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Patho > Patho Exam 3 part 2 > Flashcards

Patho Exam 3 part 2 Flashcards

1
Q

Hyponatremia

-Stages?

A

Hyponatremia stages
mild - Na 125-134
moderate - Na 115-124
severe - Na 110-114

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2
Q

Hyponatremia

-epidemiology

A

Hyponatremia epidemiology

  • most common electrolyte disorder
  • 28% of hospitalized patients
  • 7% of patients in community clinics
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3
Q

Hyponatremia

-risk factors?

A

Hyponatremia risk factors

  • certain medications
  • advancing age > 30
  • increased intake of hypotonic fluids
  • -PO water in martathon water
  • -PO water or hypotnic IV fluids in nurisng home patients
  • smaller body size in women
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4
Q

Clinical Presentation of Hypoatremia

-stage symptoms?

A

Clinical Presentation of Hypoatremia
Mild - Nausea, malaise
Moderate - HA, lethargy, restlessness, disorientation
severe - seizures, coma, respiratory arrest, brainstem herniation, death

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5
Q

Clinical Presentation of Hypoatremia

-acute vs chronic symptoms?

A

Clinical Presentation of Hypoatremia
chronic - > 48hours, frequent asymptomatic, may have impaired attention, posture, gait

rapid onset - HA, lethargy, restlessness, disorientation, seizures, coma, respiratory arrest, brainstem herniation, death

depends on volume status

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6
Q

Clinical Presentation of Hypoatremia

-magnitude of hypoatremia?

A
  • SOsm decreases in proportion to SNa

- as SOsm decreases, water movement into brain cells increase

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7
Q

Clinical Presentation of Hypoatremia

-rapidity of onset?

A
  • Brain cells can adjust intracellular osmolality to minimize cellular changes to volume changes
  • compensation begins within minutes
  • maximal compensation takes 48 hours
  • -therefore more acute changes are not yet compensated and are more likely to be associated with symptoms
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8
Q

Hyponatremia

-Diagnosis?

A

Asymptomatic patient - Routine labs
Symptomatic patient - Chem-7 (including Na+) and other screening laboratories are drawn
–serum osmolality, urine Na, serum glucose, lipids, renal function, thyroid function
-physical exam
-history of present illness
-past medical history
-home medications

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9
Q

Hyponatremia diagnosis approach?

A
  1. Assess the serum osmolality
    - hypertonic
    - isotonic
    - hypotonic
  2. Assess the volume status
    - volume overload
    - euvolemic
    - dehdrated
    - volume depleted
  3. assess acuity and severity
    - acute vs chronic
    - mild vs severe
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10
Q

Isotonic Hypoatremia

  • SosM
  • other thing
A

Isotonic Serum Osmolality

  • Sosm - 280 mOsm/kg
  • Lab Artifact - Seen in patients with hyperlidemia or hyperproteinemia when a specif lab technique is used
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11
Q

Hypertonic Hypoatremia
-SOsm
-Symtpoms?
-

A

Hypertonic Hypoatremia

  • SOsm > 280
  • Excess effective osmoles in ECF
  • -elevated glucose
  • –for every 100mg/dl increase in glucose, Na increases by 1/7 mEq/L
  • mannitol, glycine, sorbitol, polyethylene glycol
  • -associated with osmolal gap
  • -measured SOsm - calculated SOsm
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12
Q

Hypotonic Hypoatremia

  • SOsm?
  • how to assess etiology?
  • causes?
A

Hypotonic Hypoatremia

  • SOsm <280
  • most common cause of hypoatremia
  • many causes
  • must assess volume status to determine etiology
  • -euvolemic hypotonic hypnatremia
  • -hypervolimic hypotonic hypoatremia
  • -hypovolemic hypotonic hyponatremia
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13
Q

Hypovolemic Hypotonic Hyponatremia

  • what is it?
  • causes?
A

Hypovolemic Hypotonic Hyponatremia
-ECF volume contraction –> loss of hypotonic fluids

  • -diarrhea
  • -excessive sweating
  • -Thiazide diuretics
  • –usually mild, asymptomatic
  • –within 2 weeks of initiaton
  • –elderly women at greater risk
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14
Q

Hypovolemic Hypotonic Hyponatremia

-initally?

