1/7 Let’s go over the evidence-based physical exam for lower extremity deep vein thrombosis (LE DVT). In the spirit of quantifying clinical concern, here is a question - besides inspection (and #POCUS), which tool will help you the most?

#MedTwitter #FOAMed #MedEd
2/7 The answer is a ruler! Let’s look at the LRs.

Quick review of LRs:
- The (+) and (-) indicate the LR if a finding is present or absent, respectively
- The more the LR deviates from 1, the more useful it is
3/7 For this particular set of exam findings, it may be more helpful to see how much the LRs change your post-test probability (assuming a pre-test probability of 50%). The presence of absence of asymmetric calf swelling seems to be the most helpful.

Graphic from McGee
4/7 The change in probability for the presence of absence of these findings is not great (they are all close to 1). Ultimately, your history (and that ruler) are going to help the most to decide whether or not you need to do a lower extremity ultrasound to assess for LE DVT.
5/7 An often-used calculator is the Well’s score, which stratifies patients into pre-test probability of LE DVT.
2 things worth noting:
1⃣Meant for outpatient diagnosis
2⃣Up to 2 points go into the clinician deciding if an alternative diagnosis to DVT is likely or more likely.
6/7 Here is another way to see how your probability changes (assuming a pre-test probability of 50%). The impact of the 2 points going into “clinical gestalt” is tremendous (you can go from low to intermediate pre-test or from intermediate to high pre-test)
7/7 We RARELY use clinical calculators when our pre-test probability is intermediate (something is making you invoke the use of the calculator, right?). The LRs are still helpful and you can use a calculator like this to quantify your suspicion: sample-size.net/post-probabili…

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More from @SatyaPatelMD

7 Jul
Let's review the evidence-based physical exam for Cushing syndrome!

Quick review of LRs:
- The (+) and (-) indicate the LR if a finding is present or absent, respectively
- The more the LR deviates from 1, the more useful it is

#MedTwitter #MedEd #EndoTwitter #FOAMed Image
Things that stand out to me
- "Buffalo hump" doesn't have a defined LRs despite being taught as a "classic" finding (occurs in 34-75% of patients)
- The presence of moon facies has a lower LR than I expected (1.6)
- The absence (or presence) of abdominal striae is not particularly helpful
- The presence of a thin skinfold (thickness on the back of the hand <1.8 mm in women of reproductive age) can be VERY telling
Read 4 tweets
23 May
1/ Had some fun today on rounds with these! The Rinne and Weber tests stress out a lot of folks, so let's tackle them today.

#MedTwitter #MedEd #EndNeurophobia @MedTweetorials
2/ What are the Weber and Rinne tests used to help identify?
3/ The answer is both! Remember that the most useful exams are hypothesis-driven so you need to do a history to begin suspecting if a patient has either type of hearing loss. This will help you generate a pre-test probability for disease (this will become relevant later).
Read 13 tweets
14 May
1/8 When might an FeUrea not be as useful as FeNa? Let's explore briefly!

#NephTwitter #MedEd #MedTwitter #Tweetorial #FOAMEd @MedTweetorials
2/8 First of all, a quick reminder that the utility of the FeNa and FeUrea in evaluation of AKI needs to be carefully considered before they are ordered (I'm a big fan of looking at UAs). journalofhospitalmedicine.com/jhospmed/artic…
3/8 You might see a table like the one below that can be used to (cautiously) interpret FENa and FEUrea.
Read 8 tweets
22 Mar
1/11 Congrats to those who matched! I tweeted about an inpatient pocket card set in 2020 and got great feedback. Here is the result of a big overhaul: bit.ly/pocketcardset

Let's review what's inside!

#MatchDay2021 #MedStudentTwitter #MedTwitter #TipsForNewDocs #FOAMed
3/11 First up is a pre-rounding checklist. Be systematic and read all of the notes in your patient’s chart (interdisciplinary care is critical).

H/t @nickmmark for the idea to use a QR code to maintain an updated version! This QR code also has some additional resources. Image
Read 11 tweets
23 Jun 20
1/14 I was always asked as a student if I wanted to give fluids to a patient, but no one ever told me how they think about. Here is my approach to giving IV fluids.

Disclaimer: Things are simplified for the sake of pragmatism.

#MedTwitter #MedEd
2/14 I call my approach an "IV fluid timeout." It involves asking yourself four questions before giving someone IV fluids.
3/14 I broke down the answer two question one into two major buckets. This is the most important question because if a patient does not need IV fluids, do not give IV fluids.
Read 15 tweets

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