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#MedTwitter #MedStudentTwitter #NeuroTwitter! This morning on @CPSolvers #VMR we discussed an approach to peripheral polyneuropathy so here’s a #tweetorial to add to the #EndNeurophobia series
Link to whole series here:
twitter.com/i/events/12671…
@rabihmgeha @DxRxEdu @caseyalbin
Link to whole series here:
twitter.com/i/events/12671…
@rabihmgeha @DxRxEdu @caseyalbin
Peripheral neuropathy can be classified as:
Mononeuropathy: single nerve affected
Polyneuropathy: nerves affected throughout body symmetrically
Mononeuropathy multiplex: multiple individual nerves affected, asymmetric
Check out @DxRxEdu video!
clinicalproblemsolving.com/peripheral-neu…
Mononeuropathy: single nerve affected
Polyneuropathy: nerves affected throughout body symmetrically
Mononeuropathy multiplex: multiple individual nerves affected, asymmetric
Check out @DxRxEdu video!
clinicalproblemsolving.com/peripheral-neu…
MonoN and polyN are most common.
Mononeuropathy multiplex=rare
MonoN most commonly compressive or traumatic (ulnar neurop @ elbow, median neurop @ wrist, peroneal neurop @ fibular head)
Rarely: tumor (neurofibroma), infiltration (amyloid, neurolymphomatosis
Mononeuropathy multiplex=rare
MonoN most commonly compressive or traumatic (ulnar neurop @ elbow, median neurop @ wrist, peroneal neurop @ fibular head)
Rarely: tumor (neurofibroma), infiltration (amyloid, neurolymphomatosis
We didn't have a #Neuro case today on @CPSolvers #VMR with @AaronLBerkowitz but don't worry! Let's recap a prior episode for some #SpacedLearning @DxRxEdu @rabihmgeha
With @ddeng_22 @KannuBansalMD
clinicalproblemsolving.com/morning-report…
With @ddeng_22 @KannuBansalMD
clinicalproblemsolving.com/morning-report…
A 26 yo M w/ a PMH of nodular sclerosing hodgkins lymphoma p/w left-sided facial droop, L arm weakness, and dysarthria.
He presented 12 hours after onset and his symptoms had resolved.
3 months prior he had an autologous stem cell transplant and is currently on Brentuximab.
He presented 12 hours after onset and his symptoms had resolved.
3 months prior he had an autologous stem cell transplant and is currently on Brentuximab.
First of remembering that E=MC2
Time of onset and localization
Sudden Onset: Think stroke, seizure, Todd's paralysis, toxic metabolic, migraine with aura
Localization: Brainstem ipsilateral face and contralateral body
Time of onset and localization
Sudden Onset: Think stroke, seizure, Todd's paralysis, toxic metabolic, migraine with aura
Localization: Brainstem ipsilateral face and contralateral body
1/ When @CPSolvers - @rabihmgeha @DxRxEdu @Sharminzi @ArsalanMedEd @haematognomist etc. started #VMR - did they understand the power of the zoom chat room? While magic (& math) in the main zoom, the chat room is participating in a very high spirited educational discussion.
2/ While I will forget some starts (please add in reply section), I always look forward to bouncing ideas with @AnnKumfer @RosenelliEM @TheRealDSrini @TxID_Edu @fernandbteich @RezidentMD @coyefish379 @ABRezMed @MohitHarshMD @k_vaishnani
3/ The same excitement is occurring in @UnremarkableLab
The chat room enhances learning. We teach each other and all grow. We need special T-shirts = We chat clinical reasoning.
The chat room enhances learning. We teach each other and all grow. We need special T-shirts = We chat clinical reasoning.
