Reza
@DxRxEdu
Followers
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Following
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Media
498
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@rabihmgeha brother | Co-founder @CPSolvers | | @Gurpreet2015 mentee | Doctor for 🇺🇸 veterans | Aghajoon's grandson
Joined April 2016
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<3
Ever thought about being involved with
@CPSolvers
?
Here are the 2 ways EVERYONE is welcome
<3
@DxRxEdu
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I love surgeons so much.
Why?
I sent an email to a surgeon that could have been a book chapter as to why I felt a certain way.
Surgeon's response: "Thank you, Sounds good"
She was surgical even with her email.
We talk way too much in internal medicine.
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S1Q3T3 = PE
WRONG
S1Q3T3 = RV strain
Brilliant article
"S1Q3T3 is neither sensitive nor specific for the diagnosis of pulmonary embolism.
S1Q3T3 indicates right ventricular dysfunction with a broad differential including any condition causing obstruction or hypoxic
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Lactated Ringer
Is it always the right fluid to choose? No.
3 instances in which I avoid it
1. Hypercalcemia (LR contains calcium)
2. Metabolic alkalosis (liver converts lactate to bicarbonate)
3. Liver disease (liver can't convert lactate to bicarbonate so lactate level builds)
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Dear rising interns: Book intelligence is abundant in medicine. It is kindness and humanism that will separate you.
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Don't let MedTwitter intimidate you.
Most people don't post their insecurities, failures, and mistakes.
They post highlights. "I received this award." "I published this paper." "I made this dx."
But remember we all FAIL, struggle, and have doubts. Wish we posted those more.
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I was in $348,765 of student debt. I could not quit medicine even if I wanted to.
I participated in
@BarackObama
PSLF program.
A few days ago all my debt was forgiven tax free. It changed my life.
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Internal medicine is the best.
No boundaries to what you can and should learn.
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The more I undertand the more I LOVE medicine.
Unfortunately, med school did not emphasize learning but rather memorization.
Come on this journey with me for a topic I did not understand years ago but experienced a case and now understand.
Hope to inspire/educate
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Understanding is so so so beautiful.
He had Cr 2.6 (baseline 0.6) yet his K 3.3.
You may not know the significance of this but that is not important.
What matters is that you ask, "Wait that is odd. Lower eGFR but low-normal potassium. Why would that happen?"
No GI loss. No
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So proud of our chief residents for launching a new initiative w/ morning report that highlights cool cases but more importantly highlight individual participants!
We pick 4 cases every 2 weeks to highlight!
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This is important. You might save a life (or at least myocardium) by knowing this EKG finding. I am not an EKG fanatic but so grateful for today's morning report.
Let me teach you what I learned. I welcome feedback. I'll perform a cognitive autopsy and tell you why I missed
@AmierHaidar
presented a 51 yo man w/ left upper arm pain. n/v, and diarrhea. X-ray w/ left humeral bone lesion. BMP w/ K 5.8 and normal Cr. No known meds. CXR w/ small left diaphragmatic blunting.
What do you make of the EKG? The answer will be revealed tomorrow.
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SIADH
1. What is the metabolic profile of SIADH and why?
2. What are the mimics?
3. What are main causes? (I forgot CNS disorders)
Retweet if you found this useful to give me the fuel to make more mini-videos!!
❤️
@rabihmgeha
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I missed a diagnosis 3 years ago (luckily someone made the dx) > reflection (writing and talking to colleagues) > early diagnosis in another patient 3 years later
Do not beat yourself up when you make a diagnostic error. Reflect, learn, and apply to the next patient.
<3
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Storytime - Sometimes it is OK to blame the cats
He had a peritoneal dialysis catheter. He presented with/ abdominal pain. Peritoneal fluid analysis was diagnostic of peritonitis.
Nephrology attending note - "His cats lick his PD catheter."
Culture resuls - Pasteurella
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Understand then memorize.
ESR? How fast RBCs fall (mm/h).
RBCs carry a negative charge. RBCs repel each other and fall slowly.
Inflammation > acute phase reactants > neutralize negative charge > now RBCs fall fast (high number).
<3
@rabihmgeha
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Misnomers in medicine and few pearls re: AST/ALT, ALP/Bili
Let us eradicate the term LFTs as NONE of these enzymes measure function.
Let us eradicate the term “transaminitis” as enzymes cannot be inflamed (e.g., say “troponitis” to a cardiologist).
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Tip to all faculty whether you are the greatest clinician or the chief of a department: Always speak to the trainees with kindness and respect. I am shocked at the way some faculty interact with trainees. Remember it is not what you say but how you say it.
