Ed
@Rx_Ed
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Professor, Author & Researcher - Internal Medicine, Infectious Diseases & Clinical Pharmacology
New York, NY
Joined December 2011
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Medicine is a service much more than a science. Doctors need to understand social theory and human rights abuses in order to deepen their comprehension of who becomes sick and why, and of who has access to healthcare and why.
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Did you know insulin DECREASES the production of lung surfactant?
That is why gestational diabetes is associated with lung disease in neonates.
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Lung cancer = high amylase
Ovarian cancer = high amylase
Perforated esophagus = high amylase
Ectopic pregnancy = high amylase
Aspirin = high amylase
Tthiazide diuretics = high amylase
OCPs = high amylase
But most of you will only think of pancreatitis when you see high amylase.
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Residency is hard. In this thread, I’m not going to tell you how to make it easier, because that’s subjective.
Instead, I’ll tell you the top 10 mistakes most of you make that result in a residency experience that is even harder!
#MedEd
#ERAS
#Match2023
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Studying medicine makes you reach a point where you feel going to the supermarket to buy milk is like going out to a fancy event!
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SAFE in pregnancy:
All Penicillins
All Cephalosporins
All Carbapenems
Doxycycline
Aztreonam
Azithromycin
Nitrofurantoin
Metronidazole
Hydroxychloroquine
Sulfasalazine
TNF inhibitors
Heparin
Acyclovir
Oseltamivir
Tenofovir
Raltegravir
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Heparin does two things outside the clotting cascade:
-DECREASES the level of aldosterone, which causes HYPERkalemia and HYPOnatremia
-INCREASES the level of PTH, which causes HYPERcalcemia and osteoporosis
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Don’t call them “white nationalists” — they’re domestic terrorists.
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In medicine, not everything meaningful has to be useful.
For example, holding a terminal cancer patient’s hand is not useful therapeutically. But extremely meaningful personally.
Medicine is a service more than a science. See my pinned tweet.
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Yes, my friends, azithromycin is now the FIRST line agent for traveller’s diarrhea.
As an infectious diseases specialist, it still blows my mind to think about it. But facts are facts!
Traveller’s diarrhea
=
Give azithromycin
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-All diabetes patients are magnesium deficient until proven otherwise.
-All hypokalemia patients not responding to potassium supplementation are magnesium deficient until proven otherwise.
-All patients on long-term PPIs are magnesium deficient until proven otherwise.
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Why is bradycardia common in inferior MI?
Because of the hyperactive vagal tone which inhibits SA node.
(You get to impress me on rounds if you know that what I just described is called the Bezold-Jarisch reflex)
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H1 receptor blockers treat ALLERGY.
H2 receptor blockers treat HEARTBURN.
H3 receptor blockers treat NARCOLEPSY.
Pitolisant is the **ONLY** H3 receptor blocker.
**blocking ANY histamine receptor prolongs QTc**
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HER2+ breast cancer gets trastuzumab
ER+/PR+ breast cancer gets tamoxifen
BRCA+ breast cancer gets olaparib
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There are two facts the majority of medical students find absolutely shocking, it’s like I insulted them.
1. Doxycycline is SAFE in pregnancy
2. ACEi are the drugs of choice for HTN in patients with renal artery stenosis
I know what you were taught & I’m sorry they lied to you.
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Most of you know vitamin B12 deficiency causes megaloblastic anemia.
But not many of you know vitamin B12 deficiency causes PANCYTOPENIA.
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Abdominal pain that radiates to the back has TWO emergent conditions:
-Pancreatitis
-Aortic dissection
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In acute MI, oxygen is not just useless, but also HARMFUL.
Stop using MONA and start using CAST:
-Clopidogrel
-Aspirin
-Statin
-tPA
Really depressing to see books and question banks still use the horrible MONA till this day. You are harming patients!
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The most common type of onychomycosis is DISTAL.
Persons with PROXIMAL onychomycosis are immunocompromised until proven otherwise.
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Pay attention to this thread:
Sodium/Glucose Cotransporter *2* (SGLT2) receptors are in the *1st* part of the proximal tubule, where 90% of glucose reabsorption occurs & also where SGLT2 inhibitors like empagliflozin work.
