1/
She had an itch for 10 years and then finally a dx was made.
Hope you don't get itchy reading this one.
<3 @rabihmgeha
2/ PMD "How are you doing?"
Her "I am fine. My diabetes is under better control."
PMD "How are your kids?"
Her "My youngest just graduated college"
(10 minutes later)
PMD "Anything else bothering you?"
Her "I've had an itch all over for 10 years but no one can figure out why."
Jan 24 • 12 tweets • 2 min read
1/12
Leukemia Series - Part 3/5: APL (Acute Promyelocytic Leukemia)
@Anand_88_Patel, @rabihmgeha, and yours truly are back at it.
Knowing this condition is literally the difference between life and death
2/12
It is a unique subtype of AML that is curable with Rx but fatal without
Those affected are ~20-60 yo (younger-onset than AML)
Its uniqueness includes leukopenia, DIC, and smear findings including high # Auer rods, blasts with bilobed nuclei, and/or blasts with hypergranular cytoplasm
Jan 24 • 19 tweets • 3 min read
1/
It all started with debilitating fatigue.
@rabihmgeha and I present this very important case.
An astute diagnostician can be the difference between life and death.
2/ He was 68 years old when he suddenly felt fatigued. He no longer could garden or play with his dog.
It worsened day by day. His wife brought him to the ED.
Jan 22 • 18 tweets • 3 min read
1/ How much can be learned from a single case?
Well let's go on a journey w/ RR (@rabihmgeha and his older brother)
2/ 43 yo M was baking cake for his wife.
Him in the kitchen. Her in the living room.
Then suddenly she hears a thud. She runs into the kitchen. Blood oozed down from his forehead.
"What happened?" She asked.
"I don't know. I was up but next moment I am on the ground."
Jan 19 • 8 tweets • 2 min read
1/ Constipation
We have all experienced it.
Viewed as a benign diagnosis (though not benign to the person experiencing it).
You need to know when it is not a "benign" diagnosis but rather a proximal clue to a sinister diagnosis.
2/ During 28-hour calls in the hospital, I definitely experienced constipation, likely reflecting my lack of fluid intake. And trust me it was not benign to me though increasing fluid intake resolved this problem.
1/ An important story that might save a person's life.
He felt something in his groin. You quickly look, touch, and POCUS to dx enlarged right inguinal lymph nodes.
What is your next action? No multiple choices to guide you. Pause and really think about what you'd do next.
2/ You examine the ipsilateral leg. No signs of infection. You look at the genitals but no obvious pathology.
What is your next action? And do you admit?
Dec 6, 2023 • 17 tweets • 3 min read
1/ Leukemia Series - Part 2/5: AML
@Anand_88_Patel, @rabihmgeha, and prof Rez are back at it.
Review Part 1 then dive into Part 2.
You will understand leukemia if you spend 5 min w/ each part.
Ask @Anand_88_Patel any questions for clarification! He is an expert.
Before we dive into the type of leukemia let us step back and look @ the big picture.
By the end of this thread, you’ll have a 3-step approach to the diagnostic journey of leukemia.
Nov 16, 2023 • 18 tweets • 3 min read
1/ An important one folks.
Elderly man p/w subacute worsening chest pressure and dizziness.
2/ Our focus should be his chest pressure. The subacute nature significantly lowers likelihood of ACS, PE, and aortic dissection.
Nov 13, 2023 • 13 tweets • 2 min read
1/ She was a centenarian. She had hypertension her whole life. She was on a classic regimen.
2/ Over a period of months she developed severe LE edema, jugular venous distention, orthopnea, dyspnea, and recurrent transudative left-sided pleural effusion
Nov 7, 2023 • 13 tweets • 2 min read
1/ One of the main reasons I chose IM was to develop an approach to any abnormality.
I will never know all the nuances but you better bet I will try until I retire.
Let's go on a walk and discuss the basics of post-kidney transplant ...
2/ The learning comes from a phenomenal CORE IM episode.
