Fluid_Lyte_LectureFinal_2012

Case 5 joe is an 85 yo with advanced dementia who was

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Case # 5 Joe is an 85 y/o with advanced dementia who was sent to the ED from his skilled nursing facility. This AM the nurse found him to be unresponsive. The remainder of his PMH is unknown. Aside from his mental status, his physical exam is remarkable for a BP 100/50, HR 110. Labs: 164 / 126 / 50 98 4.8 / 28 / 2.6 Q: What is the serum osmolality? Q: Assess the volume status. Q: Are there any electrolyte abnormalities? Q: What would potentially correct this situation?
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CNS Altered mental status Lethargy Irritability Restlessness Seizures Muscle twitching, hyper-reflexia Fever Nausea / vomiting Labored breathing
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Hypernatremia Caused by: Hypertonic Na Gain NaHCO 3 infusion Hypertonic enteral feeding formulation Ingestion of NaCl Sea water Hypertonic saline enemas Hypertonic saline infusion Hypertonic dialysis Primary hyperaldosteronism Cushing’s disease
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Causes of Hypernatremia Decreased total body sodium (loss of both water > sodium) Diarrhea Excess sweating Diabetes insipidus Osmotic diuresis Normal total body sodium (loss of water) Increased insensible losses Low humidity Increased ambient temperature Fever
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Decreased total body sodium (loss of both water > sodium) Renal causes Loop diuretics Osmotic diuresis (glucose, mannitol) Post-obstructive Polyuric phase of ATN Intrinsic CKD Diabetes insipidus GI causes Vomiting NG suction Enterocutaneous fistula Diarrhea Osmotic laxatives (lactulose) Cutaneous causes Burns Excessive sweating
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Neurogenic (Central) Diabetes Insipidus Etiology Post-neurosurgery, idiopathic, other CNS injury Problem: ADH secretion is impaired Presentation Polyuria w/ slightly elevated Sosm Not hypernatremic unless no water access/thirst Relative euvolemia Diagnosis Low Uosm (50-400 mosm/kg) Water deprivation test + ADH administration Result uOsm > 600 mOsm/L
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Nephrogenic Diabetes Insipidus Etiology Reduced effect of ADH on distal kidney Lithium carbonate , tubulointerstitial kidney disease, congenital Problem: ADH secretion is appropriate but the kidneys are not responsive to it Presentation Polyuria w/ slightly elevated Sosm Not hypernatremic unless no water access/thirst Relative euvolemia Diagnosis Low Uosm (50-400 mosm/kg) Water deprivation test + ADH administration Result uOsm < 300 mOsm/L
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POTASSIUM
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A 67 y/o volunteer gardener arrives to her routine physician visit tired and weak. When asked she indicates that the weeds are out of control & she is just tired from to much work. glaucoma. She takes furosemide 20 mg QD, diltiazem 90 mg QID, and metformin 500 mg BID. Her physical exam is unremarkable with the exception that her extremities & mucous membranes are dry. 154 / 98 / 15
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Case 5 Joe is an 85 yo with advanced dementia who was sent...

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