general data name of patient: m.c.b. age/sex: 96 yrs.old / female address: meycauyan bulacan ...
TRANSCRIPT
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ELECTROLYTES CONFERENCE
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General Data
Name of Patient: M.C.B. Age/Sex: 96 yrs.old / Female Address: Meycauyan Bulacan Civil Status: Married Nationality: Filipino Occupation: none Religion: Catholic
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Chief Complaint
Dizziness
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HPI Hypertensive (2000)
Highest: 160/100 mmHg; Usual 120/80 mmHg
Losartan potassium + hydrochlorthiazide (combizar) 50mg OD
Interval period: (+) chest heaviness, relieved by intake of meloxicam 15mg prn
8 days PTA (+) dizziness, fell (-) loss of consciousness
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HPI 7 days PTA
(+) pain, swelling, bruises right shoulder and arm
POC, X ray right shoulder was done A> Oblique fracture displaced head of the
proximal humerus right M> cast was applied, celecoxib 500mg/tab
1 tab BID then prn; TCB: 2 weeks after 6 days PTA
(+) bruises chest, back (+) pain at the right shoulder area
temporary relived by celecoxib (+) gradual loss of appetite, (+) weakness,
(+) bed ridden
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HPI 3 days PTA
(+) yellow discoloration of the skin (-) abdominal pain, (-) vomiting, (+) tea colored urine; (-) changes in
stool characteristics, (-) hematochezia, (-) hematemesis
2 day PTA Agitated, removed the bandage of the cast (+) pain at the right shoulder POC: work up and cast placement done CBC: anemia(hgb 62, hct 0.19); Urinalysis: pyuria
(28-30/hpf) and bacteuria (3+) PT and aPTT: elevated ECG: marked sinus bradycardia
Due to lack of facilities, patient opted to transfer to our institution, hence admission
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Review of Systems
No nausea, vomiting No tinnitus, ear discharge No epistaxis, nasal discharge No gum bleeding, (-) hyperemic pharyngeal wall No hematemesis, no hematochezia No heat or cold intolerance, tremors, polydipsia,
polyuria (+) urgency, frequency, no flank pain,
hypogastric pain No limitation of Range of motion, Myalgia No seizures, paresthesia, headache
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Past Medical History
Enucleation Right eye : Glaucoma (1980’s) Hypertensive Urgency (2007) MCU
BP: 160/100 mmHg (highest) Usual 120/80mmHg (+) epistaxis (-) chest pain, headache, nape pain or focal
deficit Nasal packing was done.
Fracture of the right proximal leg (2008) Cataract surgery left eye (2009) (-) DM, allergies, Asthma, Thyroid disease
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Personal and Social History
Denies smoking, denies ethanol beverage drinking, denies illicit drug use
Mixed food diet No regular exercise
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Family History
(+) DM type 2 - son (+) Bell’s palsy -Son (+) Heart attack HPN – eldest son (-) Cancer, (-) allergies, (-) asthma (-)
blood dyscaria (-) thyroid disease
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Physical ExaminationConscious, lethargic, incoherent,
wheelchair borne, in respiratory distressBP:140/80mmHg CR 60bpm/regular
RR 29cpm/regular T 36.7oCHt 157.48 cm Wt: 70kg BMI: 29Warm moist skin, (+) hematoma(bluish-
black patches) over the upper extremities, chest and back; (+) pustules scattered at the neck and face; (+) jaundice
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Enucleated right eye; Left eye: pale palpebral conjunctivae, icteric sclera, pupil 3-4mm ERTL
No tragal tenderness, midline septum, no nasoaural discharge
Moist buccal mucosa, uvula midline, tonsils not enlarged, non-hyperemic posterior pharyngeal wall
Supple neck, neck veins not distended, trachea midline, no palpable cervical lymphadenopathies, no thyromegaly
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Physical Examination
I:Symmetric chest expansion, no use of accessory muscles, (-) intercostal retractionsP: Equal tactile and vocal fremiti on both lungsP: Resonant on both lung fields upon percussionA: Clear breath sounds on both lung fields(-) crackles
