I am currently on three medications and birth control. Prednisone, Metronidazole, and Doxycycline. The steroids are for this rash I have on my neck. Met was for bacterial vaginosis, while Doxy was for trich that was discovered a day later. Now, my symptoms have been all over the place. I have been having the worst anxiety, panic attacks, dizziness, stomach pain, and just overall uncomfortable. I called my doc (CVS minute clinic) about the steroids being the possible problem, and was only told to cut it down a little early and continue to taper off. I’m now looking at the other side effects of the antibiotics and wondering if I’m just taking too much at once.

So I don't have health insurance right now and was having bad allergy symptoms at work so I went to CVS minute clinic for an allergy test and they use Quest Diagnostics for lab testing. I looked online to see what Quest charges for the 25 common allergens test and its about $400. 2 weeks after my cvs visit I finally get the Quest bill and it's $905. Is it supposed to be this high? Do they charge different prices based on whether you have insurance or not? I tried searching to see if anyone else had a situation like this, but nothing gave me a conclusive answer.
Link to the allergy test:
https://www.questhealth.com/product/common-respiratory-allergy-panel-expanded-11114M.html

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42 y/o male, prior AV Nodal Reentry, Ablate in 2002. No other serious medical issues, Covid about 6 months ago, and had long covid for about 3 months, and spent a lot of time in bed during that time. Also had about 60 lb rapid weight gain during covid and from quitting smoking, going from 190 lbs to 250 lbs within a few months,
I have a history of palpatations, lived with AV Nodal Reentry which caused a lot of SVT attacks as I was growing up, some of these were pretty bad and resulted in hospitalization and medication in the ER to stop the Rythm. I got Ablated when I was 22, about 20 years ago. Having lived with them so long, became very familiar with the feeling. I had no issues after the ablation, except for a few Preventrical contractions, which I know about becaue I went to the ER and they were picked up on EKG, so I can identify how those feel also, amnd I know they are common and not dangerous. I had no other issues until bout a week ago. I had gained a lot of weight during covid and dealt with Long covid, I finally started running on a treadmill about a month ago, for 1 mile each day, all within 1 session, generally I run 1/4 mile, take a 5 min break and run another 1/4 mile and etc. Last week, I started having what felt like PVC's so a skipping or even a double beat, but the rythm wasn't stable What I am having is more random, with extra beats thrown in, so my heart beats normally, but I feel that trange flutter in my chest, and I get what feels liek extra beats, but unlike PVC' they aren't consistent, sometimes it'll be 2 quick ones, or just one in between the normal beats, This lasts about 5 min then goes away. I also had it happen today after walking around the block, and it is always when I am restign and my heart rate is lowering back down.
I am waiting to see a new doctor, but the clinic is packed full of peopel that avoided doctors during the pandemic, so it might be another month until I get seen. I spent a good 6 months jsut laying in bed with long covid and depression, actual covid, etc, so I assume this is just from getting my body used to moving again, as I use to be very physical, but just want to be sure it doesn't sound dangerous, and I know all heart issues are dangerous, but this doesn't sound like it could end up as atrial fib or anything, right? Thanks!

​
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Please please ask your pharmacists if you yourself don’t know how the text can be sent and share it here. It’s highly appreciated.

Welcome!
This is a series I am going to be working on where I endeavour to cover various topics in physiology intermixed with clinical pearls to impart some knowledge that doctors of most specialties and grades will hopefully find useful when looking after acutely unwell patients. Join me as we dredge through the depths of anaesthetic exam revision to answer important questions like "why do CT ask for a pink cannula", "why frusemide is okay to give in AKI", "why is hypoxic drive a bunch of horse manure" and many more. Pick up some of this material and you'll be well on your way to becoming a pernickety anaesthetist, whether you like it or not!
Questions, comments, feedback, and suggestions are both encouraged and welcome.

Previous installments:

• IV access, resuscitation, fluids, and the cardiovascular system
  
• The physiology of ageing and illness, and its impact on critical care decision making
  
• Respiratory failure, oxygen therapy, and gas exchange
  
• Reduced consciousness, intracranial events, and the central nervous system
  

Kidney function, acute kidney injury, and acid-base disorders

Next stop along our systems review are the mighty kidneys. I won't talk to you about Lupus nephritis or renal tubular acidosis, however I will try my best to cover some more typical things you might encounter like acute kidney injury (AKI) and drug dosing in renal impairment while trying to avoid embarrassing myself as a non-renal doctor.

What do the kidneys do?

An obvious question, they allow us to get rid of waste substances in urine. They are so much more than that however, they:

• Regulate electrolyte concentrations, water balance and plasma volume, plasma osmolality
• Regulate red blood cell production
• Regulate blood pressure via RAA system influencing vascular resistance
• Maintain acid-base homeostasis
• Control Vitamin D production
• Produce glucose from proteins and triglycerides (gluconeogenesis)

We will focus on only a few of these in this post, but the kidney's multiple roles and complex biochemical signalling deserves as mention as it can make diagnosing and understanding disease states difficult. It can also make us forget what other consequences there might be for patients in these disease states.

How do we measure kidney function?

In some respects knowing the heart or the brain aren't working is easy. Low blood pressure and infection? Septic shock. Low blood pressure + STEMI? Cardiogenic shock. Unconsciounsess or coma? Well whatever it is, it ain't working. So what about the kidneys, well we have creatinine, right? WRONG.
Although the kidney has many functions as we noted before, the easiest methods to quantify function look at the obvious: waste production. Its function is the sum of filtration through all the glomeruli in the kidneys, the glomerular filtration rate (GFR). When a substance is freely filtered through the kidneys and is neither secreted nor reabsorbed (which occur in the tubules rather than the glomeruli), the rate at which that substance is removed or cleared from the plasma can be used to measure GFR (in mL/min).
This substance is inulin and not creatinine. Because inulin isn't naturally present in our bodies, it has to be infused and then its concentration and the rate of decay measured. This is impractical clinically, so creatinine was selected as a practical alternative. The correlation between serum creatinine and measured GFR was researched and various formulas like MDRD and CKD-EPI were developed to estimate GFR (eGFR). This is why labs report eGFR as opposed to GFR. (There are also other methods to determine GFR like radionuclide scintigraphy...)

What's the problem?

The estimation of the GFR relies on assumptions that are not without problems. This review covers the topic at length, however the main points are:

• Creatinine is secreted, unlike inulin. As mentioned this occurs in the tubules, so changes in secretion will affect serum creatinine level despite a static filtration rate. As renal diseases progress, more and more creatinine is secreted, making serum concentrations less reflective of actual filtration.
  
• To truly reflect instrinsic renal function creatinine has to be in a steady state with stable generation and serum concentration. Creatinine is produced as a waste product of protein breakdown mainly from muscles. Therefore anything affecting catabolism, muscle activity, dietary protein intake, can alter this steady state. Frail sarcopenic patients will have artificially low creatinines and may not get as significant of a rise as a young muscular person in AKI.
  
• There has to be adequate delivery of creatinine to the glomeruli. The kidneys receive ~20% of the cardiac output, so the heart has to be pumping out effectively with healthy blood vessels, good volume and blood flow. A hypovolaemic patient with an MI may have a high creatinine despite working kidneys, they're just not being adequately perfused. Chronic diseases like hypertension, diabetes, heart failure, lead to upset of autoregulation of normal afferent (entering) arterioles, whereas ACE inhibitors and ARBs block AT-II from causing vasoconstriction of efferent (outgoing) arterioles, an imbalance can lead to renal impairment if perfusion isn't maintained, or improved blood flow and urine output if it is.
  
• The studies from which eGFR formulas are derived were conducted in mostly European and North American populations with elderly, black and CKD patients being significantly underrepresented. They only measured GFR a few times a year. With increasingly older, frailer, sicker patients, leading more sedentary industrialized diets and lifestyles, will the accuracy of these formulas hold up with time?
  
• eGFR correlates loosely with important indicators like proteinuria, fluid status, blood pressure, acidosis, anaemia, bone disease, iron deficiency, tubular function, etc. In the absence of those indicators, the elderly often have decreased GFR without increases in morbidity and mortality.
  

The takeaway is that creatinine and eGFR are tools developed from the assessment and monitoring of long term renal function. It is not designed for use in patients with acute fluctuations or those with zero kidney function (eg, anuric dialysis dependent).

What else we can monitor?

The example of the heart earlier was misleading. Blood pressure is influenced by many factors. Septic shock is actually a high cardiac output state with low systemic vascular resistance (SVR). Patients with heart failure can have normal blood pressures despite severe systolic dysfunction and poor exercise tolerance. Blood pressure is an easy surrogate marker because determining cardiac output and SVR is invasive and complex (of course we have focused echocardiography to help us these days).
A surrogate marker we can use for the kidneys is urine output (UO). After all the end product of glomerular filtration is the ultrafiltrate which will become the urine. If there is adequate urine output despite raised or increasing creatinine levels, we can be reasonably satisfied the kidneys are actually receiving enough blood flow to get rid of waste and perform its other functions.

