cases are lower GI

🔴💩 HEMATOCHEZIA
- Non-Cirrhotic: ⬇️
only 15% of cases are from upper GI

- Cirrhotic: ⬆️
50% of cases are from upper GI

🔴🤮 HEMATEMESIS:
Rectal exam for triage
3/ For hematemesis 🔴🤮,

The color of 💩 on a rectal exam guides triage. See the slide below in terms of urgency!

🚨Red stool suggests a brisk bleed that will need urgent attention🚨 Image
Read 4 tweets

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