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 'base'. Sat, 03 Sep 2011 02:04:56 +0100 http://www.medworm.com/index.php?rid=5181698&cid=t_168242_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_168242_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=5159221&cid=t_168242_109_f&fid=36089&url=http%3A%2F%2Fthesituationist.wordpress.com%2F2011%2F08%2F23%2Ftaxi-to-the-darkside%2F * * * ] * * * (BBC Broadcast, 2011) From jigsawproductions: This documentary murder mystery examines the death of an Afghan taxi driver at Bagram Air Base from injuries inflicted by U.S. soldiers. In an unflinching look at the Bush administration’s policy on torture, the filmmaker behind Enron: the Smartest Guys in the Room takes us from a village in Afghanistan to Guantanamo and straight to the White House. In English and Pashtu. Related Situationist posts: “The Situation of Bullying,” “Lessons Learned from the Abu Ghraib Horrors,”  “Bush, Cheney, Rumsfeld, and Tenet: ‘Guilty‘,” Divided Loyalties Symposium “Lessons Learned from the Abu Ghraib Horrors,”  “The Justice Department, Milgram, & Torture,” “The Bush Frame: Us vs. Them; Good vs. Evil;... The Situationist blogs http://www.medworm.com/rss/comments.php?id=5159221 Tue, 23 Aug 2011 04:01:53 +0100 5159221 http://www.medworm.com/index.php?rid=5139645&cid=t_168242_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_168242_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_168242_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_168242_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=4934021&cid=t_168242_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_168242_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_168242_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_168242_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=4893457&cid=t_168242_88_f&fid=38129&url=http%3A%2F%2Ffeedproxy.google.com%2F%7Er%2Flifeinthefastlane%2FWZHV%2F%7E3%2FSen8YuWqphg%2F Some fun figures well worth engraving on the surface of your encephalon if you're an emergency or critical care doc in this week's FFFF. (Source: Life in the Fast Lane) Life in the Fast Lane blogs http://www.medworm.com/rss/comments.php?id=4893457 Fri, 03 Jun 2011 00:00:23 +0100 4893457 http://www.medworm.com/index.php?rid=4893339&cid=t_168242_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=4803146&cid=t_168242_88_f&fid=38129&url=http%3A%2F%2Ffeedproxy.google.com%2F%7Er%2Flifeinthefastlane%2FWZHV%2F%7E3%2FRL51oCgViVc%2F The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care (Source: Life in the Fast Lane) Life in the Fast Lane blogs http://www.medworm.com/rss/comments.php?id=4803146 Mon, 02 May 2011 05:51:07 +0100 4803146 http://www.medworm.com/index.php?rid=4734114&cid=t_168242_88_f&fid=38129&url=http%3A%2F%2Fwww.emergencyweb.net%2Flibrary%2Fmp3.php%3Ff%3Deits_ep039_als_review_2010.mp3 The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care. (Source: Life in the Fast Lane) Life in the Fast Lane blogs http://www.medworm.com/rss/comments.php?id=4734114 Mon, 18 Apr 2011 03:55:11 +0100 4734114 http://www.medworm.com/index.php?rid=4684687&cid=t_168242_136_f&fid=39212&url=http%3A%2F%2Fbahtocancer.com%2F2011%2F04%2Fsave-2nd-base-bah-giveaway%2F One of the things I enjoy about blogging (apart from the blogging) is hearing from other people out there doing their own thing on Planet Cancer. I love the different ways that people choose to challenge cancer, fundraise, raise awareness, and generally say Bah! in their own sweet way. I recently heard from an organisation in the US called ‘Save 2nd Base’. They work to raise funds and breast cancer awareness in memory of Kelly Rooney, who died of breast cancer in 2006 at the age of 43. And I just love the way they do it. What I wouldn’t have given to walk into an oncology clinic wearing one of these babies. For the uninitiated – and I had to check with Twitter – in the US there are dating analogies related to baseball. So, getting to first base is kissing, se... Bah! to cancer blogs http://www.medworm.com/rss/comments.php?id=4684687 Wed, 06 Apr 2011 07:19:51 +0100 4684687 http://www.medworm.com/index.php?rid=4610773&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F6188 Happy Hospitalist enjoys interpreting arterial blood gases.  I wonder if he enjoys electrolyte panels as much.  I do love lab test interpretation (all lab tests) because as a diagnostician (med talk for detective) I want to take advantage of every possible clue. Extreme Metabolic Alkalosis: Classic Blood Gas Physiology Management Simply Explained\ We become really good at fixing abnormal blood gases, or at least getting them to a stable base line.   If you are ever being pimped by your attending and the question involves a blood gas, the answer will almost always be administer saline first, ask questions later.  Medical students, keep this in mind the next time your attending asks you about that anion gap metabolic acidosis.   That may not fly with Dr Centor duri... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4610773 Fri, 18 Mar 2011 22:12:02 +0100 4610773 http://www.medworm.com/index.php?rid=4507242&cid=t_168242_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_168242_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=4399466&cid=t_168242_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_168242_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_168242_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=4219698&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5969 Any day you get published in the NEJM is a good day.  As of 5 p.m. today, you can read a very interesting Clinical Problem Solving case that I participated in – In Search of . . . This patient fit my definition of a "great case", because after a struggle to make the diagnosis the patient had a great response to treatment.  The diagnostic struggle made a difference. I particularly like this case because it takes a common internal medicine differential and likely expands it for many readers.  