A
B
C
D
1$
1$
1$
1$
2$
2$
2$
2$
3$
3$
3$
3$
4$
4$
4$
4$
Final
Jeopardy
5$
5$
5$
C1 $100
The osmolarity of the extracellular fluid space is determined primarily by the
concentration of:
A. Bicarbonate
B. Chloride Ions
C. Phosphate radicals
D. Sodium Ions
C1 $100
The osmolarity of the extracellular fluid space is determined primarily by the
concentration of:
A. Bicarbonate
B. Chloride Ions
C. Phosphate radicals
D. Sodium Ions
Na- Main determinant of ICF and ECF osmotic pressure
Proteins- Main determinant of oncotic pressure
C1 $200
When lactic acid is produced in response to injury, the body minimizes pH change by:
A. Decreasing production of sodium bicarbonate in tissues
B. Excreting carbon dioxide through the lungs
C. Excreting lactic acid through the kidneys
D. Metabolizing the lactic acid in the liver
C1 $200
When lactic acid is produced in response to injury, the body minimizes pH change by:
A. Decreasing production of sodium bicarbonate in tissues
B. Excreting carbon dioxide through the lungs
C. Excreting lactic acid through the kidneys
D. Metabolizing the lactic acid in the liver
C1 $300
A patient s/p Whipple has a rising creatinine due to ARF and ultimately gets started on
hemodialysis. This will help remove all of the following except:
A.
B.
C.
D.
E.
F.
G.
H.
K
Na
Ca
Mg
Urea
PO4
Contrast agents
Fat soluble vitamins
C1 $300
A patient s/p Whipple has a rising creatinine due to ARF and ultimately gets started on
hemodialysis. This will help remove all of the following except:
A.
B.
C.
D.
E.
F.
G.
H.
K
Na
Ca
Mg
Urea
PO4
Contrast agents
Fat soluble vitamins
C1 $400
Which of the following is not an indication for dialysis?
A. Fluid overload
B. Hyperkalemia
C. Uremic encephalopathy
D. Hypernatremia
E. Metabolic acidosis
F. Poisoning
C1 $400
Which of the following is not an indication for dialysis?
A. Fluid overload
B. Hyperkalemia
C. Uremic encephalopathy
D. Hypernatremia
E. Metabolic acidosis
F. Poisoning
Uremic coagulopathy is also an indication
C1 final
An elderly diabetic patient who has acute cholecystitis is found to have a serum
sodium level of 122 mEq/L and a glucose of 600 mg/dL. After correcting the
glucose concentration to 100 mg/dL with insulin, the serum sodium concentration
would:
A.
B.
Decrease significantly unless the patient also received 3% saline
Decrease transiently but return to approximately 122mEq/L without specific
therapy
C.
D.
Remain essentially unchanged
Increase to the normal range without specific therapy
Timer
C1 final
An elderly diabetic patient who has acute cholecystitis is found to have a serum
sodium level of 122 mEq/L and a glucose of 600 mg/dL. After correcting the
glucose concentration to 100 mg/dL with insulin, the serum sodium concentration
would:
A.
B.
Decrease significantly unless the patient also received 3% saline
Decrease transiently but return to approximately 122mEq/L without specific
therapy
C.
D.
Remain essentially unchanged
Increase to the normal range without specific therapy
DKA
• Exclusively in Type I DM
• Usually precipitated by infection (UTI, appendicitis, cholecystitis, pancreatitis,
bowel ischemia)
• No insulin  Glucose not entering cells  hyperglycemia  fatty acid oxidation
in liver  increased ketones  ‘Anion Gap’ metabolic acidosis and ketones in
urine
• Pseudohyponatremia (due to increased glucose)
• K may be elevated initially (Not going into cells) but ‘total body K’ is low
• Rx:
•
•
•
•
•
r/o causes (esp infection) and Rx
Hydration:
NS 10 cc/kg/hr (adjust to UOP)
Insulin:
10 U iv push (+ glucose if <250)
Potassium:
Later if <4.5
HCO3:
Only if severe acidosis
• Hyponatremia corrects with correcting hyperglycemia
C2 $100
A 70 yo lady with metastatic breast cancer presents with hypercalcemia. Which
treatment is NOT adequate?