Acute Kidney Injury

This leads us into one of the most commonly encountered entities in hospitalised patients: AKI. Let's look at the KDIGO criteria seen in the table below.

AKI Stage	Serum creatinine criteria	Urine output criteria
1	SeCr increase ≥26 umol/L <48hrs or SeCr increase ≥1.5 - 2x from baseline	<0.5mL/kg/hr for ≥6hrs
2	SeCr increase ≥2-3x from baseline	<0.5mL/kg/hr for ≥12hrs
3	SeCr increase ≥354 umol/L <48hrs or SeCr increase ≥3x from baseline or started on renal replacement therapy (any stage)	<0.3mL/kg/hr for ≥24hrs or anuria for ≥12hrs

^{Note: UO <0.5mL/kg/hr is the definition of oliguria.}
Definining by creatinine is a more practical screening test in most situations, allowing earlier diagnosis and intervention. UO can be monitored during the course of the day to identify patients who are borderline or not responding to treatment, may need re-evaluation of the cause, or escalation of care. This way a combination of the two can help offset the limitations of each method.
NICE guidance already exists on the diagnosis and management of AKI, most hospitals will have care bundles or even 'AKI nurses', so I'll run over a few important points.

• Pre-renal - This only means the cause lies outside the kidneys, and in at least in the early stages there is no histological change in the kidneys. In many cases like sepsis, diarrhoea, haemorrhage, there can be a relative or absolute fluid deficit and IV fluids are generally indicated. However excessive fluids can result in interstitial oedema in the kidneys, reducing the glomerular pressure gradient and so also reducing filtration. Similarly in poor cardiac output states where there is venous congestion there is a problem with the outflow of blood from the kidneys, so this is not a cause to reflexively withhold diuretics.
  
• Intrinsic - Here there are structural histological changes in the kidney, caused by many intrinsic renal diseases or nephrotoxic agents like aminoglycosides, vancomycin, NSAIDs, etc. If this is suspected, stopping the offending agent generally resolves AKI without needing a biopsy. Furosemide is not mentioned here as it is not inherently nephrotoxic. Acute tubular necrosis is often mentioned as a specific clinical entity, either due to nephrotoxic agents or sustained hypoperfusion from pre-renal causes. It is not a very helpful term since histological tubular damage has rarely been proven in studies, nor does it help with treatment.
  
• Post-renal - Obstruction may be incomplete, acute on chronic, with a normal ultrasound, no oligo/anuria, and may be associated with other pathologies like a kidney stone with pyelonephritis or sepsis. Catheters can get blocked too so don't forget a bladder scan if anuric, and obstruction can rarely be external such as by tumours or abdominal compartment syndrome.
  

When do I refer to renal or ICU?

Local protocols aside, advice should be sought when the patient does not appear to be responding to medical management and there may be a need for renal replacement therapy (RRT). This is often in the form of intermittent haemodialysis (iHD) on renal wards, and continuous venovenous haemodiafiltration (CVVHDF) in ICU. There are small differences in mechanism, efficacy, and indications of the many forms of RRT, the details of which aren't important for most non specialists. Generally accepted indications for RRT include:

• Symptomatic uraemia - Encephalopathy, neuropathy, pericarditis. Elevated urea on its own is not generally an indication.
  
• Hyperkalaemia - Persistent hyperkalaemia (>6.5) despite insulin/dextrose. Severe hyperkalaemia (>8 ) with arrhythmias, requiring pacing or isoprenaline. This can occur even without anuria and should be escalated as it obviously can be life threatening.
  
• Severe metabolic acidosis, pH <7.1 - This will depend upon the cause and patient's condition. Patients with DKA and pH <7 can almost always quickly be turned around with insulin and fluids. Severely septic patients may not be able to tolerate medical management long enough to improve without RRT.
  
• Toxins or overdose - Some medications and toxins may be removed by RRT (eg, lithium, vancomycin), with specific type of RRT better for some drugs than others. This is uncommon and decisions will depend on the input from renal, clinical state of the patient, and advice from toxbase or national poisons service. A drug may not be removed by RRT but if it leads to another entity such as acidosis it may still warrant RRT.
  
• Fluid overload or pulmonary oedema refractory to diuretics - If patient is anuric despite diuretics then it's more likely they'll end up requiring RRT. In contrast pulmonary oedema in decompensated heart failure with worsening renal function is not helped more by RRT than by adequate diuresis.
  

Absent from above include oligo/anuria or specific values of urea and creatinine. This doesn't exclude them as considerations, however the whole picture should be taken together to make decisions on an individualised basis. It might be that the patient improves despite a creatinine of 700, it might be they become acidotic and hyperkalaemic with a creatinine of 400. Even on the ICU we still don't know when the right time is to start RRT.
This is a reason why renal and ICU often advise the generic "monitor I/O" rather than taking over care. We do appreciate accurate monitoring is unrealistic on the wards, but we also don't have the ability to admit everyone when few will need a specific intervention like RRT. An adequate UO to aim for is above 0.5mL/kg/hr. As AKI resolves some patients enter a polyuric phase, this will resolve but watch that they don't become hypovolaemic in the process, it may require further fluids matching what is lost.

Renal vs ICU referral

This will depend on local arrangements and acuity. Refer to renal if:

• Single organ kidney failure - Normotensive haemodynamically stable patients, not septic or comorbid with poor cardiac function. The principal reason haemodialysis is intermittent because fluid is more rapidly removed therefore borderline hypotensive patients may not tolerate large volumes of blood and fluid being rapidly withdrawn from their intravascular space. I have seen patients arrest from starting dialysis!
  
• Unclear cause of AKI - ICU can offer RRT as a bridge, but the underlying cause has to be treated, if the cause is unclear or there is persistent renal dysfunction, this will require renal input. We refer for this from the ICU too.
  
• Diagnosis requiring specialist treatment - Immunosuppressive therapy for vasculitis.
  
• Renal transplant patients - Even with a clear cause and response to treatment, the precarious nature of immunosuppression, renal impairment and graft function mean these usually merit a call to transplant renal physicians.
  

Refer to ICU if:

• Multiorgan failure - Borderline blood pressure, high oxygen requirements, fluctuating consciousness level, coagulopathy, these patients are unlikely to tolerate iHD, but more importantly it suggests they are critically ill and may need rapid escalation of care (if appropriate) beyond what renal can provide (intubation, vasopressors, etc).
  
• No on-site dialysis service - In hours there may be arrangements to transfer to partnetertiary hospital particularly for complex patients. However hospitalised dialysis patients known to the renal team may require more urgent RRT than this allows. Some ICUs have the plumbing to offer dialysis (this will need a dialysis nurse however).
  
• Patient in extremis - ICU may be able to offer more timely input in patients needing urgent intervention especially if prior to surgery. A patient with bowel perforation and severe AKI will usually be septic and in multiorgan failure anyway, but a 70 year old with obstructive pathology may benefit from being close to theatre to offer RRT while awaiting a nephrostomy (or exchange). If it's reversible and there is somebody willing to operate, I would even dialyse a patient with a DNACPR we wouldn't otherwise admit.
  

Specific considerations

• AKI in heart failure
  
  • The heart-kidney interaction is complex and works both ways (see this review). Volume status and cardiac function needs to be carefully evaluated. Seeing CCF documented in the notes is meaningless. What does their most recent echo show? What did they present with? Stable HF with reasonable ventricular function and sepsis with no signs of overload can receive fluids. Acute cardiogenic pulmonary oedema with severe ventricular dysfunction probably has AKI rooted in the decompensation of heart failure (type 1 cardio-renal syndrome) and would benefit from diuresis.
  • Acute decompensated HF is usually a hypervolaemic state. Elevated right atrial pressures reduce the arteriovenous pressure gradient in the kidney leading to venous congestion, poor outflow. Inflow is also limited adding to the poor cardiac output so glomerular filtration is reduced, leading to a vicious cycle. Aggressive diuresis with furosemide reduces this congestion, improves glomerular pressure gradient and increasing filtration (as long as the patient does not become hypovolaemic). Furosemide's initial beneficial effects in venous congestion is preceded by its diuretic action and is thought to be due to it causing venodilation, reducing preload. The addition of acetazolamide may improve decongestion further.
  • Creatinine rising is not an indication to stop diuresis, it may in fact signify adequate decongestion with improved patient outcomes.
• AKI in liver disease
  
