The Quantified Self in the Nephrology Clinic

I am a big believer in home blood pressure monitoring. In fact, I don’t think you can be serious about treating blood pressure without getting readings outside of the clinic. Everyone thinks about white coat hypertension which is surprisingly frequent. But don’t forget masked hypertension which should call to question normal office blood pressures readings. I did a great interview about this for eAJKD.
A few weeks ago I had a patient bring in a pile of home blood pressure readings and in order to make sense of it I did an informal histogram in our EMR:

Home blood pressure nomogram in my EMR. Tufte would be proud.
— Joel Topf (@kidney_boy) July 10, 2013

Clearly this was not ideal blood pressure control and showing the histogram to the patient convinced him to intensify his treatment.

Edgar Lerma then asked for an app-based solution

@ChristosArgyrop @kidney_boy Can you recommend a Free APP that does useful Home BP Tracking/ Plotting? I realize not everyone can do it 🙁
— Edgar V. Lerma (@edgarvlermamd) July 12, 2013

I linked to an old post on PBFluids that highlighted iBP but in the last few weeks patients have shown me two new free options:

BP Companion on iOS and BPwatch on Android. I do not have a full review, but both seemed like well designed apps and the patients really liked them.

Significant change to my Sodium and Water handout.

I re-worked my sodium and water handout to better track my IV fluid and diuretic lecture that I do for residents in July. The old hand-out focused on IV fluids and dysnatremia. The new one goes deeper into IV fluids including new data on the advantages of LR over NS, and the problem of iatrogenic fluid overload. I then stripped a bunch out on the principles of total body sodium and put an abridged section on hyponatremia with more contemporary view on vaptans and their role the treatment of hyponatremia. I removed the hypernatremia section.

The next step is to remove the dysnatremia section completely and make that a stand alone book.

Work in progress.

More on the Electrolyte Handbook

I am making a significant commitment to the The Electrolyte Handbook. I plan on making continuous tweaks, corrections, and additions. A quick list of ideas include:

  • More references
  • More pictures
  • More tables and lists
  • Integrated calculator in the e-book version
  • Acid-base chapters
  • Sodium
  • IV fluids
  • CKD
  • ARF

The fact that this is going to be a living book leads to some problems. A website always shows the most up-to-date version, but since the PDF and e-book don’t auto-update I have a problem on how to get the most up-dated version in to the hands of users. I have not worried about this issue with my existing hand-outs because the content is entirely conceptual so mistakes did not have clinical implications.

This handbook, however is intended to guide therapy so I need a way to notify users of fixes. So I am going to build an e-mail list. I will only send e-mails when updated versions of the handbook come out. I have no plans to spam. This e-mail is designed to help you, by making sure you are using the most up to date version of the Electrolyte Handbook.

Latest version of the Electrolyte Handbook:

Change log:

Introducing the electrolyte handbook

This is a quick guide to correcting electrolytes designed for new interns. It works in Apple iBooks. PDF format and e-Pub format are forthcoming. I also plan adding: IV fluids, sodium, acid-base and acute renal failure to be a quick, on-call guide for interns.

electrolyte handbook
New link: More on the Electrolyte Handbook
This is a work in progress so send me feedback.

Rhabdo, in the news

Giants pitcher, Chad Gaudin, was arrested Jan. 27 and charged, July 3 with open and gross lewdness.

“Chad Gaudin was examined in the emergency room of a local hospital while experiencing symptoms believed to be related to acute renal failure due to a condition known as rhabdomyolysis. The symptoms included confusion, dehydration and loss of orientation and/or consciousness. Although he has been accused of improperly touching another hospital patient while on the premises that night, there are differing and exonerating versions of what occurred that have been reported by eye witnesses.”

More merit badges

Another month of consult service and another flight of merit badges:

The first is for the case of rhabdo described in this post.

The second was for a particularly vexing acid-base conundrum that left us all scratching our heads.

And the last was for a diagnosis of Goodpastures Syndrome we made by history and U/A. We found a RBC cast that along with the description of hemoptysis a month prior to admission directed us to the diagnosis. Unfortunately we were too late and unable to salvage any kidney function and the patient now is on dialysis looking for a transplant. When I asked what to do for the badge, my fellow suggested a frowny face.

The badges can be downloaded as a PDF or Pages document and print beautifully on Avery 5163
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