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Dehydration

Dehydration. Department of Geriatric Medicine Edward Warren, MD, Chair Geriatrics, Carolinas Campus, February 2012. Past Medical History. Recent CHF( congestive heart failure) Left Ventricular Ejection Fraction of 20% Cor pulmonale HTN (hypertension)

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Dehydration

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  1. Dehydration Department of Geriatric Medicine Edward Warren, MD, Chair Geriatrics, Carolinas Campus, February 2012

  2. Past Medical History • Recent CHF( congestive heart failure) • Left Ventricular Ejection Fraction of 20% • Corpulmonale • HTN (hypertension) • S/P (status post) CVA( cerebrovascular accident • Alzheimer's dementia • COPD ( chronic obstructive pulmonary disease) • Pulmonary hypertension

  3. Surgical History • Cholecystectomy • Cardiac Catheterization without abnormality on recent hospital admission • 4 vessel CABG ( coronary artery bypass graft) 5 years earlier

  4. History of Present Illness 98 Year old white female with increasing lethargy and mental confusion over the past 2 days. Patient has recently returned from the hospital after being successfully treated for congestive heart failure. Nursing staff states that she has being doing well since her return and that she has been eating and sleeping well, but awakening due to nocturia.

  5. Medications • Aspirin 81 mg - 1 tab po daily • Sildenafil 20 mg - 1 tab po tid • Furosemide 40 mg - 2 tabs po bid • KCl 40 meq - 1 tab po qd • Lisinopril 20 mg - 1 tab po qd • Fluticasone/salmeterol 500/50 - 1 puff bid

  6. Review of Symptoms • Patient is poorly arousable and denies shortness of breath (SOB), chest pain ,or headache. In fact she states that she feels “OK”. Staff relates that patient has had no bowel movement today and that they’re not sure when she last voided.

  7. Physical Exam • Vitals: T 98.2 P 90 and reg.-supine, P 115 standing R 24 and regular BP120/80 supine and 100/60 standing O2 Sat 88%( staff states that this is “normal for her”) Weight 70 Kg Height 152.4 cm • Heent: PERRLA, EOM equal bilaterally, sclerae slightly injected, buccal mucosa dry and tacky, Not erythematous and not injected. • Neck: neck veins flat , no JVD, bruit, nor lymphadenopathy. • Heart: increased rate with regular rhythm, No S3/ S4, no murmurs • Lungs: clear to auscultation and percussion. • Abdomen: Obese, BS present but decreased in all quadrants, No organomegaly • Extremities: No clubbing nor cyanosis. Trace pitting edema bilateral lower extremities • Skin: Dry, with widespread tenting, cap refill >3 sec • Neuropsych: patient is arousable to loud voice. Patient can answer simple questions but appears sleepy.

  8. Case Question 1 The patient in the preceding case has a decreased level of consciousness. This is most likely due to • Myocardial infarction • Hypoxemia due to her CorPulmonale • Hyperkalemia • Dehydration • Congestive heart failure

  9. Case Question 2 If this patients serum Creatinine is 2.0, what would be her rough estimate of GFR in ml/min ? a. 5.85 b. 15.65 c. 17.35 d. 20.85 e. 25.35

  10. Case Question 3 This patient’s symptoms are due to hypovolemia and she has relatively normal renal function. Would you expect her to be FENa( Fractional Excretion of Sodium) to be a. Greater than 1% b. Less than 1%

  11. Case Question 4 Which of her medications would you think most contributory to her current situation? a. Lisinopril b. Furosemide c. Fluticasone/salmeterol d. KCl e. Sildenafil

  12. Case Question 5 Which of the following is most consistent in all parameters with dehydration in an elderly patient? a. Na 155,FENa < 1%, BUN 40, weight decreased b. Na 125,FENA > 1%, BUN 12.5, weight stable c. Na 155,FENa 4%, BUN 15, weight increased d. Na 125,FENA > 1%, BUN 10, weight unchanged e. Na 135,FENa > 1%, BUN 20, weight increased

  13. Question Answers 1. Dehydration, “d”, is the answer. -An acute MI is not supported by any findings in the history such as chest tightness or dyspnea, and the coronaries were recently found to be OK. -Hypoxemia due to her corpulmonale and CHF is not the cause of the delirium because the hypoxia is mild at worst and it is said to be her usual state. -Hyperkalemia is not documented in the history at all. Even if it were there, it would not cause a mental status change. The dose of KCl is half of that indicated by the dose of furosemide. Still the lisinopril and renal failure could result in a high K. -CHF is unlikely with modest edema, no JVD, and clear lungs. 2. 17.35, “c” is the answer. Estimated creatinine clearance = [(140 - age) (weight in kg) (0.85 for female)] / [(72)(serum creatinine)] [(140 – 98)(70 kg)(0.85)] / [(72)(2 mg/dl)] = 17.35 • FENa is less than 1% in hypovolemia with normal renal function. This retains Na and water in the body to restore homeostasis. • The drug most responsible is furosemide (it is also a massive dose), “b”. The other listed medications would not do this, except for the lisinopril which does inhibit proper renal function.

  14. Question Answers 5. “a”, Na 155,FENa < 1%, BUN 40, weight decreased is the correct answer. The Na is high due to difficulty in maintaining hydration in elderly. The FENa is low due to resorption of Na in the kidneys from the stimulus of hypovolemia. The BUN is elevated from prerenal azotemia. As the Na is resorbed, urea is resorbed with it passively. The weight is down due to water loss. Every pint lost is a pound.

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