******* ELECTROLYTE QUIZ ******* Biff F. Palmer, M.D. and Michael Emmett, MD Question 1 A 64 year old female presented with the recent (2-3 months) onset of hypertension, diabetes mellitus, and for the for the past two weeks had progressive weakness and confusion. She had been in good health and held a responsible position as an Arthur Anderson auditor. Question 1 (continued) Physical examination revealed the following: A confused woman, BP: 165/105 mmHg, Afebrile, RR: 15/min; HEENT: unrevealing but for brown discoloration of her forehead and cheeks; Wheezing which cleared with coughing was noted; Heart, Abdomen and Pelvic examinations were normal. Neurological Examination: Although confused as to time and place she had no localizing findings All four and place she had no localizing findings. All four extremities revealed weakness (+1/+4). Question 1 (continued) Key Laboratory Observations included: Electrolytes: Na 145 mM, K 1.7 mM, Cl 100 mM, Total CO2 30 mM. BUN 25 mg%; Creatinine 1.2 mg%; Glucose: 230 mg%; Plasma ACTH: 2,100 pg/ml; 24 Hour Urinary excretion of K: 150 mmols 24 Hour Urinary excretion of K: 150 mmols Question 1-A: Which ONE of the following diagnoses is the MOST likely cause of this patients syndrome? a. Adenoma of the anterior pituitary gland (Cushings Disease) b Adenoma of the adrenal corte b. Adenoma of the adrenal cortex c. Carcinoma of the adrenal cortex d. Oat cell carcinoma of the lung e. Surreptitious vomiting and volume contraction Question 1-A: Which ONE of the following diagnoses is the MOST likely cause of this patients syndrome? a. Adenoma of the anterior pituitary gland (Cushings Disease) b Adenoma of the adrenal corte b. Adenoma of the adrenal cortex c. Carcinoma of the adrenal cortex d. Oat cell carcinoma of the lung * e. Surreptitious vomiting and volume contraction Question 1-B: Which ONE of the following therapies would MOST likely stop her kaliuresis? a. Bilateral adrenalectomies b. High dose ketoconazole c Lisinopril c. Lisinopril d. Trimethoprim e. Amiloride Question 1-B: Which ONE of the following therapies would MOST likely stop her kaliuresis? a. Bilateral adrenalectomies b. High dose ketoconazole c Lisinopril c. Lisinopril d. Trimethoprim e. Amiloride * Question 2 Two patients present with plasma Ks of 2.5 mEq/l. One of the patients has hypokalemic periodic paralysis, while the other has hypokalemia from vomiting. Question 2: Which ONE of the following statements is TRUE? a. The patient with periodic paralysis is more likely to be symptomatic because he has a higher intracellular K concentration. b. The patient with vomiting is more likely to be t ti b f th i t t symptomatic because of the coexistent metabolic alkalosis. c. The patient with periodic paralysis is more likely to be symptomatic because of coexistent Na channel mutations. d. Both are equally likely to be symptomatic. Question 2: Which ONE of the following statements is TRUE? a. The patient with periodic paralysis is more likely to be symptomatic because he has a higher intracellular K concentration. * b. The patient with vomiting is more likely to be symptomatic because of the coexistent metabolic alkalosis. c. The patient with periodic paralysis is more likely to be symptomatic because of coexistent Na channel mutations. d. Both are equally likely to be symptomatic. Question 3: Which ONE of the following therapeutic/diagnostic agents does NOT cause hyperkalemia? a. Lysine b. Arginine c Epsilon amino caproic acid c. Epsilon amino caproic acid d. Meglumine e. Tris Buffer (Tromethamine) Question 3: Which ONE of the following therapeutic/diagnostic agents does NOT cause hyperkalemia? a. Lysine b. Arginine c Epsilon amino caproic acid c. Epsilon amino caproic acid d. Meglumine * e. Tris Buffer (Tromethamine) Question 4: A patient with diabetic ketoacidosis presents with a serum K concentration of 4 mEq/l. Which ONE of the following statements is most likely TRUE? a. This patient has normal K stores. b. This patient has high potassium stores due to volume contraction and the concomitant oliguria. Th ti t h l t i t d t c. The patient has low potassium stores due to an osmotic diuresis, but serum K is normal because K losses are not large enough. d. The patient has low potassium stores due to an osmotic diuresis, but serum K is normal because K shifts out of cells in response to the metabolic acidosis. e. The patient has low potassium stores due to an osmotic diuresis, but serum K is normal because K shifts out of cells in response to insulin deficiency. Question 4: A patient with diabetic ketoacidosis presents with a serum K concentration of 4 mEq/l. Which ONE of the following statements is most likely TRUE? a. This patient has normal K stores. b. This patient has high