🧵100 timeless bedside gems every doctor should know.
Straight from Hutchison’s Clinical Methods — distilled into 10 clean infographics.

If you love real clinical medicine, this thread will remind you why you chose it.

🩺 Let’s bring back the art of examination 👇

(Save this thread — it’ll outlive most AI tools.) #MedTwitter #MedEd #FOAMed @DrAkhilX @IhabFathiSulima @drkeithsiau @DurgaPrasannaM1 @JasmineNephro General Principles

1️⃣ The patient will tell you the diagnosis — if you learn to listen.

History first. Examination next. Investigations last.

🩺 The foundation Hutchison built 125 years ago still holds true.

🧵 DADA2 & Vasculitis — The Hidden Culprit

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What if one mutation causes vasculitis, strokes, immune deficiency & cytopenias — all in one patient?
That’s DADA2 (Deficiency of Adenosine Deaminase 2).
@DrAkhilX @IhabFathiSulima #MedTwitter #RheumTwitter 2/
🔍 What is DADA2?
•Rare, autosomal recessive disease
•Mutations in ADA2 gene → enzyme deficiency
•Impacts vessels, immune system, bone marrow

🧵 Management of Scleroderma (Systemic Sclerosis) – 2025 Update

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Scleroderma (Systemic Sclerosis, SSc) is a chronic autoimmune connective tissue disease with fibrosis, vasculopathy, and autoimmunity at its core.
Management is organ-specific and evolving with new evidence. Let’s break it down. 👇
@DrAkhilX @IhabFathiSulima #MedTwitter 2/
🔹 General Principles
•No single “cure” exists.
•Approach is multidisciplinary: rheumatology, pulmonology, cardiology, nephrology, dermatology.
•Early recognition of organ involvement = better outcomes.

🧵: Proteinuria – When to Think Beyond the Kidneys

Tweet 1:
Proteinuria isn’t always just nephrology.
Sometimes, it’s the first clue to systemic disease.
Here’s how to approach proteinuria with an internal medicine + rheumatology lens 👇 @DrAkhilX @IhabFathiSulima #MedTwitter #RheumTwitter #NephroTwitter Tweet 2:
🔍 Step 1: Confirm proteinuria
•Dipstick vs. spot UPr/Cr ratio vs. 24h collection
•Rule out false positives (alkaline urine, hematuria, concentrated sample)

🧵 : Shortness of Breath – When is it Rheumatology?

Tweet 1:
Shortness of breath (SOB) isn’t always cardiac or pulmonary.
Sometimes, the cause is hidden in the immune system.
Here’s how to separate Medicine vs Rheumatology causes 👇
@DrAkhilX @IhabFathiSulima @CelestinoGutirr #MedTwitter #RheumTwitter #PulmoTwitter Tweet 2:
📌 Internal Medicine causes (common):
•Heart failure
•COPD/asthma
•Pneumonia
•Pulmonary embolism
•Anemia

(Always rule these first.)

🧵 Approach to Recurrent Fever – Don’t Miss These Clues

Tweet 1:
Recurrent fever is a diagnostic puzzle.
Is it infection, malignancy, or autoimmunity?
Here’s a structured approach every clinician should know 👇
@DrAkhilX @IhabFathiSulima #MedTwitter #RheumTwitter Tweet 2:
📌 Step 1: Define it
•Recurrent fever = fever episodes with return to baseline in between.
•Different from persistent FUO.
•History of pattern (daily, cyclical, periodic) is vital.

🧵 Rheumatology hides its best lessons in the wards, not the pages.
These are 5 clinical pearls that every resident must know 👇
@IhabFathiSulima @DrAkhilX #MedTwitter Tweet 2 (Pearl 1 – MAS in sJIA):
💡 MAS in systemic JIA doesn’t always shout at you.
•Ferritin >5000 ng/mL is a warning bell
•Don’t wait for pancytopenia or multi-organ failure
•Early recognition + immunosuppression = life-saving

🧵 Pancytopenia – A Clinical Approach

You see a patient’s CBC, and all 3 cell lines are down.
Hemoglobin ↓, WBC ↓, Platelets ↓.
That’s pancytopenia — and it always demands respect.

