Ryan O'Keefe
@rokeefemd.bsky.social
MD/MBA PennMedicine/Wharton | Hospitalist | Onc, Pall Care, MedEd | Creator Point of Care Medicine | Clinical threads and pearls
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February 1, 2026 at 10:00 PM
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The testes are considered an immune privileged “sanctuary site,” which can harbor and be the initial site of presentation or relapse for hematologic malignancies. 🧵
Source - November 20, 2025 VMR with Rabih & Umbish - scrotal swelling and pain
Source - November 20, 2025 VMR with Rabih & Umbish - scrotal swelling and pain
February 1, 2026 at 10:00 PM
The testes are considered an immune privileged “sanctuary site,” which can harbor and be the initial site of presentation or relapse for hematologic malignancies. 🧵
Source - November 20, 2025 VMR with Rabih & Umbish - scrotal swelling and pain
Source - November 20, 2025 VMR with Rabih & Umbish - scrotal swelling and pain
When presenting in patients with no prior history of hematologic disease, it’ll often precede the development of overt AML in the blood and bone marrow.
Common sites include skin, lymph nodes, soft tissue, bone, and the GU tract.
Common sites include skin, lymph nodes, soft tissue, bone, and the GU tract.
February 1, 2026 at 10:00 PM
When presenting in patients with no prior history of hematologic disease, it’ll often precede the development of overt AML in the blood and bone marrow.
Common sites include skin, lymph nodes, soft tissue, bone, and the GU tract.
Common sites include skin, lymph nodes, soft tissue, bone, and the GU tract.
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January 31, 2026 at 10:00 PM
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4. Block adrenergic effects with a beta blocker. Propranolol is preferred as it also reduces T4 to T3 conversion. I’ll note that the efficacy of beta blockers in such critically ill patients has been called into question.
Source: CPS - November 19, 2025 VMR with Sharmin & Reza - AMS
Source: CPS - November 19, 2025 VMR with Sharmin & Reza - AMS
January 31, 2026 at 10:00 PM
4. Block adrenergic effects with a beta blocker. Propranolol is preferred as it also reduces T4 to T3 conversion. I’ll note that the efficacy of beta blockers in such critically ill patients has been called into question.
Source: CPS - November 19, 2025 VMR with Sharmin & Reza - AMS
Source: CPS - November 19, 2025 VMR with Sharmin & Reza - AMS
2. Block hormone release with an iodine solution, such as SSKI or Lugol’s. This should be given at least one hour after the thionimide.
3. Block the peripheral conversion of T4 to T3 with glucocorticoids.
3. Block the peripheral conversion of T4 to T3 with glucocorticoids.
January 31, 2026 at 10:00 PM
2. Block hormone release with an iodine solution, such as SSKI or Lugol’s. This should be given at least one hour after the thionimide.
3. Block the peripheral conversion of T4 to T3 with glucocorticoids.
3. Block the peripheral conversion of T4 to T3 with glucocorticoids.
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January 30, 2026 at 10:00 PM
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A temporal bone CT helps evaluate chronic conductive hearing loss to delineate middle ear pathology, ossicular chain integrity, and bony erosion that’s not visible on the physical exam.
Source: CPS - November 18, 2025 VMR Ravi & Jas - hearing loss
Source: CPS - November 18, 2025 VMR Ravi & Jas - hearing loss
January 30, 2026 at 10:00 PM
A temporal bone CT helps evaluate chronic conductive hearing loss to delineate middle ear pathology, ossicular chain integrity, and bony erosion that’s not visible on the physical exam.
Source: CPS - November 18, 2025 VMR Ravi & Jas - hearing loss
Source: CPS - November 18, 2025 VMR Ravi & Jas - hearing loss
Patients often present with painless, foul-smelling otorrhea.
The presence of a tympanic membrane perforation and granulation tissue is a clue which might suggest chronic suppurative otitis media and a potential underlying cholesteatoma.
The presence of a tympanic membrane perforation and granulation tissue is a clue which might suggest chronic suppurative otitis media and a potential underlying cholesteatoma.
January 30, 2026 at 10:00 PM
Patients often present with painless, foul-smelling otorrhea.
