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Arjun Khadilkar, MD

@akhadilkarMD

Mar 1

One of the most important (and challenging) thing to do in residency is to write a good discharge summary.

Here are 8 components that may be helpful for you! 🧵.

#arjuncardiology #MedTwitter #MedEd

Background:
- Discharge summaries are an essential note that summarizes a patient’s (often complicated) hospital course that can span days to weeks.

- They are often reviewed by primary care physicians at a post-hospitalization follow-up appointment.

1) Dates of Admission
- Pretty straightforward; can preliminarily highlight whether it was a straightforward admission or a complicated stay

- Important for the PCP / other consultants to know the recency of their recent hospitalization.

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Arjun Khadilkar, MD

@akhadilkarMD

Jul 21, 2024

I think one of the hardest skills in med school, residency, and fellowship is presenting new patients to the attending effectively and thoroughly, as well as remembering their clinical course

It took me years to perfect my system, which is a 3 x 5 notecard (front and back).

This is my strategy to learn new patients in the morning and during their hospital course. (Bookmark for future reference!)

On Twitter, I will keep the topic brief. For more expanded thoughts and tips on this topic, join my newsletter here:
arjun-cardiology.ck.page/fec5d1458a (Join the 600+ people that have joined so far!)

*Information on this feed is based on a made up patient* #MedTwitter #Cardiotwitter #MedEd #arjuncardiology

1) At the top of the notecard, I write the last name of the patient, their age, gender, and date of admission. Pretty-self explanatory. If the patient is not moving rooms, might be helpful to write this down as well.

2) For cardiology, I write the reason for consult. In cardiology, common reasons include: atrial fibrillation, bradycardia, hypertensive urgency, heart failure exacerbation, etc. This allows the attending to focus his/her attention on what the clinical question is being asked as a consultant.

For Internal medicine, I would write the chief concern the patient came to the hospital (shortness of breath, abdominal pain, fever, etc).

3) Relevant past medical history. You don't need to list every past medical problem, rather focus on those related to the diagnosis and clinical picture. This could include HTN, DM, HLD, COPD, CKD, AF, HFrEF.

- If not relevant, can avoid mentioning to condense presentation.

4) I make lines for separation (see image). At the bottom of the front of the card, I take brief notes on the ER course (vitals, labs, imaging studies, medications administered). This helps when you are presenting clinical story to the attending physician!

Labs:
- Labs (relevant): electrolytes, Creatinine (and baseline), troponin trends & BNP (compared to prior admissions), UDS, Hemoglobin & Platelets) (baseline), LDL, A1c

Imaging:
- EKG (provide interpretation) and print-out if not by a computer (follow a methodical approach with rate, rhythm, axis, intervals, ischemic changes, etc). Can compare to prior if available
- CXR: signs of volume overload, effusions
- CTA: Evaluation for PE

ER Course:
- Mention the work-up in the ER, such as medications provided
- Common ones include ASA: 324 mg, Heparin gtt, IV Lasix, Sublingual Nitroglycerin

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Arjun Khadilkar, MD

@akhadilkarMD

Jul 15, 2024

Pre-Rounding Tips 3d: How to think about Troponin? (
(Bookmark or Like/Retweet, will be high-yield for future reference)

If helpful, check out my other threads or join my newsletter (starting on Friday - 7/19/24) for more in-depth insights and Internal Medicine and Cardiology notes:

Pro-Tip: If you can print out a pre-rounding sheet with the labs auto-populated, that is always helpful.

Let's Dive in!
#arjuncardiology #medtwitter #cardiotwitterarjun-cardiology.ck.page/fec5d1458a

One of the most common consults from the Emergency Room to Cardiology is 'elevated troponin.'

Yes, elevated troponin can be scary, but here is the framework that I use to analyze / consider troponin.

1. Patient Presentation?
2. Patient's risk factors and prior cardiac history?
3. What is the troponin trend?
4. What does the ECG look like?
5. What are some non-cardiac reasons troponin may be elevated?

1. Patient Presentation?

In Cardiology, the clinical presentation is the most important part of the story when determining the significance of an elevated troponin! In many situations, clinical decisions (whether to pursue a LHC) may be made in the absence of having a troponin available.

Key Questions:
1. If the patient presents with chest pain, how does he/she describe it?
- Some common worrisome symptoms associated with angina. Elevated troponin in the setting of these symptoms should always be taken seriously.
a) Chest pressure, constant, sub-sternal.
b) Radiation of pain to the neck or jaw
c) Diaphoresis
d) Numbness to the left arm
e) New onset dyspnea
f) Worse with exertion, better with rest

2. What makes the pain better?
- If the patient got improvement with nitroglycerin more likely to be consistent with cardiac chest pain.
- If patient's pain improves with muscle relaxers, IV toradol, IV PPI, IV Ativan, less likely to be a cardiac etiology.

3. Has the patient had this type of pain before?
- If similar recent presentation with a negative work-up, this might be reassuring. However, you don't want to have anchor bias and should keep an open perspective.

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Arjun Khadilkar, MD

@akhadilkarMD

Jul 10, 2024

When I was an intern, pre-rounding was one of the most stressful parts of the day. I would take too long and be inefficient. Part 1.

Now as a PGY7 (long-time, right?), here is 3 parts of my system that I use for new patients.

If you liked this thread, be sure to subscribe to the newsletter in my bio.

On Twitter, I will provide a more condensed version for easier reading. In the email format, I will expand on my thoughts to provide more detailed insights. I will walk you through my thought process and make sure they are concise but helpful.

Future direction will be ECG/Echo/General Cardiology Topics!

#arjuncardiology #cardiotwitter #MedTwitter

1) Why is the patient here / chief concern?

- This seems like the most basic question that is often overlooked. What made the patient decide to leave his/her house to come to the hospital?

- When reading the overnight H&P, the abundance of clinical documentation can create confusion.

- Simplicity is key. What is the chief concern? Is it chest pain? Is it dyspnea on exertion? Knowing this information will help frame your thoughts.

2) What are the relevant past medical problems?

- Most patients will have chronic medical problems that will contribute to the current presentation.

- It is easy to get lost in the weeds of this presentation. In Cardiology, I typically focus on (but not limited to) coronary artery disease, atrial fibrillation, hypertension, hyperlipidemia, diabetes mellitus, history of CVA. Again, this is not all inclusive but it is a start.

- Although patients may present to the hospital with a new diagnosis, it is more likely that the presentation may be an exacerbation of a previous problem.

Read 5 tweets

Arjun Khadilkar, MD

@akhadilkarMD

Jun 6, 2023

As an intern, chart checking new patients was intimidating and time-consuming.

Even as a cardiology fellow, I continue to refine my system.

Here are 7 tips and tricks to help you out!

#arjuncardiology #MedTwitter #MedEd #Cardiotwitter #IMG

Read 10 tweets

Arjun Khadilkar, MD

@akhadilkarMD

Jun 4, 2023

Studying for the IM Boards and Step 2 CK can be challenging.

Here are some of my notes that can help you.

Part #24: Ophthalmology : 5 High-yield facts!
#arjuncardiology #medtwitter #MedEd #IMG

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