SGLT *1* receptors are in the *2nd* part of the tubule.
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While we protest and get arrested here in New York fighting for the lives of the innocent civilians killed and kidnapped in the Middle East, the “beacon” of Islam, Saudi Arabia, celebrates Halloween!
ماشاء الله 🤡
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1st line Tx for PCOS:
-Metabolic dysfunction: metformin
-Infertility: clomiphene
-Hirsutism: spironolactone
-Menstrual irregularity: OCP
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H. pylori doesn’t cause GERD. So why do we use PPIs to treat the infection? Shouldn’t Abx be enough?
Raising the pH with PPIs does TWO things:
-Increases bioavailability of Abx by increasing its ionization potential
-Decreases bacterial transcription of the neutralizing urease
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-Mitral stenosis
-Mechanical valve
-Antiphospholipid syndrome
These are the only three indications for warfarin in contemporary medicine. For everything else, we have DOACs.
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The most common physical finding in Sjögren syndrome is JOINT PAIN!
The most common WRONG answer is dry mouth.
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Vitamin B12 deficiency can cause ALL sorts of neurological complications.
The MOST common is peripheral neuropathy and the LEAST common is dementia.
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The two most common drugs associated with vitamin B12 deficiency are...?
Metformin and PPIs!
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TIA:
Use aspirin + clopidogrel for 21 days
OR
Use aspirin + ticagrelor for 21 days
Then discontinue clopidogrel or ticagrelor and continue aspirin ALONE indefinitely
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What is the mechanism of anemia in multiple myeloma?
-The HUGE plasma cells SQUEEZE the RBCs (red arrow)
-The dysfunctional Golgi apparatus inside the cell (yellow star) makes the cell produce faulty immunoglobulins (will not fight infection but will clog-up the kidney instead)
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Propofol has NO analgesic effect
Etomidate has NO analgesic effect
Thiopental has NO analgesic effect
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This is super important:
Unexplained microcytic anemia in a person 45-years or older is colon cancer until proven otherwise.
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B-cells are produced with IgM & IgD as default antibodies
If B-cell receives IL4, it switches to IgG1 & IgE
If it receives IL5, it switches to IgA
If it receives TGFß, it switches to IgG2 & IgA
If it receives INFγ, it switches to IgG3
If it receives BAFF, it switches to IgG4
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Regardless of age, postcoital bleeding is cervical cancer until proven otherwise.
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A quick review of SGLT2 inhibitors in a mini-thread:
Sodium/Glucose Cotransporter *2* (SGLT2) receptors are in the *1st* part of the proximal tubule, where 90% of glucose reabsorption occurs & also where SGLT2 inhibitors like empagliflozin work.
SGLT *1* receptors are in the
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Oral ulcers are PAINFUL in:
-Behçets
-Sjögrens
-Herpes
Oral ulcers are PAINLESS in:
-SLE
-IBD
-Reactive arthritis
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Anti-diabetes medications and cardiac protection:
-The best are SGLT2 inhibitors (eg dapagliflozin)
-Followed by GLP1 analogs (eg semaglutide)
-DPP4 inhibitors (eg linagliptin) have NO significant cardiac protection
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GI bleeding makes your stool black.
Ferrous replacement makes your stool black.
How to differentiate?
Ferrous makes you CONSTIPATED!
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Parkinson
+
Orthostatic hypotension
=
Shy Drager Syndrome
Parkinson
+
Ataxia
=
Olivopontocerebellar atrophy
Parkinson
+
Vertical gaze palsy
=
Supranuclear palsy
Parkinson
+
Acute Sx onset
=
Vasculitis
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The most common infection after tattooing is staphylococcus.
Not HIV, HBV or HCV.
Also, if someone comes to clinic telling you they plan on getting a tattoo, the first thing to do is to check their TETANUS vaccine status!
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What are the BIGGEST updates in nephrology?
-SGLT2i for CKD priegrssion & HF regardless of DM
-Finerenone (non-steroidal MRA) for CKD progression in T2DM
-Patiromer & Zirconium for hyperkalemia with ACEi/ARBs
-Tolvaptan (V2 blocker) for PCKD
We’re updating all videos & slides!
