Generic Case Review
Robert Zaid
2/24/06
Chief Complaint
• 59 year old caucasion female brought in after
falling down 13 stairs that morning
• Consultation for medical management was
ordered for our service
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CC
HPI
PMHx
MEDS
History of Present Illness
Allergies
Pt is a 59 y/o c female who was found at bottom of
SocHx
stairs by her husband who noticed that she was
having trouble breathing. Pt is unresponsive and
FMHx
unable to provide history and her husband does not
ROS
know her history as well. This was her first admission
Physical Exam to the hospital. She has consumed alcohol in the past
day.
Differential
LABS
Radiological
Differential
Diagnosis
Treatment
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CC
HPI
PMHx
MEDS
Allergies
SocHx
FMHx
ROS
Physical Exam
Differential
LABS
Radiological
Differential
Diagnosis
Treatment
Past Medical History
Unable to obtain
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CC
HPI
PMHx
MEDS
Allergies
SocHx
FMHx
ROS
Physical Exam
Differential
LABS
Radiological
Differential
Diagnosis
Treatment
Medications
Unable to obtain
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CC
HPI
PMHx
MEDS
Allergies
SocHx
FMHx
ROS
Physical Exam
Differential
LABS
Radiological
Differential
Diagnosis
Treatment
Allergies
Unable to obtain
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CC
HPI
PMHx
MEDS
Allergies
SocHx
FMHx
ROS
Physical Exam
Differential
LABS
Radiological
Differential
Diagnosis
Treatment
Social History
She is a smoker and drinks
alchohol
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CC
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MEDS
Allergies
SocHx
FMHx
ROS
Physical Exam
Differential
LABS
Radiological
Differential
Diagnosis
Treatment
Family Medical History
Unable to obtain
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CC
HPI
PMHx
MEDS
Allergies
SocHx
FMHx
ROS
Physical Exam
Differential
LABS
Radiological
Differential
Diagnosis
Treatment
Review of systems
General:
Head:
Respiratory:
Cardiac:
GI:
GU:
MSK:
Neuro:
Psychiatric-
weight change, fever, chills, weak
headache, nasuea, vomitting
SOB, wheeze, cough
HTN, murmurs, angina, palpitations
appetite, n/v, incont., const/diarrhea
frequency, hesitancy, urgency, dysuria
hematuria, incont., stones,
no dyspareunia, no discharge
muscle weakness, flank pain
parasthesias, loss of sensation
Pt is not depressed
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CC
HPI
PMHx
MEDS
Allergies
SocHx
FMHx
ROS
Physical Exam
Differential
LABS
Radiological
Differential
Diagnosis
Treatment
Physical Exam
VSBP- 113/65 HR 92 11 R 97
General- Pt is well nourished and not alert
Heent- EOMI, PERRLA, no vision changes
CVRRR w/o murmurs or rubs, clicks or gallops
RESP- Clear to auscultation bilaterally, no wheezes
Abdomen- Soft, NT, ND, no masses, BS, no bruits
GUNo discharge, bleeding, nodules or masses
MSK- No weakness,
EXT- No edema, negative moses, pulses b/l
Skin- No rashes
OstNeuro-
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Physical Exam
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LABS
Radiological
Differential
Diagnosis
Treatment
Differential
Need to rule out any foul play
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CC
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Allergies
SocHx
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ROS
Physical Exam
Differential
LABS
Radiological
Differential
Diagnosis
Treatment
What do we want to order?
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CC
HPI
PMHx
MEDS
Allergies
SocHx
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Physical Exam
Differential
LABS
Radiological
Differential
Diagnosis
Treatment
Labs
Chemistry
CBC
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CC
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PMHx
MEDS
Allergies
SocHx
FMHx
ROS
Physical Exam
Differential
LABS
Radiological
Differential
Diagnosis
Treatment
CBC
13.6
10.4
218
40.5
Chemistry
120
85
2
98
3.3
22
0.6
Pregnancy Test
Negative
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CC
HPI
PMHx
MEDS
Allergies
SocHx
FMHx
ROS
Physical Exam
Differential
LABS
Radiological
Differential
Diagnosis
Treatment
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CC
HPI
PMHx
MEDS
Allergies
SocHx
FMHx
ROS
Physical Exam
Differential
LABS
Radiological
Differential
Diagnosis
Treatment
Diagnosis
1. Medical management of hypokalemia with
hyponatremia
Hyponatremia
Background
• Maintenance
– Homeostatic mechanisms
• Thirst
• Antidiuretic hormone (ADH)
• Renal handling of filtered sodium
• Clinically significant hyponatremia
– Relatively uncommon
– Nonspecific in its presentation
• Correction
– Irreparable harm
• If corrected too quickly or too slowly
Hyponatremia
Background
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Hypovolemic hyponatremia
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– Total body water (TBW)
decreases
– Total body sodium (Na+)
decreases more
– Extracellular fluid (ECF) volume is
decreased.
