Travis Smith, DO
@RosenelliEM
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Assoc Dean of Clinical Ed & Assoc Prof of Emergency Medicine @1LECOM . FSU & UF grad. Aging & Longevity. God. Golf @medtweetorials @hdx @EMBoardBombs @CPSolvers
United States
Joined February 2018
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The Journey begins!! LECOM at Jacksonville University
@1LECOM
@JacksonvilleU
The first medical school in
#Jacksonville
Excited to be the founding Dean. A true honor. Let’s Go!!!
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Grey turner sign: In a review of patients with severe acute pancreatitis who underwent CT imaging, The presence of these findings predicted organ failure and death with an overall mortality rate near 40%.
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Had a pt recently with multiple Dupuytren contractures in both hands. I took a closer look at his palms (be a palm reader like
@DxRxEdu
) & noted Palmar Erythema. My eyes then went to the chest and found spider angiomas
@AndreMansoor
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Chronic Diarrhea? Get a Stool osmolar gap. It is calculated as 290 mOsm/kg − 2 × (stool Na + stool K). A normal gap is between 50 and 100 mOsm/kg
@CPSolvers
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Radiographic signs specific for Methanol toxicity
The image below shows bilateral symmetrical putaminal hyperintensities (the most characteristic radiological feature of methanol poisoning)
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Ever heard of thyroid acropachy? Me either
It is a rare complication of autoimmune thyroid disease with characteristic imaging findings.
On radiographs, it manifests as prominent irregular and spiculated periosteal new bone formation in the hands and feet.
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If your doctor tells you that your blood pressure at 130/85 is good. Tell them it isn’t good enough. SPRINT found that the lower target (less than 120 mm Hg) reduced cardiovascular events by 25 percent and reduced the overall risk of death by 27 percent.
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Ferritin Pearls in IDA:
✔️Serum ferritin levels directly correlate with total body iron stores & is very specific for iron deficiency.
✔️Iron deficiency is diagnosed < 15μg/L in patients > 5 years old.
✔️A ferritin level of 50 μg/L is used by many clinicians as a target level
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A 31-year-old man presented with a rapidly progressive, burning pustular rash of 1 day's duration, along with malaise, nausea, and dizziness following a ct scan of the abd with contrast
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Pyoderma gangrenosum is an inflammatory non-infectious neutrophilic dermatosis that may start following minor trauma as a papule or nodule and progresses to a fibrinous necrotic ulcer.
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Pallor is caused by hemoglobin in the blood
Where does it show first?
The conjunctival🔽tissue bc it is thin, & therefore the vessels underneath are more visible
Pallor of the conjuntivae more sensitive > palmar or skin pallor. Lookout for spoon-shaped nails (koilonychia)
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Some optics neuritis pearls in a short
#Medtweetorial
🧵…. We all know that optic neuritis is frequently associated with multiple sclerosis (MS). But optic nerve inflammation can exist from autoimmunity, infection, granulomatous disease, paraneoplastic disorders, & demyelination
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Pulmonary Coccidioidomycosis
▶️Cavitary lesions are single, 2-4cm in size, thin-walled w/o air-fluid levels, & usually peripherally located
▶️Small cavities resolve spontaneously in most cases
▶️Large cavities don't usually resolve spontaneously & may require surgical resection
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Pencil Cup Deformity on Hand Xray. Think Psoriatic Arthritis.
It can also be seen in RA, Scleroderma, and Behcet’s disease but much rarer and the clinical presentations are much different.
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Chronic kidney disease increases the risk of pneumonia. The increased risk of infection can be attributed to uremia-related impairment of monocyte and neutrophil phagocytosis and increased cytokines in general. Hat Tip Suresh Reddy
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I’ve heard of interesting locations for
#Endometriosis
like in the 🫁 but never the skin. It’s seen in a <1% of endometriosis case. They can be painful and even bleed
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Classic halo sign in patient with diagnosis of cerebrospinal fluid leak.
Not as sensitive as sending the fluid off for glucose or Beta-2-tranferrin, a protein found only in CSF, perilymph and aqueous humor
@EMBoardBombs
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What is Hutchinson's sign?
