Michelle Kittleson MD PhD
@MKIttlesonMD
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#kittlesonrules | Cardiologist | Prof of Medicine @CedarsSinai | Author Mastering the Art of Patient Care available at
Los Angeles, CA
Joined November 2018
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Pinned Tweet
#TipsForNewDocs
On night call, I used to answer: “What's the emergency?"
Then, I needed on-call peds for my kid- his first words: “How can I help?"
That’s how I respond now.
Not being nice won't limit calls, it just makes them unpleasant for all involved.
#kittlesonrules
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Hydroxychloroquine and azithromycin
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#TipsForNewDocs
Past medical history:
Wrong:
- AF
- DM
Right:
- Persistent AF managed w/rate control/anticoag, CHA2DS2-VASc 3
- Type 2 DM, Hgb A1c 7.5% 7/20, no end-organ dz
The PMH should provide descriptions of dz severity. Don't list- stratify!
#kittlesonrules
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#TipsForNewDocs
Patient: “When can I go home?”
Bad: “Maybe 3 days.”
Good: “When you can walk around without symptoms and we’ve optimized meds – could be 3 to 7 days.”
Respond by providing criteria to meet, not days- that way, you’re less likely to be wrong.
#kittlesonrules
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#TipsForNewDocs
You’re never too important to look it up.
I’m a cardiologist and I still look up the treatment of pericarditis. I don't treat it a lot and want to ensure I have the duration/taper of NSAIDs right.
UpToDate should be your friend for life.
#kittlesonrules
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#TipsForNewDocs
Past medical history--
Wrong:
- AF
- DM
Right:
- Persistent AF managed w/rate control/anticoag, CHA2DS2-VASc 3
- Type 2 DM, Hgb A1c 7.5% 7/20, no end-organ dz
The PMH should provide descriptions of dz severity. Don't list- stratify!
#kittlesonrules
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#TipsForNewDocs
Presenting your plan:
A non-plan: "Pt is on lasix 40 IV BID."
A great plan: "Pt hypervolemic, neg 2.5 L yesterday. Goal > 2L neg so continue lasix 40 IV BID."
Anatomy of a plan: status + response to current rx + goal + tool to achieve goal.
#kittlesonrules
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#TipsForNewDocs
You’re never too important to look it up.
I’m a cardiologist and I still look up the treatment of pericarditis. I don't treat it a lot and want to ensure I have the duration/taper of NSAIDs right.
UpToDate should be your friend for life.
#kittlesonrules
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You're heard of elf on the shelf but what about
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Sometimes I’m asked how I “do it all“ w/3 kids and career.
I don’t.
Career extras like research get put on hold when family requires more attention.
Life happens in stages- don’t be hard on yourself- you’re not supposed to accomplish it all at once.
#kittlesonrules
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#TipsForNewDocs
Patient doesn’t accept your recommendation. How to document?
No: "Patient refuses X.”
Yes: "Patient declines X due to ____. I explained the indications, risks, benefits of X. S/he understands the medical consequences of his/her decision."
#kittlesonrules
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If you’ve never screamed YOU DON’T SHOCK ASYSTOLE!!! at the TV, do even work in healthcare?
If you've never criticized the quality of on-screen CPR, do you even work in healthcare?
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Elevated D-dimer does not equal pulmonary embolism.
Elevated D-dimer does not equal pulmonary embolism.
Elevated D-dimer does not equal pulmonary embolism.
Elevated D-dimer does not equal pulmonary embolism.
Elevated troponin does not equal myocardial infarction
Elevated troponin does not equal myocardial infarction
Elevated troponin does not equal myocardial infarction
Elevated troponin does not equal myocardial infarction
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#TipsForNewDocs
If a patient tells you they want a second opinion, encourage it.
If the 2nd opinion is the same as yours, you look great.
If the 2nd opinion is different, you can learn something new.
Regardless, you and the pt benefit: win-win!
#kittlesonrules
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#TipsForNewDocs
Don't ask pts/families to make medical decisions.
Bad: We could do CPR on your mom if you want.
Good: Your mom is sick. CPR might keep her alive longer, but not achieve the QOL she said she wanted.
Frame medical options by goals/values.
#kittlesonrules
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#TipsForNewDocs
Past medical history--
Wrong:
- AF
- DM
Right:
- Persistent AF managed w/rate control/anticoag, CHA2DS2-VASc 3
- Type 2 DM, Hgb A1c 7.5% 7/20, no end-organ dz
The PMH should provide descriptions of dz severity. Don't list- stratify!
