BCM IM Residency
@BCM_InternalMed
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Caring for a diverse community of patients and fostering the development of physicians as leaders and life-long learners.
Houston, TX
Joined June 2016
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Monday practice:
Read this X-Ray and give the most specific diagnosis you can before reading the rest of the short thread.
1/3
53
299
867
In the context of the acute rib fracture, hemothorax should be suspected. This patient had a history of chest trauma 2 weeks ago and progressive dyspnea since.
3/3
10
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148
Wonderful take on the approach to shock/hypotension from PGY2 Brandon Blau.
2
24
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With “white out” of one hemithorax, look at the trachea.
Deviation toward whiteout -> pulled by lung collapse (atelectasis / bronchial plug / intubation of contralateral mainstem bronchus).
Deviation away -> pushed by pleural effusion or hemothorax.
Which is the case here?
5
35
133
Wow! PGY3
@AnthonyXuMD
gave an awesome review of variceal bleeding and the relative benefits for the interventions in acute bleeding esophageal varices...with references to boot!
@bcm_gihep
2
36
109
Congrats to our residents on the 2023 fellowship match! 🥂We are so proud of you 😊
4
13
93
How to think about non-resolving pneumonia, from PGY-2
@bahdi_firas
.
Take a minute to review:
- when to consider things "non-resolving"
- etiologies / differential
- diagnostic approach (great emphasis on iterative history-taking)
Thanks Firas for great teaching.
1
19
90
This is an intercostal lung herniation, presenting with acute pain and bulge while coughing.
When symptomatic, they need reduction and surgical repair of the defect to treat pain and prevent recurrence and complications.
Thanks
@DrCavazosDeLeon
4
16
86
Tuesday practice:
Interpret this EKG before reading the rest of the short thread. It was obtained in a patient with cirrhosis and subacute dyspnea.
1/7
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83
Hey,
#MedTwitter
!
What is the overlap between "Infective Endocarditis" and "Acute Kidney Injury." Let's get a broad differential diagnosis running!
16
19
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Monday detective practice:
Deduce a narrative based on this snapshot.
1. What do you think happened?
2. What one thing do you want to know to confirm?
3. What would you do next?
11
28
75
A couple pearls from recent morning report case:
Non-ischemic cardiomyopathy is a syndrome, not a diagnosis. Use history and targeted work-up to determine an underlying cause if possible. A useful schema from
@CPSolvers
:
1/5
2
17
75
We are pleased to announce the selection of our 2021-2022 Chief Residents and MEDVAMC CRQS!
Please join us in congratulating these educational leaders. We look forward to all they will accomplish.
0
8
72
🔥🔥Hot off the press!🔥🔥
We are SO excited to share our fellowships matches from this year. Congratulations to everyone who matched! 🎊
#match2021
#MatchDay
#fellowshipmatch
0
10
70
Intermittent dysarthria (difficulty articulating speech).
Chest X-ray below.
What's the diagnosis?
12
16
70
Very excited to welcome Dr. Kimberly Manning, aka
@gradydoctor
, of
@EmoryMedicine
to
@BCMDeptMedicine
Grand Rounds tomorrow!
3
5
64
Introducing the BCM IM Intern Class of 2023-2024! We are pumped!! 🥳
1
8
65
Monday practice:
Read the X-Ray systematically and give the most specific/comprehensive interpretation you can before reading the rest of the thread.
This patient presented with acute respiratory failure.
1/7
3
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62
A rapidly enlarging neck mass is most concerning for bacterial infection or lymphoma.
Thanks
@Ali_ElHalwagi
for excellent teaching.
#MorningReport
4
14
59
shoutout to
@CPSolvers
for the inspiration behind our Virtual Morning Report. We have been using this format since May (seems so long ago!) and our residents and faculty love it. Morning report attendance has actually gone up with the virtual format!
4
2
60
BCM Morning Report! Check out PGY3 Emma Ye's teaching points on eosinophilic lung diseases
1
16
61
3 Physiologic States of AFib with RVR
1. Demand
2. Decreased cardiac output
3. Increased AVN conduction
Great teaching at morning report by PGY-3 and rising chief resident Josh Hirsch!
@JRH_MD
#MedEd
#CardioTwitter
#morningreport
3
14
61
Some pearls from
#BCMIMMorningReport
:
1. Fever, abdominal pain, pancytopenia, abnormal LFTs...
Bartonella henselae has three common presentations:
- self-limited cutaneous
- disseminated with visceral involvement
- bacillary angiomatosis in HIV/immunocompromise
2
13
58
Great
@JAMAInternalMed
Teachable Moment about urine eosinophils by our residents
@AStrasma
and
@shradhakulk
.
“The positive and negative likelihood ratios were 0.97 and 1.01, respectively, indicating that the test has no diagnostic utility for AIN.”
