MedWorm provides a medical RSS filtering service. Over 6000 RSS medical sources are combined and output via different filters. This feed contains the latest medical blog items that have been tagged with 'attending'. Sat, 03 Sep 2011 02:31:34 +0100 http://www.medworm.com/index.php?rid=5181698&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6448 To recap:   47-year-old woman found stuporous and hypotensive.  She has known alcohol abuse and decreased LVEF around 30%.   Her labs come back, and you should provide plausible reconstructions of these results. Fluid Balance Panel  110 59 38 73 3.2 30 2.2 8.0 Arterial Blood Gas on 2L nasal oxygen pH 7.57 pCO2 31 pO2 99 c HCO3 29 What do you think her acid-base diagnosis is?  What additional information do you want (history, physical and/or labs)? ======= New information: The ER gave 3000 cc of NS (plus a banana bag).  Her BP slowly increased. Her sodium increased from 110 to 120 over 6 hours.  You get back her serum osm – 240 and her urine osm – 150. Her lactic acid level confirms a mild lactic acidosis which... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=5181698 Thu, 01 Sep 2011 12:48:11 +0100 5181698 http://www.medworm.com/index.php?rid=5181699&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6445 47-year-old woman found stuporous and hypotensive.  She has known alcohol abuse and decreased LVEF around 30%.   Her labs come back, and you should provide plausible reconstructions of these results.   Fluid Balance Panel  110 59 38 73 3.2 30 2.2 8.0   Arterial Blood Gas on 2L nasal oxygen   pH 7.57 pCO2 31 pO2 99 c HCO3 29 What do you think her acid-base diagnosis is?  What additional information do you want (history, physical and/or labs)? (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=5181699 Tue, 30 Aug 2011 22:51:08 +0100 5181699 http://www.medworm.com/index.php?rid=5139645&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6429 Kudos to torontointernist.  The Canadian understood the big clues.  Here we have a patient with a normal gap metabolic acidosis plus a proximal tubule leak – 2+ urine glucose with a normal serum glucose.  This suggests strongly Fanconi's syndrome.  I mentioned a chronic disease and a medication.  Several medications can cause Fanconi's, but the most likely in 2011 is tenofovir, an HIV drug. So Torontointernist nailed it using careful logic.  And db claps wildly!!! (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=5139645 Wed, 17 Aug 2011 12:47:20 +0100 5139645 http://www.medworm.com/index.php?rid=5139646&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6426 45-year–old man with a chronic disease, gets admitted for increased creatinine and abnormal urinalysis.  His previous creatinine was less than 1.0. 140 107 9 105 4.1 21 1.9   ABG confirms metabolic acidosis with appropriate compensation. U/A includes 2+ protein, 2+ glucose, 2+ blood U Na 24, K 12, Cl 18 Day 2 K drops to 3.1, Phos 1.8, Mg 2.1 What is the underlying disease, and what medication caused these abnormalities?   (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=5139646 Tue, 16 Aug 2011 12:32:40 +0100 5139646 http://www.medworm.com/index.php?rid=5069404&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6396 To repeat: 44-year-old man has had a recent drinking binge.  He has fallen several times (unclear whether this is syncope or not)     Fluid Balance Panel (6 pm) 137 92 15 91 4.9 16 0.7     Arterial Blood Gas(midnight)   pH 7.45 pCO2 30 pO2 84 c HCO3 21 What do you think his acid-base diagnosis is?  What tests would you order? He initially had a significant anion gap.  His U/A was positive for ketones, but a serum ketone test was negative.  He had a slightly elevated lactate of 6.2.  I suspect he came in with a mild lactic acidosis and perhaps alcoholic ketoacidosis.  These problems resolved quickly, explaining his ABG results 6 hours later. We had a confusing issue – his serum osms on the initial blood equal... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=5069404 Wed, 27 Jul 2011 12:02:03 +0100 5069404 http://www.medworm.com/index.php?rid=5050457&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6387 44-year-old man has had a recent drinking binge.  He has fallen several times (unclear whether this is syncope or not)   Fluid Balance Panel (6 pm) 137 92 15 91 4.9 16 0.7     Arterial Blood Gas(midnight)   pH 7.45 pCO2 30 pO2 84 c HCO3 21 What do you think his acid-base diagnosis is?  What tests would you order? (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=5050457 Tue, 19 Jul 2011 16:48:15 +0100 5050457 http://www.medworm.com/index.php?rid=5028067&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6376 Earlier this week, our 3rd year students saw a patient die.  Every time we see this passage we come to terms with mortality.  But the first time has a profound impact.  We spent some time discussing this aspect of doctoring on rounds the next morning. Sometimes we do things that have a major positive effect for patients.  We prolong life; we improve the quality of life.  Even when we cannot prolong life we can comfort patients and make the dying process a natural passage. But this unfortunate patient died suddenly and unexpectedly.  We had a good treatment plan and expected a good short term outcome. We suspect that he had a pulmonary embolism.  He had just come to the hospital about 12 hours prior to death, so we feel certain that we did not contribute t... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=5028067 Sun, 10 Jul 2011 22:36:40 +0100 5028067 http://www.medworm.com/index.php?rid=5008312&cid=t_161717_109_f&fid=34750&url=http%3A%2F%2Fpsychcentral.com%2Fblog%2Farchives%2F2011%2F07%2F05%2Fapproaches-to-knowledge-interview-with-nathaniel-b-jones%2F Dr. Brian Jones has a PhD in exercise science and is a full-time professor at the University of Louisville where he teaches both graduate and undergraduate courses. He approaches all his courses with a scientific mindset, emphasizing the importance of critical thinking. Recently, Dr. Jones sent me a file containing one of his lectures on critical thinking. The lecture was for college students, but after reading the file I thought the subject matter would be great for everyone to know, not just those who are attending college. In the following interview, we discuss important points on critical thinking and approaches to knowledge. I think most people know that the media is not the best source for reliable information.  Yet, many seem to almost exclusively turn to the media for knowledge. ... World of Psychology blogs http://www.medworm.com/rss/comments.php?id=5008312 Tue, 05 Jul 2011 10:22:38 +0100 5008312 http://www.medworm.com/index.php?rid=4997502&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6367 Over the past several years, I have noted that many students and residents have a very simple approach to diuretic use.  They furosemide as their main loop diuretic; they use hydrochlorothiazide as their antihypertensive.  Many of them do not really know the alternatives, and therefore resort to a single standard. Here are my main teaching points: 1. Many patients do not respond well to oral furosemide.  Furosemide has very variable absorption with an average of only 50%.  We have two other loop diuretics – bumetanide and torsamide.  Bumetanide is on all the $4 lists. It has almost 100% consistent absorption.  When I have a patient who is responding to IV furosemide, but not oral furosemide, I often switch them to bumetanide.  The conversion factor ... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4997502 Sun, 03 Jul 2011 23:13:02 +0100 4997502 http://www.medworm.com/index.php?rid=4968423&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6358 Recently I have become obsessed with learning about the diagnostic process.  Some colleagues have taught me about dual process diagnostic thinking, and of course I have been reading articles. Here is my summary: As we develop experience we start the diagnostic process with an intuitive model.  I don't like the label, because it suggests that we are not thinking at all.  What I believe we are doing is matching a problem representation to an illness script.  We could call this pattern recognition, but there are really two concepts at play here.  We must know enough about the illness scripts to develop a problem representation.  Dr. Judy Bowen's great NEJM article really helped me here - Educational Strategies to Promote Clinical Diagnostic Reasoning... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4968423 Fri, 24 Jun 2011 12:41:33 +0100 4968423 http://www.medworm.com/index.php?rid=4934021&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6347 60-year-old man admitted for 3-5 days of nausea, vomiting (undigested food), watery diarrhea (volume not specified) and alcohol on his breath. Patient has significant orthostasis with pulse increase (just raising head of bed).  PMH of hypertension – only prescribed metoprolol. Predict the electrolyte disorders and acid base disorders. There are no surprises here – we predicted the direction of everything at morning report. 139 75 13 159 2.3 15 1.3     Unfortunately we do not have an ABG, but we can get quite close to the truth. First, I assumed that an alcohol abuser with vomiting and watery diarrhea would have significant hypokalemia.  That is the easiest prediction. Second, we cannot predict the sodium level.  The patient would likely have vol... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4934021 Thu, 16 Jun 2011 12:23:39 +0100 4934021 http://www.medworm.com/index.php?rid=4934022&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6345 A 60+ year old man was admitted for a 1 day history of abdominal pain, hematochezia, and a rash developing over his lower extremities bilaterally.  No significant PMH other than chronic pain. H&P revealed a history of nausea and vomiting the day previous to admission with 6 bright red bloody stools and diffuse abdominal pain. Later that day he noticed a rash developing over his left foot which eventually progressed to involve both lower extremities to the knee. Exam was notable for a benign abdomen and palpable, nonblanching petechiae present from the soles proximally to the thighs.  Physical exam is otherwise unremarkable.   Labs:   WBC 12.3k H/H 13.4/40.7 Plts 389k   134 100 42 136 5.4 26 2.8 8.2 UA – moderate protein, 6 hyaline casts, + bacter... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4934022 Wed, 15 Jun 2011 22:41:22 +0100 4934022 http://www.medworm.com/index.php?rid=4934023&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6343 60-year-old man admitted for 3-5 days of nausea, vomiting (undigested food), watery diarrhea (volume not specified) and alcohol on his breath. Patient has significant orthostasis with pulse increase (just raising head of bed).  PMH of hypertension – only prescribed metoprolol. Predict the electrolyte disorders and acid base disorders. There are no surprises here – we predicted the direction of everything at morning report. 139 75 13 159 2.3 15 1.3   (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4934023 Wed, 15 Jun 2011 22:36:21 +0100 4934023 http://www.medworm.com/index.php?rid=4934024&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6341   A 60+ year old man was admitted for a 1 day history of abdominal pain, hematochezia, and a rash developing over his lower extremities bilaterally.  No significant PMH other than chronic pain. H&P revealed a history of nausea and vomiting the day previous to admission with 6 bright red bloody stools and diffuse abdominal pain. Later that day he noticed a rash developing over his left foot which eventually progressed to involve both lower extremities to the knee. Exam was notable for a benign abdomen and palpable, nonblanching petechiae present from the soles proximally to the thighs.  Physical exam is otherwise unremarkable.   Labs:   WBC 12.3k H/H 13.4/40.7 Plts 389k   134 100 42 136 5.4 26 2.8 8.2 UA – moderate protein, 6 hyaline casts, +... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4934024 Tue, 14 Jun 2011 20:19:04 +0100 4934024 http://www.medworm.com/index.php?rid=4902386&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6325 This past weekend I attended an internal medicine meeting during which several internists expressed strong concerns about medical education with the new work hour restrictions.  Readers know that I make rounds often (probably > 150 days each year) and in two disparate sites – a large community hospital with family medicine residents and a VA hospital with internal medicine residents.  We also have 3rd year students in each program. I first served as ward attending in January 1980.  Much has changed since then, but more has stayed the same. Patients still present with a variety of diseases.  Some patients arrive early in their course; some patients wait a dangerous amount of time.  The art of history taking remains a challenge that probably takes years to m... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4902386 Mon, 06 Jun 2011 17:32:10 +0100 4902386 http://www.medworm.com/index.php?rid=4893339&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6320 60-year-old man admitted for 3-5 days of nausea, vomiting (undigested food), watery diarrhea (volume not specified) and alcohol on his breath. Patient has significant orthostasis with pulse increase (just raising head of bed).  PMH of hypertension – only prescribed metoprolol. Predict the electrolyte disorders and acid base disorders. There are no surprises here – we predicted the direction of everything at morning report. (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4893339 Thu, 02 Jun 2011 14:32:28 +0100 4893339 http://www.medworm.com/index.php?rid=4797760&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6285 We presented several posters on this topic during the meeting.  The workshop allows participants to discuss the many techniques one can use to improve attending rounds. I can't blog too much about our data, because we have not yet published our results.  