A

Hypovolemic Hypotonic Hyponatremia

  1. initally, transient hypernatremia
    - osmotic AVP release, stimulation of thirst
    - if salt and water losses continue, more AVP released
    - if patient drinks water or are given hypotonic IV fluids, they retain water and hyponatremia develops
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15
Q

Hypovolemic Hypotonic Hyponatremia

  • clinical presentation ?
  • laboratories?
A

Hypovolemic Hypotonic Hyponatremia

  1. Clinical Presentation
    - orthostasis, hypotension, tachycardia, dry mucous membranes, CNS changes
  2. Laboratories
    - Hyponatremia
    - Uosm usually >450
    - UNa will help determine cause
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16
Q

Euvolemic Hypotonic Hyponatremia

-causes?

A

Euvolemic Hypotonic Hyponatremia

  1. Most common cause is syndrome of inappropriate antidiuretic hormone (SIADH)
    - Nonosmotic or nonphysiologic increase in AVP release and/or enhanced sensitivity of kindey to AVP
    - -water intake exceeds kidneys capacity to excrete water
    - -UOsm > 100
    - -UNa > 20 due to ECF volume expansion
  2. When SIADH is suspected, need to rule out hypothyroidism, hypocortisolism, and renal failure
    - UOsm > 100
    - UNa > 20
17
Q

Euvolemic Hypotonic Hyponatremia

-Causes of SIADH?

A

Causes of SIADH

  • Lung or pancreatic cancer
    1. CNS disorders
  • -Head trauma, ischemic or hemorrhagic stroke, meningitis, tumor
  1. Pulmonary disorders
    - -Pneumonia (PNA), Tuberculosis (TB), acute respiratory distress syndrome (ARDS)
  2. Medications
    - carbamazepine, oxcarbazepine
    - SSRIs, tricyclic antidepressants, typical antiphyshotics, MAOI inhibitors
    - ecstasy
    - chemotherapeutic agents
18
Q

Euvolemic Hypotonic Hyponatremia

-Other causes than SIDAH

A
  1. Primary or psychogenic polydipsia
    - PO water intake > kidneys ability to excrete solute-free water
    - -usually > 20 L /day
    - -dilulation - UNa < 20 mEq/L
    - UOsm < 100 mOsm
19
Q

Euvolemic Hypotonic Hyponatremia

  • clinical presentation?
  • labortories?
A

Euvolemic Hypotonic Hyponatremia

  1. Depends on magnitude of hypoatremia and rapidity of onset of hypoatremia
    - Mild: Nausea, malaise, or asymptomatic
    - Mod: HA, Lethargy, restlessness, disorientation
    - Severe: seizures, coma, respiratory arrest, brainstem herniation, death

2.Labs- Una and UOsm will help determine etiology

20
Q

Hypervolemic Hypotonic Hyponatremia

  • What is it?
  • Compensating mechanisms?
A
  1. decreased effective arterial blood volume (EABV)
    - cirrhosis
    - heart failure (CHF)
    - nephrotic syndrome
  2. Comp
    - impaired renal sodium and water exretion = ECF volume expansion, edema
    - nonosmotic AVP release
    - -Water retention > NA retetntion
21
Q

Hypervolemic Hypotonic Hyponatremia

  • clinical presentations?
  • laboratories?
A
  1. Symptoms due to ECF volume expainsion
    - edema (peripheral or pulmonary)
  2. Depends on magnitude of hyponatremia & rapidity of onset of hypoatremia
    - Mild: Nausea, malaise, or asymptomatic
    - Mod: HA, lethargy, restlessness, disorientation
    - Severe: seizures, coma, respiratory arrest, brainstem herniation, death

Laboraties

  • UNa < 20
  • UOsm > 100
22
Q

Hypervolemic Hypotonic Hyponatremia

-Clinical Outcomes?

A
  • Worse for women than men
  • Worse for children than adults
  • severe risk factor for morbidity and mortality in patients with HF and cirrhosis
23
Q

Hypervolemic Hypotonic Hyponatremia

-treatment?