  • Like in heart failure this is a complicated topic (see this recent review). AKI is very common, occuring in up to 50% of hospitalised patients with cirrhosis. While we hear things like hepatorenal syndrome thrown around, common things being common we have to look at all the usual causes we've discussed first (so don't just throw terlipressin at everyone!)
  • Pre-renal causes are most common: Discontinue nephrotoxic drugs. Look for and cover for infections and spontaneous bacterial peritonitis. Hypovolaemia from diuretics or GI bleeds, resuscitate with crystalloids and blood as needed until euvolaemic (careful to avoid overload). Albumin has been found to improve survival in patients with SBP and can be considered if worsening renal function despite resuscitation (or following paracetensis for large volume >5L ascites). Hypervolaemia from congestion (cirrhotic cardiomyopathy leading to right heart failure can benefit from diuretics, abdominal compartment syndrome from tense ascites should be drained).
  • Intrinsic leaves us with tubulointerstitial causes and hepatorenal syndrome (HRS). Low fractional excretion of sodium and urine microscopy can help confirm HRS which offers a grim prognosis. Terlipressin may improve renal function at the cost of significant pulmonary oedema so regular volume assessment and avoidance of overload is paramount. RRT would only expected to be offered if waiting, or under consideration, for liver transplantation. If not, palliation will be the most likely alternative course.
• Drug dosing
  
  • I would avoid using the BNF in renal impairment. Many of its recommendations are different than common guidelines and frankly weird. Do talk to your pharmacist (also microbiologist where appropriate), they'll often refer to The Renal Drug Handbook which is a good resource and covers scenarios like RRT. Most drugs will be dosed based on creatinine clearance not eGFR so arm yourself with an app or calculator.
• Sodium bicarbonate
  
  • Bicarbonate infusions offer temporary extra buffering capacity, mopping up excess hydrogen ions resulting in a higher pH. This is beneficial in hyperkalaemia as a higher pH favours potassium moving intracellularly (for this reason saline is more harmful and Hartmann's more beneficial in hyperkalaemia). It also has accepted roles in tricyclic antidepressant overdose with adverse ECG findings (QRS, QT prolongation), urinary alkalinization (in salicylate poisonining, poor evidence in rhabdomyolysis), and normal anion gap metabolic acidosis (there is high cloride to replace loss of bicarbonate, see later).
  • Its use outside these indications is contentious. There is no evidence of benefit in DKA over conventional fluids even if normal saline's tendancy for acidosis may slow resolution of the acidaemia in DKA. It may be actively harmful in lactic acidosis and respiratory failure as the increased pH shifts the O2Hb dissociation curve to the left, causing reduced oxygen offloading. It also results in net CO₂ production (HCO₃⁻ + H⁺ → H₂CO₃ → H₂O + CO₂) which will have to be blown off with excess minute ventilation.
  • So why do ICU and renal advise it or use it themselves even with a lack of solid indications? Well, essentially it's a temporising measure. Severe acidaemia contributes to myocardial dysfunction, arrhythmias, and catecholamine resistance. In the critically ill it can be useful as a delay while you insert lines or in the hope it will avoid the need for RRT. The BICAR-ICU trial did find it delays the need for RRT and may even possibly reduce the need. I'm not entirely sold on the latter, but it can be reasonable to try if there are positive indicators like good UO.
  • How? Usually available in concentrated (8.4% with 1000mmol/L of each ion) or dilute (1.26% with 150mmol/L) forms. Due to the high tonicity of the former, 1.26% is generally preferrable especially if you can or want to give larger volumes. 8.4% should be reserved for fluid restricted states and should be given slowly via a central line except in an emergency. Slow infusions help combat significant CO₂ rises and hypernatraemia (especially with 8.4%). Dosing is 1 mmol/kg which is 1mL/kg of 8.4% or 6-7mL/kg of 1.26%. For real simplicity most patients can take a 50mL vial of 8.4% or 500mL bag of 1.26%.
• Iodinated contrast
  
  • The entity contrast induced nephropathy, better termed contrast associated acute kidney injury, is a contentious topic. There are many good reviews already on this topic.
  • The evidence is from old studies using high osmolality agents during PCI. Fluctuations in creatinine may not be indicative of actual renal function and may simply reflect the underlying illness requiring a scan rather than the contrast itself. Patients are not more likely to need long term RRT.
  • IV contrast with modern low osmolality agents isn't associated with AKI in patients who aren't and even those who are critically ill. There was no association in patients even with pre-existing AKI. Prophylaxis with intravenous saline nor sodium bicarbonate have been found to make a difference even in CKD patients with eGFR >30.
  • The tl;dr is unless you're in cath lab or IR suite bolusing large quantities of dye arterially it is probably irrelevant. The benefit of a quality contrast enhanced scan in diagnosing and treating the patient are likely to outweigh any miniscule risk. RCR guidelines mention appropriate consent and identification of patients at risk (eGFR <40) they do not exclude the use of contrast or require hydration, at any renal function. You are the doctor, it's up to you to discuss and determine need and benefit. (It's the radiographer's job to ask, don't @ them, but they shouldn't refuse either).

Acid-base disturbances

Now it would seem we are forced to consider the fundamental concept of what acid-base physiology even is. You might have heard about strong ion difference and become lost in confusion. You're not alone. Put simply, there are two competing theories that try to explain how pH changes occur in the body: the traditional model that uses the Henderson-Hasselbalch equation to mathematically explain pH with bicarbonate, and the Stewart model that uses the concept of strong ion difference to explain why changes in bicarbonate occur. The bottom line is that these are detailed explorations of physiology more useful for bed time reading than the bedside. For the interested details can be read elsewhere.
More practically, we can work through a blood gas in a systematic fashion to help decipher the type of acid-base disturbance. Start with pH → PO₂ (always check oxygenation) → PCO₂ (respiratory component) → HCO₃⁻ (metabolic component). I've reproduced this in a simple but limited table below for reference, but this is a more intuitive flowchart to work through.

pH	PCO₂	HCO₃⁻	Disturbance
<7.35	>6	↔	Acute respiratory acidosis
		↑	Chronic respiratory acidosis
	↔ /↓	<22	Metabolic acidosis
>7.45	<4.5	↔	Acute respiratory alkalosis
		↓	Chronic respiratory alkalosis
	↔ /↑	>26	Metabolic alkalosis

^{Numbers indicate primary abnormalities, arrows indicate compensatory changes. Respiratory compensation by altering ventilation occurs quickly, while renal compensation by altering bicarbonate excretion is a much slower process.}

Respiratory

With the topic being the kidney, I won't discuss respiratory acidosis here (see this earlier physiology bite). Acute respiratory alkalosis is due to hyperventilation blowing off CO₂. This can be due to obvious things like pain or anxiety, a compensation for hypoxaemia (eg, high altitude climbing), pregnancy (increased minute ventilation stimulated by progesterone), or salicylate poisoning (direct stimulation of respiratory centre).

Metabolic

Dipping back into some physiology, we can consider two concepts that can give us more information: base excess and anion gap. The purpose of these concepts is help narrow our differential diagnosis, rather than serve as pathophysiological explanations of illness.

• Base excess (BE) - This idea comes from Danish physicians during the polio epidemic where patients often experienced chronic CO₂ retention. For a standardised numerical way of gauging the degree of disturbance Siggaard-Andersen proposed BE to represent the quantity of acid in a lab that needed to be added to a solution of blood to normalise it to a pH to 7.40 and PCO₂ of 5.3. Not because the plan was to literally add acid, but this way you could easily quantify the degree of disturbance. Rather than use this concept Americans appear obsessed with the more complicated Winter's formula instead. Most blood gas analysers will calculate BE for us, often reported as standardised base excess (SBE), with a normal range of +/- 3. A negative base excess is sometimes described as a base deficit, they're the same thing.
  
  • SBE <-3 - There is a metabolic acidosis, alone or as compensation for a respiratory alkalosis.
  • SBE >3 - There is a metabolic alkalosis, alone or as compensation for a respiratory acidosis.
  • Mild -4 to -9, moderate -10 to -14, and severe <-15 (same but positive values for alkalosis)
  • It is especially helpful with mixed disorders or causes. A lactate of 4 doesn't explain a BE of -12 alone, are there other contributors to the acidosis? A bicarb of 30 doesn't explain a BE of +10, what else can be causing alkalosis?
• Anion gap (AG) - I have a more detailed reply here explaining anion gap. It is a theoretical number that exploits the body's need to maintain electroneutrality: we have a bunch of positively charged ions (cations) that are evenly matched with negatively charged ions (anions), and we measure some of these. When we have an excess of some anions that we don't measure like lactate this calculated number rises because one of the measured anions (bicarbonate) drops to compensate to maintain electroneutrality. Like BE, most blood gas analysers will calculate AG for you.
  

There are far too many causes and detailed physiology to discuss here exhaustively. If you want to read about the Cori cycle, Type A and B lactic acidosis, helpful mnemonics and more, head to this review or this section on Deranged Physiology.

