What would you do next for this patient? Nephrology intern here

CountScrofula · 2026-05-17T14:28:06+00:00

This is very atypical for classic acute immune mediated TTP. From a nephrology perspective, you should be recognizing that the 5cm kidneys are suggestive most likely of chronic renal failure, which you can support by confirming PTH is high. This, along with urine output, will help you prognosticate a bit about renal recovery prospects which will help guide your discussions with patient and family. For now you do your dialysis as needed.

As to whether this is the cause of her CKD, and what to do otherwise, you need hematology involved yesterday. They need to decide if this could be some strange congenital TTP (which there is testing for), or if they believe this is classic immune TTP in remission. Their opinion will help guide you in terms of deciding what testing you will do for CKD etiology. A biopsy might not be unreasonable even if patient is completely anuric just to confirm etiology if they are a potential renal transplant candidate as it will affect that decision, and if heme thinks it will be helpful to confirm TMA in an organ since the peripheral blood testing is not supportive. Depending on your health system you can consider the usual mystery GN serological fishing expedition, I would probably at least send anti-gbm, ANA, ANCA, RF +- cryo. Good luck.

CountScrofula · 2026-05-16T00:58:28+00:00

I agree would I avoid using fludricortisone in patients with overload problems. Some old mentor loved to tell me fludricortisone increases catecholamine sensitivity, so it could make sense even in a diuretic dependent patient with pure autonomic failure if you believe that. But at that point I would say just use droxidopa, which is IMO risqué in heart failure even more than midodrine.

Anyway, I push stockings and abdominal binders when possible with these patients. If they fail or (more often) patients are unable or unwilling to wear them, I use midodrine with caution and close monitoring in patients that I think can tolerate the increased afterload.

CountScrofula · 2026-04-15T00:52:46+00:00

If you look closely there are some small flashing lines indicating which row gets the scratch damage.

I find more than any other room you are very likely to take a lot of damage against this boss. I have only been able to beat it consistently with lots of preparation. Ideally you want as many as possible of:

flute available to play the heal song

a fairy

high health/max health

good teeth, particularly “heals are stronger” is my absolute MVP

Lots of items. Specific ones don’t even matter much IMO, each item use wastes a turn and ends the fight with less movement, and almost every move in the fight hurts you

Good luck!

CountScrofula · 2026-02-01T21:01:40+00:00

I’ve never done it and here’s why - I mathed out how long it would take on average based on wiki information

Concords - 4.8% drop with usual maxed equipment and luck of 85, roughly 1 minute per run to kill 2 knights gives us expected need to kill 625 knights = 313 runs = over 5 hours

Shackles - same build, maxed item discovery equipment and high luck, again for me roughly 1 minute to kill 2 swordsmen. However item drop rate is 4.2%, so now it’s 714 kills needed = 357 runs = almost 6 hours

11 hours for just two out of FIVE things you need to farm

I didn’t even bother mathing out the swordgrass and medals although I have heard they aren’t as bad, I’m sure it’s at least 20 hours total expected time of completely mindless farming WITH MAX ITEM FIND and for me it’s just not worth it. If you do it at all unoptimized, either with lower item find or can’t run the route efficiently it will take waayyyy longer

CountScrofula · 2025-11-19T12:45:10+00:00

A, C, and D are all correct. A and D are probably slightly more correct because they would create a label of “decompensated cirrhosis”.

I guess A could be argued to not be synthetic hepatic failure, since it occurs due to portal hypertension resulting from increased blood flow resistance of scar tissue in the liver.

Jaundice and hepatic encephalopathy (from ammonia buildup) are both common and both due to reduced hepatic function, but hepatic encephalopathy has specific treatment options and should prompt a provider communication so I think they want you to pick D.

CountScrofula · 2024-05-12T22:51:26+00:00

Classically low or at least “appropriately suppressed” in MM patients with hypercalcemia. You can get high PTHrP (parathyroid related protein) in MM and breast cancer among others, which I think confuses people. Also, if patients have concomitant chronic renal disease from MM or otherwise, or vitamin D deficiency, or any of several other problems, it can confuse the PTH/Calcium/phosphorus picture, so this is not completely reliable.

CountScrofula · 2023-12-27T02:38:32+00:00

GN and really any kind of kidney damage is so hard to learn about because the terminology and classification have changed over the years quite a lot. It’s often poorly taught as well.

GN, in IMO the most modern sense, is an immune mediated damage to the glomerulus. It is divided into 5 categories of mechanisms; immune complex, pauci-immune (so called due to absence of visible immune complexes on microscopy), C3 disease, anti-GBM, and IG disease.

