Zach London
@zach_london
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University of Michigan #Neurology localization nerd and Prog Director @umichneurores , board game influencer , songwriter, fort builder.
Ann Arbor, MI
Joined May 2015
Don't wanna be here?
Send us removal request.
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🎉 It’s finally here… Field Cut!
A “confrontational” board game about the anatomy of visual fields.
Perfect for all levels of learners, from “I Don’t Know What An Eye Is” up through “I Have An PhD In How To Spell the Word Neuro-Ophthalmology.”
1/👁️
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I administered the Montreal Cognitive Assessment (MoCA) to the image-generating AI program DALL-E this morning. Thing really went off the rails.
Let's see how it did. 🧵
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If you're studying
#neurology
, you have to learn about different gates. I'm here for you all day.
A normal casual gate.
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🧷🔥The Sensory Exam.🧊👈
Some neurologists just skip it. Compared to other parts of the exam, it's mired in subjectivity.
And slow! you could spend 10 minutes doing it and learn nothing.
But it can still be valuable, especially when done EFFICIENTLY.
#tweetorial
#neurology
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Not pointing fingers, but I think some of us are misusing the word "bulbar."
The Bulb is the archaic term for the medulla. So bulbar weakness refers only to muscles supplied by cranial nerves 9-12.
Let's play a game called "Is THIS bulbar weakness?"
1/🧵
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Saw another patient with sensory neuronopathy who had been misdiagnosed with functional neurological disorder.
What is sensory neuronopathy, and why do we keep missing it? A
#tweetorial
.
1/
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As a neuro PD, I've read thousands of personal statements. Many say, "I have always been fascinated by the brain." Which is awesome, of course.
But I'm still waiting patiently for the one that starts, "I have always been fascinated by the peripheral nerve."
@NMatch2022
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It gives my great pleasure to announce the release of THE PLEXUS, a new strategy card game about peripheral nervous system localization.
Folks, this may be our only hope to
#endplexusphobia
!
Click here ➡️
And open the 🧵for more surprises.
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1/6. This chart shows you everything you need to know about localizing foot drop. But let’s make it even simpler. If dorsiflexion is weak, there is one muscle that really matters: the tibialis posterior, which does ankle INVERSION. Let’s unpack that with a cool mnemonic.
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In my first and only basic science research experience, I was complicit in scientific fraud.
There was no fabrication of data, per se. No doctoring of images. It was subtle experimental misconduct, and certainly an anomaly in the scientific community. I assumed.)
1/🧵
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I do EMGs as part of my job, and I will be the first to admit that we do too many for neuropathy. If a patient has symmetric foot numbness, we may or may not find evidence of neuropathy, but the results rarely impact management.
A
#tweetorial
about when I recommend EMGs.
1/4
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@UMICHNeuroRes
resident Dan Mannion shows off the functional eye movement educational tool he invented and 3-D printed! Seriously, check this out!
#neurotwitter
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Thinking about opening a
#neurology
-themed bar, but I can't decide what to call it. Here are some of the options.
Having one of those days when you just want to curl up into a ball? Let's relieve some of that opening pressure. Hopefully, the experience won't be traumatic.
1/8
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"A bag with feet."
That's what the patient said he saw when we showed him the cookie jar picture. He was an older man who had been brought to the ED after being found driving his car around a field.
Here is what I think he was seeing:
#neurotwitter
#tweetorial
#MedEd
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"What do you see when you're walking HOME from church?"
She was an older woman with a right MCA syndrome, and I will never forget what she said when my attending asked her that question.
Not a full
#tweetorial
, just some mind-blowing examples of neglect for neuronerds. 1/🧵
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Today, I saw a resident perform a successful Epley maneuver for the first time.
She walked out of the patient room, wide-eyed, realizing that she just cured somebody with her bare hands.
#NeurologyMagic
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Did you realize how many of your favorite celebrities are named after MRI sequences?