6
17
59
Wednesday practice:
Pitch a unifying diagnosis / narrative before reading the rest of this short thread.
@MedEdPGH
@UTSWIMchief
@OHSUIMRes
@UCSFIMChiefs
@BostonChiefs
@BrighamChiefs
1/5
12
24
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Our categorical + MD Anderson + preliminary tracks include 50% women and 28% UiM trainees. Thanks to our resident recruitment leaders and faculty interviewers for showcasing our fantastic training and community! 💥
1
8
56
🎉🎈Congrats to everyone who matched and especially our wonderful new class of incoming interns!! We are over-the-moon excited for each of you to join us come June 🥳🥳🥳
1
7
55
Outstanding discussion of microangiopathic hemolytic anemias and mimickers from
@quillanhuang
1
14
54
We couldn’t be prouder of our residents and are overjoyed to announce our 2022 Fellowship Match results!
1
5
52
Happening now:
Our ⭐️ residents
@AngieRao92
and
@BasimAlee
are representing
@BCM_InternalMed
at
@Texas_ACP
Associate’s day!
Thanks
@HMinternalmed
for hosting this event!
2
3
53
Syncope.
Based on this ECG (which was obtained while asymptomatic), what electrical events or hemodynamic processes may have caused transient loss of consciousness?
9
19
51
Concern of hyperkalemia should not be a reason to avoid balanced crystalloid solutions.
Thank you PGY-1
@alyssa_kahl
for teaching us at our Clinical Question Conference today!
2
10
48
PGY2 Sarah Premji presented a great case this morning: Young man with no medical problems presented with dyspnea on exertion and this CXR. Differential and next steps?
3
5
50
As we’re closing out this academic year and starting a new one, we’re super excited to meet all the new interns and are looking forward to a great year with everyone! Here are the new chief residents for BCM AY23-24 (left to right): Claire, Erica, Codey, Phil and Jung.
1
4
48
Today is our first interview day!! 🎉
We wish our applicants could be here in person on this crisp and beautiful day, but we’re so excited to meet them virtually and grateful for their visit!
1
1
49
Things we do for no reason: routinely obtaining repeat echo for acute decompensation of known chronic heart failure.
Congrats Darren Harrison, Arunima Misra, Komal Muradali,
@StephVSherman
et al!
#BCMIMResScholar
@JHospMedicine
0
17
47
Pill esophagitis hurts.
Doxycycline
Clindamycin
Bisphosphonates
K+, Fe++(+)
NSAIDs
[Warn your patients to] take them while upright, with good amount of water, and >30 min before sleeping/lying down.
0
14
48
the wonderful Ali El-Halwagi shared this excellent schema with us that he made after caring for a patient with double vision
👀👀
#medtwitter
#BCMmorningreport
@CPSolvers
2
7
48
Syndromes of autonomic instability can present dramatically and mimic sepsis or cardiopulmonary emergencies.
Check out this great table. Thanks PGY-2 Zish Palejwala teaching this morning.
1
7
47
Jumping to the huge pleural effusion can make you miss another important finding. Read the X-Ray again, now systematically, including looking at the bones.
2/3
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9
44
Wednesday practice:
A patient has encephalopathy, hypoglycemia, and this ECG.
What’s your differential?
9
12
45
When considering fulminant, visceral, or venous+arterial thrombosis, we should add COVID to our list of usual CHAMPs of clotting.
Cancer (with or without DIC)
Heparin-induced TCP
Antiphospholipid syndrome
Myeloproliferative do
PNH
Thanks Ali Ghergherehchi for teaching.
0
7
41
Strong showing at the regional
@Texas_ACP
Associate’s Day by
@BCM_InternalMed
residents hosted by
@UTMBInternalMed
!
Our residents won awards in the QI, Clinical Research, Story Slam categories AND won the inter-residency Doctor’s Dilemma competition! 🔥 Congrats to the winners!
3
8
40
Congrats to our incoming 2021-2022 interns!!! We can't wait to see you in June 💯☺️
#MatchDay2021
1
11
39
In athletics, you spend >90% of your time practicing, <10% in the game. Medicine is a performance too, but the ratio is opposite.
We loved the comment from our new PCCM faculty Sergio Treviño on this tension:
“It’s tough, cause every patient is the Super Bowl”
3
17
40
Congratulations to everyone who matched today!
Special welcome to all the students who matched into our program.
We welcome you to our big Internal Medicine residency family. We are proud to have you join our ranks here in Houston, TX.
Happy
#Match2020
#bcmmatch
!
2
1
39
We are so grateful to our residents - wonderful people, inspiring doctors, fantastic teachers and leaders. It's an absolute privilege be part of your journey in medicine. ♥️
0
3
38
Congratulations to all our newly IM board-certified physicians and fellows
@BCMDeptMedicine
!
