Discover and read the best of Twitter Threads about #5goodminutes
Most recents (24)
1/ Thoughts on presenting on rounds #UncleBob - #5goodminutes
This is how I do rounds - would love questions and critiques.
I explain my expectations the first day on the service.
@WrayCharles @LisaWillett13 @iMedEducation #MedEd @ShreyaTrivediMD @AdamRodmanMD
This is how I do rounds - would love questions and critiques.
I explain my expectations the first day on the service.
@WrayCharles @LisaWillett13 @iMedEducation #MedEd @ShreyaTrivediMD @AdamRodmanMD
2/ New patient presentations:
Deliver a succinct HPI - start with chief complaint - insert RELEVANT PMH as desired. Tell the story chronologically if possible. Include related review of systems, social history, health behavior history, medication list as pertinent.
Deliver a succinct HPI - start with chief complaint - insert RELEVANT PMH as desired. Tell the story chronologically if possible. Include related review of systems, social history, health behavior history, medication list as pertinent.
3/ Stop after HPI and we will discuss the HPI. The goal of the discussion is to improve how each learner tells the story. The goal is complete, yet succinct. Don't give too much information. Avoid redundancy. We call this discussion IMMEDIATE FEEDBACK.
1/ #UncleBob - how I use the delta gap. Hopefully worth #5goodminutes
@UnremarkableLab
Here is the idea - we have an increased anion gap and want to see if the patient also has either a normal gap metabolic acidosis or metabolic alkalosis. Here are the assumptions:
@UnremarkableLab
Here is the idea - we have an increased anion gap and want to see if the patient also has either a normal gap metabolic acidosis or metabolic alkalosis. Here are the assumptions:
2/ Expected gap = 11 - 2.5*(albumin -4) but that is hard to remember, so we use a reasonable approximation = albumin * 3.
Example, patient has an albumin of 2.3 so we expect a gap of 7.
Example, patient has an albumin of 2.3 so we expect a gap of 7.
3/ Second assumption - the increased anion gap has replaced bicarbonate. - thus treating the gap will restore bicarbonate
2 examples to follow:
2 examples to follow:
1/ #UncleBob has thoughts on planning your career for young clinician-educators. Read for #5goodminutes, then consider for longer.
Do not plan your career, rather strive to be the best you. Excellence gets recognized. Opportunities will appear.
Do not plan your career, rather strive to be the best you. Excellence gets recognized. Opportunities will appear.
2/ Have a trusted mentor who will listen to you explain the opportunity and help you decide if it works with your goals.
I just finished listening to an episode of Broken Record - an interview with Huey Lewis. He become a very successful singer and band.
I just finished listening to an episode of Broken Record - an interview with Huey Lewis. He become a very successful singer and band.
3/ As he told his story, it was clear that early in his career his goal was to make good music. Eventually, opportunity shone on him. Because he had worked on his craft he was able to both succeed and not get sucked into the fame trap.
1/ #UncleBob presents a #5goodminutes tweetorial on the FeNa. The idea is simple, with normal kidneys and volume contraction, the kidney should avidly reabsorb sodium. With acute tubular injury, the problem is that the tubules cannot reabsorb Na.
2/ Here are the cautions - with a non-oliguric patient the stimulus to reabsorb Na is either not there (patient not volume contracted) or the patient has underlying CKD. When you understand the concept of fractional excretion, this will make sense.
3/ Here (from Wikipedia) is a good definition of FeNa: The fractional excretion of sodium is the percentage of the sodium filtered by the kidney which is excreted in the urine. You can substitute any measurable for sodium.
1/ #UncleBob believes your job is to help them grow. Make clear your expectations for rounds. If they are not presenting well, suggest improvements. Sometimes you need to restate the HPI as an example - the same goes for daily rounds - teach them how to meet your expectations
2/ Almost all interns will improve quickly if you are explicit and immediate in feedback. BTW - tell them you are giving them feedback on how to improve. When they do improve - now you can give them positive feedback on their progress.
3/ Ask them each day what they learned (1 or 2 things) and encourage them to spend #5goodminutes reading to own that new knowledge. Learn their strengths and what they need to work on. Help them grow every day. Let them know that July is the biggest growth month of GME.
1/ #UncleBob is so proud if his former intern, now excellent ICU attending! #5goodminutes on this patient
Let's start with the acid-base status.
Let's start with the acid-base status.
