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 -
15 days at the VA – day 4
20 Dec2009
The team is relatively stable, but most things remain on hold until Monday. Our patients were improving yesterday. Here was our big discussion point of the day.
We have a patient with ascites and a new cirrhosis diagnosis. We first proved that he had secondary hyperaldosteronism using the transtubular potassium gradient. We started spironalactone and furosemide. Because the patient did not have a significant response to oral furosemide 40 mg, I raised the question of trying bumetanide 1 mg instead.
Here was my reasoning. Both loop diuretics are currently generic drugs available at WalMart prices. Furosemide has inconsistent absorption, ranging from 10%-90% across patients. Bumetanide has consistent absorption in the range of 80-90%. The estimated equivalence ratio is 40 mg to 1 mg.
Given the more predictable absorption, we should wonder whether we should abandon furosemide and switch to bumetanide as our loop diuretic of choice. I believe if both diuretics were released simultaneously, we would clearly choose bumetanide.
We decided to try bumetanide 1 mg b.i.d. I will report back on the impact of that decision. For more on loop diuretics, I highly recommend a colleague's paper – A Comprehensive Review of the Loop Diuretics: Should Furosemide Be First Line?
Related posts:
- 15 days at the VA – day 10
- 15 days at the VA – day 5
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2 Responses to 15 days at the VA – day 4
PMD
December 20th, 2009 at 11:44 pm
Why not Torsemide? Torsemide causes much more diuresis and dont have much effect on electrolytes especially hypokalemia as compared to Furosemide.
DB's Medical Rants » Blog Archive » 15 days at the VA – day 10
January 4th, 2010 at 7:27 pm
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