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INPATIENT PRACTIC APPROACH AKI > hyperCa, hypoNa > Flashcards

hyperCa, hypoNa Flashcards

1
Q

hypercalcemia with high PTH

A

adenoma; hyperplasia; carcinoma
lithium
FHH
PTH r tumor

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2
Q

PTH LOW under 25 and hypercalcemia

A 
PTH r peptide - ca lung / renal 
MTS bones MM 
Vit D1/25 -- granulomatous dx sarcoid; histo, silicosis 
Vit D 25
granulomatous 
hyperthyroidism 
milk alkali sy 
hctz 
vit A
Immobilization
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3
Q

Ca 10, PTH 50

A

This is still primary hyperPTH / PTH should be suppressed/

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4
Q

which medication can mimick hyperPTH

A

Lithium

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5
Q

PTH 325 Ca level 10

A

elderly frail; likely lack of vit D 0H25

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6
Q

Tertiary hyperparathyroidism

A

ESRD with poor phosphorus binder compliance

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7
Q

HIGH CALCIUM LOW PTH, HIGH1/22 VIT D DX

A

SARCOID

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8
Q

WEIGHT LOST; LOW PTH, HIGH CA;

DIARRHEA

A

CHECK THYROID - HYPERTHYROIDISM

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9
Q

low urine calcium; mild elevated calcium; PTH wnl, vit D wnl.; healthy person

A

FHCC

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10
Q

TREATMENT OF HYPOCALCEMIA IN RHABDO?

A

released P is binded by calcium –> low calcium; do not replace as rhabdo stop you would have hypercalcemia

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11
Q

vitamin D mediated hypercalcemia examples

A

sarcoid
any granulomatous disease
Lympho
Good paster

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12
Q

jaundice and hyperalcemia

A

suspect vitamin A OD

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13
Q

jaundice without eyes icterus

A

vitamin A

check for calcium

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14
Q 
confusion 
calcium 12
 PTH low 
D1/25 LOW 
high vitamin D 25OH over 150
A

HYPERVITAMINOSIS D
STORAGE TIME LONG
TRY STEROIDS

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15
Q

which mechanism is MM causing hypercalceia

A

lytic release from bones

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16
Q 
high vitamin D 
low PTH 
low vitamin D 25OH,
low vitamin D 1/25
total protein elevated
A

MM

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17
Q

hypercalcemia with NL PTH
low vitamin D 1,25 and d25
mild elevated kappa chain in urin

A

ddx MGUS - with primary hyper PTH / PTH should be in this case suppressed /
MM would be much higher

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18
Q

silicon implants and electrolyte abnormalities

A

hypercalcemia due to granulomatous mechanism
high D1/25
low pth
low D25OH
LEAKING SILICON - GRANULOMAS - MACROPHAGES CONVERTING 250H D TO 1-25D

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19
Q

first two steps evaluation of hyponatremia

A

serum osmolarity

urine osmolarity

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20
Q

true hyponatremia serum osmolarity

A

below 275

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21
Q

second step to eval hyponatremia

A

urine osmolarity

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22
Q

urine osmolarity over 100

urine omsolarity below 100

A

> 100 - ADH activated

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23
Q

3d step of hyponatremia eval

A

urine sodium

24
Q

Urine osmo over 100

urine sodium over 40

A

SIADH
thyroid
diuretics

25
Q

URINE OSM 100

URINE SODIUM BELOW 20

A

cirrhosis
CHF
hypovolemia

26
Q

serum osmo <275

urine osmo below 100

A

polydipsia

or solute

27
Q

plasma osmolality

28
Q

URINE Na < 20 ? RAAS?

A

RAAS is activated. Hypovolemia or kidney sense hypovolemia but edema / CHF, CIRRHOSIS/

29
Q 
Plasma osm 265
urine Sodium less then 13
urine chloride less then 14
Na 123
U osmo 700
A

true hyponatremia
if edema - cirrhosis, chf
if no edema hypovolemia

ADH is activated

30
Q 
Na 125
Plasma osmo 260
urine osmo 500
urine Sodium 44
urine Chloride 41
A

edema –> CHF—> ON LASIX / URINE SODIUM HIGH/ THAT WHY NEED TO CHECK URINE CHLORINE

31
Q 
Na 120
serum osmo 260
urine osmo 500
urine sodium 12
urine chloride 12
A

if no edema suspected dehydration

hypovolemic hyponatremia

32
Q

disproportionally elevated urine Na compare to CL

A

ddx diuretics

or metabolic alkalosis - N/V

33
Q

Na 120
plasma osmo 250
urine Na 100
urine Cl 90

A

IF NO HTN SIADH

34
Q

HOW MUCH NEED TO DRINK HEALTHY PERSON OF WATER BEFORE BECOMING HYPONATRIEMIC?