Here's hoping that you enjoy this story as much as we did. (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4219698 Thu, 02 Dec 2010 01:32:22 +0100 4219698 http://www.medworm.com/index.php?rid=4164506&cid=t_168242_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=4159429&cid=t_168242_136_f&fid=37846&url=http%3A%2F%2Fhealthinfoispower.wordpress.com%2F2010%2F11%2F11%2Fnew-assay-test-predicts-that-50-of-ovarian-cancers-will-respond-to-in-vitro-parp-inhibition%2F U.K. researchers develop a new test that could be used to select ovarian cancer patients who will benefit from a new class of drugs called “PARP inhibitors.” U.K. researchers have developed a new test that could be used to select which patients with ovarian cancer will benefit from a new class of drugs called “PARP [...] (Source: Libby's H*O*P*E*) Libby's H*O*P*E* blogs http://www.medworm.com/rss/comments.php?id=4159429 Fri, 12 Nov 2010 00:19:19 +0100 4159429 http://www.medworm.com/index.php?rid=4155208&cid=t_168242_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=4121919&cid=t_168242_109_f&fid=34750&url=http%3A%2F%2Fpsychcentral.com%2Fblog%2Farchives%2F2010%2F10%2F31%2Fare-your-children-safe-on-halloween%2F The short answer is, “Yes.” At least from sex offenders. Halloween is today. And parents around the country walk along their young children for fear of their safety. And yet, what do the data show about sex offenders offending on or around Halloween? Are they more likely to target the holiday because so many children are out and about? Police are on alert during Halloween, especially for sex offenders. The common wisdom is that sex offenders are out and about on Halloween, looking for targets. Researchers led by Mark Chaffin (2009) looked at the National Incident-Base Reporting System which reports crime report data. They examined sex crimes data from 1997 to 2005 against children ages 12 year and younger by non-family members. Halloween crime rates were compared with expected ... World of Psychology blogs http://www.medworm.com/rss/comments.php?id=4121919 Sun, 31 Oct 2010 12:43:34 +0100 4121919 http://www.medworm.com/index.php?rid=4036592&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5851 Periodically we get a patient admitted with profound hyponatremia < 105.  These patients generally have a great risk for developing a demyelination syndrome.  This case report discusses a novel and logical strategy to avoid having the sodium level increase too rapidly.  They recommend a combination of 3% NS and desmopressin with a goal of 6 mEq/day.  The link is to the abstract, I recommend that all hospitalists get the article, read it and study it.  It will likely help you avoid a dreaded complication.  Treating Profound Hyponatremia: A Strategy for Controlled Correction (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=4036592 Wed, 06 Oct 2010 11:05:16 +0100 4036592 http://www.medworm.com/index.php?rid=3998920&cid=t_168242_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_168242_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_168242_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_168242_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_168242_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_168242_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_168242_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=3794775&cid=t_168242_87_f&fid=39187&url=http%3A%2F%2Fgetbetterhealth.com%2Fthe-insulting-term-physician-extender%2F2010.07.27 “Physician Extender.” It sounds like the name of a male enhancement product. It’s a term often used to describe a nurse practitioner or a physician’s assistant. I hate it. It’s insulting. A nurse practitioner is not an adjunct physician. They do not supplement the care of a physician. They provide essential advance-practice nursing services, services that include diagnosis and provision of medical care. While some of these services overlap those of medicine, nurse practitioners are not extensions of another profession, they provide care in their own right — as educated, licensed practitioners. Sometimes the only care provider for a community is a nurse practitioner. (more…) *This blog post was originally published at Emergiblog* (Source: Better Health) Better Health blogs http://www.medworm.com/rss/comments.php?id=3794775 Tue, 27 Jul 2010 12:00:12 +0100 3794775 http://www.medworm.com/index.php?rid=3726575&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5632 2 days ago I posed a question about low anion gaps.  I found this list: Decreased anion gap * Acidemia: Causes dissociation of protons from plasma proteins, decreasing their negative charge. * Decreased albumin: A very common cause of a lower than expected or decreased anion gap. * Assay artefacts: Artefactually elevated chloride, e.g. bromide therapy. * Dilution: Dilutes plasma proteins. * Increased unmeasured cations: Calcium, magnesium, gamma globulins, lithium. (These rarely cause an increased anion gap as most increases are incompatible with life. It is unusual to see a low anion gap in multiple myeloma.) The "pimp questions" include bromide and lithium.  While this is often a pimp question, you get the anion gap at no extra cost when you get a basic me... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3726575 Mon, 05 Jul 2010 10:44:16 +0100 3726575 http://www.medworm.com/index.php?rid=3723297&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5628 I love this story – Shopping at the GAP Can you provide other causes of a low (or even negative) anion gap? (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3723297 Sat, 03 Jul 2010 10:50:50 +0100 3723297 http://www.medworm.com/index.php?rid=3714122&cid=t_168242_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=3706673&cid=t_168242_87_f&fid=39187&url=http%3A%2F%2Fgetbetterhealth.com%2Fnon-endorsement-of-the-national-nurse-act-a-letter-to-the-ana%2F2010.06.28 To the American Nurses Association, I am a member of the American Nurses Association (ANA) and a dedicated supporter of HR 4601 The National Nurse Act. For the life of me, I cannot understand ANA’s reluctance to endorse the National Nurse Act. The infrastructure already exists, in fact the position already exists. The Act seeks to have the Chief Nursing Officer of the U.S. Public Health Service designated as the National Nurse. There is nothing political about this –- the nominating procedure for the position does not change. It is not a presidential appointment, nor is it a Cabinet position. And it costs nothing to implement -– it’s already funded. It takes no resources away from other nursing initiatives and competes with no other nursing organization. But more importantly, it g... Better Health blogs http://www.medworm.com/rss/comments.php?id=3706673 Tue, 29 Jun 2010 04:06:00 +0100 3706673 http://www.medworm.com/index.php?rid=3640968&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5534 30 something patient with HIV dementia, comes in with depressed mental status.  CD4 count 17, no HAART therapy.  Long standing diabetes mellitus and CKD stage III.  Albumin 2.4.   170 143 39 79 4.2 13 2.6   What are the problems? The patient has new hypernatremia.  The patient lived at home and was left alone for periods of the day.  The patient could not get to water.  The CKD prevented the patient from maximally concentrating the urine.  The fixed urine output exacerbated the problem.  The patient has a mildly increased anion gap (14 with expected gap of 7) and an underlying normal gap acidosis.  We obtained an ABG pH 7.30 pCO2 28 pO2 81 HCO3 14 This ABG confirmed the mixed acidosis.  The CKD was unchanged from previo... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3640968 Tue, 08 Jun 2010 01:29:46 +0100 3640968 http://www.medworm.com/index.php?rid=3632237&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5528 30 something patient with HIV dementia, comes in with depressed mental status.  CD4 count 17, no HAART therapy.  Long standing diabetes mellitus and CKD stage III.  Albumin 2.4.             170 143 39 79 4.2 13 2.6   What are the problems?  What fluids do you want to give? (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3632237 Fri, 04 Jun 2010 22:11:44 +0100 3632237 http://www.medworm.com/index.php?rid=3475762&cid=t_168242_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_168242_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=3457812&cid=t_168242_83_f&fid=34856&url=http%3A%2F%2Finsidesurgery.com%2F2010%2F04%2Fmilitary-surgeon-removes-live-explosive-soldiers-skull%2F An Air Force surgeon donned body armor recently while removing a 2 inch long unexploded ordinance from the skull of an Afghanistan soldier at Bagram Air Force base. A bomb disposal unit was on hand to disarm the explosive after it was removed. (Source: Inside Surgery) Inside Surgery blogs http://www.medworm.com/rss/comments.php?id=3457812 Sat, 10 Apr 2010 17:49:48 +0100 3457812 http://www.medworm.com/index.php?rid=3408323&cid=t_168242_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_168242_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_168242_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_168242_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_168242_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=3283485&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5305 The patient is a 69 year old woman admitted with abdominal pain and nausea.  She may have lost weight.  She has no known past medical history and is taking no medications.  Her labs give many clues: Electrolyte panel Na 142 Cl 113 BUN 106 K 6.5 HCO3 11 creat 9.1 Blood Sugar 79 Alb 3.2; Calcium 5.1 ABG on room air ABG pH 7.23 pCO2 23 pO2 80 HCO3 10 So please address these questions: 1. What is the acid-base disorder? Here is my approach.  Anion gap = 18.  Therefore, the patient has an increased anion gap acidosis by definition.  The expected gap is approximately 9 (note the albumin). The delta gap is 9; adding to 11 (the HCO3 ) gives an estimated prior bicarb of 20. pH shows acidemic and according to the Winter's equation the respi... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3283485 Thu, 18 Feb 2010 02:21:41 +0100 3283485 http://www.medworm.com/index.php?rid=3279930&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5298 The patient is a 69 year old woman admitted with abdominal pain and nausea.  She may have lost weight.  She has no known past medical history and is taking no medications.  Her labs give many clues: Electrolyte panel Na 142 Cl 113 BUN 106 K 6.5 HCO3 11 creat 9.1 Blood Sugar 79 Alb 3.2; Calcium 5.1 ABG pH 7.23 pCO2 23 pO2 80 HCO3 10 So please address these questions: 1. What is the acid-base disorder? 2. Predict other laboratory testing? 3. What would you do at admission? Related posts:An acidosis question AMS – an acid-base problem II AMS an acid-base problem – part 1 (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3279930 Tue, 16 Feb 2010 19:19:43 +0100 3279930 http://www.medworm.com/index.php?rid=3189101&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F5211 This article makes one think differently.  I like articles that challenge common wisdom. Is Metformin Associated With Lactic Acidosis? It appears that metformin itself may not increase the risk for lactic acidosis. And although metformin use has increased over the years, the incidence of lactic acidosis has not increased. Additionally, there is no evidence to suggest that sulfonylureas alone increase the risk for lactic acidosis. Rather, the presence of underlying conditions and concomitant use of other medications may elevate an individual's risk level. Some suggest that diabetes mellitus, rather than specific antidiabetes medications, may predispose a patient to lactic acidosis. The mechanisms for this increased risk are unknown. In practice, it may be important to consider d... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=3189101 Wed, 20 Jan 2010 10:48:34 +0100 3189101 http://www.medworm.com/index.php?rid=3100741&cid=t_168242_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_168242_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=3092652&cid=t_168242_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=3044691&cid=t_168242_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=3029774&cid=t_168242_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_168242_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=3018960&cid=t_168242_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=3015325&cid=t_168242_109_f&fid=34750&url=http%3A%2F%2Fpsychcentral.com%2Fblog%2Farchives%2F2009%2F11%2F20%2F2009-rosalynn-carter-symposium-on-mental-health-policy-recommendations%2F Earlier this month, I was honored to attend the 25th Annual Rosalynn Carter Symposium on Mental Health Policy in Atlanta, Georgia. The focus of this symposium every year is to tackle a particular issue in mental health policy, population or care. This year focused, fittingly enough, on health care reform and how mental health and substance abuse programs need to be an integrated part of that effort: Currently health care in this country is focused on illness rather than health, on procedures and face-to-face interventions rather than on coordination and prevention, and on fragmented, specialty-driven care rather than on a primary care-driven delivery system. There is a solid evidence base that shows that a health system centered on primary care costs less and has better outcomes on a popu... World of Psychology blogs http://www.medworm.com/rss/comments.php?id=3015325 Fri, 20 Nov 2009 19:05:44 +0100 3015325 http://www.medworm.com/index.php?rid=3012342&cid=t_168242_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_168242_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=2993737&cid=t_168242_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_168242_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=2948297&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F4948 Readers know that I love teaching acid-base and electrolytes.  For several years my students and residents have encouraged me to collect my teaching philosophy on paper. Today I started the project.  I will be writing an online book, which may become a paper book in the future.  I need critics and beta testers.  I need you.  Each time I add a new case, I will post here. The web site is called Interpreting Laboratory Tests.  Please help me, if you have questions – submit them.  If I do not make a concept clear – let me know. The first case was written today. Related posts:Acid-Base, Fluids and Electrolytes – Case #1A 2 part acid-base problemAcid base answer (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2948297 Sun, 01 Nov 2009 00:27:04 +0100 2948297 http://www.medworm.com/index.php?rid=2946875&cid=t_168242_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_168242_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=2823927&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F4869 Happy Hospitalist has a great post today. Of course, he linked to 2 of my previous posts so perhaps I am influenced to like his post. Why Do Doctors Order Blood Gases? Happy focuses primarily on the possibility of an acid-base abnormality in his entry. I would add that sometimes an ABG is necessary to really understand oxygenation. Let’s take the ABG he cites. ABG pH 7.47 pCO2 48 pO2 58 One point that I teach to students and residents is to always at least estimate the A-a gradient. And then we review how to calculate the A-a gradient. In this case the patient has a very slightly elevated A-a gradient, despite having a low pO2. Experienced clinicians quickly recognize this situation of hypoventilation causing a modest decrease in pO2. I also will get an ABG to assess oxyg... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2823927 Wed, 23 Sep 2009 11:31:02 +0100 2823927 http://www.medworm.com/index.php?rid=2782275&cid=t_168242_135_f&fid=35246&url=http%3A%2F%2Faids-write.org%2F%3Fp%3D1691 San Diego police raid and close medical marijuana dispensaries by Eric Wolff September 9, 2009 The San Diego Police Department and other county law-enforcement agencies are conducting a sweeping raid on marijuana dispensaries this afternoon. As of this writing, CityBeat has heard that Green Kross Collective, Total Care Collective, San Diego Discount Caregivers, Hillcrest Compassionate Care, Downtown Kush lounge, Top Quality Collective, Medical Cannabis Providers, and Nature’s Rx Collective have been shut down (We will updates this list as we learn more) by the San Diego Police Department and their owners arrested if they were present. Sources tell CityBeat that the owners have been given 48 hours to provide proper paperwork for their shops, but everything is very tentative at the moment.... aids-write.org blogs http://www.medworm.com/rss/comments.php?id=2782275 Thu, 10 Sep 2009 12:05:03 +0100 2782275 http://www.medworm.com/index.php?rid=2744072&cid=t_168242_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_168242_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_168242_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=2667652&cid=t_168242_136_f&fid=37846&url=http%3A%2F%2Fhealthinfoispower.wordpress.com%2F2009%2F08%2F03%2Fbeyond-brca1-brca2-u-k-researchers-identify-genetic-defect-that-could-increase-risk-of-ovarian-cancer-up-to-40%2F Scientists have located a region of DNA which – when altered – can increase the risk of ovarian cancer according to research published in Nature Genetics today. An international research group led by scientists based at the Cancer Research UK Genetic Epidemiology Unit, at the University of Cambridge and UCL (University College London) searched [...] (Source: Libby's H*O*P*E*) Libby's H*O*P*E* blogs http://www.medworm.com/rss/comments.php?id=2667652 Mon, 03 Aug 2009 21:59:29 +0100 2667652 http://www.medworm.com/index.php?rid=2638005&cid=t_168242_150_f&fid=38374&url=http%3A%2F%2Ffeedproxy.google.com%2F%7Er%2FePharmaSummit%2F%7E3%2FaYTjsgOixOc%2Fdepartment-of-defense-testing-out.html (Source: ePharma Summit) ePharma Summit blogs http://www.medworm.com/rss/comments.php?id=2638005 Fri, 24 Jul 2009 18:34:00 +0100 2638005 http://www.medworm.com/index.php?rid=2522942&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Farchives%2F4454 So I thought about the problem overnight.  