Group A2-a

Alegre.Almora.Alonzo.Amaro.

Name: H.N. Age: 51 Gender: Female Citizenship: Filipino

Chief Complaint: Persistent vomiting

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2 days PTAHeadache, body malaise, nausea and vomiting-vomited 3x per day, 50ml per episode (approximately of 150ml/day)

ADMISSION

1 week PTA Fever, Dysuria, Urgency-Self-medicated w/ Paracetamol and antibiotics (unknown) that relieved the fever; no consult was done

• Hypertension (1999) maintained on telmisartan + hydrochlorothiazide 40 mg / 12.5 mg OD for 1 month; • Previously prescribed with Amlodipine

but developed bipedal edema. Poorly controlled.

– Usual BP 130/80.

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Non smokerNon alcoholic beverage drinker

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Patient is weak looking and wheelchair borne

Poor skin turgor, dry mouth and tongue, dry axilla

JVP<5cm H2O at 45 degrees

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BP: 120/180 (supine); 90/60 (sitting)HR: 90 bpm, reg (supine); 105 bpm, reg (sitting) Weight: 50 kg (usual wt. = 53kg)

Note: (not given)Respiratory Rate, Height, Temperature

SUBJECTIVE

51 y/o F History of vomiting

(150ml/day) History of fever,

dysuria and urgency Medications used

(HCTZ and telmisartan)

History of nausea, body malaise, headache

OBJECTIVE

Weak looking and wheelchair borne

Orthostatic hypotension

Possible weight loss Poor skin turgor, dry

mouth and tongue, dry axilla

Hypovolemia secondary to dehydration to consider

electrolyte imbalance

Complete Blood Count

Hemoglobin 132 mg/dl (120-170 mg/dl)

Normal

Hematocrit 0.35 (0.37-0.54) Low

WBC 12.5 (4.5-10) High

Neutrophils 0.88 (0.5-0.7) High

Lymphocytes 0.12 (0.2-0.4) LowBlood Chemistry

BUN 22 mg/dl (8-23 mg/dL)

Normal

Serum Creatinine 0.9 mg/dl (0.2-0.7 mg/dl)

High

Plasma Sodium 123 meq/L (135-145 meq/L)

Low

Plasma Potassium 3.7 meq/L (3.5-3.0 meq/L)

Normal

Chloride 71 meq/L (95-103 meq/L)

Low

Glucose 98 mg/dl (70-110 mg/dl)

Normal

Urinalysis

Color Yellow, slightly turbid Normal

pH 6.0 Normal

Specific gravity 1.020 Normal

Urinary Sodium 100 meq/L (<20 meq/L)

Albumin and sugar (-) Normal

Pus cells 10-15/hpf High

Hyaline casts 5/hpf High

RBC 2-5/hpf NormalArterial Blood Gas

pH 7.3 (7.35-7.45) Low

pCO2 35 mm Hg (35-45 mm Hg)

Normal

HCO3 18 (22-26 meq/L) Low

Anion Gap 34 (<12) High

History Physical examination

- assess ECF volume status and effective circulating arterial volume

Laboratory- plasma osmolality, urine osmolality- urine Na and K concentrations

Plasma osmolality

high normal low

Hyperglycemia

mannitol

Hyperproteinemia

Hyperlipidemia

Bladder irrigation

Max volume of max dilute urine

(<100 mosmols/kg)

ECF volume Primary polydypsia

Reset ormostat

YesNo

normalincreased decreased

ECF volume

Heart failureHepatic cirrhosis

Nephrotic syndromeRenal insufficiency

SIADHExclude hypothyroidism

Exclude adrenal insufficiency

Urine [Na]

< 10 mmol/L >20 mmol/L

Extrarenal Na lossRemote diuretic use

Remote vomiting

Na-wasting nephropathyHypoaldosteronism

Diureticvomiting

Hypovolemic hyponatremia w/ uncompensated hypochloremic metabolic acidosis secondary to dehydration (ECF volume contraction)

Primary Sodium Loss (secondary water gain) Integumentary loss:

▪ Increased insensible loss during febrile illness Gastrointestinal loss:

▪ Vomiting Renal loss:

▪ Diuretics▪ Osmotic diuresis

Gastrointestinal Loss Vomiting (high H+ ion loss) Decreased intake of fluids (w/ nausea) or

replaced by inappropriately hypotonic fluids, such as tap water, half-normal saline, or dextrose in water

