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Andrew Sanchez Profile picture
Andrew Sanchez
@ASanchez_PS
Hospitalist @BIDMC_IM Teaching/Learning Dx @harvardmed❓, Co-host @Dx_Atypia 🦓 🐎, @CPSolvers Academy🕵🏽‍♂️, @YaleIMed @ColumbiaPS @UF 👨🏽‍🎓
4 subscribers
Nov 27, 2024 • 6 tweets • 2 min read
🫧 Approach to Blistering Skin Disorders 🫧

What? → Fluid-filled skin lesions occurring by 1 of 3 mechanisms:

1. Acantholysis

2. Spongiosis

3. Epidermal-dermal Dissociation Image The key pivot of this schema emphasizes a search for exogenous culprits of life-threatening disease, as these culprits must either be treated or avoided in the future.

🚨 This classification is very imperfect (e.g. numerous SJS/TEN cases are idiopathic) 🚨 Image
Aug 16, 2024 • 18 tweets • 6 min read
🟡 Monoclonal Gammopathies of Renal Significance (MGRS)! 🟡

How should we organize this long list of Paraprotein-mediated, kidney-damaging diseases?

Heme/onc aficionado @MatthewHoMD & I teamed up to simplify things for the diagnostician.

Let's re-do MGRS. Image Newcomer to the land of monoclonal gammopathies of clinical significance (MGCS)?

Check out the original thread on MGCS here 👇, then read on!

Jun 4, 2024 • 24 tweets • 9 min read
❤️‍🔥 Myocarditis: the Diagnostic Journey ❤️‍🔥

It's been a while, #MedTwitter!

Today, @Gurleen_Kaur96, @Mark_Heslin, & I bring you our diagnostic approach to myocarditis.

First we'll give a lay of the HFrEF land; then, we'll cover presenting features & Endpoint DDx.

Onward! Image The "diagnostic arc" of HFrEF 🏔️

Lots of ways to break down the assessment of new HFrEF... Here's how we do it:

☠️ 1st Pass = Base Rate/Sick

- Ischemic cardiomyopathy reigns in the elderly & at-risk: ECGs should be scrutinized for signs of occlusive MI & pathologic Q waves👇 Image
Apr 26, 2024 • 13 tweets • 4 min read
Rising #MedTwitter #MedX interns, here are my favorite approaches for acute inpatient medicine issues! 🚨

1) Hypoxemia, by @ClementLeeMD 🫁

Ditch the alveolar gas equation (sorry @PulmPEEPs) & use this practical approach.

✍️ Dr. Lee's approach is summarized by @MatthewHoMD here, with Dx/Rx considerations by @Sophia_Hayes_MD.

Apr 2, 2024 • 27 tweets • 9 min read
🩸 Paraprotein Evaluation 🩸

SPEP, SIFE, SFLC, UPEP, UIFE.

What do these abbreviations mean & how does one arrive to the land of paraproteinemias?

Here is a tweetorial for the internist diagnostician, in collaboration with @cullen_lilley! Image 🗻 The path to paraprotein evaluation may or may not begin with the observation of a "protein gap," meaning a (roughly) 4 g/dL difference between the serum Total protein & Albumin. Image
Dec 5, 2023 • 14 tweets • 4 min read
"Auto-antibody Craze" DDx 🔥

A short list of 🦓 diagnoses tied together by a rare, confusing disease signature.

Here's a super brief tweetorial. Image Signature ✍️

- Variable auto-antibody positivity → polyclonal hypergammaglobulinemia & autoimmune disease

- B-symptoms +/- LAD

What do I mean by variable auto-antibody positivity? Just take a look at these labs 👇 Image
Aug 6, 2023 • 9 tweets • 2 min read
❗️Rapid Diagnosis Challenge❗️

A middle-aged human with "COPD" (no PFTs on file, on chronic 2L), HFpEF, & morbid obesity presents w/ subacute DOE → resting dyspnea & worse hypoxemia:

🫁 SpO2 86% on 6L

❤️ Other VS show: no fever, HR 100s, 110/70s Image 🥼 Below are the presenting labs (Baseline SCr = 2.0 mg/dL, Baseline NT-proBNP = 2000 pg/mL)

🥼 The VBG shows pH 7.39 & pCO2 73

🥼 The serum bicarbonate trend from recent past is also shown below Image
Image
May 3, 2023 • 16 tweets • 9 min read
🫠 Approach to Hypotension 🫠

Recent ICU shifts = newfound appreciation for this clinical dilemma.

