#Clinical reasoning

[eiretearoa]

Guarding and flow: an observational study

It’s been a while since I reviewed a paper but this one caught my eye! Amanda C. de C. Williams is one of my favourite researchers because her work captures social and anthropological aspects of pain – and she’s been researching and teaching for a very long time. This study is an observational study of physiotherapists watching videos of people with chronic low back pain doing movements. The…

[inkskinned]

so one of the things that's so horrifying about birth control is that you have to, like, navigate this incredibly personal choice about your body and yet also face the epitome of misogyny. like, someone in the comments will say it wasn't that bad for me, and you'll be utterly silenced. like, everyone treats birth control like something that's super dirty. like, you have no fucking information or control over this thing because certain powerful people find it icky.

first it was the oral contraceptives. you went on those young, mostly for reasons unrelated to birth control - even your dermatologist suggested them to control your acne. the list of side effects was longer than your arm, and you just stared at it, horrified.

it made you so mentally ill, but you just heard that this was adulthood. that, yes, there are of course side effects, what did you expect. one day you looked up yasmin makes me depressed because surely this was far too intense, and you discovered that over 12,000 lawsuits had been successfully filed against the brand. it remains commonly prescribed on the open market. you switched brands a few times before oral contraceptives stopped being in any way effective. your doctor just, like, shrugged and said you could try a different brand again.

and the thing is that you're a feminist. you know from your own experience that birth control can be lifesaving, and that even when used for birth control - it is necessary healthcare. you have seen it save so many people from such bad situations, yourself included. it is critical that any person has access to birth control, and you would never suggest that we just get rid of all of it.

you were a little skeeved out by the implant (heard too many bad stories about it) and figured - okay, iud. it was some of the worst pain you've ever fucking experienced, and you did it with a small number of tylenol in your system (3), like you were getting your bikini line waxed instead of something practically sewn into your body.

and what's wild is that because sometimes it isn't a painful insertion process, it is vanishingly rare to find a doctor that will actually numb the area. while your doctor was talking to you about which brand to choose, you were thinking about the other ways you've been injured in your life. you thought about how you had a suspicious mole frozen off - something so small and easy - and how they'd numbed a huge area. you thought about when you broke your wrist and didn't actually notice, because you'd thought it was a sprain.

your understanding of pain is that how the human body responds to injury doesn't always relate to the actual pain tolerance of the person - it's more about how lucky that person is physically. maybe they broke it in a perfect way. maybe they happened to get hurt in a place without a lot of nerve endings. some people can handle a broken femur but crumble under a sore tooth. there's no true way to predict how "much" something actually hurts.

in no other situation would it be appropriate for doctors to ignore pain. just because someone can break their wrist and not feel it doesn't mean no one should receive pain meds for a broken wrist. it just means that particular person was lucky about it. it should not define treatment.

in the comments of videos about IUDs, literally thousands of people report agony. blinding, nauseating, soul-crushing agony. they say things like i had 2 kids and this was the worst thing i ever experienced or i literally have a tattoo on my ribs and it felt like a tickle. this thing almost killed me or would rather run into traffic than ever feel that again.

so it's either true that every single person who reports severe pain is exaggerating. or it's true that it's far more likely you will experience pain, rather than "just a pinch." and yet - there's nothing fucking been done about it. it kind of feels like a shrug is layered on top of everything - since technically it's elective, isn't it kind of your fault for agreeing to select it? stop being fearmongering. stop being defensive.

you fucking needed yours. you are almost weirdly protective of it. yours was so important for your physical and mental health. it helped you off hormonal birth control and even started helping some of your symptoms. it still fucking hurt for no fucking reason.

once while recovering from surgery, they offered you like 15 days of vicodin. you only took 2 of them. you've been offered oxy for tonsillitis. you turned down opioids while recovering from your wisdom tooth extraction. everything else has the option. you fucking drove yourself home after it, shocked and quietly weeping, feeling like something very bad had just happened. the nurse that held your hand during the experience looked down at you, tears in her eyes, and said - i know. this is cruelty in action.