The key here was the persistent respiratory acidosis.  The patient clearly did not have COPD.  I did mention his weight, and then I decided he must have obesity hypoventilation syndrome.  So we go into the room the next morning and he is now alert and his wife is in the room.  I turn to her and ask if he snores – and then the floodgates open.  He had a history of sleep apnea, and was supposed to be using CPAP, but his mask had broken. When he came to the emergency department, he had altered mental status, and thus the history was incomplete.  We initially blamed his hypoventilation on the hyperosmolar state.  However, the hypoventilation persisted after his blood sugar came down to normal and he... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2522942 Sun, 21 Jun 2009 12:04:24 +0100 2522942 http://www.medworm.com/index.php?rid=2452479&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F4314   To remind readers     ABG pH 7.48 pCO2 50 pO2 96   On a respirator   Making rounds yesterday in the ICU, we found this electrolyte panel Electrolyte panel Na  138 Cl  97 BUN  32 K 3.6 HCO3 36 creat  1.1 Blood Sugar  165   As usual, figure out the acid-base disorder and explain the sequence of events.  The patient has been intubated for 3 days.  He has COPD and CHF.   His ABG from 3 days previously -   ABG pH 7.36 pCO2 57 pO2 115   There are two likely possibilities here, and they are not mutually exclusive.  One strong possibility is the entity known as "revealed" metabolic alkalosis.  This occurs when a patient has respiratory acidosis and appropriate ... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2452479 Thu, 04 Jun 2009 13:05:42 +0100 2452479 http://www.medworm.com/index.php?rid=2447521&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F4308     ABG pH 7.48 pCO2 50 pO2 96   On a respirator   Making rounds yesterday in the ICU, we found this electrolyte panel Electrolyte panel Na  138 Cl  97 BUN  32 K 3.6 HCO3 36 creat  1.1 Blood Sugar  165   As usual, figure out the acid-base disorder and explain the sequence of events.  The patient has been intubated for 3 days.  He has COPD and CHF.   (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2447521 Mon, 01 Jun 2009 18:33:32 +0100 2447521 http://www.medworm.com/index.php?rid=2447523&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F4301   Tolvaptan is an ADH antagonist.  We will have few indications, but in the rare true SIADH patient, this drug will have some value.  I do not know the cost. I see many hyponatremia patients, and few of them have persistent SIADH.  I am glad to have this option for those rare patients.  The NEJM had a couple of important articles about tolvaptan a couple of years ago.   (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2447523 Sun, 31 May 2009 00:48:58 +0100 2447523 http://www.medworm.com/index.php?rid=2441336&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F4289   Making rounds yesterday in the ICU, we found this electrolyte panel Electrolyte panel Na  138 Cl  109 BUN  58 K 4.2 HCO3  17 creat  1.8 Blood Sugar  206 Clinical context - 50 year old woman with known cirrhosis and gram negative sepsis.  Her creatinine and BUN are improving with volume expansion.  I asked readers to explain her decreased HCO3 Let me add that she was intubated and on a respirator. I thank the readers for falling for my trap.  I have posted cases like this in the past, but this may be a better example.  You cannot make an acid-base diagnosis without an arterial blood gas. On FiO2 30%   ABG pH 7.42 pCO2 25 pO2 112   The decreased bicarbonate is appropriate for the degree of hyperve... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2441336 Thu, 28 May 2009 10:46:14 +0100 2441336 http://www.medworm.com/index.php?rid=2441337&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F4287   Making rounds today in the ICU, we found this electrolyte panel Electrolyte panel Na  138 Cl  109 BUN  58 K 4.2 HCO3  17 creat  1.8 Blood Sugar  206 Clinical context - 50 year old woman with known cirrhosis and gram negative sepsis.  Her creatinine and BUN are improving with volume expansion.  Explain her decreased HCO3       (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2441337 Wed, 27 May 2009 15:57:12 +0100 2441337 http://www.medworm.com/index.php?rid=2415713&cid=t_168242_136_f&fid=37846&url=http%3A%2F%2Fhealthinfoispower.wordpress.com%2F2009%2F05%2F16%2Fginger-quells-cancer-patients-chemotherapy-related-nausea%2F “People with cancer can reduce post-chemotherapy nausea by 40 percent by using ginger supplements, along with standard anti-vomiting drugs, before undergoing treatment, according to scientists at the University of Rochester Medical Center. …” People with cancer can reduce post-chemotherapy nausea by 40 percent by using ginger supplements, along with standard anti-vomiting drugs, before undergoing treatment, according [...] (Source: Libby's H*O*P*E*) Libby's H*O*P*E* blogs http://www.medworm.com/rss/comments.php?id=2415713 Sat, 16 May 2009 23:21:44 +0100 2415713 http://www.medworm.com/index.php?rid=2347912&cid=t_168242_87_f&fid=34825&url=http%3A%2F%2Fwww.wesleyjsmith.com%2Fblog%2F2009%2F04%2Ftelling-paramedics-not-to-resuscitate.html The UK is permitting terminally ill patients to be listed on a register so that they are not resuscitated by paramedics in the event of a medical emergency. From the story:Health Service paramedics have been told not to resuscitate terminally-ill patients who register on a controversial new database to say they want to die.It has been set up by the ambulance service in London for hundreds of people who have only a few months to live so that they may register their 'death wishes' in advance. It is believed to be the first in the country, but other trusts around the country are expected to follow suit to comply with Government guidelines which state that patients' wishes should be taken into account, even at the point of death. Similar plans exist here in the USA, and I'm not opposed to them... Secondhand Smoke blogs http://www.medworm.com/rss/comments.php?id=2347912 Sat, 18 Apr 2009 05:05:00 +0100 2347912 http://www.medworm.com/index.php?rid=2348032&cid=t_168242_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_168242_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=2156140&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F4065   The case:   A 53-year-old man, with a history of DM II, hypertension, depression and hepatitis C,  He is admitted for muscle cramps.  