Friday, July 27, 2012

The Finale

At nearly 11 pm the senior resident walks in and says that the on call nephro wasn't sure what was going on, so I asked him to call the attending.
"It's 11pm"
"Uh, huh -Look, this morning I was told that Tomas' ph was high because his kidneys were dumping acid in order to offset the high bicarbs in his lung, thereby preserving his balanced blood ph. This was a good thing since it meant his kidneys were responding appropriately. His bicarbs were high because his potassium was low. His potassium was low because he had decreased G tube intake and increased G tube output. Well, we fixed the potassium, he is eating through his tube, he isn't dumping gastric fluid and his potassium is dead on normal. Why did his urine not normalize? Do you understand why this makes no sense to me?"
"Ok, let me get her on the phone"

He calls her on the phone and gives her a quick run down. That I needed more information on todays labs.
"Hello Mrs. Hernandez, what can I answer for you?"
"Hello Dr. X, actually what I need cleared up is why we waited here for Tomas' UA results; what were you expecting to see?'
"I was hoping to see a resolution on the urine alaklinity. The assumtion was his urine ph was high due to the high bicarbs, I was expecting to see that go down since we resolved his electrolyte imbalance. Since that didn't happen, we now need to look for another cause. The first step was to see if it self-resolved, which it did not. The second step is to see if this is due to medication. He is on two that can cause this issue, the more likely one being his Prevacid. My next step is to send him home on half the Prevacid dosage than he was taking before. If that doesn't bring his ph down to under 7.5 then I will have to investigate further into the kidney as a culprit, which I hope not to be the case."

"Ahh..that was the piece of the puzzle I was missing, thank you very much. I will need a new script for the Prevacid dose before we leave though."

"Don't you have one?  I wrote for it in case the urine was unchanged."

"No I don't think the night team is aware of your orders."

"I am so terribly sorry, Mrs. Hernandez. Now I understand the confusion and why you needed to speak with me. I thought I had made myself understood at the team meeting this afternoon, but apparently not. May I speak with Dr. Senior Resident please."

"Of course, thank you Doctor and have a good evening."

The senior resident took the phone, walked out of the room listening the entire time, about 10 minutes later the NURSE came in with the script, discharge orders, and a great big hug telling me she was eavesdropping and cheerleading in the corner the entire time.

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