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Patients present to us with symptoms and signs. These are the pieces of information from which we make our diagnoses. Some of these pieces of information are like noise and smoke, because they can mislead us from the true diagnosis. The ability to hone in on the correct diagnosis requires the skill of clinical reasoning – an ability that requires us to have our minds open to all possibilities. The story below (adapted from an article by Mitch Ditkoff in a newspaper), gives an idea of what it means to have a mind that is open to receiving the truth.

A monk lived in a monastery for 20 years seeking enlightenment. But he never got what he was seeking. Thoroughly disillusioned, he left the monastery and became a sweeper somewhere else. A week later, as he was doing his job sweeping the gardens, a brick that he had brushed aside hit a tree and broke in half. As he looked at the broken brick, something snapped inside him and his mind was freed from the web of Time within which his mind was always entangled. He found the enlightenment that he had been seeking for so long.

This story tells us that enlightenment or the understanding of our reality is not a function of Time. While we may argue that he received this enlightenment only because of the 20 years he spent in the monastery (“chance favours the prepared mind”), the fact remains that he was always just a second away from what he was seeking. His way of thinking in the monastery was probably the barrier to his understanding. As doctors we sometimes miss the correct diagnosis because of our way of thinking. Arriving at the truth is not directly related to knowledge or time. It comes from the ability to be open to what we are really being told by the symptoms and signs of our patients.

A summary of student-initiated discussions during this semester

  1. Evaluating patients with syncope
  2. Prescribing antibiotics for acute gastroenteritis
  3. Beta blockers after an acute MI
  4. Blood transfusions in renal failure
  5. Role of benzodiazepines and fondaparinux after acute MI
  6. Hepatotoxicity of methyldopa
  7. Blood pressure management in acute ischemic stroke
  8. Permanent pacemaker implants
  9. Extended spectrum beta lactamases
  10. Receptive aphasia
  11. Leptospirosis
  12. Cushing's syndrome
  13. Distinguishing between COPD and heart failure
  14. Target hemoglobin in CRF
  15. Stress ulcer prophylaxis
  16. About iron studies
  17. Aspirin for CV prophylaxis in patients with hypertension
  18. Anticoagulation in atrial fibrillation
  19. Using digoxin
  20. About Wellens syndrome
  21. About bradycardia
  22. IV fluids in dengue fever
  23. Congestive cardiac failure
  24. Bradycardia in acute coronary syndrome
  25. Sick sinus syndrome
  26. Using anti epileptic drugs
  27. Rheumatic heart disease
  28. Infective endocarditis
  29. Atrial fibrillation versus atrial flutter
  30. Multiple myeloma as a cause of renal failure
  31. Asthma versus COPD
  32. Beta thalassemia, iron deficiency and HbA2
  33. Using anticoagulants
  34. About Metformin and lactic acidosis
  35. Immediate (emergency) dialysis

Managing diabetes during the Muslim fasting month of Ramadan

Dr Velayudhan Menon, MD
Clinical Associate Professor of Medicine
International Medical University, Malaysia

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