GENERAL DATA Name: F.H.S. Age: 73 Sex: F Address: Tondo, Manila Occupation: None Religion: Roman Catholic CC: generalized body weakness
Jan 03, 2016
GENERAL DATA
Name: F.H.S.Age: 73Sex: FAddress: Tondo, ManilaOccupation: NoneReligion: Roman CatholicCC: generalized body weakness
HISTORY OF PRESENT ILLNESS
3 days PTA:-generalized weakness (difficulty getting up from bed, feeling of falling when ambulating-headache, nausea & vomiting (3episodes)-loss of appetite-hospital: BP 190/100, meds: Clonidine 75mg/tab sublingual
REVIEW OF SYSTEMS• Review of Systems• No weight loss• Wears glasses• (+) decreased hearing acuity, No ear pain, discharge or tinnitus• No sore throat, oral sores• No neck masses, no limitation of motion• No difficulty of breathing• (+) nocturia, frequency, (-) dysuria, (-) oliguria• (+) polyuria, polydipsia • No tremors, no heat or cold intolerance• No seizures, syncope• No joint pains, no joint stiffness, no swelling• No easy bruisability
PAST MEDICAL HISTORY
• (+) Hypertension (1987) medication: Losartan+hydroclorothiazide 100mg/12.5mg tab OD and Amlodipine 10mg/tab OD
• (+) 2007 – hospitalized for multiple electrolyte imbalance secondary to GI losses secondary to AGE
• (-) DM, CVA, Asthma, Allergy, CA, PTB
FAMILY HISTORY
• (+) Hypertension – father, siblings• (+) renal disease – sibling• (-) Diabetes Mellitus• (-) PTB • (-) Cancer
PERSONAL AND SOCIAL HISTORY
• Non Smoker• Non Alcoholic beverage drinker • No illicit drug use• Diet: prefers salty foods
PHYSICAL EXAMINATION• Conscious, coherent, asthenic, well-kempt, ambulatory with assistance, not in
cardiopulmonary distress• VS: BP: 120/70 PR 69 bpm, RR 24 cpm, T 36.3 °C • Wt 56kg Ht 152.4 BMI 23.93 • Warm moist skin with no active dermatoses• Pink palpebral conjunctiva, anicteric sclera, pupils 2-3 mm ERTL, (+) arcus senilis OU• No tragal tenderness, no nasoaural discharge, nasal septum midline• Moist buccal mucosa, non-hyperemic posterior pharyngeal wall, tonsils not enlarged• Supple neck, no palpable cervical lymph nodes, thyroid gland not enlarged• Symmetrical chest expansion, no lagging, no retractions, resonant on percussion, clear
breath sounds on both lung fields• Adynamic precordium, no heaves, lifts and thrills, AB at 6th LICS AAL, S1 > S2 at apex, S2 > S1
at base, no murmurs• Abdomen flabby, NABS, no bruits, no masses, no guarding, nontender, tympanitic on
percussion, liver not enlarged, (-) CVA tenderness• Pulses full and equal, no edema, no cyanosis
Neurological Exam• Conscious, coherent, can follow commands. GCS 15 E4V5M6• Cranial nerves: • CN I (-) anosmia• CN II intact papillary light reflex, and (+) ROR• CN III, IV, VI- EOMs full and equal• CN V- V1-V3 intact• CN VII- can raise eyebrows, can frown, can smile, can puff cheeks• CN VIII- decreased hearing acuity AU• CN IX, X- uvula midline on phonation• CN XI- can raise shoulders against resistance• CN XII- tongue midline uvula is in the midline on protrusion• MMT 5/5 on all extremities• No sensory deficits• Cerebellar function intact• (-) Babinski, (-) Nuchal rigidity, (-) Kernigs, (-) Brudzinski
ASSESSMENT
• Electrolyte imbalance secondary to 1.) GI loss 2. diuretic use 3. herbal use
• Hypertension St. II• Urinary tract Infection
PLAN• Plan:• Diagnostic• CBC c platelet,• CBG• Na, K• Plasma Osmolality• Urine Osmolality• Na Urine• K Urine• Urinalysis
CBC c Platelet Reference Range 7/21Hgb 120-170 124RBC 4.0-6.0 4.36Hct 0.37-0.54 0.37
