Fluid_Lyte_LectureFinal_2012

Nausea vomiting cramps lethargy disorientation

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Nausea Vomiting Cramps Lethargy Disorientation Decreased DTR’s Acute condition Seizures Coma Respiratory arrest Cerebral edema Herniation
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Case # 2 A 25 year old female presents to the ED with a chief complaint of feeling dizzy upon standing. The history of present illness is significant for 4 days of diarrhea / vomiting. She has not been able to keep food or much liquid down. She has no other past medical history and is not on any medications. Wt 62 kg 122/60-100-16 108/52-131-16 PE: dry mucous membranes, sunken eyes, poor skin turgor Lungs, cardiovascular, abdomen, extremities – normal 124 / 104 / 42 97 Na / Cl / BUN glucose 4.2 / 12 / 1.4 K / HCO 3 / SCr ABG: 7.2/44 /91 uNa 8 mEq/L
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Case # 2 Q1: Estimate her total body water Q2: Is she hypo-, hyper-, or euvolemic? Q3: Explain the fluid shifts that are occurring. How will you approach the case?
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Hypotonic, Hypovolemic , Hyponatremia sOsm < 280 Hypovolemic Uosm > 450 U Na < 20 U Na > 20 Extrarenal losses: GI Skin, Lung Renal loss, Diuretics, Adrenal insufficiency Extrarenal Loss Excess sweating, diarrhea, vomiting, 3 rd spacing, wound drainage Renal Loss Diuretics (thiazides) P’col:block Na reabsorption in the distal tubule → Na & water excretion; Stimulates ADH Water < Na loss Renal tubular acidosis Adrenal insufficiency Ketonuria Osmotic diuresis
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Case # 3 Jane is a 65 y/o with a past medical history significant for heart failure (HF) secondary to an acute myocardial infarction (AMI) 3 years ago. She presents for a routine medicine clinic visit. She indicates that she has been short of breath; more recently has had swelling in her lower leg and headaches. PE: 132/88-118-12 afebrile Lungs: crackles in the lower base, Ext: see next slide 132 / 97 / 24 128 3.8 / 27 / 1.2
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Case # 3 Q: Calculate the serum osmolality Q: How do you assess her fluid balance? Q:Why is the sodium low? Q: Are there any signs/symptoms of hyponatremia present?
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Hypotonic, Hypervolemic, Hyponatremia sOsm < 280 Hypervolemic Uosm > 100 U Na < 20 HF, Cirrhosis, Nephrotic syndrome, Chronic renal failure Disease condition leads to a decrease in effective circulating volume, an expanded ECF & edema ADH is released due to low circulating volume resulting in retention of more water Excretion of Na and water are both impaired
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in.com accessed 9/2011
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Jefferson Clinical Images Signs Symptoms of Hypervolemia Shortness of breath Orthopnea Edema Increased blood pressure Weight gain Distended neck veins Crackles, rhonchi, wheezes Tachycardia Moist skin
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Case # 4 The family of a 65 y/o female called EMS after witnessing her having a seizure. On arrival to the ED she is confused and combative. She has a recent diagnosis of small cell lung cancer. On physical exam she appears to be well nourished, mucous membranes are moist, normal skin Turgor, no signs of edema.
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