A

Hypervolemic Hypotonic Hyponatremia

  1. Depends on
    - magnitude
    - rapidity
    - patients volume status
24
Q

Hypernatremia

  • Serum Na?
  • Risk factors?
  • outcome?
A
  1. Na > 145
    - always associated with hyperosmolality & cellular dehydration
  2. Risk factors
    - impaired thirst response
    - lack of access to water
    - -elderly, infants, children, disabled, comatose
    - latrogenic
    - -too little free water or too much hypertonic solution plus increased renal free water loss
  3. Outcomes in adults
    - High mortality rate in chronic acute cases
25
Q

Hypernatremia

  • symptoms?
  • compensation of 24 hours
A

Hypernatremia

  1. Symptoms caused by decreased brain cell volume
    - weakness, lethargy, restlessness, irritability, confusion
    - signs of more severe or rapidly developing hypernatremia
    - -twitching, seizures, coma, death
  2. Compensation can occur within 24 hours
    - chronic hypernatremia associated with fewer symptoms
  3. Often associated with serious underlying illness
    - volume depletion or dehydration
26
Q

How to approach a patient with hypernatremia?

A
  1. assess the following:
    - ECF volume
    - Urine osmolality
    - Urine volume
    - Patient history
27
Q

Hypovolemic Hypernatremia

  • Causes?
  • Clinical presentation?
A
  1. Causes
    - insensible losses not replaced
    - hypotonic GI losses (N/V)
    - fever or exposure to high temperatures
    - excessive or not replaced renal losses
    - -Inappropriate osmotic diuresis
  2. Clinical presenation
    - symptoms related to hypovolemia
    - UOsm high
    - UNa low if non-renal losses
    - UNa high if renal losses
28
Q

Hypovolemic Hypernatremia

-volume depleted or dehydrated?

A

Hypovolemic Hypernatremia

  1. Volume depleted
    - Urine volume 450 mOsm/kg
    - Postural hypotension, hypotension
    - -key finding which guid therapy
    - -these findings indicate Na + H20 depletion
  2. Dehydrated
    - Urine volume >3L/day
    - UOsm > 300 mOsm/kg
    - No postural hypotension
    - these findings indicate H20 depletion
29
Q

Osmotic Diuresis

  • Associated with?
  • causes?
A
    • Hypernatremia
      - Normal or increased ECF volume
      - Urine volume > 3L/day
      - High UOsm > 350mOsm/kg
  2. Causes
    - increased solute
    - -glocuse, sodiu, urea, mannitol
    - -urine level will be elevated
    - postobstructive
    - -excessive solute previously not able to secreted
30
Q

Diabetes Insipidus (DI)

  • Associated with?
  • Types?
A
  1. “Water Diuresis”
  2. Associated with
    - hypernatremia - mild elevation
    - normal ECF volume
    - increased urine volume
    - Low UOsm < 250mOsm/kg
  3. Types
    - Nephrogenic
    - -decreased renal response to AVP
    - Central
    - -Decreased secretion of AVP
31
Q

Central Diabetes Insipidus (DI)

-Causes?

A
  1. Neurogenic
    - neurosurgery
    - tuberculosis
    - head trauma
    - CNS malignancy
    - hypoxic encephalopathy
    - sarcoidosis
  2. Familial
  3. Hypodipsia
  4. Unreplaced skin or lung losses
32
Q

Nephrogenic Diabetes Insipidus (DI)

-Causes?

A
  1. Familial
  2. Chronic Hypocalcemia
  3. Hypokalemia
  4. Kidney disease
  5. Drug induced
    - Cidofovir
    - Lithium
    - Amphotericin B
    - Demeclocycline
    - Foscarnet
    - Ifosfamide
    - Vasopressin V2-receptor antagonists
33
Q 
Diabetes Insipidus (DI)
-central or nephrogenic?
A

Diabetes Insipidus (DI)

  1. Central
    - rapid onset polyuria
  2. Nephrogenic
    - gradual onset of polyuria
34
Q

Diabetes Insipidus (DI)

  • Water deprivation test?
  • central vs nephrogenic results?
A
  1. Water Deprivation Test
    - used to differentiate central and nephrogenic DI
    - withold water x 8-12 hours
    - measure UOsm, urine volume, body weight
    - administer desmopressin acetate 5mcg subcutaneously for 1 hour
    - measure UOsm, urine volume, body weight
  2. Results
    - central DI
    - -increase in UOsm to 600mOsmkg + decrease in urine volume
    - nephrogenic DI
    - -UOsm remains around 300 mOsm/kg
35
Q

Sodium Overload

-causes

A
  1. Hypertonic saline infusion
    - 0.9%, 3% NacL
    - NaHCO3
    - concentrated enternal feedings
    - hypertonic dialysate
    - sodium-containg mediations
    - sea water ingestion
  • assoacited wtih hyperchlomemia
  • -may result in hyperchloremic metabolic acidosis

Patho (5 decks)

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