2/ The ABG clearly shows respiratory alkalosis. I suspect it is secondary to oxygen stimulus. The patient has a huge A-a gradient (suspect secondary to her IHD). Suspect she is volume overloaded & due to ESRD the only way to correct her volume would be dialysis. Call renal
3/ We can probably explain the mildly low Na from the hyperglycemia - will not spend more time on that. Would love an albumin for 2 reasons - to assess her anion gap and the decreased Calcium. Suspect it is low and her gap is even more significant than it appears.
1/ On Chalk Talks - #UncleBob opines for #5goodminutes
I consider the development of chalk talks a very useful (perhaps even essential) activity for successful clinician-educators.
@Sharminzi @AnnKumfer @IgG4thewin @CPSolvers @DxRxEdu @rabihmgeha @tony_breu #MedEd
I consider the development of chalk talks a very useful (perhaps even essential) activity for successful clinician-educators.
@Sharminzi @AnnKumfer @IgG4thewin @CPSolvers @DxRxEdu @rabihmgeha @tony_breu #MedEd
2/ Chalk talks evolve over time, and can be used in shortened or full form. I will use 1 of my favorite chalk talks to illustrate their development and use: Anion Gap Metabolic Acidosis (I do love the practical use of renal physiology.)
3/ Many years ago, I was determined to have a good way to teach Anion Gap Metabolic Acidosis. My learners quickly note that I love developing categories as that is how I best use my memory. So I developed KILU (Ketoacidosis, Ingestions, Lactic Acidosis and Uremia.)
1/ #UncleBob presents #5goodminutes about the term AKI. For references I suggest - Acute Kidney Injury @AnnalsofIM acpjournals.org/doi/10.7326/AI… and Annals On Call - Care of Patients With Acute Kidney Injury acpjournals.org/doi/10.7326/A1…
2/ KDIGO definition of AKI includes a change in serum creatinine clearance (SCC) within 2–7 days & oliguria for 6 or more hours. The stage is defined by the peak rise in SCC compared w/ previous values & nadir in urine output & is related to risk for complications &prognosis
3/ Thus, when a patient comes to the hospital with an increased creatinine from previous creatinines, that does NOT constitute AKI. When a patient comes in with an increased creatinine, or develops an increase in the hospital you must first determine several things
1/ #UncleBob presents #5goodminutes on estimated GFR - eGFR
Before estimating equations, we measured 24 hr urine creatinine. GFR = (Ucr * V/1440 minutes)/ Scr
Collecting 24 hour urine is fraught with difficulty.
@ABsteward @CPSolvers @kidney_boy @uabimres @TMcCarty2010
Before estimating equations, we measured 24 hr urine creatinine. GFR = (Ucr * V/1440 minutes)/ Scr
Collecting 24 hour urine is fraught with difficulty.
@ABsteward @CPSolvers @kidney_boy @uabimres @TMcCarty2010
2/ The first estimation equation appeared in 1976 - pubmed.ncbi.nlm.nih.gov/1244564/ Cockcroft-Gault
They developed an equation for estimating the numerator. The idea - weight in kg and age (and gender) gives a reasonable estimate of the creatinine produced each day.
They developed an equation for estimating the numerator. The idea - weight in kg and age (and gender) gives a reasonable estimate of the creatinine produced each day.
3/ Consider the numerator - Ucr * V/1400 min - this equals the amount of creatinine created & excreted in 24 hours. Creatinine production is a function of muscle mass. Muscle mass decreases with age. Their equation for creatinine production each day - (28-age)mg/cc* wt in kg
1/ #UncleBob opines for #5goodminutes on the labs from @CPSolvers Episode 95 @Sharminzi
Briefly - unfortunate woman in her 50s, severe brain injury, all input from IV & feeding tube, stage 4 decubitus ulcer, now has markedly increased urine output (3 l/day) & hypernatremia 159
Briefly - unfortunate woman in her 50s, severe brain injury, all input from IV & feeding tube, stage 4 decubitus ulcer, now has markedly increased urine output (3 l/day) & hypernatremia 159
2/ Has known CKD with previous creatinine of 2.5
Labs in hospital
161/4.0. 103/20. 50/2.5 98. (calcium not given)
Urine Na 46, K 9, Cl 49, osm 148
with ADH administration urine osms ~ 180
Labs in hospital
161/4.0. 103/20. 50/2.5 98. (calcium not given)
Urine Na 46, K 9, Cl 49, osm 148
with ADH administration urine osms ~ 180
3/ The #VMR chat room knows that I seriously nerd out over these numbers. My thinking:
Hypernatremia is water-handling problem. The patient is not taking in as much free water as she is excreting. By definition hypernatremia is dehydration (not necessarily volume contraction).