Time for some #SpacedRepetition: @CPSolvers @DxRxEdu @rabihmgeha
July 15th Day 93: clinicalproblemsolving.com/morning-report…
Chat recap of the #ClinicalPearls #VirtualMorningReport
Featuring: @sargsyanz @StephVSherman @tonlajr @AdamTapley
Teaching points overview by @sukritibanthiya
July 15th Day 93: clinicalproblemsolving.com/morning-report…
Chat recap of the #ClinicalPearls #VirtualMorningReport
Featuring: @sargsyanz @StephVSherman @tonlajr @AdamTapley
Teaching points overview by @sukritibanthiya
Before we start, if you didn't check out @_HarryPaul_ twitter thread from last wk, 👉👉
Now the initial PR:
A 60 y/o M w/ PMH of relapsing MS dx (last flare 4 yrs ago) p/w unsteadiness, trouble focusing & weightloss was tx for MS flare w/o improvement
Now the initial PR:
A 60 y/o M w/ PMH of relapsing MS dx (last flare 4 yrs ago) p/w unsteadiness, trouble focusing & weightloss was tx for MS flare w/o improvement
"difficulty focusing on objects" --> interesting
maybe he has diplopia, Check out this flow chart for this "blurry" topic
Is this JC virus reactivation with PML?natalizumab and some of the new oral agents can cause: iomcworld.org/open-access/na…
maybe he has diplopia, Check out this flow chart for this "blurry" topic
Is this JC virus reactivation with PML?natalizumab and some of the new oral agents can cause: iomcworld.org/open-access/na…
Transient worsening of poststroke neurologic deficits or reemergence of previous stroke-related deficits (or poststroke recrudescence [PSR]) in the setting of toxic metabolic factors is a frequently encountered phenomenon
PSR is often referred to as an anamnestic recall or recrudescence and have associated it with systemic infections and the use of sedative medications and anesthetic drugs.
PSR can occur after ischemic and hemorrhagic stroke. Infection, hypotension, hyponatremia, insomnia or stress, and benzodiazepine use are important triggers. New neurologic deficits are usually mild to moderate in severity and do not exceed the previous stroke deficits.
This is #Part2
A reflection from the #ChatRecap of the special #Juneteenth edition of @CPSolvers #VMR episode w/ @gradydoctor
and her wonderful Father Mr. William (Tony) Draper.
The "Positive Stories from Tuskegee"
A reflection from the #ChatRecap of the special #Juneteenth edition of @CPSolvers #VMR episode w/ @gradydoctor
and her wonderful Father Mr. William (Tony) Draper.
The "Positive Stories from Tuskegee"
Part 1 was hard to stomach. It demonstrated the racial disparities that existed & we should all self reflect on as clinicians to make sure it doesn't happen again
But it shouldn't overshadow what has transpired since
This is why Mr. Draper wears the hat. (not this exact one)
But it shouldn't overshadow what has transpired since
This is why Mr. Draper wears the hat. (not this exact one)
Before them, no African-American had been a U.S. military pilot.
So who were the Tuskegee airmen?
They were a group of Black & Caribbean-born military pilots who fought in WW II.
They formed the 332nd Fighter Group and the 477th Bombardment Group of the US Army Air Forces
So who were the Tuskegee airmen?
They were a group of Black & Caribbean-born military pilots who fought in WW II.
They formed the 332nd Fighter Group and the 477th Bombardment Group of the US Army Air Forces
I usually do a #ChatRecap of the @CPSolvers #VMR episodes.
This past Friday was #Juneteenth and we had 2 special guests. @gradydoctor and her wonderful Father Mr. William (Tony) Draper.
And not to my surprise, there was no chatter. We just listened!
This past Friday was #Juneteenth and we had 2 special guests. @gradydoctor and her wonderful Father Mr. William (Tony) Draper.
And not to my surprise, there was no chatter. We just listened!
We learned about the holiday celebrating the day when all remaining enslaved Black Americas were freed in Texas, on June 19th, 1865, with this hour-long storytelling event.
There was something notable that Mr. Draper was wearing and I thought I would give a #tweetorial on it.
There was something notable that Mr. Draper was wearing and I thought I would give a #tweetorial on it.
He was wearing a Tuskegee hat and shirt. Although I had heard about it in the past, I didn't know much about it to the detail that I felt comfortable with.
I wanted to share some notable things that I found.
I wanted to share some notable things that I found.
1/ #UncleBob presents #5goodminutes about the term AKI. For references I suggest - Acute Kidney Injury @AnnalsofIM acpjournals.org/doi/10.7326/AI… and Annals On Call - Care of Patients With Acute Kidney Injury acpjournals.org/doi/10.7326/A1…
2/ KDIGO definition of AKI includes a change in serum creatinine clearance (SCC) within 2–7 days & oliguria for 6 or more hours. The stage is defined by the peak rise in SCC compared w/ previous values & nadir in urine output & is related to risk for complications &prognosis
3/ Thus, when a patient comes to the hospital with an increased creatinine from previous creatinines, that does NOT constitute AKI. When a patient comes in with an increased creatinine, or develops an increase in the hospital you must first determine several things
After a great @CPSolvers #VMR on PML the other day, I found myself in the dark about U-fibers. Thanks to some nice #SpacedRepetition by @haematognomist I took a deeper dive.
