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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 27, 2022 • 11 tweets • 4 min read
🫁💧 Pleural Effusion Schema 💧🫁

1) Thoracentesis → Calculate Light's criteria (Note: ~20-25% of true transudates are misclassified)

2) Stratify transudative DDx by Starling equation (Hydrostatic, Oncotic etiologies) & Diaphragm-related etiologies

3) Exudative DDx = longer! Image B/c hydrostatic pressures are higher on the parietal pleura than on the visceral pleura & the oncotic pressures are equivalent, pleural fluid is primarily produced from the parietal pleura. The lymphatic vessels on the parietal pleura are responsible for pleural fluid resorption. Image
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