Electrolytes

q 13

You are the resident on call, and the nurse calls you in the middle of the night to inform you about a patient who just had a generalized seizure. The patient is a 66-year-old Caucasian male who had a right hemicolectomy one day prior for colon carcinoma. Postoperatively, the patient had a hypotensive episode, which responded to aggressive fluid resuscitation with 0.45% normal saline. The patient was in significant pain postoperatively and was receiving high doses of morphine for the pain. On physical examination, the patient is extremely drowsy and lethargic. His temperature is 36.7 C (98 F), blood pressure is 110/60 mmHg, pulse is 68/min, and respirations are 12/min. His pulse oximetry reading is 96% at room air. You order a stat electrolyte panel, and the results are as follows:Serum Na 114 mEq/L Serum K 4.2 mEq/L Chloride 90 mEq/L Bicarbonate 22 mEq/L BUN 24 mg/dL Serum Creatinine 1.2 mg/dL Calcium 9.4 mg/dL Blood Glucose 120 mg/dL What is the most appropriate next step in the management of the patient? B. C. D. E. A. 3% normal saline 0.9% normal saline 0.4 mg of IV naloxone Ringer lactate Water restriction to less than 1 liter/day

This subscription is licensed to user: roopika only User ID: 123489 Explanation: Hyponatremia is a relative excess of water in relation to sodium in the body. It is caused by excessive free water intake (primary polydipsia), endocrine disorders (e.g. , adrenal insufficiency, hypothyroidism) and impaired water excretion from advanced renal failure and excessive antidiuretic hormone (ADH) release. Excessive ADH release can be due to a decreased effective circulating volume (volume depletion, CHF, cirrhosis, and overuse of thiazide diuretics) and syndrome of inappropriate ADH secretion (SIADH). SIADH is seen in a variety of CNS disorders, tumors (especially small cell lung cancer), drugs (e.g., carbamazepine, cyclophosphamide, and selective serotonin reuptake inhibitors), pulmonary diseases, HIV infection, as well as in postoperative patients. Major abdominal or thoracic surgery is commonly associated with hypersecretion of ADH,

which is probably mediated by pain afferents. Other factors that may contribute to the development of hyponatremia in the postoperative patients are nausea, hypotension, and excessive use of hypotonic intravenous fluids. The symptoms are primarily neurologic and are due to water movement into the brain cells, thereby causing cerebral edema. It occurs due to rapid reduction in the plasma sodium concentration, especially in postoperative patients receiving large quantities of hypotonic fluids. Nausea and malaise are the earliest symptoms, followed by headache, lethargy, obtundation, seizures, coma, and respiratory arrest if the sodium level falls below 115 to 120 mEq/L. The treatment of hyponatremia depends on the cause, the plasma sodium concentration, and the severity of symptoms. In patients with symptomatic or severe hyponatremia (sodium level below 115 mEq/L), an aggressive initial correction at the rate of 1.5 to 2 mEq/L/hour for the first three to four hours is indicated. Hypertonic saline should be used initially in this setting for rapid correction of hyponatremia. The plasma sodium levels should be monitored frequently to avoid raising sodium levels more than 12 mEq/L in the first 24 hours. (Choices E and B) Most patients with hyponatremia are usually asymptomatic. These patients are best managed by fluid restriction or the use of isotonic saline. (Choice C) The patient does not have any signs of morphine overdose; therefore, the use of naloxone is not indicated in this setting. (Choice D) Ringer lactate should not be used in the initial management of symptomatic hyponatremia. Its role in the treatment of hyponatremia is not well defined. Educational Objective: Hyponatremia causing seizures or other severe neurologic abnormalities should be initially treated aggressively with hypertonic saline. 62% of people answered this question correctly; This subscription is licensed to user ID: 123489 only A 64-year-old Caucasian man is brought to the emergency department because of nausea, vomiting, and abdominal distention. He denies any abdominal pain. His symptoms have been present for the past two days, and are progressively getting worse. His other medical problems include hypertension, hypercholesterolemia, coronary artery disease, and congestive heart failure, with an ejection fraction of 25-30%. He drinks 1-2 beers daily. His father had a myocardial infarction at age 68. His medications include aspirin, furosemide, metoprolol, and simvastatin. His temperature is 37.2 F (99 F), blood pressure is 130/70 mmHg, and heart rate is 98 beats/min. The abdomen is soft and nontender, but distended. Bowel sounds are decreased. There is no rebound tenderness or rigidity. The patient's laboratory tests reveal: CBCHb 13 g/dL