The presence of a tympanic membrane perforation and granulation tissue is a clue which might suggest chronic suppurative otitis media and a potential underlying cholesteatoma.
The presence of a tympanic membrane perforation and granulation tissue is a clue which might suggest chronic suppurative otitis media and a potential underlying cholesteatoma.
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January 29, 2026 at 10:00 PM
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A TTE with a bubble study is the definitive non-invasive test to diagnose an intracardiac shunt as the cause of POS.
Source: CPS - November 15, 2025 IMG Initiative VMR w/Allegheny IM Residency - worsening fatigue & SOB after a fall
Source: CPS - November 15, 2025 IMG Initiative VMR w/Allegheny IM Residency - worsening fatigue & SOB after a fall
January 29, 2026 at 10:00 PM
A TTE with a bubble study is the definitive non-invasive test to diagnose an intracardiac shunt as the cause of POS.
Source: CPS - November 15, 2025 IMG Initiative VMR w/Allegheny IM Residency - worsening fatigue & SOB after a fall
Source: CPS - November 15, 2025 IMG Initiative VMR w/Allegheny IM Residency - worsening fatigue & SOB after a fall
When a patient experiences sudden, severe hypoxemia with an unchanged chest x-ray, consider dynamic causes like pulmonary embolism or shunt physiology rather than purely parenchymal lung disease.
January 29, 2026 at 10:00 PM
When a patient experiences sudden, severe hypoxemia with an unchanged chest x-ray, consider dynamic causes like pulmonary embolism or shunt physiology rather than purely parenchymal lung disease.
POS requires the combination of an anatomical shunt (most commonly a PFO) and a functional trigger (PE, pulmonary hypertension, flash pulmonary edema) that increases right-to-left shunting.
January 29, 2026 at 10:00 PM
POS requires the combination of an anatomical shunt (most commonly a PFO) and a functional trigger (PE, pulmonary hypertension, flash pulmonary edema) that increases right-to-left shunting.
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January 28, 2026 at 10:00 PM
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January 27, 2026 at 10:00 PM
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An inflammatory syndrome with fever, cytopenias, and hepatosplenomegaly in a patient with HIV should make you think of an HLH-like state which can be driven by an underlying opportunistic infection.
Source: CPS - November 13, 2025 VMR with Rabih & Magnus - nosebleeds
Source: CPS - November 13, 2025 VMR with Rabih & Magnus - nosebleeds
January 27, 2026 at 10:00 PM
An inflammatory syndrome with fever, cytopenias, and hepatosplenomegaly in a patient with HIV should make you think of an HLH-like state which can be driven by an underlying opportunistic infection.
Source: CPS - November 13, 2025 VMR with Rabih & Magnus - nosebleeds
Source: CPS - November 13, 2025 VMR with Rabih & Magnus - nosebleeds
Serologic testing for Bartonella is often negative in severely immunocompromised patients due to an inability to mount a sufficient antibody response.
Management is often a prolonged course of doxycycline.
Management is often a prolonged course of doxycycline.
January 27, 2026 at 10:00 PM
Serologic testing for Bartonella is often negative in severely immunocompromised patients due to an inability to mount a sufficient antibody response.
Management is often a prolonged course of doxycycline.
Management is often a prolonged course of doxycycline.
The disease can manifest with cutaneous lesions, systemic symptoms (fever, weight loss, malaise), or both.
The skin lesions are typically friable, red to purple papules or nodules that can resemble Kaposi’s sarcoma or pyogenic granulomas.
The skin lesions are typically friable, red to purple papules or nodules that can resemble Kaposi’s sarcoma or pyogenic granulomas.
January 27, 2026 at 10:00 PM
The disease can manifest with cutaneous lesions, systemic symptoms (fever, weight loss, malaise), or both.
The skin lesions are typically friable, red to purple papules or nodules that can resemble Kaposi’s sarcoma or pyogenic granulomas.
The skin lesions are typically friable, red to purple papules or nodules that can resemble Kaposi’s sarcoma or pyogenic granulomas.
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January 26, 2026 at 10:00 PM
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