A.
Rapid infusion of LR @ 200-300 cc/hr
B.
C.
D.
Lasix
Dialysis
Bisphosphonates
E.
F.
G.
Calcitonin
Steroids
Mithramycin
C2 $100
A 70 yo lady with metastatic breast cancer presents with hypercalcemia. Which
treatment is NOT adequate?
A.
Rapid infusion of LR @ 200-300 cc/hr
B.
C.
D.
Lasix
Dialysis
Bisphosphonates
E.
F.
G.
Calcitonin
Steroids
Mithramycin
Hypercalcemia
• MCC:
• Hyperparathyroidism (MCC parathyroid adenoma)
• Malignancy
• MCC (Malignant): Lung and breast Ca
• Symptoms: Stones (renal or biliary), Bones (bone pain), Groans (abdominal pain,
nausea and vomiting), Thrones (sit on throne - polyuria), Psychiatric overtones
(Depression 30-40%, anxiety, cognitive dysfunction, insomnia, coma).
• Rx:
•
•
•
•
•
NS @200-300 cc/hr (NO LR- contain Ca+)
Lasix (No thiazide diuretics: cause Ca+ resorption)
If no reponse  Dialysis
If malignancy  bisphosphonates, calcitonin, steroids, mithramycin
If hyperPTH  parathyroidectomy after recovery
C2 $200
Which of the following is NOT a cause of ‘anion gap metabolic acidosis’?
A. DKA
B. Renal failure
C. Diarrhea
D. Lactic acidosis
E. Ethylene Glycol ingestion
C2 $200
Which of the following is NOT a cause of ‘anion gap metabolic acidosis’?
A. DKA
B. Renal failure
C. Diarrhea
D. Lactic acidosis
E. Ethylene Glycol ingestion
Anion Gap
• Anion Gap = Na+ – (HCO3 + Cl-)
• Normal < 10-15
• Most metabolic acidosis is anion gap type
• Non anion gap acidosis:
• Due to gaining HCO3 or loss of NaHCO3
• GI loss of HCO3: Diarrhea, ECF, ileostomy
• RTA
• Lactulose (for liver failure. Metabolized to short chain fatty acids  acidifies
colon  increase H+ absorption)
• Type IV RTA: (Aldosterone resistance)
• Diabetic nephropathy
• Decreased aldosterone activity  hyperkalemia  K+/H+ exchanger
excretes K+ and absorbs H+  acidosis
C2 $300
Which of the following is true concerning the compensatory mechanisms and
management of metabolic acidosis?
A. Maximal renal compensation for metabolic acidosis occurs before full respiratory
compensation can occur
B. All patients with lactic acidosis should receive prompt treatment with bicarbonate
C. Potassium replacement is essential even in the face of normal or high serum
potassium levels in the management of DKA
D. Sodium bicarbonate administration should be simultaneous with volume
resuscitation in the care of patient with hypoxia secondary to shock
C2 $300
Which of the following is true concerning the compensatory mechanisms and
management of metabolic acidosis?
A. Maximal renal compensation for metabolic acidosis occurs before full respiratory
compensation can occur
B. All patients with lactic acidosis should receive prompt treatment with bicarbonate
C. Potassium replacement is essential even in the face of normal or high serum
potassium levels in the management of DKA
D. Sodium bicarbonate administration should be simultaneous with volume
resuscitation in the care of patient with hypoxia secondary to shock
Metabolic Acidosis: Compensation
- Renal compensation:
- Kidney sensitive to changes in serum HCO3 levels
- In acidosis, kidneys respond by increasing acid excretion MOSTLY by
increasing ammonia excretion
- Renal compensation takes time (2-4 days)
- Respiratory compensation (CO2 blow off):
- Immediate BUT is partial
- Takes 12-24 hrs
- Use of HCO3 infusion: Controversial.
- No improvement in outcomes seen in studies
- Some advocate pH >7.25 with HCO3 infusion to avoid myocardial
depression
C2 $400
Three days after surgery for gastric carcinoma, a 50-year-old alcoholic man exhibits
delirium, muscle tremors, and hyperactive tendon reflexes. Magnesium deficiency is
suspected. All of the following statements regarding this situation are true EXCEPT:
2-4a (Type a clue in the
form of a statement)
A. A decision to administer magnesium should be based on the serum magnesium
level.