Here’s how to approach it 👇
@IhabFathiSulima @DrAkhilX @CelestinoGutirr #MedTwitter #Rheumatology #Hematology 1. Definition 📌
Pancytopenia = reduction in all 3 lineages:
•Hb < 10 g/dL
•TLC < 4,000 /mm³
•Platelets < 100,000 /mm³

Not just a lab number — it reflects a systemic problem.

🧵 Fever of Unknown Origin (FUO) – A Clinical Approach

Every doctor faces this: a patient with fever that just won’t go away.
Here’s how to tackle FUO in a systematic, bedside-friendly way 👇

1. Definition 🔑
FUO = Fever >38.3°C (101°F) on multiple occasions, lasting >3 weeks, with no diagnosis despite 1 week of inpatient evaluation.

👉 Not just “fever for long time” — it’s a diagnosis of exclusion.
@IhabFathiSulima @DrAkhilX #MedTwitter #RheumTwitter 2. Categories of FUO 📂
Classically 4 buckets:
•Infectious
•Malignancy
•Autoimmune / Rheumatologic
•Miscellaneous / Undiagnosed

🧵 Thread: Approach to Low Back Ache:
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Low back ache (LBA) is one of the most common reasons patients visit a doctor.
But not every back pain is the same.
A structured approach helps us identify who needs urgent care, who needs simple reassurance, and who needs long-term management.
@IhabFathiSulima @DrAkhilX #MedTwitter #RheumaTwitter 2/
🔑 First step: Duration
•Acute: <6 weeks
•Subacute: 6–12 weeks
•Chronic: >12 weeks
This simple classification guides the urgency and depth of evaluation.

🧵 Red Cell Morphology in Clinical Medicine:

Looking at a peripheral smear is like reading the story of a patient’s blood.
Here’s how to approach it 👇
@IhabFathiSulima @DrAkhilX #MedTwitter #Hematology 1. Normal Smear
•Central pallor ~1/3 of RBC diameter
•Round, biconcave cells
👉 Baseline before spotting abnormalities

🧵 Key Terms in Rheumatology — Simplified & Explained ⬇️

Rheumatology is full of terms like synovitis, enthesitis, tenosynovitis, dactylitis.
Let’s break them down in a clear way

1️⃣ Synovitis
= Inflammation of the synovial lining of a joint.
Signs: swelling, warmth, tenderness, ↓ ROM.
Seen in: RA, lupus arthritis, JIA.
Think: “the joint lining is angry.”
@DrAkhilX @IhabFathiSulima #MedTwitter #RheumatTwitter 2️⃣ Enthesitis
= Inflammation at the enthesis (where tendons/ligaments insert into bone).
Common in: Spondyloarthritis (PsA, AS, IBD-arthritis).
Typical sites: Achilles tendon, plantar fascia, costochondral junctions.
Pain is deep, localized, worse with stress.

🧵 Urinalysis in Clinical Medicine:

1️⃣ Why it matters
Urinalysis = bedside, cheap, high-yield test.
Helps in:
•AKI & CKD workup
•Nephritis & nephrotic syndrome
•Infections & metabolic disorders
•Drug monitoring in rheumatology (cyclophosphamide, NSAIDs)
@IhabFathiSulima @DrAkhilX @CelestinoGutirr #MedTwitter #nephrology #rheumatology 2️⃣ Components of urinalysis
1.Physical exam – color, clarity, odor, volume
2.Chemical (dipstick) – protein, blood, glucose, ketones, pH, nitrite, leukocyte esterase, SG
3.Microscopy – cells, casts, crystals, organisms

🧵 Hypercalcemia – A Clinical Approach plus Rheumatological causes:

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Hypercalcemia isn’t just “high calcium.”
It can cause kidney stones, bone pain, abdominal symptoms, psychiatric changes – and even cardiac arrest.
Here’s a structured approach 👇
@IhabFathiSulima @DrAkhilX #MedTwitter 2/
🔎 Step 1 – Confirm
•Correct serum Ca for albumin OR check ionized Ca.
•Rule out lab error.
•Always assess severity & symptoms.

Mild: 10.5–12
Moderate: 12–14
Severe: >14 or symptomatic

🧵 Hypokalemia – A Clinical Thread plus Rheumatological causes:
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Hypokalemia = serum K+ < 3.5 mmol/L.
It may look “just a number” on labs, but in reality → can cause paralysis, arrhythmias, and death if missed.
Here’s the clinical approach 👇
@IhabFathiSulima @DrAkhilX #MedTwitter #RheumTwitter #Nephrology 2/
🔎 Step 1 – Confirm & Assess
•Rule out lab error (hemolysis, delayed sample).
•Check ECG: U-waves, flattened T-waves, arrhythmias.
•Assess symptoms: weakness, cramps, ileus, palpitations.