He has a recent history of epididymitis and is taking 2 antibiotics (he cannot remember the names.)  He also takes lisinopril 10 mg daily and fluoxetine 20 mg daily.     ABG pH 7.31 pCO2 32 pO2 105 His EKG showed mildly peaked T waves. He was successfully treated with IV insulin and glucose, albuterol nebulizer and sodium bicarbonate.  He also took sodium polystyrene (Kayexalate). On discharge his lab tests:     Electrolyte panel Na  138 Cl  109 BUN  19 K 4.3 HCO3  22 creat  1.3 Blood Sugar  184   Speculate on the cause and underlying physiology.&nb... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2156140 Tue, 03 Feb 2009 19:03:02 +0100 2156140 http://www.medworm.com/index.php?rid=2144411&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F4059   A 53-year-old man, with a history of DM II, hypertension, depression and hepatitis C,  He is admitted for muscle cramps.  He has a recent history of epididymitis and is taking 2 antibiotics (he cannot remember the names.)  He also takes lisinopril 10 mg daily and fluoxetine 20 mg daily.     ABG pH 7.31 pCO2 32 pO2 105 His EKG showed mildly peaked T waves. He was successfully treated with IV insulin and glucose, albuterol nebulizer and sodium bicarbonate.  He also took sodium polystyrene (Kayexalate). On discharge his lab tests:     Electrolyte panel Na  138 Cl  109 BUN  19 K 4.3 HCO3  22 creat  1.3 Blood Sugar  184   Speculate on the cause and underlying physiology.  We do have a ... DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=2144411 Thu, 29 Jan 2009 14:06:21 +0100 2144411 http://www.medworm.com/index.php?rid=2137612&cid=t_168242_113_f&fid=34933&url=http%3A%2F%2Fpalmdoc.net%2F%3Fp%3D2155 Free Radical have released Acid Plus for the iPhone Features: * Fast, accurate input using the dial * Primary calculations including compensations and anion gap with delta delta * Ability to discern complex acid/base problems with secondary disorders * Detailed views listing common causes of the primary acid-base disorder * Colorful graph activated by turning the device right or left * Real-time arrow pointing to the correct disorder on the graph * Works on both iPhone and iPod touch (via Medgadget.com) See more iPhone medical apps in this thread in the Palmdoc.net forums from the Palmdoc Chronicles Acid Base for iPhone (Source: The Palmdoc Chronicles) The Palmdoc Chronicles blogs http://www.medworm.com/rss/comments.php?id=2137612 Tue, 27 Jan 2009 05:00:00 +0100 2137612 http://www.medworm.com/index.php?rid=2129730&cid=t_168242_105_f&fid=36987&url=http%3A%2F%2Ffeeds.feedburner.com%2F%7Er%2FIvorKovicMd%2F%7E3%2F521345667%2F During my medical school years and now when I myself practice medicine, I have noticed that a lot of people have trouble interpreting the arterial blood gases (ABG) test. This test normally provides partial pressure of oxygen (PaO2), partial pressure of carbon dioxide (PaCO2), pH and bicarbonate (HCO3) values. It is important and quite easy to notice if some of these figures are not normal, but interpretation is crucial and sometimes difficult. For these reasons I am sure a lot of practicing medical workers will be pleased to hear that there is now a great application for the iPhone which can be of big help during the interpretation of the ABG test. The mentioned app is called Acid Plus and is available through the iTunes Store for only $1.99. Acid Plus is extremely easy to use. You open ... Ivor Kovic, M.D. blogs http://www.medworm.com/rss/comments.php?id=2129730 Sat, 24 Jan 2009 02:07:07 +0100 2129730 http://www.medworm.com/index.php?rid=2040150&cid=t_168242_135_f&fid=35246&url=http%3A%2F%2Faids-write.org%2F%3Fp%3D1339 chers— the art of maps. namaste —rk Number of People With HIV/AIDS (Source: aids-write.org) aids-write.org blogs http://www.medworm.com/rss/comments.php?id=2040150 Tue, 16 Dec 2008 20:51:39 +0100 2040150 http://www.medworm.com/index.php?rid=2027195&cid=t_168242_133_f&fid=35096&url=http%3A%2F%2Ffeeds.b5media.com%2F%7Er%2Fb5media%2FAutismVox%2F%7E3%2FpQubl1wZPHo%2F 12-year-old Joshua Wilson has made it all the way to the base camp of Mt. Everest, the highest mountain in the world, today’s Bournemouth Echo reports. Wilson, who’s autistic, is believed to be the youngest ever to trek that far. Talk about climbing every mountain………. Tags: asd, asperger, autism, autism blog, base camp, bournemouth, climbing, disabilities blog, disability, Education, Health, mt everest, nepal, parenthood, special needsShare This (Source: Autism Vox) Autism Vox blogs http://www.medworm.com/rss/comments.php?id=2027195 Wed, 10 Dec 2008 23:15:52 +0100 2027195 http://www.medworm.com/index.php?rid=1955123&cid=t_168242_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_168242_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=1926570&cid=t_168242_135_f&fid=35246&url=http%3A%2F%2Faids-write.org%2F%3Fp%3D1132 sacbee mast Draft report: Prison medical care costs $2.3 billion higher By Andy Furillo afurillo@sacbee.com Published: Friday, Oct. 31, 2008 The prison medical care czar’s $8 billion plan to build 10,000 long-term care beds and other health facilities for inmates will cost taxpayers an additional $2.3 billion a year in operation costs, according to a draft internal state corrections