potassiumstores due to volume contraction and the concomitant oliguria. c. The patient has low potassiumstores due to an osmotic diuresis, but serum K is normal because K losses are not large enough. d. The patient has low potassiumstores due to an osmotic diuresis, but serum K is normal because K shifts out of cells in response to the metabolic acidosis. e. The patient has low potassium stores due to an osmotic diuresis, but serum K is normal because K shifts out of cells in response to insulin deficiency. * Question 5 J L is a 27 year old Caucasian male with stable renal failure from chronic interstitial nephritis. His BUN, creatinine and serum potassium have been measured daily for each of the past five days and have all values have been 100 mg%, 10 mg% and 4.7 mM, respectively. Question 5 (continued) RL, his identical twin brother, has also had the same chemical studies made on each of the past five days and they have all been 10 mg%, 1.0 mg% and 4.7 mM, respectively. Theyve been ingesting identical amounts of an identical diet for the past five days. Their body weights and muscle mass are identical. On day five both brothers collected their urine for 24 hours collected their urine for 24 hours. Question 5: Which ONE of the following statements about the chemical composition of their urine is CORRECT? a. J L (CRF) excretes less potassium, creatinine and urea than RL b. J L (CRF) excretes the same amount of potassium but less creatinine and urea than RL less creatinine and urea than RL c. J L (CRF) and RL excrete equal amounts of potassium, creatinine and urea Question 5: Which ONE of the following statements about the chemical composition of their urine is CORRECT? a. J L (CRF) excretes less potassium, creatinine and urea than RL b. J L (CRF) excretes the same amount of potassium but less creatinine and urea than RL less creatinine and urea than RL c. J L (CRF) and RL excrete equal amounts of potassium, creatinine and urea * Question 6 A patient presents with a family history of hypertension and hypokalemic alkalosis. He is found on work-up to have low renin and aldosterone levels. Question 6:All but ONE of the following diagnoses could be responsible for this patients disorder. Select the INCORRECT diagnosis? a. Liddles syndrome b. Syndrome of Apparent Mineralocorticoid Excess y pp c. Activating mutation of the mineralocorticoid receptor d. Glycyrrhizinic acid e. J uxtaglomerular Cell Tumors Question 6:All but ONE of the following diagnoses could be responsible for this patients disorder. Select the INCORRECT diagnosis? a. Liddles syndrome b. Syndrome of Apparent Mineralocorticoid Excess y pp c. Activating mutation of the mineralocorticoid receptor d. Glycyrrhizinic acid e. J uxtaglomerular Cell Tumors * Question 7: Which ONE of the following statements regarding the therapy of a paretic patient with thyrotoxic periodic paralysis is TRUE? a. Intravenous acetazolamide reliably reverses the paresis. b High dose propranolol should be begun immediately b. High dose propranolol should be begun immediately after making the diagnosis. c. Methimazole (Tapazole) reverses the symptoms and signs within a few days. d. After RAI administration other TPP therapies can be stopped within 7 days. e. When euthyroid, attacks often recur but are less severe than when thyrotoxic. Question 7: Which ONE of the following statements regarding the therapy of a paretic patient with thyrotoxic periodic paralysis is TRUE? a. Intravenous acetazolamide reliably reverses the paresis. b. High dose propranolol should be g p p begun immediately after making the diagnosis. * c. Methimazole (Tapazole) reverses the symptoms and signs within a few days. d. After RAI administration other TPP therapies can be stopped within 7 days. e. When euthyroid, attacks often recur but are less severe than when thyrotoxic. Question 8: A patient presents with a family history of hypertension and hypokalemic alkalosis. He has high renin and aldosterone levels. Which ONE of the following choices offers the MOST likely diagnosis? a. Familial renal artery stenosis b. Gitelmans syndrome c. Liddles syndrome d. Pseudohypoaldosteronism type II Question 8: A patient presents with a family history of hypertension and hypokalemic alkalosis. He has high renin and aldosterone levels. Which ONE of the following choices offers the MOST likely diagnosis? a. Familial renal artery stenosis * b. Gitelmans syndrome c. Liddles syndrome d. Pseudohypoaldosteronism type II Question 9: With regard to CHRONIC SIADH, which ONE of the following statements is TRUE? a. If water intake is not carefully restricted, hyponatremia will progressively worsen. b. Knowing the amount of water retained allows for a reasonably precise calculation of the serum Na