Ht 38% Platelet count 300,000/cmm Leukocyte count 11,000/cmm Segmented neutrophils 70% Bands 3% Lymphocytes 27% Serum ChemistrySerum Na 132 mEq/L Serum K 2.7 mEq/L Chloride 104 mEq/L Bicarbonates 24 mEq/L BUN 32 mg/dL Serum Creatinine 1.2 mg/dL Calcium 10 mg/dL Blood Glucose 80 mg/dL Which of the following is the most appropriate next step in the management of this patient? B. C. D. E. A. Urgent surgery consultation Start IV potassium replacement Start antibiotic therapy Order an abdominal CT scan immediately Order an abdominal x-ray immediately

This subscription is licensed to user: roopika only User ID: 123489 Explanation: This patient has an acute abdomen syndrome. Findings from the physical examination and laboratory tests point towards hypokalemic paralytic ileus as the most probable etiology. This patient has been taking a loop-diuretic, which can produce hypokalemia and hyponatremia. Parenteral potassium replacement is necessary to treat the ileus, as well as to prevent any untoward cardiac complications associated with hypokalemia. (Choice C) There is no evidence of infection; therefore, there are no indications to begin antibiotic therapy. (Choice A) A surgery evaluation is not urgent. An underlying cause (hypokalemia) of the paralytic ileus has been identified, and should be addressed first in the management of this patient.

(Choice E) Abdominal x-rays can confirm the ileus, showing dilatation of the gastric chamber, small bowel, and colon; however, potassium replacement and an EKG recording are more important at this moment. (Choice D) An abdominal CT scan is not very helpful in the management of paralytic ileus. Educational Objective: Diuretic-induced hypokalemia is a common complication of antihypertensive/congestive heart failure therapy, especially when loop-diuretics are used. Paralytic ileus is one of the indications for prompt parenteral potassium replacement. 78% of people answered this question correctly; This subscription is licensed to user ID: 123489 only A 68-year-old female on the surgical floor developed generalized seizures. She underwent an elective hernia repair one day ago. Postoperatively, she was placed on intravenous fluids containing 5% dextrose. She has mild bronchial asthma. She has never been intubated or received oral glucocorticoids for her bronchial asthma. On physical examination, her vital signs are stable. She is in an obtunded state secondary to her postictal status and administration of lorazepam. While the patient is being examined, the laboratory technician calls and reports that her serum sodium is 110 mEq/L. Her other lab tests are pending. What is the next best step in the management of this patient? A. Rapid infusion of 0.9% saline intravenously B. Infuse 3% saline intravenously to increase her serum sodium at the rate of 0.5 to 1 mEq/L per hour C. Infuse 3% hypertonic saline to increase her serum sodium to normal limits within 16 hours D. Check the urine and serum osmolality E. Infuse 3% hypertonic saline to increase her serum sodium to normal limits within eight hours This subscription is licensed to user: roopika only User ID: 123489 Explanation: Postoperative hyponatremia is a common problem, and is caused by SIADH secondary to the use of anesthetic agents, postoperative pain and nausea. This patient has postoperative severe hyponatremia, which is manifested by her generalized seizure activity. She received hypotonic fluids in the form of 5% dextrose, which aggravated this problem and caused a precipitous fall in serum sodium levels. Severe hyponatremia is preferably treated by a slow infusion of 3% hypertonic saline (513 mEq/L of sodium). The initial goal is to increase the sodium level by 3 mEq/L in the first three hours. Subsequently, the rate of 3% hypertonic saline is adjusted to increase the serum sodium level by 0.5 to 1 mEq/L in the next 12-18 hours. Frequent monitoring of

the serum sodium level is warranted to prevent a rapid increase in serum sodium, which may lead to central pontine myelinolysis. The increase in serum sodium level achieved by infusion of one liter of 3% hypertonic saline can be calculated with the following formula: (513 - serum sodium)/(total body water + 1). For instance, the serum sodium level in this patient is 110 mEq/L and her weight is 60 Kg. Applying these numbers to the formula will give us: (513 - 110)/(60 x 0.5 + 1) = 403/31 = 13 mEq/L. One liter of hypertonic saline in this patient will increase the serum sodium by 13 mEq/L. (Choice A) Infusion of normal saline is not indicated in patients with SIADH. (Choice D) Checking the urine and serum osmolality is generally used for the diagnosis of SIADH. Waiting for the results will be disastrous, and will not lead to any change in the management of this patient. (Choices C and E) A rapid infusion of 3% hypertonic saline to quickly increase the serum sodium level could be potentially dangerous because it may lead to central pontine myelinolysis. Educational Objective: 3% hypertonic saline is the preferred treatment for severe symptomatic hyponatremia. The serum sodium level should be gradually increased in hyponatremic patients to prevent central pontine myelinolysis. 71% of people answered this question correctly; This subscription is licensed to user ID: 123489 only A 46-year-old Caucasian woman comes to the office because of weight gain. She is also complaining of a lack of energy, constipation and memory deficits. She has no other medical problems. She denies the use of tobacco, alcohol or drugs. Her family history is not significant. She is not taking any medications. Physical examination shows an obese woman, with an increased abdominal girth. Relaxation phase of the ankle reflex is slow. Laboratory tests are ordered, and the patient is asked to return one week later. The results are the following: Thyroid testsTSH 15 U/mL Free T4 0.1 ng/dL Serum chemistrySerum Na 126 mEq/L Serum K 4.2 mEq/L Chloride 90 mEq/L