department report obtained by The Bee. Most of the $230,000 cost per inmate will result from a staffing ratio of 1.4 employees per prisoner - including art therapists, music therapists, beauticians and barbers, the report said. It “will far exceed any per inmate cost” of any correctional agency in the country, according to the report. It currently costs an average of $43,000 a year to house a... aids-write.org blogs http://www.medworm.com/rss/comments.php?id=1926570 Sat, 01 Nov 2008 19:50:43 +0100 1926570 http://www.medworm.com/index.php?rid=1917754&cid=t_168242_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=1907711&cid=t_168242_133_f&fid=35096&url=http%3A%2F%2Ffeeds.b5media.com%3A80%2F%7Er%2Fb5media%2FAutismVox%2F%7E3%2FAstUfKIKdZo%2F “Figuring out his signs, it’s like watching a third-base coach.” Says Brian Rattner about his oldest son, Jarrett, who is 13 years old and does not talk or walk. An October 23rd New York Times article describes Jarrett’s bar mitzvah last Sunday, and how his parents came to focus on “who Jarrett was and what he could do”: When he wanted a ball, he would pound his chest until he got it. “Sometimes, he wants to communicate so badly, you can hear him from the other room pounding his chest,” Mr. Rattner said. “There’s a lot of emotion there.” He is good at making eye contact, and his mother noticed that if she asked what he wanted for lunch — turkey? tuna? chicken? — he would say yes by blinking his eyes and then holding them closed an extra second.... Autism Vox blogs http://www.medworm.com/rss/comments.php?id=1907711 Sat, 25 Oct 2008 17:00:37 +0100 1907711 http://www.medworm.com/index.php?rid=1905706&cid=t_168242_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_168242_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_168242_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_168242_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=1605759&cid=t_168242_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=1501498&cid=t_168242_132_f&fid=35624&url=http%3A%2F%2Fsuicyte.wordpress.com%2F2008%2F06%2F07%2Fturning-part-of-the-proteasome-on-its-head%2F I am a bit short on time, but I have seen that the Glickman paper on the proteasome base structure has finally appeared in print - this event should not go unnoticed. Before I begin to discuss the paper, I must admit that I haven’t really read it - I have heard Michael talk about this model at least three times, and had lengthy discussions with him and others during the Lake Garda meeting.  The new model, now published in Nature Structural and Molecular Biology, departs from the old dogma how subunits of the 19S proteasome regulator complex are arranged. Not surprisingly, reactions from the proteasome field are mixed. It is no coincidence that it took more than a year to get this story published. Before describing the new model, let me briefly recount the conventional wisdom on prot... Suicyte Notes blogs http://www.medworm.com/rss/comments.php?id=1501498 Sat, 07 Jun 2008 22:13:19 +0100 1501498 http://www.medworm.com/index.php?rid=1449200&cid=t_168242_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=1442618&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3576   Was It the Drinking Binge?   Solution to "Was It the Drinking Binge?"     (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1442618 Wed, 14 May 2008 15:24:43 +0100 1442618 http://www.medworm.com/index.php?rid=1409491&cid=t_168242_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_168242_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=1323071&cid=t_168242_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_168242_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=1289868&cid=t_168242_134_f&fid=36049&url=http%3A%2F%2Ffeeds.b5media.com%2F%7Er%2Fb5media%2FDiabetesNotes%2F%7E3%2F248742099%2F Diabetic MLB ex-Tiger Dmitri Young is frustrated with his lack of weight loss and diabetic complications that could occur as a result. The 2007 National League comeback player of the year told mlb.com that he exercised, hired a chef to prepare food out of a cookbook for diabetics and even tried to fast for a day. But he still tips the scales around 290 pounds. His doctors are blaming his weight retention on insulin. He is now on new medication and the Nationals have hired a nutritionist. Mr. Young had been on the same medication since his diagnosis so maybe it is time for an adjustment, get things all stirred up. Battling for his first base position against fellow teammate Nick Johnson should also help to get him movin’ and groovin’. via freep.com Tags: Diabetes, Dmitri Young,... Diabetes Notes blogs http://www.medworm.com/rss/comments.php?id=1289868 Mon, 10 Mar 2008 08:07:22 +0100 1289868 http://www.medworm.com/index.php?rid=1277533&cid=t_168242_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_168242_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=1223611&cid=t_168242_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_168242_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_168242_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_168242_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_168242_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=1207315&cid=t_168242_109_f&fid=34750&url=http%3A%2F%2Fpsychcentral.com%2Fblog%2Farchives%2F2008%2F02%2F05%2Fsurrounded-by-clocks-but-no-time%2F I looked around my desk today and realized I have about 5 clock faces staring back at me. Not because I’m a crazy person holed up in a world of clocks (although now I’m beginning to wonder…), but because clocks seem to be an added component of other, largely unrelated things. There’s one on my computer screen, always reminding me of how little I’ve done today. There’s one I got from Ireland, in an ornate, hand-carved base. I bought the clock for the base — the clock itself is just some cheap, made-in-china timepiece. The clock on my weather station leaves me scratching my head a little (I need the weather forecast, not the time!). To say