We are all SO proud of you.
@BCM_MedPeds
@ACPinternists
0
4
36
A low-voltage ECG. A normal baseline from a couple years prior.
But look at what happened to atrial voltage (same) vs ventricular voltage (decreased).
How does this narrow the usual ddx we consider for low voltage?
3
9
36
We love learning medicine. Here are some pearls from two recent
#MorningReport
conferences. Thanks to our amazing residents for teaching us.
0
5
36
Pearls on rheumatoid arthritis from
@merventi
- 40% of patients with RA have lung disease on CT, but only 5% w clinical manifestations
- RA incidence in women is decreasing, likely tracking smoking rates
- caries bacteria may contribute to RA (e.g. they citrullinate proteins)
0
7
35
This PRN menu (part of admission order set) is thoughtful, both in what it does and doesn’t offer.
0
2
35
Back-2-back lactic acidosis cases at BCM Morning Report today!
PGY2 Jonathan Lockhart taught us the about Warburg Effect in oncology patients
PGY3 Yazan Kherallah presented a case of persistent lactic acidosis due to thiamine deficiency
Great slide courtesy of
@YKherallah
5
9
35
Interpret A1c cautiously in patients with increased red blood cell turnover. Great pearls from PGY-2 Nathan Spezia-Lindner during BCM IM Morning Report
#morningreport
#MedEd
#MedTwitter
.
0
4
34
The morning report digests that the chiefs have been compiling and sending out every week are so🔥🔥🔥
Here's a few pearls from one day of morning report cases across our hospitals.
3
7
33
We don't always process bad outcomes with colleagues, but almost all of us think we should.
Thanks Nikki Oakman,
@JonLimMD
, Christine Bui,
@HollandKaplan
, and
@StephVSherman
for creating this initiative and sharing it with others.
#BCMIMResScholar
0
3
34
We are so thrilled to start meeting our applicants and future interns!
Application season is both an exciting and stressful time, and we hope that sharing our
#Match2023
recruitment season timeline provides helpful clarity.
2
6
32
Aaand that’s a wrap for our graduating residents! Congrats on your last day of residency! Here’s a
#thread
dedicated to you 🍾🎉
1/8
1
4
33
Hosted our 2nd ever (and hopefully last) virtual graduation last night for
@bcmhouston
IM & Med-Peds Class of 2021! 👏🥂
2
8
33
By the time length-dependent neuropathy gets to the level of the knees/thighs, it also tends to affect the hands.
0
10
34
Congrats to all our fellowship-bound residents!! We are so proud of your accomplishments and can't wait to follow your successes over the years! 🍾🎉🫀🫁🩸💩🦴
@BCMDeptMedicine
@bcm_gihep
@BCMHeart
@BCMIDFellowship
@BCM_ALD
@MDAndersonNews
2
1
33
Clinical reasoning moment:
Confirmation bias - the tendency to seek/emphasize info that supports your notions of the moment and overlook/minimize data that challenges them - is one of the strongest cognitive traps.
1/5
2
13
31
Check it out! PGY2
@AngieRao92
made this diagram to help remember when and how to work up secondary HTN
#MedTwitter
#BCMmorningreport
0
5
31
Approach to cavitary lung lesions from PGY-2 Charles Nguyen. Thanks Charles!
2
4
32
Chest pain in a 25-year-old healthy woman is often benign. But if she is post-partum, consider the increased risk for:
Aortic dissection
Amniotic fluid embolism
Pulmonary embolism
Stress cardiomyopathy / takotsubo
Spontaneous coronary dissection
1
3
32
BCM Morning Report! PGY2
@ssjaroudi
presented a case today of an older man with history of salmonella bacteremia and recurrent UTIs.
CT A/P is below, showing a prostatic abscess which grew salmonella.
1
5
31
If you’re in the habit, systematic doesn’t = slow. Here’s one system, Quality-ABCDEFGH
Quality (inspiration rotation penetration)
Airway
Bones
Cardiac silhouette
Diaphragms and rest of pleura
Extra lines and tubes
Fields (of lungs)
Gastric and abdomen
Hila
6/7
2
7
29
Knee aspirate, spun down.
Arrow points to a uric acid crystal inside a neutrophil. There are 3 more of them on the slide. This is acute gout.
Share your go-to treatment and the question you might have before pursuing it.
5
6
31
Pearls about psoriasis, courtesy of Smriti Prasad
- HIV can severely worsen psoriasis, and antiretrovirals will improve it
- Systemic steroids can worsen psoriasis
- Psoriatic plaques do not ulcerate on their own: consider additional process such as HSV
#MRPearls
2
1
30
Congratulations to all our graduating residents tonight. We thank you for all your hard work and dedication to all our patients. You are the heart of our program. Can’t wait to see what you all do next!
