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Are those so-called "sports drinks" beneficial during exercise? The composition of these
drinks is basically water, electrolytes (minerals capable of carrying an electrical charge), and
glucose. Sweat consists mostly of water and electrolytes. In prolonged endurance events, glucose
(carbohydrate) replacement may be beneficial. Also, endurance exercise in heat contributes to
heavy losses of water and electrolytes which need to be replenished.
Is it O.K. to drink water while exercising? Yes, your body's circulation system must get food
and nutrients to the working cells to carry out their chemical reactions. Sweating during exercise
depletes your body's water supply, which may lead to dehydration. Do not depend on your thirst
to tell you to drink water. Try to drink at least 8 ounces of cool water for every 30 minutes of
vigorous exercise. Use that water bottle!
What are free radicals and antioxidants? Free radicals are unstable molecules produced by
chemical reactions utilizing oxygen in the body's cells. A variety of external factors can promote
free radical formation including smoking, drinking alcohol, and pollution. Antioxidants (vitamin
C, E, and beta carotene—a precursor to vitamin A) protect the cells from free radicals by
neutralizing the process of molecular oxidation that leads to their formation.
Does the distribution of body fat have any health consequences? Yes, people who gain fat in
the abdominal area have a higher risk of coronary heart disease, high blood pressure, diabetes
and stroke as compared to individuals who gain fat in the hip area. Men tend to gain fat around
the waist and women at the hip.
What are the leading causes of death in the United States? According to the National Center
for Health Statistics, they are heart disease, cancers, strokes, injuries, chronic lung diseases,
pneumonia, diabetes, suicide, AIDS, and homicide.
Is it O.K. to drink beer after working out? Alcohol is a diuretic, which means that it
stimulates urine production. Following a workout you want to replenish your body with lost
fluids. Consequently, drinking any alcohol beverage before or after exercise is not
recommended.
Do you burn more calories when you are hot or cold, or does it even make a difference?
Shivering in clold weather requires more energy but not enought to enhance a weight loss
program.
What are the limiting factors of flexibility? With the muscles relaxed, and reflex mechanisms
minimally involved, researchers have found the relative contributions of soft tissue to joint
stiffness to be the following: joint capsule, including ligaments (47%), muscles and their fascial
sheaths (41%), tendons (10%), and the skin (2%).
Why does the mirror show your change of shape before the scale? Muscle is denser than fat.
A pound of fat bulges out 18% more than a pound of muscle. Since you are adding muscle to
your body as you shape up, you will often notice a loss of inches before a loss of weight.
Why do people who exercise have fewer colds and viral infections? It has been observed that
exercise may boost the immune system and that physically active people take better care of
themselves. It should be noted that regular, strenuous exercise has also been shown to have an
opposite effect on the body's immune system. This adds support for an exercise prescription
directed towards regular, moderate levels of exercise participation.
Why do you perspire more after you stop working out? During exercise your muscles need
most of the blood to get oxygen for the activity. Upon the cessation of exercise, more blood is
diverted to the skin to cool the body by means of sweat production. Also, during most modes of
exercise you are moving allot, which helps sweat evaporate more efficiently during the activity.
What is cholesterol? Cholesterol is a fat-like substance used to help build cell membranes,
make some hormones, synthesize vitamin D, and form bile secretions that aid in digestion. Since
fat can't mix with water, which is the main ingredient of blood, cholesterol's most important job
is to help carry fat through your blood vessels. Before cholesterol can enter the bloodstream it is
coated with a protein, referred to as a lipoprotein. Lipoproteins are transport vehicles in the
circulation plasma that are composed of various lipids such as cholesterol, phospholipids,
triglycerides and proteins known as apoproteins. The major classes of lipoproteins are
chylomicrons, very low-density lipoprotein cholesterol, low-density lipoprotein cholesterol and
high-density lipoprotein cholesterol.
Which is the 'bad' and 'good' cholesterol? The low-density lipoprotein cholesterol (LDL-C) is
the primary transport carrier of cholesterol in the circulation. It is referred to as the 'bad'
cholesterol because too much cholesterol, from eating foods high in saturated fat, often leads to
LDL-C pieces adhering to the inner walls of the blood vessels, narrowing the blood passages. On
the other hand, the high-density lipoprotein cholesterol's (HDL-C) primary function is to
transport cholesterol from the tissues and blood to the liver for excretion or recycling. It is
referred to as the good cholesterol.
Are natural vitamins better for you than manufactured vitamins? No, your body can't
distinguish the difference between vitamins manufactured in a laboratory and natural vitamins
extracted from food.
Does cold weather give you colds? People exposed to chilling temperatures often feel they are
more susceptible to colds. However, it is viruses that give you colds, not the weather. Colds are
actually more common in cold weather because people are inside more, and thus more exposed
to germs.
What's a good substitute for those high-fat potato chip snacks? Try pretzels. They are almost
fat-free. As a matter of fact, pretzels are one of the fastest growing snack foods in the U.S.
However, there is good news for you 'chip' lovers. There are now some new and improved chips
that are low in sodium, fat and calories. Read the labels at your supermarket. Look for the chips
that are baked, not fried, and avoid chips made in hydrogenated oil. Remember to check the total
fat content and serving size, too.
Can you drink too much caffeine? Most people have internal regulators that tell them when to
stop drinking caffeine. However, drinking 4-6 cups of coffee a day may result in symptoms
referred to as caffeinism: breathlessness, headache, lightheadedness and irregular heartbeat. Too
much caffeine may also trigger a panic attack. For college students, caffeine-containing soft
drinks have overtaken coffee as the primary source of caffeine. Most experts advice no more
than 200 milligrams of caffeine consumption, which is about the same as two to three 5-ounce
cups of coffee.
Are these low-carbohydrate, high-protein diets any good? Initially these diets help people
lose weight because the body loses water; approximately 3 parts of water to 1 part of
carbohydrate. A low carbohydrate diet is fairly unappetizing. However, the body cannot handle
the extra amounts of proteins and will end up storing much of it as fat.
How do you avoid repetitive strain injuries? With the wonderful benefits of computer use
there are also some physical perils to know. Repetitive strain injury (RSI) results from hand,
wrist, arm and neck injuries from a repetitive (fast) work. Carpal tunnel syndrome is a form of
RSI which results from pain in the tendons and nerves across the wrist. To avoid, take frequent
breaks during your typing and make sure your computer set-up avoids any neck, back, wrist and
eye strain (see Sitting at your Computer Station).
Are vegetarian diets more healthful than diets that include animal foods? Vegetarian diets
are higher in fiber and lower in saturated fats and cholesterol. Studies also show that vegetarians
suffer less from high blood pressure, diabetes, heart disease and obesity. However, many
‘vegetarian foods’ such as chips and candy contain allot of fat and calories, with little nutrient
value. Also, vegetarians need to be conscious of deficiencies in iron, calcium, vitamin D, vitamin
B12, and zinc.