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Unbelievable lecture on outpatient HTN management.
Few things I did not know
-losartan half life is 4-6h and should be dosed BID; I thought it was daily!
-rise in Cr after ACE/ARB is just unmasking the patient's actual eGFR - the glomerular hyperfiltration d/t HTN, prior to med,
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More
#COVID
ー19 related Dx content coming out from
@CPSolvers
soon.
We would love your feedback on our evolving COVID-19 illness script (3/12/2020).
#medtwitter
&
#IDTwitter
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Nephrotic syndrome made simple.
Walk with this non-nephrologist.
1/n
She developed swelling in her legs at the age of 53. She had h/o DM. Exam w/ mild HTN. JVP normal. No stigmata of cirrhosis.
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To academic leadership:
Value your clinician-educators.
Reward your clinician-educators.
Promote your clinician-educators.
It is a huge detriment to your learners if you do not.
Yes, science is important but so is teaching the concepts from scientific research.
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You do not need a high IQ or standardized exam score to master medicine. You need passion, reflection, and hard work. Just like building muscles, mastery does not happen overnight. It happens one rep at a time, one day at a time. Learning -> enjoyment in medicine.
#staythirsty
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Syncope in 2 steps
1. Consider the three "S" mimics, Seizure, low Sugar, Stroke (TIA)
2. Heart vs SVR
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The practice of medicine is NOT an art.
The practice of medicine is NOT binary (right or wrong).
Medicine is a probability-based profession with endless care and shared decision making.
❤️
@rabihmgeha
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The other day someone lamented via email that "trainees are just not the same as they once were." My response, "You are right ... they are better." Let's stop pretending like the past generation was better. If that were the case, then the past (clinicians) failed the future.
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We are all an OSH to someone. It is thought that providers at an OSH are less competent. This is unequivocally wrong. Use the term “neighboring hospital” instead, and until you practice in an under-resourced facility stop judging your fellow providers.
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Medicine is simple.
We just complicate it with fancy language, pretentiousness, and constant seeking of validation from others and the system.
Wipe away the bs, devote yourself, understand its simplicity, alleviate pain and suffering, inspire and teach the next generation.
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MAHA and thrombocytopenia
Learn this really well and you might save a life
1. Why does it happen?
2. Secondary causes?
3. Primary TMAs and the four critical questions!?
❤️
@rabihmgeha
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I will never master medicine.
I will make mistakes as long as I practice medicine.
However ...
I will never stop learning for the next patient.
I will never make a mistake because of laziness or arrogance.
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An important story that might save a person's life.
He felt something in his groin. You quickly look, touch, and POCUS to dx enlarged right inguinal lymph nodes.
What is your next action? No multiple choices to guide you. Pause and really think about what you'd do next.
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Let's learn bout a condition that affects > 95% of the world's population.
Note I said learn not just memorize a list of symptoms/signs.
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Teaching service Day 2/14
Our patient was urinating 8L of fluid a day. This prompted me to read about polyuria.
Almost only 2 min!!!
Please share your thoughts
❤️
@rabihmgeha
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An easy approach to thunderclap headache -
What can happen to a vessel?
It can ...
Rupture > SAH
Spasm > RCVS
Dissect > Carotid artery dissection
Leak > PRES
Obstruct > Venous sinus thrombosis
Other > Pituitary apoplexy
<3
@rabihmgeha
@AaronLBerkowitz
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The key to joy in medicine is in its relationships.
Relationships with patients.
Relationships with learners.
Relationships with teachers.
And a healthy relationship with self.
Go enjoy your day through relationships with others.
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ANCA - The Basics in 5 tweets
Anti-Neutrophil Cytoplasmic Antibodies (ANCA) positivity does not mean there is an ANCA-associated vasculitis (AAV)
ANCA negativity does not r/o AAV
Clinical context is KEY!!
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Medicine is tough. We are overworked. We experience unexpected outcomes. We are made aware of the "wrongdoings" more so than the right actions.
My advice: Find aspects of medicine that bring you joy and make them your center of gravity.
For me, it is teaching.
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I remember as a resident I struggled with the WHO classification of pHTN. In my first year as attending, I learned from my residents a memory tool to remember the 5 Groups. I am not sure who created the “mirror” mnemonic, but thank you!
@rabihmgeha
@david_furfaro
@CPSolvers
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Dear new intern:
1. Never be ashamed to ask for help.
2. You earned the right to be in this position.
3. No one is expecting you to be independent.
4. Take one step at a time.
5. Don't study outside of the hospital. Focus on your health.
<3
@rabihmgeha
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EKG changes in hyPerkalemia. The 4 Ps.