#kittlesonrules
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#TipsForNewDocs
Sinus tachycardia is the delirium of cardiology.
Delirium --> it's (basically) never the brain's fault.
Sinus tach --> it's (basically) never the heart's fault.
Don't be distracted by the wrong organ in search of the right answer!
#kittlesonrules
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Heart transplant pt w/chronic pain calls me: out of pain meds.
Saw pain doc 3w ago, rec'd 3w supply, follow-up appt.
Appt cancelled- pain doc said no pain meds w/o appt. I filled it.
Medical issues don't stop in a pandemic- plan contingencies for your pts.
#kittlesonrules
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#TipsForNewDocs
Past medical history--
Wrong:
- AF
- DM
Right:
- Persistent AF managed w/rate control/anticoag, CHA2DS2-VASc 3
- Type 2 DM, Hgb A1c 7.5% 7/20, no end-organ dz
The PMH should provide descriptions of dz severity. Don't list- stratify!
#kittlesonrules
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#TipsForNewDocs
Sinus tachycardia is the delirium of cardiology.
Delirium --> it's (basically) never the brain's fault.
Sinus tach --> it's (basically) never the heart's fault.
Don't be distracted by the wrong organ in search of the right answer!
#kittlesonrules
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#TipsForNewDocs
On rounds, ask: is it necessary?
-BID labs
-Foley catheters
-nasal cannulas
-restricted diets (cardiac/low Na, etc)
Per Coco Chanel: “Before you leave the house, look in the mirror and take one thing off.”
Look at your pt and do the same!
#kittlesonrules
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#TipsForNewDocs
Patient doesn’t accept your recommendation. How to document?
No: "Patient refuses X.”
Yes: "Patient declines X due to __. I explained the indications, risks, benefits of X. S/he expresses understanding of the consequences of his/her decision."
#kittlesonrules
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#TipsForNewDocs
Ask hospitalized pts if they are walking daily, and if not, why.
Otherwise, when you have resolved the medical issues, you may discover they haven’t walked in a week and are too deconditioned to go home.
Discharge planning begins at admission!
#kittlesonrules
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#TipsForNewDocs
Sinus tachycardia is the delirium of cardiology.
Delirium --> it's (basically) never the brain's fault.
Sinus tach --> it's (basically) never the heart's fault.
Don't be distracted by the wrong organ in search of the right answer!
#kittlesonrules
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#TipsForNewDocs
Get in the habit of NOT referring to AST/ALT as liver function tests.
High AST/ALT -> liver injury.
High INR and low albumin -> abnormal liver synthetic function.
Right terms --> right interpretation of test results --> right diagnoses.
#kittlesonrules
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#TipsForNewDocs
When the nurse asks you to come to a pt's bedside, you should run, not walk.
When the cath lab tech suggests a different catheter, say yes.
Experience trumps education every time.
#kittlesonrules
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#TipsForNewDocs
“Family decided to withdraw care” is never appropriate in the chart.
Better: "After discussion of prognosis and pt's values/preferences; life-prolonging measures to be withdrawn."
Families don’t make medical decisions- don't document as such.
#kittlesonrules
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Older male doc: Hey, it's the cute Dr. K!
Me: By cute, you meant brilliant cardiologist whom you’d trust with your life, right?
Older male doc: Uh, yes, of course!
Even if meant in jest, don't ignore slights. Sarcasm/humor can get the point across.
#kittlesonrules
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#TipsForNewDocs
When examining/doing a procedure on a sedated or unresponsive pt, address them by name and narrate your actions.
It’s good to keep in the habit, it’ll remind you they’re a person, and you never know what they might absorb even if unconscious.
#kittlesonrules
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#TipsForNewDocs
You can say "I don't know" to a patient and still inspire confidence.
"I don't know. . . but I have a plan to figure it out."
"No one knows. . . but here's what we can do about it."
Honesty + plan = do your best to maintain patient's trust.
#kittlesonrules
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Sometimes I’m asked how I “do it all“ w/3 kids and career.
I don’t.
Career extras like research get put on hold when family requires more attention.
Life happens in stages- don’t be hard on yourself- you’re not supposed to accomplish it all at once.
#kittlesonrules
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#TipsForNewDocs
TID dosing of IV lasix is mean- there is no way to schedule w/o pt up all night peeing.