We did provide a copy of this article, which provides a good abridgment of our discussions – Become a better ward attending. I actually reread this periodically to remind myself of everything I might consider. (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4797760 Sat, 07 May 2011 14:29:27 +0100 4797760 http://www.medworm.com/index.php?rid=4714692&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6229 Over the past few weeks I have considered doctoring philosophically.  My thoughts started to coalesce after Rich Baron's outstanding keynote address at IM 2011.  His remarks struck a chord and enhanced some ideas that I have considered the last few years. Many academicians, many wonks, most congressmen, and most "suits" believe that we can define high quality care easily.  They view doctoring like flying an airplane.  If A happens, then clearly we should do B. They forget that a pilot trains on each variety of airplane and becomes an expert on that particular plane.  Each plane of that series works in the same way. If I could doctor one patient repeatedly, then I could develop rules.  But my patients all differ.  They might have the same dis... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4714692 Thu, 14 Apr 2011 16:44:58 +0100 4714692 http://www.medworm.com/index.php?rid=4676730&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6213 CONCLUSION: Certain clerkship characteristics are associated with better student examination performance, the most salient being caring for more patients per day.     (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4676730 Mon, 04 Apr 2011 16:00:38 +0100 4676730 http://www.medworm.com/index.php?rid=4664117&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6201 Attending rounds in internal medicine in many ways define the internal medicine rotation.  We who love making attending rounds each develop our own implicit rules.  In this post I am working to make those rules explicit.  I do not pretend that my list is comprehensive or complete.  I would appreciate additions and suggestions. Be timely – there is nothing worse than abusing time when you are the attending.  You should arrive on time (5-10 min leeway is acceptable) and end on time.  Residents and interns work hard.  When we spend too much time rounding they have difficulty getting their other work down. Be efficient – give the house staff time to contact consultants during rounds Think out loud – all learners want to understand how you a... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4664117 Thu, 31 Mar 2011 16:34:21 +0100 4664117 http://www.medworm.com/index.php?rid=4545011&cid=t_161717_109_f&fid=34750&url=http%3A%2F%2Fpsychcentral.com%2Fblog%2Farchives%2F2011%2F03%2F03%2Fmechanical-turk-to-the-rescue-of-psychology-research%2F One of the problems faced with psychology research — really, with all medical research — is finding enough appropriate subjects to study. Subjects have to be obtained in a way that is representative of the population as a whole for research findings to be generalizable. Which is a real problem, because as I noted back in August 2010, there are literally thousands of psychology studies based upon nothing more than a bunch of college students from a single campus at a university in the U.S. While young adults who are attending college may indeed help us understand some aspects of human behavior, you can’t just assume that the behaviors you observed in those studies apply to 60-year-old women and men too. Enter Amazon.com’s Mechanical Turk service to the rescue. Can te... World of Psychology blogs http://www.medworm.com/rss/comments.php?id=4545011 Thu, 03 Mar 2011 17:21:54 +0100 4545011 http://www.medworm.com/index.php?rid=4507242&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6132 50-something year-old woman is admitted for weakness.  She has a history of chronic diarrhea.  She has had type II DM for over 15 years.  Her labs are remarkable: Fluid Balance Panel 137 113 48 163 5.6 14 1.5   Arterial Blood Gas pH 7.24 pCO2 36 pO2 79 c HCO3 16 What do you think her acid-base diagnosis is?  How do you prove it, i.e., what further tests do you order? First, the patient is not taking any RAS blockers (ACE-I, ARB or spironalactone). Urine lytes: Na 58 K 22 Cl 65 Thus UAG = +15, and acidosis is due to impaired buffering Urine Osm = 362, calculated TTKG = 3.2.  In the presence of hyperkalemia, this low TTKG supports hypoaldesteronism. The patient has type IV RTA – hyporenin, hypoaldo – commonly associated with diabe... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4507242 Mon, 21 Feb 2011 20:16:18 +0100 4507242 http://www.medworm.com/index.php?rid=4495160&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6124 Presented this week at morning report: 50-something year-old woman is admitted for weakness.  She has a history of chronic diarrhea.  She has had type II DM for over 15 years.  Her labs are remarkable: Fluid Balance Panel 137 113 48 163 5.6 14 1.5   Arterial Blood Gas pH 7.24 pCO2 36 pO2 79 c HCO3 16 What do you think her acid-base diagnosis is?  How do you prove it, i.e., what further tests do you order? (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4495160 Fri, 18 Feb 2011 17:32:52 +0100 4495160 http://www.medworm.com/index.php?rid=4419431&cid=t_161717_147_f&fid=39273&url=http%3A%2F%2Ffeedproxy.google.com%2F%7Er%2FePharmaSummit%2F%7E3%2F4H7V7wyrHvA%2Fwho-can-you-meet-next-week-at-epharma.html The largest most exciting ePharma Summit to date is only one week away! You won’t want to miss this exciting 10th Anniversary Program, taking place on February 7th-9th at the Sheraton NY Hotel & Towers in NYC.We are proud to highlight our Marquee Sponsor, Klick Pharma, on this year’s program through the thought leader contributions of Brian O’Donnell, EVP of Interactive Services, and Jay Goldman, Vice President of Strategy.Join representatives from:University of Washington * Topin & Associates Inc * Communications Media Inc * Medi Promotions * Intouch Solutions * Takeda Pharmaceuticals * Atellas Pharmaceuticals * PDR Network LLC * Element Market Research * US Oncology Clinical Development * Enspektos LLC * Forest Laboratories Inc * Acxiom Corporation * Wired Magazine * Finger... ePharma Summit blogs http://www.medworm.com/rss/comments.php?id=4419431 Mon, 31 Jan 2011 14:00:00 +0100 4419431 http://www.medworm.com/index.php?rid=4399466&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6077 The most important teaching point here is that the markedly elevated phosphate explains the increased anion gap.  I have probably seen this about 4 times in the past 5 years.  I agree with the comments that the FeNa is very high, suggesting acute tubular necrosis.  The rapid correction suggests that the patient was in the diuretic phase. Another possibility is that the patient had extreme volume contraction, and had the urine lytes checked after receiving significant IV fluids.  I do not know the exact time frame, but this is clearly a possibility. The serum osms were 296 and the ethylene glycol level was negative.  Calcium oxalate crystals in the urine are sensitive but not specific for ethylene glycol.  Fortunately, fomipazole only costs ~$500 now (it is ge... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4399466 Wed, 26 Jan 2011 13:23:34 +0100 4399466 http://www.medworm.com/index.php?rid=4394387&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6072 To recount:     Na 124 Cl 71 BUN 99 glu 114 K 5.5 CO2 31 creat 6.6       ABG on room air pH 7.46 pCO2 18 pO2 70 calc HCO3 13 Step 1 Define the acid-base problem. Several readers understood that the ABG does not fit the BMP.  Let us start with the BMP. 1. We have an increased anion gap – 22 – therefore we should explain the unknown anion 2. We have an increased bicarbonate and when we consider the delta gap, it is very high 3. Surprisingly we have a normal K (usually low in volume contraction) 4. We have a marked elevation in BUN and creatinine, suggesting acute renal failure 5. From the ABG we see a respiratory alkalosis, probably explained by hypoxemia – note the very large A-a gradient I suspect the ABG was drawn at a ve... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4394387 Tue, 25 Jan 2011 13:00:48 +0100 4394387 http://www.medworm.com/index.php?rid=4372001&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6063 They saved this one for me for 6 months!  Here is the intro as written by an excellent resident: 52 yo WM with hx of heroin use presented to ER from jail for AMS, nausea, vomiting, and diarrhea.  Pt was arrested 2 days prior to presentation, and per guard had been somewhat confused but ambulating normally.  No other details elicited from guard or pt.  PE:   AF  147/96 (unable to do orthostatics 2/2 too unstable to stand)  HR 82   O2 sat 96% on 2L NC Physical exam notable for cachectic appearing WM awake but lethargic and not answering questions.  Track marks noted to bilateral upper extremities.  Dry mucous membranes.  Lungs clear.  Abd benign.  Foley w/ ~200 cc urine in bag after ~1 liter in ER.  Co... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4372001 Wed, 19 Jan 2011 18:09:42 +0100 4372001 http://www.medworm.com/index.php?rid=4179280&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5941 Over the past week we had 2 patients with hepatic encephalopathy.  One patient responded nicely to oral lactulose, but the other remained encephalopathic despite 2-3 stools daily for a week.  We considered several possibilities.  The classic choices have been neomycin or metronidazole.  Neomycin is great short term, but can cause renal failure or deafness when used chronically.  Metronidazole is not acceptable to many patient, primarily because of the bitter metallic taste associated with that drug (not to mention the antabuse like properties). So we decided to use rifaximin 550 mg twice daily.  These articles informed our decision: Rifaximin Reduces Encephalopathy Recurrence, Improves Quality of Life in People with Liver Cirrhosis Antibiotic Rifaximin Mainta... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4179280 Thu, 18 Nov 2010 18:07:35 +0100 4179280 http://www.medworm.com/index.php?rid=4175628&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5937 In this study wide QRS is defined as 120 or greater. EMPHASIS-HF: Eplerenone shows large benefits in milder heart failure The aldosterone antagonist eplerenone (Inspra, Pfizer) produced large reductions in both the risk of death and the risk of hospitalization compared with placebo in patients with systolic heart failure and mild symptoms in the EMPHASIS-HF trial [1]. These two studies suggest that the LVEF should drive therapeutic options.  Some patients remain Class II despite LVEF < 30%.  These studies show that we should treat their decreased ejection fraction aggressively.  I will likely use spironalactone rather than eplerenone for cost reasons. (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4175628 Wed, 17 Nov 2010 13:37:16 +0100 4175628 http://www.medworm.com/index.php?rid=4164506&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5930 So we went to the bedside.  The patient appeared unhappy and uncomfortable. My questions started with the nausea and vomiting, but quickly we moved to the patient's job.  He had a recent promotion to a supervisory position.  Since that time sleep was restless and never adequate.  He was anhedonic, and cried often.  During the interview he started crying.  He had lost 20 pounds in the past month due to decreased appetite. So I thought that I had solved the entire problem – depression and generalized anxiety disorder. And that was a big part of his problem, but probably did not explain his frequent vomiting.  My colleague focused on the vomiting and asked if taking showers improved his symptoms.  She suggested a diagnosis of cannabinoid hyper... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4164506 Mon, 15 Nov 2010 00:39:34 +0100 4164506 http://www.medworm.com/index.php?rid=4155208&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5921 I know that I say this almost every day.  When I am confused, I retreat to the bedside and start again.  Often when residents and students present patients I feel that an important clue is missing.  Going to the bedside can provide that clue. This is a case where the labs spurred a bedside visit and a diagnosis. The patient is 30 something.  The patient complained of sudden onset of vomiting early in the morning, coming to the ER 3 hours later, still having frequent dry heaves.  He/she admitted to frequent vomiting, but this episode was worse.  He/she also complained of loose stools since a cholecystectomy when a teenager. These labs confused me:   140 105 7 4.4 19 0.8 The glucose is normal.  The albumin is 5. We then got an ABG.  Step 1... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4155208 Thu, 11 Nov 2010 12:01:17 +0100 4155208 http://www.medworm.com/index.php?rid=3998920&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5825 Now the resident on the 5th day asks me why the bicarbonate is depressed.  The patient is stuporous on benzodiazepines.  He is breathing 16 times per minute (my own count) and snoring loudly.  We cannot do a good exam at this time.   136 105 8 3.6 16 0.6 What do you tell the resident? This post is dedicated to Happy and Cory.  They both agree on getting an ABG. We obtained one and the patient was breathing room air.  Do they agree on anything else? pH 7.4 pCO2 23 pO2 74 calc HCO3 15 Now what do you think and what do you do? (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3998920 Fri, 24 Sep 2010 13:48:16 +0100 3998920 http://www.medworm.com/index.php?rid=3993819&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5819 60+ year old man admitted for altered mental status – he is well known to our hospital and a heavy alcoholic 117 82 6 3.3 26 0.6 The glucose is normal This is part 1 – what tests do you order?  What further information do you want?  