What are triglycerides? Triglycerides (TG) are fats that circulate in the bloodstream that
provide energy for the body. It is uncertain whether high TG levels are associated with coronary
heart disease. However, high TG levels are associated with diabetes, kidney diseases, and
obesity. Steps to lower TG levels include cutting down on saturated fat, losing weight, exercise,
and quitting smoking.
What is this creatine supplement craze? Creatine is an amino acid found predominantly in the
muscles in the form of creatine phosphate, where if facilitates energy production. It also helps to
reduce the lactic acid accumulation during intense exercise. Most investigations have shown that
creatine supplements boost short-term muscle strength and power. However, it is important to
note that the long-term effects of high doses of creatine are unknown.
Are the sunless tanning lotions safe? According to the U.S. Food and Drug Administration
they are safe. The main ingredient in self-tanning products is dihydroxyacetone, which reacts
with the top layer of skin to form a light brown tan stain. Remember that these lotions do not
give you any sun protection, however.
How successful are all the stop smoking interventions? The interventions range from
acupuncture, nicotine gum and patches, hypnotism, anti-depressants and behavior modification
approaches. None of the methods has outstanding long-term effects, with each method showing a
20% success rate after one year. Quitting smoking is essential. A person needs the support of the
family and friends as well as a sustained effort to find the intervention that works.
What causes your limbs to "fall asleep?" A limb will become numb when you remain seated
or lying in a position that compresses a nerve in the limb or stops the blood flow to the nerve.
This sometimes happens when you cross your legs or arms for an extended period of time. When
you remove the pressure the tingling is the nerve sensitivity returning. Moving the limb helps to
speed up the recovery. Men who carry a thick wallet in their back pocket (with tight pants) can
put pressure on the sciatic nerve, causing a similar numbness and pain.
Will exercise reduce a woman’s risk to breast cancer? Exercise reduces the risk of heart
disease, diabetes, stroke and obesity. It appears to have a protective effect against breast cancer
but more research is needed. However, the best advice for men and women is that they should
exercise.
What dietary substances are needed to prevent osteoporosis besides calcium and vitamin
D? Two other substances of importance are magnesium and potassium which are both found in
fruits, vegetables, milk and whole grains.
Is it true that when you eat out, you usually eat more calories than at home? Yes, large
portion sizes and high-fat entrees burden most of this responsibility. Be aware that when you go
out you are less likely to eat nutritious food. Forego eating appetizers as they add to the calories.
Perhaps split a desert as opposed to ordering one for yourself. Also, most Americans neglect
fruits and vegetables when eating out.
I read a recent study that said high-fiber diets don’t cut colon cancer? Even if the study was
well-conducted research, it is still only one study. Decades of research suggest that high-fiber
foods are a protection against colon cancer. Remember, stay away from those sugary sweets that
are consistently associated with colorectal cancer.
I read allot about the health benefits of soy. Are they true? Soy has been shown to be very
health beneficial. For instance, research shows that soy consumption will lower triglycerides and
LDL-cholesterol (lousy cholesterol) in people with high blood lipids, while raising the HDL-
cholesterol (helpful cholesterol). Note also that heart disease is much lower in Asian countries,
where soy is a dietary staple. Soy also has been shown to play a role in lowering breast and
uterus cancer.
How does soy improve one’s health? It is felt that the hormone phytoestrogen mimics some of
the effects of estrogen, actually blocking off some of the harmful effects associated with
estrogen. Also, remember soy foods are low in saturated fat and are cholesterol free. For an
internet source on soy-based foods and products go to www.soyfoods.com/
Is it true that tea may possibly be a healthful beverage? Yes, black and green tea (sorry, not
herbal teas) appears to lessen cholesterol’s damaging affect on your arteries, as well as protect
against cancers of the skin and gastrointestinal tract. Make sure you step tea for 3 minutes for the
beneficial antioxidants in the leaves to enter in the beverage.
How effective is the supplement creatine? Creatine is made by your body and supplied in
foods such as fish and vegetables. It is beneficial when your muscles need short, quick spurts of
energy for activities like resistance exercise and sprinting. However, the weight gain experienced
by some individuals may actually be more attributable to an uptake of water by the muscle cells.
What are the effects of removing the cool-down from your exercise routine? The purpose of
the cool-down is to restore all cells,tissues and organs of the body that have been stressed (or
challenged) from the exercise workout. Removing the cool-down removes this process and thus
hinders the body’s ability to restore itselt to homeostasis.
I am so rushed to get things done I am contemplating taking some of these liquid meal
replacements on a regular basis. Many of these liquid meals provide plenty of calories as well
as a number of minerals and vitamins. But typically they do not provide the health-promoting
fiber and phytochemicals that are found in fruits and vegetables. So, this is not to discourage
their consumption, but make sure you balance the intake with real meals.
What does it mean when a food has the American Heart Association logo on it? The red
heart with white check mark means no more than 3 grams of fat, 20 milligrams of cholesterol,
and 480 milligrams of sodium. The food must also have at least 10% of the daily value for one or
more of these nutrients: protein, vitamin A, vitamin C, calcium, iron, or dietary fiber.
As you age, is there anything you can do to slow the decline in mental PROCESSES? The
degree of decline varies from person to person, but the age-related changes are due to alterations
in the brain’s frontal lobe, right behind the forehead. However, new research suggests that
sedentary older people who take up aerobic exercise (such as walking) can slow the loss in
mental agility even if they never exercised before in their lives. Researchers believe that the
aerobic activity improves mental functioning by increasing the supply of oxygen to the brain.
How can I, as a young man, protect against prostate cancer? Very wise preventative
measure. Prostate cancer is the second leading cause of cancer in American men. Research
confirms that diets high in fat, calories, and animal products are strongly associated with this
deadly disease. Diets high in grains, cereals, soybeans, nuts and fish, on the other hand, appear to
have protective effects.
What’s the final scoop: Butter or Margarine? Good question. While margarine is indeed
lower in saturated fat than butter, it’s higher in trans fatty acids, which do contribute to high
levels of cholesterol. Recent research does suggest that margarine is healthier. Also, it appears
that soft tub margarine may be the best overall choice.
What are the most common types of arthritis? There are actually more than 100 different
forms. Osteoarthritis is a wearing and tearing form that affects the fingers and weight-bearing
joints (knees, back, hips). Rheumatoid arthritis causes irritating joint stiffness and swelling.
Fibromyalgia leads to pain at different points of the body as well as insomnia, morning stiffness
and constant fatigue. Gout is caused when uric acid accumulates in the joints, specifically the big
toe, knees and wrists. Lupus can damage the kidneys, heart, skin, lungs and joints.
What is the most common nutritional deficiency in the U.S? Iron deficiency. It affects some 8
million women of childbearing age and upwards of 700,000 toddlers.
I only have time right before bed to exercise and am worried that it will impair my evening
sleep patterns. Interestingly enough, recent research has shown that vigorous exercise ending 30
minutes before bedtime failed to disrupt sleep.
