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 5
21 Dec2009
Still rounding on 8 patients yesterday. We are on call again today, but plan multiple discharges today.
A reader posed a good question yesterday in my discussion about bumetanide and furosemide. The reader championed torsamide. That loop diuretic might be the best, but it is not available at the VA or on the WalMart $4 list. The comment makes some good points.
Looking at the lab tests on our patient with cirrhosis, yesterday he had hyponatremia and urine osms > 500. I have not seen this explicitly discussed in the literature, but I make the following observations:
- Hyponatremia is a very bad prognostic sign – Hyponatremia and Mortality among Patients on the Liver-Transplant Waiting List
- Hyponatremia occurs due to decreased intra-arterial volume, despite increased plasma volume – Decreased Effective Blood Volume in Edematous Disorders: What Does This Mean?
- We discussed the possible use of Tolvaptan in this situation – but remembered that it cost $177 per pill!
- We offered palliative care to this patient, he is not ready to accept this strategy.
Today we will focus on the treatment of our patient with achalasia. He had a failed botox treatment last week, although he had success in the past. First thing this a.m. I will discuss options with our GI consultants.
We are treating his serious infection successfully, but we need to help him get oral nutrition.
Related posts:
- 15 days at the VA – day 6
- Tolvaptan finally available
- 17 days at the VA – day 13
- 17 days at the VA – day 12
- The focus of 9 inpatients
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- In: Medical Rants
3 Responses to 15 days at the VA – day 5
cory
December 21st, 2009 at 8:04 am
Does hyponatremia occur because of decreased intravascular volume or do they often coexist ? Cause and effect or common cause?
And what is decreased intravascular volume anyway? It can't be directly measured unless you have massive acute fluid losses. IT's a pretty nebulous concept in the chronic state.
I have always thought edematous states like cirhossis result from avid sodium retention and an excess of total body sodium. For whatever reason, portal pressure, decreased oncotic pressure, this fluid is not retained in the vascular space creating edema and ascites..
Many patients have an increased sense of thirst, you often have to hide water from them, (?angiotensin system) and so you are faced with a total body excess of sodium, undeniable and an intravascular excess of free water.
Absent correcting the liver problem the only real treatment is sodium restriction, mild diuresis (so as not to aggravate the liver problem) and water restriction.
Thoughts?
NornMedic
December 21st, 2009 at 7:11 pm
Palliative care discussed when there are potential therapeutic options available?
wtf?
david
December 21st, 2009 at 8:18 pm
what was his serum sodium?