The traditional breakdown of hypotension/shock is very classic: my schema aims to sub-divide this framework & cover some new buckets.

Read on! 🧵 Image First, recall BP is a product of Cardiac Output * Systemic Vascular Resistance.

When assessing hypotension, cardiogenic etiologies should come to mind first because a markedly abnormal Heart Rate derangement may provide an up-front answer.

Think extremes:

- HR < 30

- HR > 150 Image
Jan 18, 2023 • 15 tweets • 7 min read
🫀 Approach to HFpEF Dx 🫀

I loved creating this one-pager because my understanding of how to clinch this Dx shifted enormously throughout my intern year.

Turns out, "no diastolic dysfunction" on TTE doesn't = no HFpEF.

Let's go through the pathophys & see how this assists Dx. The pathophys of HFpEF first involves diastolic dysfunction.

(This may or may not be visualized on TTE; more on this in a second.)

With an expected ↑ LV-EDP during exercise (+/- at rest), LA pressure then ↑.

This will, chronically, lead to LA enlargement.
Jan 5, 2023 • 4 tweets • 2 min read
✨ TMA Schema 2.0 ✨

- Trigger: anemia + thrombocytopenia → (+) hemolysis & (–) DAT testing → (+) schistocytes on smear! 🔫

- Note 1: not all MAHA (non-immune hemolysis 2/2 RBC fragmentation) is caused by a TMA, but nearly all TMAs cause MAHA & thrombocytopenia 📚 Image 📚 Note 2: unless concurrent blood disorder, coags = normal!

- More on the Hemolytic Anemia journey 🚶‍♀️ here:

- More on the TMA journey 🚶‍♀️ here:
Dec 31, 2022 • 11 tweets • 8 min read
Very pleased to close out 2022 with the opportunity to share important clinical lessons from a case just published in @BrownHospMed:

"Unilateral Pneumonitis and Hydropneumothorax Following Pembrolizumab" 🫁 💊

Case report available here: bhm.scholasticahq.com/article/39747-… Many thanks to @YaleIMed's Drs. Harriet Kluger & @PeterKahnMD for both their active involvement in this case & their support of this write-up.

Additionally, thankful to have had @yalepathology's Dr. Christine Minerowicz provide invaluable input on the pathology of this case.
Dec 15, 2022 • 14 tweets • 8 min read
💀 Pulmonary Infarction 💀

Is that focal chest consolidation a pneumonia? 🤔

Let's talk about a pneumonia mimicker that can be *very* easily missed if you've never seen it before 🎭 Image Pulmonary Infarction is the result of a simple series of events:

🩸 Pulmonary artery obstruction

↓

🩸 Alveolar hemorrhage & edema

☠️ If fluid not absorbed, RBC lysis & hemosiderin release leads to lung necrosis! ☠️
Oct 25, 2022 • 11 tweets • 5 min read
😵‍💫 Approach to Dizziness! 😵‍💫

4 big buckets:

- Pre-syncope
- Vertigo
- Imbalance/Dysequilibrium
- Psychiatric

This approach is very much a bird's eye view approach that should assist in history/data acquisition. I'll also cover a tricky don't-miss Dx. Dizziness 2/2 Pre-syncope:

🔴 History: "lightheadedness"

🔴 Pre-syncope DDx is stratified by the classic approach to syncope (orthostatic hypotension, reflex, cardiac)

Let's touch more on orthostatic hypotension, as this is not an endpoint Dx.
Oct 23, 2022 • 6 tweets • 2 min read
✨ Approach to Infiltrative Diseases 2.0 ✨

- After reading original 🧵 linked in this specific tweet, see new 🧵 below for beautified one-pager & illness scripts! Image Updated Lymphoma review:
Oct 17, 2022 • 13 tweets • 7 min read
🟤 Approach to Acute Hepatocellular Injury 🟤

The DDx of ↑ AST & ALT out of proportion to ↑ in cholestatic labs is easy for most.

