Fluid_Lyte_LectureFinal_2012

Of breath more recently has had swelling in her lower

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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 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. Lab: 122 / 92 / 18 78 urine Osm 430 mOsm/L 4.2 / 24 / 1.4 urine Na 32 mEq/L Q: What is the serum osmolality? Q: Is there an electrolyte abnormality? Q: What should be considered in the differential diagnosis?
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Hypotonic, Euvolemic, Hyponatremia sOsm < 280 Euvolemic Uosm > 100 Uosm < 100 U Na > 20 r/o hypothyroid, SIADH, renal failure U Na < 20 Primary polydipsia Low solute intake Increased TBW & ECF volume, decreased ECF Na Water intoxication Glucocorticoid deficiency Hypothyroidism Hypokalemia SIADH – SIADH causes: CNS – head trauma, stroke, pituitary surgery CA – lung Pulmonary dz pneumonia Drugs – next slide
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Drug Induced SIADH ADH analogues DDAVP Oxytocin Enhanced ADH release Chlorpropamide Carbamazepine Vincristine Nicotine Narcotics Antipsychotics Antidepressants Ifosfamide Potentiate ADH effects Chlorpopramide Cyclosphosphamide NSAIDs Acetaminophen Unknown etiology Haloperidol Fluphenazine Amitriptyline Thioridazine Fluoxetine
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Hypertonic Conditions Sosm > 300 mOsm/kg Abnormal water balance secondary to: 1. Excessive water loss 2. Sodium/solute gain Hypernatremia does not occur unless 1. No access to water 2. Hypodipsia
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Hyponatremia with Elevated or Normal Sosm Hypertonic, hyponatremia High plasma osmolality (> 280 mOsm) Hyperglycemia Mannitol Pseudohyponatremia Normal plasma osmolality (~ 280 mOsm) Pseudohyponatremia Hyperlipidemia Hyperproteinemia Glycine solutions ↑ 100 mg/dl glucose - ↓ [Na] 1.6 128 / 98 / 10 524 3.6 / 18 / 0.8 7.21 / 35 / 92 524-100 = 424 424/100 = 4.24 4.24 (1.6) = 6.78 128+6.78 = 135 Na / Cl / BUN glucose K / HCO 3 / SCr pH / pCO 2 / pO 2
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