and it's fucked up because the conversation is never just "hey, so the way we are doing this is fucking barbaric and doctors should be required to offer serious pain meds" - it's usually something around the lines of "well, it didn't kill you, did it?"

you just found out that removing that little bitch will hurt just as bad. a little pinch like how oral contraceptives have "some" serious symptoms. like your life and pain are expendable or not really important. like maybe we are all hysterical about it?

hysteria comes from the latin word for uterus, which is great!

you stand here at a crossroads. like - this thing is so important. did they really have to make it so fucking dangerous. and why is it that if you make a complaint, you're told - i didn't even want you to have this in the first place. we're told be careful what you wish for. we're told that it's our fault for wanting something so illict; we could simply choose not to need medication. that maybe if we don't like the scraps, we should get ready to starve.

we have been saying for so long - "i'm not asking you to remove the option, i'm asking you to reconsider the risk." this entire time we hear: well, this is what you wanted, isn't it?

[thedreadvampy]

Losing my shit about this article in which a transphobic Tory was so busy panicking about existing in the vicinity of a Trans that she almost certainly misheard "jeans" as "penis" and decided that not only was this a problem with the other woman, but also that the world must be informed of this pressing danger.

"a trans woman! I had to stand directly behind her....I thought, 'this is going well', I'm handling The Situation fine'..."

translated: I saw a tall woman with broad shoulders. How would I get out of this alive? I thought. she has a PENIS. PENIS PENIS PENIS. through some force of PENIS I mean will I managed to PENIS behave normally towards her. My hands were PENIS PENIS PENIS shaking as I tried to dry them. summoning up all my PENIS courage I said 'dryer's crap innit'. she turned to me and said " yeah I'm just goiPENIS PENIS PENIS"

It's been a week and I'm still shaking. This proves trans women are the problem and I'm not weird. I'm fine. It's fine. If you think about it I'm the hero hePENIS!!!!!

very this

[verityontheothersites]

In no particular order:

a lot of diagnostic thinking is about pattern recognition. this takes time, lots of repetition and validation by following patients over time.

med school gives you a blunt, but versatile tool. a systematic method of getting a history is a powerful skill that gets easier with practice

clinical reasoning sometimes comes from clerking undifferentiated patients, but sometimes it's from asking why. Why CT head for this patient and not another? Why repeat bloods? Why change antibiotics (or step down)?

putting this into practice on placement can be difficult if you're only ever on a ward and the few suitable patients have done their histories to loads of medical students 😅 the template you learn is great for the medical take and the emergency department, BUT I think the same principles apply when seeing an unwell patient on the ward or even on ward round.

unwell ward patient: what is the most likely reason for them being so unwell? how do you stabilise them? (hence you're trying to find how this acute episode fits with the overall story of what's been happening so far)

ward round review: what is going on with this patient? why? what are they waiting for and why does it need to happen? (hence your history may not focus so much on what happened at admission, but in the team discussions in the last few days, investigations etc)

(all this might be a bit meta at this point! but making sense and finding the narrative is, for me, the really special bit about medicine.)

Hi, hope you're well! Wanted to ask if you have advice about how to improve clinical reasoning as a medical student? Thanks for your support so far!

Hello! I don't know when this snuck into my inbox so apologies if this has come a bit late

I think there's a few ways you can practice this but ultimately it comes down to practice and experience of things you've seen before

When you are on wards, ask if there's patients you can take a history from, the junior doctors will know who has a "good" history of something that you'll be able to work out, and definitely if you are in A&E or somewhere where noone has seen the patient before, this means you can start from scratch and practice your reasoning (don't worry, the doctor will ask extra questions if needed and review the patient as well!) But make a habit of giving a list of differentials when you're presenting a patient - it doesn't matter if you're wrong!

