Favorite Quotes
"For every complex problem, there is a solution that is simple, neat, and wrong." - HL Mencken
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"I hear and I forget. I see and I remember. I do and I understand." - Confucius
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"The good physician treats the disease; the great physician treats the patient who has the disease" - Sir William Osler
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" The best test of a person's character is how he or she treats those with less power." - Bob Sutton
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"Those are my principles, and if you don't like them - well, I have others." - Groucho Marx
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"The difference between genius and stupidity is that genius has its limits." - Albert Einstein
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"It is hard enough to remember my opinions, without also remembering my reasons for them" - Friedrich Nietzsche
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"Anyone can make the simple complicated. Creativity is making the complicated simple." - Charles Mingus
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"Not everything that can be counted counts, and not everything that counts can be counted." - Albert Einstein
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"A foolish consistency is the hobgoblin of little minds, adored by little statesman and philosophers and divines. With consistency a great soul has simply nothing to do." - Ralph Waldo Emerson
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"This ain't no party, this ain't no disco, this ain't no fooling around." - Talking Heads, Life During Wartime
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"What is hateful to you, do not do to your neighbour. This is the whole Torah; all the rest is commentary. Go and learn it." - Hillel, Talmud, Shabbath 31a
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"You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing." - Thomas Sowell
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"An idealist is one who, on noticing that a rose smells better than a cabbage, concludes that it will also make better soup." - HL Mencken
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"If you only have a hammer, you tend to see every problem as a nail." - Abraham Maslow
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"A great teacher is one who realizes that he himself is also a student and whose goal is not to dictate the answers, but to stimulate his students creativity enough so that they go out and find the answers themselves." - Herbie Hancock
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"There are no facts, only interpretations." - Nietzsche
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"An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you do know and what you don't." - Anatole France
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"In character, in manner, in style, in all things, the supreme excellence is simplicity." - Henry Wadsworth Longfellow ====
Nov - 15
Dec - 19
Jan - 21
Feb - 8
Mar -
17 days at the VA – day 9
23 Nov2009
So yesterday was day 9. We have 4 patients, relatively stable, on call today. We did have a major teaching point.
We have a patient with legitimate severe pain. The intern had written a prn order for a narcotic. The patient complained that he was not getting the pain medicine often enough.
This is a teachable moment. Our palliative care physicians have taught me the superiority of order pain med every 4 – patient may refuse. The resident knew that; I knew that; yet we had not noticed. So we changed the order yesterday with a new twist I learned – "do not awaken patient to give".
So our big lesson yesterday involved making narcotic administration more patient centric.
Back to our acid base problem from yesterday:
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 |
My explanation – the anion gap is 15. We would normally consider that a minor elevation, but here is the teaching point – the expected anion gap is around 7 because the albumin is only 2.2. The albumin normally is the major component of the anion gap. We could subtract 2.5 *1.8 (4g normal – 2.2g observed) from 12. The multiplication gives 4.5, so 4.5 from 12 equals 7.5.
At UAB we use the shortcut – albumin times 3 – that gives us an expected gap of 6.6. Either way we expect a gap of 6-8. Our actual gap is 15, thus we have an excess gap of approximately 8.
First, we must explain the gap. This is a classic uremic anion gap acidosis – the patient has a markedly elevated PO4 of 6.6. While we cannot use a formula to estimate the gap from an elevated PO4 this clearly is in range. When we do the "delta gap" we add 8 (the excess gap) to 18 (the observed bicarb) to obtain a "initial bicarb" of 26 – i.e. normal once we subtract the gap.
This finding was a bit surprising because so many predialysis patients do have a normal gap acidosis.
The patient did great with his first 2 dialyses. His phosphate is now normalized, and his gap is normal.
Related posts:
- Yesterday’s acid-base problem
- Part 2 of the acid-base problem
- My thoughts on March 8 acid-base
- AMS – an acid-base problem II
- Normal gap acidosis from diarrhea
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- In: Medical Rants