Peaked T wave
Prolonged QRS
Prolonged PR
P-wave loss
Start at T wave and work your way to the P wave. T->QRS->PR->P. Importantly EKG cannot predict potassium levels.
<3
@rabihmgeha
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Finding Joy in Medicine.
Inspired by my deceased grandfather.
Release date: 6/1
Editor:
@dereckwpaul
Foreword:
@gradydoctor
Afterword:
@Gurpreet2015
Academic partner:
@rabihmgeha
May you all find joy in medicine b/c you deserve it.
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You don’t need a medical degree to have emotional intelligence. And just because you have a medical degree doesn’t mean you have EQ. It is a skill like any other and needs cultivation.
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Stop the "back in my day we lived in the hospital" nonsense to justify poor work hours for trainees. This is their lives. And tomorrow is not promised. We must care more about their well-being than ever before.
Medicine is not a sprint but a marathon.
<3
@rabihmgeha
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I’ve been following
@theliverdr
for the past year. I have not only learned many medical facts from him but also how to be professional. He is the real deal. He loves his craft. Much respect to this amazing physician-scientist. A role model. Follow him. He is amazing.
Dear Ranveer
@BeerBicepsGuy
I appreciate your response and the kind invitation to come on TRS 🙏
The human body is complex and there are many "yet-unknowns" waiting to be found to improve our understading of health and disease - and the scientific method is what will take us
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Thinking of starting ACE
STOP STOP STOP
Why not ARB? (one exception, see below)
ARB removes the risk of cough (~10%)/angioedema.
BUT wait if it is for HFrEF then it should be ARNI (it is an injustice to keep your patient on ACE/ARB if they can tolerate ARNI).
One exception
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A clinician said “if this was your mother ...” to justify transfer to another service.
My response “the patient does not need to be my mother for me to want the best possible care for the patient.”
We need to remember that we are all on one team with one goal - to heal
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Medicine is beautiful. Always ask why.
He had hyperkalemia and hyperphosphatemia.
WHY?
Acute kidney injury (fluid responsive)
Why?
Hypovolemia
Why?
Hyperglycemia-induced diuresis
Why?
Background diabetes + Dexamethasone for COVID19
<3
@rabihmgeha
and medicine
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Euglycemic DKA in 3 tweets ... Learn to dx rapidly
EuDKA = relatively normal glu + very high ketones
Its phenomenon is not only associated w/ SGLT2-inh
Core component = very low insulin levels +/- starved state, low BMI, stress, SGLT2-inh ...
SGLT2-inh is NOT mandatory
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She was a centenarian. She had hypertension her whole life. She was on a classic regimen.
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Medicine is beautiful once you have space to understand.
It is unfortunate that much of med school is memorizing random facts without context.
Thrombotic microangiopathy > (micro)thrombi of small vessels > RBCs shear while passing through > fragmented RBCs > schistocytes
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Ever wonder why gout most commonly involves the big toe and the foot in general?
If not, stop reading this LOL
We have to start with why monosodium urate crystals form?
They form from uric acid. Uric acid comes from purine. Uric acid (Urate) at normal pH and temperature is
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The more I practice medicine the more I realize how little I know.
The safeguard - know what you don’t know, trust the feeling, and ask for help when that feeling comes knocking on the door.
Don’t ignore it
❤️
@rabihmgeha
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If you don’t know the dx, you will never get it.
WRONG.
If you know how to think, most specifically if you know how to frame the problem, then a search engine will give you the dx.
Learn how to think. Most important skill of an internist (next to compassionate care)
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Are you sick of not understanding hyponatremia?
Are you sick of not having enough hair on your head? (I am)
We cannot help you with the latter but can help you with the former!
Hyponatremia through understanding.
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Never stop asking why?
It is through "why" that the best care is delivered.
"Iron deficiency" is not a final diagnosis.
"Hyperglycemia" is not a final diagnosis.
"SIADH" is not a final diagnosis.
Anyone can reverse an abnormality but patients deserve "the why."
<3
@rabihmgeha
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The academic life is liberating after tests are over.
You get to understand rather than memorize.
Understanding > curiosity/passion > pushes the boundaries of our current knowledge
Understanding the "why" is key to enjoying and advancing our understanding of medicine.
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I wanted to extend a thank to all the nurses I have worked with over the past decade. I have been saved more than once by my nursing colleagues. I recall once a nurse said, "I feel something is going to happen to this patient."
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In 40 years I won’t care whether I am full professor or have 100 publications.