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Euvolemic hyponatremia
– TBW increases
– Total sodium remains normal
– ECF volume is increased
minimally to moderately
– No edema
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Hypervolemic hyponatremia
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Total body sodium increase
TBW increases to a greater extent
ECF is increased markedly
Edema is present.
Redistributive hyponatremia
– Water shifts from the intracellular
to the extracellular compartment
– Resultant dilution of sodium
– TBW and total body sodium are
unchanged
– Occurs with hyperglycemia.
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Pseudohyponatremia
– Diluted by excessive proteins or
lipids
– TBW and total body sodium are
unchanged
– Hypertriglyceridemia and multiple
myeloma
Hyponatremia
Pathophysiology
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Regulation
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Stimulation
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Thirst
ADH
Renin-angiotensin-aldosterone system
Renal handling of filtered sodium
Increases in serum osmolarity above the normal range (280-300 mOsm/kg)
Stimulate hypothalamic osmoreceptors
Cause an increase in thirst and in circulating levels of ADH
Mechanism of ADH
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Increases free water reabsorption from urine
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Low urine volumes
Relatively high urine osmolarity
Returning serum osmolarity toward normal
ADH also is secreted in response to:
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Hypovolemia
Pain
Fear
Nausea
Hypoxia
Hyponatremia
Pathophysiology
• Regulation
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Thirst
ADH
Renin-angiotensin-aldosterone system
Renal handling of filtered sodium
• Aldosterone
– Synthesized by the adrenal cortex
– Regulated primarily by serum potassium
– Released in response to hypovolemia
• Renin-angiotensin-aldosterone axis
– Effect:
• Causes absorption of sodium
– Distal renal tubule
• Sodium retention obligates free water retention
• Aides the hypovolemic state.
Hyponatremia
Pathophysiology
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Disorders of sodium balance
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Disturbance
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Thirst
Water acquisition
ADH
Aldosterone
Rrenal sodium transport.
Significant hyponatremia
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State of extracellular hypo-osmolarity
Tendency for free water to shift from the vascular space to the intracellular space
Cellular edema is well tolerated by most tissues
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Not tolerated by calvarium
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Cerebral edema.
Rate
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Slowly
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Several days or weeks
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Brain is capable of compensating
Extrusion of solutes and fluid to the extracellular space
Fast
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24-48 hours
Compensatory mechanism is overwhelmed
Severe cerebral edema may ensue
Resulting in brainstem herniation and death.
Hyponatremia
History
• Symptoms
– May be limited
• Mild anorexia
• Headache
• Muscle cramps
– Severe
• Obtundation
• Coma
• Status epilepticus
• Look for causes in history
– Seen with chronic disease
• Pulmonary/mediastinal disease
• CNS disorders
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Medications
Poor diet
Intake of large amounts of beer
Ectasy
Hyponatremia
History
• Hypoosmolor hyponatremia
– Hypothyroidism
– Adrenal insufficiency
• Clinically significant hyponatremia
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Anorexia
Nausea and vomiting
Difficulty concentrating
Confusion
Lethargy
Agitation
Headache
Seizures
Hyponatremia
Physical
• Neurological
– Level of alertness
– Variable degrees of cognitive
impairment (eg, difficulty with
short-term recall; loss of
orientation to person, place, or
time; frank confusion or
depression)
– Focal or generalized seizure
activity
– Signs of brainstem herniation
• Severe hyponatremia
– Coma;
– Fixed, unilateral, dilated
pupil
– Decorticate or decerebrate
posturing
– Respiratory arrest
• Hydration status
– Low volume
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Dry mucous membranes
Tachycardia
Diminished skin turgor
Orthostasis
– Excess free water
(hypervolemic)
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Pulmonary rales
S3 gallop
Peripheral edema
Ascites
– Euvolemic
• Hypothyroidism
• Cortisol deficiency
• Syndrome of inappropriate
antidiuretic hormone (SIADH)
Hyponatremia
Causes
• Hypovolemic
• Euvolemic
• Hypervolemic
Hyponatremia
Causes
• Hypovolemic hyponatremia
– Sodium and free water are lost
– Replaced by inappropriately hypotonic fluids
– Mechanism
• Renal
– Acute or chronic renal insufficiency
» Unable to excrete free water
– Salt-wasting nephropathy
• Nonrenal route
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GI losses
Excessive sweating
Third spacing of fluids (eg, peritonitis, pancreatitis, burns)
Prolonged exercise in a hot environment
Hyponatremia
Causes
• Euvolemic hyponatremia
– Normal body sodium
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Total body excess of free water
Patients who take in excess fluids.