concentration. c. Daily 24-hour urinary Na excretion generally exceeds dietary salt intake. d. Daily 24-hour urinary Na excretion generally is less than dietary salt intake. e. Despite chronic hypotonic hyponatremia, most SIADH patients do not complain of diminished thirst. Question 9: With regard to CHRONIC SIADH, which ONE of the following statements is TRUE? a. If water intake is not carefully restricted, hyponatremia will progressively worsen. b. Knowing the amount of water retained allows for a reasonably precise calculation of the serumNa concentration. c. Daily 24-hour urinary Na excretion generally exceeds dietary salt intake. d. Daily 24-hour urinary Na excretion generally is less than dietary salt intake. e. Despite chronic hypotonic hyponatremia, most SIADH patients do not complain of diminished thirst. * Question 10 A neurosurgeon asks for your advice regarding his patient who underwent the removal of a craniopharyngioma five days ago. The patient, a 42-year-old Caucasian male, is doing well neurologically, has normal vital signs and is receiving 0.6 mg of d-DAVP orally each day. Despite intravenous 0.45% saline his serum sodium concentration remains 150 mM His 24 hour urine volume is 5 5 L remains 150 mM. His 24-hour urine volume is 5.5 L containing 80 mM Na and 40 mM K. Question 10: Which ONE of the following statements regarding this patient is TRUE? a. He has a complicating nephrogenic DI. b. His resistance to d-DAVP requires that therapy with aqueous pitressin be substituted. c Circulating vasopressinase has inhibited the activity of c. Circulating vasopressinase has inhibited the activity of the administered d-DAVP. d. Hypothalamic damage has impaired ACTH secretion causing polyuria. e. He has a mixed polyuria. Question 10: Which ONE of the following statements regarding this patient is TRUE? a. He has a complicating nephrogenic DI. b. His resistance to d-DAVP requires that therapy with aqueous pitressin be substituted. c Circulating vasopressinase has inhibited the activity of c. Circulating vasopressinase has inhibited the activity of the administered d-DAVP. d. Hypothalamic damage has impaired ACTH secretion causing polyuria. e. He has a mixed polyuria. * Question 11 The first set of electrolytes from a chronic alcoholic who complained of having the shakes,revealed the following. Na: 140 mEq/L, K: 4.0 mEq/L; Cl: 105 mEq/L; CO 2 : 25 mEq/L. BUN and creatinine were normal. He then had a grand mal seizure. Question 11: Which ONE of the following sets of electrolytes would be MOST typical of the immediate post-seizure state? a. Na: 140 mEq/L; K:5.4 mEq/L; Cl: 105 mEq/l; CO 2 : 15 mEq/L b. Na: 140 mEq/L; K:4.0 mEq/L; Cl: 115 mEq/l; CO 2 : 15 mEq/L c. Na: 145 mEq/L; K:4.0 mEq/L; Cl: 110 mEq/l; CO 2 : 15 mEq/L d. Na: 135 mEq/L; K:4.0 mEq/L; Cl: 100 mEq/l; CO 2 : 15 mEq/L Question 11: Which ONE of the following sets of electrolytes would be MOST typical of the immediate post-seizure state? a. Na: 140 mEq/L; K:5.4 mEq/L; Cl: 105 mEq/l; CO 2 : 15 mEq/L b. Na: 140 mEq/L; K:4.0 mEq/L; Cl: 115 mEq/l; CO 2 : 15 mEq/L c. Na: 145 mEq/L; K:4.0 mEq/L; Cl: 110 mEq/l; CO 2 : 15 mEq/L * d. Na: 135 mEq/L; K:4.0 mEq/L; Cl: 100 mEq/l; CO 2 : 15 mEq/L Question 12 A 63 year old African American man with type II diabetes mellitus and moderate renal insufficiency (BUN: 35 mg/dl; creatinine: 3.0 mg/dl) developed lactic acidosis from metformin. Six hours after the onset of the acidosis his blood chemistries revealed: Electrolytes (mEq/L): Na: 138; K: 5.0; Cl: 105; CO 2 : 14. Arterial Blood Gases (ABG): pCO : 28 mmHg; HCO : 13 mEq/L; pH: 7 29 pCO 2 : 28 mmHg; HCO 3 : 13 mEq/L; pH: 7.29. Question 12: If a lumbar puncture were done immediately after the ABGs were drawn, and the CSF pH, pCO 2 and HCO 3 were measured, which SET of CSF acid-base parameters would MOST typically be seen? a. pH: 7.29; pCO 2 : 28 mmHg; HCO 3 : 13 mEq/L b. pH: 7.40; pCO 2 : 40 mmHg; HCO 3 : 24 mEq/L c. pH: 7.48; pCO 2 : 28 mmHg; HCO 3 : 21 mEq/L Question 12: If a lumbar puncture were done immediately after the ABGs were drawn, and the CSF pH, pCO 2 and HCO 3 were measured, which SET of CSF acid-base parameters would MOST typically be seen? a. pH: 7.29; pCO 2 : 28 mmHg; HCO 3 : 13 mEq/L b. pH: 7.40; pCO 2 : 40 mmHg; HCO 3 : 24 mEq/L c. pH: 7.48; pCO 2 : 28 mmHg; HCO 3 : 21 mEq/L * Question 13: All but ONE of the following causes hyperkalemia. Select the ONE exception. a. amiloride b. angiotensin converting enzyme inhibitors c. pentamidine c. pentamidine d. Heparin e. Chloroquine Question 13: All but ONE of the following causes hyperkalemia. Select the ONE exception. a. amiloride b. angiotensin converting enzyme inhibitors c. pentamidine c. pentamidine d. Heparin e. Chloroquine * Question 14 Following surgery for