They are affected differently bc they are among the last parts of the brain to myelinate, as late as the third or fourth decade
They have very slow myelin turnover and thus are affected last in diseases in which the abnormality is one of myelin metabolism/turnover like CADASIL
They have very slow myelin turnover and thus are affected last in diseases in which the abnormality is one of myelin metabolism/turnover like CADASIL
Just bc they are spared initially, over time they can become involved
Diseases in which the damage is direct to oligodendroglial cells, then no such relative sparing will be seen
And because JCV has tropism to oligodendrocytes, the pathology is seen!
Diseases in which the damage is direct to oligodendroglial cells, then no such relative sparing will be seen
And because JCV has tropism to oligodendrocytes, the pathology is seen!
1/ #UncleBob opines for #5goodminutes on the labs from @CPSolvers Episode 95 @Sharminzi
Briefly - unfortunate woman in her 50s, severe brain injury, all input from IV & feeding tube, stage 4 decubitus ulcer, now has markedly increased urine output (3 l/day) & hypernatremia 159
Briefly - unfortunate woman in her 50s, severe brain injury, all input from IV & feeding tube, stage 4 decubitus ulcer, now has markedly increased urine output (3 l/day) & hypernatremia 159
2/ Has known CKD with previous creatinine of 2.5
Labs in hospital
161/4.0. 103/20. 50/2.5 98. (calcium not given)
Urine Na 46, K 9, Cl 49, osm 148
with ADH administration urine osms ~ 180
Labs in hospital
161/4.0. 103/20. 50/2.5 98. (calcium not given)
Urine Na 46, K 9, Cl 49, osm 148
with ADH administration urine osms ~ 180
3/ The #VMR chat room knows that I seriously nerd out over these numbers. My thinking:
Hypernatremia is water-handling problem. The patient is not taking in as much free water as she is excreting. By definition hypernatremia is dehydration (not necessarily volume contraction).
Hypernatremia is water-handling problem. The patient is not taking in as much free water as she is excreting. By definition hypernatremia is dehydration (not necessarily volume contraction).
Some really good #ClinicalPearls about #Psittacosis with a short #medtweetorial
Something mentioned in today's @CPSolvers #VMR
It's not something that I commonly ask patients with #CAP but I think I will insert the question about them owning a parrot or bird into my questioning
Something mentioned in today's @CPSolvers #VMR
It's not something that I commonly ask patients with #CAP but I think I will insert the question about them owning a parrot or bird into my questioning
In the 1960s and 1970s it was the model organism that laid the foundation for modern chlamydia research.
Psittacosis is also known as avian chlamydiosis, ornithosis, and parrot fever.
It causes an atypical pneumonia when it infects the lungs.
Psittacosis is also known as avian chlamydiosis, ornithosis, and parrot fever.
It causes an atypical pneumonia when it infects the lungs.
All birds are susceptible, pet birds and poultry are most frequently involved in transmission to humans but not human to human
It can also be found in non-avian domestic animals, such as cattle & sheep, but cases of clinical disease & transmission to humans have not been proven
It can also be found in non-avian domestic animals, such as cattle & sheep, but cases of clinical disease & transmission to humans have not been proven
1/
#UncleBob shares his reflections #5goodminutes) on a #VMR from last Wed- clinicalproblemsolving.com/wp-content/upl…
This was a complex case that started w/ chest pain, fevers, weakness, etc. After seeing the labs, I guessed the diagnosis.
@CPSolvers @rabihmgeha @DxRxEdu @RosenelliEM
#UncleBob shares his reflections #5goodminutes) on a #VMR from last Wed- clinicalproblemsolving.com/wp-content/upl…
This was a complex case that started w/ chest pain, fevers, weakness, etc. After seeing the labs, I guessed the diagnosis.
@CPSolvers @rabihmgeha @DxRxEdu @RosenelliEM
2/
Cognitive autopsies are always valuable - for mistakes and for guessing the correct answer. Did I make a sound diagnosis, or was I just lucky? Why did I suggest Hepatitis A?
Let's examine the liver tests and how they stimulated my thinking:
Cognitive autopsies are always valuable - for mistakes and for guessing the correct answer. Did I make a sound diagnosis, or was I just lucky? Why did I suggest Hepatitis A?
Let's examine the liver tests and how they stimulated my thinking:
3/
I divide liver tests into 3 categories - cellular destruction:
AST 2160 ALT 1750; obstruction: alkaline phophatase 240 T Bili 3.4 Direct 2.4; loss of factory function: albumin 2.3 but PT not reported.