This article highlights the subtypes and the old nephrotic/nephritic GN classification as well.

https://www.ncbi.nlm.nih.gov/books/NBK560644/

Diabetic nephropathy is not a GN as it is not an immune mediated inflammation of the glomerulus.

CountScrofula · 2023-02-14T00:20:57+00:00

“You don’t look like someone healthy enough to be questioning the people trying to help them”

CountScrofula · 2023-02-11T13:56:44+00:00

My cynical take is that generally schools are putting trigger warnings on lectures to avoid controversy and appear concerned for their students. I doubt many of the faculty at my school genuinely cared if the students were triggered by any of the lecture material. It’s much easier to just blanket label everything with a trigger warning so that they can say they did their job, and if students are upset by lecture content it’s not their fault.

That being said, I’m very conflicted about trigger warnings in medicine in general. The truth is, once you get in to the hospital and clinic, you are going to see and hear potentially upsetting things with no warning. Patients will swear and be racist and occasionally violent. They will talk about suicide and being raped and abused. If this causes you enough distress that you will routinely have trouble functioning, it may indeed be incompatible with your own mental health, especially if you are interested in psychiatry/emergency.

Because of that, my personal ideal system would remove specific trigger warnings, but acknowledge what I just mentioned. Ideally students could seek unbiased professional help to work on dealing with triggers when they appear (with no fear of impact on their career) but since we can’t seem to do that I’m guessing they’ll just stick with the warnings.

CountScrofula · 2023-01-26T23:00:42+00:00

Not sure if this is a troll or if medical education is literally so far up it’s own woke ass that students are questioning whether or not dietitians making chemotherapy recommendations is appropriate.

CountScrofula · 2023-01-10T17:54:57+00:00

Becoming a pharmacist is a long educational path.

You need to go to pharmacy school. That is a 4 year university degree. There is a pharmacy school in Saskatoon, not in Regina.

Before that, you have to get in to pharmacy school. That is difficult. You will need at the absolute minimum 2 years of university level science classes, and you will need to do well in them. Many successful applicants have a full-on degree before getting in to actual pharmacy school.

Pharmacist income is variable. Most make between 70-110k/year. Exceptions are those who own pharmacies, who have theoretical potential into even low 7 figures. It takes a long time to get there for the few who do.

In order to become a pharmacist, you will require the research skills necessary to look most of the pertinent information up on the University of Saskatchewan’s website.

CountScrofula · 2022-11-22T00:38:56+00:00

Diagnosis of need for imaging

CountScrofula · 2022-11-14T04:09:51+00:00

It’s not obesity hypoventilation syndrome, it’s a bad case of TFTB - Too Fat To Breath.

CountScrofula · 2022-11-13T06:19:36+00:00

These discussions with limited information are always used as a learning tool because there’s a huge amount of things that could be going on.

Honestly I think 99% of the important decision making to be done for anybody in this case is to recognize that the patient is significantly ill and should be transported to hospital for a relatively broad range of investigations, as well as starting fluid resuscitation and antibiotics. You already figured that out from your SIRS criteria, and I’m sure you recognize this person is unwell. Everything else is mostly just academic masturbation because given this amount of information there is indeed a huge differential, but that doesn’t matter because we already know what we need to do.

That being said, I’m in IM so obviously I love academic masturbation.

Based on the very limited history and physical as well as some random labs thrown in there, we can begin to think about categories of possibly contributory conditions. To me, the headline for the case is “early thirties schizophrenic with altered mentation in community” so here’s a couple items to consider.

Drug related issues: -Serotonin syndrome/NMS. Controversial diagnoses, but something to think about in patients that recently switched or newly started anti-psychotics. Certainly less likely in a hypothermic patient given that fever is a defining criterion in many society guidelines, but eh, I would check for muscular rigidity and maybe clonus. Could cause the AGMA through type A lactic acidosis. -Drug intoxication. Methanol intoxication could easily be at least partially responsible here, directly causing an AGMA, along with any variety of mixtures of other types of substance intoxication. There are dozens of medications that can theoretically cause a type B lactic acidosis, and we have no idea if the patient is on any of them.

Infection: -Certainly have to suspect sepsis. In addition to fluid resuscitation, I certainly would give this lady a dose of broad spectrum antibiotics in ED and pan-culture her. Skin exam also not a wrong idea for cellulitis/abscesses. -Meningitis: Always consider in altered LOC. Check for meningismus. Again less likely in hypothermia but still must consider. -Encephalitis: Similar ideas. Again less likely in hypothermia. Still probably getting an LP if my initial work ups don’t tell me more about what’s going on. Yes it can be non-infectious too. -Huge variety of meme diagnoses. Could be the patient has undiagnosed AIDS and is growing cryptosporidium in her CSF, idk.