MCV 87±5 84.10MCH 29±2 28.40
MCHC 34±2 33.70RDW 11.6-14.6 14.10MPV 7.4-10.4 5.60
Platelet 150-450 295WBC 4.5-10.0 11.00
Neutrophils 0.65
Metamyelocytes -
Bands -
Segmented 0.65
Lymphocytes 0.34
Monocytes -
Eosinophils 0.01
Basophils -
Chemistry Reference Range
7/20 7/21 7/22
BUN 9-23 8.39Creatinine 0.5-1.2 0.72
Sodium 137-147 119.84 124.00/131.79 135.00
Potassium 3.8-5 3.73 3.48/3.48 3.93
Plasma Osmolality
280-295 275.00
Urine Sodium 40-220 13.00
Urine Potassium
25-125 4.30
Urine Osmolality
500-800 92.00
FBS 70.9-110 111.41
Urinalysis 7/21Color light yellow, Transparency turbid, pH 7.0, Specific gravity 1.005, Albumin (-), Sugar (-), RBC 20-30/hpf, Pus over 100/hpf, Squamous cells few, Bacteria ++++, Mucus threads few
Chest X-ray (Official) 7/21The heart is enlargedAorta is calcifiedThe pulmonary vascularity is normalThe diaphragm and sinuses are intactThe visualized osseous structures are unremarkableIMPRESSION: Cardiomegaly, Atheromatous aorta
Urine Gram stain 7/21No microorganisms seen on both centrifuged and uncentrifuged sample
Urine Culture 7/23/10No growth after 2 days of incubation
Potassium
• major intracellular cation• plasma K+ concentration is 3.5–5.0 mmol/L• intacellular: 150 mmol/L• extracellular: 30–70 mmol – constitutes <2% of the total body K+ content (2500–
4500 mmol).• ratio of ICF to ECF K+ concentration – (normally 38:1) : due to resting membrane potential
• crucial for normal neuromuscular function
Potassium balance
– basolateral Na+, K+-ATPase pump actively transports K+ in and Na+ out of the cell in a 2:3 ratio
– passive outward diffusion of K+ • quantitatively the most important factor that generates
the resting membrane potential– Na+, K+-ATPase pump• Stimulated by increased intracellular Na+
concentration• Inhibited by:
– digoxin toxicity or chronic illness such as heart failure or renal failure
Potassium balance
• Maintenance of the steady state necessitates matching K+ ingestion with excretion
• extrarenal adaptive mechanisms, followed by urinary excretion– Prevents doubling of the plasma K+ concentration that
would occur if the dietary K+ load remained in the ECF compartment
• following a meal, most of the absorbed K+ enters cells– initial elevation in the plasma K+ concentration – facilitated by insulin release and basal catecholamine
levels
Potassium balance
• excess K+ is excreted in the urine • amount of K+ lost in the stool can increase
from 10 to 50% or 60% (of dietary intake) in chronic renal insufficiency
• colonic secretion of K+ is stimulated in patients with large volumes of diarrhea– severe K+ depletion
Potassium Excretion
• Renal excretion– major route of elimination of dietary and other
sources of excess K+
– filtered load of K+ (GFR x plasma K+ concentration = 180 L/d x 4 mmol/L = 720 mmol/d) is ten- to twentyfold greater than the ECF K+ content
Potassium Excretion
– 90% of filtered K+ is reabsorbed by the proximal convoluted tubule and loop of Henle
– Proximally, K+ is reabsorbed passively with Na+ and water
– luminal Na+-K+-2Cl– co-transporter mediates K+ uptake in the thick ascending limb of the loop of Henle
Potassium Excretion• K+ delivery to the distal nephron [distal
convoluted tubule and cortical collecting duct (CCD)]– approximates dietary intake
• Net distal K+ secretion or reabsorption occurs in the setting of K+ excess or depletion, respectively.
