1/16 Yet another fantastic AM report @LosAngelesVA!

Facilitator: @BrandonCSmithMD
Presenter: Danny Xu, MD (@uclaimchiefs PGY-2)

CC: lower back pain (LBP)

#MedTwitter #MedEd #FOAMed 2/ Brandon asked the group three questions:
1⃣ What is your approach to the pain?
2⃣ How does that inform your next steps for history and physical?
3⃣ How does that inform your next diagnostic steps?

1/10 We often talk about evaluation of AKI in the context of ⬆️ creatinine, but let’s take a step back and think about eGFRs. Here is an approach to interpreting ⬇️ in eGFR! #NephTwitter #MedTwitter #FOAMed #MedEd 2/ This differential focuses on the estimated GFR (eGFR), which is calculated using serum creatinine +/- serum cystatin C levels (we will take a look at the equations in a bit). Biomarkers that actually measure GFR (such as inulin) are not clinically practical to obtain.

1/10 As someone who struggles with test-taking, I made a framework for tackling some common test-taking hurdles. I had the opportunity to go over this with all our @uclaimchiefs housestaff and decided to make it into a 🧵 #MedTwitter #MedStudentTwitter #FOAMed 2/ Test scores are important because they are what you need to become board-certified. Scores are often conflated with competency - that is quite a fallacy as so many other factors go into competency.

1/12 The cognitive load on rounds can be high, so I like using daily e-mails as an adjunct to teaching on rounds. Here is a 🧵 on my approach! #MedTwitter #MedEd #FOAMEd 2/ I am of the opinion that you can form an outline of a lesson plan BEFORE you even start on service! My group attends for 14 days at a time, so this tells me how much “time” I have allotted to teach (more on this later).

1/8 Medical education has evolved tremendously, and I am a HUGE fan of having a peripheral brain. An common question trainees ask me is “how do you cultivate references?” A 🧵 on my methodology for organizing information #MedTwitter #MedEd 2/8 Before we start, it is important to categorize the purpose of the info you are gathering:
1⃣ To teach others
2⃣To teach myself
I don’t organize my references this way, but I start here to remind myself that everyone learns best with different modalities!

1/18 Chest pain is a frequently seen reason for admission. Here's my take on when to consider ACS in patients with chest pain!
#MedTwitter #CardioTwitter #MedEd #FOAMed #MedTweetorial @MedTweetorials 2/18 Our evaluation of ACS starts with 3 things:

1⃣ History
2⃣ EKG
3⃣ Troponin

The primary focus of this thread is going to be on the history (a heads up - the flowchart at the end will go a little bit out of order)!

1/5 How can you calculate the estimated DAILY risk of ischemic stroke (and other events) in patients with atrial fibrillation?

#MedTwitter #HemeTwitter #CardioTwitter #MathTwitter #FOAMed #MedEd

Note: the original post was deleted due to a mathematical error 2/5 While the CHADSVASc is helpful for annual estimation of ischemic stroke risk (and other events), what is the risk of DAILY risk? Turns out we can do some math to derive it from the annual risk estimation!

1/7 Considering how to manage community-acquired pneumonia (CAP)? Is it CURB-65 or should it be CARB-65? No idea what I am talking about? Let's talk about azotemia and uremia!

#MedTwitter #FOAMEd #MedEd #NephTwitter #IDTwitter 2/7 The CURB-65 score has been used for diagnosis and treatment of adults with community-acquired pneumonia (CAP). The most recent IDSA CAP guidelines in 2019 (pubmed.ncbi.nlm.nih.gov/31573350/) referenced the 2007 IDSA CAP criteria for defining severity

1/9 You admit a patient overnight with hyponatremia and you diagnose it as SIADH. But how are you going to manage it?

To review how to diagnose SIADH, check out the volume-based or ADH/RAAS-based approaches below.

#MedEd #FOAMed #MedTwitter #NephTwitter #Tweetorial 2/9 The cornerstone of treatment is to treat the underlying cause. Everything else is just a 🩹. It can sometimes be very hard to treat the underlying cause immediately (assuming you can identify it).

1/8 A patient with compensated HFrEF (EF 35%) has positive orthostatics. He is not hypovolemic. What medication is reasonable to prescribe?
#MedTwitter #MedEd #FOAMed #NeuroTwitter #GeriTwitter 2/8
💥Fludrocortisone will increase ⬆️ RAAS and can cause volume overload, so you should avoid it here
💥 Caffeine and ibuprofen are last-line agents to manage orthostatic hypotension
💥 Midodrine is probably your best bet here

1/5 A 78 yo F with no prior medical history p/w progressive pill-rolling tremor, shuffling gait, and dizziness upon standing. She takes no meds. Orthostatics are ➕. What is the likely cause of her orthostatic hypotension?
#MedTwitter #MedEd #FOAMEd #GeriTwitter #NeuroTwitter 2/5 The answer is Parkinsonism! Parkinsonism is a synucleinopathy (the protein alpha-synuclein accumulates in neurons and glia) leading to autonomic dysfunction. Review this approach on orthostatic hypotension here:

https://twitter.com/SatyaPatelMD/status/1417493742768902144?s=20

. Let's keep going.

