62yo woman is seen in the clinic complaining of muscle cramps and weakness. She denies abdominal pain, N/V. Has a hx of CHF.
Meds: Lisinopril 40mg/day, lasix 20mg/day. Pt reports increase in lasix dose to 60mg/day for the past 5days d/t fluid overload.
PE: unremarkable, except for dry skin and low skin turgor.
Labs: Na 140, K 2.5, Cl 94, CO2 32, BUN 18, Scr 0.9, pH 7.49, PCO2 44
Name the disorder and compensatory mechanism?
54yo male s/p gastric bypass surgery is admitted to ICU. Pt did well post-operatively. Two days later he developed abdominal distension, fever, and septic shock. Pt is not able to tolerate PO.
Labs: pH 7.26, PCO2 42, PO2 98, HCO3 19, Na 136, K 4.6, Cl 97, BUN 22, Scr 3
Primary team resident writes an order for TPN per pharmacy to be started on this pt.
What factors will you consider before coming up w/ a TPN formula?
Why is fat not metabolized?
77yo female admitted in the ICU due to SOB, cough, and fever (T 102F). CXR reveals R LL PNA. Pt had to be intubated.
PMH: COPD, CAD.
PSH: smokes 3+ packs/day x50 years.
Chemistry: Na 138, K 3.7, Cl 96, CO2 33, BG 121, BUN 8, Scr 0.7
ABG: pH 7.37, pCO2 57, pO2 39.5, HCO3 31.9
What is the diagnosis? (include acute or chronic)
What is the compensation? (include acute or chronic)
BB is a 66yo, 70-kg man presenting to the ED w/ increasing shortness of breath (SOB), fatigue, and marked edema.
PMH: DM, HCV cirrhosis, CKD II, and CHF (EF 30%).
PE: jugular venous distension and rales.
Neuro: alert, following commands.
CXR: bilateral pleural effusions.
VS: T 100.4F, BP 100/60, HR 95.
Labs: Na 124, Scr 1.5, urine Na 7, plasma osmolality 265.
Q: What type of hyponatremia does BB exhibit and why?
O2 saturation began to drop → pt was intubated and started on mechanical ventilation;
Due to pt's sedation → pt's BP decreased → pt was started on dopamine;
Repeat Na = 122.
Q: What factors need to be taken into considerations for treating BB's hypo-Na?
Q: What is the best initial option for correcting BB's hyponatremia?
a. 0.9% NaCl infusion
b. Fluid restriction + furosemide
c. Hypertonic saline infusion + furosemide
Three days after initiating fluid restriction and diuretics, BB remains intubated with only minimal reduction in total body volume and frequent PVCs are noted on EKG.
Labs: Na 127, K 2, Scr 2, urine Na 9, plasma osmolality 270.
Q: Is there role for Conivaptan?
CD is a 76yo white female presenting to ED after hitting her head as a result of a fall. She complains of hip pain, nausea, and dizziness and relates that she has been "unsteady on her feet" over the past few days.
PMH: HTN, CAD, hyperlipidemia, DJD (hip and knees), depression after recent death of her spouse.
Home meds: lisinopril, HCTZ, ASA, simvastatin, citalopram, ibuprofen prn joint pain.
PE: laceration to right brow, right hip pain, normal skin turgor, slightly dry oral mucosa.
VS: T=98.2F, BP=150/80, HR=88.
Neuro: slightly confused, disoriented to time and place, no focal deficits.
MRI brain: moderate small vessel disease, no evidence of stenosis, mass, infarct, or subdural hematoma.
X-ray hip: evidence of hip fracture.
Labs: Na 117, K 3.9, Scr 2.1, BUN 15, glucose 102.
Q: What additional laboratory tests for CD would be helpful to obtain? Select all that apply.
a. Serum osmolality
b. Urine sodium and osmolality
c. TSH and cortisol
Based on additional lab results, CD was diagnosed with SIADH release.
Q: What category of hyponatremia is CD exhibiting?