Hypernatremia is water-handling problem. The patient is not taking in as much free water as she is excreting. By definition hypernatremia is dehydration (not necessarily volume contraction).
1/
#UncleBob shares his reflections #5goodminutes) on a #VMR from last Wed- clinicalproblemsolving.com/wp-content/upl…
This was a complex case that started w/ chest pain, fevers, weakness, etc. After seeing the labs, I guessed the diagnosis.
@CPSolvers @rabihmgeha @DxRxEdu @RosenelliEM
#UncleBob shares his reflections #5goodminutes) on a #VMR from last Wed- clinicalproblemsolving.com/wp-content/upl…
This was a complex case that started w/ chest pain, fevers, weakness, etc. After seeing the labs, I guessed the diagnosis.
@CPSolvers @rabihmgeha @DxRxEdu @RosenelliEM
2/
Cognitive autopsies are always valuable - for mistakes and for guessing the correct answer. Did I make a sound diagnosis, or was I just lucky? Why did I suggest Hepatitis A?
Let's examine the liver tests and how they stimulated my thinking:
Cognitive autopsies are always valuable - for mistakes and for guessing the correct answer. Did I make a sound diagnosis, or was I just lucky? Why did I suggest Hepatitis A?
Let's examine the liver tests and how they stimulated my thinking:
3/
I divide liver tests into 3 categories - cellular destruction:
AST 2160 ALT 1750; obstruction: alkaline phophatase 240 T Bili 3.4 Direct 2.4; loss of factory function: albumin 2.3 but PT not reported.
Thus, I emphasized massive acute cellular destruction.
I divide liver tests into 3 categories - cellular destruction:
AST 2160 ALT 1750; obstruction: alkaline phophatase 240 T Bili 3.4 Direct 2.4; loss of factory function: albumin 2.3 but PT not reported.
Thus, I emphasized massive acute cellular destruction.
1/ #UncleBob takes #5goodminutes to wax philosophically
I love Saturdays … but no #VMR today. During the pandemic #VMR has made a wonderful contribution to my sense of purpose & community. @CPSolvers @DxRxEdu @rabihmgeha @Sharminzi @ArsalanMedEd @haematognomist
I love Saturdays … but no #VMR today. During the pandemic #VMR has made a wonderful contribution to my sense of purpose & community. @CPSolvers @DxRxEdu @rabihmgeha @Sharminzi @ArsalanMedEd @haematognomist
2/ As many know, I am semi-retired - only work 3/8 at the VA as a ward attending. My wonderful colleagues have decided that because of my age (fortunately my only risk factor) that they will keep me off the wards for now.
3/ Those who know me will understand that my career highlights all involve ward attending. I am fortunate to have good health and the resources to stay away from the hospital without any major difficulty.
1/ #UncleBob has some thoughts about thiazide induced hyponatremia. I hope this takes less than #5goodminutes
Thiazides inhibit NaCl reabsorption in the DILUTING SEGMENT. This is the simple explanation for why patients can develop hyponatremia.
Thiazides inhibit NaCl reabsorption in the DILUTING SEGMENT. This is the simple explanation for why patients can develop hyponatremia.
2/ Often there are other contributing factors. For example, if you have a borderline tea and toast diet (normal Na prior to starting the thiazide), the thiazide can unmask the dietary cause. The patient goes from a very dilute urine to much closer to isothenuria.
3/ In some patients, thiazides do result in volume contraction, and thus ADH stimulation, adding to the risk. I personally would be interested in the urine osms, but one can definitely treat empirically first.
1/ #UncleBob discussed BMP on #VMR - spend #5goodminutes 2 analyze. Pt ~80 & weighs ~55kg (recent 5 kg wt loss). Sarcopenia Pt has orthostasis (HR & BP).
Na 134 K 4.7 Cl 99 HCO3 23 BUN 22 cr 1.2 nl glucose
tweetorial later today
Can these labs help?
@kidney_boy
@uabimres
Na 134 K 4.7 Cl 99 HCO3 23 BUN 22 cr 1.2 nl glucose
tweetorial later today
Can these labs help?
@kidney_boy
@uabimres
2/
Gregory (Scotland Yard detective): “Is there any other point to which you would wish to draw my attention?”
Holmes: “To the curious incident of the dog in the night-time.”
