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 -
Archive for the ‘Acid-Base & Lytes’ Category
My thoughts on March 8 acid-base
11, Mar 2010First, 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 [...]
Yesterday’s acid-base challenge
10, Mar 2010We 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.
March 8, 2010 – an acid base challenge
8, Mar 2010The 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 [...]
Yesterday’s acid-base problem
17, Feb 2010The 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 [...]
A new acid-base problem
16, Feb 2010The 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? 2. [...]
Perhaps metformin does not cause lactic acidosis
20, Jan 2010This 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 [...]
15 days at the VA – day 3
19, Dec 2009Not too bad, 9 admissions, but several were just overnight admissions. I always am hyperfunctioning on Friday post call days. We have to work hard, because many things are not available on the weekends.
Yesterday I posed a question about treating metabolic acidosis with bicarbonate. I recommend this article – Bicarbonate Therapy in Severe Metabolic Acidosis
Here [...]
15 days at the VA – day 2
18, Dec 2009I 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 [...]
Normal gap acidosis from diarrhea
17, Dec 2009Yesterday 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 [...]
Diarrhea and an abnormal BMP
16, Dec 2009Interesting 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?
17 days at the VA – day 17
1, Dec 200955 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. [...]
17 days at the VA – day 12
26, Nov 2009
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 [...]
17 days at the VA – day 11
25, Nov 2009Day 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 [...]
17 days at the VA – Day 8
22, Nov 2009Relatively 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 [...]
17 days at the VA – Day 6
20, Nov 2009Day 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. [...]
17 days at the VA – Day 3
17, Nov 2009My 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 [...]
ABG dilemma discussed
15, Nov 2009This 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 [...]
An ABG dilemma
13, Nov 2009This 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?
My acid base project
1, Nov 2009Readers 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.
I have finally started the project. I am writing an online book, which may become a paper book in the future. I need critics and beta testers. I need you. [...]
A normal gap acidosis dissected
31, Oct 2009The 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 [...]
An acidosis question
28, Oct 2009The 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 [...]
On ABGs (w/ a h/t to Happy Hospitalist)
23, Sep 2009Happy 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 [...]
Acid base 2 part – the answer
29, Aug 2009I 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 [...]
Part 2 of the acid-base problem
27, Aug 2009To 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 [...]
A 2 part acid-base problem
26, Aug 2009The 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 [...]
AMS – an acid-base problem solution
21, Jun 2009So 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 [...]
AMS – an acid-base problem II
19, Jun 2009
To restate:
41 year old man with left hemipareis s/p right brain aneurysm surgery in the past. Now presents with increasing obtundation, increased urination and abdominal discomfort. Labs follow:
On 2l nasal oxygen:
ABG
pH
7.41
pCO2
47
pO2
95
Electrolyte panel
Na
128
Cl
83
BUN
8
K
4.2
HCO3
24
creat
0.7
Blood Sugar
742
The patient is a large man (110 kg) who now admits to 4 weeks of increased urination and recent constant thirst with a [...]
AMS an acid-base problem – part 1
18, Jun 2009
41 year old man with left hemipareis s/p right brain aneurysm surgery in the past. Now presents with increasing obtundation, increased urination and abdominal discomfort. Labs follow:
On 2l nasal oxygen:
ABG
pH
7.41
pCO2
47
pO2
95
Electrolyte panel
Na
128
Cl
83
BUN
8
K
4.2
HCO3
24
creat
0.7
Blood Sugar
742
Now for the hard part, figure out the acid-base problem. Next I will give you his labs 2 days later, then my interpretation.
My answer to intubated
4, Jun 2009
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 [...]
Intubated and difficult to wean
1, Jun 2009
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.
Tolvaptan finally available
30, May 2009
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 [...]