For starters, you can't spell DWIGHT without DWI.
#neuroradiology
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Final score? 2/30, and that's being generous.
Fellow
#neurologists
, our jobs are safe, at least for a few more weeks.
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Does anyone have a favorite line a textbook?
This one is solid gold: "Unilateral loss of ear wiggling among natural ear wigglers is an uncommon finding in Bell's palsy." Brazis, et al.
#neurotwitter
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If you blow on someone’s foot and the toe goes🆙, that’s the London Sign. Sure, you could use a descriptive name, but I invented the maneuver, so I’m naming it after me. Everyone cool with that?
An irreverent/irrelevant
#tweetorial
on the rise & fall of neurologic eponyms. 1/
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Who wants to know the most important crucial critical high yield thing about nerve conduction studies?
Once you learn this concept, everything else in your life will fall into place. You may "find yourself," at least in an electrodiagnostic sense.
#tweetorial
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Describe your specialty with a Titanic-themed cartoon. I'll go first.
#neuromuscular
#neurology
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The wait is over.
We are honored to announce the release of Foramina!
A fast-paced tabletop game that celebrates cranial nerves and the magical little holes through which they travel.
👉👈
Co-author:
@MikaelaStiver
Art:
@alexludai
Please share!
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Naive idea:
Why do we need hundreds of med schools giving different versions of the same lectures when students just stream them? If we must have preclinical lectures, we should just hold teaching auditions, and have the best of the best teach everyone.
#medtwitter
#meded
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1/
We often check SPEP and/or immunofixation in patients with neuropathy. Why bother, and what should I do with the results?
Welcome to Paraproteinemic Neuropathy: A
#tweetorial
for neurologists who order tests they have no business interpreting.
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It gives me unnatural pleasure to announce the long-awaited release of Cranial Vault: The Neurology Game Pack.
Learn about this
#meded
smorgasbord here ➡️
Please share, and check out the rest of this 🧵for pics, songs, videos, and more surprises!
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The best medical suffix Is -osis, which just means “affected by.”
- Thrombosis: Affected by clots
- Sarcoidosis: Affected by sarcoid
- Necrosis: Affected by death
- Sclerosis: Affected by the whites of your eyes
- Ptosis: Affected by physical therapy
What’s your favorite -osis?
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1/11
Time for a
#tweetorial
on one of my favorite topics: Wrist Drop.
@aanmember
@nmatch2022
#neurology
#futureneurologist
#neurotwitter
#neurotwitternetwork
@AANEMorg
#meded
@KoriPoRodri
The first thing you should think of when you see a patient with weak wrist extension is…
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Myth: Inuits have 50 terms for snow.
Not myth:
#neurology
residents have 50 terms for "I'm not sure what's going on but I don't think they should be admitted."
➡️Recrudescence
➡️Acephalgic migraine
➡️Stress
➡️Small fiber neuropathy
➡️Older people just get dizzy sometimes
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I'm definitely paying attention during your long Zoom meeting, not completing my collection of
#neurotwitter
rhyming riddles.
Answers at the end of the 🧵, but how many can you get without cheating?
You've heard of Elf on the Shelf, but have you heard of... 1/
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Hey there! Would you like to know a reasonable workup for distal symmetric polyneuropathy (DSP)?
(Zach waves hand, warmly beckoning you in.)
Mr. X has progressive distal symmetric foot numbness and that's it. What labs & studies do you want?
#tweetorial
#meded
#NeuroTwitter
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Ulnar neuropathy "at the wrist" is really in the hand. Guyon's canal is between the pisiform and hamate bones. It's close to the wrist, though.
The numbers in this image are the Zones where injuries can take place, and they each create a unique clinical picture.
#tweetorial
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Cranial Nerve Lesions:
A
#pootorial
What is this?
A Turd Nerve Palsy. You can tell by the asymmetric poop-ils.