Gregory: “The dog did nothing in the night-time.”
Holmes: “That was the curious incident.”
Gregory (Scotland Yard detective): “Is there any other point to which you would wish to draw my attention?”
Holmes: “To the curious incident of the dog in the night-time.”
Gregory: “The dog did nothing in the night-time.”
Holmes: “That was the curious incident.”
3/
We have a patient with presumed simple intravascular volume contraction. Do the labs support that hypothesis?
The sodium is slightly low - volume contraction is definitely a potential cause of low sodium - if the patient is drinking fluids freely.
We have a patient with presumed simple intravascular volume contraction. Do the labs support that hypothesis?
The sodium is slightly low - volume contraction is definitely a potential cause of low sodium - if the patient is drinking fluids freely.
1/
#UncleBob is very pleased with the Alabama Surprise. Spend #5goodminutes letting me describe how, what and why.
@DrJeanneM @TMcCarty2010 @DoctorRachael @MollyFleece @msaagmd @uabimres @drmarkewilson
The Surprise is how we are managing COVID-19, especially in metro Birmingham
#UncleBob is very pleased with the Alabama Surprise. Spend #5goodminutes letting me describe how, what and why.
@DrJeanneM @TMcCarty2010 @DoctorRachael @MollyFleece @msaagmd @uabimres @drmarkewilson
The Surprise is how we are managing COVID-19, especially in metro Birmingham
2/
When the first IHME state report came out Alabama was labelled as predicting to have the worst outcomes in the country. We are now one of the least bad. What has happened?
When the first IHME state report came out Alabama was labelled as predicting to have the worst outcomes in the country. We are now one of the least bad. What has happened?
3/
First, our Jefferson County Health Officer @drmarkewilson invoked shelter in place in mid-March before we had a surge.
@randallwoodfin Birmingham Mayor has worked to keep the city (with a large URM population) safe with aggressive measures.
First, our Jefferson County Health Officer @drmarkewilson invoked shelter in place in mid-March before we had a surge.
@randallwoodfin Birmingham Mayor has worked to keep the city (with a large URM population) safe with aggressive measures.
1/ #UncleBob shares #5goodminutes worth of lab nerdy thoughts from today's sadly interesting patient. These are thoughts that I often share on rounds. I feel that we should maximize what we can learn from the labs.
@CPSolvers @DxRxEdu @rabihmgeha @Anand_88_Patel
@CPSolvers @DxRxEdu @rabihmgeha @Anand_88_Patel
2/We heard that the patient had 5 days of diarrhea, but heard little more about that symptom. If the diarrhea had been profound then we could see a normal gap acidosis, therefore the labs suggest modest diarrhea.
125/4.5/83/26
Disappointing to me, we were not given BUN or creat
125/4.5/83/26
Disappointing to me, we were not given BUN or creat
3/ Let's think about the Na of 125. That is low enough to cause altered mental status. Even patients who slowly lower their Na to that level often become confused.
The main differential for decreased sodium starts with volume contraction, euvolemia or edematous sate.
The main differential for decreased sodium starts with volume contraction, euvolemia or edematous sate.
#UncleBob has a #MedEd tip, perhaps worth #5goodminutes - not a new thought, but one that we sometimes forget. It comes from a story.
Thursday night @rabihmgeha @DxRxEdu and I "recorded" a podcast, but the recording did not properly process (I probably made some rookie error.
Thursday night @rabihmgeha @DxRxEdu and I "recorded" a podcast, but the recording did not properly process (I probably made some rookie error.
So the Magician and the Mathematician kindly agreed to rerecord yesterday. Properly recorded, we did a quick post-mortem on the second recording. Clearly, we all did a better job on the second recording, because we all personally critiqued our performance from the first.
All successful performers, be they athletes, musicians, actors or medical speakers, learn to self critique. They are never satisfied, and always strive to improve. They get and accept constructive criticism.
1/
Reflections on big lessons from #VMR from #UncleBob - hopefully less that #5goodminutes
@CPSolvers @rabihmgeha @DxRxEdu @Sharminzi @ArsalanMedEd @LindseyShipley8 @SZKamal
CAP
Understanding what the patient means with their words
Naturalistic decision making
Travel history
Reflections on big lessons from #VMR from #UncleBob - hopefully less that #5goodminutes
@CPSolvers @rabihmgeha @DxRxEdu @Sharminzi @ArsalanMedEd @LindseyShipley8 @SZKamal
CAP
Understanding what the patient means with their words
Naturalistic decision making
Travel history
2/
CAP
Should we do a schema for "not CAP"? It seems like some of the most fascinating presentations start out as CAP. How can we convince physicians that CAP has a relatively specific illness script against which to compare their problem representation?