When you are trying to collate the information from a patient history into some sort of diagnosis think about:

- what is the main/worse symptom that the patient has presented with

- what order did symptoms happen in

- what are the patients risk factors/demographics (beware that people can have unlikely conditions, but when you're starting out with clinical reasoning, it's OK to say for example you don't think a 30 year old's headache is because if giant cell arteritis - it's very very rare under 50)

When revising I used to start with a presenting symptom and list everything I could think of that could present with that, and then try and list specific features for each condition that would rule it in/out or some investigations you would do

I'll end all this by saying I'm not sure my clinical reasoning was any good as a medical student so don't worry if it feels difficult. Even when you start out as a doctor (at least in the UK), you will be well supported and not expected to have all the answers, and seniors should help talk things through with you and develop your reasoning skills!

[l3irdl3rain]

going to go to vet school and become a vet but I only want to work with cats and chihuahuas

[crows-of-buckets]

Au where Carver, instead of fleeing Ostagar, ends up with the hero of Fereldan, and follows them around to help stop the blight. He eventually ends up at Amaranthine, and becomes a full warden alongside all the others. He becomes kinda friends with Anders (I think he would be a bit less of an ass to pre justice anders) and somehow the two end up leaving for Kirkwall together.

Hawke walks into the clinic looking for grey warden maps and runs into their baby brother they thought was dead. He's just chilling in the sewer clinic like it's a normal thing to be doing.

[feroluce]

For some weird reason, I've always been fascinated by how wildly different Sampo operates in the Underground vs the Overworld.

Sampo is present in both places and even in official sources, he's not really counted as one side or the other- now that the theory has been confirmed in-game, he's generally just lumped in with the Masked Fools.

But there really is a big difference!

Probably the most obvious and well known instance of Sampo's...business practices *cough burglary and fraud COUGH* in the Overworld is from the Belobog Museum event. In it, you don't find out Sampo is the main culprit until near the end, because Pela has to set up a sting just to catch him in the act. And that sting is necessary all because the initial suspect they arrested, Norbert, had pretty much no idea of his partner's identity. Sampo wouldn't even speak to him face-to-face.

And whereas Sampo is normally very pleasant and friendly with the trailblazer...when he thinks he's talking to Norbert here, he straight up says that they are NOT friends. Like he really shuts that shit DOWN.

There's also an Overworld NPC, Chavez, who heads the "Dark Blue Scam Support Group." And he. Really really really does not like Sampo fjkdasjklfdj

Chavez clearly wants Sampo caught, and has literally no positive feelings about him. So. Why call it the Dark Blue Scam? Why not just out him by name? Chavez obviously doesn't give a single shit about Sampo's dignity or privacy. But he never once refers to him as "Sampo," and even the pamphlets he passes out make no mention of it. No one in the entire support group seems to know how to identify him or how to refer to him except by his hair color. If the trailblazer says his name, Chavez reacts as though he's never heard it before.

(I've seen people say this means Sampo Koski is an alias and not his real name? But Ray pointed this out, and honestly I agree; even the Fools call him Sampo, after all. I think it's just that Chavez never knew Sampo's name in the first place, and given his immense distrust, immediately assumes it's an alias.)

And then there's his characters stories, where he proceeds to pull off a heist in the Overworld while in disguise as Brughel Poisson the entire time. Literally his own stories don't mention Sampo's name even once.

So anyway, all this shows that when he's up in the Overworld working cons, Sampo is incredibly slippery and secretive about his identity. The only people who seem to know him are Pela, Serval, and Gepard. He doesn't get close to anyone else, and is even surprisingly unfriendly. Nobody knows his name. No one knows his face. He has zero qualms about backstabbing or double-crossing, and even plans for it in some cases.

Meanwhile, down in the Underground, I'm pretty sure literally the worst thing we hear of him doing is scalping tickets in front of the Fight Club. Which isn't even illegal in a lot of places (although it's certainly a dick move).

In Hook's companion quest, a vagrant miner steals Fersman's equipment and tries to sell it to Sampo. Even before the trailblazer and Hook jump in and out the vagrant as a thief, Sampo hesitates to buy it because it sounds like stolen goods, which he doesn't want any part of.

