A 🧵 on chest Xray signs in pulmonary thromboembolism. The 𝗙𝗹𝗲𝗶𝘀𝗰𝗵𝗻𝗲𝗿 𝘀𝗶𝗴𝗻 is a prominent central artery that can be caused either by pulmonary hypertension or by distension of the vessel by a large pulmonary embolus seen on chest x ray.

💥Smith 𝘦𝘵 𝘢𝘭. reported draining a world record of 41 𝗹𝗶𝘁𝗿𝗲𝘀 of ascitic fluid in a single paracentesis session of a patient with decompensated cirrhosis.

How much Albumin would be needed in this case to prevent post paracentesis circulatory dysfunction ? 🧵 Read on👇

A 🧵 on important points to consider while performing Large Volume Paracentesis (LVP)

𝘏𝘰𝘸 𝘮𝘶𝘤𝘩 𝘢𝘭𝘣𝘶𝘮𝘪𝘯 𝘪𝘴 𝘵𝘰 𝘣𝘦 𝘪𝘯𝘧𝘶𝘴𝘦𝘥 𝘥𝘶𝘳𝘪𝘯𝘨 𝘱𝘦𝘳𝘧𝘰𝘳𝘮𝘪𝘯𝘨 𝘓𝘝𝘗❓️

𝘞𝘩𝘢𝘵 𝘪𝘴 𝘵𝘩𝘦 𝘮𝘢𝘹𝘪𝘮𝘶𝘮 𝘢𝘮𝘰𝘶𝘯𝘵 𝘰𝘧 𝘢𝘴𝘤𝘪𝘵𝘪𝘤 𝘧𝘭𝘶𝘪𝘥 𝘵𝘩𝘢𝘵 𝘤𝘢𝘯 𝘣𝘦 𝘥𝘳𝘢𝘪𝘯𝘦𝘥❓️

🛑Large Volume Paracentesis(LVP)
is arbitrarily defined as a paracentesis with >5 L of ascitic fluid drained.

In patients undergoing LVP, the use of albumin is crucial to prevent a further reduction of effective arterial blood volume, which may precipitate postparacentesis circulatory dysfunction (PPCD).

The clinical manifestations of PPCD include renal impairment, including HRS, dilutional hyponatremia, hepatic encephalopathy and death.

Albumin infusion is particularly important if more than 5 L of ascites are removed to prevent the development of PPCD.

Paracenteses of a smaller volume(<5L) are not associated with significant hemodynamic changes and albumin infusion may not be required.

Although there has not been a dose‐response study on albumin use with LVP, the administration of 6‐8 g of albumin per liter of ascites removed has been recommended.

💥For example, after the fifth liter, approximately 40 g of albumin should be infused, and after 8 L removal, the amount of albumin given should be approximately 64 g.

It has been held that there is no limit for the amount of ascites that can be removed in a single session, provided an appropriate amount of albumin is administered.

However, the risk of PPCD increases with >8 L of fluid evacuated in one single session.

A study showed that by limiting the LVP volume to <8 L per session and providing a higher than recommended dose of albumin (9.0 ± 2.5 g per liter of ascites removed), renal function and survival may be better preserved over a mean period of 2 years despite the development of PPCD in 40% of patients.

In patients with hemodynamic instability (systolic blood pressure <90 mm Hg), hyponatremia (serum sodium <130 mmol/L), and/or the presence of AKI, albumin infusion should be strongly considered for paracentesis of a smaller volume.

LVP is a safe procedure even in the presence of coagulopathy. In a study that included patients with an international normalized ratio of >1.5 and a platelet count of <50 × 109/L, only 1% of patients experienced minimal cutaneous bleeding after LVP.

Therefore, elevated prothrombin time or thrombocytopenia is not a contraindication for paracentesis, nor is transfusion of clotting factors or platelets recommended.

Possible exceptions may include patients with disseminated intravascular coagulation or uremia with thrombocytopenia.

1/3 👇 𝘾𝙤𝙣𝙩. 💥Ideal site for needle insertion in abdominal paracentesis

For patients with high blood pressure.

Please read !

If you have 𝙃𝙔𝙋𝙀𝙍𝙏𝙀𝙉𝙎𝙄𝙊𝙉 try to make the following diet and lifestyle changes.

1. Consider 🌺hibiscus tea, pomegranate juice, beetroot juice and cocoa as they are rich in nitrates and lowers BP.

1/16 2. Alcohol consumption should be zero for the best cardiovascular health.

Immediate adverse effects can lead to heart beat rythm disturbances, increase risk for accidents etc.

Long term consumption is associated with adverse effects on heart and liver & also can cause cancer.