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Physical Examination
JVP: 3.5 cm at 30 degrees Carotid pulse: rapid upstroke, gradual downstroke, Adynamic precordium, apex beat at 6th LICS AAL sustained, localized, no thrills, lifts, heaves, S1>S2 at the apex, S2>S1 on the base, no murmurs
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Physical ExaminationAbdomen:I: flabby abdomen (-) visible pulsation, (-) distensionA: Normoactive bowel sounds, (-) bruit P: Tympanitic on all quadrants, Traube’s space not obliteratedP: No masses, (+) CVA tenderness, Liver span 8cm, smooth liver edge
Musculoskeletal/Extremities:Right shoulder:(+) cast/ splint, bruises, edema, limitation of motion
Rest of the extremities:No swelling, no cyanosis, clubbing, edema
Pulses are full and equal
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Neurologic Examination
Conscious, lethargic, not oriented to time and place
GCS 10 (E3V2M5)Cranial Nerves:
◦ II – pupils 3mm constricting to 2mm ERTL, no ptosis, (+) ROR, III, IV, VI – EOMs full and equal , V – Intact motor, (+) corneal reflex, VII – No facial asymmetry, can raise eyebrows, can frown, smile, and puff out both cheeks, VIII – slight hearing deficit, IX, X – Uvula midline ,XI – Can raise shoulder, XII – Tongue midline on protrusion
Not assessed due to patients uncooperativeness:Cerebellar ,MMT, Sensory
DTR’s +2 on all extremities except the right upper extremities
No signs of meningeal irritation
No Babinski, no pathological reflexes
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Assessment on admission
1. ASHD, CAD Sinus bradycardia, left ventricular hypertrophy, t/c sinus node disease, not in failure, Class III-C
2. Sepsis, prob 2nd to UTI3. Hemolytic anemia, prob 2nd to sepsis4. Multiple fractures, R humerus, pelvis5. t/c electrolyte imbalance prob 2nd to
diuretic use (thiazide)
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Plans
General Neutropenic Diet IVF: PNSS IL to run at 24 gtts/min Monitor VS q1 and record Monitor I&O q shift and record
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Plans
Diagnostic CBC with platelet count, retic count; PT, aPTT;
ABO and rH Peripheral smear Creatinine, LDH Na, K, iCa, iPO, Mg Xray of the right humerus 12 lead ECG Plasma osmolality Urine culture and sensitivity 2 D echo once stable
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Plans
Therapeutic Atorvastatin 80mg/tab 1 tab ODHS Enalapril 5mg/tab 1 tab OD Trimetazidine 35mg/tab 1 tab BID Tramadol ₊ Paracetamol tab 1 tab q8
prn for pain For blood transfusion of 2 U of pRBC Coaptation splint, right arm Calcium gluconate 10%, 10ml
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Laboratory ResultsDate Time Na Urine
NaK Urine
KiCa Mg iPO
49/30/2010
9:00pm 111.44
4.41
1.09
1.75
10/1/2010
7:15am 115 50 4.38
27.31
5:40pm 118 3.50
2.21
10/2/2010
5:15am 120 3.36
1:50pm 126.67
3.99
9:51pm 126.32
3.92
10/3/2010
11:00am 126 4.28
9:15pm 128.69 3.63
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Creatinine BUN Plasma Osmolality
Urine Osmolality
9/30/2010
0.91
10/1/2010
34.57 272 374
10/2/2010
0.87
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Coombs Test Direct - Negative Indirect - Negative Autocontrol - Negative
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Ref range Unit 9/30 10/6
Hgb 120-170 g/L 82 99
HCT 0.37-0.54 0.23 0.29
Platelet 150-450 X10^9/L 216 222
WBC 4.5-10.0 X10^9/L 29 11.40
Differential Count
Neutrophils 0.50-0.70 0.83 0.90 0.75
-Metamyelocytes
-Bands 0.00-0.05 0.04
-Segmented 0.50-0.70 0.86
Lymphocytes 0.20-0.40 0.10 0.23
Monocytes 0.00-0.07 0.01
Eosinophils 0.00-0.05 0.01
Basophils 0.00-0.01
retics 245
RPI 2.39
Nucleated rbc 03n/100wbc
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Laboratories
September 30, 2010 SGPT : 41.21 Total Bilirubin 7.22
Direct Bilirubin 1.24 Indirect Bilirubin 5.98
LDH: 1,250
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Urinalysis Date Findings
