by rcentor on August 9, 2010
I have just received IRB approval on a study to help define the natural history of Lemierre syndrome. We hope to better understand the natural history of this disease in the 21st century, as well as both the financial and personal costs that the syndrome inflicts. I will start running an advertisement about this study very soon.
Lemierre syndrome is a devastating, potentially fatal infection that attacks previously health adolescents and young adults. The syndrome does not get the attention it deserves in medical education. We want to make a difference and possibly save morbidity or mortality. We hope some of our readers will be able to help.
by rcentor on August 10, 2010
The diagnosis is not tricky, but I do have a few questions:
| Na |
121 |
Cl |
73 |
BUN |
57 |
glu |
1820 |
| K |
9.6 |
CO2 |
6 |
creat |
3.2 |
Ca++ |
|
- Has anyone seen a higher glucose?
- A higher K?
- Postulate the sequence of events leading to these numbers
Background information – 17 year history of type I DM. Several recent admissions for DKA, but usually with blood glucose lower than 1000.
ABG
| pH |
7.20 |
| pCO2 |
17 |
| pO2 |
324 |
| calc HCO3 |
17 |
by rcentor on August 7, 2010
To repeat the problem:
26-year-old man comes in for flank pain. He has a history of renal stones. It is August in Alabama, he has been working outside. He does state that he has been drinking and urinating.
| Na |
139 |
Cl |
92 |
BUN |
28 |
glu |
128 |
| K |
4.5 |
CO2 |
22 |
creat |
2.5 |
Ca++ |
10.6 |
These lab tests led to his admission. What can you glean from these labs? Postulate on the cause of these numbers.
The comments were spot on – increased anion gap acidosis (gap 25) and metabolic alkalosis (delta gap of approximately 13 with a normal bicarb)
The patient was markedly volume contracted. We explained his anion gap from his phosphate level of 9.6. After volume expansion his phosphate returned to normal, as did his increased gap. His calcium also returned to normal.
The resident did not get an ABG; I agree that it would have added some information, but in this situation I believe we can understand what happened without it.
Teaching points:
1. Always look at the anion gap.
2. When the patient has an increased anion gap, estimate the delta gap.
by rcentor on August 7, 2010
I spent the last two days preparing and testifying in a malpractice case. Yesterday was a deposition that lasted almost 3 hours.
I will not write at all about the case, only to say that I was an expert witness for the defense.
I had not served as an expert witness in approximately 20 years. While I receive many offers to review cases, I really do not like doing this. However, I understand that I have a responsibility to the profession to sometimes testify.
We all have a responsibility to our profession to provide expert testimony when in fact we are experts. In talking with the lawyer who hired me, it became clear that finding knowledgeable expert witnesses becomes problematic. Those of us who spend time with patients and stay up to date generally dislike the legal process.
In reviewing the case I had strong feelings of empathy for those charged with malpractice. I can imagine how they felt.
The last 2 days involved hard work. I did the best job possible telling the truth as I saw it. I still would rather have health courts, but until we have malpractice reform, I urge you to participate in the process in an ethical and knowledgeable way.