nothing about the clocks on my wrist or in my pocket on my cell phone. But the worst clock of them all is the ... World of Psychology blogs http://www.medworm.com/rss/comments.php?id=1207315 Tue, 05 Feb 2008 21:13:44 +0100 1207315 http://www.medworm.com/index.php?rid=1149552&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fwww.medrants.com%2Findex.php%2Farchives%2F3437 A 52-year-old Man With a Low Bicarbonate Level Enjoy - the answer will be posted next week (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=1149552 Mon, 14 Jan 2008 20:13:03 +0100 1149552 http://www.medworm.com/index.php?rid=983276&cid=t_168242_107_f&fid=35025&url=http%3A%2F%2Frrresearch.blogspot.com%2F2007%2F10%2Fmodeling-mutation-with-transition-bias.html As part of our new-improved Perl model of uptake sequence evolution, we had been intending to incorporate the usual transition:transversion bias into the part of the model that simulates mutation of the evolving sequence. But it's turning out to be HARD.In the previous version, the mutation step incorporated a bias of the same strength as the user-specified base composition. For the H. influenzae genome (38% G+C), the routine we were using caused the mutagenesis to produce As and Ts each 31% of the time and to produce Gs and Cs each 19% of the time. This was perfectly satisfactory (or would have been if not for other components of the mutagenesis that were unnecessarily cumbersome).At a recent planning session we thought we had figured out a way to also have transition mutations (AG and CT... RRResearch blogs http://www.medworm.com/rss/comments.php?id=983276 Sat, 27 Oct 2007 02:19:00 +0100 983276 http://www.medworm.com/index.php?rid=911711&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fmedrants.com%2Findex.php%2Farchives%2F3350 The housestaff obtained this ABG on a patient presented yesterday at morning report. Your task is to explain the acid-base disorder and the oxygen level. On room air - serum bicarbonate is 44 ABG pH 7.52 pCO2 54 pO2 62 (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=911711 Fri, 28 Sep 2007 15:27:46 +0100 911711 http://www.medworm.com/index.php?rid=861303&cid=t_168242_87_f&fid=34469&url=http%3A%2F%2Fmedrants.com%2Findex.php%2Farchives%2F3328 I saw a similar patient 3 years ago. This case report is important - A case of valproate-induced hyperammonemic encephalopathy: look beyond the liver The patient was admitted to hospital for further investigations and for monitoring with video electroencephalography. In the first 48 hours after admission, her level of consciousness fluctuated. Subsequent tests revealed an [...] (Source: DB's Medical Rants) DB's Medical Rants blogs http://www.medworm.com/rss/comments.php?id=861303 Tue, 11 Sep 2007 13:29:37 +0100 861303 http://www.medworm.com/index.php?rid=587940&cid=t_168242_113_f&fid=34898&url=http%3A%2F%2Fbillkosloskymd.typepad.com%2Fwirelessdoc%2F2007%2F05%2Fnew_transceiver.html Zarlink Introduces High Performance Implantable Wireless ChipThis British company is introducing "an ultra low-power RF system-on-a-chip"  for wireless monitoring systems including implanted devices.Previous home health-monitoring systems required the patient to accurately position an inductive wand over the implanted device. In comparison, using Zarlink MICS technology, patient health and implanted device performance data can be stored in the implanted medical device's memory and wirelessly transmitted to a base station, without requiring patient intervention. Data can then be forwarded over the telephone or Internet to a physician's office.Technorati Tags: Zarlink Semiconductor, medical wireless, wireless monitoring, implanted device, RF link, transceiver, chip, base stations, Power... Wireless Doc blogs http://www.medworm.com/rss/comments.php?id=587940 Thu, 03 May 2007 13:07:14 +0100 587940 http://www.medworm.com/index.php?rid=540730&cid=t_168242_133_f&fid=35129&url=http%3A%2F%2Fwhitterer-autism.blogspot.com%2F2007%2F04%2Fjust-typical-social-skills-and-autistic.html [Fast forward to real time for my annual gloat]Of course the disappointment stems from faulty expectations on the part of the parent, but it stings none the less for that. I think most parents find that the pin pricks of their children feel like personal stabs. It’s part and parcel of being the adult. If you are the adult, then it should be you who is the rational being and dismisses these petty hurts. When you see the real glee in the typical child’s eyes on arrival for a play date, your chest swells with vicarious pleasure. When you explain that ‘electronics’ are not permitted until 5, you also recognize disappointment in the visitor. The declaration of universal boredom, coupled with discrete enquiries as when mom will be collecting, tells you really all you need to know. But it... Whitterer on Autism blogs http://www.medworm.com/rss/comments.php?id=540730 Fri, 13 Apr 2007 00:00:00 +0100 540730 http://www.medworm.com/index.php?rid=539102&cid=t_168242_87_f&fid=34882&url=http%3A%2F%2Fbreathspakids.blogspot.com%2F2007%2F04%2Fchildren-trek-on-everest-for-medical.html My husband is participating in a medical trek to Everest Base Camp next month: for those of you interested in such things, the Base Camp is at an altitude of 17,600 feet and the air pressure is at 50% of normal sea level. As part of the same Caudwell Xtreme Everest project there is an expedition of children, accompanied by their parents, a grandmother, paediatricians and physiologists. The Times carried an account of the Tears and triumph of children who tackled Everest for medical science and it is well worth reading. The serious side of the article is enlivened by comments such as those from 11 year old Harriet, "Ate some dodgy porridge, seen some yaks, met a monk and walked up all these hills". My husband was away over Easter on a pre-trek orientation and these comments are pretty much ... Breath Spa for Kids blogs http://www.medworm.com/rss/comments.php?id=539102 Thu, 12 Apr 2007 13:53:00 +0100 539102