Bicarbonate 25 mEq/L BUN 14 mg/dL Serum creatinine 0.8 mg/dL Calcium 9.8 mg/dL Glucose 90 mg/dL Which of the following is the most appropriate pharmacotherapy for this patient's hyponatremia? B. C. D. E. A. Water restriction Hypertonic saline Free water administration Levothyroxine Demeclocycline

This subscription is licensed to user: roopika only User ID: 123489 Explanation: Plasma osmolality is calculated as: 2 x serum Na + glucose / 18 + BUN/2.8 Normal plasma osmolality is around 280-290 mOsm/L. In this case: (2 x 126) + 90/18 + 14/2.8 = 252 + 5 + 5 = 262 mOsm/L. This patient has euvolemic hypoosmolar hyponatremia, which has various etiologies, such as: hypothyroidism, adrenal insufficiency, and syndrome of inappropriate ADH secretion (SIADH). She presents with signs and symptoms characteristic of hypothyroidism, which is the most likely cause for the euvolemic hypoosmolar hyponatremia. She does not appear dehydrated or volume overloaded. Therapy for asymptomatic patients with chronic, mild hyponatremia (125-135mEq/L) is aimed at correcting the underlying cause; therefore, treatment with levothyroxine will control the symptoms of hypothyroidism and will correct hyponatremia. (Choice A) Patients with SIADH and mild or moderate (115-124mEq/L) hyponatremia can be managed with water restriction. (Choice B) Sodium replacement using hypertonic saline is reserved for symptomatic patients with severe hyponatremia (<115 mEq/L). (Choice C) Free water administration is part of hypernatremia management.

(Choice E) Demeclocycline is helpful in the treatment of some chronic, persistent cases of SIADH or antipsychotic-induced hyponatremia. Educational Objective: Euvolemic hypoosmolar hyponatremia can be due to SIADH, hypothyroidism or adrenal insufficiency. If the patient is asymptomatic or the hyponatremia is mild, treatment is first directed at correcting the underlying disorder (e.g. using corticosteroids or levothyroxine). Moderate hyponatremia and SIADH respond to water restriction. Symptomatic patients and those with severe hyponatremia may need sodium replacement using hypertonic saline solution. 61% of people answered this question correctly; This subscription is licensed to user ID: 123489 only A 22-year-old Caucasian man comes to the office for his laboratory test results. He is asymptomatic, except for mild epigastric discomfort, which responds to antacids. He is unemployed. He does not use tobacco, alcohol or drugs. He takes no medications. His laboratory evaluation was done as part of a routine pre-employment work-up. The test results show the following: CBCHt 42% Platelet count 300,000/cmm Leukocyte count 6,500/cmm Segmented neutrophils 65% Lymphocytes 30% Monocytes 5% Serum ChemistrySerum Na 141 mEq/L Serum K 4.0 mEq/L Chloride 105 mEq/L Bicarbonate 25 mEq/L BUN 22 mg/dL Serum creatinine 1.1 mg/dL Calcium 11.8 mg/dL Glucose 84 mg/dL Which of the following clinical findings is most likely present in this patient? B. C. D. E. A. Tinel's sign Chvostek's sign Hyperreflexia Hyperpigmentation No specific findings

