Satya Patel Profile picture
Hospitalist @LosAngelesVA | Anesthesiology Intern APD @UCLAHealth | Interested in meded, curriculum design, and QI | Views my own | #pundofknowledge
darigadu Profile picture Sarah Owens Profile picture 2 added to My Authors
2 Nov
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).
3/ Make sure to include every learner who will rotate with you while you are on (I use amion to figure out which trainees are on with me). They might appreciate getting learning when they are off service and if there is an ongoing thread of teaching, they won’t miss out!
Read 12 tweets
27 Oct
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!
3/8 Now that we’ve acknowledged that, you must create a list of modalities that you can consistently categorize information into. Here is my organizational system.
Read 8 tweets
6 Sep
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)!
3/18 When taking a chest pain history, we ask lots of questions about associated symptoms and alleviating/aggravating factors, mostly because we were taught to obtain and report this history. But is there a more focused way to approach this? Image
Read 18 tweets
30 Aug
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!
3/5 The math here doesn't EXACTLY reflect the daily risk of for patients because there are countless variables that we cannot control. @JessieCurrier17 describes the rationale using probability quite nicely. Image
Read 5 tweets
25 Aug
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
3/7 The original article that describes validation of the CURB scoring system (ncbi.nlm.nih.gov/pmc/articles/P…) does NOT use the word "uremia," but instead references an serum urea level cutoff.
Read 7 tweets
25 Jul
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).
3/9 Free water restriction is going to help (to a certain degree), but make sure that it’s feasible for the patient (they often need to do this beyond hospitalization). Consider restricting 500 cc below their 24-hour urine output:
Read 9 tweets
22 Jul
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
3/8 You prescribe midodrine 2.5 mg PO q8h and end up titrating it up to 5 mg PO q8h over the course of a few weeks. The patient shows you their BP log and you notice that their nighttime supine BPs are elevated. What do you do next?
Read 8 tweets
21 Jul
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: . Let's keep going.
3/5 She is diagnosed with Parkinsonism, and started on carbidopa-levodopa BID with improvement in symptoms. Her family has hired 24/7 caregivers who ensure her PO intake is adequate.
Read 5 tweets
19 Jul
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.…
3/9 Now that you’ve identified a goiter, you will probably end up ordering some lab and imaging studies. But don’t leave the bedside just yet! Let’s first break down the differential for an enlarged thyroid (thanks again to the Stanford 25).
Read 9 tweets
12 Jul
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…
3/7 MDIs have various advantages and disadvantages, some of which can be mitigated by spacers.
rc.rcjournal.com/content/50/9/1…
Read 7 tweets
9 Jul
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
3/7 For this particular set of exam findings, it may be more helpful to see how much the LRs change your post-test probability (assuming a pre-test probability of 50%). The presence of absence of asymmetric calf swelling seems to be the most helpful.

Graphic from McGee
Read 7 tweets
7 Jul
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 Image
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)
3/4
- The absence (or presence) of abdominal striae is not particularly helpful
- The presence of a thin skinfold (thickness on the back of the hand <1.8 mm in women of reproductive age) can be VERY telling
Read 4 tweets
4 Jun
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/… Image
3/8 For a way to clinically interpret the LRs, let's turn our attention to Dr. McGee's book "Evidence-Based Physical Diagnosis." Although sunken eyes has the highest LR, notice how small the difference in increase in probability there is with each exam finding. Image
Read 8 tweets
2 Jun
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 Image
3/12 For VTEs, it is helpful to tell the listener/reader if you think it is provoked vs. unprovoked. A hypercoagulable work-up should not be sent routinely. Image
Read 12 tweets
1 Jun
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.
3/8 An Absolute Reticulocyte Count (ARC) is often calculated by your lab, but you need to be sure you are looking at the right parameter. Lots of folks use MDCalc to calculate RI, but the calculator gives you an ARC and RI.
Look at the first parameter to enter - it's a %! Image
Read 8 tweets
28 May
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)." Image
3/ Here is a great description on physicaldiagnosispdx.com on the exam technique Image
Read 5 tweets
23 May
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?
3/ The answer is both! Remember that the most useful exams are hypothesis-driven so you need to do a history to begin suspecting if a patient has either type of hearing loss. This will help you generate a pre-test probability for disease (this will become relevant later).
Read 13 tweets
14 May
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…
3/8 You might see a table like the one below that can be used to (cautiously) interpret FENa and FEUrea.
Read 8 tweets
22 Mar
1/11 Congrats to those who matched! I tweeted about an inpatient pocket card set in 2020 and got great feedback. Here is the result of a big overhaul: bit.ly/pocketcardset

Let's review what's inside!

#MatchDay2021 #MedStudentTwitter #MedTwitter #TipsForNewDocs #FOAMed
3/11 First up is a pre-rounding checklist. Be systematic and read all of the notes in your patient’s chart (interdisciplinary care is critical).

H/t @nickmmark for the idea to use a QR code to maintain an updated version! This QR code also has some additional resources. Image
Read 11 tweets
8 Feb
1/11 I like this flowchart, but my brain starts to melt. If yours does to, follow along and we'll take it from the top! This is my first #tweetorial on hypercortisolism!

#MedEd #MedTwitter #FOAMEd #MedStudentTwitter #EndoTwitter

bitly.ws/bDnZ Image
2/11 Let's start with a question. Which of the following are TRUE?
a. Cushing disease = hypercortisolism
b. Cushing disease is a type of Cushing syndrome
c. Cushing syndrome is a type of Cushing disease
3/11 a. and b. are correct! Here are some physical exam features of hypercortisolism.

bitly.ws/bDo5 Image
Read 11 tweets
2 Jan
1/15 Disposition from the hospital can be confusing, so let's review two potential options that are often mixed up:
- SNF
- RCFE

#MedEd #MedStudentTwitter #MedTwitter #FOAMEd

@kelleychuang reminded me that prepping dispo should happen in advance, so let's review before Monday!
2/15 A SNF is a Skilled Nursing Facility. These facilities require INSURANCE. There are two durations of stays:
- Short-term (for skilled needs)
- Long-term (for custodial care)
3/15 Which of the following is NOT an example of a skilled need?
Read 15 tweets