Month: May 2014

Heart Murmurs: A Quick Guide for Students and Medical Professionals





Part One:  Maneuvers and Positions

Preload: In cardiac physiology, preload is the end diastolic pressure that stretches the right or left ventricle of the heart to its greatest geometric dimensions under variable physiologic demand. Generally it is the venous blood that is returning into the right atrium for oxygenation. Preload is affected by venous blood pressure and the rate of venous return. These are affected by venous tone and volume of circulating blood.

Maneuvers that increase preload or Venous return to the heart are: Raising your legs or Squatting.

Maneuvers that decrease preload or venous return to the heart are: Standing or Valsalva maneuver. Standing decreases venous return and ventricular filling. As a result, standing decreases the intensity of all murmurs except Idiopathic Hypertrophic Subaortic Stenosis (IHSS) and mitral valve prolapse.

Squatting increases peripheral resistance and increases ventricular filling. It brings out the murmurs of ventricular septal defect, aortic insufficiency, and mitral insufficiency.

Generally ALL murmurs increase in intensity (They get louder or Worsen) with an increase in Venous return (increased blood volume inside heart) EXCEPT for two cases:
Hypertrophic obstructive Cardiomyopathy (HOCM) and Mitral Valve Prolapse (MVP). The increase in preload will reduce the intensity [Quiet down or Improve] the murmur.

Breathing: All right-sided murmurs increase with inspiration (Carvallo sign). Many left-sided murmurs decrease with inspiration, but they may be very difficult to hear. Therefore, respiratory variation can help differentiate corresponding right-sided from left-sided murmurs; for example, tricuspid regurgitation from mitral regurgitation.

Sitting up and leaning forward accentuates the second heart sound (S2) and increases the aortic insufficiency murmur. The left lateral decubitus position increases murmur of mitral stenosis. Some people feel that the exercise component of moving into the left lateral decubitus position accounts for the increase in the murmur.

Part Two: Afterload

Afterload is the tension or stress developed in the wall of the left ventricle during ejection. In other words, it is the end load against which the heart contracts to eject oxygenated blood to the body. Afterload is readily broken into components; aortic pressure and/or the pressure the must overcome to eject blood.


Afterload maneuvers – will change the artery diameter making it smaller and therefore resistance to forward flow (decreasing the amount of blood that leaves the left ventricle).  Therefore, the hand grip maneuver will increase the afterload.

Think about it like this… Hand gripping is like squatting of upper limb but since upper limb unlike the legs has very small amount of blood- this doesn’t affect venous return rather it only effects the afterload by increase in AFTER LOAD since it makes it harder for the forward flow of oxygenated blood. Therefore we can understand that “backward flow” murmurs seen in: Aortic Regurgitation, Mitral regurgitation and Ventral Septal Defects (VSD) will increase the intensity of the murmur.
Consider Murmur groups in FORWARD FLOW AND BACKWARD FLOW MURMURS. Forward flow [Obstruction] murmurs i.e. Aortic Stenosis (AS), Mitral Stenosis (MS), HOCM and MVP with the handgrip maneuver which increases vascular resistance the murmur intensity would logically decrease or improve.

Think about it: A murmur is a pathologic heart sound due to turbulent blood flow. If there is a great pressure difference across a valve the murmur turbulence will increase. Once you start to equalize the pressure on two sides of valve i.e. reduce turbulence via the handgrip maneuver this will reduce the intensity of forward flow murmur.


Amyl nitrite is a potent vasodilator (i.e., it expands blood vessels, resulting in lowering of the blood pressure). Alkyl nitrites function as a source of nitric oxide, which signals for relaxation of the involuntary muscles. Physical effects include decrease in blood pressure, headache, flushing of the face, increased heart rate, dizziness, and relaxation of involuntary muscles, especially the blood vessel walls and the anal sphincter. Mainly Amyl nitrite reduce afterload by vasodilation this causes a decrease in the forward flow pressure, hence blood flows forward more smoothly in Aortic Stenosis (AS), Mitral Stenosis (MS), HOCM and MVP.


Backflow murmurs [AR MR VSD] reduce in intensity as pressure gradient increases across a valve where as forward Flow (AS, MS, HOCM and MVP) obstruction Murmurs INCREASE in Intensity as Pressure gradient across valve increases. High pressure in the left ventricle combined with a very low pressure in aorta will lead to more turbulent flow and increased intensity of murmur.



Did God Give Me Cancer?