Instead, switch to a drip (off 10 p - 4 a) or add AM thiazide- just as effective + pts gets rest.
Diuresis is important, but not at the expense of sleep.
#kittlesonrules
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#TipsForNewDocs
There’s nothing magical about NPO after midnight.
If the pt’s procedure/surgery is after noon, give them breakfast. When in doubt, ask the operator before defaulting to this arcane order.
Less interminable fasting = better pt experience.
#kittlesonrules
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A heart transplant pt came to clinic: a thriving medical miracle.
He stopped himself in the middle of describing some minor aches and pains and said, "Irritation is the luxury of healthy person."
And just like that, a
#kittlesonrules
was born.
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#TipsForNewDocs
Before ordering a test, have a plan for a normal, abnormal, or indeterminate result.
If this thought experiment demonstrates the test won’t change management, or if you don’t know how to interpret/act upon all possible results, don’t order it.
#kittlesonrules
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Hi
#medtwitter
!
Is there a non-medical accomplishment of which you are particularly proud?
Here’s mine: my homemade brownies are famous amongst my son’s 2nd grade classmates. In fact, they have been christened: “Michelle’s famous brownies.”
Share yours!
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#TipsForNewDocs
HF patient:
Wrong: "No rales- switch to oral diuretics!"
Right: "JVP elevated- continue IV diuresis!"
Worst way to assess volume status: rales. They're often absent in chronic HF due to pulmonary lymphatic compensation.
#kittlesonrules
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#TipsForNewDocs
How I explain renal dysfunction to pts:
Kidneys are like cats. You can't make them do something they don't want to do. You can optimize the environment for their comfort (BP, volume, no NSAIDs) but ultimately, they'll decide which way to go.
#kittlesonrules
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#TipsForNewDocs
Pt prescribed a med- on follow-up, is not taking it.
Wrong: "Pt is noncompliant."
Right: "Pt unable to take med because __. We discussed strategies including __."
Don't start chart rumors - understanding problems >>>> labeling patients.
#kittlesonrules
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My medical bucket list:
1) diagnose a pheo
2) treat a tension pneumo with a large-bore needle into the 2nd IC space
3) have an essay in NEJM
1 out of 3 isn't too shabby! I hope you like it :)
A Good Physician — On Complacency and Communication | NEJM
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#TipsForNewDocs
Minimize indignities of inpatient care:
-no vitals 12AM-5 AM
-no routine labs/standing diuretics past 6 PM
-no late-night diuretic spotting unless critical
-ask about and address insomnia/constipation
#kittlesonrules
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Hi,
#MedTwitter
!
Is there a non-medicine-related interest or activity that made you a better health care professional?
For me: playing the piano. Taught me focus, discipline, organization, and manual dexterity.
Share yours!
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I have an cardiology joke but it’ll shock you.
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#TipsForNewDocs
Pt prescribed a med- on follow-up, is not taking it.
Wrong: "Pt is noncompliant."
Right: "Pt unable to take med because __. We discussed strategies including __."
Don't start chart rumors - understanding problems >>>>> labeling patients.
#kittlesonrules
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#RandomTip
I used to send emails with lots of "I think. . ."
When I deleted the "I think"s, the message didn't change, but the tone was more confident.
My advice: remove "I think"s from your words/speech --> you'll sound and feel more sure of yourself!
#kittlesonrules
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#TipsForNewDocs
When you first examine a patient in shock, check their feet.
Warm feet = good chance it's NOT cardiogenic shock.
Simple test --> lots of information.
#kittlesonrules
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I ask a new pt who referred him.
Son says, "15 y ago, I was a surgical intern and called you for consults. You were nice, wore great shoes, and taught me that sinus tachycardia is a symptom, not a disease."
There's no expiration date on positive feedback!
#kittlesonrules
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#TipsForNewDocs
When you're seeing a pt w/dementia, speak directly to the pt whenever possible.
They might not understand everything, and their caregiver can chime in, but benefit of the doubt = engage them as much as possible and preserve their dignity.
#kittlesonrules
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#TipsForNewDocs
I observed a mentor evaluate a pt with dementia. He spoke directly to the pt.
When answers didn't make sense, he asked if it was OK w/the pt to speak to the accompanying caregivers.
I adopted this act of respect and made it a
#kittlesonrules
.
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#TipsForNewDocs
Address the elephant in the room.
