Comments for db's Medical Rants http://www.medrants.com Internal medicine, American health care, and especially medical education Sat, 11 Feb 2012 15:15:48 +0000 hourly 1 http://wordpress.org/?v=3.3.1 Comment on Answer to the acid-base question from 2 days ago by Cory http://www.medrants.com/archives/6695/comment-page-1#comment-545365 Cory Sat, 11 Feb 2012 15:15:48 +0000 http://www.medrants.com/?p=6695#comment-545365 Good case.  Good instruction for the housestaff. Respiratory alkalosis is quite common in advanced liver disease (until the kidneys begin to fail) if you look for it. Also respiratory alkalosis is common in the alter stages of pregnancy is you do an ABG   Good case. 
Good instruction for the housestaff.
Respiratory alkalosis is quite common in advanced liver disease (until the kidneys begin to fail) if you look for it.
Also respiratory alkalosis is common in the alter stages of pregnancy is you do an ABG
 

]]> Comment on An acid-base question by Malick http://www.medrants.com/archives/6693/comment-page-1#comment-545364 Malick Sat, 11 Feb 2012 01:01:00 +0000 http://www.medrants.com/?p=6693#comment-545364   My guess during the morning report was a Normal-Anion gap metabolic acidosis secondary to osmotic diarrhea caused by lactulose, but was told by Dr.Centor that i shouldn't jump to conclusions without knowing the Blood Gases and when Dr.Centor revealed the Blood Gases of that patient, the acid base disorder was completely the opposite to what i guessed. That time i didn't calculate the expected HCO3 as compensation to the primary disorder and i still think the given HCO3 value of the patient is probably lower than would be expected as compensation to the primary acid base disorder. i believe there is concurrent primary normal anion gap metabolic acidosis as well, though i am not 100% sure as i don't remember the Blood Gases and would request Dr. Centor to kindly post the Blood gases so we can calculate the expected compensations.  
My guess during the morning report was a Normal-Anion gap metabolic acidosis secondary to osmotic diarrhea caused by lactulose, but was told by Dr.Centor that i shouldn't jump to conclusions without knowing the Blood Gases and when Dr.Centor revealed the Blood Gases of that patient, the acid base disorder was completely the opposite to what i guessed.
That time i didn't calculate the expected HCO3 as compensation to the primary disorder and i still think the given HCO3 value of the patient is probably lower than would be expected as compensation to the primary acid base disorder.
i believe there is concurrent primary normal anion gap metabolic acidosis as well, though i am not 100% sure as i don't remember the Blood Gases and would request Dr. Centor to kindly post the Blood gases so we can calculate the expected compensations.

]]> Comment on An acid-base question by torontointernist http://www.medrants.com/archives/6693/comment-page-1#comment-545363 torontointernist Fri, 10 Feb 2012 15:12:40 +0000 http://www.medrants.com/?p=6693#comment-545363 my first guess is to say that he has a nongap metabolic acidosis due to diarrhea - but it would be important to know how much diarrhea he is having either by patient or nursing report that could drive the serum bicarb that low - also he is not hypokalemic as one would expect with major diarrhea (although the aldactone might prevent some drop in K).   Another caveat is that he likely has low serum albumin and his real anion gap is higher than the calculated 7 perhaps masking another process.   ABG would help sort out what the primary acid base problem is and urine ph and electrolytes might help determine the cause if primary nongap metabolic acidosis confirmed (urine anion gap to suggest cause of acidosis as diarrhea vs RTA) my first guess is to say that he has a nongap metabolic acidosis due to diarrhea – but it would be important to know how much diarrhea he is having either by patient or nursing report that could drive the serum bicarb that low – also he is not hypokalemic as one would expect with major diarrhea (although the aldactone might prevent some drop in K).   Another caveat is that he likely has low serum albumin and his real anion gap is higher than the calculated 7 perhaps masking another process.   ABG would help sort out what the primary acid base problem is and urine ph and electrolytes might help determine the cause if primary nongap metabolic acidosis confirmed (urine anion gap to suggest cause of acidosis as diarrhea vs RTA)

]]> Comment on An acid-base question by Anonymous http://www.medrants.com/archives/6693/comment-page-1#comment-545362 Anonymous Fri, 10 Feb 2012 15:12:11 +0000 http://www.medrants.com/?p=6693#comment-545362 I'm a second year....never seen a paper record, only seen labs in an outpatient setting where it was electronic (but the software looked pretty old). I'm a second year….never seen a paper record, only seen labs in an outpatient setting where it was electronic (but the software looked pretty old).