You may have seen the above graphic on a friends page and did not know how to respond appropriately:

The clearest Biblical verse that answer this question for the believer is found in Psalm 119:67-68. Notice what the psalmist comes to realize in his own sickness: 

Before I was afflicted I went astray, but now I obey your word… you are good and do good teach me your statutes.”

The author of Psalm 119 realizes that before he became sick, he sinned -“Before I was afflicted”, I went astray”… but now (through his sickness and suffering) he realizes that God is not the cause of sickness. The psalmist who is suffering sicknessbecause of his rebellion to God realizes that God is not the cause of His suffering and decides to repent and trust in God because he finally learns that only God is good. 

  • Just like the psalmist we too must understand that God did not create cancer! nor did HE create sickness, murder, death, hatred etc… These are the all the result of our sin infecting the once perfect paradise that God originally created. When we sinned it caused a separation between man and God. God no longer dwelled with man.
  • Secondly, we must understand (if you have a disease) He did not single you out to punish you because of sin in your life.  God loves ALL people (John 3:16). Cancer and other diseases are a result of people falling prey to an evil world.

Q. If God is not the cause of cancer, then what is the cause of cancer? The discovery of “oncogenes” in the 1980s, followed by the “tumor suppressor genes” i.e. BRCA1 and BRCA2 (breast cancer) and “DNA repair genes” in the 1990s, has given us a clear picture of why cancer cells reproduce without restraint.

It has been shown that most cancers arise through a multistep process—multiple mutations may cause continuous activation of some oncogenes (cancer causing genes) these mutations may inactivate some of the tumor suppressor genes (cancer suppressing genes).

In many other important ways cancer cells have degenerative features. Contrary to many evolutionist cancer shows no gain of information, but generally cancer shows a loss or disorder of functions. This is only another example of the peculiar insistence of evolutionists of perceiving advancement where there is only variation.

SIN In The World And Cancer?: One needs only a glance at a News channel to be dismayed by the continual metastasis/spread of violence, theft, and lawless behavior displayed by sinful humanity. The most degenerate human societies sink to ritual murder, cannibalism, and torture. These human behaviors, which have plagued the world almost from its beginning, are remarkably similar to the physiologic behaviors displayed by cancer cells. Cancer cell do not follow the natural healthy order, instead these mutated cells “pride” themselves in overabundance and lawlessness by taking and stealing nutrients from other cells – causing cell death to healthy cells. These cancer cells however, continue to grow and divide without stopping. These cancer cells change the natural healthy balanced environment metastasizing all throughout our body until all that is left is death and destruction.

To conclude, the tragedy of cancer is the result of ongoing genetic deterioration in our body cells, and as such is a manifestation of SINS curse of decay and death. However, the Bible foretells a time when violence, death and sickness will be suppressed and peace will reign for Gods community. Isaiah 11:9 “They shall not hurt nor destroy in all my holy mountain: for the earth shall be full of the knowledge of the Lord, as the waters cover the sea”  and Revelations 21:4 He will wipe every tear from their eyes. There will be no more death’ or mourning or crying or pain, for the old order of things has passed away.” Until that day comes we must bare our cross and follow Jesus. We might now understand everything but at least we know that God is good. 

IF Churches Paid Taxes Would They Be Able To Pay….




The argument on the above graphic states (IF churches paid taxes… it would pay for ALL the food stamps for every person on welfare $76 Billion with enough left over to house the entire homeless population). This graphic is based on a significantly flawed article from the Council for Secular Humanism.

You may have seen this graphic posted on a friends facebook page but did not know how to answer back… Here is a step by step answer.

1. Reliable or Not? The first thing that needs to be noted is that this report is NOT from a neutral source. The Council for Secular Humanism exists to promote secular humanism, which largely defines itself by the absence of religion, and Free Inquiry is not a peer-reviewed journal. This does not mean we reject it, of course – it means that we should apply a skeptical analysis to the report, which the rest of this answer will do.

2. Hypocrisy? The report by the Council for Secular Humanism implies that many tax breaks are given to churches when in fact churches only have one tax break which is (the parsonage allowance highlighted in red). Where the rest of the tax breaks are available to other non-profits, whether they are religious or not, and whether they do any charitable work or not. 

  • Federal Income Tax Subsidy – $35.3billion
  • State Income Tax Subsidy $6.billion
  • Property Tax Subsidy $26.2 billion
  • Investment Tax Subsidy $41 million
  • Parsonage Subsidy $1.2 billion (Churches)
  • Faith Based Initiatives Subsidy $2.2 billion
  • Total $71 billion

It is interesting to note that the Council for Secular Humanism is registered for tax exempt status under the tax breaks that are not in red. 