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Explanation: This patient has mild hypercalcemia. Hypercalcemic patients usually lack specific findings on physical examination. Hypertension may or may not be found, and may be due to other conditions when present. (Choice A) Tinel's sign is elicited by the repetitive tapping of the palmar aspect of the wrist with the examiner's thumb, which produces or increases the paresthesias in the median nerve area. This sign is positive in carpal tunnel syndrome. (Choice B) Chvostek's sign (contraction of the facial muscles when the facial nerve is tapped) is a feature of hypocalcemia. (Choice C) Hyperreflexia is found in upper motor neuron conditions, and sometimes in hypocalcemia, but not in hypercalcemia. (Choice D) Hyperpigmentation is characteristic of renal and liver disease, chronic hypocalcemia, Addison's disease and some cases of hyperthyroidism. It is not present in hypercalcemia. Educational Objective: Hypercalcemia is not associated with specific physical findings. There may be anxiety, depression, mild muscular weakness, constipation, and peptic ulcer disease. Hypocalcemic patients, in contrast, may present with Chvostek's or Trousseau's sign, hyperpigmentation, seizures, muscular weakness or hypotension. 56% of people answered this question correctly; This subscription is licensed to user ID: 123489 only A 74-year-old Caucasian woman comes to the emergency department because of fever, nausea, dysuria, and frequency. She also complains of loss of appetite and abdominal pain. She has not been eating or drinking well for the past two weeks. She lives alone at home. She does not use tobacco, alcohol, or drugs. Her medications include aspirin, lisinopril, and ibuprofen. Her blood pressure is 130/80 mmHg and pulse is 98/min. Physical examination shows dry mucus membranes, clear lung fields, and normal first and second heart sounds. Her abdomen is soft, mildly tender, and non-distended. Her laboratory tests reveal the following: CBCHb 12.8 g/dL Ht 38% Leukocyte count 13,000/cmm Segmented neutrophils 90% Lymphocytes 10% Serum ChemistrySerum Na 148 mEq/L

Serum K 7.1 mEq/L Chloride 112 mEq/L Bicarbonate 17 mEq/L BUN 78 mg/dL Serum Creatinine 2.8 mg/dL UrineSpecific gravity 1.020 Blood Trace Leukocyte esterase Positive Nitrites Positive WBC 20-30/hpf RBC 1-2/hpf The electrocardiogram shows sinus tachycardia, peaked T-waves in all leads, and no changes in the ST segments. Which of the following is the most immediate step in the management of this patient? B. C. D. E. A. Intravenous antibiotics Intravenous hydration Intravenous insulin Intravenous calcium gluconate Intravenous bicarbonate

This subscription is licensed to user: roopika only User ID: 123489 Explanation: The patient has a urinary tract infection and is developing high anion gap metabolic acidosis, dehydration, acute renal failure, and hyperkalemia. This latter condition is especially serious because there are EKG changes, potassium is higher than 7 mEq/L, and the process seems to be acute. In such a situation, the first thing to do is to administer intravenous calcium gluconate to stabilize the membrane of the cardiac conduction tissue and prevent the development of life-threatening arrhythmias. (Choices C and E) Insulin and bicarbonate are also part of the therapy, but these will take some time to act. (Choices A and B) Hydration and antibiotic treatment are not as urgent as the management of significant hyperkalemia. Educational Objective: Significant hyperkalemia can be life threatening and needs to be managed immediately. Hyperkalemia is considered a medical emergency when there is an acute increase in the

serum potassium level, the potassium is higher than 7, or there is simultaneous metabolic acidosis. In such situations, administration of calcium gluconate is the first thing to do. 81% of people answered this question correctly; This subscription is licensed to user ID: 123489 only The following vignette applies to the next 2 items An elderly male is brought to the emergency department by the police when he was found wandering on the street in the night. He is confused, disoriented, and intermittently complaining of generalized abdominal pain and thirst. Any further history is unobtainable. His blood pressure is 110/80 mmHg, pulse is 98/min, temperature is 36.7C (98 F) and respirations are 22/min. There is no abdominal rigidity or rebound tenderness. Laboratory examination shows that his urine is positive for ketones. His plasma glucose level is 167 mg/dL. Other laboratory results are pending. Item 1 of 2 What is the most likely cause of this patient's condition? B. C. D. E. A. Acute appendicitis Cholecystitis Alcoholic ketoacidosis Henoch-Schonlein purpura Diabetic ketoacidosis

This subscription is licensed to user: roopika only User ID: 123489 Explanation: The patient most likely has alcoholic ketoacidosis, as suggested by his impaired mental function with ketonuria and mildly elevated plasma glucose levels. Plasma glucose levels can be low, high, or normal. High plasma glucose levels are speculated to be due to impaired insulin secretion combined with increased insulin resistance. Biochemically, the patients with alcoholic ketoacidosis will have increased anion and osmolal gap. (Choice A) The patient is unlikely to have acute appendicitis, as he does not have tenderness in his right lower quadrant; however, appendicitis can be associated with starvation ketoacidosis. (Choice B) Similarly, the patient does not have cholecystitis because his pain is not localized to the right upper quadrant. (Choice D) Henoch-Schonlein purpura is mainly seen in the pediatric age group. It is characterized by abdominal pain, skin rashes and joint inflammation. Mental status change is not a feature of Henoch-Schonlein purpura.