a craniopharyngioma, a 40 year old Caucasian male developed polyuria, hypotonic urine and hypernatremia. Pre-operatively, renal function and serum electrolytes had been normal. Question 14: Which SET of postoperative orders would be BEST for this patient? a. Give parenteral d-DAVP if serum sodium exceeds 145 mEq/L; infuse two liters of normal saline daily. y b. Give parenteral d-DAVP if urine volume exceeds 200 ml/hour; infuse 1L of normal saline and 1 liter of normal saline daily. c. Stable daily dose of parenteral d-DAVP, modify intravenous saline and water to maintain blood pressure and serum sodium at 138-142 mEq/L. Question 14: Which SET of postoperative orders would be BEST for this patient? a. Give parenteral d-DAVP if serum sodium exceeds 145 mEq/L; infuse two liters of normal saline daily. b. Give parenteral d-DAVP if urine volume exceeds 200 ml/hour; infuse 1L of normal saline and 1 liter of normal saline daily. y c. Stable daily dose of parenteral d- DAVP, modify intravenous saline and water to maintain blood pressure and serum sodium at 138-142 mEq/L. * Question 15 Following head trauma from a motor vehicle accident, a 50 year old oriental male developed diabetes insipidus. Following recovery he was discharged on effective doses of nasal d-DAVP. He reports that over the ensuing 4-6 weeks he has become progressively weaker and is occasionally made dizzy when he stands up. Control of his polyuria and nocturia has required decreasing doses of d polyuria and nocturia has required decreasing doses of d- DAVP. Question 15: Which ONE of the following choices BEST describes this clinical picture? a. Worsening hyponatremia b. Advancing renal failure c. Adrenal insufficiency d. Hyperparathyroidism Question 15: Which ONE of the following choices BEST describes this clinical picture? a. Worsening hyponatremia b. Advancing renal failure c. Adrenal insufficiency * d. Hyperparathyroidism Question 16 A 43 year old Caucasian woman complains of muscle weakness and "not feeling well". The symptoms have worsened over the past one month. Physical examination, including blood pressure, is normal. Laboratory studies reveal: SerumElectrolytes (mM): Na: 137 Serum Electrolytes (mM): Na: 137, Cl: 107, K: 2.6, HCO 3 : 20 Random Urine Electrolytes (mM): Na: 30, Cl: 65, K: 8 Question 16: Which ONE of the following disorders is the MOST likely cause of her hypokalemia? a. Liddle's Syndrome b. Barrter Syndrome c Type I Distal R T A c. Type I Distal R.T.A. d. Laxative abuse Question 16: Which ONE of the following disorders is the MOST likely cause of her hypokalemia? a. Liddle's Syndrome b. Barrter Syndrome c Type I Distal R T A c. Type I Distal R.T.A. d. Laxative abuse * Question 17 A 27 year old woman presents to her physician complaining of fatigue and has the following laboratory values: Serum Electrolytes (mM): Na: 138, Cl: 87, K: 3.1, HCO 3 : 35 Random Urine Electrolytes (mM): Na: 40, Cl: 3, K: 37 Question 17: Which ONE of the following disorders is the MOST likely cause of these electrolyte abnormalities? a. Vomiting a. Vomiting b. Barrter Syndrome c. Distal (Type I) Renal Tubular Acidosis d. Laxative abuse Question 17: Which ONE of the following disorders is the MOST likely cause of these electrolyte abnormalities? a Vomiting * a. Vomiting b. Barrter Syndrome c. Distal (Type I) Renal Tubular Acidosis d. Laxative abuse Question 18: Which ONE of the following disorders does NOT cause K to shift out of cells? a. Cell necrosis b. Intravenous infusion of HCl c Insulin deficiency c. Insulin deficiency d. A less negative resting membrane potential e. Hypercalcemia Question 18: Which ONE of the following disorders does NOT cause K to shift out of cells? a. Cell necrosis b. Intravenous infusion of HCl c Insulin deficiency c. Insulin deficiency d. A less negative resting membrane potential e. Hypercalcemia * Question 19: The hyperkalemia associated with trimethaprim therapy is caused by which ONE of the following abnormalities? a. Low aldosterone levels b Reduced distal Na delivery b. Reduced distal Na delivery c. Increased GI absorption of K+ d. Inhibition of the Na channel in the cortical collecting duct (CCD) e. Faster reabsorption of Cl in the CCD Question 19: The hyperkalemia associated with trimethaprim therapy is caused by which ONE of the following abnormalities? a. Low aldosterone levels b Reduced distal Na delivery b. Reduced distal Na delivery c. Increased GI absorption of K+ d. Inhibition of the Na channel in the cortical collecting duct (CCD) * e. Faster reabsorption of Cl in the CCD Question 20: Which ONE of the following sets of urine electrolytes would you MOST expect to find in a patient with a contracted ECF volume due to recent vomiting? The patient has alkaline urine, and 