Paucis Verbis: Approach to increased osmolal gap

We often talk about calculating the anion gap in the evaluation of patients. What about the osmolal gap? When do you calculate this? What’s the differential diagnosis for an increased gap?

I recently came upon a nice 2011 review in the American Journal of Kidney Disease called “Approach to the evaluation of a patient with an increased serum osmolal gap and high-anion-gap metabolic acidosis”. It’s always nice to revisit and review this concept. You’ll always learn something new. For instance, I didn’t know that salicylates cause anion gaps as well as osmolal gaps.

So don’t forget to calculate an osmolal gap for patients with an unexplained metabolic acidosis anion gap.

PV Card: Approach to Osmolal Gap

Adapted from [1]
Go to ALiEM Cards for more resources.

Reference

Kraut J, Xing S. Approach to the evaluation of a patient with an increased serum osmolal gap and high-anion-gap metabolic acidosis. Am J Kidney Dis. 2011;58(3):480-484. [PubMed]

By Michelle Lin, MD|2021-10-10T18:55:20-07:00Jun 1, 2012|ALiEM Cards, Tox & Medications|

Survey: Why do you use Twitter?

I recently got a comment on the blog asking why people need to use Twitter, if they’re already following blogs. I thought I would open this up to the blogosphere.

I personally use my Twitter account (@M_Lin) for a variety of reasons:

I tweet the link to my blog whenever there is a new post (I just tweeted a link to this post!)
Scan quick, real-time information from clinicians I trust
Know “what’s hot” in EM, medical education, and education technologies
Learn of new blogs and websites which I didn’t know about
Quickly check tweets on-the-fly on my iPhone during downtimes
Make new friends who I then meet in person at EM conferences!

Please comment below and include your Twitter name, if possible. I’d love to know why (or why you don’t) use Twitter.

By Michelle Lin, MD|2019-01-28T22:20:36-08:00May 30, 2012|Social Media & Tech|

Trick of the Trade: Mark your sites with a Sharpie

Marking the surface anatomy for procedures can significantly increase your chances for success, such as for lumbar punctures and central lines. I can never seem to find surgical skin markers.

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By Michelle Lin, MD|2019-02-19T18:07:58-08:00May 29, 2012|Tricks of the Trade|

Twitter conference notes: High Risk EM and Gaming Symposium

Yesterday, I attended two fantastic conferences and so wasn’t able to make a new Paucis Verbis card:

UCSF High Risk Emergency Medicine
UCSF Gaming and Learning Symposium

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By Michelle Lin, MD|2026-06-16T16:02:40-07:00May 25, 2012|Medical Education, Social Media & Tech|

Trick of the Trade: Ear foreign body

Sometimes classic techniques need to be revisited, especially when I get new photos from the collective readership. Let’s review a painless way to remove beads from the ear canal. You can’t exactly have the patient’s provider blow in the other ear to expulse the bead, similar to a nasal foreign body…

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By Michelle Lin, MD|2022-03-26T13:57:19-07:00May 22, 2012|ENT, Tricks of the Trade|

Paucis Verbis: Upper GI bleeding

Do you know what the Blatchford clinical prediction score is for upper GI bleeding? It can help you predict whether a patient with an upper GI bleed is severe and requires urgent intervention.

Hot off the presses, JAMA just came out with a great Clinical Rational Examination article on this topic. Thanks to Dr. Ryan Radecki (EMLitOfNote) for the heads up. The likelihood ratios and Blatchford risk stratification score are so useful that I’m breaking my PV rule to keep things down to the size of one index card. Note the absence of a NG lavage result to help you risk stratify for an upper GI bleed requiring urgent intervention using the Blanchard score.

Let’s say you have a patient with a Blanchard score of 0, as in the case of the JAMA example. Starting with a general 30% pretest probability that your upper GI bleed patient has a severe GI bleed, your post-test probability becomes <1% for a severe GI bleed.

PV Card: Upper GI Bleed

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Adapted from [1, 2]
Go to ALiEM (PV) Cards for more resources.

References

Kumar R, Mills A. Gastrointestinal bleeding. Emerg Med Clin North Am. 2011;29(2):239-52, viii. [PubMed]
Srygley F, Gerardo C, Tran T, Fisher D. Does this patient have a severe upper gastrointestinal bleed? JAMA. 2012;307(10):1072-1079. [PubMed]

By Michelle Lin, MD|2021-10-10T18:50:55-07:00May 18, 2012|ALiEM Cards, Gastrointestinal|

KidsCareEverywhere-Vietnam study findings: SAEM 2012 meeting

I recently had the pleasure of presenting our KidsCareEverywhere-Vietnam team’s study findings at the national SAEM meeting in Chicago.

Bottom line

Despite knowing English as a second language, Vietnamese physicians were able to easily navigate an English-based, clinical decision support software (PEMSoft) after only a brief 80-minute training session, conducted by non-physicians. Their post-test exam scores improved by 84%!

By Michelle Lin, MD|2016-11-11T18:44:53-08:00May 16, 2012|Medical Education|

About Michelle Lin, MD

PV Card: Approach to Osmolal Gap

Reference

PV Card: Upper GI Bleed

References

Bottom line