3. What is fair? The report by the Council for Secular Humanism states that ALL churches should be taxed to pay 70% of their income taxes. They claim that $70 billion is the tax due to churches. No other corporation, profitable or not, pays 70% of their income taxes; a 70% rate is not “paying taxes the same as everyone else”.

4. Churches are loaded with Money: The Council for Secular Humanism states “We calculated the subsidies to religions under the assumption that religions are more like for-profit corporations providing entertainment (such as movie theaters or amusement parks) rather than charities.

This is a highly selectively illogical comparison… First, churches have many differences with a movie theatre – they don’t charge admission, and they don’t make a profit for two.“Churches don’t typically have significantly more income than expenses”. Any church treasurer will back this up.

5. Property tax subsidy: The Council is very vague about how it arrives at its figure for the total value of church property. It claims (without support) that the average value of a church building is $1.7 million. However, many congregations do not even own buildings at all, and are currently renting space to meet as required, or sharing space with other congregations. The report by the Council for Secular Humanism did not take this into account when preparing there argument.


Churches have no special treatment regarding property taxes compared with other non-profits. Non-profits are frequently (not always) exempt from property taxes, but churches are treated equally with them.


  • This article has proven that the Federal and State Income Tax subsidies presented by the Council for Secular Humanism are entirely mythical and false. Treating churches as a business would not bring in any of the $35billion federal tax, nor the $6 billion state tax claimed. The investment subsidy falls in the same category.
  • The Property Tax Subsidy applies to all tax-exempt non-profits, including those with no ‘charitable’ activity for example organizations like The Council for Human Secularism.
  • The Parsonage subsidy is real, and if abolished would bring in about $1.2billion.
  • The real level of subsidy is much, much less than $70 billion and closer to 1.2 billion however this would take away 90% of all homeless shelters 90% of all humanitarian work done worldwide by Christian missionaries (doctors, nurses, healthcare workers etc…)




. Sadly, these people proudly post these unoriginal inciting arguments in order to try and shame Christians without ever researching their own arguments that they themselves are claiming.

They say, “here’s a post that  some other person put together, it defames Christian beliefs – I want to sound smart without having figure out if the claims are true or not…”






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When you are in the process of being mentally stimulated to do or feel something, especially to do something creative, inventive, original it’s called having INSPIRATION.

But do you know why it’s called INSPIRATION?

Synonyms of INSPIRATION ARE: creativity, inventiveness, innovation ingenuity, genius, imagination and originality… Another definition of INSPIRATION is: drawing in of breath; inhalation.

Genesis 2:7 says, “Then the LORD God formed a man from the dust of the ground and breathed into his nostrils the breath of life, and the man became a living being.”

God had an inspiration that was moved by His great love… an inspiration to create a being similar to Himself so that He can share His great love with us (His children). I like to compare this affection much like the love of a husband and a wife who create a child in their own image. The Bible says in Genesis 1:27So God created mankind in His own image, in the image of God He created them; male and female He created them.”

And so, our Creator breathed into our nostrils and as we inspired His Spirit we became a living being

Since we too are made in Gods image we too are creators and we have our own inspirations… moments like our Creator where we breath life into a project, moments where we breath life into a situation, moments where we are able to create something with so much imagination and ingenuity!

Practically speaking: Just like our Heavenly Father we should go to lifeless places and breathe life into them! That is exactly what happened to the prophet Ezekiel. Ezekiel stood before a large grave site in the desert. It was a lifeless place that was full of dead bones.

Ezekiel 37:3- He (God) asked me, “Son of man, can these bones live?”

I said, “Sovereign Lord, you alone know.”

4Then he said to me, “Prophesy to these bones and say to them, ‘Dry bones, hear the word of the Lord5This is what the Sovereign Lord says to these bones: I will make BREATH enter you, and you will come to life.

Are you stuck somewhere? don’t know what to do or where to go? Pray to God and know that you are His child. You are His very own creation created to do amazingly good works.


Psalm 100:3 says “Know that the LORD is God. It is he who made us, and we are His; we are His people, the sheep of His pasture.” Therefore, once we acknowledge God as our Creator and we realize that we are His children – there is no situation great or small that we can not over come! Think about the word impossible; the very word impossible says I’M POSSIBLE and remember always that you have been equipped with the same Spirit of the living God. The One who came down from heaven to overcome all impossibilities (even death) to save us.