BUT! I think some can't-miss conditions are frequently left out by early learners.

Here's a diagnostic approach that'll prioritize those causes. Acute hepatocellular injury = 3 P's.

- Plumbing (Biliary & Vascular)
- Pregnancy
- Parenchyma
Oct 15, 2022 • 4 tweets • 3 min read
🍺 EtOH-associated Hepatitis 🍺

- A diagnosis that considers careful consideration of history & entire clinical presentation.

- If fever, must consider occult infection prior to steroids.

- All should be offered an addiction medicine consultation (@DrMelissaWeimer). Maddrey discriminant function calculator here: mdcalc.com/calc/56/maddre…

Courtesy of @grahamwalker's wonderful site
Oct 7, 2022 • 7 tweets • 5 min read
How I teach students & interns on rounds without 📜 & ✒️:

1) "You'll get an email summary at end of the day. Feel free to not take notes!"

2) Verbal teaching 5-10 minutes

3) Send durable educational resource vs. new, free-form bulleted teaching via email! I usually do both! 💭 Tips 💭:

1) Save & keep your resources organized!

I use @msonenote & @GlassHealthHQ & @appleicloud for collecting/organizing notes that ultimately get sent to my learners:
Sep 25, 2022 • 20 tweets • 7 min read
🦀 Approach to Lymphomas 🦀

Re-sharing this updated framework with some increased organization, new references, & more specific terminology.

Let's take this ride again! 🔬 Previously, a lymphoid neoplasm of the marrow/blood = leukemia, solid lymph node (LN) neoplasm = lymphoma

🔬 However, many "lymphomas" can evolve into "leukemia," & vice-versa

🔬 Now, the WHO classifies lymphoid neoplasms based on cell of origin

Aug 29, 2022 • 4 tweets • 3 min read
🟡 DDx of AKI 🟡

AKI is a proximal diagnosis requiring a final etiological explanation.

In other words, when encountering AKI, one must ask, "why?"

Here's a one-pager organized by AKI's etiological buckets, which encourage the pursuit of an endpoint diagnosis! Image This framework inspired by:

1) @JFBirnbaum @HollandKaplan @PrathitKulkarni

More on "endpoint diagnoses" (authors above) here: pubmed.ncbi.nlm.nih.gov/35942949/

2) My lack of a one-pager capturing *all* etiological buckets of AKI
Aug 18, 2022 • 17 tweets • 12 min read
💥 Monoclonal Gammopathies of Clinical Significance! 💥

Everyone knows MGUS.

Monoclonal proteins are simply blameless protein markers until clonal B-cells progress to Myeloma, Waldenstrom's, or another disorder, right?

...It turns out, not quite!

Let's explore! First, some review. Where does monoclonal protein come from?

- Clonal B-cells 👉 Monoclonal protein secretion

- Such protein is also called "M-protein" or "Paraprotein"

Ref: @cullen_lilley
Jul 28, 2022 • 6 tweets • 4 min read
🪟 Pulmonary Alveolar Proteinosis (PAP) 🪟

- Rare cause of insidious-onset dyspnea on exertion
- On DDx of Crazy Paving on chest CT
- Due to 👇 production/clearance of surfactant ImageImageImage What is Crazy Paving?

🪟 Ground glass opacification (GGO) w/ superimposed thickening of interlobular septa & intralobular interstitium

🪟 See below for anatomy of the secondary pulmonary lobule!

🪟 Graphics by @LandsbergManual ImageImage