B. Adequate cellular replacement of magnesium will require 1-3 weeks.
C. A concomitant calcium deficiency should be suspected.
D. Calcium is a specific antagonist of the myocardial effects of magnesium.
C2 $400
Three days after surgery for gastric carcinoma, a 50-year-old alcoholic man exhibits
delirium, muscle tremors, and hyperactive tendon reflexes. Magnesium deficiency is
suspected. All of the following statements regarding this situation are true EXCEPT:
A. A decision to administer magnesium should be based on the serum magnesium
level.
B. Adequate cellular replacement of magnesium will require 1-3 weeks.
C. A concomitant calcium deficiency should be suspected.
D. Calcium is a specific antagonist of the myocardial effects of magnesium.
Magnesium
- Hypomagnesemia:
- MCC: Diuretics.
- Also seen with TPN use
- Mostly asymptomatic (70% ICU pts have this)
- S&S similar to hypocalcemia
- Rx with Mg
- Hypermagnesemia:
- MCC: Renal failure
- Rx:
- Calcium (competitive antagonist to Mg)
- Diuretics
- Dialysis
C2 $500
70 yo male with a history of asthma undergoes right colectomy for cecal volvulus and
is found obtunded postop on the floor. A code is called and ABG drawn after which the
patient is intubated. Choose the correct ABG from below:
A. pH 7.6, pCO2 25, HCO3 20, pO2 60
B. pH 7.25, pCO2 83, HCO3 35, pO2 98
C. pH 7.25, pCO2 83, HCO3 35, pO2 60
D. pH 7.25, pCO2 25, HCO3 18, pO2 60
E. pH 7.7, pCO2 83, HCO3 35, pO2 60
C2 $500
70 yo male with a history of asthma undergoes right colectomy for cecal volvulus and
is found obtunded postop on the floor. A code is called and ABG drawn after which the
patient is intubated. Choose the correct ABG from below:
A. pH 7.6, pCO2 25, HCO3 20, pO2 60
B. pH 7.25, pCO2 83, HCO3 35, pO2 98
C. pH 7.25, pCO2 83, HCO3 35, pO2 60
D. pH 7.25, pCO2 25, HCO3 18, pO2 60
E. pH 7.7, pCO2 83, HCO3 35, pO2 60
C3 $100
Match the correct fluid compositions:
A. 0.9% NS
Na 513, Cl 513
B. 3% Saline
Na 130, Cl 109
C. 0.45% Saline
Na 154, Cl 154
D. LR
Na 77, Cl 77
C3 $100
Match the correct fluid compositions:
A. 0.9% NS
Na 154, Cl 154
B. 3% Saline
Na 513, Cl 513
C. 0.45% Saline
D. LR
Na 77, Cl 77
Na 130, Cl 109
C3 $200
A 30 Kg child is brought to the ER after an MVC. His pulse is 180 and BP 50/20. You
place an intraosseous line, resuscitate and after definitive management of injuries, he is
on the floor. Nurse calls you for IVF orders:
A. NS @ 70 cc/hr
B. LR @ 70 cc/hr
C. NS @ 60 cc/hr
D. LR @ 60 cc/hr
E. D5 1/2NS @ 70 cc/hr
C3 $200
A 30 Kg child is brought to the ER after an MVC. His pulse is 180 and BP 50/20. You
place an intraosseous line, resuscitate and after definitive management of injuries, he is
on the floor. Nurse calls you for IVF orders:
A. NS @ 70 cc/hr
B. LR @ 70 cc/hr
C. NS @ 60 cc/hr
D. LR @ 60 cc/hr
E. D5 1/2NS @ 70 cc/hr
- Maintenance IVFs:
- 4 cc/Kg/hr for 1st 10 Kg
- 2 cc/kg/hr for next 10 Kg
- 1 cc/kg/hr for each Kg after that
- Open abdominal surgery: 0.5-1 L/hr fluid loss from open abdomen
- Insensible losses: 10 cc/kg/day
- IVF replacement after surgery:
- 1st 24 hrs: LR
- After 24 hrs: D5½NS + 20 mEq KCl
C3 $300
LR is the replacement fluid of choice for all the following losses EXCEPT:
A. Diarrhea (K lost)
B. ECF from distal jejunum (HCO3 + K)
C. Bile (HCO3)
D. G tube losses (HCl)
