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Ravi Singh

23 Feb, 11 tweets, 5 min read

1/ Is bandemia with a normal WBC count concerning for a lethal infection?
It's a very interesting concept which I've faced and will explore below :
#MedTwitter #MedStudentTwitter #FOAMed

2/“Left shift” means that a particular population of cells is “shifted” towards more immature precursors
Josef Arneth (1873-1955) described this left-shift term.

% neutrophils is commonly reported as a "left shift" in the Diff which is incorrect
jamanetwork.com/journals/jama/…

3/Mechanical hematologic counters were used early on last century which perpetuated the term" left shift" with the manual counting of immature neutrophils which were towards the left side of the mature cells on the counter.

4/Now comes the question when you're faced with a left shift with a normal WBC. How significant can this be to considering a serious infection ?

5/An interesting case involved such a situation with a 48 year old pt with pancreatitis.
The pt had a benign presentation, elevated bands of 24% with a normal WBC at 9.8K/mm3 and lipase 102 U/L.
The patient improved after a day of observation.
acoep-rso.org/the-fast-track…

6/The question came up- Should the patient have been admitted or discharged with close outpatient follow-up?
Ultimately it was decided to discharge the patient with close followup.

7/The patient returned to the ED less than 12 hours later with hemorrhagic pancreatitis and was intubated during his inpatient stay and eventually recovered.
Dress et al determined high bandemia was associated with increasing odds + Blood cx and inpt mortality.

8/Another patient that I encountered with high bands and normal WBC with an suspected infection for weakness. I started pointing alarmingly to the bandemia indicating that it was dangerously high. That patient ended up in the ICU an hour later inspite of our efforts

9/In this paper by Seigel et al:
Bandemia had a sensitivity of 82% for culture proven bacteremia.
jem-journal.com/article/S0736-…

10/The DDx for bandemia is broad and must be kept in mind.

11/There are currently no clinical standards by which otherwise healthy-appearing patients with isolated bandemia should be treated with antibiotics and admitted.
Clinicians should understand the value of band counts so they don't delay the Dx or overlook severe infections.

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More from @rav7ks

Ravi Singh

@rav7ks

17 Dec 20

1/ "Don't forget to correct that phosphate so that the it can help the patient recover from acute respiratory failure !" This concept triggered a lot of questions on rounds.
It's worth taking a quick look at this association !
#medtwitter #MedStudentTwitter #FOAMed #phosphate

2/⬇️Phosphate leads to ⬇️red cell 2,3-DPG and a reduction in ATP.
⬇️Phosphate diverts glucose -> 1,3-DPG into the Rapoport-Leubering pathway away from ATP generation towards producing 2,3-DPG so that the oxygen affinity of RBC's does not increase and the tissues receive O2.

3/⬇️Phosphate does also impact RBC survivability with a
⬆️hemolysis, ⬇️in RBC deformability, ⬇️ capillary transit and ⬇️GSH.

Read 11 tweets

Ravi Singh

@rav7ks

25 Sep 20

1/Why does the Hg/Hct drop in the first two days during hospitalization ?
We'll explore this issue in this short #medtweetorial
#medtwitter #FOAMed #MedStudentTwitter

2/Interestingly , anemia of hospitalization is commonly thought to be due to
- phlebotomy
- IVF
- invasive procedures/ bleeding etc

However, prolonged bed rest can contribute to a drop in your pts blood count !
Another reason to get our patient's out of bed if possible !

3/Until the mid-20th century, bedrest was considered a benefit that helped people heal. Hippocrates had already noted the risk of loss of muscle, bone and tooth(Chadwick and Mann, 1950)
Today, there is recognition of bedrest’s negative effects on body and the blood volume.

Read 14 tweets

Ravi Singh

@rav7ks

8 Sep 20

@MohitHarshMD

1/ LR has been making the rounds on #MedTwitter recently so I decided to put all of the important points versus NS into an infographic with additional points
@MohitHarshMD
#MedTwitter #MedStudentTwitter #Medtweetorials

2/ NS can cause coagulopathy
- NS dilutes clotting factors ➡️ impairing coagulation and hemostasis.
-NS can cause a functional impairment of thrombin and fibrinogen
- ⬆️ disruption of existing clots.
- acidic milieu can also ⬇️ clot formation/stability

pubmed.ncbi.nlm.nih.gov/17414340/

3/ In Traumatology:
NS can lead to:
-compartment syndrome
-dilutional coagulopathy
-hyperchloremic metabolic acidosis
-immune dysfunction

pubmed.ncbi.nlm.nih.gov/16832250/

Read 12 tweets

Ravi Singh

@rav7ks

1 Sep 20

1/ In medicine, we get to eat humble pie time and time again. The vast amount of knowledge necessary can be a daunting task and what we learn isn't necessarily what we may see in the clinical realm. You can almost say there is an atypical presentation for everything.

2/ This leads to our case, on consults we come across a elderly pt with confusion and psychosis.
Normal Temp and RR: 18 and Low normal BP
Clinically dry with labs:
Normal Albumin and Normal gap.

3/ Her NAGMA was not competely explained by the hyperchloremia but this could be a contributor.
The next step was to pursue a UAG.
Her ABG was unremarkable and a run through of causes of NAGMA came up empty.

Read 15 tweets

Ravi Singh

@rav7ks

21 Aug 20

1/ We recently had a patient on service with B/l lower extremity edema with inflammation which was considered to be cellulitis and received antibiotics. This definitely made for some great teaching points as well as a rethink of the Dx.
#medtwitter #MedStudentTwitter #FOAMed

2/This was a great opportunity for a deep dive into domain of pseudocellulitides and this approach made the team reconsider the diagnosis especially since this was a bilateral process.

3/Bilateral cellulitis is exceedingly rare and most likely Dx for this patient was gravitational eczema AKA Stasis dermatitis AKA varicose eczema especially with the Hx of decomp. CHF.
The legs did exhibit calor, dolor, rubor, and tumor. Does this help with a Dx of cellulits ?

Read 9 tweets

Ravi Singh

@rav7ks

12 Aug 20

@k_vaishnani

1/6 @k_vaishnani discussed Cement PE recently and it reminded me of a patient I had with N/V due to a procedural complication that I was also not familiar with. A great learning point is to try to associate the procedure to the complication whilst trying to entertain other #DDX

2/6 The patient presented with a past medical history of DM and paroxysmal AFib s/p Ablation two days prior to admission.
One day after the procedure, she developed generalized progressive abdominal discomfort (+) persistent n/v, exacerbated with food intake.

@CPSolvers

3/6 The abdominal pain was diffuse and intensity was 6/10 Intermittent and relieved by vomiting.
It was associated with palpitations and diaphoresis. The team ran through causes of abd pain via @CPSolvers schema. Her labs showed met. alkalosis /dehydration from excessive vomiting

Read 7 tweets

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