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Insulin does not remove potassium form the body.
Insulin redistributes potassium within the body.
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Statins are one of the most potent anti-inflammatory drugs known to man.
As a side effect, they also lower LDL.
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Gallstone is the most common cause of ACUTE pancreatitis.
Alcohol is the most common cause of CHRONIC pancreatitis.
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So you feel “stressed out” studying for the USMLE?
I will have to learn how to live with myself without having had the honor of having this saint in my class.
This Palestinian doctor in Gaza reached a level of nobility the rest of us can only dream about.
الله يرحمه
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What is more dangerous than ignorant people?
Pseudo-educated people. People who THINK they know things.
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There are 2 major advantages with bumetanide over furosemide:
-Bumetanide is 40x more potent vs frusemide
-Bumetanide diffuses passively vs furosemide needs active tubular secretion
That is why we teach our residents bumetanide is the loop diuretic of choice in the ICU setting.
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If a drug that inhibits CYP450 is used concomitantly with another that induces CYP450, the inhibitor usually dominates.
Why?
Inhibitors act on EXISTING enzyme molecules. Inducers need time for NEW molecules to be synthesized.
It’s easier to ruin a relationship than build one!
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For every 10-point increase in pCO2, the HCO3 will:
Rise 1 point (acutely)
Rise 3.5 points (chronically)
For every 10-point decrease in pCO2, the HCO3 will:
Drop 2 points (acutely)
Drop 5 points (chronically)
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-Doxycycline is SAFE in pregnancy
-ACEi are the drugs of choice for HTN in patients with bilateral renal artery stenosis
(I know what you were taught and I am sorry they lied to you)
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Aspirin for MI patients is time dependent (the faster you give aspirin, the lower the mortality)
Beta blockers and statins are not time dependent (as long as they’re given at any point before discharge, it’s OK)
Remember - NO oxygen at all unless the patient hypoxic!
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One of the “quick and dirty" tricks I teach the residents — to correlate the urine osmolarity with specific gravity, multiply the last 2 digits by 30.
e.g. if the specific gravity is 1.010, the urine osmolarity is 300
1.020; 600
1.040; 1,200
and so on...
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Drug-induced hearing loss:
IRREVERSIBLE:
-Aminoglycosides
-Chemotherapy
-Loop diuretics
REVERSIBLE/partially reversible:
-Aspirin
-NSAIDs
-PDE5i
-Anti-malarial
The risk depends on:
-Dose
-Tx duration
-Infusion rate
-Clearance rate
-Concomitant use
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What EXACTLY is tumor lysis syndrome (TLS)?
Malignancy PLUS at least 2 of the following:
- K > 6 mEq
- UA >8 mg/dL
- Ca > 7 mg/dL
- PO4 > 4.5 md/dL
(TLS can happen after chemotherapy *OR* radiation therapy)
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Why is hypercalcemia associated with nephrogenic diabetes insipidus?
Because excess calcium DECREASES the affinity of ADH to V2 receptors.
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Placebo:
-Glucosamine
-Omega-3
-Fish oil
-Collagen
-Probiotics
-Hyaluronic acid
-Vitamin E
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Normal adrenals make 80% epinephrine and 20% norepinephrine.
In pheochromocytoma, the ratio is FLIPPED (20% epinephrine and 80% norepinephrine).
That is why we don’t see vasodilation in pheochromocytoma (norepinephrine does NOT stimulate ß2 receptors).
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Why PPIs in upper GI bleeds?
PPIs stabilize blood clots over ulcer formation and CLEARS visualization of the lesion with endoscopy.
We don't wait for endoscopy to start PPIs. We start STAT!
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Stop saying smoking is “protective” against UC. That is just STUPID!
The right link is this: if UC patient (previously well controlled with drugs) presents to clinic with flare up, the question you should ask is “Did you recently quit smoking?”
BIG DIFFERENCE!
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The most common cause of toxic shock syndrome is staphylococcus. The most common WRONG answer is tampons (stop blaming women for everything).
TSS is treated with vancomycin + clindamycin
Why?
Vancomycin KILLS the bacteria.
Clindamycin stops the RELEASE of toxin.
