Blog | Friday, October 26, 2012

The acid-base problem solved part 3--Hickam’s dictum for the patient


So my two renal consultants have done a wonderful job, but have forgotten a key point. This point does not relate to the acid-base problem, but still should be mentioned.

We have a patient with hyponatremia (modest), hypotension, and chronic steroids. The primary hospital service diagnoses iatrogenic adrenal suppression late. When I discussed this patient at morning report, before hearing about the cortisol level and the ACTH stimulation results, I stressed that this patient should have received stress dose steroids on presentation. We should have a high index of suspicion for glucocorticoid deficiency. Giving stress dose steroids will not hurt the patient, and could save many complications.

Once I assumed glucocorticoid deficiency, I had to consider the possibility of total adrenal failure. However, I could not develop a good hypothesis.

My former intern guessed the urine lytes: Na 90 K 20 Cl 88.

This gives us indirect evidence of hypoaldosteronism and the type IV RTA that was postulated. I had to guess the tacrolimus could cause a type IV RTA. Apparently this is rather common as Eric pointed out so well. The team actually measure renin and aldo and proved that they were both low.

So this patient had "ticks and fleas." He had two significant adrenal problems for different reasons.

I suggested that this patient might do well with 9 alpha fludrocortisone as he had no contraindication.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.