1/11 I like this flowchart, but my brain starts to melt. If yours does to, follow along and we'll take it from the top! This is my first #tweetorial on hypercortisolism!
2/11 Let's start with a question. Which of the following are TRUE?
a. Cushing disease = hypercortisolism
b. Cushing disease is a type of Cushing syndrome
c. Cushing syndrome is a type of Cushing disease
3/11 a. and b. are correct! Here are some physical exam features of hypercortisolism.
4/11 Once we suspect hypercortisolism, the next step is to:
5/11 Take that history! Our goal is to figure out if the patient is taking any steroids (inhaled, oral, topical, injectable). If they are, this is EXOGENOUS hypercortisolism.
6/11 If you are concerned about ENDOGENOUS hypercortisolism, we have to start looking at tests, but before that, let's start getting our paradigm straightened out.
7/11 Before we continue, we have to look at the HPA axis. Here is one of the clearest versions that I can find:
8/11 Let's go back to ENDOGENOUS hypercortisolism. We have two think of two types. 1. ACTH-dependent 2. ACTH-independent
9/11 In ACTH-dependent hypercortisolism:
Something is ⬆️ circulating ACTH, leading to ⬆️ serum cortisol (go look at the HPA axis in tweet 7!)
10/11 In ACTH-independent hypercortisolism
Something is ⬆️ circulating cortisol, leading to ⬇️ ACTH levels (go look at the HPA axis in tweet 7!)
Note: EXOGENOUS hypercortisolism is also ACTH-independent
11/11 If we combine all of this, we get this paradigm for hypercortisolism. There is nuance with this, and we will get there in a stepwise fashion. As always, feedback is welcome!
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2/ Brandon asked the group three questions:
1⃣ What is your approach to the pain?
2⃣ How does that inform your next steps for history and physical?
3⃣ How does that inform your next diagnostic steps?
3/ Group answers:
1⃣ We discussed an approach that is nicely captured by this slide
1/10 We often talk about evaluation of AKI in the context of ⬆️ creatinine, but let’s take a step back and think about eGFRs. Here is an approach to interpreting ⬇️ in eGFR! #NephTwitter#MedTwitter#FOAMed#MedEd
2/ This differential focuses on the estimated GFR (eGFR), which is calculated using serum creatinine +/- serum cystatin C levels (we will take a look at the equations in a bit). Biomarkers that actually measure GFR (such as inulin) are not clinically practical to obtain.
3/ Thanks to @ZacNephron for explaining GFR vs eGFR, referring me to Chapter 2 of @BookBurton, and sharing this thread to deepen my understanding of the utility of GFR:
1/10 As someone who struggles with test-taking, I made a framework for tackling some common test-taking hurdles. I had the opportunity to go over this with all our @uclaimchiefs housestaff and decided to make it into a 🧵 #MedTwitter#MedStudentTwitter#FOAMed
2/ Test scores are important because they are what you need to become board-certified. Scores are often conflated with competency - that is quite a fallacy as so many other factors go into competency.
3/ Here is a non-comprehensive set of examples of test-taking hurdles. Let’s go through each of them systematically in a way that resonates with internists - problem listing! FYI, all of these end of overlapping a lot
1/12 The cognitive load on rounds can be high, so I like using daily e-mails as an adjunct to teaching on rounds. Here is a 🧵 on my approach! #MedTwitter#MedEd#FOAMEd
2/ I am of the opinion that you can form an outline of a lesson plan BEFORE you even start on service! My group attends for 14 days at a time, so this tells me how much “time” I have allotted to teach (more on this later).
3/ Make sure to include every learner who will rotate with you while you are on (I use amion to figure out which trainees are on with me). They might appreciate getting learning when they are off service and if there is an ongoing thread of teaching, they won’t miss out!
1/8 Medical education has evolved tremendously, and I am a HUGE fan of having a peripheral brain. An common question trainees ask me is “how do you cultivate references?” A 🧵 on my methodology for organizing information #MedTwitter#MedEd
2/8 Before we start, it is important to categorize the purpose of the info you are gathering:
1⃣ To teach others
2⃣To teach myself
I don’t organize my references this way, but I start here to remind myself that everyone learns best with different modalities!
3/8 Now that we’ve acknowledged that, you must create a list of modalities that you can consistently categorize information into. Here is my organizational system.
The primary focus of this thread is going to be on the history (a heads up - the flowchart at the end will go a little bit out of order)!
3/18 When taking a chest pain history, we ask lots of questions about associated symptoms and alleviating/aggravating factors, mostly because we were taught to obtain and report this history. But is there a more focused way to approach this?