Even knowing that a geomarrow detector is rare and incredibly valuable in the mines, Sampo makes no attempt to double-cross Hook or profit off of her loss, and even tells her who to go to to get it fixed.

And my favorite example of Sampo in the Underground is the Survival Wisdom adventure mission. In it, Sampo starts up a business with Peak, another miner. And like. In wild contrast to all the cons he pulls above ground, Sampo is actually super nice and helpful here.

Just the same as with Hook's quest, Sampo talks to Peak face-to-face, with no disguises or barriers. When the trailblazer finds them, they're just in the Great Mine, no secretive meeting places. Peak knows Sampo, is familiar with him, and calls him by name. It's not even a con! There's nothing illegal going on; it really is just a business partnership. Peak is more than happy with their deal, he's even pretty enthusiastic about it, because thanks to Sampo he can now make enough money to get by while also accommodating his chronic fatigue.

The only person Sampo lies to in this whole ordeal is the trailblazer, who he manipulates into getting Peak's mining equipment back from the vagrants that stole it in the first place. And when it's done, he rewards them with a legit treasure map.

So when he's working in the Underground, Sampo is MUCH more upright and lawful. Part of this is probably to do with his "business" model- Sampo only takes advantage of the wealthy, and poverty runs rampant in the Underground. When he charges Peak an extra 30% (the same percentage he charges Norbert as a consultation fee in the museum heists- Sampo seems to go by percentage instead of a flat rate, which means his prices are more fair for lower incomes) for carelessly losing their supply, Peak literally starts counting out pocket change.

Dude's working for pennies and good will down there dknsmdmd

And you can twist this into a Robin Hood thing if you want- Sampo IS technically working to feed orphans and heal the sick. He says himself he's more than happy to make up the shortfall between the greedy and the marginalized- I mean he says it in the shadiest way possible, but I doubt the people benefiting from his work really care that he's a slimeball if it means they can survive another day. Even the two heists he pulls in his character stories are literally just him stealing absurd amounts of food.

Personally though I think it is solely because of Natasha, and Sampo is hilariously well-behaved specifically for her, because she keeps him on a short leash JSKZJMSMSKS

[taradactyls]

Something I love about how Pride and Prejudice is told through an omnipresent narrator, aside from the witty remarks and insight into other characters it allows even though it's usually focused on Elizabeth, is how it plays on the audience's own prejudices and assumptions.

The narrator tells us very early on, chapter 4, that Darcy is "haughty, reserved, and fastidious, and his manners, though well-bred, were not inviting." We've already seen that when we meet him the previous chapter, and will see more of it in those following. But it's the readers, along with Elizabeth, who take that observation as not only a list of flaws (despite only the first actually being negative) but presumes even more damaging flaws must be attached to it. Darcy can be off-putting, especially so in the setting we meet him in: he dismissed Elizabeth within earshot of her, didn't engage with people attempting to converse with him, etc. It's easy to assume the worst of him in a world so driven by social niceties, and because we follow Elizabeth, who is so lively and playful amidst the rules which govern society. Elizabeth thinks he's bad tempered? It would make sense - he hasn't shown consideration for others much socially, why would he care when he's angry? He acted from resentment and jealousy and went against his father's will? That's not such a jump after the conclusion of a bad temper, his own acknowledgement of implacable resentment, and evidence of pride. The awareness of one offensive trait so naturally leads to prejudice against it, that we easily assume still worse qualities must exist. We are as mistaken as Elizabeth.

Even the idea that 'No, Darcy was never haughty or rude, he was just shy and misunderstood, the narrator is wrong' is just magnifying that prejudice. Yes, we do find out later that Darcy is not at ease among strangers, and was always intrinsically good; his morals and core values meant he was never as bad as Elizabeth believed. But that doesn't mean he was without flaws, and it's so fascinating that some analysis of his character seek to completely remove the negative traits which he eventually overcame after acknowledging them in himself. The logic seems to be that they feel if he had them in the start that he isn't actually such a good person. It's just another example of being so prejudiced against certain flaws that it's impossible for some people to reconcile that there doesn't have to be more serious failings attached, and someone can still be a good person despite being arrogant and not always nice. It's, ironically, being prejudiced in the exact same way that Elizabeth was at the start of the novel. It's amazing that Jane Austen was able to tap into that aspect of human nature so deftly, and invoke in both in her main character, and readers to this day.