🧵 Lupus Nephritis (LN) Thread:

Tweet 1:
Lupus Nephritis (LN) is one of the most serious complications of SLE—responsible for major morbidity & mortality.
Here’s an updated 2025 thread on LN 🧵
@IhabFathiSulima @DrAkhilX #MedTwitter #RheumatTwitter #Nephrology Tweet 2:
⚠️ Clinical clues
•Proteinuria (often nephrotic range)
•Hematuria (microscopic or gross)
•Hypertension
•Reduced renal function
•Sometimes asymptomatic → only labs reveal disease

1/🧵 Acute Kidney Injury (AKI) is a common but critical problem in Internal Medicine.
Early recognition & classification into Prerenal, Intrinsic, Postrenal is essential for patient outcomes.
Here’s a stepwise approach
@IhabFathiSulima @DrAkhilX #MedTwitter #RheumTwitter #NephroTwitter 2/
🔹 Definition (KDIGO):
•↑ Serum Creatinine by ≥0.3 mg/dL within 48 hrs OR
•↑ Serum Creatinine to ≥1.5× baseline within 7 days OR
•Urine output <0.5 mL/kg/hr for 6 hrs

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Chest pain in rheumatology patients?
Don’t forget Pericarditis — one of the most frequent cardiac manifestations of autoimmune disease.
Here’s a stepwise approach. 🧵
@ihabFathiSulima @DrAkhilX #MedTwitter #RheumTwitter 2/
🔹 Autoimmune causes of pericarditis:

Connective Tissue Diseases (CTD):
•SLE (most common), RA (long-standing, nodular), Scleroderma/systemic sclerosis, Sjögren’s disease, MCTD, Overlap syndromes

Systemic Vasculitis:
•PAN, ANCA vasculitis, Takayasu arteritis, Giant cell arteritis (rare),Behçet’s disease

Other Rheumatic Conditions:
•Adult-onset Still’s disease, Sarcoidosis, IgG4-related disease, Autoinflammatory syndromes (TRAPS, FMF)

Renal Tubular Acidosis (RTA) in Autoimmune Diseases:🧵

1/ Not every metabolic acidosis is due to sepsis or renal failure.
In rheumatology, think Renal Tubular Acidosis (RTA) — a subtle but important clue to underlying autoimmune disease. @IhabFathiSulima @DrAkhilX #MedTwitter #RheumTwitter #NephroTwitter 2/
🔹 What is RTA?
A defect in renal acid handling → normal anion gap metabolic acidosis with preserved GFR.
Types:
•Type 1 (Distal)
•Type 2 (Proximal)
•Type 4 (Hypoaldosteronism-related)

🧵 Liver & Autoimmune Diseases (AIH, PBC and PSC):
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When the immune system attacks the liver or bile ducts, 3 classic conditions come to mind:
•Autoimmune Hepatitis (AIH)
•Primary Biliary Cholangitis (PBC)
•Primary Sclerosing Cholangitis (PSC)

Let’s walk through them 👇 @IhabFathiSulima @DrAkhilX @Janetbirdope @theliverdr @drkeithsiau @Gastronaut___ @NatRevGastroHep #MedTwitter #Hepatology #GastroTwitter 2/
📌 Autoimmune Hepatitis (AIH)
•Mostly affects young women
•Symptoms: fatigue, jaundice
•Labs: very high AST/ALT, ↑IgG
•Autoantibodies: ANA, SMA, anti-LKM

Untreated → cirrhosis in a few years.

Tweet 1
Acid–Base Disorders — Stepwise Interpretation 🧪
A clean, clinical approach every resident should know.
Mnemonic: ROME
Respiratory: Opposite
Metabolic: Equal
@IhabFathiSulima @DrAkhilX #MedTwitter #MedEd #NephroTwitter Tweet 2
Step 1: Look at the pH
• pH < 7.40 → acidemia
• pH > 7.40 → alkalemia

This tells you the primary direction.
Next: is it respiratory or metabolic?