(Choice E) The patient is unlikely to have diabetic ketoacidosis in the presence of mild hyperglycemia. Blood glucose levels are generally higher than 250 mg/dL in patients with diabetic ketoacidosis. Educational Objective: Alcoholic ketoacidosis is characterized by anion gap acidosis, increased osmolal gap, ketonemia or ketonuria and variable blood glucose levels. Blood glucose levels are generally higher than 250 mg/dL in patients with diabetic ketoacidosis. 80% of people answered this question correctly; This subscription is licensed to user ID: 123489 only Item 2 of 2 What is the best next step in the management of this patient? B. C. D. E. A. Intravenous fluids and thiamine Intravenous fluids and insulin NPO, abdominal ultrasound, surgical consult Intravenous thiamine and glucose and send him home Intravenous hydrocortisone

This subscription is licensed to user: roopika only User ID: 123489 Explanation: Most patients with alcoholic ketoacidosis respond to an administration of dextrose normal saline. Insulin is generally not required. Dextrose leads to an increase in insulin secretion, which leads to the metabolism of ketone bodies to bicarbonate. Almost all alcoholics are likely to be thiamine-deficient unless proven otherwise. (Choice B) There is no need to give insulin in patients with alcoholic ketoacidosis. (Choice C) This patient does not have a surgical abdomen; therefore, NPO, ultrasound, and surgical consultation are not required. (Choice D) Discharging the patient after the initial treatment is not an appropriate choice. These patients are likely to develop alcohol withdrawal, electrolyte imbalance and aspiration pneumonia. Furthermore, the administration of glucose can increase the utilization of thiamine, thus aggravating thiamine deficiency and leading to Wernicke' s encephalopathy. (Choice E) IV hydrocortisone is not indicated in the management of alcoholic ketoacidosis. Educational Objective:

Most patients with alcoholic ketoacidosis will respond to an administration of intravenous dextrose containing normal saline and thiamine. Insulin is generally not required. All patients need to be hospitalized for treatment. 78% of people answered this question correctly; This subscription is licensed to user ID: 123489 only A 48-year-old Caucasian man is brought to the emergency room because of persistent drowsiness for the past two days. He has cirrhosis of the liver secondary to chronic hepatitis C. He has smoked one pack of cigarettes daily for 20 years, and uses marijuana intermittently. His medications include lactulose, spironolactone and furosemide. His vital signs are stable. Examination shows a drowsy but easily arousable patient, with multiple spider nevi and cherry angioma. There is shifting dullness and caput medusae in the abdomen. Asterixis is present. There are no focal neurologic deficits. Laboratory tests show the following: Serum chemistrySerum Na 146 mEq/L Serum K 2.9 mEq/L Chloride 110 mEq/L Bicarbonate 28 mEq/L BUN 19 mg/dL Serum creatinine 0.8 mg/dL Calcium 9.0 mg/dL Blood Glucose 74 mg/dL LFTTotal bilirubin 2.6 mg/dL Direct bilirubin 1.8 mg/dL Alkaline phosphatase 420 U/L Aspartate aminotransferase 84 U/L Alanine aminotransferase 78 U/L Which of the following is the most appropriate immediate step in the management of this patient? B. C. D. E. A. Start high dose oral lactulose Perform a paracentesis Give intravenous potassium Give intravenous antibiotics Place a nasogastric tube (NG tube)