'perfect" kidneys. (All values are in mmol/L). [Na] urine [Cl] urine a. 5 75 b. 75 5 c. 5 5 d. 75 75 Question 20: Which ONE of the following sets of urine electrolytes would you MOST expect to find in a patient with a contracted ECF volume due to recent vomiting? The patient has alkaline urine, and 'perfect" kidneys. (All values are in mmol/L). [Na] urine [Cl] urine a. 5 75 b. 75 5 * c. 5 5 d. 75 75 Question 21: Which ONE of the following sets of urine electrolytes would you MOST expect to find in a patient with a contracted ECF volume due to use of diuretics in the recent past? No diuretic exposure has occurred for several days and the patient has perfect kidneys? (All values are in mmol/L). [Na] urine [Cl] urine a. 5 75 b. 75 5 c. 5 5 d. 75 75 Question 21: Which ONE of the following sets of urine electrolytes would you MOST expect to find in a patient with a contracted ECF volume due to use of diuretics in the recent past? No diuretic exposure has occurred for several days and the patient has perfect kidneys? (All values are in mmol/L). [Na] urine [Cl] urine a. 5 75 b. 75 5 c. 5 5 * d. 75 75 Question 22: In an ESRD patient with the serum electrolytes shown below, which ONE of the following therapies (A-D) is typically INEFFECTIVE in lowering the serum potassium level? Serum Electrolytes (mM): Na: 135, Cl: 99, K: 7.5, HC0 3 : 21; BUN: 85 mg/dL K: 7.5, HC0 3 : 21; BUN: 85 mg/dL Creatinine: 8.0 mg/dL a. Insulin b. Bicarbonate c. Beta adrenergic agonists d. Kayexalate Question 22: In an ESRD patient with the serum electrolytes shown below, which ONE of the following therapies (A-D) is typically INEFFECTIVE in lowering the serum potassium level? Serum Electrolytes (mM): Na: 135, Cl: 99, K: 7.5, HC0 3 : 21; BUN: 85 mg/dL K: 7.5, HC0 3 : 21; BUN: 85 mg/dL Creatinine: 8.0 mg/dL a. Insulin b. Bicarbonate * c. Beta adrenergic agonists d. Kayexalate Question 23 A 22 year old pregnant, otherwise healthy Caucasian female in her third trimester, has had the recent onset of polyuria and polydipsia. Relevant laboratory data include: Serum Electrolytes (mM): Na: 150, Cl: 115, K: 4.0, HCO 3 : 22 BUN (mg/dL): 8, Creatinine (mg/dL): 0.7 Urine Studies: Tot Vol: 4,500 ml/dy, Uosm: 150mOsm/L, UNa: 20 mM mEq/L Administration of intravenous aqueous pitressin exerted no effect on the urine whereas d-DAVP rapidly reduced urine volume and increased her Uosm to >500 mOsm/L. Question 23: Which ONE of the following statements BEST explains the cause of her syndrome? a. Hypothalamic secretion of vasopressin is subnormal. b Circulating enzymes consumed secreted b. Circulating enzymes consumed secreted vasopressin. c. A renal tubular defect impairs responsivity to vasopressin. d. Excess circulating cortisol impairs end-organ response to vasopressin. Question 23: Which ONE of the following statements BEST explains the cause of her syndrome? a. Hypothalamic secretion of vasopressin is subnormal. b Ci l ti d b. Circulating enzymes consumed secreted vasopressin. * c. A renal tubular defect impairs responsivity to vasopressin. d. Excess circulating cortisol impairs end-organ response to vasopressin. Question 24 A 65 year old African American man with angina controlled with nitroglycerine, has been taking 50 mg hydrochlorothiazide (HCTZ) daily for his hypertension. He is normotensive on therapy but has had repeated serum K values ranging between 3 0 and 3 4 mEq/L His E C G's reveal between 3.0 and 3.4 mEq/L. His E.C.Gs reveal frequent premature atrial and ventricular beats. Question 24: Indicate which ONE of the following statements is FALSE regarding the best treatment of this man's mild hypokalemia. a. Restriction of Na intake to 70-80 mEq/day will reduce his kaliuresis. b. Reduction of his dose of HCTZ from 50 to 25 mg/day may maintain blood pressure control and reduce renal potassium wasting. c. Supplementing his diet with 2 bananas and an orange each day is likely to correct the Hypokalemia. d. Salt substitutes may be used as cheap sources of KCl. Question 24: Indicate which ONE of the following statements is FALSE regarding the best treatment of this man's mild hypokalemia. a. Restriction of Na intake to 70-80 mEq/day will reduce his kaliuresis. b R d ti f hi d f HCTZf b. Reduction of his dose of HCTZ from 50 to 25 mg/day may maintain blood pressure control and reduce renal potassium wasting. * c. Supplementing his diet with 2 bananas and an orange each day is likely to correct the Hypokalemia. d. Salt substitutes may be used as cheap sources of KCl. Question 25 A 42 year old black female asthmatic came to the E.R. with the acute onset of S.O.B. and wheezing. She has a 5 year history of hypertension well- controlled with 50 mg daily of hydrochlorothiazide. Therapy with aerosolized albuterol has improved