1/💩
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Neurology residents often tell me that OB/Gyn was their least favorite rotation in med school. But why? Seriously, neuro and OB have so much in common:
1. Cervical
2. Fundus
3. Vault
4. Peroneal (they spell it wrong)
5. Claustrum (they pronounce it "colostrum")
@helenjkmorgan
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Has anyone made a visual
#tweetorial
to help you remember the common features of MuSK myasthenia gravis using pictures of... Elon Musk? The world doesn't need this, but here it is anyway.
#neurotwitter
#meded
1/6
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🧠 Looking for a comprehensive, yet accessible educational resource for residency training in
#NeuroOphthalmology
?
The curtains part, revealing...
"Neuro-Ophthalmology At Your Fingertips," a free online resource by Dr. Jonathan Trobe
@UMneurosciences
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Cranial nerve buffs, In a few days, we drop our new tabletop game, Foramina!
The pump-up begins NOW, starting with this (purely educational) song parody.
Share and tag someone who loves cranial nerves or singing puppets. Which is everyone!
@MikaelaStiver
@alexludai
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Academic life is full of opportunities. There are ones you seek, and ones that fall into your lap. For the most part, the ones you seek are almost always better.
But when one falls into your lap, ask yourself 3 questions before responding...
#AcademicTwitter
#medtwitter
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What do inkblots and puppies hugging teach us about the way the long tracts are organized in the spinal cord? Everything.
Behold, our favorite tracts in the cervical cord.
A = fibers to/from the arm
T = fibers to/from the trunk
L = fibers to/from the leg
#tweetorial
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What do these pictures have in common?
1. The 2010 Clippers
2. The original case series of CLIPPERS syndrome published in 2010
A
#tweetorial
about both.
#neurology
@UMICHNeuroRes
@NMatch2023
1/🏀🧠
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The shirt is nice, but if we’re being honest, most
@AANmember
neurologists who signed up for the
#aanam
5K just did it for the safety pins.
@AANmember
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The NIH site has detailed instructions on how to administer the Stroke Scale.
I inputed the instructions into an AI image generator, and the results make me giggle. (This kind of thing will probably stop being funny soon, but I still love it.)
1/15
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If a Lego has dysconjugate gaze, does it develop… Duplopia?
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Beyond excited to introduce you to Endowed Chairs: Neurology
A 2-player game that celebrates the most illustrious women in the history of neurology while gently poking fun at academic medicine.
Groovy co-author:
@OligoclonalBand
Please share!
1/🪑
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Need to pull up next to this car to see if the driver is a neurologist or a zombie or both.
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I ♥️nortriptyline for neuropathic pain or HA prophy in the non-elderly.
- Cheap as dirt!
- Once a day!
- ⬇️ side effects vs. amitriptyline!
- We can pretend it treats comorbid insomnia/depression!
High 5 to my fellow nortriptylovers.
Anyone have a different favorite TCA to plug?
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Uh oh. Somebody needs a funduscopic examination.
One ophthalmoscope head lets you view the whole retina at once👁️.
The other induces crippling anxiety.😱
They have the SAME LETTERS.
@UMICHNeuroRes
@DGlaucomflecken
@NMatch2023
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Why is she calling it the ERAS tour?
- The MEAN # of programs applied to is 22.
- If you want to match into the program of your WILDEST DREAMS, YOU NEED TO CALM DOWN. Trust ME!
- BAD BLOOD with an interviewer? Just SHAKE IT OFF and BEGIN AGAIN.
@Inside_TheMatch
@NMatch2023
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First time in Oslo, and I’m impressed how much they love their vertebrobasilar vasculature. Nice AICAs!
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In 1993, the WHO dropped the word multiforme from its classification, so a grade IV astrocytoma is correctly called glioblastoma.
Thus this marks the 30th consecutive year that we have been incorrectly calling it a GBM instead of a GB.
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With so many new
#migraine
🤕treatments in the last few years, the old reliables haven't been getting much love.