Do you start treatment? Clues – no seizures, no alcohol in blood Serum osms = 245 Urine osms = 90 Therefore beer potomania However, the patient goes into DTs.  The team increases his sodium slowly (2 days to achieve 130). Now the resident on the 5th day asks me why the bicarbonate is depressed.  The patient is stuporous on benzodiazepines.  He is breathing 16 times per minute (my own count) and snoring loudly.  We cannot do a good exam at this time.   136 105 8 3.6 16 0.6 What do you tel... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3993819 Wed, 22 Sep 2010 18:47:45 +0100 3993819 http://www.medworm.com/index.php?rid=3983380&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5813 60+ year old man admitted for altered mental status – he is well known to our hospital and a heavy alcoholic 117 82 6 3.3 26 0.6 The glucose is normal This is part 1 – what tests do you order?  What further information do you want?  Do you start treatment? Clues – no seizures, no alcohol in blood Several more parts ensue (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3983380 Sun, 19 Sep 2010 11:01:56 +0100 3983380 http://www.medworm.com/index.php?rid=3861969&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5720 The diagnosis is not tricky, but I do have a few questions:   Na 121 Cl 73 BUN 57 glu 1820 K 9.6 CO2 6 creat 3.2     Has anyone seen a higher glucose? A higher K? Postulate the sequence of events leading to these numbers Background information – 17 year history of type I DM.  Several recent admissions for DKA, but usually with blood glucose lower than 1000. ABG  pH 7.20 pCO2 17 pO2 324 calc HCO3 17 Here are the numbers the next morning and the following day Na 145 Cl 105 BUN 49 glu 909 K 4.9 CO2 14 creat 2.5     Na 143 Cl 108 BUN 14 glu 110 K 3.6 CO2 23 creat 0.9     Some additional information: The patient presented unconscious and hypotensive He required intubation for several hours He has multiple ... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3861969 Thu, 12 Aug 2010 14:05:48 +0100 3861969 http://www.medworm.com/index.php?rid=3854482&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5709 The diagnosis is not tricky, but I do have a few questions:   Na 121 Cl 73 BUN 57 glu 1820 K 9.6 CO2 6 creat 3.2 Ca++   Has anyone seen a higher glucose? A higher K? Postulate the sequence of events leading to these numbers Background information – 17 year history of type I DM.  Several recent admissions for DKA, but usually with blood glucose lower than 1000. ABG  pH 7.20 pCO2 17 pO2 324 calc HCO3 17   (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3854482 Tue, 10 Aug 2010 19:24:06 +0100 3854482 http://www.medworm.com/index.php?rid=3833415&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5705 To repeat the problem: 26-year-old man comes in for flank pain.  He has a history of renal stones.  It is August in Alabama, he has been working outside.  He does state that he has been drinking and urinating.     Na 139 Cl 92 BUN 28 glu 128 K 4.5 CO2 22 creat 2.5 Ca++ 10.6  These lab tests led to his admission.  What can you glean from these labs?  Postulate on the cause of these numbers. The comments were spot on – increased anion gap acidosis (gap 25) and metabolic alkalosis (delta gap of approximately 13 with a normal bicarb) The patient was markedly volume contracted.  We explained his anion gap from his phosphate level of 9.6.  After volume expansion his phosphate returned to normal, as did his increased gap.  His c... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3833415 Sat, 07 Aug 2010 11:33:05 +0100 3833415 http://www.medworm.com/index.php?rid=3822864&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5701 26-year-old man comes in for flank pain.  He has a history of renal stones.  It is August in Alabama, he has been working outside.  He does state that he has been drinking and urinating.     Na 139 Cl 92 BUN 28 glu 128 K 4.5 CO2 22 creat 2.5 Ca++ 10.6  These lab tests led to his admission.  What can you glean from these labs?  Postulate on the cause of these numbers. (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3822864 Thu, 05 Aug 2010 01:35:31 +0100 3822864 http://www.medworm.com/index.php?rid=3772193&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5669 Staph lugdunensis is (as Eric points out) becoming much more important.  As the reference points out, it is a coagulase negative Staph that has similar virulence to Staph aureus.  Thus, the comments are correct. We had to look for endocarditis.  The TTE did not show a vegetation, but the TEE did.  We pulled the permcath and arranged for a new permcath.  We stuck with vancomycin because of the ease of administration (dosing at dialysis). I presented this patient because his story has important educational points.  I had not heard of Staph lugdunensis prior to caring for him.  These are (in my opinion) the key teaching points: Coagulase negative Staph is not always a contaminant.  We treated this patient because we treated his clinical syndrome while ... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3772193 Tue, 20 Jul 2010 10:43:52 +0100 3772193 http://www.medworm.com/index.php?rid=3757817&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5658 The patient story should attract attention from nephrologists, ID experts, residents, students and hospitalists.  Please express you opinion – we have a definite answer.   Several months ago, a 60 year old man was admitted to our service with a hot right knee.  He has CKD on dialysis and has a "permcath" in place – all his potential vascular access no longer work.  He identified no history of trauma and denied fevers or chills.  He received initial treatment with prednisone. Due to lack of symptom resolution, he underwent an arthrocentesis that showed 46,333 cells per cubic mm, but no visible crystals. Four days later his cultures grew a coagulase negative Staphylococcus species. Your problem – what do you do with the coagulase... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3757817 Thu, 15 Jul 2010 20:16:56 +0100 3757817 http://www.medworm.com/index.php?rid=3750007&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5650 As I wrote recently, internal medicine should focus on diagnosis.  That focus ensnared my heart back in 1973, and the focus has not changed over the years.  Internists often like physiology and pharmacology.  Internists can develop lists of differential diagnosis. Why is diagnosis so important?  Because without correct diagnosis, our treatments make no sense.  We entertain several levels of diagnosis.  For example, we are caring for a man admitted for a fever and rigors.  We considered several different infections and thus started with broad spectrum coverage.  On day 2 of his hospitalization we learned that his blood cultures were growing a gram negative rod.  At that time we narrowed our differential diagnosis and stopped 1 of his 3 antibiotic... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3750007 Tue, 13 Jul 2010 11:11:59 +0100 3750007 http://www.medworm.com/index.php?rid=3721723&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5623 So I am back at the VA.  I joined my team yesterday, and will round through July 15.  The first day of a rotation involves getting to know everyone and setting expectations.  We were admitting for the past 24 hours so today I expect to see a large number of patients. I probably went a bit crazy with my teaching yesterday.  My excitement was probably out of control.  We have 2 enthusiastic, bright and green 3rd year students.  Every topic opens a new window to medicine.  While we covered many topics (probably too many), I will focus today on syncope.  When the team presented the patient to me, they had not taken an adequate syncope history.  As I wrote yesterday, we have an obligation to develop a complete and careful history for each problem.&n... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3721723 Fri, 02 Jul 2010 10:37:45 +0100 3721723 http://www.medworm.com/index.php?rid=3714122&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5578 This article will add several important teaching points to my standard hyponatremia discussion.  If you have a significant interest in hyponatremia, I recommend the article.  I believe all hospitalists should be experts in hyponatremia. (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3714122 Wed, 30 Jun 2010 12:52:52 +0100 3714122 http://www.medworm.com/index.php?rid=3710561&cid=t_161717_87_f&fid=39187&url=http%3A%2F%2Fgetbetterhealth.com%2Freflections-of-a-clinician-educator%2F2010.06.29 A version of the following post by Kimberly Manning appeared on the blog Reflections of a Grady Doctor: May and June mark the end of our academic year in medical education. The medical students either advance to the next level or become sho’ nuff and bonified doctors — albeit uncertified and untrained — but doctors nonetheless. The interns exit the novice stage and become residents — one week asking someone senior what to do, the next telling someone junior what to do. And of course, the senior residents and fellows finally get the stamp of approval that officially releases them from the nest. It’s kind of bittersweet for folks like me — the surrogate mommies and daddies that helped guide them along this path to becoming full-fledged physicians. (more&#... Better Health blogs http://www.medworm.com/rss/comments.php?id=3710561 Tue, 29 Jun 2010 12:00:00 +0100 3710561 http://www.medworm.com/index.php?rid=3655807&cid=t_161717_151_f&fid=35818&url=http%3A%2F%2Frecoveryissexy.com%2Fna-works-for-recovery-2%2F Drug Addicts Recover with Help from the 12 Step Program What’s working in Yakima to help fight drug and alcohol addiction? People say the local 12 step programs, Narcotics Anonymous, are helping them recover. Accepting your addiction is the first step. Anthony Salas, a recovering drug addict, says it hasn’t been easy. He’s been clean for four years now, but temptation is always there.  "If I have just one drug, I have to have more and more and more and I can’t stop," said Salas. Recovering is an ongoing process. People like Cathy Hale and Anthony say going to the 12-step program and attending meetings is what helps them stay away. "I get emotional thinking about it cause it means a lot to me, I couldn’t do life without them," said C... Recovery Is Sexy.com blogs http://www.medworm.com/rss/comments.php?id=3655807 Fri, 11 Jun 2010 17:33:00 +0100 3655807 http://www.medworm.com/index.php?rid=3475762&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5435 To recap 50 something man admitted to our service after being found unresponsive.  He is well known to our hospital, is homeless, an alcoholic and has a seizure disorder. In the ER he is found to have bilateral lower lobe pneumonia, and an alcohol level of 426.  He becomes hypotensive, requires intubation and pressors.  The resident presents these laboratory tests:   Na 138 Cl 109 BUN 15 glu 151 K 3.9 CO2 15 creat 1.0     On 50 % oxygen: pH 7.29 pCO2 33 pO2 86 HCO3 16 Over 24 hours we were able to extubate the patient and discontinue the pressors.  He became alert, but without any memory of his admission. I had speculated about his acid base status on presentation.  I needed more information.  His albumin was 4.  Previou... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3475762 Fri, 16 Apr 2010 12:16:04 +0100 3475762 http://www.medworm.com/index.php?rid=3467701&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5423 50 something man admitted to our service after being found unresponsive.  He is well known to our hospital, is homeless, an alcoholic and has a seizure disorder. In the ER he is found to have bilateral lower lobe pneumonia, and an alcohol level of 426.  He becomes hypotensive, requires intubation and pressors.  The resident presents these laboratory tests:   Na 138 Cl 109 BUN 15 glu 151 K 3.9 CO2 15 creat 1.0     On 50 % oxygen: pH 7.29 pCO2 33 pO2 86 HCO3 16   1. What is his acid-base disorder? 2. Speculate on an etiology. 3. How would you treat him? (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3467701 Tue, 13 Apr 2010 20:51:21 +0100 3467701 http://www.medworm.com/index.php?rid=3408323&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5386 For those who are following the discussion of my most recent acid base question: I believe that the patient actually has two primary conditions – an increased anion gap acidosis and a respiratory alkalosis.  As I understand salicylate toxicity, this is the classic acid-base presentation.  I do not believe that the anion gap acidosis is compensatory. Related posts:Answer to weakness and confusion My thoughts on March 8 acid-base AMS – an acid-base problem II (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3408323 Fri, 26 Mar 2010 16:05:58 +0100 3408323 http://www.medworm.com/index.php?rid=3398853&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5376 Presented at morning report: 56 yo man with known osteoarthritis and hyperlipidemia presents complaining of weakness and confusion   Na 140 Cl 105 BUN 18 glu 128 K 3.3 CO2 16 creat 0.9       pH 7.47 pCO2 24 pO2 74 HCO3 18   1. What is the acid-base disorder – be complete? 2. What additional tests do you want? 3. Provide at least 2 possible causes for these numbers. Related posts:March 8, 2010 – an acid base challenge My thoughts on March 8 acid-base The acid base book (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3398853 Tue, 23 Mar 2010 19:11:15 +0100 3398853 http://www.medworm.com/index.php?rid=3354251&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5358 First, thanks to the great discussion.  Readers will learn as much from the discussion as they will from me.  To repeat the presentation: The patient is an 81 year old man found with altered mental status.  He has known diabetes mellitus, hypertension, COPD and CHF, but has not taken any medications for the past year. Electrolyte panel Na 142 Cl 96 BUN 99 K 5.5 HCO3 21 creat 2.3 Blood Sugar 568           Alb 3.1 ABG on 4 liters nasal oxygen ABG pH 7.38 pCO2 29 pO2 133 HCO3 18           So please address these questions: 1. What is the acid-base disorder? Great job here.  