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This patient has developed hepatic encephalopathy (HE) secondary to hypokalemia. Management of HE includes the rapid identification and reversal of the precipitating cause. The common causes of HE include: Gastrointestinal bleeding Hypokalemia Hypovolemia Hypoxia Sedatives or tranquilizers Hypoglycemia Metabolic alkalosis Infection (including spontaneous bacterial peritonitis) Intravenous potassium must be given immediately when hypokalemia is found in certain situations, such as: hepatic encephalopathy, ventilatory failure, and cardiac arrhythmias. In these cases, fast potassium replacement is critical to the patient's recovery and prognosis. (Choice A) Lactulose is part of the therapy of HE. It can be started simultaneously/after potassium replacement is initiated. Administration of lactulose is not as important as potassium replacement. (Choice B) There is no clinical suspicion of spontaneous bacterial peritonitis (SBP) to justify a paracentesis. If this procedure was indicated, it would be in an elective manner. (Choice D) There is insufficient information to determine if the HE was caused by an infection. Other causes of HE such as hypnotic drug overdose, gastrointestinal bleeding, and high-protein intake should be considered. Intravenous antibiotics should not be given to the patient at this point. (Choice E) NG insertion may be performed at a later time, depending on the patient's response. If the patient's mental status continues to deteriorate despite potassium replacement, or if the patient is not able to tolerate oral lactulose, an NG tube will be indicated. Educational Objective: Immediate potassium replacement must be done when HE is associated with moderate or severe hypokalemia. Hypokalemia itself can precipitate HE; this situation is usually associated with loop-diuretics (e.g. furosemide) use. Other situations in which potassium must be replaced immediately are: ventilatory failure and cardiac arrhythmias (hypokalemia- related electrocardiographic abnormalities). 60% of people answered this question correctly; This subscription is licensed to user ID: 123489 only A 22-year-old Caucasian female is hospitalized after a car accident. She sustained a hip fracture, fracture of several ribs, and a blunt abdominal injury that required a laparotomy. The laparotomy revealed a liver laceration and extensive hemoperitoneum. In the early

postoperative period, the patient is noted to have hyperactive deep tendon reflexes. Which of the following electrolyte abnormalities may be responsible for this condition? B. C. D. E. A. Hypokalemia Hyperkalemia Hyponatremia Hypocalcemia Hypermagnesemia

This subscription is licensed to user: roopika only User ID: 123489 Explanation: Hypocalcemia is the most probable diagnosis in this patient. Hypocalcemia can occur during or immediately after surgery, especially in patients undergoing major surgery and requiring extensive transfusions. Usually, hypocalcemia occurs due to volume expansion and hypoalbuminemia, and is therefore asymptomatic; however, sometimes it may manifest as hyperactive deep tendon reflexes, muscle cramps and, rarely, convulsions. Hypomagnesemia may mimic hypocalcemia, but is associated with alcoholism, prolonged nasogastric suction or diarrhea, and diuretic use. (Choice E) Mild hypermagnesemia results in decreased deep tendon reflexes. A severe form causes loss of the deep tendon reflexes and muscle paralysis, thereby leading to flaccid quadriplegia, decreased respiration, and eventual apnea. (Choice B) Hyperkalemia typically results in gastrointestinal disturbances (nausea, vomiting), ECG changes, and asystole, if severe. It may be associated with severe burns, crush injuries, and renal insufficiency. (Choices A and C) Hypokalemia and hyponatremia are unlikely to manifest as hyperactive deep tendon reflexes. Educational Objective: Hypocalcemia can occur during or immediately after surgery, especially in patients undergoing major surgery and requiring extensive transfusions. Hyperactive deep tendon reflexes may be the initial manifestation. Hypermagnesemia, on the other hand, results in loss of the deep tendon reflexes. 48% of people answered this question correctly; This subscription is licensed to user ID: 123489 only A 68-year-old Caucasian man is brought to the emergency department by her daughter because of altered mental status. The daughter reports that he lives alone and has a history of diabetes mellitus type 2 and hypertension. He takes aspirin, enalapril and glipizide. His blood pressure is 100/60 mm Hg, pulse is 100/min and respirations are 20/min. He is not febrile. Physical examination reveals dry mucus membranes, no jugular venous distension, clear lung fields and normal first and second heart sounds. The

abdomen is soft, non-tender, and non-distended. Neurologic examination reveals a drowsy patient who is disoriented to time and space. He is barely communicative. There are no meningeal or focal signs. His laboratory tests reveal: CBCHt 44% MCV 90fl Platelet count 300,000/cmm Leukocyte count 10,000/cmm Segmented neutrophils 70% Lymphocytes 22% Monocytes 8% Serum chemistrySerum Na 150 mEq/L Serum K 4.6 mEq/L Chloride 120 mEq/L Bicarbonate 20 mEq/L BUN 36 mg/dL Serum creatinine 1.5 mg/dL Calcium 9.7 mg/dL Blood glucose 800 mg/dL Serum ketones Negative The electrocardiogram reveals sinus tachycardia. He is started on insulin therapy. Which of the following is the most appropriate fluid solution to provide adequate hydration to this patient? B. C. D. E. A. 0.9% sodium chloride solution (normal saline) 0.45% sodium chloride solution (half normal saline) Hypertonic solution Ringer's lactate Free water