When reviewing abnormal results, ask the pt what worries them most and explain your plan to rule it in or out.
Allow pt to voice their greatest fear + make a plan for it = provide comfort in uncertainty.
#kittlesonrules
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#TipsForNewDocs
Respect tachycardia, esp in the hospital and in young pts who otherwise look OK.
There's always a reason: before you write it off to pain, anxiety, hypovolemia, don't miss HF, sepsis, ischemia, bleeding, PE, or alcohol withdrawal.
#kittlesonrules
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#TipsForNewDocs
Get in the habit of NOT referring to AST/ALT as liver function tests.
High AST/ALT -> liver injury.
High INR and low albumin -> abnormal liver synthetic function.
Right terms --> right interpretation of test results --> right diagnoses.
#kittlesonrules
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#TipsForNewDocs
If you understand pathophysiology, you'll understand etiology and then differential diagnosis.
Reason >>> memorization (unless it's interstitial lung disease or glomerulonephritis, in which case- good luck).
#kittlesonrules
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@Abradd_med
My mom always told me that there might be people that were smarter than me, but I shouldn’t let there be people who worked harder than me! And I’ve never regretted all the hours I had to put in… So hang in there because it’s totally worth it!
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I'm not on the front lines (yet), but the pandemic still has affected me and my patients.
Thank you to
@NEJM
for allowing me to tell my story, and also for quickest turnaround ever: 10 days from submission to publication!
I hope you like it :)
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#TipsForNewDocs
When rounding with your attending, It's better to have the wrong plan than no plan.
Having even the wrong plan= taking ownership for your patient.
You'll learn from your mistakes and refine your clinical judgment.
#kittlesonrules
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#TipsForNewDocs
The practice of medicine gets better (more rewarding, less scary) with experience.
Approach medicine like a foreign language- put in the effort to memorize the grammar and vocabulary and you will soon be able to appreciate the poetry.
#kittlesonrules
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#TipsForNewDocs
Some consults are interesting.
Some consults are annoying.
Some consults seem unnecessary.
But that all consults are an opportunity to help a patient and/or educate a colleague, so help, educate, and sign off when you've done so.
#kittlesonrules
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#TipsForNewDocs
Sinus tachycardia is the delirium of cardiology.
Delirium --> it's (basically) never the brain's fault.
Sinus tach --> it's (basically) never the heart's fault.
Don't be distracted by the wrong organ in search of the right answer!
#kittlesonrules
10
106
605
#TipsForNewDocs
When you first examine a patient in shock, check their feet.
Warm feet = good chance it's NOT cardiogenic shock.
Simple test --> lots of information.
#kittlesonrules
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#TipsForNewDocs
Sometimes not knowing is OK but the delivery matters.
Wrong: I don't know why you have palpitations.
Right: We've ruled out serious causes so not knowing the cause isn't critical.
Frame priorities + manage expectations = better communication.
#kittlesonrules
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#TipsForNewDocs
When examining/doing a procedure on a sedated or unresponsive pt, address them by name and narrate your actions.
It’s good to keep in the habit, it’ll remind you they’re a person, and you never know what they might absorb even if unconscious.
#kittlesonrules
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Q: What happens if you update your Twitter bio before telling your parents about your promotion?
A: You get an email like this!
#humblebrag
#thanksdad
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#TipsForNewDocs
Know the pitfalls of the tests you order.
Ex:
- Neg D-dimer makes PE unlikely, but pos D-dimer doesn't indicate PE
- Normal uric acid doesn't rule out gout.
- A stress test is neg only if the pt achieves adequate HR.
Share your pitfalls!
#kittlesonrules
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#TipsForNewDocs
If you have a medical student on the team, go over their plans with them in advance so they shine on attending rounds.
When your med student looks good, you look good too.
#kittlesonrules
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Flight attendant: Is there a doctor onboard?
Dad: *raises my hand* HERE! MY DAUGHTER RUNS A HEART TRANSPLANT PROGRAM!
Me: Shhh, Dad, what?! Just the fellowship.
Dad: SHE’S A TENURED PROFESSOR!
Me: Dad, there is no tenure—
Dad: SHE SPEAKS FRENCH!
Me: Mon dieu...
#prouddads
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#TipsForNewDocs
I dislike knee-jerk tests.
Not every abnormal AST/ALT merits a liver u/s.
Not every abdominal pain merits a KUB.