A sign of ophthalmic zoster
Multiple crusted vesicles in distribution of the ophthalmic nerve (forehead, nasal bridge, & nasal tip)
High risk of ocular complications so consult ophtho
Tx w/ acyclovir IV or PO
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This is why we get pregnancy tests on female patients with even only RUQ pain.
@rabihmgeha
add this to your RUQ pain schema
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Turns out he drank heavily for 40 yrs. Dupuytrens contractures are commonly seen in alcoholic patients (24%). They have a much higher prevalence in those with type 1 and 2 DM (34% and 25%). Take home: be a palm reader
@pdxpdx2021
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Dear Doctors: please stop giving all patients with
#Covid_19
Azithromycin and steroids. It’s a viral infection not a bacterial one. Steroids help those who are hospitalized and hypoxic, not a low risk patient with a cough.
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Please people. Stop giving patients PRN hydralazine. It DOES NOT HELP them. Treat hypertensive emergency only. Do not give patients with asymptomatic hypertensive urgency IV BP meds.
@theABofPharmaC
@emdocsdotnet
@iEMPharmD
For patients w/ symptomatic acute HTN, ditch the PRN meds and hit ‘em with a drip. Marik’s 2007 review of hypertensive crises in Chest (PMID: 17565029) is one of my go to’s for teaching the nuances of different anti-HTN drips and has a great nugget on hydralazine:
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CC: Abdominal pain and eye pain
Glaucoma.....
There is a thing called the oculocardiac reflex, but what about the direct oculoemetic/oculoabdominal reflex
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Autoimmune hepatitis, there are 2 types
☑️Type 1: (80%) presence of anti-smooth muscle ab (ASMA) w or w/out ANA ab
☑️Type 2: + anti-liver/anti-kidney microsome (anti-LMK) type 1 ab or anti-liver cytosol (anti-LC) type 1 ab
☑️Nitrofurantoin & minocycline are notable culprits
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Hypokalemia and acidosis? Thinking RTA? Check urine lytes. Remember that the Urine AG is nml in a healthy pt and should be negative in an acidosis reflecting ⬆️ NH4+. If the urine AG is + then 💡type 1 or 4 RTA as proton excretion is abnormal
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While on the topic on
#Angioedema
with
@EMBoardBombs
It was mentioned about tPA causing angioedema. It is scary and happened to me. I didn't know about it until it happened to me.
Follow along for a short
#medtweetorial
case report with some tips.
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@AndrewGutwein
I’ve heard this happens in many different specialties. Also have heard PDs tell students they were ranked to match & they didn’t. All are guilty in this ridiculous game to find a program. only winners are
@AAMCtoday
@ERASinfo
= 120 million they get off the backs of student loans
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@charliekirk11
The unhinged at work. How dare you ask them a question they don’t know the answer too.
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Platelet Transfusion Pearls:
▶️<50K if a planned lumbar puncture/neurosurgical procedure
▶️<20K if planned for central line (preference toward compressible site)
▶️<10K in asymptomatic patients (unless due to ITP, TTP, or HIT)
In Traumatic bleeding goal of 100K
@EMBoardBombs
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The pattern of liver injury can be defined by the R value = [ALT/ULN] ÷ [Alk Phos/ULN], on which cases were defined as hepatocellular (R > 5), cholestatic (R < 2), or mixed (R 2 to 5)
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Not all pain elicited during a straight leg raising test (Lasegue sign) indicates nerve root or sciatic nerve irritation. Criteria for a true positive SLRT
1Radicular leg pain should occur (radiating below the knee).
2Pain occurs when the leg is between 30 & 60 or 70 degrees.
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Prophylaxis for
#SpontaneousBacterialPeritonitis
. After the 1st episode of SBP, recurrence rates are high at around 70% at 1-year. This comes w/ an overall survival rate of 30-50% among those who don’t receive antibiotic prophylaxis. If given, reduces SBP rates from 70% to 20%
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A great ddx for syncope includes syncope and nonsyncopal causes. syncopal causes 2/2 inadequate cerebral perfusion from orthostatic syncope, reflex syncope, cardiac arrhythmia, & structural cardiopulmonary disease.1/2
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Fun Fact: The Deans also know where our students matched 😁
Fun fact:
Residency programs already have their Match lists.