her wheezing however she has become her wheezing, however, she has become progressively weaker and her D.T.R.s have dramatically decreased. Question 25 (continued) Physical Examination: as above with BP: 120/85 mmHg. Laboratory Studies on Admission: Serum Electrolytes (mM): Na: 141, Cl: 103, K: 3.1, HCO 3 : 32 Arterial Blood Gases: pCO 2 : 40mmHg, HCO 3 : 31 mM, pH: 7.51 Laboratory Studies Two Hours Later: Serum Electrolytes (mM): Na: 140, Cl: 102, K: 1.9, HCO 3 : 29 Arterial Blood Gases: pCO 2 : 51mmHg, pH: 7.40, HCO 3 : 31 mM Question 25: Which ONE of the following choices is the MOST likely cause of her worsening hypercapnia? a. She is developing status asthmaticus. b. Pneumonia is superimposed on her asthmatic tt k attack. c. She has diffuse vasculitis affecting her lungs and muscles. d. The bronchodilator therapy. Question 25: Which ONE of the following choices is the MOST likely cause of her worsening hypercapnia? a. She is developing status asthmaticus. b. Pneumonia is superimposed on her asthmatic tt k attack. c. She has diffuse vasculitis affecting her lungs and muscles. d. The bronchodilator therapy. * Question 26: Which ONE of the following findings would BEST distinguish between the chronic hypokalemia of Gitelman's syndrome (thiazide-like disease) and Barrter's syndrome (furosemide-like disease)? a. Hypomagnesemia b. Supernormal magnesium excretion c. Urine osmolality of 900 mOsm/Kg H;0 d. Supernormal K excretion e. Metabolic alkalosis Question 26: Which ONE of the following findings would BEST distinguish between the chronic hypokalemia of Gitelman's syndrome (thiazide-like disease) and Barrter's syndrome (furosemide-like disease)? a Hypomagnesemia a. Hypomagnesemia b. Supernormal magnesium excretion c. Urine osmolality of 900 mOsm/Kg H;0 * d. Supernormal K excretion e. Metabolic alkalosis Question 27 A 68 year old, homeless, hypertensive man with arteriosclerotic heart disease was admitted for diuretic therapy of CHF. He refused to eat or drink. Physical Examination: BP: 155/95 mmHg, neck vein distension, rales, +2 peripheral edema. Therapy: Furosemide 40 mg BID Therapy: Furosemide 40 mg BID Laboratory Studies: Serum Electrolytes (mM): Na: 145, Cl: 108, K: 4.0, HCO 3 : 25 BUN: 23mg/dL, Creatinine: 1.3mg/dL Urine Values: Volume: 2L/24hr, Osm: 300mOsm/L, Na: 50mEq/L, K: 20mEq/L Question 27: While replacing lost K, which ONE of the following regimens would be BEST? a. D5/NS: give 1 cc for each cc of urine b. D5/1/2 NS: give 1 cc for each cc of urine c. D5/1/2 NS: keep open IV. (250 cc/day) d. D5W: give cc for each cc of urine Question 27: While replacing lost K, which ONE of the following regimens would be BEST? a. D5/NS: give 1 cc for each cc of urine b. D5/1/2 NS: give 1 cc for each cc of urine c. D5/1/2 NS: keep open IV. (250 cc/day) d. D5W: give cc for each cc of urine * Question 28 A 16-year-old Caucasian male was treated for the 'flu' at home. Despite improvement in his fever and cough, worsening lethargy prompted his overbearing mother to bring him to the E.R. Physical Examination: Afebrile; 140/85 mmHg, disoriented, no focal neurological findings. Laboratory Studies: Serum Electrolytes (mM): Na: 149, Cl: 112, K: 3.9, HCO 3 : 26 BUN: 8mg%, Creatinine: 0.5mg% Urine Studies: Tot Vol: 4L/dy, Na: 125 mM, K: 20 mM, Osm: 320 mOsm/L Question 28: Which ONE of the following is the MOST likely cause of his hypenatremia? a. Complete diabetes insipidus b. Partial diabetes insipidus c. Osmotic diuresis d. Under-replaced water loss from sweating Question 28: Which ONE of the following is the MOST likely cause of his hypenatremia? a. Complete diabetes insipidus b. Partial diabetes insipidus c. Osmotic diuresis d. Under-replaced water loss from sweating * Question 29 A cachectic 40-kg, 52 year old Caucasian male with an oat cell carcinoma of the lung is admitted to the hospital for chemotherapy. He has received 1L of D5W and 1L of 0.9% saline daily for two days. He has become progressively more lethargic lethargic. Question 29 (continued) Serum Electrolytes (mM): Admission At 48 Hours Na 130 112 K 3.4 3.2 Cl 95 82 HC0 3 24 23 Urine Electrolytes: Na 40 300 K 30 20 Question 29: Which ONE of the following contributed the MOST to his worsening hyponatremia? a. Worsening hypokalemia b. Osmotic diuresis due to glucose E ti f h t i l l f i c. Excretion of hypernatric, low volumes of urine d. Hyperlipidemia Question 29: Which ONE of the following contributed the MOST to his worsening hyponatremia? a. Worsening hypokalemia b. Osmotic diuresis due to glucose c. Excretion of hypernatric, low volumes of urine * d. Hyperlipidemia Question 30: With regard to the above-described patient, at 48 hours, which ONE of the following therapies would have been MOST appropriate? a. Lithium b D