Not every heart failure admission merits a new echo.
Use the H&P to guide your choice of tests.
Please add your pet peeves!
#kittlesonrules
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#TipsForNewDocs
When a patient is angry
1) Listen
2) Listen
3) Listen (it’ll take longer than you like)
4) Explain what you can change and what you can’t
5) Make a plan together to change what you can
6) Circle back to check in
#kittlesonrules
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#TipsForNewDocs
The active problem list is not a diary.
Ask yourself: is the fact that the patient was admitted for community-acquired pneumonia in 2002 still relevant in 2020?
If an item doesn't spark joy (i.e., better patient care), delete it!
#kittlesonrules
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#TipsForNewDocs
You’re never too important to look it up. I’m a cardiologist and I still look up the treatment of pericarditis. I don't treat it a lot and want to ensure I have the duration/taper of NSAIDs right. UpToDate = your friend for life.
#kittlesonrules
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#TipsForNewDocs
Secret to a stellar oral presentation: HPI -> PMH -> Meds/allergies -> SH -> FH -> ROS -> PE -> labs -> A/P - same order, every time.
Rounds are not the place for extemporaneous soliloquies (let's be honest: there's never a place for those).
#kittlesonrules
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#TipsForNewDocs
“Family decided to withdraw care” is never appropriate in the chart.
Better: "After discussion of prognosis and pt's values/preferences; life-prolonging measures to be stopped."
Families don’t make medical decisions- don't document as such.
#kittlesonrules
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#TipsForNewDocs
Pt learns of mass on chest CT when the nurse tells her she's NPO for biopsy.
Primary team assumed consult team told pt.
Consult team assumed primary team told pt.
Lesson: don’t assume. Include “tell the patient” as part of the plan.
#kittlesonrules
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#TipsForNewDocs
A patient once did poorly because of a decision I made and I told him that I was sorry.
It could have gone badly but he hugged and thanked me.
The lesson: in the right setting, saying sorry can help you as much as it helps the patient.
#kittlesonrules
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#TipsForNewDocs
When a HF pt is tachy, think diuresis or even mech support- don't increase the BB.
-it’s compensatory: HR up because stroke vol down
-inotropes to improve cardiac output -> higher HR -> often make things worse
Fear sinus tachycardia in HF.
#kittlesonrules
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🎆It's almost here!🎆
My book, based on the hard-won experience of
#kittlesonrules
, filled with advice for surviving and thriving in medical training and beyond, is coming out Jan 8, 2023!
1) Pick an online bookseller
2) Search "Mastering the Art of Patient Care"
3) Pre-order!
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I just overheard a nurse asking her supervisor if she could go and donate blood on her lunch break because she heard there was a shortage.
I’m neither a hugger nor a crier but if it weren’t for social distancing, I would’ve done the former with the latter.
#nursesareheroes
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#TipsForNewDocs
HF patient:
Wrong: "No rales- switch to oral diuretics!"
Right: "JVP elevated- continue IV diuresis!"
Worst way to assess volume status: rales. They're often absent in chronic HF due to pulmonary lymphatic compensation.
#kittlesonrules
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“I obtained the report of the echocardiogram done 2 months ago at another hospital instead of ordering one here because that would waste resources and put the patient through an unnecessary procedure.”
What would someone have to whisper in your ear for this to happen?
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#TipsForNewDocs
A good checklist to ask when you exit a patient's room:
-lights on/off?
-TV on/off?
-where's the tray table go?
-door open/closed?
"Leave it better than you found it" applies to inpatient rounding too!
#kittlesonrules
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#TipsForNewDocs
Consult etiquette:
Bad: I'm referring you to cardiologist for angiogram.
Good: I'm referring you to cardiology to determine the next best step for your abnormal stress test.
Let the specialist use their expertise and set them up for success!
#kittlesonrules
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#TipsForNewDocs
Before ordering a test, have a plan for a normal, abnormal, or indeterminate result.
If this thought experiment demonstrates the test won’t change management, or if you don’t know how to interpret/act upon all possible results, don’t order it.
#kittlesonrules
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#TipsForNewDocs
When I meet a sick pt:
"We don’t have answers, but here’s our plan to get them."
"When you’re overwhelmed, remember our goal is to get you back to the life you love.”
“If the plan isn't working, I promise to be honest about your options."
