I am current at the ACP annual meeting, and this morning heard a brilliant grand rounds on hyponatremia - given by Juan Carlos Ayus. I have found an excellent article in the Southern Medical Journal that he co-authored on treatment of dysnatremias and also provide this Medscape link - Hospital-Acquired Hyponatremia — Why Are Hypotonic [...]
Was It the Drinking Binge?
Solution to "Was It the Drinking Binge?"
Yesterday’s numbers:
Electrolyte panel
Na
141
Cl
112
BUN
18
K
4.3
HCO3
15
creat
0.7
Blood Sugar
105
ABG
pH
7.33
pCO2
25
pO2
103
calc HCO3
13
Additional information:
1. She had increased ileal output.
2. Serum albumin was 5.7
3. Urine Na 10, urine K 47 and urine Cl 72
Her anion gap is 14, which is normal given her elevated albumin
Her urine anion gap is negative, consistent with sufficient ammonium (NH4+) in her urine
The urine anion gap results supports increased [...]
Started rounds today and had several interesting laboratory findings. I plan to post some patient quizzes for the next 3 days.
Electrolyte panel
Na
141
Cl
112
BUN
18
K
4.3
HCO3
15
creat
0.7
Blood Sugar
105
ABG
pH
7.33
pCO2
25
pO2
103
calc HCO3
13
Today’s patient is well known to our service. She is 32 and has a long history of Crohn’s disease, with an ileostomy. Consider the differential diagnosis, and recommend tests to prove your [...]
To remind you:
Exam reveals a markedly volume contracted 61 year old woman.
Electrolyte panel
Na
135
Cl
88
BUN
127
K
4.3
HCO3
14
creat
7.4
Blood Sugar
109
ABG
pH
7.3
pCO2
26
pO2
70
calc HCO3
13
Her serum albumin was 4.8. Her urine creatinine was 330 with a urine sodium of 14. Her PTH level was 138.
Resolution
This patient had remarkable volume contraction. She had both an increased anion gap acidosis as well as a metabolic [...]
Here is another puzzle for acid base aficionados.
The patient is a 61 year old woman admitted for severe nausea and vomiting. She states that she has had 6 days of severe nausea, vomiting and diarrhea. The diarrhea was watery.
Her past medical history included “CHF with normal EF”, gout, hypertension and a previous episode [...]
Congrats to the readers, most of you understood the point. Here is my analysis.
ABG
pH
7.46
pCO2
66
pO2
61
calc HCO3
46
1. The patient is alkalotic, therefore the patient clearly has a metabolic alkalosis.
2. I had to look up the compensation for metabolic alkalosis (I remember the Winter’s equation but not this equation). The predicted pCO2 = 0.7*HCO3 [...]
We made rounds on an 82 year old man today. Because his electrolyte panel revealed a bicarbonate level of 40, we order an ABG. The patient has known COPD and CHF. He was intubated until 2 days ago. He received aggressive diuresis for volume overload. Now his ABG reveals:
ABG
pH
7.46
pCO2
66
pO2
61
calc HCO3
46
Questions [...]
Readers know that I love teaching acid base and electrolytes. For years I (and many other educators) have difficulty explaining why edematous states can lead to hyponatremia. We always have talked about ineffective intravascular volume, although when you measure the intravascular volume it measures as increased. Thus, we had a difficult concept [...]
I have used this presentation for the past 30 years. It provides students a wonderful opportunity to consider the entire differential diagnosis of hypercalcemia. The answer is a surprise to many. In the presentation I fail to mention that the tachycardia persisted after volume expansion.
Today my team is admitting, so I made rounds in the afternoon. Our service is relatively quiet, so I took time to discuss a classic case from my residency. I previously did a podcast on this patient, but I suspended the podcast service and will have to write out the case now.
This case [...]
I forgot to include the calculated HCO3 in the acid base problem. I have editted the entry to now include that number.
My apologies to readers - I hope this number make the explanation more clear.
One of my main teaching philosophies includes understanding how to teach basics and when to move to more advanced concepts. Solving yesterday’s problem requires some more advanced concepts.