Metabolic acidosis

Symptoms are non-specific, with the most obvious being hyperventilation for compensation. In severely acidotic states (pH <7) seek early ICU help. Awake patients will hyperventilate sometimes down to PCO₂ <2 which can dramatically increase work of breathing. Initiating invasive ventilation in this stage or patient fatigue can be very dangerous if hyperventilation isn't maintained, the acidosis can worsen and precipitate cardiac arrest. Hypotension from vasodilation and reduced cardiac contractility can occur, as well as arrhythmias, confusion, delirium, coma.

• High anion gap metabolic acidosis - The presence of unmeasured anions including: lactate, ketones (diabetes, starvation, alcoholic), salicylates, formate (metabolite of methanol), oxalate and glycolate (metabolites of ethylene glycol), other toxins.
  
• Normal anion gap metabolic acidosis - Losses of base (bicarbonate loss in GI tract via high ouput ileostomy or diarrhoea, renal loss via acetazolamide) or excess of acid (renal tubular acidosis, hyperchloraemia, adrenal insufficiency).
  
• Pitfalls: Albumin is an unmeasured anion, so low albumin can mask a high anion gap. Albumin corrected formulas have been developed. Similarly excessively high unmeasured cations like magnesium, calcium, and even lithium, can also lower the gap.
  

Treatment is aimed at eliminating the underlying cause with specific therapies as required like insulin in DKA, fomepizole for ethylene glycol poisoning, folinic acid in methanol poisoning, etc.

Metabolic alkalosis

Despite metabolic acidosis being the usual focus, metabolic alkalosis is actually the more common abnormality of the two in hospitalised patients and is frequently seen as a mixed disorder (like as a response to prolonged CO2 retention as seen in mechanically ventilated patients). In severe states it can lead to delirium, seizures, obtundation, arrhythmias.
The 'opposite' of acidosis, here we see a gain of alkali or loss of acid, with impaired bicarbonate excretion required to maintain this (via chloride or potassium depletion, impaired renal function, or volume depletion).

• Gain of alkali - Iatrogenic from bicarbonate infusions, citrate in transfused blood.
  
• Loss of acid - From the kidneys via diuretic therapy, or mineralocorticoid excess, hypokalaemia. From the GI tract by vomiting especially with pyloric stenosis or obstruction as there is gastric acid loss (with chloride) only, laxative abuse diarrhoea.
  

Treating the underlying cause is important as always. Where there is low chloride and hypovolaemia, this usually responds well to fluid replacement with saline and potassium as required. Acetazolamide can be given if there is hypervolaemia although in practice this is rarely required unless continued diuresis with other diuretics is required. Alkalosis results in low ionised calcium that can cause paraesthesias, but as calcium is buffered by albumin this rarely requires treatment and resolves with correction of the alkalosis.

Conclusion

This is another large topic where there was plenty to talk about. I had to cut down the scope significantly as it rapidly spun out of control, however I thought the nuances deserved a detailed writeup. Nothing is ever absolute so don't take any of this as incontrovertible evidence of the incompetence of a hated colleague (or their brilliance)! It will hopefully have given you some ideas to think about and research further when you see patients with AKI yourself.
Until next time!

Hi everyone,
The autisticwomensgroup Zoom group is meeting Tuesday, May 30, from 12-1 pm Eastern US time. The topic is: "Paperwork". Our highly structured meeting is guided with a slideshow. The host, an autistic woman, reads aloud the group reading of the day, and we take turns sharing on discussion questions relating to the meeting. Our event post is here (complete with Zoom login info).
TIME ZONE INFO: The meeting takes place at 9:00 am Pacific US time 10 am US Mountain time 11 am Central US time 12 pm Eastern US time 5 pm UK-Ireland time 6 pm Central European time 2 am (Wednesday) in Sydney, Australia
Our group welcomes clinically diagnosed, self-diagnosed, and questioning women and all other marginalized genders. Disclosure of diagnosis status/gender identity is the personal choice of each member and will never be required for participation. We share on our own experiences only and do not offer advice or opinions.
Participants may share on any/all (or none!) of the following questions:

• Share period I (to about 35 min past the hour): How do you feel about paperwork? Is it easy? Hard? Why? How do you feel before, during, and after doing paperwork? Is there a certain kind of paperwork you have to do often? Please describe. Were/are there any times in your life when paperwork has been especially burdensome? What happened? Is there any paperwork you just *love* doing? If so, why? Any paperwork life hacks to share? Anything else to add?
• Share period II (to about 57 min past the hour): How's your week going? Any struggles, triumphs, or other experiences to share?

Members share by speaking or by typing in the chat. It's also totally cool if you want to lurk - video/mic participation is not mandatory at all.
Thank you, and I hope to see you at the meeting :)
Due to the group's values of privacy and anonymity, we do not record this meeting.

I'm (36/m) not diagnosed with anything but having strange symptoms that don't fit a clinical picture. I'm doing tests with my nephrologist but he is a little confused too.
I'm not looking for diagnosis here, I know that's up to my doctor, but wondering if anyone else might relate to any of the things happening to me.
My GFR is normal (100+) for the last 4 months.
Started with frequent urination. Sometimes I go every 30 mins, sometimes I go a normal 4 - 5 times a day. Some nights I get up 4 times to pee. Some times I don't pee at all.
Trace blood twice on dipstick, no RBC on microscopy (same sample). Hasn't happened since.
Creatinine was usually around 80 - 90 before all this (ref is 66 - 112). But it suddenly dropped to 59 (lower than range). I'm a fairly large man and doctor was very confused and surprised that it was so low. Now it's climbed up a little to 72.
Also had elevated phosphate (calcium normal) on my last bloods.
Foamy urine pretty much constantly (in every toilet), but varying degrees (sometimes can't see the water, sometimes just the edges and on occasion none). There are bits of foam even when I pee on the side of the bowl.
I'm almost always positive for protein on home dipstick - sometimes just edges change colour and sometimes it's clearly 1+.
I did a PCR and it was negative (2.24 creatine and <0.04 protein). Waiting for a second ACR result now. When I did it I was dehydrated but there was no foam at all. Bad luck?
Haven't done a 24hr yet — they don't do it here as standard.
The frequent urination comes and goes still. Sometimes I pee 4 times a day. Other days I'm peeing 20+ times. I don't get it.
Also had a few night sweats (although seem to have gone) and some pain under ribs (low level and had for 2 years which I assumed was muscular).
All other bloods/prostate etc fine. I'm at a loss.
The protein on dipstick points to my kidneys but so far urinalysis tests say negative (is this possible?).
Can I have proteinuria intermittently like this? Both times I did the PCR tests by some coincidence I had no foam but most of the other times I do (what's the chances of this?).
I just want to know what the hell is going on and what I need to do. But nobody has any answers.
Does anyone else have wildly varying symptoms that change on a daily basis?
Side note: I already eat a vegan diet, I exercise, have no diabetes and normal blood pressure.
Very confused

Hiya, firstly I'd like to again thank everyone who responded to my last post - made some adjustments to my meals and plans for future meals, so thank you! 💕
Yesterday I decided to buy my own tracker in the pharmacy, because I really wanted to see if I'm on the right track with the diet and I'll have to wait quite a while to get the one that the clinic issues. I looked up the diabetes clinic's recommendations and cut off numbers they put in an online pamphlet, so I am following the medical advice of the clinic I was referred to.
They recommend testing for fasting numbers (cut-off at 5.3) and then 90 min after every major meal (cut-off at 6.6)
So far my numbers have been: 4.9 fasting (a welcome surprise after a fairly sleepless night, yay third trimester) and then 90 min after breakfast, I had 5.5
The main thing that concerns me is if it is okay that there isn't such big of a difference between these two? They are within range at least...hopefully I'm doing everything right...thank you in advance!