• principal cell – responsible for K+ secretion in the late distal
convoluted tubule (or connecting tubule) and CCD• Virtually all regulation of renal K+ excretion and
total body K+ balance occurs in the distal nephron
Potassium Excretion
• secretion is regulated by two physiologic stimuli– aldosterone and hyperkalemia
• Aldosterone– secreted by the zona glomerulosa cells of the
adrenal cortex in response to high renin and angiotensin II or hyperkalemia
– plasma K+ concentration, independent of aldosterone, can directly affect K+ secretion
Potassium Excretion
Aldosterone– K+ concentration in the lumen of the CCD, renal K+
loss depends on the urine flow rate, a function of daily solute excretion
– increased distal flow rate can significantly enhance urinary K+ output
– severe K+ depletion• secretion is reduced and reabsorption in the cortical
and medullary collecting ducts is upregulated.
Estimation of Potassium Deficit
• For a fall in serum potassium from 4.0 to 3.0 meq/L, body potassium deficit is 200-300 meq/70 kg BW
• For a serum potassium at 2.5 meq/L, body deficit is 500 meq/70 kg BW
• For a serum potassium at 2.0 meq/L, body deficit is 700 meq/70 kg BW
In the patient....Reference
value7/20 7/21 7/22 Potassium
Deficit
Serum Potassium
3.8-5 3.73 LOW 3.48/3.48 LOW
3.93 200-300 meq/70 kg
BW
Urine Potassium
25-125 4.30 LOW
Plasma Osmolality
280-295 275.00 LOW
Urine Osmolality
500-800 92.00 LOW
Hypokalemia• Symptoms seldom occur unless the plasma K+
concentration is <3 mmol/L. • Fatigue, myalgia, and muscular weakness of
the lower extremitieslower (more negative) resting membrane potential.
• More severe hypokalemia :– progressive weakness,– hypoventilation (due to respiratory muscle
involvement),– complete paralysis.
• Increase risk of rhabdomyolysis
Electrographic changes of hypokalemia
• Early changes:– flattening or inversion of the
T wave, – a prominent U wave– ST-segment depression,– a prolonged QU interval.
• Severe K+ depletion:– prolonged PR interval– decreased voltage and
widening of the QRS complex, – increased risk of ventricular
arrhythmias, especially in patients with myocardial ischemia or left ventricular hypertrophy.
CAUSES OF HYPOKALEMIAI. Decreased Intake
A) starvationB) clay ingestion
II. Redistribution into the cellsA) Acid-Base
1) Metabolic AlkalosisB) Hormonal
1) Insulin2) B2-Adrenergic agonists3) Alpha-Adrenergic antagonists
C)Anabolic state1) Vitamin B12 or folic acid 2) Granulocyte-macrophage colony stimulating factor 3) Total parenteral nutrition
D) Others1)Pseudohypokalemia2)Hypothermia3)Hypokalemic periodic paralysis4)Barium toxicity
CAUSES OF HYPOKALEMIA
III. Increased lossA) Nonrenal
1. Gastrointestinal loss (diarrhea)2. Integumentary loss (sweat)
B) Renal 1. Increased distal flow: diuretics, osmotic diuresis, salt-wasting nephropathies2. Increased secretion of potassium
2) Increased secretion of potassium
A. Mineralocorticoid excess: primary hyperaldosteronism, secondary hyperaldosteronism (malignant hypertension, renin-secreting tumors, renal artery stenosis, hypovolemia), apparent mineralocorticoid excess (licorice, chewing tobacco, carbenoxolone), congenital adrenal hyperplasia, Cushing's syndrome, Bartter's syndrome
B. Distal delivery of non-reabsorbed anions: vomiting, nasogastric suction, proximal (type 2) renal tubular acidosis, diabetic ketoacidosis, glue-sniffing (toluene abuse), penicillin derivatives
C. Other: amphotericin B, Liddle's syndrome, hypomagnesemia
Causes of Hyponatremia
I. PseudohyponatremiaA. Normal plasma osmolality