🌟 MALAR RASH- A🧵

🔸️Malar rash is classically described in SLE as a "butterfly" shaped erythematous rash in the malar distribution, which includes the cheeks and crosses the nasal bridge but spares the nasolabial folds.

Let's look at the mimickers👇

Do read the whole🧵 🌟 Systemic Lupus Erythematosus

🔸️Classic finding in SLE

🔸️The ORIGINAL Malar Rash🦋

From Kelley's Textbook of Rheumatology, 9e

🌟 SGLT2i and UTI - A 🧵

There is ❌️ NO convincing evidence that the use of SGLT-2 inhibitors is associated with an increased risk of UTI according to this expert consensus statement. (PMID- 37153973)

Concerns about UTIs should not be a deterrent to initiating SGLT-2i...👇 ▫️In patients with T2DM and atherosclerotic risk factors, SGLT-2i should be used for its organ protective benefits such as reducing the risk of hospitalization for heart failure and kidney disease progression, regardless of glycemic control.

Honourable citizens, please read this!

A🧵 on Cardiopulmonary Resuscitation #CPR

When to start CPR in a person ❓️

How to do effective CPR❓️

What is this👇 device❓️ If you "feel" like somebody has collapsed and has a cardiac arrest, start CPR.

Before starting CPR ensure that the victim is positioned flat on ground/bed.

Ensure that you are in a safe space

Call Ambulance

Start CPR.

▪️
▪️
▪️
A🧵 on management of hypertensive emergencies.

The 𝗕𝗔𝗥𝗞𝗛 algorithm for management of hypertensive emergencies and end-organ damage

𝗕 - Brain
𝗔 - Arteries
𝗥 - Retina
𝗞 - Kidney
𝗛 - Heart

#MedTwitter #MedEd #MedX

Read on 👇 for BP Lowering rate and goals. Hypertensive urgency, hypertensive crisis & malignant hypertension are terms that have been used to describe severely elevated BP with no evidence of end-organ damage.

Hypertensive emergency is a clinical syndrome of significantly elevated BP that is assoc with end-organ damage.

If you have 𝙃𝙔𝙋𝙀𝙍𝙏𝙀𝙉𝙎𝙄𝙊𝙉 try to make the following diet and lifestyle changes.

⚠️ Discuss with your doctor before attempting. #hypertension

1. Consider hibiscus tea, pomegranate juice, beetroot juice and cocoa as they are rich in nitrates and lowers BP.

1/15 If you don't want a thorough read, just scroll through the images to get an idea.

I recommend to go through the whole 🧵 as it is an extract of recommendations from the apex global medical body on hypertension-
International Society of Hypertension ( ISH)

Let's go..

Pregnant lady with fever and chills.

Treated with Artesunate + Artemether

Requires radical therapy for eradication of hypnozoites.

How to give radical therapy for plasmodium vivax malaria in pregnancy❓️

Is primaquine safe ❓️

A🧵

#MedTwitter #MedEd #MedX Radical cure is given with Primaquine in P vivax and P. Ovale malaria.

Primaquine causes severe hemolysis in patients with G6PD deficiency.

So testing for G6PD is to be done before giving primaquine.

Lamotrigine, Levetiracetam & Oxcarbazepine prefered in pregnancy.

American Academy of Neurology, American Epilepsy Society, Society for Maternal-Fetal Medicine -

𝗚𝗨𝗜𝗗𝗘𝗟𝗜𝗡𝗘𝗦 on drug therapy of epilepsy in pregnancy just dropped.

A 🧵 on recommendations👇

#MedTwitter Recommendations regarding the effects of antiseizure medications (ASMs) and folic acid supplementation on the prevalence of major congenital malformations (MCMs) & adverse perinatal outcomes in children born to people with epilepsy of childbearing potential (PWECP).

Read on.. 👇

A 🧵 on recommendations on steroid therapy

First a question ❓️

45 Yr male diagnosed with Tuberculous Meningitis was started on antitubercular drugs and 60mg presnisolone daily.

How do you plan to taper and stop steroids❓️

#MedTwitter #MedEd #MedX #steroid What is steroid eqivalence ❓️

How to taper steroids ❓️

What is fast and slow taper ❓️

How to monitor if tapering is optimal❓️

What is therapeutic taper and endocrine taper ❓️

Read on for answers ....

#MedTwitter #CPR #MedX

💥 𝗖𝗣𝗥

A🧵 on high quality Cardiopulmonary Resuscitation

The tempo of 1977 song "Stayin Alive" by Bee Gees has the same rate as chest compressions given during CPR

5️⃣ main components of high-performance CPR have been identified.....Read on👇 5️⃣ main components of high-performance CPR

👆Chest compression fraction (CCF)

✌️Chest compression rate

🤟 Chest compression depth

👊 Chest recoil

🤚 Ventilation

Uncomplicated Urinary Tract Infection ( UTI) in females is a spot diagnosis based on history alone.