Sometimes I feel un-prioritized by my boyfriend. Idk if I’m just over thinking or being crazy. We live about 40 minutes away. I go to his house on weekends or when I can (usually 3-4days a week) I drive to see him. Which costs a lot when you’re driving back and fourth for work/school. I go to school full time, go to two 12s, and work at my family’s restaurant. When I mean I try my best to see him and spend time/money on him I meant it. I barely sleep just to get homework done to see him. I drive back and fourth to see him. I do things for him such as cook food for him, take him lunch for school, see him at school, take care of him when he’s sick/down. And I barely get min in return.
Today we were suppose to hang out and I was going to drive to his house to see him and we were going to his friends house… well as soon as I got out of work he texts me to not worry on seeing him because he’s already at his friends house… and I’m like “??” Because we were suppose to go. His answer was “well you don’t like to wake up early so I assumed you didn’t want to go” and I said “I wake up early regardless just to be with you”. I told him I called of work tomorrow and then he’s like “well I can pick you up and go back to my friends house” I didn’t reply to that because I feel like he said that since I called off work. I also stayed up for 25 hours for a clinical shift that was 13 hours, came home took a shower, did homework till 4am, slept, woke up at 6am and packed my stuff for the weekend… I was also pissed because he says we never do anything fun. I booked a nice hotel in my town to go out drinking and just spend the night in the hotel without having to drive for so long. Well that I was pissed because I lost money, once I did the same to take a little weekend trip and we got into a fight and broke up and I couldn’t get my refund. I go to the hospital for 12 hours and during my shifts he texts me “i miss you” and then I say “then come see me for lunch” just let me know an hours ahead so I know what to do with my patients. He does nothing, no school over the summer, no job. Yet he complains of being bored. He can spend a little bit of time with me seeing me and eating lunch with me. He has the money to do so, he has 100k or more saved up. Im also not saying for him to spend it all. When he’s lonely or upset he asks me to come and if I don’t he guilt trips me with “you don’t miss me?” “I see you don’t care about me” “you’re lame”…
I used to have an ex who would be amazing at being a boyfriend. He always made me the priority even after we broke up and I made him a priority too. He would come have lunch with me at my clinical shifts, school, and work. Help out at my work to just be with me. Surprise me with little things such as coffee, flowers, candy, snacks, food, jewelry, worry about my doctor appointments, take me out on dates, didn’t keep count on what he spent on me (my current bf does this to me. I absolutely hate it. He’s like “ I paid last, you’re turn” “you’re paying this”) it bothers me a lot because I pay for things over and over without telling him that he owes me X thing. I’ll buy something without looking at the price tag or being like “too expensive, not the right time” . I’m not broke, I can buy it myself. However you cannot invite me out and then when the tab comes hit me with “you pay” . It’s not even about money, it’s about like also him not planning things for me, being romantic, or hand making things
I once had a a ceremony for school which was a huge thing. He asked to go and I said yes. Later the following 1-2 weeks I tell him if he was coming and he’s like “no I have a doctors appointment” so that hurt me a lot.

Info: 26M, 173cm, no medication nor any allergies before this.
So I'd really appreciate for someone to tell me what's happening and if you can give me any advice!
so this infection/allergy started out as small red dots in the front of my scalp (right over my forehead) over time these dots would spread and after a few days they started to form brownish red crystals, which dissolved when I ran water over them. Then I started noticing an orange liquid coming out of them along with a small bump forming on my forehead.
Over the next few days the bump on my forehead kept growing and the amount of liquid that came out of the "rash" looking area continuously spread.
The bump got so big that it would noticably extrude beyond my skull shape, it basically looked abnormally swollen. I put diluted tea tree oil, put it in salt water, used warm compresses and nothing worked. The only thing it did was get rid of the red dots but my skin would stay rough and itchy. Laying down would drain the little dots and the bump would get slightly smaller but then it'd go back to how it was like 10-20 mins minutes later.
I then decided to go to the ER, they hooked me up to an antibiotic IV then prescribed me an allergy cream + allergy medication (the doc said that those are just for in case I'm having an allergic reaction instead of an infection) and they kept the IV needle in my arm and I was instructed to do at-home antibiotic IV for the next 2 days (basically I'd go to a nearby clinic and they'd do the IV thing again). Also my lumph nodes on my neck are noticably swollen (the left one way more than the right)
Now that I'm back home, my forehead is extremely swollen and my eyes are so puffy that it's very difficult to open my eyes, and this liquid is still leaking out of my forehead but now it's more than ever (I'm assuming it's pus). Can anyone please explain what's going on, and what do I need to do to feel better?? I did scratch the front of my head before and my pillow case might've not been washed so maybe that caused it? Any help would be greatly appreciated!
p.s: I do not have a fever, nasia, nor fatigue despite sleeping for only 3 hours cause of the burning.

TLDR at the end!
Hey I was hoping someone could explain to me how collecting hours worked. My current work supervisor says she’s swamped and won’t supervise my coworker (she supervising one coworker for BCBA and another for BCaBA but the latter doesn’t seem to need much supervision)
To be honest, I don’t think she’s a big fan of my coworker, but I know my supervisor really likes me and believes in me and my success in the field. Also the coworker doesn’t meet with her and discuss clients with her as often as I do.
I was accepted to FIT and am waiting back on 3 other programs, all start mid August/early September.
I was wanting to do a mock-up of what my supervision hours would look like so I could show her that really it’s not any additional work for her, or very bare minimum.
I mostly do group therapy (like Children’s Friendship Training, PEERS, programs like that or group language/social skills classes) I do have one individual client that I work on PEAK with.
I’ve based the following on my current caseload for this quarter.
How do you count a month? Literally the calendar dates? I’m just realizing my hours are going to vary because my groups are held on certain days of the week.
So I currently technically teach groups 21 hours a month. I do direct 1:1 16 hours a month. So that’s 37 hours restricted hours if I’m understanding correctly.
Then I support and take data in 2 groups every month, which totals 14 hours a month. I see this could be either restricted or unrestricted??
I would estimate that I do 2 hours a day of graphing, report writing, revising goals/targets, preparing for lessons, speaking with parents, etc so that would be 40 hours a month unrestricted.
Can someone please clarify. So it’s 40% restricted and 60% unrestricted? So 800 hours and 1200 hours?
Also the other supervisor at our second site offers group supervision monthly that I would most likely be able to join.
As of now, my supervisor and I meet at a minimum, once a week for at least 15 mins discussing clients and goals (sometimes more). She also at a minimum watches my groups at least 15 mins a week, probably more. For today for example she was there 1.5 hours for my individual client doing PEAK.
So that’s around 50 restricted hours a month, 40 hours unrestricted a month. Does the supervision percentage of 5% apply to the total hours of just one of the categories? That would be 90 hours a month, and 5% would be 4.5 hours a month. I already meet with her 1 hour a month minimum, and then she probably watches me teach 1 hour minimum a month, so that would leave 2.5 hours that we would have to make up? Is it also possible to not claim as many hours and only do 50 hours a month, and then I would only need 2.5 hours supervision a month? At 50 hours a month it would take just over 3 years to complete and my program is just over 2 years so that isn’t too bad in my opinion.
Does this sound doable?
Personal stuff you can skip if you’d like: My coworker is my friend but she’s a VERY different personality from me and the other BCBA candidate, so I think that’s part of the issue. I’d feel so guilty if my supervisor said yes to me and still wouldn’t supervisor my coworker, but our situations are completely different. My supervisor keeps telling my coworker to “take her time” and that she “has to lots of time!” But personally I need to finish ASAP as I’m almost 31 and I want to be finished before I have children. And I have endometriosis and adenomyosis so I’m already at risk for infertility and can’t put it off any longer than 34/35. I know we could get supervision else where, but our agency is a former Ontario (Canadian) government agency with a union so it pays way more than the private clinics and has great benefits and pension plan.
I’m sorry this is so long. I’m severely ADHD and don’t stop talking 😩
TLDR: Are total restricted hours 800 and restricted 1200? If I collected 90 hours a month, would I need supervision for 4.5 hours then? Can I collect less hours than I’m actually earning so my supervisor doesn’t have to do as many hours with me?

Need to see a doctor in Victoria, but like many don't have / can't get a family doctor, so trying to get an appointment at an urgent care facility.
As there are no more walk-in clinics (politicians trying to avoid stories on horrendous wait times?!), trying to make an appointment, but can't get through to anyone as getting connected to make an appointment is a total lottery. On hold for 15 mins then cut off multiple times...
I am a staunch defender of public Healthcare, but the situation is unsustainable for everyone living the CRD.
If public healthcare is not accesible, is private healthcare the only option left?!

Male 56, healthy beside a few common issues here and there and covid 30 months ago. 6 days ago Monday i woke up in the middle of the night with a painful sore throat. When i woke up it was gone completely and never came back.
The following day i felt dizzy, nauseous with shortness of breath that i have never experienced. In the afternoon after lunch every symptoms disappeared completely.
I have been taking dayquill like at 5-6 am when i get up, there is no way it would start working only around noon. From Wednesday to today Saturday the 3 symptoms happen until lunch then disappeared in the afternnon but they have not been as bad in the morning especially the shortness of breath which is real scary.
I was at 185lbs forever after having been up to 221lbs at one point. But my goal being 165lbs the last 2 weeks i went in second gear. Fruits, veggies all day and a tiny bit of protein for dinner.
Last night Friday i woke up coughing non stop in the middle of the night. Woke up this AM, it’completely gone. I tested myself on Thursday for covid and it tuned out negative.
I went to see a heart doctor that did not find anything wrong but suggested checking my blood pressure which i take meds for and could have dropped with the change of diet. I had it taken twice since and more high than low.
There are so many avenues i could take that i wonder which one you would pursue first? Test again for covid? (I m vaccinated with boosters)
Monitor my blood pressure more closely?
Increase my protein in my diet which i considerably cut?
Try to take meds for common viruses (Which?)?
Go to CVS clinic?
Thxs