Neither will you. Trust me.
What I will cherish are the relationships I am forming along the way.
This is my family and I care about them dearly.
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I love physiology.
Understanding >>> memorization.
Learn normal to CRUSH the abnormal.
Here is calcium's story.
Learn its physiology then put your knowledge to the test with VMR
#51
and
#52
.
#RiverofBlood
@rabihmgeha
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Think twice before you start a heparin drip for PE. It is the inferior option for most PEs compared to LMWH or DOAC (increased bleeding, delayed anticoagulation).
Ask why can't my patient get LMWH or DOAC? (LMWH prob the way to go for intermediate-risk PE)
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My approach to dizziness was flawed until I read
@DNewmanToker
SUPERB 2015 article. Start with timing and trigger, not "type" (i.e.., lightheaded vs vertigo vs disequilibrium), to decrease diagnostic error. Tweetorial and teaching video to follow.
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@anand_88_patel
@rabihmgeha
and I bring to you - The 5-part Leukemia Series
The focus is presentation & diagnosis. Hold on to your seats. Let’s learn through understanding.
There will be a summary figure @ end.
I've struggled with understanding leukemia. The different types, the different diagnostic tests, etc. It had remained a blackbox for many years. But no longer.
Thanks to
@rabihmgeha
for always pushing me to learn more, to understand more, to never stop seeking clarity.
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There is no room for arrogance in medicine. Knowing what you do not know is more important than knowing what you do know.
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One of the main reasons I chose IM was to develop an approach to any abnormality.
I will never know all the nuances but you better bet I will try until I retire.
Let's go on a walk and discuss the basics of post-kidney transplant ...
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I've struggled with understanding leukemia. The different types, the different diagnostic tests, etc. It had remained a blackbox for many years. But no longer.
Thanks to
@rabihmgeha
for always pushing me to learn more, to understand more, to never stop seeking clarity.
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I’ve been practicing medicine for six years independently. I still call my favorite attending for help when I am unsure about a case.
Why is he my favorite? Never judges and is patient with my growth.
@Gurpreet2015
thank you for being the best attending a learner could have.
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Don't be intimidated by anyone's fund of knowledge.
Knowing a fact is just having dedicated time to read that fact.
Don't praise them for their IQ. Praise them for their commitment to learning.
<3
@rabihmgeha
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Had an epic moment with intern last night.
We both arrived at a rapid response at 02:22. We talked medicine for ~2hours.
By the end of the conversation he said, "Reza I have a confession. I listen to you in 2x speed. And right now you are speaking too slowly."
<3
@UCLAHealth
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Your patient has hypocalcemia
You prescribe tums (CaCO3) but it worsens
Why?
@rabihmgeha
you a genius for this one LOL
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When you give feedback to a learner remember you were once that learner. Invest in their emotional bank account with genuine positive feedback so when the time comes for constructive feedback their ears and hearts are all yours.
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Medicine is beautiful.
In med school, I had a simple definition of endocarditis.
Fast forward 12 years
Acute or subacute?
Right-sided or left-sided?
Infective or noninfective?
Culture-positive or culture-negative?
Ratbite or not?
@rabihmgeha
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The pain experienced by your patient as the phlebotomist searches for a vein should be the strongest deterrent of unnecessary daily labs.
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Love this question. Thank you for asking it. The pathophysiology here is exciting.
Let's take one step back and ask why do we even sweat?
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Recipe to burnout?
NOT money. NOT titles. NOT publications. NOT awards.
Relationships.
Tonight I want to say goodbye to someone who left this world way too young.
Thank you for letting me be your doctor. Thank you for reminding me of why I became a doctor.
@rabihmgeha
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Tip to improve your clinical reasoning
Never end at it can be infectious, autoimmune, or malignant. Not helpful.
Ask what types of infections, what types of autoimmune processes, and what types of cancers
Need to get granular to improve diagnostic performance.
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Extremely grateful for the warm welcome by everyone. 🙏🙏🙏
We’re excited to announce the addition of the one and only
@DxRxEdu
to the UCLA IM fam!
Dr. Reza Manesh is our newest faculty hospitalist at the West LA VA, and we can’t want to clinically problem solve with you 😉
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When to use “corrected sodium” versus "measured sodium" in caring for a patient with hyperglycemia?
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This article changed my approach to rounding. So much value to rounding at the bedside. If there is interest, I can share my approach to (efficient) bedside rounds.
Things We Do for No Reason™: Card Flipping Rounds
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Important and common topic - Aspiration
Is it pneumonia or pneumonitis?