]]> Comment on #SGIM2011: Tweeting the Meeting: Why and How by “From Twitter to Tenure”: MD Shares How Twitter Can Be A Valuable Tool for Academics « BioMed 2.0 http://www.medrants.com/archives/6066/comment-page-1#comment-545360 “From Twitter to Tenure”: MD Shares How Twitter Can Be A Valuable Tool for Academics « BioMed 2.0 Thu, 09 Feb 2012 18:56:37 +0000 http://www.medrants.com/?p=6066#comment-545360 [...] task force as a result of my interest in social media.  Our most recent effort was a piece about‘tweeting the meeting’ with @medrants and an older piece focused on the top Twitter Myths and [...] [...] task force as a result of my interest in social media.  Our most recent effort was a piece about‘tweeting the meeting’ with @medrants and an older piece focused on the top Twitter Myths and [...]

]]> Comment on An acid-base question by Joseph Nicholas http://www.medrants.com/archives/6693/comment-page-1#comment-545359 Joseph Nicholas Thu, 09 Feb 2012 18:44:00 +0000 http://www.medrants.com/?p=6693#comment-545359 Interesting- can I ask the medical student if he/she has only viewed labs on an EMR?  This short hand way of writing labs is very common in the "handwritten note" era.  I wonder if it is becoming obsolete. Interesting- can I ask the medical student if he/she has only viewed labs on an EMR?  This short hand way of writing labs is very common in the "handwritten note" era.  I wonder if it is becoming obsolete.

]]> Comment on An acid-base question by rcentor http://www.medrants.com/archives/6693/comment-page-1#comment-545358 rcentor Thu, 09 Feb 2012 18:19:51 +0000 http://www.medrants.com/?p=6693#comment-545358 This is a standard way to show a basic metabolic panel. Going from left to right - the first row is Na/Cl/BUN/glucose Second row K/HCO3/creatinine This is a standard way to show a basic metabolic panel.

Going from left to right – the first row is Na/Cl/BUN/glucose
Second row K/HCO3/creatinine

]]> Comment on An acid-base question by Anonymous http://www.medrants.com/archives/6693/comment-page-1#comment-545357 Anonymous Thu, 09 Feb 2012 18:05:53 +0000 http://www.medrants.com/?p=6693#comment-545357 Maybe I'm a naive medical student...but what are those lab values of? All I see is a table of numbers with no labels. Maybe I'm a naive medical student…but what are those lab values of? All I see is a table of numbers with no labels.

]]> Comment on An acid-base question by Siva Rama Buchi Gadde http://www.medrants.com/archives/6693/comment-page-1#comment-545356 Siva Rama Buchi Gadde Thu, 09 Feb 2012 14:10:20 +0000 http://www.medrants.com/?p=6693#comment-545356 Distal renal tubular acidosis due to chronic active hepatitis. Distal renal tubular acidosis due to chronic active hepatitis.

]]> Comment on An acid-base question by Cory http://www.medrants.com/archives/6693/comment-page-1#comment-545355 Cory Thu, 09 Feb 2012 13:58:07 +0000 http://www.medrants.com/?p=6693#comment-545355 you have bunch of reasons why the bicarb is low- and you need an ABG to sort them out. First you almost certainly have a respiratory alkalosis, common in cirhossis - many causes - anemia, ascites causing mild hypoxemia, relative progesterone excess, pulmonary shunting. Second there is a component of bicarb loss form the lactulose. There may be a mild spironolactone component to the acidosis but that is generally minor compared to the lactulose.  There is no way to sort out whether it is predominantly a nonunion gap acidosis or a primary respiratory alkalosis without an ABG.  you have bunch of reasons why the bicarb is low- and you need an ABG to sort them out.
First you almost certainly have a respiratory alkalosis, common in cirhossis – many causes – anemia, ascites causing mild hypoxemia, relative progesterone excess, pulmonary shunting.
Second there is a component of bicarb loss form the lactulose. There may be a mild spironolactone component to the acidosis but that is generally minor compared to the lactulose. 
There is no way to sort out whether it is predominantly a nonunion gap acidosis or a primary respiratory alkalosis without an ABG. 

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