l li b. Demeclocycline c. Increased salt intake and oral thiazide diuretics d. 3% saline and furosemide Question 30: With regard to the above-described patient, at 48 hours, which ONE of the following therapies would have been MOST appropriate? a. Lithium b D l li b. Demeclocycline c. Increased salt intake and oral thiazide diuretics d. 3% saline and furosemide * Question 31: Indicate which ONE of the pathophysiologic diagnoses (a-c) BEST describes the following set of electrolytes (mM): Na: 140 mM; Cl: 105 mM; pCO 2 : 25 mmHg; K: 3 8 mM; HCO : 15 mM; pH: 7 40 K: 3.8 mM; HCO 3 : 15 mM; pH: 7.40 a. Simple metabolic acidosis b. Mixed acid-base disorder c. Compensated metabolic acidosis Question 31: Indicate which ONE of the pathophysiologic diagnoses (a-c) BEST describes the following set of electrolytes (mM): Na: 140 mM; Cl: 105 mM; pCO 2 : 25 mmHg; K: 3 8 mM; HCO : 15 mM; pH: 7 40 K: 3.8 mM; HCO 3 : 15 mM; pH: 7.40 a. Simple metabolic acidosis b. Mixed acid-base disorder * c. Compensated metabolic acidosis Question 32: Indicate which ONE of the following findings is NOT caused by acidosis. a. Decreased ionized calcium b. Leukocytosis y c. Arteriolar vasodilatation d. Increased alveolar ventilation Question 32: Indicate which ONE of the following findings is NOT caused by acidosis. a. Decreased ionized calcium * b Leukocytosis b. Leukocytosis c. Arteriolar vasodilatation d. Increased alveolar ventilation Question 33: Which ONE of the following abnormalities INCREASES renal bicarbonate excretion? a. Hypercapnia b. Extracellular fluid volume contraction c. Hypokalemia d. High circulating parathyroid hormone levels Question 33: Which ONE of the following abnormalities INCREASES renal bicarbonate excretion? a. Hypercapnia b. Extracellular fluid volume contraction c. Hypokalemia d. High circulating parathyroid hormone levels * Question 34 A 60-year-old hypertensive took 120 mg of furosemide daily while continuing to ingest 250 mEq/day of NaCl. He was admitted to the hospital within hours of suffering a mid-brain stroke. His blood pressure was 220/130 mmHg; respirations were 40 per minute and deep He was afebrile were 40 per minute and deep. He was afebrile. Papilledema was noted. Question 34 (continued) With control of his blood pressure his BUN and creatinine progressively rose to 100 mg/dL and 8.5 mg/dL, respectively, and the remainder of his studies revealed: Serum Electrolytes (mM): Na: 144; Cl: 93; K: 3.0; HCO 3 : 20 Arterial Blood Gases: pCO 2 : 20 mmHg; pH: 7.62 Question 34: Which ONE of the following choices BEST characterize his acid-base status? a. Simple acid-base disorder b. Double acid-base disorder c. Triple acid-base disorder d. Quadruple acid-base disorder Question 34: Which ONE of the following choices BEST characterize his acid-base status? a. Simple acid-base disorder b. Double acid-base disorder c. Triple acid-base disorder * d. Quadruple acid-base disorder Question 35 You are called to see a 42-year-old Hispanic woman who developed renal failure 4 days ago following an I.V.P. She complained of worsening back pain, progressive lethargy and was moderately anemic. Vital signs were normal and the physical examination was unrevealing the physical examination was unrevealing. Serum Electrolytes (mM): Na: 135; Cl: 115; K: 4.5; HCO3: 18 BUN: 85 mg/dL; Creatinine: 9 mg/dL Question 35: Which ONE of the following statements regarding her disease is True and which is False? a. Her type of renal failure is characterized by RBC casts? True or False? b. Her type of renal failure may cause a negative urinary anion gap? True or False? c. She has a hyperchloremic acidosis? True or False? Question 35: Which ONE of the following statements regarding her disease is True and which is False? a. Her type of renal failure is characterized by RBC casts - True or False? b. Her type of renal failure may cause a negative urinary anion gap - Trueor False? c. She has a hyperchloremic acidosis - Trueor False? Question 35: Which ONE of the following statements regarding her disease is FALSE? a. Her type of renal failure is characterized by RBC casts. b. Her type of renal failure may cause a negative urinary anion gap. c. She has a hyperchloremic acidosis. Question 35: Which ONE of the following statements regarding her disease is FALSE? a. Her type of renal failure is characterized by RBC casts * characterized by RBC casts. b. Her type of renal failure may cause a negative urinary anion gap. c. She has a hyperchloremic acidosis. Question 36 A comatose 82-year-old Caucasian woman was brought to the E.R. No history was available. Temperature: 37 C; blood pressure: 130/80 mmHg; respiration: 30 per min.. Many ecchymoses covered her body. No focal neurological signs were noted were noted. Serum