Q: Which of CD's home medications is most likely to contribute to hyponatremia?
Q: What is the appropriate treatment for this patient?
a) K, BUN, Scr, WBC, PO4, Ca: b) Hgb, Hct, Alb: K, Ca, PO4: ensure has increase K: stage 5 CKD leads to decreased renal function: EKG changes, weakness, damage to cardiac cells: IV Ca reverses effects of K on cell membranes, insulin to redistribute K and Na, diuretics to eliminate K: dialysis: 11.16: Ca acetate for hyperphosphatemia increases Ca, Vit D/calcitrex increases Ca: hyperphos due to hyperparathyroidism bc vit D not activated and phos not reabsorbed, hyperCa due to increase in PTH and kidneys not responding: diet and HD: phosphonal or reno gel that binds phos without Ca: sensipar for secondary hyperparathyroidism bc it increases PTH receptors so PTH isn't released: HPI: BF is a 42yo man with type I DM, HTN, and stage 5 CKD (chronic kidney disease) comes to the clinic complaining of "not feeling too good". He receives HD (hemodialysis) TIW (three times a week). Two days earlier, he developed fever, chills, general malaise, and SOB. This morning, he developed N/V. He admits to missing his HD session 2 days ago.
1. IDDM since age 18.
2. HTN x12yrs.
3. CKD 5, on HD x5yrs (pt has no residual renal function).
4. L arm AV graft thrombus formation with thrombectomy last month; multiple episodes of AV graft thrombus formation.
5. AV graft infected with MRSA 2 months ago.
7. Secondary hyperparathyroidism.
FH: Father with CAD; no family history of DM, HTN, CA.
SH: retired from glass factory; on disability; past history of smoking (quit 3yrs ago); (-) EtOH for the past 7yrs.
Warfarin 2.5mg po qd
Ranitidine 150mg po qd
Calcium acetate 667mg, 2tabs po tid
Nephrocaps 1tab po qd
Sodium ferric gluconate 62.5mg IV once weekly w/ HD
Clonidine patch, TTS-2, 1patch once weekly
Procardia XL 60mg po qd
Lipitor 10mg po qd
Lispro 6units SC before meals
Glargine 24units SC at HS
Epogen 6000IU IV TIW w/ HD
Calcijex 2mcg IV TIW w/ HD
Ensure 1bottle (240ml) po tid
PE (physical exam): Patient appears to be in mild to moderate distress.
VS: BP 172/86, P 122, RR 18, T 39oC
Dry body wt 72kg, ht 5'11"
Erythematous L arm AV graft site with marked tenderness, warm to the touch. Extremeties: trace B (bilateral) pedal edema.
Na 135 Hgb 12.3 Ca 10.2
K 5.8 Hct 35.5% Mg 2.2
Cl 97 Plt 205x103 Phos 7.6
CO2 22 WBC 13.4x103 AST 35
BUN 71 ALT 29
Scr 8.8 T. bili 0.9
Glu 127 Alk Phos 87
Intact PTH 140 (last month 175) (normal 10-55)
EKG: sinus tachycardia.
Blood culture from AV graft (+) for coagulase-positive cocci.
Plan: Will dialyze now to correct some of the electrolyte abnormalities. Will start Vancomycin for probable MRSA-infected dialysis graft.
1. Evaluate patient's lab values and indicate which are elevated and which are low.
2. List three main electrolyte abnormalities:
3. Could any of the medications or nutritional supplements the patient is receiving be contributing to his hyperkalemia?
4. What is the pathophysiology of the patient's hyperkalemia?
5. List signs and symptoms of severe hyperkalemia:
6. List pharmacological agents used for the treatment of severe/symptomatic hyperkalemia (K>7mEq/L) and explain their mechanism of action?