E. Pancreatic fistula (HCO3)
C3 $300
LR is the replacement fluid of choice for all the following losses EXCEPT:
A. Diarrhea (K lost)
B. ECF from distal jejunum (HCO3 + K)
C. Bile (HCO3)
D. G tube losses (HCl)
E. Pancreatic fistula (HCO3)
- Maintenance IVFs:
- Replace all losses distal to the pylorus with LR
- May need to add HCO3 to pancreatic, biliary and enteric
- May need to add K to colonic losses
- Replace gastric loss with D5 ½ NS with 20 K
C3 $400
68 yo female with recent total colectomy and loop ileostomy presents with high
ostomy output, seizures and hypernatremia. Choose the most appropriate cause of
hypernatremia and treatment course:
A. Increased sodium reabsorption – D5 water given slowly (corrected < 0.7
mEq/L/hr)
B. Dehydration - D5 water
C. Dehydration - D5 water given slowly (corrected < 0.7 mEq/L/hr)
D. Active sodium excretion – D5 water given slowly (corrected <0.7 mEq/L/hr)
E. Dehyrdation – 0.45% NS given slowly (corrected < 0.7 mEq/L/hr)
C3 $400
68 yo female with recent total colectomy and loop ileostomy presents with high
ostomy output, seizures and hypernatremia. Choose the most appropriate cause of
hypernatremia and treatment course:
A. Increased sodium reabsorption – D5 water given slowly (corrected < 0.7
mEq/L/hr)
B. Dehydration - D5 water
C. Dehydration - D5 water given slowly (corrected < 0.7 mEq/L/hr)
D. Active sodium excretion – D5 water given slowly (corrected <0.7 mEq/L/hr)
E. Dehyrdation – 0.45% NS given slowly (corrected < 0.7 mEq/L/hr)
Hypernatremia
- MCC: Dehydration
- Rx:
- D5 water
- Slowly (<0.7 mEq/L/hr) to avoid brain swelling
C3 $500
A patient 3 days s/p lobectomy goes into acute renal failure with hyperkalemia
needing treatment with calcium gluconate, sodium bicarbonate, insulin and dextrose.
What is the mechanism for correction of hyperkalemia?
A. Inducing alkalosis which stimulates renal excretion of potassium
B. Inducing alkalosis which causes K to enter cells in exchange for Na
C. Inducing alkalosis which causes K to enter cells in exchange for H
D. K driven into intestinal lumen with insulin and glucose
E. K driven into cells with insulin and glucose
F. C and E
C3 $500
A patient 3 days s/p lobectomy goes into acute renal failure with hyperkalemia
needing treatment with calcium gluconate, sodium bicarbonate, insulin and dextrose.
What is the mechanism for correction of hyperkalemia?
A. Inducing alkalosis which stimulates renal excretion of potassium
B. Inducing alkalosis which causes K to enter cells in exchange for Na
C. Inducing alkalosis which causes K to enter cells in exchange for H
D. K driven into intestinal lumen with insulin and glucose
E. K driven into cells with insulin and glucose
F. C and E
Hyperkalemia
- MCC: Renal failure
- Rx:
1.
2.
3.
4.
5.
6.
•
1 amp Calcium gluconate (Cardiac membrane stabilizer)
1 amp NaHCO3 (Alkalosis causes K to enter cells in exchange for H)
10 U Insulin and 1 amp 50% dextrose (K driven into cells with glucose)
Kayexelate (long term)
Lasix
Dialysis (If not responding to above)
Pseudohyperkalemia:
• Hemolysis of blood sample
C4 $100
30 yo male ATV victim s/p ex lap and open abdomen in the ICU for >4 wks, started
having seizures and work up showed a serum sodium of 120. Which is the MOST
appropriate therapy for this patient?