CAP
Should we do a schema for "not CAP"? It seems like some of the most fascinating presentations start out as CAP. How can we convince physicians that CAP has a relatively specific illness script against which to compare their problem representation?
3/
Maybe it is the curmudgeon in me screaming out at this point, but repeatedly I see major diagnostic delays due to a reflex of "abnormal CXR" - CAP. They ignore the history of chronic symptoms rather than acute symptoms. There is often a very incomplete history.
Maybe it is the curmudgeon in me screaming out at this point, but repeatedly I see major diagnostic delays due to a reflex of "abnormal CXR" - CAP. They ignore the history of chronic symptoms rather than acute symptoms. There is often a very incomplete history.
#UncleBob has some thoughts about liver test interpretation. During today's @CPSolvers Virtual Morning Report, we had a robust discussion of the meaning of the liver tests. I hope this thread will be worth #5goodminutes
@MohitHarshMD @rabihmgeha @DxRxEdu
@MohitHarshMD @rabihmgeha @DxRxEdu
2/
Preface: Our Chair of Medicine during my residency was a hepatologist. We could not use the term LFT because most of the tests do not evaluate liver function. So I always use the term liver tests.
Preface: Our Chair of Medicine during my residency was a hepatologist. We could not use the term LFT because most of the tests do not evaluate liver function. So I always use the term liver tests.
3/
In general we can divide liver tests into 3 buckets: cellular destruction, obstruction and production.
Cellular destruction: AST & ALT, GGTP
Obstruction: ALP, Direct Bilirubin, GGTP
Production: albumin, INR
In general we can divide liver tests into 3 buckets: cellular destruction, obstruction and production.
Cellular destruction: AST & ALT, GGTP
Obstruction: ALP, Direct Bilirubin, GGTP
Production: albumin, INR
1/ #UncleBob thought a lot about diagnostic error this week #5goodminutes
2 important podcasts: Hoofbeats: A 39M on Inpatient Psychiatry with a Fever coreimpodcast.com/2020/01/22/hoo…
2 important podcasts: Hoofbeats: A 39M on Inpatient Psychiatry with a Fever coreimpodcast.com/2020/01/22/hoo…
2/
Episode 63 - Human Dx unknown with Reza & Pitt residents - blurry vision and headache clinicalproblemsolving.com/2020/01/26/epi… via @CPSolvers
Episode 63 - Human Dx unknown with Reza & Pitt residents - blurry vision and headache clinicalproblemsolving.com/2020/01/26/epi… via @CPSolvers
3/
These remind me of a patient I saw around 10 years ago. The team had missed the diagnosis for 9 days before I joined the team. I too missed the diagnosis for 1 day.
Here is the story:
These remind me of a patient I saw around 10 years ago. The team had missed the diagnosis for 9 days before I joined the team. I too missed the diagnosis for 1 day.
Here is the story:
1/ #UncleBob spent > #5goodminutes reviewing this new important article - Invasive infections with Fusobacterium necrophorum including Lemierre’s syndrome – An eight-year Swedish nationwide retrospective study sciencedirect.com/science/articl…
This thread highlights some findings
2010-2017
This thread highlights some findings
2010-2017
2/ Of course I am obsessed w/ Fusobacterium necrophorum and its sequelae - especially the Lemierre Syndrome(LS)
They studied 3 groups w/ avg age
LS 20
Peritonsillitis (either abscess or phlegmon) 25
Other invasive (+ blood cultures) 64
300 total pts. (104, 102 & 94 )
They studied 3 groups w/ avg age
LS 20
Peritonsillitis (either abscess or phlegmon) 25
Other invasive (+ blood cultures) 64
300 total pts. (104, 102 & 94 )
3/ LS patients
75% thrombocytopenia
83% met sepsis criteria
18% septic shock
43% required ICU care
mortality has decreased to 2%
4/ in the 15-19 age group LS incidence increased from 10/million/year in the 2010-2013 group
to
23/million/year in the 2014-2017
75% thrombocytopenia
83% met sepsis criteria
18% septic shock
43% required ICU care
mortality has decreased to 2%
4/ in the 15-19 age group LS incidence increased from 10/million/year in the 2010-2013 group
to
23/million/year in the 2014-2017
1/ Multiple diagnostic errors