CORE IM episodes are like the best talks at a national conference but FREE. You have charismatic hosts & an expert who knows how to teach. Stop reading this if you have time to listen to episode
1/ Let's learn bout a condition that affects > 95% of the world's population.
Note I said learn not just memorize a list of symptoms/signs.
2/ Learning medicine in the context of patients hits way differently than just reading a book to pass a test.
Why?
The stimulus to learn is way greater. The stakes are much higher. You won't leave any stone unturned. And you'll remember the salient features forever.
Oct 21, 2023 • 19 tweets • 3 min read
Nephrotic syndrome made simple.
Walk with this non-nephrologist.
1/n She developed swelling in her legs at the age of 53. She had h/o DM. Exam w/ mild HTN. JVP normal. No stigmata of cirrhosis.
2/n What is the most likely cause of the swelling?
Aug 29, 2023 • 8 tweets • 1 min read
1/8 Let's through undertanding learn a potential neurosurgical emergency - cauda equina syndrome
The story starts at its name
2/8 Cauda = tail
Equine = horse
The lumbosacral nerve roots literally look like a horse's tail (google it!)
Cauda equine represents L2-L5, S1-S5, and coccygeal nerve
Aug 15, 2023 • 5 tweets • 1 min read
1/5
ANCA - The Basics in 5 tweets
Anti-Neutrophil Cytoplasmic Antibodies (ANCA) positivity does not mean there is an ANCA-associated vasculitis (AAV)
ANCA negativity does not r/o AAV
Clinical context is KEY!!
2/5
2 STEPS involved in ANCA testing.
(1) Immunofluorescence (IF) to determine if there is staining that is cytoplasmic or peri-nuclear. Sensitive but not specific. Need to follow-up w/ antibody testing.
(2) ELISA for 2 cytoplasmic enzymes, PR3 and MPO.
Jul 22, 2022 • 4 tweets • 2 min read
1/4 Come w/ RR to explore the dizzy patient (@rabihmgeha). @DNewmanToker simple approach applied.
You get a call. The patient is experiencing new onset dizziness.
What are the 3 most useful questions?
Think of 3 possible questions before moving on.
2/4 1. Any associated symptoms? Nope. The focus is dizziness not for example fever. 2. Is it episodic or persistent? Episodic. Last 4-5 min @ a time. 3. Is it triggered by position? Nope. Spontaneous.
Exam showed swelling, decreased range of motion, erythema, and pain
What's your ddx? Create one before moving on
2/4 Easy way to remember. Just like consolidation in lung think of molecules.
WBC -> septic joint
RBC -> hemorrhagic
H2O -> trauma
Crystals -> (pseudo)Gout
***All have white cell but easy way to activate DDx
Apr 18, 2022 • 32 tweets • 5 min read
1a/ You are on the medicine consult service.
The page comes through “Consult request - hypocalcemia.”
Many times when there is an asymmetry in the body the abnormal component is obvious. For example, right lower extremity edema.
But there are times where the first step is figuring out which component of the asymmetry is abnormal. For example, unequal pupil size.
2/6 Here we must understand physiology.
CN3 constricts. Sympa dilates. Both elevate the eyelid.
We must localize the site of neuropathology to CN3, oculosympathetic pathway, or other.
Aug 23, 2020 • 6 tweets • 1 min read
Trigeminal neuralgia and 3 teaching points inspired by recent NEJM review
1/ Understand how and the rest makes sense
Nerve compressed usually by vessel -> demyelination -> sodium entry -> hyperexcitability -> firing of neurons -> OUCH
2/ Paroxysmal firing of pain neurons = paroxysms of pain (usually a few seconds).
If pain longer than 2 min, consider a different dx.
Does this sound familiar? Yes, BPPV. We will discuss that beautiful pathophysiology another time.
Aug 2, 2020 • 5 tweets • 1 min read
1/ (2 min read)
Phosphate homeostasis via the beautiful lens of physiology
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