A. Water restriction
B. Lasix
C. Water restriction followed by Lasix
D. 3% Hypertonic saline
E. Slow administration of 3% hypertonic saline (To correct <0.5 mEq/L/hr)
C4 $100
30 yo male ATV victim s/p ex lap and open abdomen in the ICU for >4 wks, started
having seizures and work up showed a serum sodium of 120. Which is the MOST
appropriate therapy for this patient?
A. Water restriction
B. Lasix
C. Water restriction followed by Lasix
D. 3% Hypertonic saline
E. Slow administration of 3% hypertonic saline (To correct <0.5 mEq/L/hr)
C4 $200
A diabetic patient with a history of HTN and hyperlipidemia presents with abdominal
pain, nausea and headaches and workup reveals Na-130, K-4.8, Glucose-300, Lipase200, cholesterol-270. What factors are contributing to hyponatremia?
A. Hyperglycemia
B. Hyperlipidemia
C. Elevated lipase levels
D. A and B
E. All of the above
C4 $200
A diabetic patient with a history of HTN and hyperlipidemia presents with abdominal
pain, nausea and headaches and workup reveals Na-130, K-4.8, Glucose-300, Lipase200, cholesterol-270. What factors are contributing to hyponatremia?
A. Hyperglycemia
B. Hyperlipidemia
C. Elevated lipase levels
D. A and B
E. All of the above
Hyponatremia
- MCC: Fluid overload
- Rx:
• If asymptomatic:
1. Water restriction
2. Diuresis
3. Hypertonic saline
• If symptomatic:
1. Hypertonic saline
•
Correct slowly to avoid CPM (<0.5 mEq/L/hr)
•
Pseudohyponatremia:
• Hyperglycemia or hyperlipidemia
• Rx underlying cause
C4 $300
A patient with chronic renal failure needs a screening colonoscopy. Which prep is
contraindicated in this patient?
A.
Golytely
B.
Nulytely
C.
D.
Mg sulfate
Fleets Phosphosoda
E.
C and D
C4 $300
A patient with chronic renal failure needs a screening colonoscopy. Which prep is
contraindicated in this patient?
A.
Golytely
B.
Nulytely
C.
D.
Mg sulfate
Fleets Phosphosoda
E.
C and D
CRF
- Electrolyte abnormalities:
- Volume overload
- Decreased Na and Ca
- Increased K, PO, Mg
- Any Mg & PO containing antacids and laxatives are C/I
C4 $400
A patient with thyroid cancer undergoes thyroidectomy and 2 days postop has perioral
tingling with positive Chvostek’s sign. Which of the following is NOT appropriate
therapy for this disease process?
A. Calcium gluconate administration
B. If hyperglycemic, administer insulin
C. Magnesium Sulfate administration
D. If hypoproteinemic, administer albumin
E. None of the above
C4 $400
A patient with thyroid cancer undergoes thyroidectomy and 2 days postop has perioral
tingling with positive Chvostek’s sign. Which of the following is NOT appropriate
therapy for this disease process?
A. Calcium gluconate administration
B. If hyperglycemic, administer insulin
C. Magnesium Sulfate administration
D. If hypoproteinemic, administer albumin
E. None of the above
Hypocalcemia
- MCC: Previous thyroid surgery  parathyroid injury/removal
- S&S:
- Perioral numbness (1st symptom)
- Chvostek’s Sign
- Trousseau’s sign
- Laryngospasm
- Hyperreflexia
- Prolonged QT interval
- Rx:
1. Calcium Gluconate
2. If not correcting, give Magnesium
•
Hypoprotonemia causes low Ca levels:
• 0.8 gram of Ca for each gram of protein
• No need to do anything
C4 $500
Which of the following is true concerning respiratory alkalosis?
A. Exposures to high altitudes can result in respiratory alkalosis
B. Renal compensation for respiratory alkalosis is obtained by means of increasing
excretion of bicarbonate
C. Symptoms of respiratory alkalosis can mimic those of hypercalcemia
D. Management of acute respiratory alkalosis should involve increased respiratory
rate
C4 $500
Which of the following is true concerning respiratory alkalosis?