Recently at morning report #UncleBob & @uabimres discussed a sad patient story w/ a bad outcome. Pt was ill for 3 months. Multiple chances for a proper diagnosis were missed. @LindseyShipley8 @SZKamal @ImproveDX @CPSolvers
Recently at morning report #UncleBob & @uabimres discussed a sad patient story w/ a bad outcome. Pt was ill for 3 months. Multiple chances for a proper diagnosis were missed. @LindseyShipley8 @SZKamal @ImproveDX @CPSolvers
2/ Cognitive autopsy
After working through the discussion, I asked the residents to take less than #5goodminutes to write down the reasons for the delayed diagnosis. Here are some of the clues that were missed prior to transfer to our hospital:
After working through the discussion, I asked the residents to take less than #5goodminutes to write down the reasons for the delayed diagnosis. Here are some of the clues that were missed prior to transfer to our hospital:
3/ Missed opportunities
Diagnostic inertia
Several clues in laboratory testing
Incomplete history taking
Incorrect image interpretation
Physical exam of obvious weight loss ignored
Over-reliance on a positive lab test that did not match the problem representation
Diagnostic inertia
Several clues in laboratory testing
Incomplete history taking
Incorrect image interpretation
Physical exam of obvious weight loss ignored
Over-reliance on a positive lab test that did not match the problem representation
1/
#Humility
#UncleBob dedicates this #5goodminutes to one of my medical school heroes - the late Dr. Orhan Muren. He was a Turkish pulmonologist who won the Golden Apple award from the students so many times that they had to retire him.
#Humility
#UncleBob dedicates this #5goodminutes to one of my medical school heroes - the late Dr. Orhan Muren. He was a Turkish pulmonologist who won the Golden Apple award from the students so many times that they had to retire him.
2/
He was the first educator who stimulated my love of acid-base disorders.
But the dedication is for one of his pet phrases:
"In clinical medicine, never get cocky." He taught us clinical humility before it was in vogue.
He was the first educator who stimulated my love of acid-base disorders.
But the dedication is for one of his pet phrases:
"In clinical medicine, never get cocky." He taught us clinical humility before it was in vogue.
3/
The NY Times recently had a wonderful column on the value of humility - Be Humble, and Proudly, Psychologists Say nyti.ms/32AuoGj
So what is humility? Humility is not false modesty. My favorite basketball coach - Tony Bennett at UVa defines it this way:
The NY Times recently had a wonderful column on the value of humility - Be Humble, and Proudly, Psychologists Say nyti.ms/32AuoGj
So what is humility? Humility is not false modesty. My favorite basketball coach - Tony Bennett at UVa defines it this way:
1/ #UncleBob presented this patient at @midwesthospmed yesterday - here is my analysis:
41yo woman, s/p bariatric surgery (100# loss), “feeling drunk”
Chronic diarrhea - short gut syndrome
Mild gait instability
140/3.8/116/9/5/0.8/82
pH 7.2/pCO2 13/pO2 138/bicarb 5
#5goodminutes
41yo woman, s/p bariatric surgery (100# loss), “feeling drunk”
Chronic diarrhea - short gut syndrome
Mild gait instability
140/3.8/116/9/5/0.8/82
pH 7.2/pCO2 13/pO2 138/bicarb 5
#5goodminutes
2/
First, let's determine the acid-base disorders. The patient has an albumin of 2. Anion gap is 15, but should be around 6. Therefore a mildly increased anion gap acidosis.
Next, we have a delta gap of 9 (15-6). Therefore the patient also has a normal gap acidosis.
First, let's determine the acid-base disorders. The patient has an albumin of 2. Anion gap is 15, but should be around 6. Therefore a mildly increased anion gap acidosis.
Next, we have a delta gap of 9 (15-6). Therefore the patient also has a normal gap acidosis.
3/
Finally, let's do Winter's equation. Calculated bicarb from the ABG was 5. Therefore expected pCO2 = 1.5(bicarb)+8(+or-)2
7.5+8 = 15.5 - close enough to 13.
So we have two causes of metabolic acidosis - anion gap and normal gap.
Finally, let's do Winter's equation. Calculated bicarb from the ABG was 5. Therefore expected pCO2 = 1.5(bicarb)+8(+or-)2
7.5+8 = 15.5 - close enough to 13.
So we have two causes of metabolic acidosis - anion gap and normal gap.