Key to answer this is tempo of onset and tempo of offset.
Pneumonitis is LITERALLY acid from stomach (same ph as Coca Cola, ~2) spilled on the lungs.
What do you expect to happen if someone dumps acid on
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Had to get my copy. This is my smile after a 12 hour shift because I get to learn from the legendary
@AndreMansoor
Frankly It is the only IM book I recommend to purchase. Because its style and content can’t be found in uptodate.
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A Letter to the Future Teaching Physician (5-minute read)
@rabihmgeha
@AmitGoyalMD
@medrants
@Gurpreet2015
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I barely got into college but graduated from med school.
I almost dropped out of med school but love being a doctor now.
Each moment is me.
What allows you to thrive?
Reflect on it. Write it down. Revisit it weekly.
No single moment defines you, good or bad
<3
@rabihmgeha
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The 5 Ps of pleuritic chest pain (Tier 1 DDx)
Pericarditis
PE
Pneumonia
Pleuritis
Pneumothorax
<3
@rabihmgeha
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Pleuritic chest pain
1. What do we exactly mean by it?
2. What are the 6 life-threatening causes?
3. What is one very helpful test to start the work up?
Bonus
What element in history is most concerning for life threatening cause?
❤️
@rabihmgeha
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#EndNeurophobia
I am so fortunate to have met
@AaronLBerkowitz
. He is an epic human being, teacher, and neurologist.
3 steps in neurology
1. Identify the neurologic syndrome
2. Localize the lesion
3. DDx guided by associated symptoms and their tempo of onset.
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It is impossible to know it all in medicine. You never will.
The goal is to be slightly better tomorrow than you are today. Small steps lead to "unbelievable" growth over time.
<3
@rabihmgeha
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Hyponatremia significant enough to warrant blood tests should start with serum OSMOLALITY NOT volume status.
No ones volume status exam with or without ultrasound is as accurate as sOSM, uOSM, and uNa for IV vol.
Volume status plays a role but not a central one
❤️
@rabihmgeha
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This book is amazing. It consists of all the pearls a astute clinician would make at report. You will not find these pearls in a textbook or uptodate. It is best for the experienced clinician (after you learn the basics).
@AashishDidwania
@Anand_88_Patel
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Tip to trainees: Follow your passion and the rest will take care of itself. Do not get consumed with what others consider important. Get completely lost in what you love and do not fear failure. I promise tomorrow will be better than yesterday with practice.
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Dear MedTwitter family: Mistakes will happen. Accept them, learn from them, share them, and move on from them. The only error is not learning from your mistake.
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Iron deficiency anemia is not a final dx. It should be treated like a symptom (eg., dyspnea).
The question is why is the patient iron deficient.
Esophageal webs (PVS), spooned nails, glossitis, and pallor are a consequence of iron deficiency.
IDA prompts why IDA?
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Want to become your best during medical training?
Reflect for 10 min at the end of each day.
What went well? What could have gone better?
But no shame, guilt, or feeling of inadequacy is allowed.
You are growing. Be kind to yourself. And be excited to grow tmr.
@rabihmgeha
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Calcium homeostasis is BEAUTIFUL. A thread coming soon but here is a sneak peek.
3 organs -> Kidney, GI, and bone
3 hormones -> PTH, 1,25D, and FGF23
1 Ca++ -> feedback on Ca sensing receptors on PTH gland and kidney
<3
@rabihmgeha
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Let us start a new trend.
Describe a failure to normalize it for all.
I didn't get into medical school the first time I applied.
Don't let MedTwitter intimidate you.
Most people don't post their insecurities, failures, and mistakes.
They post highlights. "I received this award." "I published this paper." "I made this dx."
But remember we all FAIL, struggle, and have doubts. Wish we posted those more.
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HFrEF 2023 - ABCs of HFrEF management
Angiotensin inhibition (ENTRESTO) + MRAs (Aldo)
Betablocker
Cotransporter inhibition (SGLT2-inh)
Anything to add? bonus points if fits ABCs
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I am an Iranian-American.
After 9/11, I was called a terrorist.
I was afraid to go to school. I was bullied. But there was also individuals defended me. Who recognized I do not represent my government.
It is heartbreaking for me to see some of my colleagues show a lack of
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Don't shy away from an unusual concern.
"My chin is numb." He was later diagnosed with lymphoma.
It is more than ok not to know but it is not ok to dismiss a "personally" unfamiliar finding.
I have made this mistake and I don't want you to.
<3
@rabihmgeha
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I wish every hospital had a gym for their workers and gave them time to take care of their health.
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