I have trouble sleeping. Do you have any suggestions to get a better night’s rest? Try to
establish a sleeping schedule of going to bed every night and getting up at the same time each
morning. Work on the stress levels in your life as this can dramatically affect sleep. You sleep
better if the room temperature is slightly cooler than other parts of the house. Try to avoid
drinking too many fluids before bedtime so that your bladder isn’t full. Remember, spicy foods
for dinner, or as snacks, may cause heartburn or stomach acidity and impair your quality of
sleep. Also, avoid alcohol near bedtime. While it may help you fall asleep, when the alcohol
wears off your brain actually becomes more alert. Finally, stay away from sleeping pills as they
may lead to unwanted side effects and health-related risks.
I use a computer everyday. Are there any exercises that will help prevent and control
carpal tunnel syndrome? Carpal tunnel syndrome is a condition that develops from repetitive
wrist motions such as typing at a computer terminal. This motion may lead to pressure on the
median nerve in the wrist, and great pain and discomfort. Do the following exercises throughout
the day. Frequently take your wrists through a complete range of motion in both directions.
Make a tight fist with both hands, hold for 6 seconds, and repeat 3 to 4 times. Also, circle your
wrists in both directions while holding your hands in a fist. Make sure you take short breaks from
your typing to do these exercises (and to rest your wrists) in order to safeguard from developing
carpal tunnel syndrome.
What causes muscle cramps? New research on exercise-associated muscle cramping suggests
the cramp occurs as a result of abnormal nerve activity from the spine, probably related to
fatigue. Although not well understood, it is believed that tired muscles going through repeated
shortening contractions are more vulnerable to cramping. Avoiding over fatiguing workouts and
incorporate regular stretching to best ward off muscle cramps.
What is this new concept of training called periodization? Although not really new, it is now
being used regularly with recreational resistance training enthusiasts. Periodization is most
widely used in resistance training and involves systematically alternating high loads of training
with decreased loading phases in order to improve components of muscular fitness. The system
is typically divided into three cycles: 1. The microcycle, which lasts up to seven days 2. The
mesocycle, which can be from two weeks to a few months, is subdivided into preparation,
competition, peaking and transition phase. 3. The macrocycle is the overall yearly training
period.
What is ‘carbo loading’ and how do you do it? Carbo loading is a method of super saturating
your muscles with glycogen. It has been shown to improve endurance performance in events
lasting over 90 minutes and is often used in competitive events. About seven days out from the
event, begin by eating a diet high (60% to 70%) in high-glycemic carbohydrates such as rice,
pasta and potatoes. Make sure you are getting adequate amounts of fat and protein as well. Drink
plenty of water and increase your water intake four to eight cups (ABOVE NORMAL) about two
days before the event. Avoid dehydrating drinks and foods. As the event comes closer, remember
to taper down your training so you body will be appropriately rested for the contest.
What does the term ‘MET’ mean? This term is used to describe energy expenditure of an
activity. One MET is equivalent to the energy expenditure of a person at rest. It is expressed in
terms of oxygen uptake (i.e., 3.5 ml O2/kg/min). It is very much like a shorthand method of
describing energy requirements. For instance, running 6 miles per hour is about 10 METs while
walking 3 miles per hour is about 3.3 METs.
What are phytochemicals? They are not vitamins. They are not minerals. Phytochemicals, are
plant chemicals that offer great health benefits. The have been shown to project against heart
disease, cancer, diabetes, osteoporosis, and other medical conditions. The only way to get
phytochemicals is to eat or drink them in fruits, vegetables, juices, nuts and whole grain
products.
Is Yo-Yo dieting risky for you? Let’s face it, many well-intentioned diets do fail, which has
concerned researchers that the losing and regaining of weight might be harmful to the body.
However, new research with high blood pressure, which is a major risk factor for heart disease,
shows that Yo-Yo dieting doesn’t appear to have any physiological damage. However, in terms
of emotional wellness, Yo-Yo dieting may be most detrimental.
What is hypoglycemia? Hypoglycemia means low blood sugar. Most individuals may be
affected by what is referred to as reactive hypoglycemia, a condition resulting from glucose
levels dropping after a meal or when you haven’t eaten for several hours. Symptoms include
dizziness, anxiety, shaking, and uneasiness. Eating small, but frequent meals and avoiding
concentrated sources of sugar is recommended.
Can you tell me in minutes or days how much smoking reduces life? According to some
research, every cigarette a man smokes reduces his life by 11 minutes. Each carton of cigarettes
represents a day and a half of lost life. For every year a man smokes a pack a day, he shortens his
life by about two months.
Why don’t diets work? Most diets, especially fad diets, are poorly designed plans that
unrealistically restrict caloric intake. People lose weight initially, but these plans are not
permanent weight loss eating strategies which people can incorporate into a regular lifestyle.
Consequently, INDIVIDUALS usually return to their previous eating habits that encouraged the
weight gain in the first place. Eating habits (and exercise) must be changed permanently for diets
to be successful.
To some degree, the answer depends on what type of workout you are about to do. The typical
30 minute workout of easy jogging or brisk walking really doesn't have specific macronutrient
requirements. However, if your workout is going to be more intense or enduring, here are Some
suggestions. To keep “fueling your metabolic engine” you need more complex-carbohydrates a
few hours prior to the workout. Your goal is to help maintain your body's blood glucose and
carbohydrate (glycogen) stores in the muscles. Also, make sure you drink fluids before the
workout. ACSM recommends 14 to 20 ounces of fluid two to three hours before the event and
possibly another 7 to 10 ounces right before an endurance event.
LECTURE 3
Copyright © 2000 by Bowman O. Davis, Jr. The approach and organization of this material was
developed by Bowman O. Davis, Jr. for specific use in online instruction. All rights reserved. No part of the
material protected by this copyright notice may be reproduced or utilized in any form or by any means,
electronic or mechanical, including photocopying, recording, or by any information storage and retrieval
system, without the written permission of the copyright owner.
INTRODUCTION
To maintain good health, a balance of fluids and electrolytes, acids and bases must
be normally regulated for metabolic processes to be in working state.
A cell, together with its environment in any part of the body, is primarily composed
of FLUID.
Thus fluid and electrolyte balance must be maintained to promote normal function.
Potential and actual problems of fluid and electrolytes happen in all health care
settings, in every disorder and with a variety of changes that affect homeostasis.
The nurse therefore needs to FULLY understand the physiology and pathophysiology
of fluid and electrolyte alterations so as to identify or anticipate and intervene
appropriately.