This subscription is licensed to user: roopika only User ID: 123489 Explanation: Hyperosmolar, hyperglycemic state (HHS) is a complication usually experienced by poorly controlled type 2 diabetics. It is characterized by altered mental status, glycemic levels over 800 mg/dL, bicarbonate levels higher than 15 mEq/L, effective osmolality higher than 320 mOsm/kg, and the presence of minimal amount of serum ketones. Hydration and insulin therapy aim to correct the electrolyte imbalances and hyperglycemia. Hyperglycemia can cause either hyponatremia or hypernatremia in uncontrolled diabetes mellitus. Hyperglycemia increases serum osmolality, which results in osmotic water movement out of the cells; therefore dilutional hyponatremia

(pseudohyponatremia) is usually seen. On the other hand, glucosuria-induced osmotic diuresis results in water loss in excess of sodium and potassium; this may raise the plasma sodium concentration and plasma osmolality, unless there is a compensatory increase in water intake. In order to adequately correct the hypo/hypernatremia in HHS, the corrected value of serum sodium must be calculated. This is done by adding 1.6 mEq/L for every 100 mg/dL of glucose over the baseline (100 mg/dL) to the total sodium value. The patient's sodium level is 150 mEq/L, while his glucose level is 800 mg/dL. Using the abovementioned concepts, the calculation for the patient's corrected serum sodium value is as follows: (1.6 x 7) + 150 = 161.2 mEq/L The corrected sodium level indicates severe hypernatremia, which should be treated with hydration therapy using half-normal saline solution. (Choices A and C) Hyponatremia is treated with normal saline solution or hypertonic solution (for severe cases). (Choice D) Ringers lactate has a similar osmolality and sodium content as normal saline solution. (Choice E) Free (oral) water may be used in the treatment of mild hypernatremia. This patient's severe hypernatremia warrants urgent treatment with intravenous half-normal saline solution. In addition, although intravenous D5W (free water with dextrose) can be used in patients who need correction of severe hypernatremia, it cannot be used in hyperglycemic patients (such as in this case). Educational Objective: The treatment of hyperosmolar hyperglycemic state involves hydration and insulin therapy. To adequately hydrate the patient, the corrected level of serum sodium must be calculated. Only those patients with hyponatremia or hypovolemic shock should receive normal saline. Those with normal sodium levels or hypernatremia must be hydrated with half-saline solution. Most studies show that the usual water deficit is approximately 9 liters. 37% of people answered this question correctly; This subscription is licensed to user ID: 123489 only A 72-year-old, male, nursing home patient is admitted to the hospital with a three-day history of nausea, vomiting, diarrhea, and confusion. The nurses at the nursing home tell you that he has been drinking a lot of water for the past three days. He has a history of tobacco abuse, diabetes mellitus, hypertension, coronary artery disease, multiple myeloma, and schizophrenia. His medications include aspirin, insulin, metoprolol, and chlorpromazine. His laboratory findings in the hospital reveal a serum sodium level of

120 mEq/L, urine sodium concentration of 80 mEq/L, serum osmolality of 258 milliosmoles/kg, and urine osmolality of 400 milliosmoles/kg. A chest x-ray showed a 3 cm mass around the right hilar region. Which of the following is most likely cause of the patient's laboratory findings? B. C. D. E. A. Syndrome of inappropriate ADH secretion Chlorpromazine toxicity Hyperproteinemia secondary to multiple myeloma Volume depletion from excessive vomiting and diarrhea Excessive water ingestion

This subscription is licensed to user: roopika only User ID: 123489 Explanation: Hyponatremia is characterized by an excess of water in relation to the total body sodium concentration. It is caused by excessive free water intake (primary polydipsia), endocrine disorders (i.e., adrenal insufficiency and hypothyroidism), or impaired water excretion from advanced renal failure and excessive antidiuretic hormone (ADH) release. Excessive ADH secretion can be due to decreased effective circulating volume (true volume depletion secondary to vomiting and diarrhea, congestive heart failure, cirrhosis or overuse of diuretics) and syndrome of inappropriate ADH secretion (SIADH). SIADH can be seen in a variety of CNS disorders, pulmonary diseases, HIV infection, tumors (i.e., small cell carcinoma of the lung), use of drugs such as carbamazepine, cyclophosphamide and selective serotonin re-uptake inhibitors, and in postoperative patients. Patients with hyponatremia secondary to SIADH usually have a decreased plasma or serum osmolality, elevated urinary osmolality (due to excessive fluid retention), urinary sodium concentration of more than 40 mEq/L and normal renal, adrenal and thyroid functions. The patient in the above vignette appears to have SIADH secretion secondary to lung cancer, most likely small cell carcinoma of the lung. (Choice B) The drugs that can cause excessive ADH release include selective serotonin re-uptake inhibitors (fluoxetine and sertraline), chlorpropamide, carbamazepine, and cyclophosphamide. Chlorpromazine is an anti-psychotic agent and is not associated with SIADH. (Choice C) Pseudohyponatremia secondary to hyperlipidemia or hyperproteinemia from any cause is usually associated with a normal or elevated plasma osmolality. (Choice D) True volume depletion due to gastrointestinal (vomiting, diarrhea) or renal causes can cause hyponatremia with a low plasma osmolality and elevated urine osmolality; however, the urinary sodium concentration is typically less than 20 mEq/L in these patients. (The urinary sodium concentration is usually more than 40 mEq/L in patients with SIADH.)