10/1/10 Color: reddish Consistency: sl. Turbid pH 6.5 spgr 1.015 alb +++ sugar (-) RBC 3-6/hpf pus cell 10-15/hpf bacteria ++ a. urates ++
10/6/10 Color: yellow, turbid, 5.0, 1.020, hya 03/cvrslp, granular over 50/cvrslp, sugar++ alb++, rbc 0-3hlf, pus cell 15-25/hpf, bact4+, MT2+, AU 3+
9/31 10/1Trop I 0.17
CKMM 3101.91
CKMB 50.09
CK total 3132
10/1
PT 12.6
aPTT 36.8
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Chest XrayDate
Findings
10/1/10 Cardiomegay, left ventricular, atheromatous aorta, mild pulmonary congestion, incidentally, marked osteopenia of the visualized bony structures
10/3/10 Slight progression of the previously noted mild pulmonary congestion. NGT noted. Previously noted comminuted fractures of the right proximal humerus, the rest of the findings : no significant interval change
V. ECGDate
Findings
9/31/10 Sinus bradycardia, non specific ST-T wave changes
10/1/10 Sinus rhythm, 1sr degree AV block, note: compared to EC tracing done 9/30/10; 8:pm severe bradycardia is now absent
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Laboratory ResultsDate Na Urine
NaK Urine K iCa Mg iPO4
9/30/2010 111.44 4.41 1.09 1.75
10/1/2010 118 3.50 2.21
115 50 4.38 27.31
10/2/2010 120 3.36
126.67 3.99
126.32 3.92
10/3/2010 128.69 4.28
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Creatinine BUN Plasma Osmolality
Urine Osmolality
9/30/2010
0.91
10/1/2010
34.57 272 374
10/2/2010
0.87
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Hyponatremia
plasma Na+ concentration <135 mmol/L
Water shifts into cells causing cerebral edema
125 mEq/L – nausea and malaise 120 mEq/L – headache, lethargy,
obtundation <110-115 mEq/L – altered mental
status/ seizures
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CAUSES OF HYPONATREMIA
I. PseudohyponatremiaA. Normal plasma osmolality
1. Hyperlipidemia2. Hyperproteinemia3. Posttransurethral resection of
prostate/bladder tumorB. Increased plasma osmolality
1. Hyperglycemia2. Mannitol
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CAUSES OF HYPONATREMIA
II. Hypoosmolal hyponatremiaA. Primary Na+ loss (secondary water gain)1. Integumentary loss: sweating, burns2. Gastrointestinal loss: vomiting, tube drainage, fistula, obstruction, diarrhea3. Renal loss: diuretics, osmotic diuresis, hypoaldosteronism, salt-wasting nephropathy, postobstructive diuresis, nonoliguric acute tubular necrosis
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CAUSES OF HYPONATREMIA
B. Primary water gain (secondary Na+ loss)1. Primary polydipsia2. Decreased solute intake (e.g., beer potomania) 3. AVP release due to pain, nausea, drugs4. Syndrome of inappropriate AVP secretion5. Glucocorticoid deficiency6. Hypothyroidism7. Chronic renal insufficiency
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CAUSES OF HYPONATREMIA
C. Primary Na+ gain (exceeded by secondary water gain)1. Heart failure2. Hepatic cirrhosis3. Nephrotic syndrome
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Signs and Symptoms of Hyponatremia
The clinical manifestations of hyponatremia are related to osmotic water shift leading to increased ICF volume,
Therefore the symptoms are primarily neurologic, nausea and malaise. headache, lethargy, confusion, and
obtundation. Stupor, seizures, and coma <120 mmol/L or
decreases rapidly.
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Four laboratory findings provide useful information and narrow the differential diagnosis of hyponatremia:
1. the plasma osmolality2. the urine osmolality3. the urine Na+ concentration4. the urine K+ concentration
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Plasma Osmolality
Urine Osmolality
10/1/2010
272 374
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Date Urine Na Urine K
10/1/2010 50 27.31
Creatinine
BUN
9/30/2010
0.91
10/1/2010
34.57
10/2/2010
0.87BUN/Crea Ratio34.57/0.9134.57/0.87
40:1 *>20:1 pre renal
azotemia
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Patient is a known hypertensive since 2000; she is maintained on losartan + hydrochlorthiazide (Combivex) 50 mg/tab 1 tab OD and is compliant.