Fluids
Solvent
Solute
Solution
Body FluidsA.Function
IntracellularExtracellularTranscellular
Sodium*BicarbonatesChloride
CSF, Pleural fluid, Synovial Fluid and peritoneal fluidSecreted by epithelial cells
InterstitialIntravascularBound
80%75%60%50%
55%47%
50%45%
neonates reach adult values by 2 yrs and are about half-way by 3 months
Same as plasma2.Hypotonic
SolutionNaCl-K+CaGluOsm.pHLactkJ/l
D5W
000027825350840
NaCl 0.9%
1501500003005.700
NaCl 3.0%
5135130008555.700
D4W/NaCL 0.18%
3030002222823.5 – 5-5
0672
Hartmans
1291095002746.72837.8
Plasmalyte
1409852945.52784
Haemaccel
1451455.16.2502937.300
Mannitol20%
000001086.200
Dextran 70
1541540003004-700Osmole
Osmolality
Osmolarity
the number of osmoles of solute per litre of solution
Mole
Avogadro's number
= 6.023 x 1023
Molality
Molarity
THE
Normal
The methods by which electrolytes and other solutes move across biologic
membranes are Osmosis, Diffusion, Filtration and Active Transport. Osmosis,
diffusion and filtration are passive processes, while Active transport is an active
process.
1.OSMOSIS
Colloid osmotic pressure (also called oncotic pressure) is the osmotic pull exerted
by plasma proteins
TE DISTURBANCES
Phosphate
1)
c.
60T [ About 50% of body weight in women and 60% in men is water. Body fat
content influences the proportion of body weight that is water. As body fat
increases, water declines as a proportion of body weight. As muscle mass increases,
water increases as a proportion of body weight. Intracellular fluid (ICF) is the largest
compartment and is 60% of total body weight. Extracellular fluid (ECF) is 40% of
TBW. The solutes in the ICF and ECF compartments are different. See figure below.
In ICF the main cation is potassium and the anions are phosphates and bicarbonate.
In ECF the main cation is sodium, and chloride and bicarbonate are the anions.]
d.90
2)
a.30
b.40
d.80
a.
d.
12
4)
If 1 L of solute-free water is lost from the body, how much fluid is lost by the ICF
compartment?a.333 mL
b.
667 mL T [ Water is distributed between the ICF and the ECF in a 2:1 ratio.
Therefore, a given amount of solute-free water loss will result in a twofold greater
reduction in the ICF compartment than the ECF compartment. If 1 L of water is lost,
the ICF volume will decrease by 667 mL, whereas the ECF volume will fall by only
333 mL. If the 1L of fluid lost is isoosmotic, ECF compartment will decrease by 1 L
because Na+ is largely restricted to the ECF.]c.1 Ld.None
5)
a.
b.
O). The normal plasma osmolality is 275 to 290 mosmol/kg. The extracellular and
intracellular solutes (or osmoles) are markedly different, but water crosses cell
membranes to achieve osmotic equilibrium. Water moves across cell membranes
and distributes between ICF and ECF until the osmolality in these two compartments
is the same. Therefore, ECF osmolality is equal to ICF osmolality.]
d.
6)
ECF osmole(s)a.Na+
b.
Cl-c.HCO3-
d.
All of the aboveT [ Sodium is the predominant cation in ECF and associates with the
anions chloride and bicarbonate. These three electrolytes account for more than
90% of the active osmoles in ECF. The predominant cation in ICF is potassium. K+ is
electrochemically balanced primarily by organic phosphates. In addition, DNA, RNA,
and phosphate esters (ATP, creatine phosphate, and phospholipids) are anionic and
provide a negative charge to balance the positive charge of potassium in
intracellular water (ICF). K+ and phosphate esters are the predominant ICF
osmoles. Solutes that are restricted to the ECF or the ICF determine the effective
osmolality (or tonicity) of that compartment. Na+ is largely restricted to the
extracellular compartment. Therefore, total body Na+ content is a reflection of ECF
volume. Hyponatremia or hypernatremia is due to disorders of water homeostasis.]
7)
ICF osmole(s)a.ATP
b.
Creatine phosphate
c.
K+d.Phospholipids
e.
All of the aboveT [ K+ is predominantly limited to the ICF. The major intracellular
anions are phosphates and negatively charged proteins. These are necessary for
normal cell function. Therefore, the number of intracellular particles is relatively
constant. Therefore, any change in ICF osmolality is usually due to a change in ICF
water content.]
8)
a.
d.
e.
9)
What maintains the difference in cation concentration between the ICF and ECF?
a.
,K
+
-ATPase moves three sodium molecules out of the cell while concurrently two
potassium ions in ECF enter the cell. With three cations transported out and two
cations transported into the cell, the consequence of Na
,K
10)
What maintains the difference in cation concentration between the ICF and ECF?
a.
Na
,K
-adenosine triphosphate
b.
c.
d.
e.
All of the aboveT [ Sodium is the major cation in the ECF. Chloride and bicarbonate
are the major accompanying anions in the ECF. Potassium is the major cation in the
ICF. Negative charges on organic molecules maintain electroneutrality with
potassium in the ICF. The difference in cationic solute composition between these
two compartments is maintained by the activity of Na
+
,K
11)
a.
Sodium intake and thirst[ Na+ balance is regulated by varying Na+ excretion.]
b.
GFR[ Na+ excretion is mainly regulated by tubular Na+ reabsorption (not by GFR).]
c.
d.
12)
b.
c.
Normal brain T [ Brain cells can vary the number of intracellular solutes to protect
against large water shifts and resultant change in intraneuronal osmolality. This
process is called osmotic adaptation and occurs in chronic hyponatremia and
hypernatremia. Osmotic adaptation is mediated initially by shifts of K+ and Na+
and later by osmolytes.]
d.
13)
True statement(s)
a.
b.
Tonicity refers to the concentration of solutes that are “effective” in eliciting a water
shift between body fluid compartments
c.
Urea is not an effective solute [ Osmolality refers to the concentration of all solutes.
Tonicity refers to the concentration of solutes that are “effective” in eliciting a water
shift between body fluid compartments. Addition or removal of solutes causes shift
of water to restore the equality of solute concentrations. Therefore, they are
considered “effective solutes”. Solutes such as urea do not elicit such a sustained
shift in water. Therefore, urea is not considered effective solute, although they
contribute to the laboratory measurement of fluid osmolality.]
d.
Addition of water without solutes results in reduction in both osmolality and tonicity
[ The addition of water without solutes results in reduction in both osmolality and
tonicity of all body fluid compartments. The removal of water without solutes results
in increase in both osmolality and tonicity of all body fluid compartments.]
e.
14)
Ineffective osmole
a.
Sodium[ The ECF volume is a reflection of total body Na+ content. Na+ excess or
deficit are manifest as edematous or hypovolemic states, respectively.]
b.Potassium
c.
UreaT [ Urea and glucose do not contribute to water shift across cell membranes.
Therefore, they are known as ineffective osmoles.]
d.
Osmolytes [ Osmolytes are organic solutes (e.g., inositol, betaine, and glutamine).]
15)
Which of the following is the least important source of obligate water loss?
a.
Urine[ Metabolism of a normal diet generates about 600 mosmol/d. Therefore, 600
mosmols must be excreted per day through urine, primarily as urea and
electrolytes. The maximal urine osmolality that can be achieved is 1200 mosmol/kg.