Psychogenic polydipsia
Administration of hypotonic intravenous
Infants who may have been given inappropriate
amounts of free water
Hyponatremia
Causes
• Hypervolemic hyponatremia
– Sodium stores increase inappropriately
– Acute or chronic renal failure
• Dysfunctional kidneys are unable to excrete the ingested
sodium load
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Cirrhosis
CHF
Nephrotic syndrome
Uncorrected hypothyroidism or cortisol deficiency
SIADH
Consumption of large quantities of beer or use of the
recreational drug MDMA (ecstasy)
Hyponatremia
Labs
• Questions about lab error
– Was the patient's blood sample properly labeled?
– Was it obtained from a venous site proximal to an infusion of
hypotonic saline or dextrose in water?
– Is laboratory measurement or reporting in error?
– If an error is suspected, a second sample should be submitted
for testing before therapeutic measures are initiated.
• Physiological states that show hyponatremia
– The most common example is serum hyperglycemia.
• Extracellular glucose induces shift of free water from the
intracellular space to the extracellular space.
• Serum sodium is diluted by a factor of 1.6 mEq/L for each 100
mg/dL increase in serum glucose.
Hyponatremia
Labs
– A similar phenomenon is observed in patients treated with glycerol or mannitol in
an effort to control acute glaucoma or intracranial hypertension. This
phenomenon is also seen in patients with advanced renal disease who receive
radiocontrast agents for diagnostic testing.
– Hyponatremia may be noted in patients whose serum contains unusually large
quantities of protein or lipid.
• In these patients, an expanded plasma protein or lipid fraction leads to a decrease in
the plasma water fraction in which sodium is dissolved.
• Laboratory techniques that measure absolute sodium content per unit of plasma water
report low sodium levels despite the fact that the concentration of sodium in serum
water remains within the normal range.
• This phenomenon, known as pseudohyponatremia, occurs when flame emission
spectrophotometry or indirect potentiometry is used to assay serum sodium levels
rather than direct potentiometry techniques. This occurs in approximately 60% of US
laboratories.
• Serum osmolarity remains undisturbed, and attempts at correcting serum sodium are
not indicated.
• Hyperlipidemia that is severe enough to produce pseudohyponatremia almost always is
accompanied by a lipemic appearance of the serum sample.
• Hyperproteinemia of sufficient magnitude to induce pseudohyponatremia commonly is
due to coexisting multiple myeloma.
Hyponatremia
Labs
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Serum osmolarity
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Low in hypo-osmolar hyponatremia
Normal in patients with pseudohyponatremia due to hyperlipidemia or hyperproteinemia
Normal or elevated in patients with hyperglycemia.
Urine sodium levels
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Helpful in distinguishing renal causes of hyponatremia from nonrenal causes.
<20
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Hypovolemic hyponatremia
Due to nonrenal causes
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Vomiting
Diarrhea
Fistulas
GI drainage
Third spacing of fluids)
Avid renal absorption of tubular sodium
>20
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Hypovolemic hyponatremia
Due to renal causes
Diuretics
Salt-losing nephropathy
Aldosterone deficiency
Hyponatremia
Labs
• Urine osmolarity may be helpful in establishing the
diagnosis of SIADH.
– Typically, patients with SIADH have inappropriately concentrated
urine with urine osmolarities in excess of 100 mOsm/L.
– Patients with other forms of hyponatremia and appropriately
depressed levels of ADH have urine osmolarities below 100
mOsm/L.
• TSH
• Adrenal function
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Random serum cortisol levels or
Adrenocorticotropic hormone (ACTH) stimulation test
In patients who have taken oral steroids
or in any patient suspected of having cortisol deficiency
Thank you
• Questions, comments or concerns