@BCMDeptMedicine
0
5
30
Some of our ⭐️ GI-bound residents representing
@BCM_InternalMed
at
@AmCollegeGastro
(with a🫀imposter hidden in there somewhere 😉)
#acg2022
#ACG
#bcmproud
@bcm_gihep
2
3
30
ECGs challenge.
What’s the rhythm here, and what else is going on? The second ECG is baseline from few days prior.
Question (out of left field?): does knowing about the Brody effect help us here?
Looking forward to learning with everyone.
1
8
29
Word of the day - Chalk-ception: A chalk talk on how to give chalk talks by third year
@HollandKaplan
.
4
1
29
Tuesday practice:
What can get better this quickly?
9
2
28
Identify a posterior STEMI by "flipping" the EKG - important pearl from upper-level resident
@DHarrisonIM
during our morning report
#MedTwitter
#MorningReport
0
3
29
#COVID19
, we’re surgin’ right back at ya 🌊
During H-town's peak, we'll honor residents weekly for their hard work! 💯😷
Our first week of COVIctors:
PGY1 Luke Pecha
PGY2
@JennMKaplan
PGY3 Charmaine Mutucumurana
@bcmhouston
@BCMDeptMedicine
1
3
28
The wonderful
@ruben_hernaez
sharing that even when you finish training and are a senior attending, you’re never “on your own.”
Thanks Dr. Hernaez for your wisdom and humility, and thanks to all the residents, students, faculty, and staff who care for our vets
@VAHouston
1
4
27
Learning, scholarship, friendship with BCM IM residents, alum, and faculty at Society of Hospital Medicine conf in Austin, TX
#SHMConverge2023
@BCMDeptMedicine
@agraviersymmes
@alyssa_kahl
@mjhorstman
@DocJGay731
@StephVSherman
2
2
27
Thank you
@O2MD1
for your service at Ben Taub as one of our Chief Resident! Today we got to celebrate your time at the Ben Taub Chief Resident luncheon in your honor. Wish you the best.
1
5
26
Thanks PGY2 Aaron Chin on great teaching on Adrenal Insufficiency!
Extra pearl: talk to RN first thing in AM if planning to do stim test. Both to clarify Qs and for them to plan ahead.
Also, what do folks think re: single 45-min post stim cortisol?
@tmodarressi
@christieturin
0
2
25
Great case from
@crchenMD
:
HCO3 7 (down by 17)
Anion gap 15 (up by only 5)
So if AG was normal, HCO3 would still be 12: significant NAGMA.
K 2.4. No diarrhea.
Can’t do justice to his masterful explanation of urine anion gap... but a couple pearls:
2
5
25
A few learning nuggets from morning report.
Thanks to our amazing residents for the teaching!
0
8
25
Today during
@VAHouston
we celebrated Dr. Daniel Musher’s 81st Birthday including his contributions to education, mentorship of trainees, and a large body of publication that has advanced the field of medicine.
#meded
#infectiousdiseases
@BCMDeptMedicine
2
1
26
Serum CMV PCR in HIV+ patients has limited diagnostic utility (in contrast to transplant patients). If CMV disease suspected, best to test organ of interest:
- Eye sx: exam by ophtho
- Colitis: colo with biopsy
- Encephalitis: LP / CSF PCR
Thanks, Dr. El Sahly for lesson.
1
2
26
All hail the Chief Residents! Thanks for orienting our new interns to
@harrishealth
@VAHouston
@CHI_StLukes
@MDAndersonNews
@BCMDeptMedicine
@DrCavazosDeLeon
1
4
26
The chiefs can't stop, won't stop, with the amazing morning report digests. Check out these learning nuggets from one day last week.
Outstanding teaching from Sadiq Rehmani,
@Larissaandr08
, Celeste Zsembery, and Rouzbeh Kotaki 👏
2
5
25
Applying to IM...?
Come to our Under-Represented in Medicine Virtual Open House to learn about our diversity, equity, & inclusion work!
Tuesday 9/7 at 7 pm CST
Register here: 💫
2
9
26
Great discussion of culture negative endocarditis with PGY-3 Yazan Kherallah!
#MorningReport
#MedEd
1
4
25
Awesome and challenging ECG:
First, the K+ was 2.5, so note and dismiss the non-specific ST/T-wave changes and U-waves.
But what else is going on here?
9
11
24
Aaron Chin (PGY2) presented a case of hyperkalemia in a patient with diabetes on spironolactone, lisinopril, NSAIDs. We stopped the meds, but the hyperK persisted. Aaron's diagram below takes multifactorial to the next level!
#morningreport
#MedTwitter
0
5
25