IF God is all powerful then why doesn’t He stop ALL evil and suffering?



A friend asked me “IF God is all powerful then why doesn’t He stop ALL evil and suffering?” This is a really good question and one that almost everyone in the world has had at one point in their lives. So why is it that an all knowing, all loving, all power God allows sin and suffering? The answer to this is not an easy one.

The question of stopping evil means that if God is to stop evil, then He must stop ALL evil (including yours).

In order to be free from condemnation you must be perfect, unfortunately… no one is perfect, all have sinned and everyone has fallen short of God’s standard: I could try to defend myself and rely on my own righteousness saying, “well I haven’t done anything really bad… it’s not like I’ve ever killed anyone, I’ve never been to jail”. However, James 2:10 says, For whoever keeps the whole law and yet stumbles at just one point is guilty of breaking all of it.”

This means that the murderer must be stopped along with the thief, the liar must be stopped along with the adulterer (LOOK AT MATTHEW 5:28).  Stopping evil also means that thinking evil, which is in rebellion against God, must also be stopped as well; that is, IF all evil is to be stopped then you and I must be stopped as well – Romans 3:23 For EVERYONE has sinned; we ALL fall short of God’s glorious standard… (NLT)

WHAT ABOUT FREE WILL? Another problem arises, for God to stop all evil and suffering this may very well mean that He must remove the ability for people to freely choose what they want to do. Removing free will has serious repercussions. God gave us free will so that we may free chose to love Him or to not love Him. Free will allows us to truly love God, this is the love that God accepts, a real kind of love (not one based on selfish ambitions, needs, wants…) but that we chose Him over other idols out of our own free will because we truly love Him.

ALL or Some? So, if God is going to stop evil, is He required to stop all of it or just some of it?  If only some of it, then the question would still stand.  If He stops all of it, would we be free?

Our Sin: Biblically speaking, pain and suffering are the results of our sin in the world. Adam, who represented all humanity as well as creation, rebelled against God and brought suffering into the world. We in turn have not done any better than Adam. It seems like sin is continually increasing in the world. We continue to rebel against a Righteous and Holy God.

Sin is much more than simple rebellion and breaking of God’s law. It is an offense against a Holy God. God is a Holy God, who out of His great love created us in order that we may enjoy life and His creation. However, we made a choice… One that God respected and one that changed our world and our relationship with God.  We decided that we did not need our Creator we became our own God deciding for ourselves what is right and what is evil.

Our choice of sinning against Him caused a separation between man and God and ever since that day sin has been permeating throughout all of God’s creation bringing imbalance, fear, murder, injustice, lies, hate, famine, disease, etc… This is not how God originally created things but it is God who is allowing them to continue for His divine plan.  Ultimately, more and more people are realizing that we live in a broken world full of suffering and sin we can’t know all the reasons why God allows suffering, for now we just know that He does. Romans 11:34 “Who has known the mind of the Lord? Or who has been his counselor?”

Has God Done ANYTHING At All? the Bible tells us that God sent His Son Jesus (1 Peter 1:19 “a lamb without blemish or defect”) to die for our sins; Jesus came to deliver us from the pain and suffering our rebellion caused, and to restore our broken relationship with our Father God.

Despite this being our own debt Jesus came to pay a debt He did not owe, because we could not pay it. Ultimately, God is allowing evil in the world for a purpose, otherwise, He would not let it exist. Therefore, we must trust Him that He knows what He is doing.


Eight Years Of Dedication



Psalm 119:105 says, “Your word is a lamp for my feet, a light on my path.” Richard Epstein took these words to heart and began an 8 year journey that is inspiring many  because of his great dedication to the Word of God.

Q. IF you were to write for 8 years how many letters would you be able to penn down? Richard Epstein has recently finished copying the entire Torah (that’s 304,805 letters) without making a single mistake!  Many are admiring Epstein’s patience, consistency, dedication and love for the Word of God.

Richard Epstein who is a member of the Chabad Shul of Potomac, Maryland, said that he penned the entire Torah by hand using a feather quill on parchment made from sheepskin. It took him 8 whole years from start to finish. However, a professional can usually pen a Torah in about a year without making a single error!

His accomplishment was lauded by his Chabad, which held a Grand Torah Celebration on Sunday to honor Epstein’s work.

One mistake can invalidate the text, making accuracy far more important than speed, according to Mistakes — if noticed — can be corrected, provided the mistake doesn’t involve God’s name, according to Epstein, who starred in a short documentary about his endeavor.

