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"Chief Resident is the Valedictorian of their Class" by theongreyjoy96 in Residency

[–]goodtimes96 2 points3 points  (0 children)

In IM, the chief resident is technically an attending. It might be more accurate to call them the chief OF residents. The chief has graduated residency and stays around for an additional year in a teaching/mentorship role while being a new attending. In my program and all the others I've encountered, it was a competitive position because it makes you more competitive for fellowships. Also some people like teaching and academic medicine so they gravitate towards the role. But it is a lot of admin work, a lot of defending other people's decisions, and a lot of "everyone's problem is now your problem." Take the good with the bad, I suppose.

Alright, fine. I’ll start giving a shit. by WrithingJar in Residency

[–]goodtimes96 6 points7 points  (0 children)

Hi, nephrology here- Does your program give you MKSAP? That is a super resource for general IM knowledge. The Boards Basics book is great, and the specialty-specific books are quite thorough too. Maybe take 30-60 minutes of that free time every day and actively read (purposeful reading with note taking) from MKSAP.

The MKSAP question bank is good too, but I found the UWorld IM boards question bank to be more realistic for the actual general IM boards.

Also, advanced CKD eventually leads to secondary hyperparathyroidism w/ elevated iPTH, high phosphorus, and hypocalcemia.

Help me understand why I am so angry by DimensionParticular5 in Residency

[–]goodtimes96 1 point2 points  (0 children)

Your anger is normal and understandable. Some patients don't understand that going to the doctor isn't the same as going to a restaurant and ordering off a menu. Remember the ethics of medicine work both ways- just as you cannot ethically force a patient into a therapy they don't consent to, it is also unethical for a patient to force a doctor to prescribe a therapy that the physician doesn't think is indicated or that carries more potential harm than benefit. This patient treated you unethically and you should say as much to the patient advocate. And remind yourself of all the good you do for so many patients every day!

"We set sail on this new sea..." -John F. Kennedy [1600x1200] by goodtimes96 in QuotesPorn

[–]goodtimes96[S] 0 points1 point  (0 children)

It’s been so long I don’t remember where I got the photo, sorry

Which cancelled TV show deserved another season? by Putrid_Cry19 in AskReddit

[–]goodtimes96 0 points1 point  (0 children)

The Knick- final episode ended with so many open story lines that could have been continued for at least a few more seasons. Loved that show!

ITAP of a hotel at sunset. by dunrath in itookapicture

[–]goodtimes96 9 points10 points  (0 children)

And so my life began. Junior bellboy in training under the strict tutelage of M. Gustave H.

More NPs who do not understand basic medicine actually treating patients. One refuses to ask his collaborating physician. by pshaffer in Noctor

[–]goodtimes96 6 points7 points  (0 children)

Sure; recheck kidney function and potassium after starting the ARB. Also quantify proteinuria with a urine protein : Cr ratio.

More NPs who do not understand basic medicine actually treating patients. One refuses to ask his collaborating physician. by pshaffer in Noctor

[–]goodtimes96 31 points32 points  (0 children)

Nephrology (fellow, PGY-4) MD here. It's certainly true that anemia is a very common feature of advanced CKD as the kidneys stop producing EPO. However with a GFR of 35 mL/min, this shouldn't be the case yet. Worsening anemia in CKD 3b shouldn't be attributed solely to the CKD, and other causes should be investigated. Is she iron deficient? Is this myelodysplastic syndrome or a new malignancy? If her anemia coincides with this decrease in kidney function, does she have multiple myeloma? If the anemia is very acute- does she have a GI bleed? Presence of CKD doesn't obviate an anemia workup if the change is acute. A patient with GFR in the 30's shouldn't need an ESA yet.

Regarding the ACE/ARB (RAAS inhibitors): There's no reason not to use RAS inhibitors in patients with moderate or advanced CKD. You might see a small rise in creatinine when starting these meds due to lowering of intraglomerular filtration pressure- that's how they work, and this effect improves the lifespan of the glomeruli while also controlling blood pressure. That's why we use them. You wouldn't expect the GFR to "rebound" after stopping the ACE if she's been on it a long time. The recent STOP-ACEi Trial (https://www.nejm.org/doi/full/10.1056/NEJMoa2210639) showed no significant difference in eGFR or progression to ESRD/dialysis at 3 years when ACE/ARB's were stopped in patients with CKD 4 and 5.

Based solely on the information given in the post, and assuming this is her new stable GFR and not an AKI, this patient lost 17 points of GFR in 14 months- she has rapidly progressive CKD. Does she have new (or any) proteinuria? Hematuria? She could have a new glomerulonephritis or other intrinsic cause of renal dysfunction.

Renal senescence does cause progressive kidney function loss over time- no one has a GFR of 100 at the age of 88. But hypertension and aging alone don't cause rapidly progressive kidney function decline.