Get on your feet,
#headache
specialists, because it's time for an anthem celebrating the stalwarts that began the revolution... the
#Triptans
. 💊🎶
#TriptanTribute
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Doing a little dance in my office right now. The sun is out, the sky is blue, and the brightest stars are coming to Michigan!
Thanks to everyone (people and mysterious algorithms) who made this possible. I'm excited to get the 9 of you in a room and watch the magic unfold!
We are over the moon to welcome these AMAZING future neurologists to the
#umich
family. Thank you for trusting us with your training. Go blue!
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Sensory neuronopathy is a localization, not a specific diagnosis.
Causes? I usually think of paraneoplastic syndromes, Sjogren’s, platinum chemotherapies, and HIV, but there are a few other considerations. Here’s a fridge-worthy diagnostic algorithm by Kelly Gwathmey et al.
11/
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Just like its namesake, the Taylor hammer is popular, accessible, and immediately recognizable. But it doesn't get my toe tapping (because it stinks at eliciting ankle jerks.)
Perhaps Tay Tay should change her first name...
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Babinski sign
Brudzinski sign
Hoffman sign
Kernig sign
Lhermitte sign
Romberg sign
Tinel sign
Hoover sign
Yes, I paid for someone to show them to me years ago. And yes, I then taught them to my team.
So what? Everybody does it.
#signstealing
#goblue
@UMICHNeuroRes
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"Doc says it's my sciatic nerve."
Except that it's not. Please sign my imaginary petition to stop the use of "sciatic nerve" to mean lumbosacral nerve root and "sciatica" to mean radicular pain.
The sciatic nerve is its own thing and this is crying wolf!
#neurotwitter
@AANEMorg
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I appreciate people reposting. (Sometimes a gate just needs two new posts.)
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We're unbelievably excited for this group of talented doctors to join us next year!
The hardest part of my job is the 24 hours between when I see our match list and when I'm allowed to shout it to the world. But now there's no need to hold back... Welcome UM neurologists! 🧠🎉🥳
📣 We are SO thrilled to announce the University of Michigan Adult Neurology Class of 2027! So excited to welcome each of you to our family in Ann Arbor! Congratulations &
#GoBlue
!! 🎉〽️
@MunaBAlmasri
@jamarobarron
@AlexHart2023
@MandelAlex18
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Need a neurology-themed game to bolster the "It" Factor of your collection? Here's an exhaustive list of the games we have available at
@thegamecrafter
. Each one has twice as much "it" as the last.
Bonus: Scroll to the bottom for other
#meded
games by friends and colleagues!
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Anyone want to form a band? I'll play the Whatever-This-Is and someone else can sing. Here's a demo of our first single...
"Neurodiagnostics: A Celebration of Over-Testing."
Rock on,
#Neurotwitter
. 🤘🧠🤘
@UMICHNeuroRes
@UMneurosciences
@AANMember
@Inside_TheMatch
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Hear ye! Residents and students on service with me, if you make it one week and only use generic drug names, I will literally shower you with candy.
You are strong, you are proud, you are not under the thumb of Big Pharma, and you shall be rewarded!
#medtwitter
#NeuroTwitter
1/2
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When an ophthalmologist refers a patient for an EMG.
(OU is their abbreviation for Oculus Uterque, which means… both eyes. Which is apparently where this patient has ulnar neuropathy.)
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Today's
@UMICHNeuroRes
Localization Rounds case.
A patient has sudden onset of:
▶️R facial weakness, upper and lower🫤
▶️Impaired adduction of the R eye with spared convergence
▶️R hypertropia that is present in all direction of gaze
Where is the lesion?
#tweetorial
1/
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Neuropathy is the most common reason to stop chemotherapy.
Here are a few practical things to know about it.
1/
#tweetorial
#neurotwitter
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After 14 years as a program director, I'm still not sure how to feel about behavioral interview questions. You know, the ones that start with, "Tell me about a time when..."