Thus, a minimum urine output of 500 mL daily is required for excreting the daily
solute load. Oliguria is urine output < 500 mL/day. Water intake must equal water
excretion to maintain a steady state. Daily water intake exceeds physiologic
requirements in normal physiological conditions.]
b.
c.
Evaporation from the skin [ Evaporative or insensitive water losses are important in
the regulation of body temperature.]
d.
16)
a.
Thirst T [ The primary stimulus for drinking water is thirst. The thirst center is
situated in the organum vasculosum of the anterior hypothalamus. Thirst is caused
by an increase in effective osmolality or a decrease in ECF volume or blood
pressure. The osmotic threshold for thirst is about 295 mosmol/kg and varies among
individuals. Reduction of ECF volume also stimulates thirst by means of angiotensin
2, even when body tonicity is not elevated.]
b.
Reduction of ECF volume [ Reduction of ECF volume is a very potent stimulus for
release of AVP (carried by the ninth and tenth cranial nerves), even when body
tonicity is not elevated. Reduction of ECF volume also stimulates thirst by means of
angiotensin 2.]
c.
d.
Glucose[ Urea and glucose are ineffective osmoles. They do not stimulate thirst.]
e.
Urea
17)
a.
WaterT [ Body water is the primary determinant of extracellular fluid osmolality and
disturbances in water balance primarily affect body fluid tonicity. Disorders of body
water balance can cause hypotonicity or hyperotonicity. When there is an excess of
body water relative to body solute, hypotonicity results. When there is a deficiency
of body water relative to body solute, hyperotonicity develops. The main constituent
of plasma osmolality is sodium. Therefore, hypotonic disease states are
characterized by hyponatremia and hypertonic disease states are characterized by
hypernatremia. Disturbances in sodium balance primarily affect ECF volume]
b.Glucosec.Uread.Hemoglobin
18)
Sodium T [ Sodium is actively pumped out of cells by the Na+, K+-ATPase pump. As
a result, 90% of all Na+ is extracellular. The major ECF solutes are Na+ salts.
Therefore, plasma Na+ concentration determines osmolality. The normal plasma
osmolality is 275 to 290 mosmol/kg. The plasma osmolality does not vary by more
than 2%. The intake of solute-free water must be balanced by the loss of the same
volume of electrolyte-free water. Impaired free water excretion will lead to
hyponatremia.]d.Potassiume.Calcium
19)
a.
Sodium T [ Total body sodium is the principal determinant of ECF volume. Most of
the body's sodium is located in the ECF. The regulation of sodium excretion by the
kidney maintains normal ECF and hence plasma volume. The glomerular filtration
rate is 125 ml/min (80 liters/day) in a typical adult. Over 99% of this filtered fluid is
reabsorbed as a result of tubular reabsorption of sodium.]b.Reninc.Aldosterone
d.
Baroreceptors
20)
b.
285 mosmol/kgT [ The major stimulus for AVP secretion is hypertonicity. The
osmotic threshold for AVP release is 280 to 290 mosmol/kg. Arginine vasopressin
(AVP) is a polypeptide synthesized in the supraoptic and para-ventricular nuclei of
the hypothalamus and secreted by the posterior pituitary gland. An increase or
decrease in tonicity is sensed by hypothalamic osmoreceptors, leading to
enhancement or suppression of AVP secretion.]
c.300
d.
325
21)
d.
All of the aboveT [ The serum sodium concentration and thus serum osmolality are
controlled by water homeostasis. Water homeostasis is mediated by thirst, arginine
vasopressin, and the kidneys. Abnormal water balance manifests as an abnormality
in the serum sodium concentration (hypernatremia or hyponatremia).]
HYPOVOLEMIA
In internal sequestration total body sodium and water may be normal or increased.
1)
a.
b.
Mannitol IV[ The renal tubule is impermeable to mannitol. Therefore, mannitol
produces an osmotic diuresis because mannitol can be excreted along with water
only.]
c.
d.
e.
All of the aboveT [ Excessive renal losses of Na+ and water may also occur during
the diuretic phase of acute tubular necrosis and following the relief of bilateral
urinary tract obstruction.]History can determine the cause of hypovolemia
(bleeding, vomiting, diarrhea, polyuria, medications, diaphoresis).
2)
c.
e.
20 L
3)
Diarrhea causes
a.
b.
Hyperkalemia 4)Sweat
a.
b.
c.
5)
d.
6)
a.
c.
d.
e.
All of the aboveT [ The net effect is to maintain mean arterial pressure and cerebral
and coronary perfusion. In contrast to this cardiovascular response, the renal
response attempts to restore the ECF volume.]
7)
a.
b.
c.
d.
Thirst
Muscle cramps
Postural dizziness
Oliguria
Confusion
Cyanosis
Postural tachycardia
Postural hypotension
Tachycardia
Hypotension
Oliguria
Cyanosis
Intravascular volume contraction of less than 5% does not usually cause symptoms
or signs. Symptoms and signs begin to appear with intravascular volume
contraction of 5 - 15%.
Severe degrees of hypovolemia (intravascular volume contraction > 15%) cause
hypotension, peripheral cyanosis, cold extremities, and reduced levels of
consciousness.
Reduced skin turgor and dry mucous membranes are not reliable indicators of
hypovolemia.
8)
a.
b.
Raised plasma urea [ The plasma urea concentration rises because urea excretion is
reduced. Hypovolemia decreases GFR and urea excretion.]
c.
d.
e.
All of the above [ The urine specific gravity and osmolality increases because urine
concentrating mechanisms are activated to conserve water. Urine sodium
concentration falls]
9)
a.
b.
Glomerulonephritis
c.
Prerenal azotemia [ In hypovolemia, the blood urea nitrogen (BUN) and plasma
creatinine concentrations tend to be elevated due to decreased GFR. In prerenal
azotemia, hypovolemia leads to increased urea reabsorption and a proportionately
greater elevation in BUN than plasma creatinine. Therefore, BUN:creatinine ratio is
20:1 or higher.]
d.
e.
10)
In hypovolemia
a.
Low urine sodium[ Hypovolemia causes enhanced renal Na+ and water
reabsorption. Therefore, the urine Na+ concentration is usually <20 mEq/L.]
b.
High urine specific gravity[ The urine specific gravity in hypovolemic patients is
usually > 1.015 due to increased AVP secretion.]
c.
High urine osmolality[ The urine osmolality in hypovolemic patients is usually > 450
mosmol/kg due to increased AVP secretion.]
d.
All of the aboveT [ All these are the appropriate renal response to hypovolemia. In
hypovolemia due to diabetes insipidus, urine osmolality and specific gravity are
very low and indicates dilute urine. If no ADH is circulating in plasma, the osmolality
of urine produced by the kidney can be less than 100 mmol/kg H
O.]
11)
A patient has quickly lost 1 L of whole blood following an accident. What features
can you expect in such a patient? [ Answer – all choices given below are true]
a.
Tachycardia
b.
Postural hypotension
c.
d.