The patient has an increased anion gap – defining an increased anion gap metabolic acidosis.  Note that has expecte... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3354251 Thu, 11 Mar 2010 13:41:22 +0100 3354251 http://www.medworm.com/index.php?rid=3354252&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5356 We have a brilliant debate ongoing in the comment section of yesterday's problem.  I will refrain from commenting for 24 hours.  Please join the debate – then I will weigh in some time tomorrow. I cannot answer every question about this patient, but I can answer some key questions. Related posts:Duty hours – no easy answers (h/t @FutureDocs) 15 days at the VA – day 2 March 8, 2010 – an acid base challenge (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3354252 Wed, 10 Mar 2010 19:50:10 +0100 3354252 http://www.medworm.com/index.php?rid=3346415&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5353 The patient is an 81 year old man found with altered mental status.  He has known diabetes mellitus, hypertension, COPD and CHF, but has not taken any medications for the past year. Electrolyte panel Na 142 Cl 96 BUN 99 K 5.5 HCO3 21 creat 2.3 Blood Sugar 568 Alb 3.1 ABG on 4 liters nasal oxygen ABG pH 7.38 pCO2 29 pO2 133 HCO3 18 So please address these questions: 1. What is the acid-base disorder? 2.Provide a differential for the causes of the acid-base disorder? 3. What other information do you need? Related posts:A new acid-base problem An acidosis question Yesterday’s acid-base problem (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3346415 Mon, 08 Mar 2010 21:11:57 +0100 3346415 http://www.medworm.com/index.php?rid=3335265&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5347 Over the past several weeks I have emphasized in-hospital pain control.  Regularly I find patients with "legitimate" pain who complain about their pain control.  The resident's default order for many years is (pick your opioid) q 3 or 4 hours p.r.n. My palliative care colleagues have stressed that we should schedule pain control rather than provide "as needed" in those circumstances when patients will clearly have ongoing pain.  They taught me to write orders as scheduled with a may refuse provision.  More recently I have added a "do not awaken" clause from a couple of bad experiences. When the patient really has pain, do not make them hit the button and wait for someone to bring them their pain medication.  What would you want for... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3335265 Fri, 05 Mar 2010 14:57:21 +0100 3335265 http://www.medworm.com/index.php?rid=3318353&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5337 The answers were great.  I knew that GERD rarely caused severe odynophagia.  Therefore I guessed that should would have Candida esophagitis – just playing the odds. Her upper endoscopy the following day confirmed my hunch. Related posts:Medication equal to surgery for most GERD Odynophagia On PPIs (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3318353 Mon, 01 Mar 2010 02:24:32 +0100 3318353 http://www.medworm.com/index.php?rid=3311629&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5333 Took care of a young woman (with a 15 year h/o DM I) recently who presented with DKA.  We suspected that cocaine use had precipitated her DKA, but her Hgb A1c >10 also.  On day 3 we were ready to d/c the patient.  She protested because her reflux was causing too much pain.  She told us that she could hardly swallow water due to the pain.  Her oral cavity exam was unremarkable (of course I checked her tonsils).  She claimed the pain was most severe. So what would you do for her.  What diagnoses are you considering?   Related posts:Another sad Lemierre syndrome story On ABGs (w/ a h/t to Happy Hospitalist) Lisa Sanders on a patient with recurrent pain (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3311629 Fri, 26 Feb 2010 13:05:21 +0100 3311629 http://www.medworm.com/index.php?rid=3275754&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5294 This week I am rounding for 3 days.   Because at least one of my colleagues wanted to read how I used set pieces on rounds, I am planning to highlight some set pieces that I used for each day this week. 1. Pt. with COPD, s/p CABG and sterniotomy infection – admitted with increased dyspnea Set piece – main reasons that COPD patients present with increased dyspnea – he actually had atelectasis from the pain of his infection 2. Pt. with resolving pneumococcal pneumonia Set piece – what deaths do antibiotics not prevent?  what deaths do antibiotics prevent in pneumococcal pneumonia Set piece – what a pericardial friction rub sounds like 3. Pt. with hyperparathyroidism Set piece – indications for parathyroidectomy Later I did a session for th... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3275754 Tue, 16 Feb 2010 13:34:13 +0100 3275754 http://www.medworm.com/index.php?rid=3251171&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5273   Running ward-attending rounds has more in common with jazz than symphony. Patients do not follow a script. Admissions do not follow a script. The ward attending has multiple responsibilities each day.  These responsibilities include directing patient care, teaching, evaluating, and coaching learners to grow. We believe that we should combine directing patient care and teaching. The teaching during ward attending rounds generally is a response to the problems our patients represent. Sometimes we add specific talks when time permits, but our best teaching opportunities are intimately intermingled with patient care decision making.   Great ward attendings develop a mental file of important teaching points about the classic problems that we see repeat... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3251171 Mon, 08 Feb 2010 12:40:24 +0100 3251171 http://www.medworm.com/index.php?rid=3216536&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5234 In this study carvedilol decreased bleeding for stage 2 varices – and was compared with banding.  I like the study, and I will be teaching this new approach from now on. Related posts:Secondary prevention in cirrhosis 15 days at the VA – day 6 17 days at the VA – Day 2 (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3216536 Thu, 28 Jan 2010 13:59:18 +0100 3216536 http://www.medworm.com/index.php?rid=3212276&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5230 KevinMD has a great piece today – The balancing act between science and art is what makes medicine so challenging In a recent piece in The Atlantic, Dr. Verghese again writes not to let technology obstruct patient care. Indeed, he observes that “I still find the best way to understand a hospitalized patient whose care I am taking over is not by staring at the computer screen (or not by that alone) but by going to see the patient; it’s only at the bedside that I can figure out what is important.” I often tell students that I love internal medicine because being a great internist requires a fully developed left brain and a fully developed right brain.  My rounds follow a set pattern that enables us to focus fully on both the art and the science. I spend the fir... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3212276 Wed, 27 Jan 2010 12:53:10 +0100 3212276 http://www.medworm.com/index.php?rid=3148998&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5180 This month I celebrate 30 years of ward attending.  I estimate that I have done over 100 months of ward attending during this time.  I find ward attending energizing, enjoyable and rewarding.  I hope my learners agree. Here are some things I have learned: Ward attending rounds should be enjoyable.  They can only be enjoyable if the attending sets a comfortable atmosphere. Our job has two purposes – excellent patient care and learning for the students and residents.  The challenge of ward attending is that we must balance those two purposes. Teaching does not equate to learning.  Our job is to induce learning.  We should not take it personally if we "teach" something and the student does not remember it the next day.  Repetition is go... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3148998 Thu, 07 Jan 2010 14:12:25 +0100 3148998 http://www.medworm.com/index.php?rid=3136545&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5165 I left a couple of questions hanging prior to starting a vacation.  Two days of football watching, golf playing, wine drinking and great camaraderie will continue today and tomorrow.   This morning I did awaken early and go to the workout facility, continuing my exercise pattern. When last I blogged, I posed a question about the circumstances that negative eGFR.  We had a classic example of a patient who had bilateral AKA.  Here is my list, I hope that readers will add if I have omitted any important examples. Significant amputations (like our patient) Cord injury (paresis decreases muscle mass dramatically) Some muscular dystrophies Acute renal failure (remember the eGFR formulas assume a stable creatinine) Over the next few days I will contemplate the big issue... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3136545 Sat, 02 Jan 2010 13:27:32 +0100 3136545 http://www.medworm.com/index.php?rid=3133565&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5163 David understood the problem.  Our patient had had bilateral above the knee amputations, causing his creatinine to drop precipitously. I am a big fan of eGFR, but I do know the times when it does not work.  So today's question to ponder – when should you not use the GFR estimation equations. Like all laboratory tests, we must understand how to interpret the tests.  We do not teach that well in most medical schools.  I believe that ward attendings have the responsibility of teaching laboratory test interpretation, but too many are not fully versed themselves.  So I am also asking for opinions from the readers about that questions.   Related Posts:The Thanksgiving resolution - year 315 days at the VA - day 115 days at the VA - day 14Oops17 days at the ... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3133565 Thu, 31 Dec 2009 11:53:31 +0100 3133565 http://www.medworm.com/index.php?rid=3133567&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5158 Very interesting teaching point occurred yesterday.  We have a patient with long standing diabetes mellitus and known CKD Stage III.  We admit him for increasing dyspnea – probably secondary to his COPD.  I notice that his creatinine had run around 2.5, but now was around 1.3.  These values had multiple repeats 6 months ago and currently. So the puzzle for today – why did his creatinine improve so dramatically? Related Posts:17 days at the VA - Day 117 days at the VA - Day 4OopsStage III CKD - when to refer15 days at the VA - day 1 (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3133567 Wed, 30 Dec 2009 16:52:11 +0100 3133567 http://www.medworm.com/index.php?rid=3118834&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5129 This article reviews various antibiotic regimens.  As I read the article, most hospitalized patients should receive a respiratory quinolone, and 5 days of moxifloxacin is a good choice. So this gave me a new strategy – 5 days of moxifloxacin rather than 10 days as I previously prescribed. The article also supports the 3 point scoring system for antibiotics in acute exacerbations: Increased dyspnea Increased sputum production Change in sputum color to purulent The antibiotic strategy is very clear for 3 points, and clear for 2 points. Prevalence of Pulmonary Embolism in Acute Exacerbations of COPD This article recently caught my eye.  Our chief of medicine, an excellent pulmonologist, came by during rounds.  We asked him about the necessity of obtaining a chest CT ... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3118834 Wed, 23 Dec 2009 20:33:21 +0100 3118834 http://www.medworm.com/index.php?rid=3100741&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5108 I ordered a renal consult for our patient, thinking that his kidney disease might be the cause of the anemia.  The renal team decided to try iron once again, and then consider a trial of erythropoeitin as an outpatient if he does not respond to iron. I thought he might have significant diabetic renal disease, so we did a urine protein/creatinine ratio, but it was quite low.  He probably should be taking an ACE inhibitor – again he has good followup in renal clinic. By the afternoon we had 6 admissions.  We had an interesting question for you to ponder. Patient transferred from the ICU.  Patient apparently has persistent ascending cholangitis with accompanying persistent lactic acidosis.  The bicarbonate is 18.  So the question is whether to give bicarbon... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3100741 Fri, 18 Dec 2009 11:24:55 +0100 3100741 http://www.medworm.com/index.php?rid=3096800&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5102 Yesterday I provided this patient: Interesting patient presented recently.  He is HIV+ and has a 10 day history of large volume watery diarrhea. On the 3rd day his BMP showed.  On admission his HCO3 was 19. Electrolyte panel Na 149 Cl 128 BUN 13 K 3.0 HCO3 12 creat 0.8 This is actually relatively easy. 1. What is the likely acid-base problem? Given the large volume watery diarrhea, he likely has stool losses of bicarbonate. 2. How can we prove our assumption? We obtained an ABG and a urine anion gap. ABG: pH 7.2; pCO2 23; pO2 125; HCO3 9 Una 58; Uk 11; Ucl 156 – for Urine Anion Gap of -87.  This is a profound negative anion gap and confirms our suspected diagnosis. 3. How would you treat this patient? We considered 3 issues in treatment: Hypernatremia &#8... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3096800 Thu, 17 Dec 2009 13:25:18 +0100 3096800 http://www.medworm.com/index.php?rid=3096801&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5100 Back at the VA, I inherited 3 patients.  