7. What nondrug therapies are available for treating hyperkalemia in this patient?
8. Calculate corrected calcium level for this patient.
9. Could any of the patient's medications be contributing to his hyperphosphatemia and hypercalcemia?
10. What is the pathophysiology of the patient's hyperphosphatemia and hypercalcemia?
11. What non-drug therapies might be useful for treating this patient's hyperphosphatemia and hypercalcemia?
12. What pharmacotherapeutic alternatives are available for treatment of hyperphosphatemia in this patient?
13. What pharmacologic products are available to treat hypercalcemia in this patient?
HPI: J.L., a 25yo, 60-kg woman with an 8-year history of type 1 diabetes, is moderately well controlled on 24 units insulin glargine plus premeal doses of insulin lispro. Her family brings her to the emergency department, where she complains of abdominal tenderness, nausea, and vomiting. According to her family, J.L. was well until 2 days ago when she awoke with nausea, vomiting, diarrhea, and chills. Because she was unable to eat, she omitted her usual morning dose of insulin. Her GI symptoms progressed, and she was brought to the emergency department when she became lethargic.
PE: Reveals an ill-appearing woman who is lethargic but responsive. Her T is 37°C. Skin turgor is poor, mucous membranes are dry, and her eyeballs are shrunken and soft. J.L.'s lungs are clear, but respirations are deep and her breath has a fruity odor. Cardiac examination is within normal limits.
Labs on admission: BG (blood glucose) 750 mg/dL, Na 127 mEq/L, K 5.4 mEq/L, Cl 102 mEq/L, CO2 6 mEq/L, Scr 2.0 mg/dL, Hgb 14.7 g/dL, Hct 49%, WBC 15,000/mm3 with 3% bands/70% polymorphonuclear neutrophils/ 27% lymphocytes; serum ketones positive.
The urinalysis showed: 2% glucose, moderate ketones, pH 5.5, specific gravity of 1.029; there were no WBCs, RBCs, bacteria, or casts.
ABG: pH 7.05, PCO2 20 mmHg, PO2, 120 mmHg, HCO3 6mEq/L.
Patient diagnosed with DKA (diabetic ketoacidosis) and admitted for fluid, electrolytes, and insulin infusions.
1. Interpret ABG result and indicate what acid-base disorder does JL exhibit?
2. Calculate anion gap on admission for this patient. Explain the meaning of the numerical value.
3. What is the cause of patient's acid-base disorder?
4. What type of hyponatremia does this patient have? Explain the reason for it?
5. Explain the reason for hyperkalemia in this patient?
A 63-year-old male, T.K., arrived at the Family Practice Clinic for a routine follow-up. He had a history of hypertension, coronary artery disease, and chronic bronchitis, but had experienced no episodes of chest pain for the last month. T.K had a chronic cough productive of approximately 2 cups of white-yellow sputum per day and shortness of breath after walking one block. These symptoms were unchanged over the past 3 months. His medications were enalapril 10 mg oral 2 times a day, simvastatin 40 mg oral daily, enteric-coated aspirin 325 mg oral daily, tiotropium inhaler 18 mcg daily, albuterol inhaler two puffs as needed for shortness of breath, and nitroglycerin 0.4 mg sublingually as needed for chest pain.
T.K.'s vital signs included: HR 90/min, BP 130/85 mm/Hg, respiratory rate 28/min, and temperature 98.6◦F (37◦C).
His physical exam revealed rales and rhonchi throughout both lung fields.
His laboratory data included: sodium 134 mEq/L (136-145 mEq/L), potassium 3.6 mEq/L (3.5-5.0 mEq/L), chloride 92 mEq/L (96-106 mEq/L), total carbon dioxide 34 mEq/L (24-30 mEq/L), SCr 1.2 mg/dL (0.7-1.5 mg/dL), and glucose 160 mg/dL (70-110 mg/dL).
ABGs on room air were: pH 7.35 (7.36-7.44), PaCO₂ 60 mm Hg (36-44 mm Hg), PaO₂ 65 mm Hg (80-100 mm Hg), and serum bicarbonate 32 mEq/L (24-30 mEq/L).
1. What acid-base disorder does this patient have and what is the cause?
2. Is this disorder acute or chronic? Explain why.
3. Calculate anion gap.