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728
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@AvrahamCooperMD
Great photo. Check out this case
@sargsyanz
and I published in the green journal
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When you order a serum alcohol level, what does the lab measure? An answer and a quick
#Medtweetorial
on false elevations in
#ETOH
alcohol
212
alcohol dehydrogenase
194
NAD+
66
NADH
105
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Anyone else need a quick refresher on
#PFTs
, check out this Dx Schema - Approach to PFTs via
@cpsolvers
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Boerhaave syndrome Pearls:
In around 25% of patients, chest pain is followed by vomiting.
The triad of vomiting, chest pain & subcutaneous emphysema is known as the Mackler triad
Although highly suggestive of EP, it is found in < 1/3rd of cases.
@EMBoardBombs
@blakebriggsMD
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You don't need to have abnormal thiamine levels to dx Werknickes
The new criteria require only 2 of the following 4 signs; (1) dietary deficiencies, (2) oculomotor abnormalities, (3) cerebellar dysfunction, & (4) either an AMS/mild memory impairment.
@CPSolvers
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Calcinosis cutis is a term used to describe a group of disorders in which calcium deposits form in the skin. Virchow initially described calcinosis cutis in 1855.
It has been found to occur in up to 25% of patients with systemic sclerosis
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Epidural hematomas are more common in the young (20-30s) than old. But why?
There are a few reasons but one cool one is that the dura mater becomes more adherent to the overlying bone as age advances, decreasing the likelihood of a hematoma dissecting the skull and dura.
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Thanks for tackling this myth
@RyanMarino
. Video of Officer's Collapse After Handling Powder Draws Skepticism for being FAKE
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High k inhibits ammonia production and low k promotes ammonia production. That’s why hypokalemia is important in cirrhosis. A great pearl from
@medrants
on
@UnremarkableLab
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Melioidosis is an infectious disease caused by Burkholderia pseudomallei, a gram-negative aerobic, motile bacterium.
Melioidosis may present in an acute form with an incubation period of one day to three weeks.
However, latent melioidosis may not present for decades.
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Jugular venous pulse wave tracing: The tracing begins with an "A" wave peak that corresponds to the contracting RA (systole), The "C" wave peak=the contracting RV (systole) causing the TV to bulge▶️the RA during RV isovolumetric contraction.
@AndreMansoor
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@ReaganBattalion
@benshapiro
@RashidaTlaib
It’s okay, she’s a leftist. Media will look the other way. The same thing they have been doing with
@LouisFarrakhan
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Hand knob stroke? Learned this from
@rabihmgeha
A hand knob stroke refers to a stroke involving the hand knob region of the motor cortex.
It has a cool vascular supply as the hand knob region of the cortex, receives blood supply from the ACA and MCA. 🧵
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Lung ultrasound demonstrated a sensitivity of 91% compared to chest X-ray which had a sensitivity of 73% for infiltrates.
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A unique case of anemia in those with cirrhosis is spur cell hemolysis, a type of hemolytic anemia.
Spur cells are abnormal red blood with spiked projections and increased cholesterol content in the cell membrane, usually seen in patients with advanced liver disease. 1/2
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Why does
#Hypokalemia
lead to hepatic encephalopathy? It leads to ⬇️ delivery of potassium to renal tubules, causing an ⬆️ exchange of K+ & H+ ions & relative intracellular acidosis which results in renal generation of HCO3 & ammonia & ⬆️ the risk of hepatic encephalopathy
@hdx
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@jbcarmody
What is the purpose of this? Why does there have to be a certain number of failures? If you have 100 people take a test and they all know the material to pass and are proficient, why change the metric to make sure some fail?