Now, of course, the story is so well known it's rare for anyone to read it blind, so it's less likely anyone will be unaware of Darcy's good qualities despite first seeing his worst. Even if they do, Pride and Prejudice has become so genre defining that new readers who are the slightest bit genre savvy will be more aware than contemporary audiences were. But even if we know the story it's still so understandable why Elizabeth feels the way she does. We see what she sees and feel her conclusions make sense. Just as, even though the narrator tells us Darcy is starting to catch feelings for Elizabeth, we fully comprehend her not noticing and believing there's a mutual dislike. And though that is concrete evidence of Elizabeth not reading Darcy and his motives correctly, we are still so sympathetic of the basis of her prejudice that her continued belief in Darcy's lack of virtues makes sense from her point of view. We can see, as she later will, that she takes it too far, and should have noticed evidence to the contrary, but her prejudice against him based on his early behaviour and her pride at reading people correctly is so understandable.

Basically, in a story about the characters' pride and prejudices, I love, love, LOVE how the narrator's voice brings out those same traits in readers the exact same way we see it presenting in Elizabeth. We're all on that journey with her, and we can likewise learn the same lessons about ourselves as she does. Pride and Prejudice feels timeless, because even though society and thus the nuance changes, the book is about human nature, and that remains essentially the same.

[syn0vial]

living in a country with nationalized healthcare after being raised in the US is just

> experience uncomfortable medical issue > leave it untreated for months or years bc it's "not serious enough" to warrant professional medical attention > it gets worse > finally go to a clinic > they ask me how long i've had this problem and i tell them how long > they look at me like i'm a fucking nutter, treat it in 5 minutes, and charge me $6 USD > i walk out feeling like the world's luckiest idiot

[boy-pantiesss]

Them : Book Louis is boring! He’s so bland! Match Armand and Lestat’s freak? He could never!!

Meanwhile, Book Louis :

[eiretearoa]

Mindfulness: A series (3) Personalized Mindfulness Practice: Beyond Guided Meditation Scripts

When starting a mindfulness practice, people often turn to written scripts. These scripts can be used to guide the practice, and offer suggestions for what the mind can attend to. They often give cues that remind the listener that yes, minds do wander, and that this is normal – and how to bring the mind back to what the focus was on. There are heaps of these guided meditations available online…

[solivagantingrebel]

The "Actually, I believe he prefers to be—" "That'll do." Exchange lives rent-free in my brain like. What was Soap going to say? Was it 'L.t'? But I think technically Alejandro is higher ranked than him (Ghost) right(?) So I'm not sure if that works entirely and 'L.t' seems to be something that other marines/or soldiers under their command picks up anyway (probably from Soap idk, but others do call Ghost that). Was it like, 'Simon' or 'Si'? I know he calls Ghost Simon occasionally and maybe the quick shutdown of Soap's sentence comes from Ghost wanting to keep the emotional distance from others. But considering the absolute vitriol of which Ghost says, nay spits, "That'll do." I wonder if Soap has gotten away with introducing Ghost with the stupidest names, like 'Ghostie' or 'Sisi', in the past 💀

[arinrowan]

Source: person who first developed a vocal cord disorder and then started going nonverbal in addition to the vocal cord disorder and can't decide if it's that big a deal or not

[liminalweirdo]

Poll: Health and gender re medical malpractice

if you feel comfortable please share your choice as well as whether you have ever experienced medical malpractice

not to be that person but please consider reblogging this, my tumblr don't have a ton of traffic and i'm genuinely interested in the results.

[litany-writes]

(taps mic) lando norris fans. ahem. how are we feeling today

[carriesthewind]

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