Favorite Quotes
"For every complex problem, there is a solution that is simple, neat, and wrong." - HL Mencken
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"I hear and I forget. I see and I remember. I do and I understand." - Confucius
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"The good physician treats the disease; the great physician treats the patient who has the disease" - Sir William Osler
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" The best test of a person's character is how he or she treats those with less power." - Bob Sutton
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"Those are my principles, and if you don't like them - well, I have others." - Groucho Marx
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"The difference between genius and stupidity is that genius has its limits." - Albert Einstein
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"It is hard enough to remember my opinions, without also remembering my reasons for them" - Friedrich Nietzsche
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"Anyone can make the simple complicated. Creativity is making the complicated simple." - Charles Mingus
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"Not everything that can be counted counts, and not everything that counts can be counted." - Albert Einstein
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"A foolish consistency is the hobgoblin of little minds, adored by little statesman and philosophers and divines. With consistency a great soul has simply nothing to do." - Ralph Waldo Emerson
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"This ain't no party, this ain't no disco, this ain't no fooling around." - Talking Heads, Life During Wartime
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"What is hateful to you, do not do to your neighbour. This is the whole Torah; all the rest is commentary. Go and learn it." - Hillel, Talmud, Shabbath 31a
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"You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing." - Thomas Sowell
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"An idealist is one who, on noticing that a rose smells better than a cabbage, concludes that it will also make better soup." - HL Mencken
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"If you only have a hammer, you tend to see every problem as a nail." - Abraham Maslow
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"A great teacher is one who realizes that he himself is also a student and whose goal is not to dictate the answers, but to stimulate his students creativity enough so that they go out and find the answers themselves." - Herbie Hancock
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"There are no facts, only interpretations." - Nietzsche
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"An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you do know and what you don't." - Anatole France
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"In character, in manner, in style, in all things, the supreme excellence is simplicity." - Henry Wadsworth Longfellow ====
Nov - 15
Dec - 19
Jan - 21
Feb - 8
Mar -
17 days at the VA – Day 3
17 Nov2009
My team had a relatively easy Sunday call day. On post call days, we spend 3 hours presenting new patients, discussing old patients and seeing all the patients. I told me team on Sunday that I would use the entire time regardless. With only 3 new patients, we had leisurely, and I hope educational, discussions of each patient.
One patient in particular presented an interesting issue – why saline can make hyponatremia worse? Our patient presented with a sodium level of 125. His serum osms were 249. He is euvolemic. Prior to receiving the urine osm report, we started IV saline – giving approximately 1.3 liters. Then the urine osms were approximately 630.
For those who already understand this phenomenon, you might predict that the sodium would further decrease. Some readers are scratching their heads at this point. Saline has osms of approximately 300 – so how can IV saline lower the serum sodium.
In fact the serum sodium went down significantly. Here is the explanation:
Assume 1 liter of saline has 300 mOsm of solute (in this case NaCl). For calculation ease assume the urine concentration is 600 mOsm/liter.
In order to excrete the 300 mOsm of NaCl with a urine concentration of 600 mOsm/liter, we will only excrete 500 cc of urine. Thus, we have partitioned the liter of saline into 500 cc of 600 mOsm/L urine and 500 cc of water.
Under conditions of very high urine osms and euvolemia, giving saline actually provides free water to lower the sodium. Our patient proves the explanation.
If the patient had been volume contracted, saline would have worked perfectly.
Related posts:
- 17 days at the VA – day 17
- 17 days at the VA – day 13
- A normal gap acidosis dissected
- Normal gap acidosis from diarrhea
- Questions about hyponatremia and running
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2 Responses to 17 days at the VA – Day 3
Patrick Baroco
November 17th, 2009 at 9:37 am
What was the cause of the hyponatremia? Psychogenic polydipsia?
Anon
November 17th, 2009 at 11:27 pm
Your team had 2 pts before call started and got 3 new pts? Your post-call service is 5? Is this an anomaly or is that a normal pt load for a ward team? Seems like it would be hard to get any patient care experience if you only admit 3 on call and have 5 to round on total.