Oliguria - When fluid loss is extrarenal, there is water and sodium retention by the
kidneys. This normal renal response results in oliguria with an elevated urine
specific gravity (>1.020) and osmolality (>400 mOsm/kg), a sodium concentration
less than 20 mEq/L and a fractional excretion of sodium < 1%.
e.
Collapsed neck veins - Jugular venous pressure may fall (CVP < 5 cm H
O)
f.
g.
Normal blood urea - Blood urea may also remain constant initially. Later, blood urea
may increase reduced renal blood flow and the effects of destruction of
erythrocytes in the gastrointestinal tract
h.
Normal serum sodium and potassium - Sodium and potassium concentration and
acid-base parameters are not likely to change initially
12)
a.
b.
154 mEq/L T [ Normal saline or 0.9% NaCl has 154 mEq/L of Na+. See table below.
This is the solution of choice in normonatremic and mildly hyponatremic individuals.
It should be administered initially in patients with hypotension or shock. Patients
with significant hemorrhage, anemia, or intravascular volume depletion may require
blood transfusion or colloid-containing solutions (albumin, dextran).]
c.
513 mEq/L [ Severe hyponatremia may require hypertonic saline (3.0% NaCl or 513
mEq/L Na+).
d.
616 mEq/L
Cl
Other
5% dextrose
50 g200000
Normal saline
001541540
13)
What is the increase in plasma volume if 1 L of isotonic saline is given IV?a.1000 mL
b.
600 mL
c.
d.
e.
75 mL[ Infusing half isotonic saline (0.45% sodium chloride plus 5% glucose) is
equivalent to infusing half that volume as solute-free water (distributed throughout
body fluid compartments) and the other half as isotonic saline (confined to the ECF
compartment).]
14)
What percentage of a unit of packed red blood cells given remains in the vascular
compartment?
a.
100 [ A unit of infused packed red blood cells remains entirely in the vascular
compartment. However, erythrocytes are actually considered part of the
intracellular compartment. Packed red cells are used in the treatment of
hemorrhage to restore oxygen carriage and delivery and not as ECF volume
replacement.]b.66c.33d.15
HYPERNATREMIA
1)
b.
145T [ Hypernatremia is plasma Na+ concentration > 145 mEql/L. Patients have
moderate hypernatremia if their serum Na+ is 146 to 159 mEq/L. Patients with Na+
greater than 160 mEq/L have severe, life-threatening hypernatremia.
Hypernatremia may be due to primary Na+ gain or water deficit. Water loss is the
most common cause of acute hypernatremia. Hypernatremia can develop in
patients who do not replace the water lost after excessive sweating in a hot
environment, vomiting or diarrhea.]c.155
d.
165
CAUSES OF HYPERNATREMIA
Hypodipsia
Diabetes insipidus
Hypotonic fluid
Renal causes
Diuretics
Postobstructive diuresis
Vomiting
Diarrhea
Nasogastric drainage
Cutaneous causes
Burns
Excessive sweating
Hypertonic dialysis
Primary hyperaldosteronism
Cushing’s syndrome
2)
a.
Hyperosmolar sate [ Na+ and its accompanying anions are the major effective ECF
osmoles. Therefore, hypernatremia is a state of hyperosmolality and results in ICF
volume contraction. Sodium is impermeable. It contributes to tonicity and induces
the movement of water across cell membranes. Therefore, hypernatremia invariably
denotes hypertonic hyperosmolality and always causes cellular dehydration, at least
transiently.]
b.
c.
Stimulates thirst [ Hypernatremia stimulates thirst and thus increases water intake.
The severity of hyperosmolality is typically mild unless the thirst mechanism is
abnormal or access to water is limited (infants, postoperative state, impaired
mental status, and intubated patients in the intensive care unit.]
d.
e.
All of the aboveT [ The first question to be answered in any patient with
hypernatremia is why there has been inadequate intake of water.
Hypernatremia is rare in conscious patients who have free access to water because
of the extreme sensitivity of the thirst mechanism.]
3)
If 1 L of water is lost from the body, how much fluid is lost by the ICF compartment?
a.333 mL
b.
667 mLT [ Water is distributed between the ICF and the ECF in a 2:1 ratio.
Therefore, a given amount of solute-free water loss will result in a twofold greater
reduction in the ICF compartment than the ECF compartment. If 1 L of water is lost,
the ICF volume will decrease by 667 mL, whereas the ECF volume will fall by only
333 mL. If the 1L of fluid lost is isoosmotic, ECF compartment will decrease by 1 L
because Na+ is largely restricted to the ECF.]c.1 Ld.None
4)
What is the most common cause of hypernatremia?
a.
b.
a.
Loss of waterT [ Most cases of hypernatremia are due to loss of free water.
Hypernatremia with hypovolaemia results from fluid losses that is more than
sodium loss. Renal water loss (e.g., diuretics) is the most common cause of
hypernatremia. Diarrhea is the most common gastrointestinal cause of
hypernatremia. Profuse sweating is also a major cause of fluid loss resulting in
hypernatremia with hypovolaemia.]
b.
Renal failure
c.
5)
a.
d.
Viral gastroenteritides
e.
CholeraT [ Secretory diarrheas (e.g., cholera, carcinoid, VIPoma) have a fecal
osmolality similar to that of plasma. Diarrhea due these present with ECF volume
contraction and a normal plasma Na+ concentration or hyponatremia.]
6)
Fecal osmolality
a.
b.
c.
Twice the sum of stool concentrations of Na+ and K+T [ The stool osmolality is
assumed to be 300 mosmol/kg H
O. When the calculated difference is > 50, an osmotic gap is present. This suggests
that the diarrhea is due to a nonabsorbed dietary nutrient, e.g., a fatty acid and/or
carbohydrate. When this difference is < 25, it is presumed that a dietary nutrient is
not responsible for the diarrhea.]
d.
7)
c.
Severe burns
d.
Mechanical ventilation
e.
All of the aboveT [ Insensible loss of water is due to evaporation from the skin and
respiratory tract. Insensible losses are increased with fever, exercise, heat
exposure, and severe burns and in mechanically ventilated patients. The Na+
concentration of sweat decreases with profuse perspiration, thereby increasing
solute-free water loss.]
8)
a.
Renal water lossT [ Renal water loss is the most common cause of hypernatremia.
The normal renal response to hypernatremia is for the nephron to generate
hyperosmolar urine and retain water. However, renal correction of hypernatremia
depends on the patient having access to water. Severe hypernatremia rarely occurs
in conscious patients because intense thirst compels them to drink water. In
contrast, severe hypernatremia can develop in sedated patients, disoriented
patients, or patients in delirium tremens.]
b.
d.
Diabetes insipidus
9)
a.
c.
d.
10)
Diabetes insipidus[ Failure to synthesize and release ADH or failure of the renal
tubular cells to respond to ADH can result in hypernatremia.
