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Robert Centor MD MACP 🇮🇱 Profile picture
@medrants
Apr 20, 2020 • 4 tweets • 2 min read • Read on X
1/
#UncleBob regrets missing #VMR live - but he spent time on the recorded version. Love the discussion and the case - often treatable. Have made the diagnosis once ~25 years ago.

As a lab junky I have some questions for @CPSolvers @fernandbteich
@DxRxEdu @rabihmgeha
2/
Did anyone note the bicarbonate of 17? Is this a normal gap acidosis or a compensation for respiratory alkalosis? This is not essential for the main dx - but could the patient have unknown early hepatopulmonary. I would have questioned that if she was on my service.
3/
The combination of low albumin and high INR strongly suggests CLINICAL cirrhosis - the factory is not working

With the low albumin, did she have hypercalcemia - would have checked an ionized calcium.

Finally did the Echocardiogram mention pulmonary artery pressure?
4/
As I said - great case and discussion. These points are not essential, but on rounds I would ask them. They could point to management issues. Sometimes the diagnosis is complex - a main disease and then collateral damage. I like to understand the collaterals.

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More from @medrants

Robert Centor MD MACP 🇮🇱 Profile picture
Sep 15, 2022
1/ #UncleBob - on giving formative feedback on rounds. First, make it clear in your expectations discussion (day 1) that you will critique many things and label them as feedback. #MedEd @CPSolvers @uabimres
2/ Especially with new presentations, stop after the HPI and both praise the story and provide suggestions on making the presentation better. Emphasize the role of storytelling as separate from having taken a good history.
3/ Understand that when you ask questions - some are hard and some are easy. When a learner answers a hard question well - praise them and note that you are giving positive feedback.
Read 7 tweets
Robert Centor MD MACP 🇮🇱 Profile picture
Apr 19, 2022
1/Time for a #UncleBob screed. The question Andrew raises is a very interesting one. First I must provide my understanding of the purpose of teaching ward attending physicians.
I divide this into providing excellent patient care & helping learners grow.
2/ Providing high quality care is a given. Excellent ward attendings evolve with clinical practice (consider the 10,000 hour "rule"). But I would argue that both outpatient clinical practice and inpatient practice are beneficial.
3/ And I believe I learn more in a month of ward attending than if I did a month of solo patient care. Patient care requires attention to detail, diagnostic excellence, management efficiency and proper use of tests and consultants.
Read 10 tweets
Robert Centor MD MACP 🇮🇱 Profile picture
Mar 7, 2022
1/ #UncleBob recently presented a patient who had a hyperkalemia, normal gap acidosis (type 4 RTA) to @DxRxEdu & @rabihmgeha

But why does hyperkalemia cause a normal gap acidosis?

@tony_breu
2/ Some basic physiology - we metabolize around 1 mEq of H+ daily from our diet. We buffer that acid using titratable (phosphate) and non-titratable (NH4+) acids.
The phosphate pathway does not vary much, but our kidneys can normally control the ammonium pathway
3/ Where does the ammonia come from? Glutamine -> glutamate under the enzyme glutaminase produces NH3

Here is the interesting part. Increased K inhibits this enzyme, thus we produce insufficient NH3 to buffer our dietary intake.
Read 5 tweets
Robert Centor MD MACP 🇮🇱 Profile picture
Mar 7, 2022
#UncleBob posted this link yesterday. Here are a few thoughts on the article. “I don’t know what’s the matter with people: they don’t learn by understanding; they learn by some other way—by rote or something. Their knowledge is so fragile!”

— Richard Feynman

Reminds me of M1&2
"The difference between reasoning by first principles and reasoning by analogy is like the difference between being a chef and being a cook. If the cook lost the recipe, he’d be screwed."

This is so relevant to those who grow and those who stagnate.
"Some of us are naturally skeptical of what we’re told. Maybe it doesn’t match up to our experiences. Maybe it’s something that used to be true but isn’t true anymore. And maybe we just think very differently about something." - The best diagnosticians always question previous dx
Read 5 tweets
Robert Centor MD MACP 🇮🇱 Profile picture
Feb 16, 2022
1/ Here is the story - hopefully instructive. Patient (ESRD w/ dialysis) admitted 3 weeks previously for dyspnea. Portable CXR shows small pleural effusion & some haziness - pneumonia or atelectasis. No fever, no increased WBC, no productive cough. Discussed now w/ radiology
2/ Radiologist teaches our team - pneumonia is a CLINICAL DIAGNOSIS - cannot make the diagnosis by CXR/CT scan.

Patient discharged - readmitted for more dyspnea - now with moderate pericardial effusion and large left pleural effusion. Receive furosemide & then thoracentesis
3/
 fluid LDH - 136
fluid TP. - 3.8
serum LDH - 212
serum TP - 5.6

Fluid very clear - pH 7.43 - no WBCs

Light's criteria - exudative effusion

All appropriate pleural fluid studies negative
Read 6 tweets
Robert Centor MD MACP 🇮🇱 Profile picture
Jan 30, 2022
1/ #UncleBob hopes those on the fence about vaccines will understand this
Weekly COVID-19 death rate via CDC:

Unvaccinated: 9.7 deaths per 100k
Fully vaccinated: 0.7 deaths per 100k
Boosted: 0.1 deaths per 100k
2/ Yes you can get omicron even if you are boosted

BUT

You are less likely to get infected
If you get infected you are much less likely to need hospitalization
If you need hospitalization, you are much less likely to need ICU care, and MUCH less likely to die
3/ Would you turn down medical care if you got sick?

I assume no - almost everyone comes to the hospital and ask for everything

Then why would you not accept a free prevention tool?
Read 5 tweets

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