A. Exposures to high altitudes can result in respiratory alkalosis
B. Renal compensation for respiratory alkalosis is obtained by means of increasing
excretion of bicarbonate
C. Symptoms of respiratory alkalosis can mimic those of hypercalcemia
D. Management of acute respiratory alkalosis should involve increased respiratory
rate
Respiratory Alkalosis
• Due to hyperventilation secondary to:
• Hypoxia: Most common causes are:
• Pulmonary disease
• High altitude
• Reflex stimulation of hyperventilation from mechanical ventilation or
decreased pulmonary compliance
• Drugs
• Symptoms:
• Think Hysteria (SOB, nervousness, dizziness)
• Decreased pCO2  decreased cerebral blood flow
• Hypocalcemia (perioral and extremity tingling, tetany)
• Increased pH  decreased ionized calcium levels
• Renal Compensation:
• From decreased NH4 excretion (acid) and increased organic anion
excretion
Questions 1-5
The first step in the management of acute hypercalcemia should be:
A. Correction of deficit of extracellular fluid volume
B. Hemodialysis
C. Administration of furosemide
D. Administration of mithramycin
Which of the following statements is true regarding total body water (TBW)?
A.
TBW in men represents a higher percentage of body weight that it does in
women
B. In infants, TBW constitutes up to 40% of body weight
C. TBW content increases with increasing age
D. TBW is equally distributed within the intracellular and extracellular
compartments
In a patient with acute renal failure, the LEAST urgent reason for dialysis is:
A. Blood urea nitrogen> 100mL/dL
B. Hyperkalemia
C. Severe acidosis
D. Uremic pericarditis
Initial administration of fluid during the resuscitation of a patient who has a gunshot
wound of the abdomen results in a rise in blood pressure to 110/80 mm Hg. At this
point, arterial blood gases are pH, 7.25; PO2, 95 mm Hg; PCO2, 25 mm Hg; HCO3-,
15 mEq/L. The patient’s metabolic acidosis would be treated best with:
A. Tromethamine
B. Sodium bicarbonate
C. A balanced salt solution
D. Hyperventilation
Patient with gastric outlet obstruction and protracted vomiting will have all of the
following EXCEPT:
A. Hypokalemia
B. Hyperchloremia
C. Metabolic alkalosis
D. Increased urinary H+ excretion
The first step in the management of acute hypercalcemia should be:
A. Correction of deficit of extracellular fluid volume
B. Hemodialysis
C. Administration of furosemide
D. Administration of mithramycin
Which of the following statements is true regarding total body water (TBW)?
A.
TBW in men represents a higher percentage of body weight that it does in
women
B. In infants, TBW constitutes up to 40% of body weight
C. TBW content increase with increasing age
D. TBW is equally distributed within the intracellular and extracellular
compartments
TBW
- Fat has less water. Women have more fat  less TBW
- TBW:
- Women: 50% body weight
- Men: 60% body weight
- Infants: 80% body weight
- Thus proving guys are just a ‘mature kid’
- TBW  ICF and ECF:
- ICF: 2/3rd
40% body weight
- ECF: 1/3rd
20% body weight
In a patient with acute renal failure, the LEAST urgent reason for dialysis is:
A. Blood urea nitrogen> 100mL/dL
B. Hyperkalemia
C. Severe acidosis
D. Uremic pericarditis
Initial administration of fluid during the resuscitation of a patient who has a gunshot
wound of the abdomen results in a rise in blood pressure to 110/80 mm Hg. At this
point, arterial blood gases are pH, 7.25; PO2, 95 mm Hg; PCO2, 25 mm Hg; HCO3-,
15 mEq/L. The patient’s metabolic acidosis would be treated best with:
A. Tromethamine
B. Sodium bicarbonate
C. A balanced salt solution
D. Hyperventilation
Patient with gastric outlet obstruction and protracted vomiting will have all of the
following EXCEPT:
A. Hypokalemia
B. Hyperchloremia
C. Metabolic alkalosis
D. Increased urinary H+ excretion
- Loss of HCl from stomach (Hypochloremic alkalosis)
- Dehydration causes kidneys to reabsorb Na and water in exchange for K
(Na/K/ATPase) causing hypokalemia (Hypokalemia)
- K/H exchanger activated. Reabsorbs K, excretes H. (Paradoxical aciduria)