Attending Rounds

Quick acid-base answer

August 17, 2011

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 [...]

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Quick acid-base quiz

August 16, 2011

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 [...]

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Anion gap puzzle – my answer

July 27, 2011

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 [...]

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An increased anion gap puzzle

July 19, 2011

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 [...]

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On seeing death for the first time

July 10, 2011

Earlier this week, our 3rd year students saw a patient die.  Every time we see this passage we come to terms with mortality.  But the first time has a profound impact.  We spent some time discussing this aspect of doctoring on rounds the next morning. Sometimes we do things that have a major positive effect [...]

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Diuretics – some teaching points

July 3, 2011

Over the past several years, I have noted that many students and residents have a very simple approach to diuretic use.  They furosemide as their main loop diuretic; they use hydrochlorothiazide as their antihypertensive.  Many of them do not really know the alternatives, and therefore resort to a single standard. Here are my main teaching [...]

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Diagnostic processes that enhance our success

June 24, 2011

Recently I have become obsessed with learning about the diagnostic process.  Some colleagues have taught me about dual process diagnostic thinking, and of course I have been reading articles. Here is my summary: As we develop experience we start the diagnostic process with an intuitive model.  I don't like the label, because it suggests that [...]

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Explaining the actual numbers

June 16, 2011

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 [...]

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AKI – part 2

June 15, 2011

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. [...]

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The actual numbers

June 15, 2011

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 [...]

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