"I don't know, but I'll get back to you."

So I got asked a lot of questions today. Unfortunately, my preceptor didn’t get a lot of answers. And when I say “get answers,” I don’t mean that I eventually stumbled upon the answer after a couple minutes of staring off into space…I mean that I knew the answer 110% and said it with conviction! No medicine team is going to accept a recommendation that was stumbled upon. So here comes the phrase, the 9 magic words, that will make this year that much more of an enriching experience:

“I don’t know, but I’ll get back to you.” (technically 11 words I guess)

Here are some questions I was asked today, and used this respectful phrase.

1. What lab parameters would you look at if you suspect acute kidney injury on top of chronic kidney injury? Serum creatinine and BUN (and do the serum: creatinine ratio).
2. When would you not bridge a patient for anticoagulation in the hospital? If the INR is more than 1.7.
3. What’s the calcium phosphate product and how would you interpret it? First of all, the equation is [corrected calcium] x [phosphate]. If this is >55, it’s bad for the kidney, but if it’s >70 it’s really bad.
4. What are some PTH lowering agents? Calcitriol, doxycalciferol, cinacalcet.
5. What’s different about cinacalcet between these three agents? It not only lowers PTH, it also lowers calcium and phosphate.
6. How would you treat hyperphosphatemia? Foslo, TUMS, aluminum hydroxide, lanthanum [thanks Connie!]. 
7. How would you define orthostatic hypotension? If your BP drops by 20 for systolic and by 10 for diastolic when you stand  up (from your sitting BP).
8. What’s the difference between carvedilol and metoprolol in terms of effects on BP and HR? Carvedilol effectively decreases both. Metoprolol decreases the HR the same, but doesn’t lower BP as much.
9. What does CIWA stand for? Clinical Institute Withdrawal Assessment. It’s for alcohol withdrawal…there’s a grading scale of 10 things you would look for in a patient, and if this score is more than a certain defined threshold (different for each institution), then you would give lorazepam or diazepam.
10. What do you look at to determine a Child Pugh score? Total bilirubin, albumin, INR, ascites, hepatic encephalopathy. The interpretation would be 1 and 2 year survival percentages.
11. What’s MELD? Model for End-stage Liver Disease. The equation for this is: 3.78 [Total bilirubin] + 11.2 [INR] + 9.57 [SCr] + 6.43. The interpretation for this is 3-month mortality.
12. What’s the link between using lactulose in cirrhosis patients? Increased levels of ammonia that the liver isn’t able to break down could lead to hepatic encephalopathy. The lactulose increases the passage of ammonia from tissues into gut lumen and blocks the intestinal ammonia production.

And that’s about it for today!