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Diuretic Use
Hydrochlorothiazide Is a thiazide diuretic mainstay in
essential hypertension Acts by decreasing plasma volume and
thus decreasing cardiac output
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Distal tubules
Diuretic-induced hyponatremia is almost always due to thiazide diuretics
Inhibits NaCl reabsorption at the luminal side of epithelial cells of the DCT, via the NCC transporter
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Correction for Hyponatremia Goals are:
1. Raise the plasma Na concentration by restricting water intake and promoting water loss
2. Correct the underlying disorder
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Correction for Hyponatremia Asymptomatic Hyponatremia
If Mild, requires no treatment If with ECF volume contraction
Na repletion with Isotonic Saline Solution
If with Edematous states Restriction of Na and water intake,
correction of hypokalemia, promotion of water loss in excess of Na (with use of loop diuretic and replacement of Urinary losses)
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Correction for Hyponatremia Rate of correction
Depends on the presence or absence of neurologic symptoms [ (+) lethargy, GCS10 ] If asymptomatic, plasma Na concentration
should not be raised by no more than 0.5-1.0mmol/L per hour and by less than 10-12 mmol/L over the next 24 hours
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Correction for Hyponatremia Rate of correction
If with severe hyponatremia (<110-115mmol/L) Treated with Hypertonic Saline and the
plasma Na concentration should be raised by 1-2mmol/L per hour for the 1st 3-4 hours or until seizures subside
Plasma concentration should not be raised by no more than 12mmol/L during the 1st 24 hours
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Correction for Hyponatremia Rate of correction
(Desired Na – Actual Na) x wt. In kg x 0.5/0.6Date Na K
9/30/2010 111.44 4.41
10/1/2010 118 3.50
115 4.38
10/2/2010 120 3.36
126.67 3.99
126.32 3.92
10/3/2010 128.69 4.28
(120-111.44) x 70kg x 0.5 = ?(10) x 70 x 0.5 = 350 meq
Using PNSS In 1L PNSS 154meq
(350/154+100) x 1000 = ?(2.2) x 1000 =682.26cc
682.26/24hours = 28cc/hr monitor via infusion pump
*repeat serum Na after 4-6hours
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Correction for Hyponatremia Rate of correction
(Desired Na – Actual Na) x wt. In kg x 0.5/0.6Date Na K
9/30/2010 111.44 4.41
10/1/2010 118 3.50
115 4.38
10/2/2010 120 3.36
126.67 3.99
126.32 3.92
10/3/2010 128.69 4.28
Actual Computation for our patient:10 x 0.7 x 0.5 = 350 meq
**add Urine Na loss at 50meq/LUO at 1450ml1.45L x 50 meq = 73 meq
Add total need + compensate for Urine Na loss 350 + 73 =423 meq
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Actual Computation for our patient:10 x 0.7 x 0.5 = 350 meq
**add Urine Na loss at 50meq/LUO at 1450ml1.45L x 50 meq = 73 meq
Add total need + compensate for Urine Na loss 350 + 73 =423 meq
Fluid to be used is: 1L PNSS incorporated with 200 meq NaCl
1L PNSS = 154 meq154 + 200 meq = 354 meq
(423/354) x 1000 = 1194.9
1194.9/24 hours = 50cc/hr
So....Start IVF PNSS 1L + 200meq NaCl to run for 50cc/hr
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Correction for Hyponatremia Rate of correction
If with severe hyponatremia (<110-115mmol/L) Treated with Hypertonic Saline and the
plasma Na concentration should be raised by 1-2mmol/L per hour for the 1st 3-4 hours or until seizures subside
Plasma concentration should not be raised by no more than 12mmol/L during the 1st 24 hours
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Date
Time Na
9/30 9:00pm 111.4410/1 7:15am 115
5:40pm 11810/2 5:15am 120
1:50pm 126.679:51pm 126.32
10/3 11:00am
126
9:15pm 128.69
•9pm – 7am 10 hours
•115 – 111.44 = 3.56 mmol/L
•3.56 / 10 hours = 0.356mmol/L per
hour
•9pm – 5:40pm 20 hours118-111.44 = 6.56 mmol/L
•6.56 / 20 hours =0.328mmol/L per
hour
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Thank you!