Hypernatremia can develop in patients with diabetes insipidus who have sustained
a large water loss. Diabetes insipidus causes nonosmotic urinary water loss and
hypernatremia. Total solute excretion must equal solute production. Persons eating
a normal diet generate about 700 mosmol/d of solutes. Therefore, daily solute
excretion in excess of 750 mosmol is an osmotic diuresis. This can be confirmed by
measuring the urine glucose and urea.]
b.
Diabetes mellitusT [ Osmotic diuresis is water loss in excess of Na+ and K+. The
most common cause of an osmotic diuresis is hyperglycemia and glucosuria in
poorly controlled diabetes mellitus.]
c.
IV mannitol
d.
11)
a.
b.
Hypertension and cardiac failure [ Volume depletion is often present in patients with
a history of excessive sweating, diarrhea, or an osmotic diuresis. History and
physical examination will often provide clues as to the underlying cause of
hypernatremia. Important points to note are the absence or presence of thirst,
diaphoresis, diarrhea, polyuria and current drugs. Look for features of ECF volume
contraction. Evaluate neurologic and mental status.]
c.
d.
Craving for ice-cold water [ Patients with polydipsia from central diabetes insipidus
tend to prefer ice-cold water.
12)
a.
b.
ECF volume expansion and urine Na+ concentration >100 mmol/LT [ Measure urine
volume and osmolality in the evaluation of hyperosmolality. ECF volume expansion
and natriuresis (urine Na+ concentration >100 mEq/L) confirms a primary Na+
excess.]
c.
d.
13)
a.
b.
c.
d.
Any of the aboveT [ A urine specific gravity of 1.010 units or less is a dilute urine
and suggests that ADH levels are low. A urine specific gravity greater than 1.030
units suggests that the urine being produced is close to maximum osmolality. The
correct renal response to hypernatremia is the excretion of the minimum volume
(500 mL/d) of maximally concentrated urine (urine osmolality > 800 mosmol/kg).
14)
a.
b.
Urine volume X osmolalityT [ The solute excretion rate is the product of the urine
volume and osmolality.]c.Urine sodium + potassium + chloride
d.
15)
c.
Correct the water deficit [ The most common cause of hypernatremia is loss of
water. Treatment of patients with hypernatremia secondary to dehydration is IV or
oral administration of water. The amount of water required to correct the deficit can
be calculated from the equation given below. Hypernatremic patients typically have
reduced blood volumes. Treat these patients first with the IV infusion of isotonic
saline solutions until the contracted ECF has been restored. Then give sufficient
electrolyte-free water to enable their renal function to produce concentrated urine
and correct the hypernatremia. In patients with prolonged hyperosmolality,
aggressive treatment with hypotonic fluids may cause cerebral edema, which can
lead to coma, convulsions, and death. Lower Na+ only at a rate < 8 mEq/day. See
figure below.]d.Dialysis
e.
Tetracycline
Water deficit = plasma sodium concentration – 140
Total body water is approximately 50 of lean body weight in men and and 40% of
lean body weight in women
Within minutes after the development of hypertonicity, loss of water from brain cells
causes shrinkage of the brain and an increase in osmolality. Partial restitution of
brain volume occurs within a few hours as electrolytes enter the brain cells (rapid
adaptation). The normalization of brain volume is completed within several days as
a result of the intracellular accumulation of organic osmolytes (slow adaptation).
Slow correction of the hypertonic state reestablishes normal brain osmolality
without inducing cerebral edema, as the dissipation of accumulated electrolytes and
organic osmolytes keeps pace with water repletion. In contrast, rapid correction
may result in cerebral edema as water uptake by brain cells outpaces the
dissipation of accumulated electrolytes and organic osmolytes. Such overly
aggressive therapy carriesthe risk of serious neurologic impairment due to cerebral
edema.
16)
How much is the free water deficit in a 50-kg woman with a plasma Na+
concentration of 160 mEq/L?
a.
1.9 L
b.
c.
3.9 L
d.
4.9 L
17)
What is the preferred route for administering fluids in a patient with hypernatremia?
c.
Oral routeT [ The preferred route for administering fluids is the oral route or a
feeding tube. If neither is feasible, fluids should be given intravenously.]
d.
Per rectal
18)
a.
Pure water[ Only hypotonic fluids are appropriate, including pure water, 5 percent
dextrose, 0.2 percent sodium chloride (one-quarter isotonic saline), and 0.45
percent sodium chloride (one-half isotonic saline).
b.
e.
nes, decreased skin turgor, fever, tachypnea, and a blood pressure of 142/82 mm
Hg without orthostatic changes. The serum sodium concentration is 168 mEq per
liter, and the body weight is 68 kg. Hypernatremia caused by pure water depletion
due to insensible losses is diagnosed, and an infusion of 5 percent dextrose is
planned. How much is the estimated volume of total body water in liters?
a.
41[ The estimated total body water (in liters) is calculated as a fraction of body
weight. The fraction is 0.6 in children; 0.6 and 0.5 in nonelderly men and women,
respectively; and 0.5 and 0.45 in elderly men and women, respectively. Normally,
extracellular and intracellular fluids account for 40 and 60 percent of total body
water, respectively. The estimated volume of total body water in a child weighing
68 kg would be 68 X 0.6 = 40.8L]
b.
34T [ 0.5 X 68]
c.
31[ The estimated volume of total body water in an elderly men and woman
weighing 68 kg would be 68 X 0.45 = 30.6 L.]
d.
25
20)
If 1 liter of 5 percent dextrose is given to the patient described above, what will be
the fall in serum sodium concentration?
a.
b.
= (infusate Na
- serum Na
) ÷ (total body water + 1). According to this formula, the retention of 1 liter of 5
percent dextrose will reduce the serum sodium concentration by 4.8 mEq per liter
[ (0 – 168) ÷ (34+1) = - 4.8.]
c.
d.
21)
a.
0.45% sodium chloride IVT [ Hypernatremia caused by hypotonic fluid loss is the
correct diagnosis. The estimated volume of total body water is 31.5 liters (0.5 X 63).
The infusion of 1 liter of 0.45 percent sodium chloride will reduce the serum sodium
concentration by 2.5 mEq per liter (77 – 158) ÷ ( 31.5 + 1) = - 2.5. If the goal is to
reduce the serum sodium concentration by 5 mEq per liter over the next 12 hours, 2
liters of the solution is required (5÷2.5). If 1 liter is added to compensate for
ongoing losses of gastric and other fluids, a total of 3 liters will be administered for
the next 12 hours, or 250 ml per hour.]
b.
0.9% sodium chloride IV[ Although there is evidence of a depletion in the volume of
extracellular fluid, the patient’s hemodynamic status is not sufficiently
compromised to warrant the initial use of 0.9 percent sodium chloride.]
c.
Furosemide IV
d.
Furosemide oral
e.
Hemodialysis
22)
a.
b.
Withdraw lactulose and give IV 0.2 percent sodium chlorideT [ The hypernatremia is
due to hypotonic sodium and potassium losses induced by lactulose therapy.
