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Electrolytes Conference

Electrolytes Conference. 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. Chief Complaint. Dizziness. HPI. Hypertensive (2000)

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Electrolytes Conference

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  1. Electrolytes Conference

  2. General Data • Name of Patient: M.C.B. • Age/Sex: 96 yrs.old / Female • Address:MeycauyanBulacan • Civil Status: Married • Nationality: Filipino • Occupation: none • Religion: Catholic

  3. Chief Complaint • Dizziness

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. Personal and Social History • Denies smoking, denies ethanol beverage drinking, denies illicit drug use • Mixed food diet • No regular exercise

  10. Family History • (+) DM type 2 - son • (+) Bell’s palsy -Son • (+) Heart attack HPN – eldest son • (-) Cancer, (-) allergies, (-) asthma (-) blood dyscaria • (-) thyroid disease

  11. Physical Examination • Conscious, lethargic, incoherent, wheelchair borne, in respiratory distress • BP:140/80mmHg CR 60bpm/regularRR 29cpm/regular T 36.7oC • Ht 157.48 cm Wt: 70kg BMI: 29 • Warm moist skin, (+) hematoma(bluish-black patches) over the upper extremities, chest and back; (+) pustules scattered at the neck and face; (+) jaundice

  12. 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

  13. Physical Examination I:Symmetric chest expansion, no use of accessory muscles, (-) intercostal retractions P: Equal tactile and vocal fremiti on both lungs P: Resonant on both lung fields upon percussion A: Clear breath sounds on both lung fields (-) crackles

  14. Physical Examination JVP: 3.5 cm at 30 degrees Carotid pulse: rapid upstroke, gradual downstroke, Adynamicprecordium, apex beat at 6th LICS AAL sustained, localized, no thrills, lifts, heaves, S1>S2 at the apex, S2>S1 on the base, no murmurs

  15. Physical Examination Abdomen: I: flabby abdomen (-) visible pulsation, (-) distension A: Normoactive bowel sounds, (-) bruit P: Tympanitic on all quadrants, Traube’s space not obliterated P: 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

  16. 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

  17. Assessment on admission • ASHD, CAD Sinus bradycardia, left ventricular hypertrophy, t/c sinus node disease, not in failure, Class III-C • Sepsis, prob 2nd to UTI • Hemolytic anemia, prob 2nd to sepsis • Multiple fractures, R humerus, pelvis • t/c electrolyte imbalance prob 2nd to diuretic use (thiazide)

  18. 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

  19. 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

  20. 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 prnfor pain • For blood transfusion of 2 U of pRBC • Coaptation splint, right arm • Calcium gluconate 10%, 10ml

  21. Laboratory Results

  22. Coombs Test • Direct - Negative • Indirect - Negative • Autocontrol - Negative

  23. Laboratories September 30, 2010 • SGPT : 41.21 • Total Bilirubin 7.22 • Direct Bilirubin 1.24 • Indirect Bilirubin 5.98 • LDH: 1,250

  24. Laboratory Results

  25. 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

  26. CAUSES OF HYPONATREMIA I. Pseudohyponatremia A. Normal plasma osmolality 1. Hyperlipidemia 2. Hyperproteinemia 3. Posttransurethral resection of prostate/bladder tumor B. Increased plasma osmolality 1. Hyperglycemia 2. Mannitol

  27. CAUSES OF HYPONATREMIA II. Hypoosmolalhyponatremia A. Primary Na+ loss (secondary water gain) 1. Integumentary loss: sweating, burns 2. Gastrointestinalloss: vomiting, tube drainage, fistula, obstruction, diarrhea 3. Renal loss: diuretics, osmotic diuresis, hypoaldosteronism, salt-wasting nephropathy, postobstructivediuresis, nonoliguric acute tubular necrosis

  28. CAUSES OF HYPONATREMIA B. Primary water gain (secondary Na+ loss) 1. Primary polydipsia 2. Decreased solute intake (e.g., beer potomania) 3. AVP release due to pain, nausea, drugs 4. Syndrome of inappropriate AVP secretion 5. Glucocorticoid deficiency 6. Hypothyroidism 7. Chronic renal insufficiency

  29. CAUSES OF HYPONATREMIA C. Primary Na+ gain (exceeded by secondary water gain) 1. Heart failure 2. Hepatic cirrhosis 3. Nephrotic syndrome

  30. 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.

  31. Four laboratory findings provide useful information and narrow the differential diagnosis of hyponatremia: • the plasma osmolality • the urine osmolality • the urine Na+ concentration • the urine K+ concentration

  32. BUN/Crea Ratio 34.57/0.91 34.57/0.87 40:1 *>20:1 pre renal azotemia

  33. Patient is a known hypertensive since 2000; she is maintained on losartan + hydrochlorthiazide (Combivex) 50 mg/tab 1 tab OD and is compliant.

  34. Diuretic Use • Hydrochlorothiazide • Is a thiazide diuretic mainstay in essential hypertension • Acts by decreasing plasma volume and thus decreasing cardiac output

  35. Distal tubules • Diuretic-induced hyponatremia is almost always due to thiazide diuretics • Inhibits NaClreabsorption at the luminal side of epithelial cells of the DCT, via the NCC transporter

  36. Correction for Hyponatremia • Goals are: • Raise the plasma Na concentration by restricting water intake and promoting water loss • Correct the underlying disorder

  37. 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)

  38. 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

  39. Correction for Hyponatremia • Rate of correction • If with severehyponatremia(<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

  40. Correction for Hyponatremia • Rate of correction • (Desired Na – Actual Na) x wt. In kg x 0.5/0.6 (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

  41. Correction for Hyponatremia • Rate of correction • (Desired Na – Actual Na) x wt. In kg x 0.5/0.6 Actual Computation for our patient: 10 x 0.7 x 0.5 = 350 meq **add Urine Na loss at 50meq/L UO at 1450ml 1.45L x 50 meq = 73 meq Add total need + compensate for Urine Na loss 350 + 73 =423 meq

  42. Actual Computation for our patient: 10 x 0.7 x 0.5 = 350 meq **add Urine Na loss at 50meq/L UO at 1450ml 1.45L 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 meqNaCl 1L PNSS = 154 meq 154 + 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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