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Initiation of thyroid hormone replacement prior to cortisol replacement can precipitate an adrenal crisis in a pt with concurrent AI
Thyroid hormone⏫metabolic energy expenditure,& w/o adequate cortisol levels, the body cant meet that ⏫need, & shock can ensue.
@mendesthiagob
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ABG and Pulmonary Embolism Pearls:
@EMBoardBombs
✔️widened alveolar-arterial gradient [62-86%]
✔️hypoxemia [74%]
✔️respiratory alkalosis and hypocapnia can be also seen [41%]
✔️Around 18% can have a normal ABG
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Some great pearls on treating metabolic alkalosis (hco3 > 40) in those with acute CHF getting aggressively diuresed. Add on either azetazolamide or aldactone.
@thecurbsiders
@kidney_boy
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Start your day off with Global Morning Report case on
#HumanDX
@hdx
A 40-year-old female with chest pain
Dont forget a quick review of this great
@CPSolvers
Schema on chest pain,
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GI Bleeding 🩸🩸 A BUN/Cr ratio of >36 suggests UG, whereas a ratio <36 is not helpful in localizing. Annual incidence of UGI bleeding > LGI bleeding & mortality is also > (up to 40% for those with unstable hemodynamics). LGI Bleeding is around 10%-20%
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Pericarditis is classically associated w/ ECG changes that evolve through four stages.
Stage 1 – widespread STE and PR depression with reciprocal changes in aVR (occurs during the first 2weeks)
Stage 2 – normalization of ST changes; generalized T wave flattening (1 to 3 weeks)
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Fact: Methanol and Ethylene Glycol Toxicity both can present with an Elevated AG and Elevated Osm Gap
Differences? Methanol Toxicity has:
✔️Retinal toxicity
✔️basal ganglia toxicity
Ethylene Toxicity has neither ▶️, but has Calcium Oxalate in the UA
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Now I am Representing! My passions in medicine and teaching
@hdx
@CPSolvers
@DxRxEdu
@rabihmgeha
thanks
@kdog7358
for making these for me.
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Most common causes of SBOs are the ABCs. Adhesions (60%), bulges (hernias 10%), and cancer (20%). An Xray is only 60% sensitive for dx. CT around mid 90s. The more air fluid levels, the more distal the obstruction.
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What is the MC CXR finding in a pt w/
#Boerhaave
syndrome?
A L sided pleural effusion. Other findings include pneumothorax, pneumomediastinum, & mediastinal widening
Mackler's triad is chest pain, vomiting & subq emphysema
At least 10% of CXRs are initially normal
@EMBoardBombs
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Move over cephalexin, My new favorite 1st generation cephalosporin is cefadroxil. It’s twice a day and not 4x per day and also cheap!
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When starting someone on Spironolactone for cirrhosis, titrate it up until the UrNa is greater than the UrK.
A pearl from
@medrants
on
@UnremarkableLab
Remember the UrNa is reflection of how well the renin/angiotensin system is working. Shut it down!
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Anton syndrome is a condition where patients with extensive bilateral damage to the cerebral visual pathways result in complete loss of vision, but patients confabulate and deny blindness. These patient’s have cortical blindness w/o other abnormalities seen on eye examination
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Why does
#OvarianTorsion
occur more on the right?
The right ovary is more likely to rotate given the longer length of the right utero-ovarian ligament and the presence of the sigmoid colon on the left, which may prevent torsion on that side.
@EMBoardBombs
@blakebriggsMD
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Discussing hyperaldo on
@UnremarkableLab
, wow, this stuff is deep. Tons of pearls. Who should we work up for hyperaldo? When to pull the trigger?
Chat comments with pearls below.
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#MedTweetorial
coming!!! An Evidenced Based Medicine
#EMB
review of anticoagulation for
#Stroke
prevention in
#AFib
Afib A 63-year-old male presents to follow up for episodes of dizziness. He is given an implantable monitoring device. What did it show?
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Paraneoplastic syndromes are rare & distinct immunologic phenomena that arise in response to malignancy, particularly of the lung (~10% of cases). Virtually any organ system can be affected, at any stage of cancer. Their presence usually signifies a poor prognosis.