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The survey is brief and should only take a few mins. Any responses would be greatly appreciated!
​
//Quick reminder:
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Apologies this is late, I completely lost track of the date/time difference!
Disclaimer: I am very grateful to have had a lot of parental assistance over the years and also have serious mental health diagnosis, both of these flavour my money choices heavily (e.g. private healthcare and lack of car loan/insurance)
I am also heavily pregnant so please excuse any baby brain related errors!
​
START SCENE
Retirement Balance: $62,000
Equity: $35k of a $680k property, we bought our 3 bedroom apartment last year using my parents’ equity, so no deposit was required.
Savings account balance: 20k - a lot of health/baby related costs have come out of it lately!
Credit card debt (and how you accumulated it): $800 which I pay off each monthly pay, if it wasn’t for the grocery rebates I’d consider getting rid of it.
Student loan debt (HECS): BA in passion/fun area, then IT/Accounting degree, very proud to say I am down to my final $19k!
My husband P earns around $90,000 in healthcare but can be more with overtime, he has around $30k in super and his HECS debt is due to be wiped out following our recent election so won’t be including that.
Section Two: Income
Income Progression: I had been working in retail full time after loving full time work instead of uni, until my transition to IT so started as a retail casual worker on $30k 10 years ago and changed to IT 6 years ago, jumping from $55k to $95k in that time, mostly through promotions, 1 company merger and 2 company changes.
Main Job Monthly Take Home: I am paid $5200 monthly and P is paid fortnightly at $2400 to $3000 depending on his shifts. Both our pay excludes tax, HECS payment and medicare levy, his pay includes salary packaging.
Section Three: Expenses
Mortgage: 3150 (locked rate until next year, pending interest rise)
Savings contribution: $500
Donations: $25-75 a month mostly to various MH organisations
Electric/Council/Water: 400 (we’re currently overpaying ahead of Mat leave)
Internet/our mobile phones: $320 (we’re currently overpaying ahead of Mat leave)
Subscriptions (Newspapers (NYT, SMH), Youtube, Xbox, online backups/cloud, VPN, pregnancy app, Amazon Prime, Netflix, Bitlocker, UberOne, Spotify Duo): $110
Private Health insurance: $420 for Top CoveTop Extras + pregnancy
Car insurance: covered in my parents plan, our car was a gift from my parents
Regular therapy: Psychologist $220/fortnight and psychiatrist $280/quarter
Transfer to P for things like fuel: $500
7 Day Money diary:
Thursday:
5am
I’m staring at the ceiling while the baby kicks my kidney, P snoring next to me, contemplating my existence. I’m trying not to start ‘the list’ run through in my head (buy milk, have I booked my next blood test, where is my winter coat, etc).
5.30am
Give up on sleep and get up for the day, I make a weak coffee for me and a regular coffee for P (I like the taste of coffee, weak lets me have 2-3 cups throughout the day without hitting my pregnant caffeine limit) and start packing up my lunch and bags for work. It’s OB day so I won’t be in the office until 10am today.
9am
After a dance party in the car we’re at the OB, all good news and another list of final scans and tests, we’re now in the downhill run! I pay for my last half of (private) OB management fee since we’re passed 28 weeks now. ($2500 (Medicare rebate soon: $580))
Stop at a bakery to treat myself before work, danishes are the breakfast of champions! ($12.00)
2pm
Last vendor meeting of the day, and i’m ready to take a nap. I’ve decided to spend the rest of the afternoon working on my handover document, I’ve only got 8 weeks to go before Mat leave!
3pm
Text my psych to convert our Saturday afternoon to a Zoom call, I’m not up for extra waddling to the train this week.
5pm
Spend the train ride home working on my crackhead baby spreadsheet (colour-coded, multi tabbed, shopping list, meal prep list, etc) and researching baby items.
P meets me at the station to grab my bags and we walk home, well he walks ahead and I move at a more stately pace.
7pm
Crawl into bed with a bowl of pasta and Ambulance UK on the iPad, kitten at my feet, older cat at my hip. Eventually P awkwardly maneuvers around blankets, my pregnancy pillow and cats.
11pm
Spontaneously adding to my online chemist wishlist of things I need for post birth and hospital bag. Cats and P grumble when I once again get up to pee, pregnancy feels so glamorous now.
Total: 2512.00 (pending MR)
Friday:
6am
Wander around the apartment with coffee in hand and contemplate the nursery layout options, I’ll measure it all tonight and make a floor plan so I can visualise it better. After boarding the train, I scroll through my due date Bump Group on Discord and catch up on the topics, many of the mum’s are NA based so the chat pops off 12am - 4am my time. I message a few friends and my bestie spams me with tiktoks. We tell a few dark MH jokes and I try not to laugh on the train.
8am
Arrive at the office, coffee number 2 in hand and I jump into a few Teams chats with various groups, including my manager and counterparts in another city’s office. They’re in a different time zone ahead of us so they flag any issues that started earlier our time and I’m grateful.
1.30pm
Where the hell did today go? I’ve barely left my desk and can’t believe the amount of firefighting I’ve been doing today, following up vendors, coordinating fallback solutions for outages, soothing ruffled feathers and talking team off the ledge in stressful situations.
I’ve definitely not eaten enough today and decide to place an ubereats order instead of raiding my mini fridge stash - Subway it is! ($18.97)
I spend my lunch break reading my latest pregnancy/birth book (The Complete Australian Guide to Pregnancy and Birth) and it’s honestly my favourite one I’ve read so far. I’m also a big fan of the podcast the authors run. I have queued up this week’s episode for the trip home as the mum featured has a similar mental health issue to me and I’m excited to hear her journey, also to get ideas for things to raise with my care team.
5pm
Security protocols kick us out of the office building and I am thrilled to escape! P picks me up from work since he’s off today, and my hips and feet are very grateful. There’s a quick stop in at Coles for pizza ingredients, milk and the very essential choc chip waffles. ($46.94)
Once we’re home P feeds the cats and unpacks while I get started on the bases, my birthday present last month was a KitchenAid and at the rate I’m going the cost per use is coming out pretty damn good! I leave the base to rise, pop my feet up and do my nightly blood pressure (127/82) which I log into my health app. I also add my weight from yesterday’s OB appointment and I'm thrilled to say I’ve stopped losing weight now the suspected HG has finally settled.
7pm
Take several brag photos of my pizzas #homemade and settled in front of the TV with blankets, footrest and P. I do send P back to the kitchen twice for serviettes and my water bottle, but once I’m settled, I’m not bloody moving.
I queue up the latest Top Chef (International All Stars Season 20) on Plex and get ready to support my fellow Aussie! P grumbles about my fixation with Top Chef, but all he gets is side eye in response. It’s a great episode for creativity, he even admits the winning dish is impressive. He vanishes the second the episode’s over for his office and a rewatch of the extended, super, mega, special edition of The Hobbit. I move on to Ambulance UK and annoy him over text with questions about the medical terminology being used.
8pm
Bedtime with a heat pack as my back is killing me! I try to convince P to come to bed and hold it against me since bubs is not allowing stomach laying anymore.
8.30pm
Success! P is helpfully holding it against me while I finish the episode and scroll the Iconic. Oh no! There’s now Stanley cups on there, I add it to my wishlist and promise myself I’ll think about it first. I want to also be a chic put together Stanley cup girlie!
Total: 65.91
Saturday:
3am
Back scrolling the Iconic and on a hunch check my credits (after rage returning maternity clothes a few weeks ago) and bingo there’s a credit there. I play around with wishlist items and stacking discounts, there’s a pale pink theme developing between the pink pregnancy overalls and the Stanley cup.
3.30am
Screw it, I’m ordering (10 points if you can guess what room of the apartment I made this order from) and it’s all due this afternoon except the pregnancy belt I've been grumbling about wanting. ($14.95)
9am
P brings me coffee, the kitten and the statement that he’s approved our Medicare Safety Net balance (he’s our primary family member) which means the rest of our refunds will be great going forward!! I’m very excited for 90% back on out of pocket costs for most medical things from now until December. Between my mental health and pregnancy I’ve beaten my normal record of September for the max you can pay OOP.
12pm
I’m sitting on the floor in the nursery trying to sort out piles of tiny clothes and remember to get P to help me off the floor before he heads to work. I head to the kitchen and start the bread process, I make our bread from scratch every weekend and the KitchenAid has made this sooo much easier. I decide one x1 wholemeal seed bread for P and x1 rosemary focaccia for me. Once they’re rising I head off to bed for a nap before therapy this afternoon.
3pm
I made myself some tea and washed my face to prepare for therapy as I woke up from my nap feeling like I was on another planet. I head into my office, no no now the nursery, damn I slightly tear up at the thought of my nice office now being a small desk in the corner. Well that can be another topic for my session today!
3.30pm
My psych and I go over all of the last 3 weeks worth of appointments with my health team and what my next steps are. I need to sort out my postpartum stay referral and lock in when I’m starting my top up meds. We talk through some of my work frustrations (not clear cut sexism but a level of obliviousness some of male managers are showing) and how I’m tracking mood/symptoms wise across the pregnancy. We’re both very aware that the final few weeks of pregnancy and the accompanying hormones can cause serious issues, so we go over warning signs and coping mechanisms. We go over the difference between ‘normal pregnancy feelings’ and my mental health condition feelings.($220)
4.30pm
Session done and my bread has all risen nicely despite the cold weather, I start the baking process and contemplate dinner. P is at work until 10pm so I’m on my own, which means all the Top Chef reruns and Ambulance UK my heart desires! I have a craving for spätzl so dig that out of the cupboard and defrost the schnitzel.
Iconic delivery!! I am officially a Stanley cup owner! I ordered the original, not the soft matte because Tiktok told me to, so I’m hoping I’ve made the right choice. Something about cold water through a straw just hits the spot. My glittery Starbucks cup looks on in disgust.
10pm
P finds me at my desk working on my spreadsheet of crazy, I mean baby, and is impressed but also too tired to focus on it now. I hear him calmly explain to the kitten that he can’t join him in the shower but he isn’t entirely successful.
We get into bed and P puts headphones in so I can drift off faster (or because I threatened more Ambulance UK? We’ll never know!).
Total: $234.95 (pending MR)
Sunday:
4am
And I’m up early again, my passenger is apparently an early riser these days which leads to me looking down and asking for more sleep “pleeeeease!” I try 37 positions and try to get comfy before finally drifting off again.
8am
I steal P’s dressing gown (mine’s now got an awkward gap due to the bump) and start the coffee process, the kitten joins me after finding a piece of plastic to pinball around the kitchen with, I am not coordinated enough these days to dodge him so I remove him and plastic to the living room.
I’m craving an egg muffin so I cook some sausages, eggs and toast english muffins and enjoy a mindless tiktok scroll while I eat.
12pm
I’m surprisingly tired after doing nothing all morning and head back to bed for a nap. I really hope the tiredness isn’t a sign my illness from last week is back! I’ve got a support group meeting in a few hours so I set an alarm.
2pm
I join the support group Zoom and immediately hear about how many people are sick or recovering from some flu or cold thing. There’s a lot of bugs going around at the moment! I meet some new people who have the same disorder or same ‘family’ of disorders as me and I update the group on my pregnancy journey. I really bond with 2 of the new ladies and I offer my email up to both to keep in touch before next week’s meeting.
5pm
I’m happily browsing Facebook Marketplace for baby things when Mum calls, she’s been shopping for baby (uh oh) and is excited to tell me about it. Amazingly she’s bought a bedside bassinet very similar to the one I was planning on buying secondhand and a safari themed lamp for the nursery. She’s also ended up with a high chair for their house on the coast and a bunch of themed fabric for swaddles, pillows, etc.