We are on call today (day 2), but given 3 patients I stretched rounds out for 100 minutes. Internists can do that.  I dissected each patient, made multiple teaching points, and just had a blast. I have a dilemma that I uncovered.   The patient is in his early 50s, has had DM for around 10 years, and has a foot ulcer without osteomyelitis.  Incidently, he has hepatitis C and may have early cirrhosis.  The intern asked me about his anemia (Hgb <8). We got into a long discussion of anemia.  I asked about previous evaluation, and they could not recall details.  We opened up the EMR and started searching. B12 and folate are clearly normal (several times).  Iron saturation is consistently low, but ferritin is al... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3096801 Thu, 17 Dec 2009 12:25:37 +0100 3096801 http://www.medworm.com/index.php?rid=3092652&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5097 Interesting patient presented recently.  He is HIV+ and has a 10 day history of large volume watery diarrhea. On the 3rd day his BMP showed.  On admission his HCO3 was 19. Electrolyte panel Na 149 Cl 128 BUN 13 K 3.0 HCO3 12 creat 0.8 This is actually relatively easy. 1. What is the likely acid-base problem? 2. How can we prove our assumption? 3. How would you treat this patient? Related posts:An acidosis questionAnother hyperkalemia – whyMy answer to intubated (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3092652 Wed, 16 Dec 2009 13:35:13 +0100 3092652 http://www.medworm.com/index.php?rid=3066976&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5082 Some time ago, I was making post call rounds.  The team presented a patient admitted from the oncology service.  He was in his 50s and had new chest pain.  He described the chest pain as substernal pressure with radiation down both arms.  He received relief from stretching against the wall.  The pains lasted around an hour. The team reported a negative nuclear medicine stress test 2 months ago. When I talked with the patient, his story seemed 50% perfect and 50% strange.  I asked if the patient had ever tried nitroglycerin, and he had not. His ECG was unremarkable.  His troponins were normal. The housestaff were skeptical (as I would likely have been at that stage of my career).  They focused on the atypical parts of his story. I suggested that we tr... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3066976 Tue, 08 Dec 2009 13:13:17 +0100 3066976 http://www.medworm.com/index.php?rid=3044691&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5057 55 yo man with SC disease and membranous nephritis.  He is taking an ACE inhibitor to decrease his urine protein and delay progression of renal disease.  We saw these labs Electrolyte panel Na 133 Cl 107 BUN 27 K 5.1 HCO3 19 creat 1.2 This was the last day of my tour at the VA.  So instead of making this a puzzle, I will tell you what we did.  You can consider your options before you read what follows:     Serum osms 283 Urine osms 351 Urine Na 101 Urine K 13 Urine Cl- 96 We did not obtain an ABG because we felt the diagnosis was crystal clear. TTKG   was low at 2.1 confirming low aldosterone effect Urine anion gap was positive +18 confirming renal acidosis ACTH stim test was normal   So we made a diagnosis of type IV RTA.  We con... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3044691 Tue, 01 Dec 2009 15:23:22 +0100 3044691 http://www.medworm.com/index.php?rid=3036928&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5038 Yesterday we focused on the oliguric patient.  I will provide the essence of that chalk talk. For the purpose of this talk, we define oliguria as < 500 cc / day or 20 cc / hr Always consider obstruction first.  Pass a urinary catheter.  If small amount of urine, remove it.  You still need to consider a renal ultrasound.  I have seen a patient with bilateral painless kidney stones. Once obstruction is excluded, please send urine Na and creatinine.  If the patient has received a diuretic also order a urine urea. If you want to try things – diuretics or volume, you may – if you have sent off the urine values already. Calculate FeNa &/or FeUrea (see previous note)  I like Nephromatic for the calculations. If low FeNa, then the patient is p... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3036928 Sat, 28 Nov 2009 21:35:40 +0100 3036928 http://www.medworm.com/index.php?rid=3029774&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5026   Electrolyte panel Na 132 Cl 85 BUN 73 K 2.8 HCO3 37 creat 2.8 Blood Sugar 205 Seeing this BMP yesterday showed the difference between knowledge and wisdom.  For experienced clinicians, the patterns in this BMP are obvious.  For many students and interns, we just have 7 numbers. Here is how I think through this problem: The patient has an elevated creatinine and BUN. The BUN is much more elevated than the creatinine (greater than 20:1), therefore I suspect either GI bleed or significant volume contraction.  I know that the patient has a stable Hgb and heme negative stool, so I strongly suspect volume contraction. The HCO3 is markedly elevated, supporting either metabolic alkalosis or compensation for respiratory acidosis.  The patient has no history o... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3029774 Thu, 26 Nov 2009 12:24:17 +0100 3029774 http://www.medworm.com/index.php?rid=3029775&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5024 Day 11 involved discussing 5 new patients, and continuing plans on the remaining patients. One patient brought out some important teaching points.  The patient is in his 70s and came in for weakness.  His routine labs made the diagnosis:   Electrolyte panel Na 132 Cl 85 BUN 73 K 2.8 HCO3 37 creat 2.8 Blood Sugar 205   Two months ago his values were:   Electrolyte panel Na 137 Cl 103 BUN 18 K 3.4 HCO3 27 creat 1 Blood Sugar 144   While I think this is an easy one, the students and interns did not yet have the lab interpretation instincts.  So I will ask my readers to provide the explanation.  I will give my thoughts tomorrow. Related posts:17 days at the VA – Day 8Another hyperkalemia – my explanationAn acidosis q... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3029775 Wed, 25 Nov 2009 17:58:23 +0100 3029775 http://www.medworm.com/index.php?rid=3018959&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5016 I received this tweet: Do you have any recommendations on how an MS3 should approach an attending to request something like your 2 hour commitment for ed I actually do not have any recommendations.  Your have a classic problem that many students have.  Most attending physicians have a different conceptualization of their role than I have.  I have written about this problem several times.  The focus on clinical responsibility and billing has transformed the attending role for many. Many attending physicians do not consider the teaching role as the most important part of their job. We who have leadership positions in academic medicine too often fail to emphasize and reward dedication to teaching.  Fortunately there are many notable exceptions around the country. I... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3018959 Sun, 22 Nov 2009 17:05:19 +0100 3018959 http://www.medworm.com/index.php?rid=3018960&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5014 Relatively easy day – just the resident, 1 intern and me rounding on 6 patients.  We had an interesting acid-base puzzle.  The patient is in his 50s and has known hep C positivity (possible cirrhosis) and recent nephrotic syndrome.  How do you dissect information just from his electrolyte panel.  One other hint – his albumin is 2.2.   Electrolyte panel Na 141 Cl 108 BUN 67 K 4.1 HCO3 18 creat 7.9 Blood Sugar 90       Related posts:Another hyperkalemia – my explanationPart 2 of the acid-base problemA 2 part acid-base problem (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3018960 Sun, 22 Nov 2009 16:43:28 +0100 3018960 http://www.medworm.com/index.php?rid=3015254&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5009 Day #7 was a classic post-call day – we had 9 new patients.  Fortunately I had seen 2 patients on Day #6, which ameliorated the challenge. Post-call rounds after busy days have a very different flavor than other rounds.  We have to work hard, make triage decisions about what to discuss and how much depth to take.  For those former residents who are interested in the types of patients we get: 1. ICU transfer for pneumonia (called on AP film).  PA & lateral show no pneumonia.  The patient is a classic blue bloater recovering from an exacerbation, but no new disease. He did have an episode of hypotension.  The cortrysn stim test was intermediate.  We discussed his numbers with endocrine and decided to start him on low dose prednisone (5 mg) with re... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3015254 Sat, 21 Nov 2009 12:34:12 +0100 3015254 http://www.medworm.com/index.php?rid=3012342&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5006 Day 6 we admit again.  When I left yesterday we had 4 patients already. Rounds yesterday focused mostly on teaching.  As an attending, I make a 2 hour commitment to my teams.  They get me for 2 hours and I get them for 2 hours, regardless.  Yesterday we reviewed my favorite diabetes mneumonic – the FLECKS.  After that we focused on a problem from day 4. On day 4 we had a patient who needed a BKA.  This day my resident had off, so I functioned as a res-attending.  Fortunately, at the VA we have an excellent EMR.  After making rounds, I sit down to do my notes in the team room. My notes have a template that allows me to review the medications and the labs.  I quickly peruse both to be careful.  In so doing, I noticed that the patient... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3012342 Fri, 20 Nov 2009 11:43:17 +0100 3012342 http://www.medworm.com/index.php?rid=2999475&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F4996 My team had a relatively easy Sunday call day.  On post call days, we spend 3 hours presenting new patients, discussing old patients and seeing all the patients.  I told me team on Sunday that I would use the entire time regardless.  With only 3 new patients, we had leisurely, and I hope educational, discussions of each patient. One patient in particular presented an interesting issue – why saline can make hyponatremia worse?  Our patient presented with a sodium level of 125.  His serum osms were 249. He is euvolemic.  Prior to receiving the urine osm report, we started IV saline – giving approximately 1.3 liters.  Then the urine osms were approximately 630. For those who already understand this phenomenon, you might predict that the sodium wo... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2999475 Tue, 17 Nov 2009 12:20:50 +0100 2999475 http://www.medworm.com/index.php?rid=2999477&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F4991 Day 2 was easy.  We had 2 patients, and despite coming in the afternoon, we had no admissions at that point. After spending 15 minutes getting to know my team – 2 students, 2 interns, and 1 resident (all guys) – we saw the existing patients and then went to the conference room to teach.  Because both patients had left ventricular systolic dysfunction, I focused on the management of that condition. When I teach about CHF with systolic dysfunction, I tell a history story. 1975 – I am an intern.  We treat CHF with digoxin and furosemide.  We push the digoxin dose to high levels.  Admitted patients have a life expectancy of around 6 months mid-1980s – the VHeFT trial shows that hydralazine and isosorbide dinitrate can (for the 2/3 of patients wh... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2999477 Mon, 16 Nov 2009 17:58:24 +0100 2999477 http://www.medworm.com/index.php?rid=2995706&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F4989 We examined his meds and found a low dose of ACE inhibitor but he was talking amlodipine.  So we decided to d/c the amlodipine and increase the ACE inhibitor.   Over the next 2 days we will see if this strategy can work. Related posts:Treating pneumonia – 3 days of antibiotics?OopsA normal gap acidosis dissected (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2995706 Sun, 15 Nov 2009 17:52:12 +0100 2995706 http://www.medworm.com/index.php?rid=2993737&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F4987 This is a classic ABG sequence: ABG Admission (on 2 L O2) Day 2 (Bipap 100%) ABGs on successive days pH 7.28 7.52 pCO2 89 52 pO2 60 373 HCO3 42 42               Your tasks are to understand and explain the course of events for this woman having a COPD exacerbation.   1. What is the initial acid-base disorder? The patient has a chronic respiratory acidosis with metabolic compensation.  I cannot remember the calculations, so I found a calculator online.   2. What is the second day disorder? This disorder goes by the name post-hypercapnic metabolic alkalosis.  I sometimes use the phrase "revealed metabolic alkalosis".  It occurred because the patient had an appropriate compensation for a chronic respirator... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2993737 Sun, 15 Nov 2009 13:56:34 +0100 2993737 http://www.medworm.com/index.php?rid=2989112&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F4983 This is a classic ABG sequence: ABG Admission (on 2 L O2) Day 2 (Bipap 100%) ABGs on successive days pH 7.28 7.52 pCO2 89 52 pO2 60 373 HCO3 42 42               Your tasks are to understand and explain the course of events for this woman having a COPD exacerbation.   1. What is the initial acid-base disorder? 2. What is the second day disorder? 3. What would you do now? Related posts:Intubated and difficult to weanMy answer to intubatedAn acidosis question (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2989112 Fri, 13 Nov 2009 13:05:17 +0100 2989112 http://www.medworm.com/index.php?rid=2946875&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F4945 This study demonstrates that bicarbonate supplementation slows the rate of progression of renal failure to ESRD and improves nutritional status among patients with CKD. I would treat this patient to maintain a bicarbonate of 22.  