@srrezaie
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Giant Cell Arteritis (GCA) Pearls
Jaw claudication and deaded temporal artery are the most specific symptom for GCA at around 92%/98% respectively
ESR is the most sensitive lab finding (98%)
The sensitivity of TA biopsy for GCA is about 77% (you don't need this to diagnose).
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The fingernail oil drop sign. Another clue into someone with underlying
#Psoriasis
. Hat tip
@AndreMansoor
on
#PhysicalDiagnosis
#PDX
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Rhabdo pearls: Push the fluids with LR at a rate for a urine output in adults of 300 mL/h or more for at least the first 24 hours.
What about NaHCO3?
▶️only if needed to correct systemic acidosis
What about mannitol?
▶️only to maintain urine output >300 mL/h despite fluids
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The
@NBOME
@AOAforDOs
need to realize that they are indirectly forcing all
#DOstudents
to take 2 board exams. By not directly addressing this, they are complacent & endorsing this added expense to our students. With unified
#GME
comes a unified exam
@mahad_minhas
@jbcarmody
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@hughhewitt
@JeffFlake
He obviously has Trump derangement syndrome. Someone tell him that a law protecting
#Mueller
violates separation of powers. The executive branch has the power to fire anyone beneath him and doesn’t need congressional approval.
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Let's talk APML and Differentiation Syndrome (DS)
Acute promyelocytic leukemia (APML) is primarily caused by a translocation between chromosomes 15-17, causing the formation of PML-RARA fusion protein.
This causes a blockade in differentiation at the promyelocytic stage
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Trauma Pearls:
Immediate life-threatening injuries secondary to major thoracic injury are often grouped into two categories:
1) The Lethal Seven or
2) the Hidden Six.
@EMBoardBombs
@blakebriggsMD
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Somethings I learned on
@UnremarkableLab
tonight. Ketoconazole for hypercalcemia. Yes you heard me. It inhibits 1-alpha-hydroxylase activity and has been used for treating refractory cases in sarcoidosis and malignancy
@medrants
@fernandbteich
@LindseyShipley8
@k_vaishnani
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GI Bleed & FOBT?
🩸Lots of inaccuracies & lack of studies
🩸📈 rates of false + & -
🩸It changes management 34% of the time
🩸Stool color is more sensitive for UGIB than FOBT
🩸+FOBT doesn't r/i UGIB & -FOBT doesn't r/o UGIB
@blakebriggsMD
@EMBoardBombs
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Toxoplasmosis and cat scratch disease are both associated with adenopathy and exposure to cats. Other mononucleosis-like syndrome EBV, CMV, and primary HIV infection. Another random fact, approximately 50% of cats are seropositive for B. henselae.
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Since the esophagus lacks a serosal layer, it is considered more susceptible to perforations unlike the rest of the GI tract.
They can occur anywhere along the esophagus but are MC in the thoracic (54%), cervical (27%), & abdominal esophagus (19%)
@blakebriggsMD
@EMBoardBombs
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Can I give
#LactatedRingers
or LR to a patient with renal failure and hyperkalmia? The short answer is yes. There is a fear of Ringer’s lactate causing hyperkalemia and worsening lactic acidosis.
Yes it will increase K
81
No it won’t increase K
383
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Purpura Fulminans + Dog bite/scratch + Gram neg rod = Capnocytophaga and mortality approaches 30%. Tx with a cephalosporin or pip/tazo
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Check out this Classic
#STEMI
in setting of LBBB using modified. Checking all 3 boxes ✅✅✅
#ScarbossaCriteria
@smithECGBlog
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A 60 presents with Left leg weakness and slurred speech. Her CT is below. Paged out as a stroke alert. Answer will be revealed in 24 hours
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Get your morning off to a great start with another case from
@hdx
A 24-year-old female with nausea and abdominal pain
What is your initial differential? Time course? Prior Surgeries? I love using the
@CPSolvers
schema for this 👇
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@IM_Crit_
This is also an Emergency Medicine Pearl and an EMS pearl. I can’t tell you how many times this has come up. It’s okay to access when someone is in extremis
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