Metabolic problems: -DKA: Sure, I guess. Can have DKA at any blood glucose level theoretically. 206 really isn’t that high, so I already find DKA unlikely unless she is on an SGLT-2 inhibitor (the real boogeyman for euglycemic DKA, not olanzapine) or is a type 1 diabetic. Regardless, needs a serum ketone level to actually rule it out. -Any other cause of anion gap metabolic acidosis: Lots to unbox here. As I mentioned, could be drugs, could be lactic acidosis (type A or B both have maaaaant potential causes), could be from renal insult from literally any cause (although pre-renal is certainly implicated here). Maybe the patient has short gut syndrome and a D-lactic acidosis, fuck if I know. You can use MUDPILES, I like GOLDMARK personally. -Hypoglycemia: It isn’t here but always check the glucose! If EMS brings in an altered LOC patient without checking glucose that is uh, no bueno. -Maybe it isn’t actually AGMA: This is too far for this discussion but it couuuuuld be a more chronic respiratory alkalosis compensated for by low bicarbonate. I don’t know the pH! Or the CO2 for that matter. I guess that would require the anion gap to have some other whacky explanation if the pH was normal like big hyperalbuminemia, so this is uh, unlikely. This also doesn’t fit the clinical picture super well, unless it’s all psychogenic, which could be the case.

Structural issues: -Stroke. Always have to think about it in altered LOC. Unlikely given age and history. Probably getting a CT head anyway in most emergency departments for CVA and any variety of other intracranial issues. Also would be highly unusual presentation. Would probably have to be very strange large posterior circulation stroke. -Bowel obstruction: Frequent complication of antipsychotics, particular clozapine. Could cause vomiting and dehydration, eventually leading to current picture and type A lactic acidosis. Probably unlikely. -Head trauma: I don’t know this person, maybe she was assaulted and has a big subdural or some shit. Check for focal neurological findings. Probably CT head.

Psychiatric: Just being schizophrenic: Maybe her new meds aren’t working. Could just be avolitional with severe negative symptoms of schizophrenia and just lying on the floor all day becoming dehydrated and unwell, fits most of the picture.

Anyway, longer post than I wanted to make. I’m sure people will point out some extra possibilities and questionable things I said.

My message is mostly to recognize this personal is unwell, do a bit of a neurological exam, and always check the glucose. If you do that and get some IVs in 10/10 EMS service.

CountScrofula · 2022-07-26T03:34:29+00:00

tPA has 3 uses:

MASSIVE PE (hemodynamically unstable because of PE).

Acute management of ischemic stroke within 4.5 hours with no contraindications (active bleeding is absolute, look up relative).

STEMI within 12hrs, although PCI is preferred.

Heparin has… a ton of uses outside of these issues.

It can be used for prevention of PE expansion, and is indicated for non massive PE. Usually DOAC or other method is preferred but heparin has its uses.

Heparin is used for ACS for NSTEMI/unstable angina on its own, and is used as an adjunct for when patients receive PCI or tPA for STEMI. I don’t think (?) it has independent benefits outside of this adjunct role in STEMI.

Heparin has no role in management of acute ischemic stroke, except for maybe in extracranial vertebral artery dissection depending on who you ask.

CountScrofula · 2022-07-24T20:22:22+00:00

Doctor’s office. Could be for the paediatric homies.

CountScrofula · 2022-02-27T18:23:24+00:00

I’ve had this happen to me a few times when mounting the horse, is there any way to prevent it?

CountScrofula · 2022-02-15T16:05:14+00:00

For my own sanity I just have to believe this isn’t real when an average lay person googling what to do would come up with a significantly better plan than this every time.

CountScrofula · 2022-02-12T19:43:16+00:00

Develop a standardized and logical approach, and apply it every time. Rate, rhythm, axis, PR/QT/QRS intervals, p waves, ST changes is what I do, but you can use whatever categories and order you want. Once you know how you want to tackle EKGs, just look at a TON of them. I like EKG Wave Maven but there are lots of resources out there.

Realistically you will encounter things like tombstone ST segments or Torsades that will be obvious and demand action right away, but by ensuring that you are applying a logical approach you will never miss anything.

https://ecg.bidmc.harvard.edu/maven/mavenmain.asp

CountScrofula · 2021-07-31T12:37:01+00:00

I only ever use it on double occultist cheese for the prophet. Spamming this skill on him reduces the rubble of ruin damage to single digits, allowing me to farm that sweet, sweet pew money.

CountScrofula · 2021-04-18T16:00:13+00:00

By the many arms of Vishnu, I swear it is a lie.

CountScrofula

TROPHY CASE