Total: 0.00 thanks Mum!
Monday
7am
I wake with my alarm for once, which would be odd except for how awful I feel. I end up deciding to call in sick, the flu thing that knocked me around until early last week appears to be back. Pregnancy means lots of cold/flu meds etc are not an option so I can’t soldier on. I alert my manager, set my team up with urgent tasks, chuck my OOO on and crawl back into bed.
A few things debit like SMH and Youtube (accounted for in monthly expenses above)
10am
I open my phone to a flurry of emails on my personal account, OH! It’s healthcare cover day! We have finished all our waiting periods and the beacons are lit! Let the floodgates of services and information begin! Our hospital and health fund both email to welcome me to their online learning platforms.
11am
A nice lady from our health fund calls to give me the spiel. I'd normally be wary about what all these amazing services are going to cost, but it’s all covered! She tells me about the learning platform (Nourish), the sleep clinic calls I’ll get after the baby's arrival and the welcome pack I’m going to be mailed. I get my login details as soon as we hangup, another fun thing to explore tonight once I’m feeling human again.
P is amused by how excited I am for all this information, he does caution me against over planning/over researching which is something I’ve been working on with my psych. I struggle to find a good balance between planning for problems and over planning to the point of stress. It’s a work in progress. I suspect I’ll always have issues with control/over planning.
4pm
I’ve napped most of the day, dealt with 1 urgent work issue and am now getting access to the hospital’s learning platform (Cradle). I'm grateful they’re short 5-7 minute long videos so put some on the iPad while I make tea and toast before deciding to tackle the nursery again.
7pm
Mum calls about more baby things - they’ve bought me a change table!? I’m slightly annoyed then I’m thrilled - it’s a brand I like that’s normally $400 ish for $30 at auction yesterday (a Sunday afternoon family hobby). They've just collected it, they’re going to sand and paint it for me in a nice green for the safari nursery. Another thing ticked off the baby spreadsheet.
Dinner tonight was heated up leftovers, I’m too tired for cooking.
Hmm blood pressure is high, I hope this is just sickness related and log it in my app.
8pm
Bed time! Despite sleeping all day I am exhausted and pass out almost immediately.
Total: 0.00 thanks again Mum!
Tuesday
11am
I’m in the office however I cannot tell you what I’ve done today, it’s all a blur and when I sit down with my ipad to make notes for this money diary my brain goes blank. I scroll through my sent emails and can see I’ve sent 26 emails (herding a difficult vendor, setting up meetings for later in the week, submitting my sick leave for yesterday and setting up a new starter orientation). I make another coffee and realise the mini fridge hasn’t been restocked (because I am the one that stocks it each week sigh). I jump online and do a grocery order - yogurt, cheese, salami, tomato paste, sliced bread, babybel cheese, apples and several juices) (52.00) it’s due in next 2 hours.
1pm
I make myself toasted sandwiches and try not to eat the entire packet of babybel. My work lunch group tells hilarious stories from their level of the office and it’s a nice escape from my level’s workload.
2pm
I send off my psychiatrist's referral for my private postpartum care stay (1-3 weeks long) and check it’s all covered with my health care fund (it is!). The private place I’ll be staying at calls me to check in, advise me of next steps and to give me my tentative booking date of 1 week after birth. I’ve got a spare 20 mins so do my intake assessment with them over the phone and get the all clear to be accepted in a few weeks. I’ll get another assessment 2-4 days after I give birth just to make sure I’m still a good candidate. I look over the welcome pack, what to bring lists and advice on partner overnight stays that all hit my email when I hang up. I forward the relevant bits to P and jump back into work.
5pm
An afternoon of meetings meant I did no deep/focus work or work on my handover, but I accept that and move on. I top up my Opal card for the week (50.00) via the app and it’s loaded by the time I’m tapping on the train. I’d normally account for this in the expenses up top but my train trips are very sporadic right now due to pregnancy waddle, so I’ve been carpooling with coworkers and P has been collecting me if his shifts line up along with the occasional UbeShebah.
5.15pm
I’m pinged regarding a site issue and it looks like the site is down. I jump on via my phone and iPad while on the train, I also start my time tracker for out of hours work. I scrap the conference call between my team and the vendor at 6pm and instruct the site to rollover to fallback mode, my team member gets them online again. I email my manager a quick update and switch back to tiktok scrolling. I’m really enjoying not having to fight for a seat most train trips now since I’m so visibly pregnant!
6.30pm
P meets me at the station again, is horrified that I’m dragging 3 books, several cups to wash, my coat (I overheated on the train) and my iPad around in multiple bags, he snatches it all and we start the walk home.
He’s made bolognese and it is the best smell to walk into after a cold day! I smother mine in cheese and prop my feet up to depuff. Then I puppy dog eyes at him and he agrees to Ambulance UK, we’re now in the London seasons and I’m loving the big city vibes. He still cringes at the medical sounds, but takes the time to explain how these patients would be treated at his hospital after their ambulance trips. I enjoy his commentary and it adds a background I would never normally know about.
8pm
I take my blood pressure and it’s high for the 2nd night, I’m a bit concerned but trying not to stress. It’s not 160/100 aka get your butt to ED but it’s still over normal. I log it in my health app and make a note to monitor it and call the OB if it’s up again tomorrow.
I message a friend about his opinion of epidurals (since he does them all day) and ask for the dumbed down reality check, he’s been an amazing support this pregnancy so I know he’ll give me a great answer, and he replies back with all the pros/cons as well as the common issues and how they get fixed. He reminds me to ask my OB since I’ve got pregnancy hypertension, it’s likely I would almost benefit from that common side effect and I make a note in my phone to ask at the next appointment.
Total: $102.00
Wednesday
5am
Coffee, kitten pats, older cat snuggles and then a small cry because I forgot to wash my preferred pregnancy leggings. I thankfully remember I’ve got an onsite vendor meeting today so don’t dress like a potato! I still wear Stan Smith’s but a cute knit dress and scarf up top so I look presentable. I bathe in embryolisse cream after washing my face (fun pregnancy fact - you can develop dry skin patches that make you look like a lizard!) and actually put some makeup on (Charlotte Tilbury base, YSL touche elcat, innisfree powder, lancome mascara and CT blush) followed by Replica’s By the Fireplace perfume. Ready for battle!
7am
On the train scrolling through the morning reports, I’m relieved to see all systems are reporting green after a few small hiccups yesterday. I move onto discord and catch up the overnight conversations in bump group.
9am
Quick catchup with my team and then I spend the morning preparing for the big cross time zone/country catch up with all IT team leads also updating my WIP tracker. I obviously then forget to save it and rage stomp off to the kitchen to make conciliation coffee.
I rage shop for KitchenAid accessories but don’t actually buy anything and my manager comforts me over teams.
12pm
I’m wrapping up in person site meetings to see a bunch of messages from P, he’s grocery shopping and querying baby wipe brands. (One of the best tips I got was to buy a pack of nappies and wipes each grocery trip to build your stockpile so it’s not such a shock, since newborns go through 10 nappies a day!). I reply but I’m a bit late and he finishes in Aldi, Coles and the butchers for the next fortnight (389.23). I’m getting very over this cost of living price increase on basic things like milk. He’s a smart shopper so I know that he didn’t overdo it.
3pm
I’ve taken my blood pressure a few times today and it keeps coming back high. I ring the OB’s office and book in for tomorrow morning (spoiler: my blood pressure meds are increased and I’m asked to check in with my pregnancy nephrologist sooner)
4pm
What the hell is this debit? Oh it’s the meal delivery service I forgot to suspend this week, guess we’re going to be a bit overstocked on food this week. I’m just going to class this as idiot/baby brain tax. (69.95)
5pm
P collects me and I have a small cry in the carpark, he’s had the baby capsule installed and driven to collect me with it so I can see it. Things are starting to feel very real now! I practice removing it and carrying it up to the apartment when we get home.
Leftover bolognese for dinner and we do separate screen time. I head to my computer after a bit to review my spreadsheet, since P has smashed out a bunch of things today in Baby Bunting. Nappy bin, capsule + install and baby bath are all ticked off! I get the receipts off our emails to log the costs (375.16)
7pm
Mexican bowls for dinner and we decide to try out the new RPA reboot that’s recently come back to TV (from the 90s!). I honestly hate every minute of it, the talking heads are really cringe and after the gritty realism of Ambulance UK (and Nurses Down Under) I can’t cope with it. We switch over to Ambulance UK after 1 episode and discuss deleting the rest. I was also really disappointed by how “doctor focussed” it was to the point where the nurses and allied health professionals (physios, ambos, etc) were cut out of certain shots, but you could still see their hands or shoes, that’s just not reality in Australian healthcare they’re the people patients see 90% of the time! Okay getting off my soapbox now.
8pm
I start my out of hours tracker and handle an issue for a site 3 hours behind me, in the end the onsite team and I get our part done, one of the vendors does not. We decide to tackle it tomorrow and a flick off a complaint to our account manage regarding this vendor rep. I notice a few of my counterparts are all in a teams call in their timezone and realise they must be cutting over a new system since it’s so late their time. I make a note to not bother them first thing tomorrow since they’ll likely all be start late.
9pm
Yep blood pressure is still high, so I’m glad I’ve got the appointment booked for the first thing tomorrow. P takes it for me twice just in case I’m doing something wrong with the cuff but unfortunately it’s still high. I’ve finished my new pregnancy book and I would recommend it to any Aussie mums or dads to be out there, P even flicks through it.
Why are both cats trying to sit on me? Oh we forgot to feed them! I sort them out and all is well again in their world.
10pm
My glorious bed calls me to me and I bundle myself up in the blankets, scroll through tiktok and happy cry at birth videos.
Total: 834.34
END SCENE
Weekly Total: $3749.20
Food + Drink: 589.09
Fun / Entertainment: 0.00
Home + Health: 2720.00
Clothes + Beauty: 14.95
Transport: 50.00
Other (Baby): 375.16
REFLECTION:
Besides the health care costs, this is a pretty normal week for me! I’m obviously thrilled to hit the Medicare max as this makes things so much easier with health care costs. I feel really relieved to know all my future costs are being covered by private health or what isn't is at a higher rebate now. Seeing my hospital estimate last week (before private health covers 95%) was really confronting and made me briefly reconsider my choice to go private, but the things that are now covered by health fund are amazing and worth nearly $30k over the first 3 months of the baby's life (especially if we end up needing special care nursery).
I’m pretty impressed about how many wtf and ffs I say in real life that I’ve removed from this diary. I find the Aussie approach to swearing can be a bit relaxed haha, so I did my best for you guys!
The impact of the baby brain is very real, aside from mental blanks at work, I had to check things like my subscriptions and ask P a few times, since so much of it is bpay and auto-debit, I don’t pay attention to it! There’s a few charges we have always had historically like tolls and ubereats that we’ve cut way back over the past few months.
I'm also considering a "what it costs to have a private baby in Aus" as well as a follow up in a few months once I've settled into Maternity Leave life (minimum wage, not my current salary) because tracking was fascinating and I'm a data hoarder.
Happy to answer any questions in the comments if I've explained something poorly.