Epstein, who is also an author and professor, told the Washington Post that he feels as if the “Torah wrote me, more than I wrote the Torah — that it really shaped me.”






How Rich Are You?


Last week I was meditating on Matthew 6:19-21 and realized what true wealth is… true wealth is something that money can not buy and death can not steal

Matthew 6:19-21  Jesus says, 19 “Do not store up for yourselves treasures on earth, where moth and rust destroy, and where thieves break in and steal. 20 But store up for yourselves treasures in heaven, where moth and rust do not destroy, and where thieves do not break in and steal. 21 For where your treasure is, there your heart will be also.
Think about it… no matter how much money you save up, no matter how successful you are – we will all die and no amount of money or success can buy you eternal life… so the question is: What are you investing your life in?
1. WASTE: Some people waste there life “living for the moment” i.e. and wild partying, drugs, alcohol and sexually abusive behavior. You can waste it on being lazy and procrastinating and throwing opportunities down the drain.
2. SPEND: Others spend there life. You can spend it trying to be the best and reach the top of whatever it is your trying to reach. You can spend it on doing whatever it takes to reach your goals and running over whoever it takes to get there. You can spend it on being self-focused and looking out for only number one.
3. INVEST: Finally, you can invest your life. You can give back out of the things you have been blessed with, you can use your time and talents to make a difference in the lives of others and you can invest in people by being a true friend and someone that they can count on no matter what.

Sometimes I complain to God about things that I do not have… this negative attitudes inhibits me from investing my life in Him and His Word… I tend to hold on to the things of this world with clenched fist and I say to myself I have too little! However, when I look at my life I often forget how blessed I really am! Dear God thanks for this beautiful life and forgive me if I do not love it enough…
for when I looked inside of my wallet I found it to be empty, when I looked through all of my pockets and they too were all empty! But then I looked inside my heart and there I found you oh God, and only then could I realize how rich I truly am.

A Good Neuro Question: The Internal Capsule

Q. A 74 year old women with a long history of Diabetes mellitus is brought to the emergency department with a sudden onset of hemiparesis on the right side of her body. On history she has a 25-pack-per year smoking history, and is currently on metformin and hormone replacement therapy. The patient shows no signs of AMS and answers all questions very well. Her vitals are BP of 144/92 mmHg and PR of 86/min. PE confirms loss of strength in the right upper and lower extremities. There is a right sided facial weakness that is present as well. The visual field is intact. A CT scan of the head is ordered to rule out cranial bleed. Occlusion of which of the following vessels is the most likely cause of this patients symptoms?

A. Anterior cerebral artery

B. Vertebral artery

C. Penetrating arterioles of the anterior limb of the internal capsule

D. Middle cerebral artery

E. Penetrating arterioles of the posterior limb of the internal capsule

F. Posterior cerebral artery

G. Infarction of the corpus callosum 


Answer: E. Penetrating arterioles of the posterior limb of the internal capsule



Lacunar infarcts are small (< 0.5 cm) focal areas of parenchymal loss found in the basal ganglia, anterior or posterior limb of the internal capsule, pons and occasionally cerebral white matter. The five classic syndromes include:

1) Pure motor hemiparesis

2) Pure sensory stroke

3) Sensorimotor stroke

4) Ataxic hemiparesis

5) clumbsy-hand dysarthria

These are presumed to be of ischemic origin and due to occlusion of the penetrating arterioles of the aforementioned structures. Lacunar infarcts are particularly frequent in persons who suffer from hypertension or diabetes mellitus. The most common type of infarct is a pure motor lacunar infarct presenting with motor weakness of the contralateral side without any cortical sings i.e aphasia, agnosia, hemianopsia, neglect etc…

Pure motor infarcts most often occur in the genu of the posterior limb of the internal capsule where the descending corticospinal and corticobulbar tracts are located. Infarction of the anterior limb most often results in ataxic hemiparesis where both the pyramidal weakness and frontopontocerebellar (ataxia) systems are located

Desiring PEACE


Romans 12:18 says, “If it is possible, as far as it depends on you, live at peace with everyone.”

Matthew 5:9 adds Blessed are the peacemakers, for they will be called children of God.