The normal anion gap depends on the albumin level (albumin is the major component of the normal anion gap.) Therefore, when the albumin is decreased below [...]
60 yo male with strong alcohol history is admitted for cellulitis. On his second day in the hospital he develops delirium tremens and aspirates. In the ICU he requires sedation for his DTs.
He had the following laboratory values on the 3rd day of ICU care:
Electrolyte panel
Na
142
Cl
110
BUN
27
K
4.5
HCO3
17
creat
2.0
Blood Sugar
468
ABG
pH
7.24
pCO2
25
pO2
126
calc HCO3
10
His albumin is 3. His serum osms are [...]
A 52-year-old Man With a Low Bicarbonate Level
Enjoy - the answer will be posted next week
To revisit our problem -
On room air - serum bicarbonate is 44
ABG
pH
7.52
pCO2
54
pO2
62
Clearly the patient has a metabolic alkalosis with respiratory compensation. The pO2 appears low, but …
Go to an A-a gradient calculator - and I calculate an A-a gradient of 20. While this was slightly elevated, I do not [...]
This ABG is quite deceiving. Calculate the A-a gradient - does that change your thought process?
The housestaff obtained this ABG on a patient presented yesterday at morning report.
Your task is to explain the acid-base disorder and the oxygen level.
On room air - serum bicarbonate is 44
ABG
pH
7.52
pCO2
54
pO2
62
I saw a similar patient 3 years ago. This case report is important - A case of valproate-induced hyperammonemic encephalopathy: look beyond the liver
The patient was admitted to hospital for further investigations and for monitoring with video electroencephalography. In the first 48 hours after admission, her level of consciousness fluctuated. Subsequent tests revealed an [...]
I am working on a handout for a workshop on acid-base and electrolyte disorders. This entry is my attempt to explain renal ammonia physiology. I hope a few readers will critique my attempt.
Each day the average American creates 1 mEq/kg of acid which needs buffering. Most of the acid comes from protein. [...]
Thanks to Dr. RW - Propylene glycol toxicity due to high dose lorazepam infusions
ADR Prevent-ERR: IV Lorazepam Infusion and Propylene Glycol Toxicity
A hospitalized patient with respiratory failure was sedated for intubation with a continuous infusion of lorazepam, initially running at 4 mg/hour but increased over the next several days to a maximum rate of [...]
Since that patient was not otherwise ill - normal vital signs, no fever - we decided to treat his nausea and vomiting as an extension of his previous GI dysfunction. We started metoclopramide, which worked well. We also wondered if his poorly functioning indwelling catheter may have contributed to his symptoms.
In terms of [...]
2 weeks ago, on service at the VA, an 85 year old man was admitted from a nursing home for 5 days of vomiting. He told us (good mental status) that he could not keep any food down, but he did not vomit if he did not eat.
The ER physician noted that his indwelling [...]
Solution to “A 42-Year-Old Man With HIV”
This is not difficult, but the solution gives a good overview of normal gap metabolic acidosis.
Another acid-base and electrolyte case - not too difficult, but good teaching points -
A 42 year old man with HIV
My search for a reference on this phenomenon found this great story - A Medical Mystery, and How Physicians Solved It
The patient was a woman in her 80’s who complained of weakness and muscle spasms in her back. She appeared healthy and ate properly, but she had high blood pressure and, most strikingly, a [...]
My students and residents know that I love acid-base and electrolyte problems. Since hyponatremia is the most common electrolyte abnormality in the hospital, I often discuss it on rounds and in morning report.
Most hyponatremia is transient, and easily treated. However, sometimes we have a patient with chronic hyponatremia. Three major situations cause [...]
Solution to “An Ileal Bypass Patient With Watery Diarrhea”
Enjoy!
An Ileal Bypass Patient With Watery Diarrhea
One of my favorite exercise in acid-base - enjoy.
Solution to “A 60-Year-Old Woman With New Seizures”
This presentation is both interesting and important - A 60-Year-Old Woman With New Seizures
Enjoy!
