#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!”
"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
“Science is a way of thinking much more than it is a body of knowledge.” — Carl Sagan
Most of our learners in medicine want us to help them learn how to think. Our great responsibility is to first think and then model how we think.
I think this is why the first 2 years of medical school, especially the testing methods, were so frustrating to me. I sought to understand rather than memorize. And the 3rd year brought back understanding - and 48 yrs later that still helps me grow
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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.
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
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?
2/ Learn to define and expand patient words - e.g., diarrhea (how often, what color, interfere with sleep, etc.). Patients describe things in words they understand, but often we interpret those words differently. Many such examples: chest pain, dyspnea, weakness, SOB, PND
3/ Try to understand the chronology and use that during presentation. This requires careful questioning so that the learner really understands the chronology.
2/ In the very first aliquot we learn that we have a college student with throat pain and chills. We do not know if they were simple chills or rigors. This is actually a BIG DEAL. Rigors (shaking chills) have a high odds ratio for bacteremia.
3/ If she really had rigors, then she needed blood cultures and admission for likely bacteremia. Interesting that she had unilateral tonsillar swelling. I have only seen this once in a patient with Fusobacterium tonsillitis with bacteremia! No data, just an observation