How to doctor - a thread.

Very proud of my friend and colleague @uoftmedicine @UofT_DoM Internal medicine residency (PGY3), Dr. Abdulaziz AlKhayyat, for winning 3rd place in the World Street workout & Calisthenics Championship held in Latvia last week. Who said no time to workout in IM residency?!

All smiles on ☀️Yellow Team ☀️continues as they take home the big win at our Block 2 Jeopardy!! Congrats to Yellow Team, staff @WKSilverstein and SMR @YaseenWid are beaming with pride 📣

Orientation week is officially underway. We're very excited to welcome the @UofTMDprogram Class of 2T7 to #TemertyMed! #UofTBackToSchool

Yesterday the great @MohitHarshMD tagged me in a post about euglycemic DKA. Then I got an email from the knowledge-hungry master clinician (AKA @DxRxEdu) about the same topic. This is something! Starting from scratch: Demystifying DKA. Let's untangle its complexity.🧵 1/13

Are you applying to Hematology this CaRMS cycle? Stay tuned for our Town Hall to find out about the amazing program we have at UofT 😊. Info will be sent to all applicants who applied through CaRMS!

Team Yellow! Amazing experience working with such a fantastic group @Sunnybrook @GIMtoronto @UofTIMChiefs @hoft

Only good vibes on GIM Blue @Sunnybrook! Couldn’t have asked for a better team on my first block as GIM ward senior. 🙏🏻🤩 @UofT_DoM #internalmedicine

Outdoor theme continued! @WCHospital trainees mid-block meet and debrief over Jugo juices 🥤 ☀️

9/Thanks to @bmj_latest case report, https://t.co/IkQdJ3QG61 for images, and @BCM_InternalMed prev tweetorial by @bahdi_firas

8/Mgt - Treat the underlying cause!

7/Approach - Hx/Pe for clues to unusual pathogens or non-infectious causes or CAP complications - Labs per clinical suspicion - CT chest to better characterize the infiltrations - Bronchoscopy

6/The S in CHAOS - Malignancy (Bronchogenic carcinoma, Lymphoma) - Autoimmune/Inflammatory disorders (Vasculitis [GPA/MPA], eosinophilic PNA, sarcoidosis, RA, SLE) - ILD (COP, HP) - Vasc abnormalities (pulmonary infarction/PE, CHF) - Drug toxicity (Amio, bleomycin, MTX)

5/The O in CHAOS - Immunocompromised pts think mycobacterium, aspergillosis, nocardia - Endemic fungi (Histo, blast, cocci) - Zoonotic (tularemia/rabbits, c. psittaci/avian, leptospirosis or yersinia/rats, Q fever/farm) - Travellers (burkholderia pseudomallei, Hanta virus)

4/CHAOS cont'd 3. Antibiotic (inadequate dose, poor oral absorption) 4. Organism (superinfection, resistance, unusual/atypical organism not covered by empiric abx) 5. Second diagnosis (mimickers) - PE, cancer, hemorrhage, organizing pneumonia, inflammatory diseases, etc.

3/Why do people have delayed resolution of PNA? Acronym = CHAOS 1. Complication (empyema, lung abscess) 2. Host (immunocompromised: HIV, meds [chemo/steroids/immunomods], DM, CKD), impaired mucociliary clearance (CF/COPD), impaired lymphatic drainage, recurrent aspiration

2/What's a non-resolving PNA? - PNA that doesn't improve clinically/worsens despite min. 10d of adequate abx, or radiographic infiltrate that does not resolve w/in 12 wks. - Slowly resolving = radiographic infiltrate in a clinically improved patient for >4 wks (<50% res in 1 mo)

1/Typical background for duration of symptoms/sign in CAP: - Tachycardia/hypotension ~2d - Fever, tachypnea, hypoxemia ~3d - Cough, fatigue ~14d - CXR infiltrates ~30 days

Breathe easy... Morning report @Sunnybrook today done outdoors - fitting for discussing non-resolving pneumonia with GIM attending Dr. Ariel Lefkowitz. Tweetorial in thread below! Comment for feedback!