Thus, I emphasized massive acute cellular destruction.
I divide liver tests into 3 categories - cellular destruction:
AST 2160 ALT 1750; obstruction: alkaline phophatase 240 T Bili 3.4 Direct 2.4; loss of factory function: albumin 2.3 but PT not reported.
Thus, I emphasized massive acute cellular destruction.
1/ #UncleBob takes #5goodminutes to wax philosophically
I love Saturdays … but no #VMR today. During the pandemic #VMR has made a wonderful contribution to my sense of purpose & community. @CPSolvers @DxRxEdu @rabihmgeha @Sharminzi @ArsalanMedEd @haematognomist
I love Saturdays … but no #VMR today. During the pandemic #VMR has made a wonderful contribution to my sense of purpose & community. @CPSolvers @DxRxEdu @rabihmgeha @Sharminzi @ArsalanMedEd @haematognomist
2/ As many know, I am semi-retired - only work 3/8 at the VA as a ward attending. My wonderful colleagues have decided that because of my age (fortunately my only risk factor) that they will keep me off the wards for now.
3/ Those who know me will understand that my career highlights all involve ward attending. I am fortunate to have good health and the resources to stay away from the hospital without any major difficulty.
@CPSolvers #VMR inspired me to fill gaps in knowledge re: sterile pyuria (adapted from @NEJM article cited in phenomenal thread 👇🏾)
@MedTweetorials
First: what is pyuria?
▪️≥ 10 WBC/mm3
▪️≥ 3 WBC/hpf
▪️pos gram's stain (unspun urine)
▪️Urinary dipstick pos for leuk esterase
@MedTweetorials
First: what is pyuria?
▪️≥ 10 WBC/mm3
▪️≥ 3 WBC/hpf
▪️pos gram's stain (unspun urine)
▪️Urinary dipstick pos for leuk esterase
"Sterile pyuria is the persistent finding of white cells in the urine in the absence of bacteria"
And it is super common!
"13.9% of women and 2.6% of men are affected"
🤯 The DDx is waaaaay broader than I suspected, so let's take it by category
And it is super common!
"13.9% of women and 2.6% of men are affected"
🤯 The DDx is waaaaay broader than I suspected, so let's take it by category
1/ STI
▪️Gonorrhea, Chlamydia, Mycoplasma
▪️HSV-2, Herpes Zoster
▪️HPV
▪️"In one study, among 104 patients with untreated HIV infection, 13% had pyuria"
Other viruses that do *not* typically have pyuria: adenovirus, BK, CMV --> sometimes cause hemorrhagic cystitis
▪️Gonorrhea, Chlamydia, Mycoplasma
▪️HSV-2, Herpes Zoster
▪️HPV
▪️"In one study, among 104 patients with untreated HIV infection, 13% had pyuria"
Other viruses that do *not* typically have pyuria: adenovirus, BK, CMV --> sometimes cause hemorrhagic cystitis
1/ #UncleBob discussed BMP on #VMR - spend #5goodminutes 2 analyze. Pt ~80 & weighs ~55kg (recent 5 kg wt loss). Sarcopenia Pt has orthostasis (HR & BP).
Na 134 K 4.7 Cl 99 HCO3 23 BUN 22 cr 1.2 nl glucose
tweetorial later today
Can these labs help?
@kidney_boy
@uabimres
Na 134 K 4.7 Cl 99 HCO3 23 BUN 22 cr 1.2 nl glucose
tweetorial later today
Can these labs help?
@kidney_boy
@uabimres
2/
Gregory (Scotland Yard detective): “Is there any other point to which you would wish to draw my attention?”
Holmes: “To the curious incident of the dog in the night-time.”
Gregory: “The dog did nothing in the night-time.”
Holmes: “That was the curious incident.”
Gregory (Scotland Yard detective): “Is there any other point to which you would wish to draw my attention?”
Holmes: “To the curious incident of the dog in the night-time.”
Gregory: “The dog did nothing in the night-time.”
Holmes: “That was the curious incident.”
3/
We have a patient with presumed simple intravascular volume contraction. Do the labs support that hypothesis?
The sodium is slightly low - volume contraction is definitely a potential cause of low sodium - if the patient is drinking fluids freely.
We have a patient with presumed simple intravascular volume contraction. Do the labs support that hypothesis?
The sodium is slightly low - volume contraction is definitely a potential cause of low sodium - if the patient is drinking fluids freely.
1/
#ZOOMintheTimeofCOVID
The more we’re required to meet virtually, the better we need to get at it. I’ve seen some GREAT pro-tips on the technical features of @zoom_us.