I would start either with 5 tablets of sodium bicarbonate each day.  Remember that a 650 mg bicarbonate tablet has 7.7 mEq of bicarbonate.  I usually start with approximately 0.5 mEq per kg.  This assumes a normal diet of 1 mEq per kg of acid that needs buffering and some remaining buffering from phosphate. If the patient cannot tolerate sodium bicarbonate I use sodium citrate (Shohl’s solution or Bicitra) and would start with 15 cc twice a day.  Each cc converts to 1 mEq of bicarbonate. Regardless of our starting point, we need to follow the patient cl... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2946875 Sat, 31 Oct 2009 11:31:32 +0100 2946875 http://www.medworm.com/index.php?rid=2934627&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F4937 The patient is a 38 year old man admitted with a bleeding ulcer. It is 3 days later, he is otherwise stable and has these labs. He has known polycystic kidney disease with an estimated GFR of 30. He weights approximately 70 kg. Electrolyte panel Na 141 Cl 116 BUN 49 K 4.8 HCO3 16 creat 2.7 Blood Sugar 90 ABG pH 7.25 pCO2 33 pO2 83 HCO3 15 So please address these questions: 1. What is the acid-base disorder? 2. Can you likely confirm the etiology? 3. Would you treat, and how? 4. Will he need long term treatment? Related posts:Another hyperkalemia – my explanationNew acidosisAnswer to new acidosis case (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2934627 Wed, 28 Oct 2009 12:09:02 +0100 2934627 http://www.medworm.com/index.php?rid=2757681&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F4820 Making rounds this morning, we went to see a patient who had a stent placed yesterday (right circumflex). I sat down to discuss the implications of a diagnosis of coronary artery disease. I started with the statement that she would be talking 4 drug classes – aspirin, ACE inhibitor, beta blocker and statins. As I finished she turned to me teary eyed and asked if she would be able to get her drugs for $4 at WalMart (or other similar store). When I said yes, she smiled and cried. I wish I had a video to place on YouTube. The entire team had the same reaction. We took a situation that had her worried about money, and because of low cost generics she had great relief. We felt great that money would not interfere with her secondary prevention. We know that secondary prevention helps and d... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2757681 Tue, 01 Sep 2009 16:37:24 +0100 2757681 http://www.medworm.com/index.php?rid=2744072&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F4810 I have very smart readers. Two predicted the ABG. ABG pH 7.45 pCO2 24 pO2 100 As Happy Hospitalist and ProNephros both deducted, the patient likely had a chronic respiratory alkalosis.  We cannot be certain; I suspect acute on chronic respiratory alkalosis. The point that I have made several times, is that you really do need an ABG to understand acid-base problems. One commenter criticized the resident for not ordering an ABG on admission.  I agree with that criticism. Related posts:Acid base answerMy answer to intubatedAMS – an acid-base problem II (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2744072 Sat, 29 Aug 2009 12:08:20 +0100 2744072 http://www.medworm.com/index.php?rid=2737735&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F4806 To restate: The patient is a 50 year old woman who admits to “serious drinking” of at least 1 pint of vodka a day for at least 2 weeks.  She is admitted looking ill and slightly confused.  Her initial labs: Electrolyte panel Na 137 Cl 89 BUN 8 K 4.3 HCO3 7 creat 0.7 Blood Sugar 55 Other labs included an albumin of 4.9, ALT 109, AST 169, alk phos 134, Total bili 1.5 I left the history that she had vomited multiple times over the previous 24 hours. My thoughts at this point: Clearly she had an increased anion gap acidosis.  I use the mneumonic KILU to teach anion gap acidosis.  I do this because this method has physiologic coherence.  I can teach concepts rather than a seemingly random list. The resident did not get an ABG or a serum osm, but the serum did have s... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2737735 Thu, 27 Aug 2009 12:39:04 +0100 2737735 http://www.medworm.com/index.php?rid=2737736&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F4803 The patient is a 50 year old woman who admits to “serious drinking” of at least 1 pint of vodka a day for at least 2 weeks.  She is admitted looking ill and slightly confused.  Her initial labs: Electrolyte panel Na 137 Cl 89 BUN 8 K 4.3 HCO3 7 creat 0.7 Blood Sugar 55 Other labs included an albumin of 4.9, ALT 109, AST 169, alk phos 134, Total bili 1.5 Question #1 Just from the labs, please suggest her likely diagnoses and suggest treatment.  I am hiding some history for teaching purposes. Related posts:AMS – an acid-base problem solutionAMS an acid-base problem – part 1AMS – an acid-base problem II (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2737736 Wed, 26 Aug 2009 16:13:45 +0100 2737736 http://www.medworm.com/index.php?rid=2712113&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F4781 MRCP suggested cholecystitis. We consulted surgery – laporoscopic cholectystectomy the next day with confirmation of cholecystitis. The big clue is the ALT > 150. While not highly sensitive, this is highly specific for gallstone pancreatitis. My 3rd year student found the reference to that clue. I had always thought that the alk phos was the most useful test in this situation – so I learned something. Even without that clue, the symptoms made us highly suspicious of gallstone pancreatitis. This is the most common cause in the US. I believed his no alcohol history, and found no clues on labs that he was not telling the truth. h/t to David whose first post he spot on. Related posts:What caused the pancreatitis?Treating the pain of chronic pancreatitisIs heart failure sometime... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2712113 Wed, 19 Aug 2009 01:26:40 +0100 2712113 http://www.medworm.com/index.php?rid=2709140&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F4776 The patient is a 68-year-old man who presented with abdominal pain, nausea and vomiting. He described his pain as 10/10 sharp and mid-epigastric without radiation. He denied any lower gastrointestinal symptoms. Around 2 months previously he had a bout of pancreatitis, but his physicians did not find an etiology. He had type II diabetes mellitus, hypertension, coronary artery disease (stent), and a known right kidney mass. His medication list included simvastatin, januvia, aspirin, cilostazol, famotidine, actos, lisinopril, plavix, lasix prn and metformin. Social history was negative for alcohol, tobacco or illegal drugs. He was afebrile, BP 139/64, heart rate 101, respirations 18. He had mild epigastric tenderness without guarding or rebound. His stool was heme negative and rectal exam sho... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2709140 Mon, 17 Aug 2009 15:06:40 +0100 2709140 http://www.medworm.com/index.php?rid=2348533&cid=t_161717_109_f&fid=34750&url=http%3A%2F%2Fpsychcentral.com%2Fblog%2Farchives%2F2009%2F04%2F20%2Fdealing-with-adhd-while-away-at-college%2F Planning on attending college or university in the fall, but also grapple with attention deficit disorder (ADHD)? Tara Parker-Pope last week wrote a fantastic article in The New York Times that acts basically as your guide to everything you need to know if you have ADHD and are planning to head off to school in the fall. It explains that while medications may need adjusting (if you’re on an ADHD medication), your support system is probably even more important. Freshman year is hard enough for most people, but even harder for teens dealing with attention deficit disorder. Your safe family and friends you’ve known often leave if you go away to school, and you can be stuck without that support system in place. In addition to talking about medications (and where/how you’ll g... World of Psychology blogs http://www.medworm.com/rss/comments.php?id=2348533 Mon, 20 Apr 2009 18:26:52 +0100 2348533 http://www.medworm.com/index.php?rid=2348032&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F4195 To restate - this basic metabolic panel - Electrolyte panel Na  138 Cl  115 BUN  35 K 7.3 HCO3  14 creat  1.8 Blood Sugar  154  Several commenters recognized that this patient has a type IV RTA with a respiratory acidosis.  The cause of the respiratory acidosis was either hypoventilation syndrome or weakness from the hyperkalemia.  His type IV RTA is interesting. 5 months ago his BMP showed Electrolyte panel Na  142 Cl  107 BUN 16 K 5.4 HCO3  22 creat  1.1 Blood Sugar  73  He was appropriately taking enalapril 20 mg b.i.d. for his hypertension.  I suspect that the enalapril contributed to decreased aldosterone, and then the NSAID exacerbated the problem by decreasing renin production.&nb... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2348032 Fri, 17 Apr 2009 14:25:35 +0100 2348032 http://www.medworm.com/index.php?rid=2348033&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F4193   A 53-year-old man, with a history of DM II, hypertension, and history of stroke, presents with 3 days of fatigue.  He has an elevated K on routine labs.  He recently started taking Aleve twice daily for knee pain.   Electrolyte panel Na  138 Cl  115 BUN  35 K 7.3 HCO3  14 creat  1.8 Blood Sugar  154     ABG pH 7.18 pCO2 38 pO2 76   Define his acid-base abnormality and speculate on the etiology. (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2348033 Thu, 16 Apr 2009 19:29:55 +0100 2348033 http://www.medworm.com/index.php?rid=2216329&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F4101   I believe this blogs readers may be smarter than the author.  I choose to give 5 doses of indomethacin 50 mg over 2 days.  As you suggested, the creatinine did increase.  The gout did get dramatically better. After 2 days we switched to prednisone with no adverse effects. I eschewed colchicine because I do not find it as effectively for serious gouty attacks.  I dislike any medicine which has diarrhea as an endpoint. Perhaps I made a mistake.  The creatinine will decrease over the next few days. I take the first guessing as prescient.  Hats off to the many comments. I felt it important to bring out this issue.  I do not think the patient has suffered at all, but next time I will likely use prednisone in this situation. (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2216329 Wed, 25 Feb 2009 11:20:50 +0100 2216329 http://www.medworm.com/index.php?rid=2209727&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F4099   We tapped the joints that day and found gout crystals.  Now we had our dilemma.  How should we treat this patient with enterococcal endocarditis ( I was out of town yesterday and misremembered the organism) and a creatinine of 1.6? What drug would you use for this relatively severe gout attack?  I do believe the fever was the initial presentation of this attack.   (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2209727 Tue, 24 Feb 2009 17:50:04 +0100 2209727 http://www.medworm.com/index.php?rid=2206676&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F4097   50 something male was admitted 3 weeks ago for a septic right knee and subsequent endocarditis - MSSA.  His knee has no problems, but he needs 6 weeks of IV antibiotics.  Social work has worked on finding an intermediate care facility, and they find one!  But we get called during rounds because the patient has a fever of 102 (afebrile for 2 weeks.)  Discharge is delayed, and a fever workup begins.  The next morning on rounds he has tender hot joints - left elbow and right ankle.  He is in obvious pain. What do you do?  What diagnosis do you suspect?  Do you start treatment? We have a clear answer - and a controversy coming. More tomorrow … (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2206676 Mon, 23 Feb 2009 11:58:27 +0100 2206676 http://www.medworm.com/index.php?rid=2163469&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F4071   Most readers know that I run morning report 2-3 times each week (at 3 different hospitals.)  We frequently discuss the rationale for statin therapy.  Many students and residents focus on LDL and LDL goals, yet recent data suggest that statins really work in at least 2 ways.  Clearly, statins do lower LDL, and thus probably either decrease atherosclerotic plaques or delay their growth.  However, statins also decrease the ongoing inflammatory process within the atherosclerotic plaque.  This plaque stabilization should decrease cardiac events. We know that immediate statin treatment improves myocardial infarction outcomes.  We believe that this effect stems from a marked decrease in subsequent infarctions. Recent data are raising questions about our s... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2163469 Thu, 05 Feb 2009 13:36:19 +0100 2163469 http://www.medworm.com/index.php?rid=2092428&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F4035   Earlier this week I received an email asking my opinion of an ER sore throat policy.  The question focused on acute rheumatic disease prevention, and ask my opinion on testing and treatment.  Here is my short answer: This is a classic question.  I will provide a fairly long answer. I know of 5 reasons to treat sore throats.  Each deserves some discussion.   Prevent rheumatic fever.  In North America this rationale is no longer important.  We have very little rheumatic fever, and your estimates seem rational. We see no major difference in this rare complication regardless of strategy. Prevent suppurative complications.  Antibiotics do decrease the incidence of peritonsillar abscess – quoting from Cochrane: “Antibiotics reduced the ... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2092428 Fri, 09 Jan 2009 13:18:52 +0100 2092428 http://www.medworm.com/index.php?rid=2067183&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F4014   The primary care physician drew blood cultures and started moxifloxacin.  Two days later the blood cultures come back growing gram negative rods in the anaerobic bottles.  He is called back to the ER.  On exam he has a fever of 103, markedly swollen right tonsil with exudates, mild swelling of right neck, but no clear adenopathy.  He does not have a cough. CT scan shows a huge right tonsil, but no evidence of abscess and normal patent internal jugular vein. Now what would you do? What do you think is wrong with this man? (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2067183 Fri, 26 Dec 2008 13:34:23 +0100 2067183 http://www.medworm.com/index.php?rid=2065077&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F4012   A 30-year-old man comes to your office for 2 days of progressive pharyngitis.  He is unable to eat but is drinking well.  He has a temp of 103 and endorses a drenching night sweat.  He has a swollen right tonsil with marked exudates.  His right neck is slightly swollen.  You cannot feel anterior or posterior adenopathy. His rapid strep test and flu screen are both negative. Would you give antibiotics? Would you get blood cultures?   (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2065077 Wed, 24 Dec 2008 13:48:12 +0100 2065077 http://www.medworm.com/index.php?rid=2052424&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F4005 In conclusion, in this cohort of patients with advanced HF, there was an independent, dose-dependent association between loop diuretic use and impaired survival. Higher loop diuretic dosages identify patients with HF at particularly high risk for mortality. When discharging a patient from the hospital, I almost always arrange for "sliding scale" diuretics.  I try hard to minimize diuretic use and encourage diuretic free holidays. Diuretics help patients feel better when they are volume overloaded, otherwise, we should withhold them.   (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2052424 Fri, 19 Dec 2008 17:34:41 +0100 2052424 http://www.medworm.com/index.php?rid=2005729&cid=t_161717_109_f&fid=34750&url=http%3A%2F%2Fpsychcentral.com%2Fblog%2Farchives%2F2008%2F12%2F02%2Fmental-disorders-common-in-young-adults%2F A new robust, in-depth study that interviewed over 5,000 young adults from 2001 to 2002 has found that nearly half of them (47.7%) likely have a diagnosable mental disorder — most commonly, alcohol abuse, depression, ADHD or anxiety. One in five was also found to meet the criteria for a personality disorder, a more chronic condition that often interferes with the person’s ability to interact in a healthy manner with others at school, work, or in relationships. The study also compared those attending college with those who weren’t, to see if mental concerns were more prevalent in one group, or if specific concerns occurred with more frequency. It found overall rates similar between the two groups, but alcohol-related concerns significantly more prevalent in those attendi... World of Psychology blogs http://www.medworm.com/rss/comments.php?id=2005729 Tue, 02 Dec 2008 15:45:51 +0100 2005729 http://www.medworm.com/index.php?rid=1955123&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Faudio%2Fposthypercapneic%2520alkalosis.mp3   This podcast represents the answer to the acid base case I posted yesterday.  Please provide feedback on the answer and podcasting in general. Solution to acid base case of 11/11/08   (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1955123 Thu, 13 Nov 2008 10:34:16 +0100 1955123 http://www.medworm.com/index.php?rid=1951431&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3910   56 year old man with known COPD and pulmonary fibrosis was admitted a week ago for worsening respiratory status.  He slowly improved (after a few days in the ICU.)  Now he has the following ABGs:   Electrolyte panel Na   Cl   BUN   K 4 HCO3   creat   Blood Sugar   ABG pH 7.47 pCO2 49 pO2 77 calc HCO3 36  What is the acid-base disorder?  What would you do? (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1951431 Tue, 11 Nov 2008 17:46:13 +0100 1951431 http://www.medworm.com/index.php?rid=1917754&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Faudio%2Faniongap.mp3   Anion Gap Acidosis This represents the first in a series of 7 lectures that I plan for understanding acid-base problems.  Please provide feedback and questions.  I plan to collect questions over a few days and then prepare an audio addendum. (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1917754 Wed, 29 Oct 2008 17:46:05 +0100 1917754 http://www.medworm.com/index.php?rid=1905706&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Faudio%2Fcrohns.mp3       Electrolyte panel Na 141 Cl 112 BUN 18 K 4.3 HCO3 15 creat 0.7 Blood Sugar 105 ABG pH 7.33 pCO2 25 pO2 103 calc HCO3 13   Today’s patient is well known to our service.  She is 32 and has a long history of Crohn’s disease, with an ileostomy.  Consider the differential diagnosis, and recommend tests to prove your hypothesis.  Additional information - albumin 5.7 Urine lytes = Na 10, K 47, Cl 72  Crohn’s patient explanation (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1905706 Fri, 24 Oct 2008 20:39:59 +0100 1905706 http://www.medworm.com/index.php?rid=1887935&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3837     Electrolyte panel Na 141 Cl 112 BUN 18 K 4.3 HCO3 15 creat 0.7 Blood Sugar 105 ABG pH 7.33 pCO2 25 pO2 103 calc HCO3 13   Today’s patient is well known to our service.  She is 32 and has a long history of Crohn’s disease, with an ileostomy.  Consider the differential diagnosis, and recommend tests to prove your hypothesis.   I have posted this case before.  I am reposting because of all the positive feedback I received on the audio solution this week.  So within the next few days I will discuss this case with an audio response.  If I continue to get positive feedback, I will try to do one a week. (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1887935 Sat, 18 Oct 2008 21:52:45 +0100 1887935 http://www.medworm.com/index.php?rid=1872961&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Faudio%2Facidosisdiscuss.mp3 I am trying an audio version of explanation for the case presented 4 days ago.  I need your feedback - do you like this strategy, or should I type out the answer.  Acidosis discussion   49-year-old man, previously in good health, presents after a few weeks of progressive weakness and dizziness.  He admits to polyuria.  Your job is to extensively discuss his lab tests. Electrolyte panel Na 147 Cl 104 BUN 28 K 4.7 HCO3 16 creat 1.3 Blood Sugar 678 ABG pH 7.3 pCO2 33 pO2 68 calc HCO3 16   (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1872961 Tue, 14 Oct 2008 02:17:49 +0100 1872961 http://www.medworm.com/index.php?rid=1865294&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3801   49-year-old man, previously in good health, presents after a few weeks of progressive weakness and dizziness.  He admits to polyuria.  Your job is to extensively discuss his lab tests. Electrolyte panel Na 147 Cl 104 BUN 28 K 4.7 HCO3 16 creat 1.3 Blood Sugar 678 ABG pH 7.3 pCO2 33 pO2 68 calc HCO3 16   (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1865294 Thu, 09 Oct 2008 18:03:16 +0100 1865294 http://www.medworm.com/index.php?rid=1850858&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3791   On sit down rounds yesterday morning, the team told me about a gentleman with severe achalasia.  Because of the achalasia he had a G-tube in place for 15 years.  As they told the story he came in for vomiting and was found to have a left lower lobe pneumonia.  They worried that the patient had an aspiration pneumonia. At the bedside I questioned the patient: db: "When did you first get sick this time?" pt: "Sunday I got sick" db: "What was bothering you first?" pt: "I got hot and started sweating.  My wife had to wipe my brow." db: "How bad were the sweats?" pt: "I was sweating all day.  I had to change my pajamas." db: "Did you have any chills?" pt: "Yes, I was shaking." (note p... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1850858 Fri, 03 Oct 2008 12:45:50 +0100 1850858 http://www.medworm.com/index.php?rid=1645556&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3654   We have an interesting situation on our service this week.  The patient is a 62 year old man with hepatocellular carcinoma.  He has had significant hepatic encephalopathy.  Lactulose does control his encephalopathy, but he tells us that the frequent stools that lactulose causes have a significant negative impact on his quality of life.  Since he is a palliative care / hospice patient, we want to avoid negative quality of life treatments.  He is having 3 stools daily. We made a decision (which I will reveal tomorrow.)  There is no correct answer here, but we are satisfied with our approach.  So what would you do?  Our answer has modest complexity, but some simple answers probably are as satisfactory.   (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1645556 Tue, 22 Jul 2008 12:32:35 +0100 1645556 http://www.medworm.com/index.php?rid=1605759&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3630     ABG pH 7.35 pCO2 48 pO2 74 calc HCO3 25 50 year old man presents with chest pain and a recent abnormal stress test.  He has a 30-40 pack year history.  This ABG was taken on room air. Can you describe a set of circumstances that would give you these results? (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1605759 Thu, 10 Jul 2008 15:27:36 +0100 1605759 http://www.medworm.com/index.php?rid=1460838&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3590   I must congratulate the 2 responders, obviously astute diagnosticians.  As they surmised, the liver tests did not support primary liver disease.  The albumin was low but not what we would expect with cirrhosis.  The other liver tests were remarkably normal. We obtained an echocardiogram which showed severe pulmonary hypertension and pure right sided dilation and heart failure.  I will followup on the pulmonary consultation.  I suspect that the patient has obstructive sleep apnea, and possibly also COPD. This patient represents a fascinating cognitive issue.  He presented with ascites and anasarca.  The SAAG was consistent with portal hypertension.  Assuming primary liver disease was the natural error.  This presentation requires further t... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1460838 Thu, 22 May 2008 14:32:12 +0100 1460838 http://www.medworm.com/index.php?rid=1458289&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3586 55 year old man admitted to our service for ascites and anasarca (massive scrotal and leg edema.)  The patient had large volume paracentesis.  The SAAG (serum ascites albumin gradient) was 1.8 - consistent with portal hypertension.  He had no evidence for spontaneous bacterial peritonitis.  His serum ammonia was normal. Later that evening he becomes hypoxic and is transferred to intensive care.  He is placed on a 50% rebreathing mask. In reviewing his lab data we find:   Liver tests Destruction   Obstruction   Factory   AST 34 alk phos 98 albumin 2.7 ALT 27 T. Bili. 0.8 INR 1.3         His ABG the next morning on 50% O2   Arterial Blood Gas - 50% oxygen pH 7.115 pCO2 91 pO2 90   When he was adm... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1458289 Wed, 21 May 2008 01:14:02 +0100 1458289 http://www.medworm.com/index.php?rid=1449200&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3581   I am current at the ACP annual meeting, and this morning heard a brilliant grand rounds on hyponatremia - given by Juan Carlos Ayus.  I have found an excellent article in the Southern Medical Journal that he co-authored on treatment of dysnatremias and also provide this Medscape link - Hospital-Acquired Hyponatremia — Why Are Hypotonic Parenteral Fluids Still Being Used? Hospital-acquired hyponatremia can be lethal. There have been multiple reports of death or permanent neurological impairment in both children and adults. The main factor contributing to the development of hospital-acquired hyponatremia is routine use of hypotonic fluids in patients in whom the excretion of free water, which is retained in response to excess arginine vasopressin (AVP), might be impaired. ... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1449200 Sat, 17 May 2008 14:29:44 +0100 1449200 http://www.medworm.com/index.php?rid=1416100&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3559   This interesting article describes a current Archives of Internal Medicine - Reasons Documented for Heart Failure Admissions At least one identifiable precipitating factor was found in 61.3% of patients, the researchers said. In order of frequency, they were: Pneumonia or respiratory processes at 15.3%. Ischemia or acute coronary syndromes at 14.7%. Arrhythmia at 13.5%. Uncontrolled hypertension at 10.7%. Nonadherence to medications at 8.9%. Worsening renal function at 6.8%. Nonadherence to diet at 5.2%. In the cohort as a whole, there were 1,834 deaths in hospital, Dr. Fonarow and colleagues found. Being admitted with pneumonia increased the risk of dying in hospital by 60% (OR 1.60, 95% CI 1.38 to 1.85, P<0.001). Worsening renal function was associated with... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1416100 Fri, 02 May 2008 17:08:29 +0100 1416100 http://www.medworm.com/index.php?rid=1414873&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3557   The response to yesterday’s presentation was excellent.  The key point here is the markedly elevated alk phos suggests biliary obstruction.  The mildly elevated bilirubin suggests incomplete obstruction. This patient needed a biliary evaluation.  The patient had an unfortunate diagnosis - cholangiocarcinoma.   (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1414873 Thu, 01 May 2008 22:38:25 +0100 1414873 http://www.medworm.com/index.php?rid=1409490&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3556   Please create a differential diagnosis for the following liver tests in an 80 year old woman: Liver tests Total protein 4.8 Albumin 2.2 Total Bili 6.5 Direct Bili 4.3 Indirect Bili 2.2 Alk Phos 973 AST 170 ALT 100               (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1409490 Wed, 30 Apr 2008 19:52:43 +0100 1409490 http://www.medworm.com/index.php?rid=1409491&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3555   Yesterday’s numbers: Electrolyte panel Na 141 Cl 112 BUN 18 K 4.3 HCO3 15 creat 0.7 Blood Sugar 105 ABG pH 7.33 pCO2 25 pO2 103 calc HCO3 13   Additional information: 1. She had increased ileal output. 2. Serum albumin was 5.7 3. Urine Na 10, urine K 47 and urine Cl 72 Her anion gap is 14, which is normal given her elevated albumin Her urine anion gap is negative, consistent with sufficient ammonium (NH4+) in her urine The urine anion gap results supports increased ileal output and bicarbonate loss as the cause of the normal gap acidosis The respiratory response is appropriate.  Remember to use the calculated HCO3- when using the Winter’s formula.  The expected pCO2 thus is 27.5 and close enough to the observed pCO2 to exclude a... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1409491 Wed, 30 Apr 2008 19:34:45 +0100 1409491 http://www.medworm.com/index.php?rid=1406673&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3553   Started rounds today and had several interesting laboratory findings.  I plan to post some patient quizzes for the next 3 days. Electrolyte panel Na 141 Cl 112 BUN 18 K 4.3 HCO3 15 creat 0.7 Blood Sugar 105 ABG pH 7.33 pCO2 25 pO2 103 calc HCO3 13   Today’s patient is well known to our service.  She is 32 and has a long history of Crohn’s disease, with an ileostomy.  Consider the differential diagnosis, and recommend tests to prove your hypothesis.  (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1406673 Tue, 29 Apr 2008 18:45:37 +0100 1406673 http://www.medworm.com/index.php?rid=1331262&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3519 The new issue of the American Journal of Medicine has an addition to the world of CAP severity prediction - C-Reactive Protein Is an Independent Predictor of Severity in Community-acquired Pneumonia CRP does a better job of predicting complicated pneumonia than the two standard models - CURB65 and Pneumonia Severity Index .  Both indices are better at predicting 30 day mortality.  So we have 3 possibilities for estimating pneumonia severity.  The CRP at 4 days provides even more information (if it has decreased more that 50% the patient is unlikely to have complications.) I wish this study had tried combining these predictors to find how CRP can complement CURB65 and PSI.  Currently, I will probably use all three to estimate severity until we have data to help me choose just one. (Sou... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1331262 Thu, 27 Mar 2008 16:33:00 +0100 1331262 http://www.medworm.com/index.php?rid=1323071&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3516 To remind you: Exam reveals a markedly volume contracted 61 year old woman. Electrolyte panel Na 135 Cl 88 BUN 127 K 4.3 HCO3 14 creat 7.4 Blood Sugar 109 ABG pH 7.3 pCO2 26 pO2 70 calc HCO3 13 Her serum albumin was 4.8. Her urine creatinine was 330 with a urine sodium of 14. Her PTH level was 138. Resolution This patient had remarkable volume contraction. She had both an increased anion gap acidosis as well as a metabolic alkalosis. 1. Anion gap = 33, defining an increased anion gap acidosis. 2. Using the delta gap process, we subtract her expected gap (14 in this patient with an albumin of 4.8) from her measured gap. The difference is 19. If we add 19 to her observed bicarbonate of 14, we obtain her adjusted bicarbonate of 33. This suggests that she first developed ... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1323071 Mon, 24 Mar 2008 19:25:38 +0100 1323071 http://www.medworm.com/index.php?rid=1316543&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3511 Here is another puzzle for acid base aficionados. The patient is a 61 year old woman admitted for severe nausea and vomiting. She states that she has had 6 days of severe nausea, vomiting and diarrhea. The diarrhea was watery. Her past medical history included “CHF with normal EF”, gout, hypertension and a previous episode [...] (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1316543 Thu, 20 Mar 2008 13:44:50 +0100 1316543 http://www.medworm.com/index.php?rid=1277533&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3495 We made rounds on an 82 year old man today. Because his electrolyte panel revealed a bicarbonate level of 40, we order an ABG. The patient has known COPD and CHF. He was intubated until 2 days ago. He received aggressive diuresis for volume overload. Now his ABG reveals: ABG pH 7.46 pCO2 66 pO2 61 calc HCO3 46 Questions [...] (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1277533 Tue, 04 Mar 2008 17:37:30 +0100 1277533 http://www.medworm.com/index.php?rid=1234457&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3480 Readers know that I love teaching acid base and electrolytes. For years I (and many other educators) have difficulty explaining why edematous states can lead to hyponatremia. We always have talked about ineffective intravascular volume, although when you measure the intravascular volume it measures as increased. Thus, we had a difficult concept [...] (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1234457 Fri, 15 Feb 2008 19:58:03 +0100 1234457 http://www.medworm.com/index.php?rid=1231737&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3479 Today was my last day for this 2 week rotation.  While there are clear personal advantages to a 2 week rotation, I still prefer doing a full month.  My administrative circumstances make a full month very difficult, so I will probably have to compromise with shorter rotations. The month was delightful.  I had wonderful housestaff and [...] (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1231737 Thu, 14 Feb 2008 17:50:49 +0100 1231737 http://www.medworm.com/index.php?rid=1229112&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3478 Yesterday we reviewed stage III chronic kidney disease. So today I will review the main points I make as I discuss this condition. Stage GFR Description Treatment stage 1 90+ Normal kidney function but urine or other abnormalities point to kidney disease Observation, control of blood pressure 2 60-89 Mildly reduced kidney function, urine or other abnormalities [...] (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1229112 Wed, 13 Feb 2008 17:20:39 +0100 1229112 http://www.medworm.com/index.php?rid=1225000&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3474 Yesterday I did something that I rarely do - I recommended bariatric surgery. The patient has a BMI of 38.4 and is probably 100 pounds overweight.  He has severe obstructive sleep apnea(OSA).  At an earlier age he was very active, but he had “back surgery” and now he has little activity. In our conversation, we discussed the [...] (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1225000 Tue, 12 Feb 2008 20:22:39 +0100 1225000 http://www.medworm.com/index.php?rid=1223610&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3473 Today we discussed a new patient with his first bout of hepatic encephalopathy. This gentleman has known hepatitis C. Unfortunately, he is not a good candidate for antiviral therapy. His laboratory data suggest early cirrhosis (although we do not have biopsy confirmation.) His albumin is 3.5 and his INR is slightly higher than [...] (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1223610 Mon, 11 Feb 2008 21:37:40 +0100 1223610 http://www.medworm.com/index.php?rid=1223611&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3472 I have used this presentation for the past 30 years. It provides students a wonderful opportunity to consider the entire differential diagnosis of hypercalcemia. The answer is a surprise to many. In the presentation I fail to mention that the tachycardia persisted after volume expansion. (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1223611 Mon, 11 Feb 2008 21:24:12 +0100 1223611 http://www.medworm.com/index.php?rid=1221221&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3470 Today my team is admitting, so I made rounds in the afternoon. Our service is relatively quiet, so I took time to discuss a classic case from my residency. I previously did a podcast on this patient, but I suspended the podcast service and will have to write out the case now. This case [...] (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1221221 Mon, 11 Feb 2008 00:51:15 +0100 1221221 http://www.medworm.com/index.php?rid=1220795&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3469 I forgot to include the calculated HCO3 in the acid base problem.  I have editted the entry to now include that number. My apologies to readers - I hope this number make the explanation more clear. (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1220795 Sun, 10 Feb 2008 19:31:46 +0100 1220795 http://www.medworm.com/index.php?rid=1219799&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3467 One of my main teaching philosophies includes understanding how to teach basics and when to move to more advanced concepts. Solving yesterday’s problem requires some more advanced concepts. The normal anion gap depends on the albumin level (albumin is the major component of the normal anion gap.) Therefore, when the albumin is decreased below [...] (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1219799 Sat, 09 Feb 2008 12:59:08 +0100 1219799 http://www.medworm.com/index.php?rid=1217802&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3466 60 yo male with strong alcohol history is admitted for cellulitis.  On his second day in the hospital he develops delirium tremens and aspirates.  In the ICU he requires sedation for his DTs. He had the following laboratory values on the 3rd day of ICU care: Electrolyte panel Na 142 Cl 110 BUN 27 K 4.5 HCO3 17 creat 2.0 Blood Sugar 468 ABG pH 7.24 pCO2 25 pO2 126 His albumin is 3.  His serum osms are [...] (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1217802 Fri, 08 Feb 2008 19:47:25 +0100 1217802 http://www.medworm.com/index.php?rid=1217803&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3465 I have previously written about the FLECKS as my mnemonic for diabetes care.  Today on rounds we reviewed in detail the components of FLECKS. Feet - look at the feet for lesions, find tinea pedis and treat it prophylactically, screen for early diabetic neuropathy (either monofilament or tuning fork) Lipids - most patients with diabetes should take [...] (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1217803 Fri, 08 Feb 2008 17:54:14 +0100 1217803 http://www.medworm.com/index.php?rid=1215166&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3463 Today we discussed 10 new patients (a challenging post-call day.) We had to spend more time on patient care than teaching, but we did throw in a couple of points. The team voted on indications for allopurinol. The list represents my recollection. I exclude the acute use during tumor lysis, and restrict my [...] (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1215166 Thu, 07 Feb 2008 19:43:47 +0100 1215166 http://www.medworm.com/index.php?rid=1213179&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3462 I am enjoying sharing the main teaching points from my two weeks on VA service.  My team is actually reviewing my notes to reinforce the teaching. So the question - is this series worthwhile?  What comments do you have about the focus of these entries? Thanks db (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1213179 Thu, 07 Feb 2008 02:28:48 +0100 1213179 http://www.medworm.com/index.php?rid=1211900&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3461 In today’s “chalk talk” we discussed the above common problem. Here is our list: Acute dyspnea in COPD Acute bronchitis Pneumonia Pleural effusion Lung Cancer Tachyarrhythmia Ascites Heart failure Muscle weakness Rib or vertebral fracture Pneumothorax Pulmonary embolism Anemia (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1211900 Wed, 06 Feb 2008 16:49:01 +0100 1211900 http://www.medworm.com/index.php?rid=1206950&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3460 Yesterday we discussed a patient who came to the ER for decreased urine output. Our discussion involved developing a logical approach to this patient. His initial creatinine was 2.8, up from 1.6 within the past month. Whenever you see a patient with a newly increased creatinine, you must consider: 1. Progression of disease 2. Obstruction 3. Volume [...] (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1206950 Tue, 05 Feb 2008 17:36:18 +0100 1206950 http://www.medworm.com/index.php?rid=1198634&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3458 Today’s topic we picked from many candidates. My team worked 24 hours and we had 8 admissions. I asked the team (who are reading this blog) which topic today’s entry should stress. We chose the use of medications to prevent or treat complications of cirrhosis. We discussed four conditions: (1) ascites; (2) variceal [...] (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1198634 Sun, 03 Feb 2008 21:52:46 +0100 1198634 http://www.medworm.com/index.php?rid=1196583&cid=t_161717_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3457 This is the second post in a new series based upon my ward rounds.  Yesterday, I discussed learning climate.  Today I will discuss an important issue we discussed on rounds - diuretic dose for heart failure. We have a gentleman with significant heart failure, who came to the hospital with pulmonary edema.  He responded nicely to [...] (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1196583 Sat, 02 Feb 2008 15:18:37 +0100 1196583