Increased Globulin Gap And Nineteen Other Golden Rules For Fleas.

Many specialties have their own nicknames. Internists are called fleas.  We just won't go away.  We look for too much disease.  We swarm in on half dead old people looking for reasons to doctor them. One of my favorite flea action is to look for an elevated globulin gap, which is the difference between the total protein and albumin levels. 

Internist training is  intense. Internists are responsible for evaluating mosts diseases in most adults. Internists must know what they are doing. They can't fake internal medicine. They are the gateway to evaluation of most signs and symptoms of adults. Fleas are diagnostic specialists of the entire adult body.

Grandma doesn't come to the emergency room complaining of third degree heart block, or acute on chronic hypercapnic respiratory failure, or hypervolemic hyponatremia, or low compliment glomerularnephritis. Grandma comes to the ER with a complaint of weakness and dizziness and peeing blood. The internist's  job to develop a differential diagnosis, decide what to order, what not to order and which other specialties need to get involved.

An internist's entire twelve thousand plus hour residency is built around the premise of what else could it be? What else is missing? Internal medicine residency  teach internists  what to pursue and what to ignore. Internists with high confidence in their abilities can call fakers by their game or tell patients that they don't know what is going on. For that reason, internists are called fleas and they should accept that designation with pride. Patients who are sick and looking for answers should go to an internist.  Although, they may not always find the answer they were looking for.   

Residency training provided me an opportunity to develop die hard rules of evaluation.   These are rules that prevent me from missing common diseases that present in uncommon ways. These are rules that improve my diagnostic skills. Here are Happy's golden rules for fleas:

1) Always look at the differential on a CBC. Always. Microcytic and macrocytic indices can be triggers to serious underlying conditions, some easily treatable, some not. Always look for atypical cells, abnormal differentials, eosinophils, schistocytes. Abnormal cells are always abnormal.

2) Always look for a globulin gap. The difference between your protein and albumin, when too high, can indicate an abnormal protein floating around or it could be a sign of inflammation (such as elevated CRP). Evaluation should be considered. An early diagnosis of cancer can save a lot of heart ache. A serum protein electrophoresis is a bone cancer's best friend.  Multiple Myeloma or a variant of MM should always be considered in patients with an elevated globulin gap.

3) When in doubt order a CRP and ESR. While specific and sensitive for nothing, a normal value can be comforting and a great clue to malingering. A really high value can be a great trigger to be more aggressive in the pursuit of undiagnosed disease. The differential diagnosis of a sed rate greater than 100 is limited to osteomyelitis, vasculitis, endocarditis, lymphoma, nephrotic syndrome, connective tissue disorders and miliary TB.

4) Always look at the calcium. Correct it for your albumin. A high calcium is never normal and can cause a lot of complaints (stones, bones, moans, psychic overtones)

5) Always check a TSH when nothing makes sense. Thyroid disease is commonly under diagnosed.

6) Always look at the bicarb and calculate your anion gap. The anion gap can save lives. Just this week, I picked up an antifreeze poisoning by the anion gap. And remember MUDPILES, it will come in handy for the rest of your life.

7) When potassium replacement doesn't work, check a magnesium level.

8) When legs are swollen, always check a urinalysis for protein and an albumin level. Two under utilized tests to evaluate systemic edema. And often times a marker of undiagnosed renal disease.  Swollen legs does not equal cellulitis in both legs.  

9) If someone presents with renal failure, don't forget to check the CPK. Rhabomyolysis is a common but under appreciated reason for ARF. And if you see blood on a urine dipstick but no red cells on the micro, always check for rhabdo.

10) If you have elevated CPK's, always check a TSH. A common but under diagnosed cause (hypothyroidism).

11) You don't need a gastroenterologist for every case of hepatitis. 99% of nonobstructive hepatitis that I see is a medication or from fatty liver (and occasionally viral). Have your pharmacist run a medicantion side effect profile and then sit on it. If it doesn't get better then re-evaluate

12) Knowing the baseline weight in a chronic kidney patient is imperative. You have to know your starting point to know where you're going.

13) It's OK to give as much ativan as you need for alcohol withdrawal. My record is 350 mg in a 24 hour period. Don't be afraid. You can rarely over sedate the heavy drinkers. They are machines.

14) There is no reason to call me low urine output in a 90 year old. Ever.  All 90 year olds have low urine output.  They're 90.  How much urine did you make last night?  Exactly.

15) The discharge planning should begin before you admit them. Know your end point. Prepare for the unexpected and manage the expectations of the patient and family . It's rare for an old medicine patient to leave a hospital in equal or better shape than their normal base line.

16) An isolated elevated bilirubin and or a low platelet count can be an early marker for sepsis syndrome. I would draw blood cultures and empirically treat with broad spectrum antibiotics. I have picked up too many patients with sepsis based solely on an isolated elevated bilirubin (cholestasis of sepsis) or a low platelet count (a common marker of sepsis).

17) In a patient that looks sleepy and drowsy and you don't know what's going on, always consider a blood gas. You can have hypercapnea with out hypoxemia. It happens all the time. Also, in a patient with chronic elevated HCO3 on BMP, it's not a bad idea to check a blood gas  to clarify the extent of hypercapnea present.

18) If the patient is fat, they have obstructive sleep apnea until proven otherwise. Screen for it often as the morbidity associated with OSA can be huge (sudden death, CHF, arrhythmia, stroke, HTN, quality of life).

19) Don't forget venous embolism  or DVT prophylaxis. Just about everyone the hospital should have it.

20) Know your limitations. If you don't know your limitations, you shouldn't be doing this.

Facebook humor:

RN: Happy, we found fleas on your patient
Happy: Have the pharmacist fit him for a flea collar.
RN: Can you come up and talk to the patient?
Happy: No. Sorry. It's 7 pm and I'm fleaing the hospital right now.

"As an internist, I don't always order a lot of tests.  But when I do, it pisses everyone off."

As an internist, I don't always order a lot of tests.  But when I do, it pisses everyone off doctor ecard humor photo. Medical Humor Store Banner

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9 Outbursts:

  1. I hope you don't mind but I copied your rules and shared them with a couple med school buddies. Don't know if any of us plan to be internists yet but always plan for the unexpected I say

  2. #20: Know your limitations. If you don't know your limitations, you shouldn't be doing this.

    Probably the most important. This should be tattooed on some people's foreheads haha.

  3. Was coming to leave exactly the same comment as CK. #20 is your most important. The good docs know their limitations. The dangerous ones do not.

    Awesome post!

  4. 3 more I learned in my IM residency last millenium:

    21. If you're not sure if the pt needs an LP, then the pt needs an LP.

    22. If you're not sure if you need a consult, the pt needs the consult.

    23. At least once a day one very smart person will tell you to do something stupid. Part of your job is to not listen to them.

  5. Drackmans Postulates of Medicine

    #1 If it hurts, X-ray it.

  6. i just finished my internal medicine residency, and i'd have to say i agree 100%. great post.

  7. Rule #2 is to look for the globulin gap, but I'm having a hard time finding a good differential for an elevated gap. I know the typicals (hiv, hcv, multiple myeloma), but what else?

  8. I believe amyloidosis can be included in the ddx as well....

  9. lost intern:
    any occult infection. Guy came in with back pain, elevated gap? Sent blood cultures and he had thoracic osteomyelitis. Could be endocarditis, anything. I have seen senior residents send SPEPs on patients with gangrene... no need. The globulins are there as a response to the infection


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