But.
I’ve also appreciated some little things that could make #zoomlife easier.
Let's discuss, mmkay?
#ZOOMintheTimeofCOVID
The more we’re required to meet virtually, the better we need to get at it. I’ve seen some GREAT pro-tips on the technical features of @zoom_us.
But.
I’ve also appreciated some little things that could make #zoomlife easier.
Let's discuss, mmkay?
2/
First, get yourself situated:
Take a pre-login bio break.
Have water/coffee within reach.
Need to take notes? Have what you need handy—phone, tablet, it’s up to you.*
*Confession: Sometimes I have my desktop/other laptop for notes and searches--but don't tell anyone.🤫
First, get yourself situated:
Take a pre-login bio break.
Have water/coffee within reach.
Need to take notes? Have what you need handy—phone, tablet, it’s up to you.*
*Confession: Sometimes I have my desktop/other laptop for notes and searches--but don't tell anyone.🤫
3/
Signal vs. noise:
Many “big deal” lectures are becoming virtual. Internet can be shaky depending on location in your house or when too many devices are plugged in. Secure a quiet, reliable space in advance.*
*Note: Quiet is challenging with kids & pets--plan if you can.
Signal vs. noise:
Many “big deal” lectures are becoming virtual. Internet can be shaky depending on location in your house or when too many devices are plugged in. Secure a quiet, reliable space in advance.*
*Note: Quiet is challenging with kids & pets--plan if you can.
1/
#UncleBob regrets missing #VMR live - but he spent time on the recorded version. Love the discussion and the case - often treatable. Have made the diagnosis once ~25 years ago.
As a lab junky I have some questions for @CPSolvers @fernandbteich
@DxRxEdu @rabihmgeha
#UncleBob regrets missing #VMR live - but he spent time on the recorded version. Love the discussion and the case - often treatable. Have made the diagnosis once ~25 years ago.
As a lab junky I have some questions for @CPSolvers @fernandbteich
@DxRxEdu @rabihmgeha
2/
Did anyone note the bicarbonate of 17? Is this a normal gap acidosis or a compensation for respiratory alkalosis? This is not essential for the main dx - but could the patient have unknown early hepatopulmonary. I would have questioned that if she was on my service.
Did anyone note the bicarbonate of 17? Is this a normal gap acidosis or a compensation for respiratory alkalosis? This is not essential for the main dx - but could the patient have unknown early hepatopulmonary. I would have questioned that if she was on my service.
3/
The combination of low albumin and high INR strongly suggests CLINICAL cirrhosis - the factory is not working
With the low albumin, did she have hypercalcemia - would have checked an ionized calcium.
Finally did the Echocardiogram mention pulmonary artery pressure?
The combination of low albumin and high INR strongly suggests CLINICAL cirrhosis - the factory is not working
With the low albumin, did she have hypercalcemia - would have checked an ionized calcium.
Finally did the Echocardiogram mention pulmonary artery pressure?
1/
Reflections on big lessons from #VMR from #UncleBob - hopefully less that #5goodminutes
@CPSolvers @rabihmgeha @DxRxEdu @Sharminzi @ArsalanMedEd @LindseyShipley8 @SZKamal
CAP
Understanding what the patient means with their words
Naturalistic decision making
Travel history
Reflections on big lessons from #VMR from #UncleBob - hopefully less that #5goodminutes
@CPSolvers @rabihmgeha @DxRxEdu @Sharminzi @ArsalanMedEd @LindseyShipley8 @SZKamal
CAP
Understanding what the patient means with their words
Naturalistic decision making
Travel history
2/
CAP
Should we do a schema for "not CAP"? It seems like some of the most fascinating presentations start out as CAP. How can we convince physicians that CAP has a relatively specific illness script against which to compare their problem representation?
CAP
Should we do a schema for "not CAP"? It seems like some of the most fascinating presentations start out as CAP. How can we convince physicians that CAP has a relatively specific illness script against which to compare their problem representation?
3/
Maybe it is the curmudgeon in me screaming out at this point, but repeatedly I see major diagnostic delays due to a reflex of "abnormal CXR" - CAP. They ignore the history of chronic symptoms rather than acute symptoms. There is often a very incomplete history.
Maybe it is the curmudgeon in me screaming out at this point, but repeatedly I see major diagnostic delays due to a reflex of "abnormal CXR" - CAP. They ignore the history of chronic symptoms rather than acute symptoms. There is often a very incomplete history.