Electrolytes (mM): Na: 140; Cl: 113; K: 3.3; HCO3: 10 Arterial Blood Gases: pCO2: 16 mmHg; pH: 7.42 Question 36: Which ONE of the choices is NOT characteristically associated with the electrolyte/ABG pattern seen in this patient? a. Cirrhosis, ascites and hypotension b E d t i d t l f il b. Endotoxemia and acute renal failure c. Salicylate toxicity d. Proximal RTA Question 36: Which ONE of the choices is NOT characteristically associated with the electrolyte/ABG pattern seen in this patient? a. Cirrhosis, ascites and hypotension b E d t i d t l f il b. Endotoxemia and acute renal failure c. Salicylate toxicity d. Proximal RTA * Question 37 A 65 year old man presents with the chief complaint of progressive weakness over the last several months. He is normotensive and his physical examination is unremarkable. Labs: Hematocrit 25%; WBC 5600; Plt 340K; Labs: Hematocrit 25%; WBC 5600; Plt 340K; Na 135; Cl 105; K 3.0; HCO 3 18, creatinine 1.8; BUN 22; glucose 110, pCO 2 28; pH 7.33 Urinalysis: trace protein, 1+glucose, normal sediment 24 hour urine protein 2.8 g/24h Question 37: Which ONE of the following is MOST characteristic of the renal lesion present in this patient? a. Evidence of nephrocalcinosis on KUB of the abdomen. b. If bicarbonate therapy sufficient to normalize the plasma HCO3 is suddenly stopped the plasma HCO3 will rapidly fall to a value of 18. c. Bicarbonate therapy will cause the serum K to decline slightly due to a shift into cells. d. The urine pH is likely to be alkaline. Question 37: Which ONE of the following is MOST characteristic of the renal lesion present in this patient? a. Evidence of nephrocalcinosis on KUB of the abdomen. b. If bicarbonate therapy sufficient to py normalize the plasma HCO3 is suddenly stopped the plasma HCO3 will rapidly fall to a value of 18. * c. Bicarbonate therapy will cause the serum K to decline slightly due to a shift into cells. d. The urine pH is likely to be alkaline. Question 38 A patient has the following laboratory tests: Electrolytes (mM): Na 138; K 3.2; Cl 100; Serum HCO 3 13; pH 7.48; pCO 2 21 mmHg pH 7.48; pCO 2 21 mmHg Question 38: Which ONE of the following patients is MOST likely to have these acid-base abnormalities? a. A 2 year old child who has accidentally swallowed an unknown quantity of his Mothers aspirin. p b. A 28 year old women with bulimia and vomiting. c. A 35 year old man who has ingested a large amount of aspirin in a suicide attempt. d. A 50 year old women with surreptitious laxative abuse. Question 38: Which ONE of the following patients is MOST likely to have these acid-base abnormalities? a. A 2 year old child who has accidentally swallowed an unknown quantity of his Mothers aspirin. b. A 28 year old women with bulimia and vomiting. c. A 35 year old man who has ingested a large amount of aspirin in a suicide attempt. * d. A 50 year old women with surreptitious laxative abuse. Question 39 A 48 year old man with known HIV infection presents to the emergency room with a three day history of abdominal pain, nausea, vomiting, and increasing confusion. He has a history of alcohol abuse and his last drink was 36 hours ago. He is also known to be diabetic His current medications also known to be diabetic. His current medications include zidovudine, stavudine, and didanosine for treatment of his HIV infection and metformin for treatment of his diabetes. On PE he is acutely ill. BP 110/70, pulse 98, RR 28, afebrile. The abdomen is soft and has normoactive bowel sounds. Question 39 (continued) Laboratory Studies: WBC 12K, Hct 38 %, Platelets 280K, Electrolytes (mM): Na 141, K 3.5, Cl 90, HCO 3 10; Glucose 150mg%, BUN 16mg%, creatinine 1.3mg% Glucose 150mg%, BUN 16mg%, creatinine 1.3mg% Arterial Blood Gases: pH 7.18, pCO 2 20 mmHg Urinalysis: trace ketones, normal sediment Question 39 (continued) The patient is admitted to the hospital and given IV fluids consisting of D5NS. Blood cultures are drawn and broad spectrum antibiotics are given. 24 hours later laboratory examination shows: Electrolytes (mM): Na 141, K 3.8, Cl 100, HCO 3 12, Glucose 128mg%, BUN 16mg%, creatinine 1.2mg% Arterial Blood Gases: pH 7.21, pCO 2 22 mmHg Question 39: Which ONE of the following is the MOST likely cause of this patients acid-base disturbance? a. Metformin-induced lactic acidosis b Alcoholic ketoacidosis b. Alcoholic ketoacidosis c. Lactic acidosis secondary to a seizure prior to admission d. Lactic acidosis secondary to stavudine Question 39: Which ONE of the following is the MOST likely cause of this patients acid-base disturbance? a. Metformin-induced lactic acidosis b Alcoholic ketoacidosis b. Alcoholic ketoacidosis c. Lactic acidosis secondary to a seizure prior to admission d. Lactic acidosis secondary to stavudine *