(Choice E) Patients with hyponatremia secondary to primary polydipsia or excessive water ingestion excrete a very dilute urine and have a urine osmolality of less than 100 milliosmoles/kg. Educational Objective: The patients with hyponatremia secondary to SIADH typically have a low plasma osmolality, elevated urine osmolality, and a high urinary sodium concentration. 87% of people answered this question correctly; This subscription is licensed to user ID: 123489 only A 55-year-old male was involved in a motor vehicle accident. He was hypotensive at the scene and had to be resuscitated. He suffered multiple injuries to his lower extremities and required numerous surgeries and prolonged mechanical ventilation. He was started on a high concentration of enteral glucose feeds on a 24-hour protocol. After four weeks, he is still dependent on the mechanical ventilator. His chest x-ray remains clear. He has profound respiratory muscle weakness, and the MRI shows significant thinning of the diaphragm. The most likely cause of his muscle weakness is related to which of the following? B. C. D. E. A. Hypocalcemia Hypophosphatemia Zinc deficiency Hypernatremia Guillain Barre syndrome

This subscription is licensed to user: roopika only User ID: 123489 Explanation: Hypophosphatemia is not very recognized in hospitalized patients. Continuous glucose infusions are the leading cause of hypophosphatemia in hospitalized patients. The patients are usually alcoholic or otherwise debilitated, and the nadir in serum phosphate appears in the first few days after admission. Hypophosphatemia can impair ATP generation (which is needed by the skeletal muscles to perform work), and muscle weakness can result. Respiratory muscle weakness has been reported; this is severe enough to prevent weaning from mechanical ventilation. In addition, phosphate deficiency reduces cardiac contractility, and chronic phosphate deficiency has been implicated as a cause of cardiomyopathy. Phosphate depletion is also associated with depletion of 2, 3 diphosphoglycerate, and this causes a leftward shift of the oxyhemoglobin dissociation curve. As a result, the oxygen bound to hemoglobin is less readily released to the tissues. (Choice A) Hypocalcemia may be found in as many as two-thirds of patients in the ICU on admission. The clinical manifestations are those suggestive of neuromuscular excitability, such as hyperreflexia, tetany, and seizures. Cardiac effects include peripheral

vasodilatation, hypotension, and a prolonged QT interval. The most common causes are sepsis and hypomagnesemia. Hypoparathyroidism is a leading cause of hypocalcemia in an outpatient who has had neck surgery. The treatment is calcium replacement. (Choice C) Zinc deficiency is common in the ICU because of the prevalence of predisposing factors, such as diarrhea, diuresis, malnutrition, chronic renal failure, burns, and prolonged illness. Zinc is involved in DNA synthesis and lymphocyte transformations. A deficiency leads to susceptibility to infections and a skin rash. Diagnosis requires a decrease in plasma zinc levels. Effective replacement on a daily basis prevents the complications. (Choice D) Severe hyponatremia is a serious condition; however, rapid correction can also produce a serious illness called central pontine myelinolysis, which is a demyelinating brainstem lesion that causes permanent neurological deficits and can be fatal. Current evidence suggests that this lesion is produced by rapid correction of hyponatremia to normal or supra normal levels. Hyponatremia does not lead to loss of muscle strength. (Choice E) Guillain Barre Syndrome is an idiopathic polyneuritis of unknown etiology. The peripheral neuropathy advances over a few days and initially involves the distal extremities. The ascending paralysis may be associated with paresthesias. Educational Objective: Hypophosphatemia is a major cause of respiratory muscle weakness and can lead to the failure of being able to wean a patient off the respirator. 51% of people answered this question correctly; This subscription is licensed to user ID: 123489 only