1/9 Let’s say you are about to do a thyroid exam. Before the exam you do not suspect goiter (pre-test prob of 50%). How does the exam influence your probability? Let’s review some LRs from McGee!
#MedEd #FOAMed #MedTwitter #MedStudentTwitter #EndoTwitter @MedTweetorials 2/9 You may think “well that’s nice, but my thyroid exam technique is not the best.” Don’t worry, the Stanford 25 has got your back (including this clinical pearl)!
stanfordmedicine25.stanford.edu/the25/thyroid.…

1/7 Spacers confused me, so I wanted to sort them out. Let’s start with a question - what type of inhalers can benefit from a spacer?

#MedTwitter #FOAMed #MedEd #MedStudentTwitter #PulmTwitter 2/7 Metered dose inhaler (MDIs) are best used with a spacer! Pressurized devices were invented far earlier, but the technology was adapted to treat asthma in the form of an MDI in 1957 by Riker Labs. smithsonianmag.com/innovation/his…

1/7 Let’s go over the evidence-based physical exam for lower extremity deep vein thrombosis (LE DVT). In the spirit of quantifying clinical concern, here is a question - besides inspection (and #POCUS), which tool will help you the most?

#MedTwitter #FOAMed #MedEd 2/7 The answer is a ruler! Let’s look at the LRs.

Quick review of LRs:
- The (+) and (-) indicate the LR if a finding is present or absent, respectively
- The more the LR deviates from 1, the more useful it is

1/4
Let's review the evidence-based physical exam for Cushing syndrome!

Quick review of LRs:
- The (+) and (-) indicate the LR if a finding is present or absent, respectively
- The more the LR deviates from 1, the more useful it is

#MedTwitter #MedEd #EndoTwitter #FOAMed 2/4
Things that stand out to me
- "Buffalo hump" doesn't have a defined LRs despite being taught as a "classic" finding (occurs in 34-75% of patients)
- The presence of moon facies has a lower LR than I expected (1.6)

1/8 Let's review assessment of hypovolemia based on physical exam. (yes, I know #POCUS is SO valuable in making this assessment)

Which physical exam finding is most useful to detect hypovolemia in adults?

#MedTwitter #FOAMed #MedEd #MedStudentTwitter 2/8 According to a great review by Dr. McGee in JAMA Rational Clinical Exam "Is This Patient Hypovolemic" the answer is... sunken eyes!

jamanetwork.com/journals/jama/…

1/12 The jump from classroom teaching to clinical rotations is made tougher by the fact that physicians have illness-specific frameworks for presentations and documentation. Let's explore a bunch of them (feedback is most welcome)!

#MedTwitter #MedEd #FOAMed 2/12 Let's start with anemia. It is ideal if you report the baseline Hgb and an interpretation of the MCV. #HemeTwitter

1/8 This always confused me as a trainee, so I figured it would be worth reviewing! What parameter should you interpret to determine if a patient is generating an appropriate amount of RBCs?

#MedTwitter #FOAMed 2/8 While you need all this information, the answer is Reticulocyte Index (RI)! This is an underutilized test and should be one of the first tests you use when working up anemia. So how do we calculate this and what are those other terms? Let's review.

1/ What has the highest +LR for low ejection fraction?

#CardioTwitter #MedTwitter #MedEd 2/ Per 4th edition of Evidence-Based Physical Exam by McGee), the answer is "Displaced apical impulse" which is defined as "an impulse lateral to the midclavicular line (MCL)."

1/ Had some fun today on rounds with these! The Rinne and Weber tests stress out a lot of folks, so let's tackle them today.

#MedTwitter #MedEd #EndNeurophobia @MedTweetorials 2/ What are the Weber and Rinne tests used to help identify?

1/8 When might an FeUrea not be as useful as FeNa? Let's explore briefly!

#NephTwitter #MedEd #MedTwitter #Tweetorial #FOAMEd @MedTweetorials 2/8 First of all, a quick reminder that the utility of the FeNa and FeUrea in evaluation of AKI needs to be carefully considered before they are ordered (I'm a big fan of looking at UAs). journalofhospitalmedicine.com/jhospmed/artic…