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Ed’s “rule of 5” of antibiotic duration:
COPD exacerbation: 5-days, no more
Bronchitis: 5-days, no more
Cellulitis: 5-days, no more
Cystitis: 5-days of nitrofurantoin, no more
Pyelonephritis: 5-days of fluoroquinolone, no more
CAP: 5-days, no LESS
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One of our IMG residents just told me her younger sister is an ER intern in Egypt and has not gotten paid in months! al-SiSi should stop building new malls and highways and start paying his doctors! There’s a PANDEMIC!
Did you know Egyptians eat pigeons? They stuff it with rice!
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America ran out of benzathine penicillin to treat syphilis during pregnancy. Meanwhile, the rate of congenital syphilis cases increased by a stunning 203%!
We now have to borrow penicillin from France. But hey, let's spend $10 million/day to fund foreign governments instead!
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Plasmodium!
Falciparum:
-Most common
-Most deadly
-Mainly in Africa
-NO liver reservoir
-Chloroquine resistant
-High parasitemia because it infects RBCs
Vivax:
-Less common
-Has liver reservoir
-Mainly in Asia/South America
-Low parasitemia because it infects RETICULOCYTES
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Class 1 antiarrhythmics often causes confusion among students and I finally understood why. It’s because most of you don’t think of the STATE of the Na channels.
Na channels can exist in 3 states:
-Active
-Inactive
-Resting
1/3
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β-Thalassemia can cause iron overload even in the absence of transfusion therapy.
Yes? No?
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The FASTEST way to raise the platelets in acute ITP is…
IVIG!
The most common WRONG answer is steroids.
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t(15:17) = AML
t(9:22) = CML
t(11:14) = Multiple myeloma
t(8:14) = B-cell lymphoma
t(14:18) = Follicular lymphoma
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Did you know abdominal pain can be the ONLY physical finding of diabetic ketoacidosis?
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Rhabdomyolysis CAUSES high phosphate
LOW phosphate CAUSES rhabdomyolysis
Rhabdomyolysis CAUSES hyperkalemia
Hypokalemia CAUSES rhabdomyolysis
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In Parkinson disease, anosmia can be the FIRST symptom and may precede the rigidity and resting tremor by years!
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TIA:
-Start aspirin PLUS clopidogrel for 21 days
-Then discontinue clopidogrel BUT continue aspirin indefinitely
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The owner of this account is no longer with us. Dr. Alrayyes was killed last night in Gaza. We, forever, lost his contribution to medicine and patient care. Where is the rage?
Doctors without humanity are PR agents.
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Prescribing an ACEi concomitantly with an ARB is like wearing two bras on top of each other.
Wrong!
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Most common drugs that cause skin hyperpigmentation:
1. Scleral -Minocycline
2. Tongue -Hydroxyurea
3. Perioral -Chloroquine
4. Vein used for IV -5FU
5. Flagellate -Bleomycin
6. Intraoral -Imatinib
7. Photodistribution -Amiodarone
8. Nails -Vincristine
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Medicine is a TEAM service. Never trust a doctor who claims to know it all!
The more you know, the more you’ll realize that there is a lot that you don’t know. That’s the key to saving lives.
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The most common cause of osteoporosis is HORMONE deficiency (estrogen deficiency in females and testosterone deficiency in males).
The most common WRONG answer is calcium/vitamin D deficiency.
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Metronidazole does NOT inhibit acetaldehyde dehydrogenase in any clinically significant manner.
Avoiding alcohol while taking metronidazole to prevent “disulfiram-like reaction” is simply inaccurate.
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There are 3 NEW things you should know about asthma:
*LONG* acting ß-agonists plus inhaled steroids are now used as RESCUE Tx
Leukotriene inhibitors like montelukast have been UPGRADED and are now used EARLY in Tx
*LONG* acting muscarinic antagonists play a role in asthma Tx
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Ipratropium is an ACUTE management drug.
Ipratropium has NO utility in chronic management of asthma or COPD.
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More urine output with diuretics does NOT mean renal failure is reversing.
You can’t FORCE love and call it “true” love!
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Aminoglycoside associated nephrotoxicity is usually reversible.
Aminoglycoside associated ototoxicity is not.
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