Thank you to our PD emeritus Dr. Marshall Wolf & @tmmeade1 for kicking off the week with a case of syncope yesterday!
The 💰 is in the 🗣️!
1. Is this true syncope? Transient LOC + spontaneous and rapid recovery
2. How worried 😱 are you for 💔 etiology? Any ❤️ disease, new chest pain/palpitations, exertional or supine syncope, FHx sudden cardiac death, abnormal VS or ECG should set off 🚨
...May be reassured by syncope stable x years, with clear prodrome & trigger, in a younger individual (<40 y/o)
🤔 In thinking about worrisome etiologies, recurrent syncope less likely to be tamponade, dissection, ACS, PE but arrhythmia🔌💓 still on the table!
#TheBrighamFamily looooooooves a good TTE!
But consider ROMEO score (shout out to @tony_breu and @thecurbsiders) - a score of zero 99.5% sensitive for a normal TTE, so may not be needed in all comers with syncope! Image
In this case, our patient had recurrent syncope and recent event monitor: Image
Dropped beats concerning for Mobitz I vs. II - 2:1 block makes it challenging to distinguish!
While Mobitz II confers worse prognosis and ⬆️ progression to CHB, symptoms/syncope + 2nd degree block = class 1 PPM indication! Image

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More from @BrighamMedRes

Sep 2, 2020
Thanks to Dr. Carolyn Becker for a great discussion of ⭐️surprise!⭐️ osteoporosis 2/2 asymptomatic primary hyperparathyroidism!
There are MANY 2ndary causes of osteoporosis- use hx 🔎 to tailor work up. All comers get:
🧑‍🔬 BMP - Cr (CKD), Ca/Phos (⬆️⬇️parathyroid)
🧑‍🔬 LFTs - AST/ALT/bili (cirrhosis), ALP (bone turnover), albumin (nutrit. status)
🩸CBC - anemia ➡️ inflam, malabsorb
🦴 25 OH Vit D
In evaluation of hypercalcemia, PTH shapes your ddx!
🦴Inappropriately nl or ⬆️, ➡️ use urine Ca to distinguish from Fam Hypocalciuric Hypercalcemia
🦴Low PTH then can move on to more extensive work up - problems with AB or REsorption of Ca++ Image
Read 4 tweets
Aug 31, 2020
Happy Monday!

All about the thyroid this morning with teach resident presenter Dr. Deepa Manjunath and faculty discussant Dr. Pedro Sanchez.

We love these high-yield tips on initiating levothyroxine - but don't miss the other awesome pearls below 👇

1/ Image
💡The biochemical profile of elev TSH, normal FT4 has a broad DDx beyond subclinical hypothyroid!

💡Predictors of progression from subclinical to overt hypothyroidism include:
⚠️female sex
⚠️TSH >10 mIU/L
⚠️Presence of anti-TPO antibodies

2/
When to treat subclinical hypothyroidism?

🤰Pregnant women should 💯 be treated
❔Should also consider treatment if:
- TSH >10
- Anti-TPO Ab positive
- Goiter on exam
- Symptoms
- Age <70

[TRUST trial in 2017 did not show benefit in treatment in older adults >70]
3/
Read 5 tweets
Jul 21, 2020
🚨Alert! Introducing a new approach to hyponatremia 🚨

Toss aside that pesky "hypo-, eu-, hyper-volemic" algorithm framework...

Welcome to "The Pallais Approach "
1. Is it hypotonic?

Ensure no *rare* forms of pseudohyponatremia or hyperglycemia and confirm serum osm <275
2. Is it ADH-dependent?

Check urine osm!
<100 = Nope
>100 = Yep

Cool pearl to estimate Urine Osm using spec grav:
1.005 = 150 mOsm
1.010 = 300 uOsm
1.020 = 600 uOsm
Read 4 tweets

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