#MRpearls use the FIB-4 Index in pts with know risk factors for liver disease. Includes age, AST, ALT, and plt to estimate liver scarring. Low scores may be appropriate for medical management alone. Thanks Richard Sterling! VCU IM Residency Chris Young Katie Waybill, MD

#MRPearls no transition point on abdominal CT scan is 94-100% specific for ruling out bowel obstruction! Always fun to see how Patrick Fadden MD FACP works through a differential with our VCU IM Residency residents! @cderekleiner Jonathan Hillyard, DO Jared Dyer, DO AudreyJerniganMD Chris Young

#MRpearls thank you Nayef Abouzaki, MD for educating us on stable angina. Remember intervention is not always the answer. Medical therapy first with goal of two anti-anginal agents before thinking LHC. Consider even in patients with an abnormal stress test. VCU IM Residency Katie Waybill, MD

#MRpearls do you remember how loop diuretics work? Great review of physiology and pharmacology this AM. Remember that most diuretics are bound to albumin so they may not work in low protein states. @cderekleiner VCU Nephrology VCU IM Residency Katie Waybill, MD AudreyJerniganMD

#MRpearls remember this fantastic schema for hyperCa workup from the The Clinical Problem Solvers. Remember to break it down between PTH dependent and PTH independent! VCU IM Residency Lizzy Varnell Rohrbach Patrick Fadden MD FACP Sam Sullivan

17/ #MRPearls Supervised exercise that includes walking at least 3x per week (30-60 min/session) for at least 12 weeks should be first line therapy for claudication. The CLEVER study in Circulation showed supervised exercise resulted in greater mean peak walking time vs. medical tx.

#MRPearls Can consider fecal immunochemical test (FIT) for blood for colorectal cancer (CRC) screening. It directly measures hemoglobin in the stool and should be repeated annually. The sensitivity for CRC is 73.8% and 23.8% for adenomas >10mm. VCU IM Residency AudreyJerniganMD (1/4)

#MRpearls remember that ~30% of pts have a diagnosis of HTN and of those, ~15% have a secondary cause. One of the most common causes is hyperaldo. VCU IM Residency Jared Dyer, DO AudreyJerniganMD Chris Young Katie Waybill, MD

Happy Match Day! Congratulations and welcome to our new Intern class! Congratulations to all medical students celebrating today. VCU IM Residency VCU Internal Medicine Department

#PayItForwardLIVE ready to listen to some Dave Matthews! Much needed! Thanks, Dave!

#MRPearls In patients with a LVEF <35%, a wide QRS complex (>120ms), and persistent HF symptoms (NYHA 3,4) cardiac resynchronous therapy has been shown to improve outcomes. VCU IM Residency AudreyJerniganMD Jonathan Hillyard, DO @AjayPMD Jaideep

#MRPearls Do not forget to check the delta-delta ratio in the presence of a high anion gap metabolic acidosis to determine if there is a coexisting normal anion gap metabolic acidosis or metabolic alkalosis. VCU IM Residency AudreyJerniganMD Jonathan Hillyard, DO Jason Kidd

#MRPearls It is important to have a systematic approach to an anion gap metabolic acidosis in order to not miss anything on your differential. Check out this schema by the The Clinical Problem Solvers. VCU IM Residency AudreyJerniganMD Jonathan Hillyard, DO Chris Young Katie Waybill, MD Jason Kidd VCU Nephrology

#MRPearls Another approach to anion gap metabolic acidosis is the GOLDMARK mnemonic which has replaced the outdated MUDPILES mnemonic. Marina, MD Laura Pedersen M.D. NoWars Niraj Kothari, MD Benjamin Wiese @COvertonMD Neha Hippalgaonkar Anchalia Chandrakumaran Laura Paletta-Hobbs, MD, FHM Michelle Brooks, MD, SFHM @bqueenhoo @rvawellmd

#MRpearls remember the BR level is at least 2-3 when you see scleral icterus! Supports how much you can predict from a good physical exam! Jared Dyer, DO AudreyJerniganMD Katie Waybill, MD Chris Young VCU IM Residency Stephanie Call @cderekleiner Rasha Raslan Patrick Fadden MD FACP

#MRpearls ⬆️troponin following seizures may suggest underlying CAD. Check out this article!🚫elevation was found in pts with a healthy CV system. ncbi.nlm.nih.gov/pubmed/24036082 VCU IM Residency @JCook2035 @AjayPMD Jaideep Kris Pangilinan Pranav Mankad Barbara Lawson @alex_pandelidis