1. Hyperlipidemia2. Hyperproteinemia3. Posttransurethral resection of prostate/bladder
B. Increased plasma osmolality1. Hyperglycemia2. Mannitol
Causes of Hyponatremia
II. Hypoosmolal hyponatremiaA. Primary Na loss (secondary water gain)
1. Integumentary loss: sweating, burns2. GI loss: vomiting, tube drainage, fistula, obstruction, diarrhea
B. Primary water gain (secondary Na loss)1. Primary polydipsia2. Decreased solute intake3. AVP release d/t pain, nausea, drugs4. SIADH5. Glucocorticoid deficiency6. Hypothyroidism7. Chronic renal insufficiency
Cause of Hyponatremia
C. Primary Na gain (exceeded by secondary water gain)
1. Heart failure2. Hepatic cirrhosis3. Nephrotic syndrome
Four laboratory findings often provide usefulinformation and can narrow the differential
diagnosis of hyponatremia:(1)the plasma osmolality(2) the urine osmolality(3) the urine Na+ concentration(4) the urine K+ concentration
• (-) urine osmolality and specific gravity of <100 mosmol/kg and 1.003- it suggests impaired free-water excretion due to the action of AVP on the kidney
• The secretion of AVP may be a physiologic response to hemodynamic stimuli or it may be inappropriate in the presence of hyponatremia and euvolemia
SIADH• hypoosmotic hyponatremia in the setting of an
inappropriately concentrated urine (urine osmolality >100 mosmol/kg).
• normovolemic and have normal Na+ balance. • urine Na+ excretion rate equal to intake (urine
Na+ concentration usually >40 mmol/L).• normal renal, adrenal, and thyroid function and
usually have normal K+ and acid-base balance.• associated with hypouricemia due to the
uricosuric state induced by volume expansion.
SIADH
• Most common causes: neuropsychiatric and pulmonary diseases, malignant tumors, major surgery (postoperative pain), and pharmacologic agents
• Adrenal insufficiency and hypothyroidism may present with hyponatremia and should not be confused with SIADH
ADRENAL INSUFFICIENCY
• Decreased mineralocorticoids contribute to the hyponatremia of adrenal insufficiency
• Cortisol deficiency hypersecretion of AVP both indirectly (secondary to volume depletion) and directly (cosecreted with corticotropin-releasing factor)
HYPOTHYROIDISM
• The mechanisms that lead to hyponatremia:– decreased cardiac output and GFR– increased AVP secretion in response to
hemodynamic stimuli
Goals of Therapy
• (1) to raise the plasma Na+ concentration by restricting water intake and promoting water loss
• (2) to correct the underlying disorder.
• Mild asymptomatic hyponatremia no treatment• Asymptomatic hyponatremia associated with ECF
volume contraction– Na+ repletion with isotonic saline– Restoration of euvolemia removes the hemodynamic
stimulus for AVP release, allowing the excess free water to be excreted
Goals of Therapy• Hyponatremia associated with edematous states – Reflect severity of the underlying disease, usually
asymptomatic– Restriction of Na+ and water intake
• hyponatremia associated with primary polydipsia, renal failure, and SIADH
– Correction of hypokalemia• Correction of the K+ deficit may raise the plasma Na+
concentration by favoring a shift of Na+ out of cells as K+ moves in
– Non-peptide vasopressin antagonists new selective treatment for euvolemic and hypervolemic hyponatremia
Rate of Correction of Hyponatremia
• Depends on the absence or presence of neurologic dysfunction
• Asymptomatic patients– no more than 0.5–1.0 mmol/L per h and by less
than 10–12 mmol/L over the first 24 h• Acute or severe hyponatremia (plasma Na+
concentration <110–115 mmol/L) – altered mental status and/or seizures– requires more rapid correction.