@NMatch2022
@Inside_TheMatch
#neurotwitter
#neurotwitternetwork
#futureneurologists
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One of the residents and I saw a woman with episodes of uncontrollable mirthless laughter, each lasting 24-48 hours. She had headache and nausea with them. No features suggestive of seizure or neurodegeneration.
So
#Headache
folks, are gelastic migraines a thing?
#neurotwitter
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Here is why EMG rules: There is no other diagnostic test in all of medicine where you have a hypothesis, test it at the bedside, use the results to change the study and form a new hypothesis, and keep going until you’re done, all in < 1 hour.
@AANEMorg
#neurotwitter
#medtwitter
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Big/wonderful news!
Neuro-immunology announced that they will have a fellowship match starting with the 2023 application cycle (current PGY2s).
This will promote equity and fairness, and should be a huge win for residents. 1/3
@NMatch2023
@meded
#neurology
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How do you test interosseous strength? Some do it like this and pinch the abducting fingers.
The problem here is that you're using your big long finger flexors against the patient's puny interossei. You're going to win that fight every time.
#tweetorial
#meded
1/2
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A patient presents with:
❤️Neuropathy
❤️Sensory ataxia
❤️Diplopia
❤️IgM paraproteinemia
❤️Gd1b ganglioside antibodies
❤️Improvement with IVIG
What is this, and more importantly... what does it have to do with Valentine’s Day?
#tweetorial
1/4
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When the results aligned with the PI’s hypothesis, the tech would declare that I had done everything correctly.
If the results “didn’t make sense,” she would blame human error and throw them out. This happened too many times to count.
7/🧵
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Things you can buy for a dollar:
1. About 8 miles worth of gas
2. A McChicken sandwich
3. 15 minutes of street parking in Manhattan
4. Everything you need to know to pass the neurosurgery boards:
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Should I start this inpatient on thiamine?
Should I replace the sponge in the kitchen sink?
If your brain has enough subconscious concern to ask itself either of those questions, the answer is yes.
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Interested in
#meded
leadership, but secretly think you're underqualified?
For what it's worth, I've been a happy program director a long while, even though:
1. All the residents I now recruit are more qualified than I was when I was a med student.
2. I wasn't a chief resident.
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Okay, raise your hand if you want this. 🤚
The attention to detail is incredible!
Commissioned
@UMICHNeuroRes
’s very own Dr.
@DanielMannionMD
to make this amazing brainstem // circle of willis model for me! how cool is this!?! 🧠🙌🏻 🩸 Excited to use it while reviewing vessel imaging for patients, trainees and students!
#NeuroTwitter
#stroketwitter
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Sometimes, when other services call
#neurology
for a consult about a patient with mental status changes, they are really asking if they should order a brain MRI, LP, or EEG.
Other times, they already plan to do all three and just want our advice on the order in which to do them.
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My colleagues and I have been keeping a record of the best dictation errors we have found in medical records. Here's my all time favorite:
“I will start morphing as needed.”
#dictationerror
#neurotwitter
#medtwitter
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How do you recognize an extroverted neurologist?
They're staring at your feet instead of their own.
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I just learned from
@salvaunav
that in Spain, it’s called “Polygono de Willis,” because it’s a polygon, not a circle.
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Me: What roots supply the abductor pollicis brevis?
Right people: C8 & T1
Well-meaning wrong people, picturing a dermatome chart and conflating sensory and motor innervations: C6
Me: Hmmm. Enough learning for one day. Let's get some popcorn.
@NMatch2023
#neurotwitter
@aanem
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Let us sing the praises of the Pronator Teres! It’s a surprisingly useful muscle to test both clinically and on EMG, especially when looking for C6 radiculopathy.
And folks, you can’t spell INTERESTING without TERES. Mic drop.