A 🧵 on differences in approaching UTI on gender basis👇

#MedTwitter #MedEd #MedX UTI in the age group <1yr is more common in males as congenital urinary anomalies are more common in ♂️

In age group >50yrs the gender distribution of UTI is equal for ♂️ & ♀️

💥💥💥 Between 1- 50 years of age, UTI and recurrent UTI are predominantly diseases of ♀️

A 🧵 on 🏮𝗛𝗬𝗣𝗢𝗦𝗣𝗟𝗘𝗡𝗜𝗦𝗠

Few questions

🛑 46yrs old male patient with hypersplenism due to tropical splenomegaly is planned to undergo splenectomy.

What all vaccinations should he receive❓️

What should be the ideal timing for vaccinations❓️

#MedTwitter #MedX 👇 Asplenia and hyposplenism can be either anatomic or functional.

Anatomic asplenia is most often due to surgical removal of the spleen.

Functional asplenia and hyposplenism result from conditions that lead to atrophy, infarction, engorgement, or infiltration of the spleen.

A🧵 on
5️⃣ categories of ascitic fluid infection that can happen in long standing ASCITES
#MedTwitter #MedEd #MedX

First a question ❓️

A patient with ascites underwent difficult and traumatic paracentesis.
......contiunued in 🧵 👇 Ascitic fluid analysis had PMN count of 100/mm3 & multiple organisms were grown on culture of fluid.

Diagnosis❓️

A.SBP
B.Secondary bacterial peritonitis
C.Polymicrobial bacterascites

Did you know that the tunable diaphragm technology of
3𝗠 Littmann stethescopes🩺
helps you to convert the chest piece into a bell & diaphragm merely by application of pressure.

No need to turn it to hear different frequencies of sounds on auscultation.

More in 🧵
#MedTwitter First of all, let's review the parts of a conventional stethescope.

🧠 CSF HSV PCR is diagnostic of HSV encephalitis but may be negative if done during the first 72h of onset of illness.

A🧵 on

Why is it important to distinguish herpes simplex encephalitis from other viral encephalitis & how to do that❓️

#MedTwitter #MedEd #MedX The distinction of HSV encephalitis from other viral
encephalitis is important because in virtually every other instance the therapy is supportive, whereas
specific antiviral therapy💉 is available for HSV, and its efficacy is enhanced when it is instituted early.

A🧵

This 🇮🇳 doctor is the co-author of one of the most highly cited scientific papers in the world & also is credited with the discovery of

💥ATP
💥Folic acid
💥Methotrexate
💥Aureomycin (the parent of tetracycline)
💥Diethylcarbamazine

Do you know his name❓️

#MedTwitter Millions live longer, more satisfying lives because of folic acid vitamin, tetracycline antibiotics anti-filarial and anti-cancer drugs developed under the research direction of Dr. Yellapragada Subbarow🙏

💥 𝗡𝗘𝗪: November 2023

💥 Clinical Practice Update on the Use of Vasoactive Drugs and Intravenous Albumin in
𝗖𝗜𝗥𝗥𝗛𝗢𝗦𝗜𝗦 : Expert Review

💥 American Gastroenterological Association ( AGA)

💥 A 🧵 on
12 BEST PRACTICE ADVICE STATEMENTS 👇

#MedTwitter #MedEd #MedX ♦️1
Vasoactive drugs should be initiated as soon as the diagnosis of variceal hemorrhage is suspected or confirmed, preferably before diagnostic and/or therapeutic endoscopy.

In 1984, to demonstrate that H. pylori caused gastritis, Professor Barry Marshall an Australian physician, drank a beaker of H.pylori culture.

He became ill with nausea & vomiting several days later

A🧵on discovery of H.pylori & it's association with peptic ulcer

#MedTwitter The discovery of H. Pylori (🦠) had been made by chance one afternoon in 1979, while Professor Robin Warren, an Austarlian pathologist was at work on a routine gastric biopsy sample in the pathology laboratory at the Royal Perth Hospital.

A 🧵 on STORMS in medicine.
First a question ❓️

PRAZOSIN is helpful in management of which among the following conditions❓️

💥Electrical storm
💥Cytokine storm
💥Thunderstorm Asthma
💥Thyroid storm
💥Parathyroid storm
💥Dystonic storm
💥Autonomic storm

#MedTwitter #MedEd Brief overview of these emergency conditions.

One of these conditions warrants activation of disaster management protocol 🚑 ⛈️

Which one is that❓️

Read on👇