Is there someone in your life who insists on hurting you most times he/she sees you? The Bible doesn’t say you have to act like a door mat and just let it keep happening. But the Bible does say that some people are “toxic”: Psalm 58:4 describes these their hurtful acts like poisonous venom “Their venom is like the venom of a snake …”

Having someone like that in your life can mess up your identity, your peace of mind, it can mess up your attitude. It can mess up your friendships. It can mess up your family life, or your marriage… don’t let the hurtful acts these people do to you take away the good that God has placed in your heart.

Part 1. Identifying People Who Are Toxic

People who are “toxic” are going to blame anyone but themselves — including you — for the problems in their lives. They may lash out and say “It’s because of you dad/mom or it’s because of you…” They will call you on the pone and vomit their toxic slander on to you – they spread lies, they are vulgar and viciously criticize others… they love to blame others (or even you) for their pain, but you have to realize that it’s not about you. It’s about them.

When these chaotic people get around you, it starts to rub off, and you may start thinking, “Am I going crazy? I know they’re crazy, but am I crazy, too?”

No, you’re not crazy. Remember: It’s not about you. it’s about them. I repeat… don’t let the hurtful acts these people do to you take away the good that God has placed in your heart.

Part 2. If it’s possible… live at peace with everyone

Romans 12:18 says, “If it is possible, as far as it depends on you, live at peace with everyone”. Notice the two qualifiers in this verse. First, it says “IF” it is possible, not “it is.” Second, it says “as far as it depends on you.”

I don’t know if you know this yet, but (sadly) it’s not always possible to live at peace. There are some people who, no matter what you do, no matter if you apologize, even if you stay quiet they will hurt you because these people love hurting other people. It doesn’t have anything to do with you. It has to do with their pain and their hurt because those who are at war with others are NOT at peace with themselves.

This is one reason why I love the Bible… It always tells the truth about God, life, and human behavior. The Bible points out that it’s not always possible to live at peace with everybody. There are some people you are just not going to get along with. There are some people who, no matter how nice you are to them, are still going to be mean to you, they are still going to spread rumors about you and your family, they are going snicker and smile when something awful happens to you…

God says you need to realize that it’s not about you. Then, you need to move on.

Part 3. As Far As It Depends On You

What does “as far as it depends on you” mean? How can you apply this qualifier to a specific struggle you have with someone in your life?

If you struggle, thinking you must be at peace with everyone, even those who poison your life, you may need to take a step of faith toward believing Romans 12:18. Then think about Jesus Christ who is the very image of God, the very image of LOVE, compassion, sacrifice, understanding… He came to give us the gift of eternal life – yet He was crucified because of our own love for darkness and sin.  Finally pray and ask God to help you to let go of this burden.

Life appears to me too short to be spent nursing animosity or registering wrongs… therefore, forgive and live!

Electrolyte Abnormality In A Patient With Liver Disease



Q. A nurse calls you to ask you about a patients low calcium level. He is concerned about a patient on your service, specifically a 45 year-old alcoholic man who was admitted after being found drunk and stuporous in the street. The patient’s mental status has improved with restarting his lactulose and discharge is planned for this afternoon. His B/P is currently 146/82 mmHg, his temperature is 98.6 F, and respirations are 22/min. The patient is alert and oriented and does not seem to be in any distress. Physical exam reveals temporal wasting, numerous spider angiomas, mild gynecomastia and marked hepatosplenomegaly. The physical finding of shifting dullness and 2+ pitting edema bilaterally are also present. The nurse is concerned because the patients total calcium level is 7.0 mg/dL, and he wants to know what to do. Which is the most appropriate management at this time?

A. Administer vitamin D supplementation

B. Check the EKG for any dysrhythmias

C. Administer calcium carbonate, 1-2 g/day

D. Administer calcium gluconate 200mg (a ampules) stat

E. Check albumin

F. Check magnesium level

G. Preform a mini-mental status exam

H. Check for Chvostek sign


The correct answer is E. Check albumin level

The patient’s hypocalcemia is likely factitious. Given by the obvious advanced liver disease, a quick review of this patient’s recent liver function tests will likely reveal a low albumin. Calcium in the bloodstream exists as bound (mainly to albumin) and free (or ionized) calcium, the latter of which is physiologically important. As albumin levels decrease, common in advanced liver disease, total calcium also decreases; however ionized calcium remains constant. An ionized calcium level can be checked or a simple adjustment for the reduced albumin can be made… NOTE: for every 1 g reduction in albumin below 4 g/L (normal), total calcium levels will decrease 0.8 mg/dL. For example, if this patient’s albumin were 2 g/L, the calcium level would be 8.6 (7.0 + adjustment of 1.6), which is within the normal range and does not require treatment.