Rate of Correction of Hyponatremia
• Severe symptomatic hyponatremia – Hypertonic saline– 1–2 mmol/L per hour for the first 3–4 h or until the seizures
subside– no more than 12 mmol/L during the first 24 h– quantity of Na+ required to increase the plasma Na+
concentration by a given amount can be estimated by multiplying the deficit in plasma Na+ concentration by the total body water
– Amount of mmol of Na+ needed to raise the plasma Na concentration from actual to desired = [(135 – actual) x BW x 0.5].
• Asymptomatic patients:– Isotonic saline–Concentration should be raised by no more
than 0.5 to 1.0 mmol/L per hour and by less than 10 to 12 mmol/L over 1st 24 hr
• Acute/severe hyponatremia– Plasma Na concentration <110-115 mmol/L– Tends to present with altered mental status
and/or seizures– Requires more rapid correction
• severe symptomatic patients:–Hypertonic saline (3%)–Raised by 1 to 2 mmol/L per hr for the 1st 3-
4 hr or until seizure subsides–Raised by no more than 12mmol/L during
the first 24 hours
Different IV fluids and Na contentIV Fluids Na Content (mEq/L)
PNSS 154
LRS 130
0.9% NaCl 154
D5 0.45% NaCL 77
D5 3% NaCl 513
D5 5% NaCl 855
FLUIDS
• LRS and normal saline– Isotonic– useful in replacing gastrointestinal losses and
extracellular volume deficits
• Lactated Ringer's is slightly hypotonic– 130 mEq of sodium, which is balanced by 109 mEq
of chloride and 28 mEq of lactate
FLUIDS
• Sodium chloride– mildly hypertonic 154 mEq of Na+ balanced by
154 mEq of Cl-– an ideal solution for correcting volume deficits
associated with hyponatremia, hypochloremia, and metabolic alkalosis
FLUIDS• 0.45% sodium chloride– useful to replace ongoing gastrointestinal losses as
well as for maintenance fluid therapy in the postoperative period
– provides sufficient free water for insensible losses and enough sodium to aid the kidneys in adjustment of serum sodium levels
– 5% dextrose supplies 200 kcal/L, always added to solutions containing less than 0.45% sodium chloride to maintain osmolality prevent lysis of RBCs that may occur with rapid infusion of hypotonic fluids
Na Deficit = (Desired Na – Actual Na) x TBW x weight (kg)– Actual Na: 119.84– Weight: 56 kg
=
= 0.45 x 56kg x (130-119.84)= (25.2) (10.16)
Sodium deficit = 256.03 mEq/L
Total body weight (in Liters)
Children 0.6 x weightWomen 0.5 x weightMen 0.6 x weightElderly Women 0.45 x weightElderly Men 0.5 x weight
Adrogue, HJ; and Madias, NE. Primary Care: Hypernatremia. New England Journal of Medicine 2000; 342(20):1493-1499. 342(21):1581-1589. .
Different IV fluids and Na content
IV Fluids Na Content (mEq/L)
PNSS 154
LRS 130
0.9% NaCl 154
D5 0.45% NaCL 77
D5 3% NaCl 513
PNSS
__424.03 meq/L__ = 4.24 L 100 meq NaCl__4240mL = 176.7 cc/hr 24 hrs__176.7 cc/hr__ = 44.16 45gtts/min 4
Osmotic Demyelination Syndrome• Cause:– rapid correction of hyponatremia
• Characterized by:– flaccid paralysis– dysarthria– dysphagia
• At risk:– prior cerebral anoxic injury– hypokalemia– malnutrition, especially secondary to alcoholism
Osmotic Demyelination Syndrome
• Diagnosis:– suspected clinically– confirmed by appropriate neuroimaging studies
• Treatment:– no specific treatment– supportive only
• Prevention:– hyponatremia should be corrected at a rate not in
excess of 10mmol/L/24hr or 0.5 mEq/L/Hr– diligently avoid hypernatremia