Skin/Respiratory Insensible losses (normally 500 ml/d)

increases during febrile illness leading

Diuretics inhibit specific pathways of Na+ reabsorption

along the nephron with a consequent increase in urinary Na+ excretion

Osmotic Diuresis Enhanced filtration of non-reabsorbed

solutes, such as glucose or urea, can also impair tubular reabsorption of Na+ and water

ACE inhibitors Inhibit the RAAS system decreased

sodium retention Inhibit release of ADH decreased H2O

retention

Thiazides “diuretic-induced hyponatremia” Leads to Na and K depletion and AVP-

mediated H2O retention

= 2[Na+ ] + [Glucose]/18 + [ BUN ]/2.8

= 2[123 mEq/L] + [98 mg/dL]/18 + [ 22 mg/dL ]/2.8

=246 + 5.44 + 7.86 = 259.3 mOsm/KgNV = 275-295 mOsm/Kg

= 2 [Na] + [Glucose]/18 = 2 [123] + [98]/18= 246 + 5.44= 251.44 mOsm/KgNV = 270-285 mOsm/Kg

Osmolality of blood increases with dehydration

decreases with overhydration. increased osmolality in the blood will

stimulate secretion of antidiuretic hormone (ADH). This will result in increased water reabsorption, more concentrated urine, and less concentrated blood plasma.

A low serum osmolality will suppress the release of ADH, resulting in decreased water reabsorption and more concentrated plasma.

changes in ECF osmolality have a great affect on ICF osmolality - changes that can cause problems with normal cell functioning and volume.

Urine osmolality is a measure of urine concentrationin

large values indicate concentrated urine and small values indicate diluted urine.

important test for the concentrating ability of the kidney.

For determining the differential diagnosis of hyper- or hyponatraemia.

For identifying SIADH (urine osmolality > 200 mmol/kg, urine sodium > 20 mmol/L, low serum sodium, patient not dehydrated and no renal, adrenal, thyroid, cardiac or liver disease or interfering drugs)

For identifying and diagnosing diabetes insipidus (low urine osmolality not responding to water restriction).

For differentiating pre-renal from renal kidney failure (high urine osmolality is consistent with pre-renal impairment, in renal damage the urine osmolality is similar to plasma osmolality).

The sodium urine test measures the amount of salt (sodium) in a urine sample.

Normal values are generally 15 to 250 milliequivalents per liter per day (mEq/L/day), depending on how much fluid and salt you consume.

Greater than normal urine sodium levels may be caused by too much salt in the diet.

Lower than normal urine sodium levels may indicate:

AldosteronismCongestive heart failure Diarrhea and fluid loss Kidney failure

Total Body Water (TBW) Men

▪ TBW = 0.6 x weight Women

▪ TBW = 0.5 x weightTotal Body Sodium Deficit

Sodium deficit = TBW x (140 - Serum Sodium)

• Total Body Water (TBW) – Women

• TBW = 0.5 x weight = 0.5 X 50 kg = 25

• Total Body Sodium Deficit– Sodium deficit = TBW x (140 - Serum

Sodium) = 25 X (140meq/L-

123meq/L) = 425

• Total Body Water (TBW) – Women

• TBW = 0.5 x weight = 0.5 X 53 kg = 26.5

• Total Body Sodium Deficit– Sodium deficit = TBW x (140 - Serum

Sodium) = 26.5 X (140meq/L-

123meq/L) = 450.5

Two goals: Raise plasma Na concentration by

restricting water intake and promoting water loss

Correct underlying disease

Asymptomatic hyponatremia w/ECF vol contraction Na+ repletion w/ isotonic saline solution.

Hyponatremia & edema Restriction of Na+ & water intake Correction of hypokalemia Promotion of water loss in excess of Na+

Osmotic demyelination syndrome (central pontine myelinolysis ) Flaccid paralysis, dysarthria,

dysphagia, and alterations of consciousness

Asymptomatic patients: Isotonic saline Raised no more that 0.5 to 1.0 mmol/L per hour

and by less than 10 to 12 mmol/L over 1st 24 hr

Acute/severe patients: Hypertonic saline Raised by 1 to 2 mmol/L per hr for the 1st 3 to 4

hr or until seizure subsides