A

DIET 800-900 osm per 24 hr / sodium, urea/
to excrete 1l of water you need 50 osmo
you need to drink 18l of water with norma diet before you becoming hyponatriemic

35
Q

how much can be urine dilute maximally in healthy person?

36
Q

toast and coffee diet —> sodium implication

A
  • daily osmol intake 100
  • if elderly can dilute urine max to 100 person can only excrete 1L so if intake of more then 1l of water result is hyponatremia
37
Q

beer intake and sodium

A
  • beer no sodium; if poor diet and only beer intake whole day let say intake of 150 osmo max can be excreted 3l after hyponatremia
38
Q

Na 125
plasma osmo 250
urine osmo 60
urine sodium 12

A

possible
psychogenic polydipsia
or low solute / sodium intake / eg toast an tea diet

39
Q

two cases of pseudohyponatriemia

A

hyperproteinemia eg MM
OR TAG elevated eg pancreatitis and TAG 3000
OBGAIN ABG/ VBG SODIUM DO NOT TREAT

40
Q

why hyperglycemia creating hyponatremia

A

shift free water from IC space

41
Q

correction of Na for hyperglycemia

A

add 2 Na for each 100 glucose over 100

anion gap use measured sodium

42
Q

hctz effect on sodium

A

can last days of even weeks

dc and re-eval in 1week

43
Q 
what can look like SIADH 
120 Na
plasma osmo 262
urine osmo 340
urine Na 45
A

RESET OSMOSTAT

  • IF YOU GIVE WATER YOU WILL NOT SEE ANY CHANGE IN SODIUM
  • SIADH IF GIVEN WATER SODIUM WILL DROP
  • CHRONIC MILD HYPONATREMIA
44
Q

SIADH like picture with WBC up an Eo increased

A

Adrenal insufficiency

cosyntropin stim test

45
Q 
Na 123
seruem osmo 265
urine osmo 500
urine sodium 80
urine chloride 75
WBC up 
increased eosinophilia
A

adrenal insuficiency;

46
Q 
Na125
serum osmo 265
urine osmo 500
urine sodium 88
urine chloride 82
A

SIADH

if smoking look for lung ca

47
Q

SIADH TREATMENT

A
  • fluid restriction
  • diuretics
  • salt tablets
  • urea tablets
48
Q

NA vs urea

A

1000mg of NaCl is 17mmosm of Na
15gm of urea is 250mosm
30gm of urea is 500 roughly 18gm of NaCl
urea comes from protein; a high protein diet will increase urea and help to excrete water with an improvement of sodium level
SIADH
lasix fluid restrict and sodium /urea/ tablets

49
Q 
SIADH 
Na122
serum osmo 255
urine osmo fixed 500
urine Na110
calculate fluid restriction
A

excretion can be done

500mosm/500 per liter is 1 L with insenisble losses 1.5L

50
Q

How to assist a patient on fluid restriction eg SIADH?

A

Add salt tablets or urea supplementation
- if urine osmo is 500 patient can do 1L urine output so max is 1l fluid intake
add on 2 doses of urea –> 250x 2 500 osm result is ability to excrete additional 1 L fluid intake can be 2L and insensible losses

51
Q

Na 122
serum osm 265
urine osmo 600
urine sodium 90

step wise therapy

A

SIADH

  • fluid restriction - patient can excrete 1L of urine if taking low normal intake of solutes eg 600
  • add lasix - dilute urine to 300 with same solute intakes fluid restriction can be 2l
  • add on urea or salt tablets and fluid restriction can be lifted up
52
Q

SIADH urine sodium is greater then?

A

40

/ check if not on lasix; /

53
Q

correction of hyponatremia of unknown acuity

A

MAX 8MOSM / 24HR
if confusion do 3-5 in first few hours
Na check q 2hr
if overcorrection use D5/W

54
Q

WHY hypovolemia is creating hyponatremia

A

increased ADH

correction of hypovolemia resulting to quick resolution of stimulus for ADH and sodium is corrected

55
Q

cirrhosis mechanism in hyponatremia

A

vasodilation –> stimulation of RAAS AND ADH

INPATIENT PRACTIC APPROACH AKI (6 decks)

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