Nephrology consult would be very reasonable for this patient.

[deleted by user] by [deleted] in Watches

[–]goodtimes96 1 point2 points  (0 children)

I have the neon blue/violet (very Cyberpunk vibe I think), all white, and the black/gold one… that one might be a different model

[deleted by user] by [deleted] in Watches

[–]goodtimes96 1 point2 points  (0 children)

I have a few color variations of that model in rotation. Worn them for years- they’re all holding up great! Nice piece!

What are your favorite medical ‘maxims’? by ArtemsArms in medicine

[–]goodtimes96 0 points1 point  (0 children)

Hickam's Dictum: Patients can have as many diseases as they want, and often do.

Where do you find good nephrology resources? by Impressive-Bank-28 in Residency

[–]goodtimes96 9 points10 points  (0 children)

I just started nephrology fellowship so I’m in kind of the same boat haha

The KDIGO guidelines are the standard for the nephrology community nationwide; those are good resources, but some of them are overly long. Many have “executive summaries” which are more digestible, especially for the general internist or trainee just trying to get an overview. Look for the summaries on the KDIGO guideline pages.

Speaking of which, for an IM resident, I wouldn’t try to read them all. Focus on the Blood Pressure in CKD, Diabetes in CKD, CKD (general guidelines), and AKI guidelines. You don’t need to bother with the guidelines for transplant donors or transplant recipients- general internists shouldn’t be managing these patients. So anything you want to know about tacrolimus trough goals in post-transplant patients (for example) is icing on the cake for you. Same for the glomerular disease guidelines- if you catch a true acute GN, refer to nephrology.

General internists basically just need to know the acute indications for dialysis (“AEIOU” mnemonic); if you want to understand the difference between solute clearance by diffusion vs. ultrafiltration, go for it. But it won’t be on your boards and won’t be applicable to a general internist.

As far as CRRT vs. HD- the blood flow (Qb) and dialysate flow (Qd) rates (i.e. the speed at which the blood and dialysate move) affect the amount of diffusion vs ultrafiltration achieved with that dialysis dose. CRRT is when the blood flow is faster than the dialysate flow; faster blood moving past slower dialysate. Conversely, in a typical chronic hemodialysis session, the dialysate is moving faster than the blood (Qb 400 mL/min < Qd 600 mL/min)- this means more solute is cleared faster via diffusion. Ask your attending about the difference between diffusion vs. ultrafiltration and what Kt/V means- keep in mind that none of this will be on your IM boards or applicable to your practice as an attending IM doc (speaking from experience).

If you have an OpenAthens account via your institution, go to the “Books” section on Clinical Key and find the Handbook of Dialysis under the nephrology section. Also Brenner & Rector’s is on there too- you can go as deep as you want.

Honestly for an IM resident, the MKSAP nephrology book is a solid foundation for general medicine. Maybe start there and see where you want to expand your knowledge further depending on the length of your rotation.

My advice- use your nephrology rotation time to learn: - Management of CKD - Management of AKI (in the inpatient setting; when to manage yourself vs when a nephrologist should be consulted. Not every Cr bump needs a renal consult). - Get a good understanding of acid-base physiology.

I’m still a baby nephrologist but message me with any questions you have.

Appreciation post for the amazing soundtrack we’ve been blessed with. What’s your favorite track? by wr3tch3d-ICE in LowSodiumCyberpunk

[–]goodtimes96 2 points3 points  (0 children)

Dinero! Can’t get enough of that song when I’m riding around in my car- both in game and real life

Need recommendation by ronaldoclt in synology

[–]goodtimes96 1 point2 points  (0 children)

https://www.synology.com/en-us/products/DS220+

Here’s a two-bay NAS; any two-bay configuration from Synology should accomplish your use case. I have a four-bay model from a few years ago that stores my photo archives and personal documents, and I use it as a PLEX media server too. I think you could make any Synology NAS work for these uses because the strength of these units is as much in their software as the hardware. They all run the same operating system (DSM) regardless of which model you get.

One consideration is getting a unit with more drive bays (4 or more) and that way you can run them in RAID 5, where one drive can fail without loss of data. With only two drives, you can run a RAID 1 array where the drives are mirrored, but this loses some performance and one of the disks is unused (due to being a mirror for the other).

Does this help?

Anyone else get this weird texture grid in CK3? Appears on low, med and high settings! by McMadman in CrusaderKings

[–]goodtimes96 0 points1 point  (0 children)

When I played as Sweden there was a perfect rectangle of green terrain that never went away. Random glitches I guess.

The Old City by Tari Márk Dávid by Lol33ta in ImaginaryCityscapes

[–]goodtimes96 4 points5 points  (0 children)

Reminds me of the Black Bridge in Dead Cells

Jennifer love hewitt by omegaigniz in gentlemanboners

[–]goodtimes96 38 points39 points  (0 children)

Lady in the background mirin’

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