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 bicarbonate.
To make the question more generic, when should we use bicarbonate in patients with increased anion gap acidosis?
A recent article does address this question. Answer tomorrow.
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Thnx for bringing back VA series.
I learned more from this VA series than any other resources on Acid Base balance.
Urine proteinn/creat ration mentioned in this blog post, do we require 24 hour urine collection or is it spot test?
RAM, a spot protein/creatinine has been shown to be pretty much equivalent to the 24 hour urine. It is also much much easier for the patient.
I enjoy the blog, and very much like the VA series, but there is one concern I have that I HOPE has more to do with your writing style than your teaching style since I know you aim to be a conscientious teacher and I appreciate that greatly (and am stiving to do the same in my own practice!).
As a senior IM resident back in the day, one of the best aspects of my VA ward month rotations was the opportunity to take charge of the team, including a substantial part of teaching, and of the care of the patients, with the attending's role more advisory than directive. More than at our tertiary/quaternary academic hospital where we often felt like the handmaidens of the specialty teams, we were happy to be the true primary decisionmakers at our VA.
Thus, when I see you repeatedly using phrases in your blog like today's "I ordered a consult," or in the past, "I made some decisions," or, worst of all, "I sent the patient to the unit," I am very hopeful it was really your residents doing these things, primarily on their own initiative, perhaps with some nudging from you.
If my hope is correct, and it is you collectively as a team, or better yet your residents really taking charge, then I would still suggest you consider changing your verbiage in your blog out of respect to your colleagues in training, since I am certain they must read your blog too, and they deserve to take part in the ownership of the patients. These little things mean a lot.
Otherwise, I enjoy the blog, and I look forward to you continuing to champion the academic teacher's role!
would not give bicarb for lactic acidosis. would do ercp and give abx to treat cholangitis.