Species: Cat
Age: 7 y
Sex/Neuter status: male, intact
Breed: Possibly British Shorthair or Bombay breed
Body weight: 4.5kg
History: urinary blockage (2017)
Clinical signs: multiple
Duration: few weeks
Your general location: Canada
Hello,
Please help me make sense of my cat's condition.
​
A bit of a history: My cat was a few years old when he had a urinary blockage. He could not pee and the Vet was about to do a surgery when, suddenly, the cat passed the blockage and was able to pee again, first time in several days. After this he underwent a treatment course. After that his behaviour has changed, he started drinking very often and pee as often. He seemed normal but didn't play. Over the last few years he started to improve and even resumed playing again.
​
One new recent behaviour I noticed is that he would playfully run out from the litter box after pooping and play for a bit. I've read online that this happens due to vagus nerve being stimulated, so I didnt pay much attention to.
Few weeks ago, I have noticed a new sudden and concerning behaviour. He started compulsively lick himself, much more so than usual, scratch his sides and ears, and instead of walking everywhere he would sprint, sometimes even tripping on the way. Googling his symptoms matched with *hyperestesia*. He also started standing with his hind legs on the floor, in *plantigrade stance* and he seemed to have some *weakness in the hind legs* as well as he started struggling to jump up on sofa or chair. Both of his *ears were scratched* with some blood. All of these symptoms appeared suddenly and seemingly out of nowhere, and I took him to the vet. Vet had said that it seems like an ear infection and prescribed some drops. I asked about the rest of the symptoms but the Vet was not sure and said that some of it could be explained by the sense of discomfort cat feels due to ear infection. I asked if we needed to do any bloodwork or urine test but the vet said the cat looks and behaves normal so it is not necessary but he will still take it just in case.
The following day, the doctor informed me that we need to urgently bring him in as the results came back very bad. His latest results:
​
BUN: 50.5 mmol/L HIGH
Potassium: 5.7 mmol/L HIGH
Phosphorus: 3.23 mmol/L HIGH
Creatinine: 852 umol/L HIGHALT (SGPT): 59 u/L
GLUCOSE: 23.5 mmol/L HIGH
​
Doctor said that his kidney values are very bad and his sugar is very high. Doctor started him on insulin and the cat was on liquids IV for several days. The doctor commented that he was surprised that the cat with such high values would have such voracious appetite - he would eat everything they put in front of him. After a day or two they did a second blood test and the results hadn't changed much. His behaviour, aside from occasional ear scratching, was normal. Eventually we took him home and continued with insulin injections and renal diet.
​
Over the next week or two we noticed he seemed to regain his leg strength and had no trouble jumping up on sofa and chair. He also stopped scratching his ear. He stood on his hind legs in plantigrade stance much less. He still had occasional hyperestesia attacks, usually at night.
One night, few hours after the insulin dose, he was very lethargic, meowing, mouth open and half closer eyes. The vet suggested that it was hypoglycaemia as the cat came out of it by the morning and appeared getting better after eating a bit of his food.
​
Now the last few days his symptoms appear to be getting worse. He seems more *lethargic*, *less communicative*, *less responsive to petting*, he *spends all of his time sitting on a narrow windowsill* to the point where we bring his food and water to him and carry him to the litterbox. He occasionally, usually at night, gets hyperestesia attacks where he will appear restless and lick himself compulsively for about 15-20 min. His has a new behaviour of hiding under blanket for about 15 min every night for the last three days. If he decides to go anywhere, he doesn't walk back, he runs. He is also a bit wobbly when he stands. He sometimes stands over his water, but doesn't drink.
​
What is happening here? Is this diabetes? Kidney disease? Something else? If its a kidney disease, then why all these years he appeared to be getting better instead of declining over tine?