Here's what mine looks like:
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IMGs are a crucial part of our neurology workforce. We need to support their journey to bridge the physician workforce gap and provide better care for all. 🌍🧠
The September
@AUPN_leaders
Leadership Minute features
@EricaSchuyler
as she discusses the reasons behind and importance of our advocacy efforts through the
@AANmember
and
@TheNewANA1
for IMGs in Neurology.
Link:
0
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"Repeat: Face, Velvet, Church, Daisy, Red."
It appears to be trying to cast a Guillermo del Toro movie. But this one isn't worth any points anyway, so let's move on.
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It’s time to start getting pumped, psyched, and stoked for the
@AANMember
Fall Conference. Yee haw!
#aanfc
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I was taught that >5 WBC in CSF is concerning for meningitis or an inflammatory process.
But how many WBCs are you allowed when it's a bloody tap?🩸
Here'a
#tweetorial
/
#thoughtexperiment
about how to know, if your tap isn't like this one?🍾
(Video credit: Mikhail Ogenenovski)
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Here is the very last of the puppet-driven
#medsongs
videos.
"Prior Auth"
A parody of 'Firework', with apologies to Katy Perry... but no other apologies.
I tried to trim this one to fit the Twitter constraints, but it needed a second verse. See 2/🧵for YouTube link.
1/2
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When an electromyographer tries to do a MoCA.
(This may be the most niche
#neurology
meme I've ever tweeted. Best to hit Like so people don't suspect that you aren't in-the-know.)
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Shake the present and guess what's inside! A mystery case/
#tweetorial
for you to unwrap:
27 y.o. man presents with:
🎁Proximal arm WEAKNESS.
🎁Mild dysarthria🗣️
🎁Difficulty holding his head up while biking.🚴♀️
🎁It's been going on a long time, but fluctuates a lot.
1/13
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The patient was sitting up on the stretcher, holding this sign. 👇
Her husband was so sick of answering the same questions, he wrote this and pointed to it whenever she asked.
We told them that if you must come for to the ED for a neuro diagnosis, TGA is the one you want.
1/4
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Starting a new series of videos featuring puppets and song parodies about
#meded
and
#neurology
. Tentatively calling it MedSongs.
This first one lists every* muscle in the human body! Will post one new video per week until they're all gone.
(*Not every)
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"Name a lion, rhinoceros, and camel."
You can tell the Ciron knows something is seriously wrong here. The Mion, on the other hand, feels very comfortable in its own skin. Maybe even a bit smug. 0 points.
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I was at the
@DIADetroit
Museum today and saw lots of great
#neurology
.
“Subtle Exotropia”
Attributed to Giampetrino ~1400
1/
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If they have absent proprioception and close their eyes, the give-way weakness will get worse.
Now coach them to stare at their limbs during testing. They'll be able to use visual input to make up for the lack of afferent sensory input and... voila! They are actually strong!
7/
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My feed is brimming with support for unmatched applicants, which makes me proud to be part of this community.🫂
I also want to acknowledge and validate the heartbreak that unfilled programs are going through today. Some PDs are having the worst day of their professional careers.
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The time is right for neurology to have its own education journal. Excited to be part of the editorial board under the outstanding leadership of the indomitable
@RoyStrowdMD
!
So excited about the new
#NeurologyEducation
journal
@AANMember
😎 announced at the
#aanam
CDPD mtg this am
@RoyStrowdMD
@JG_Merino
@jsirven
#neurotwitter
#meded
@EricaSchuyler
@zach_london
@MarkMilsteinMD
@FurrStimming
@DorisKung3
@MChuquilinNeuro
@yaleneuropd
@JCGneuro
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Sadly, sensory neuronopathy is *idiopathic about half the time.
Or at least I am not smart enough to figure it out. But now that the flowchart is on my fridge, I hope to do better!
(*From the Greek “Idio” and “pathos” which mean that the doctor is a PATHETIC IDIOT.)
13/fin
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