#kittlesonrules
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#TipsForNewDocs
Essential checklist for calling a consult:
1) have a specific question
2) call early in the day
3) inform the pt who's coming and why
Don't forget
#3
- the oncology consult shouldn't be the first one to tell the pt they have cancer.
#kittlesonrules
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#TipsForNewDocs
Don't choose your (sub)specialty based on lifestyle.
1) If you dislike what you're doing, even short days will feel long.
2) You can fashion a flexible schedule in most specialties with creativity + supportive mentors.
#kittlesonrules
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#TipsForNewAttendings
I'm PGY-21, and I still pre-round (review charts b/f rounds).
Bonus
#1
: identify inaccuracies in presentations --> better/more efficient care.
Bonus
#2
: prepare salient teaching points.
More prep = better for patients AND trainees!
#kittlesonrules
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#TipsForNewDocs
ICU pts are complicated so it’s easy to miss some details.
I like trainees to include these as the final 2 elements in every plan:
-tubes/lines/drains: where and how old? Any to remove?
-family: updated/supported? Understand the plan?
#kittlesonrules
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#TipsForNewDocs
Volume status and ejection fraction are independent.
A pt can have an EF 20% and still be dry requiring IVF.
Examine and treat the patient, not the EF.
#kittlesonrules
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#TipsForNewDocs
Pts may not agree w/your plan.
I say: "I'm your medical consultant. I provide facts/recs, you provide goals/priorities, and you decide what's right for you."
Separate medical facts from personal decisions -> promote dialogue not confrontation.
#kittlesonrules
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#TipsForNewDocs
Patient: “When can I go home?”
Bad: “Maybe 3 days.”
Good: “When you can walk around without symptoms and we’ve optimized meds – could be 3 to 7 days.”
Respond by providing criteria to meet, not days- that way, you’re less likely to be wrong.
#kittlesonrules
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#TipsForNewDocs
Diuretics:
1) If a stable patient hasn’t met I/O goals, don’t “spot“ IV Lasix at 8 PM.
2) Treat low K with spirono, not giant K pills.
3) Stop the Lasix drip 11 PM to 5 AM.
4) BID or TID Lasix: don’t give last dose past 6 PM.
#kittlesonrules
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#TipsForNewAttendings
What's one of the best things about being an attending?
You get more respect than when you were a trainee.
So when you observe (or sense) a trainee being disrespected, step in.
Model respectful discourse and protect your team!
#kittlesonrules
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#TipsForNewDocs
When rounding with your attending, It's better to have the wrong plan than no plan. Having even the wrong plan= taking ownership for your patient. You'll learn from your mistakes and refine your clinical judgment.
#kittlesonrules
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#TipsForNewDocs
Based on a long-ago mentor’s advice to me:
Strive to be known as a doc who is 1) reliable and 2) held in high esteem by the nursing staff.
These 2 qualities sum up much of what you’ll need to be a great clinician and human being.
#kittlesonrules
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#TipsForNewDocs
You’re never too important to pre-round.
15+ years in, I still review labs and notes from RNs and consultants before team rounds.
If you already have an idea of the plan, rounding is more efficient and you can spend more time teaching.
#kittlesonrules
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#TipsForNewDocs
When assessing mental status, make sure the pt has glasses, hearing aids, dentures, speak your language.
I may or may not have called a stat neuro consult for slurred speech and neuro diagnosed. . . dry mouth from being NPO + missing dentures.
#kittlesonrules
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#TipsForNewDocs
When deciding between 2 meds in the same class with same expected benefit, always choose 1) cheaper one; and 2) one taken fewer times/day.
Adherence is better if pts can afford meds and remember to take them.
#kittlesonrules
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#TipsForNewDocs
Pt w/EF 20% adm for HF.
Wrong: order echo
Right: consider echo once euvolemic if it will change mgmt (sig MR to merit transcatheter repair, etc.)
Only role for echoes in decomp HFrEF: fund private school tuitions for the echo faculty.
#kittlesonrules
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#TipsForNewDocs
There are some essential meds in cardiology.
HFrEF: ARNI/BB/MRA/SLGT2i.
CAD: aspirin/statin.
If a pt isn’t on the first-line meds, document why.
Clear notes: you look good + others don’t have to reinvent the wheel= win-win!
#kittlesonrules
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"HFpEF"
Increased LV wall thickness
No history of hypertension
Carpal tunnel syndrome
Spinal stenosis
Peripheral neuropathy
🚩🚩🚩🚩🚩
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