Treatment is withdrawal of lactulose and IV 0.2 percent sodium chloride containing
20 mEq of potassium chloride per liter. With the presence of ascites, the estimated
volume of total body water is about 38 liters (0.6 X 64).
c.
e.
Potassium chloride IV
23)
A 60-year-old man has received 10 ampoules of sodium bicarbonate over six hours
during resuscitation after recurrent cardiac arrest. He is stuporous and is
undergoing mechanical ventilation. His blood pressure is 138/86 mm Hg, and
peripheral edema is present. The serum
sodium concentration is 156 mEq per liter, the body weight is 85 kg, and the urinary
output is 30 ml per hour. What is the treatment?
a.
b.
c.
d.
Peritoneal dialysis
e.
Dopamine
24)
Not suited for correcting hypernatremia in a 50-year-old man with a serum sodium
concentration of 162 mEq per liter and a body weight of 70 kg is
a.
c.
HYPONATREMIA
1)
a.
Altered ECF volume T [ Disorders in sodium balance present chiefly as altered ECF
volume rather than altered sodium concentration.]b.Hyponatremia
c.Hypernatremia
d.
Diabetes insipidus
2)
135T [ The normal serum sodium ion concentration ranges between 135 and 145
mEq/L. Hyponatraemia is plasma Na < 135 mEq/L. Severe hyponatremia is defined
as an Na+ less than 120 mEq/L. A falling Na
indicates that the osmolality in ECF and ICF is also falling. Hypernatremia always
indicates hypertonicity, but hyponatremia can be associated with low, normal, or
high tonicity.]c.145
d.
155
Hyperglycemia
Hyperlipidemia
Volume depletion
Cirrhosis
Heart failure
Nephrotic syndrome
SIADH
Hypothyroidism
Drugs
Pregnancy
Severe hypoalbuminemia
Primary polydipsia
b.
c.
4)
d.
5)
a.
b.
Hyperglycemia[ Hyperglycemia
c.
High blood urea[ Unlike glucose, solutes that enter cells, such as urea or ethanol, do
not cause intracellular-to-extracellular water shift and thus do not cause
hyponatremia.]
d.
6)
a.
The increases in plasma glucose raise serum osmolality, which pulls water out of
cells and dilutes the serum Na.
Plasma Na+ concentration falls by 1.6 mEq/L for every 100 mg/dL rise in the
plasma glucose concentration.]
b.
High blood urea[ Unlike glucose, solutes that enter cells, such as urea or ethanol, do
not cause intracellular-to-extracellular water shift and thus do not cause
hyponatremia.]
c.
d.
e.
Thiazide diuretics[ Thiazide diuretics lead to Na+ and K+ depletion and AVP-
mediated water retention.]
7)
a.
Primary polydipsia[ Hypotonic hyponatremia means that water intake exceeds the
ability of the kidney to excrete water. A normal kidney can excrete 30 L of water per
day. Therefore, hyponatremia with normal renal water excretion implies that the
patient is drinking more than 30 L of water per day. This condition is referred to as
primary polydipsia. These patients should have a urine osmolality less than 100
mOsm/L. Primary polydipsia is a common condition that leads to polyuria and
polydipsia, but it is uncommon as the sole cause of hyponatremia.]b.Mannitol
infusionc.Diuretics
a.
8)
a.
b.
d.
Ethracrynic acid
e.
Spiranolactone
9)
a.
b.
Cirrhosis
c.
Nephrotic syndrome
d.
Renal failure with oliguria[ Oliguric renal failure may cause hyponatremia if water
intake is more than what the kidneys can excrete.]
e.
All of the aboveT [ The severity of hyponatremia often correlates with the severity
of the underlying condition and is an important prognostic factor. See figure below.]
c.
Nephrotic syndrome
d.
All of the aboveT [ These conditions are associated with sodium and fluid overload.
The reduced effective blood volume stimulates renin-angiotensin-aldosterone axis
resulting in sodium and fluid overload. See figure above.]
11)
a.
Heart failure [ In CCF, even though there is total body ECF overload, the decreased
cardiac output causes perceived intra-arteriolar volume depletion. There is a
decrease in the effective arterial blood volume at the level of the carotid artery and
the renal afferent arteriole baroreceptors. Decreased renal perfusion activates the
RAAS, resulting in increased sodium and water reabsorption. Increased baroreceptor
firing activates non-osmotic AVP secretion, resulting in increased free water
reabsorption. These adaptive physiologic mechanisms further exacerbate
hypervolemia and progressive hyponatremia. ACE inhibitors reduce mortality in this
subgroup of patients with cardiac failure.]
b.
Cirrhosis [ Cirrhosis is the most common cause of ascites. 30% of patients with
ascites develop hyponatremia. Gastrointestinal endotoxin is less efficiently cleared
in cirrhosis due to portal-systemic shunting. This stimulates nitric oxide production
and vasodilatation. Arterial dilatation in the splanchnic vasculature, leads to arterial
underfilling and non-osmotic secretion of AVP. The increase in AVP secretion and
water retention is proportional to the severity of cirrhosis. A serum Na+ less than
125 mEq/L often indicate end-stage disease.]
c.
d.
All of the aboveT [ In hypervolemic hyponatremia, there is an excess in total body
water and total body sodium, resulting in edema or ascites. In many cases, the
increase in total body water is out of proportion to that of total body sodium,
causing hyponatremia. This pathophysiology occurs in congestive heart failure,
cirrhosis, and nephrotic syndrome.]
12)
a.
Low intravascular volume[ These patients have low ECF volume secondary to heart
failure, cirrhosis, or nephrotic syndrome. Low ECF volume stimulates nonosmotic
release of vasopressin, renal water reabsorption, and subsequent hyponatremia.]
b.
Urinary sodium is very low [ Spot urinary sodium is very low (often <10 mEq/L) due
to avid renal sodium retention.]
c.
d.
Na
e.
CAUSES OF HYPONATRAEMIA
14)
Volume statusExamples
Adrenocortical failure
Primary polydipsia
SIADH
Cirrhosis
Nephrotic syndrome
Thiazides
Postoperative state
SIADH
17)
a.
b.
c.
Serotonin reuptake inhibitor[ Drugs associated with euvolemic hyponatremia act
largely by stimulating release of ADH from the posterior pituitary gland.]
d.
Primary polydipsia[ Circulating ADH levels are high in all these disorders except for
primary polydipsia.]
SIADH – DIAGNOSIS
18)
Cause(s) of SIADH
a.
b.
c.
e.
None of the above T [ SIADH is a diagnosis of exclusion and can only be made in the
setting of normal renal, thyroid, and adrenal function.]
19)
a.
e.
20)
a.
c.
Cerebral salt wasting [ Head injury and intracranial hemorrhage can induce
negative sodium balance through urinary losses. The hypovolemia induces release
of AVP. This condition is frequently difficult to distinguish from hyponatremia caused
by the SIADH.]d.Salt-losing nephropathy
e.
21)
a.
Low circulating ADH levels[ Patients with hypovolemic hyponatremia have a deficit
in total body sodium causing low ECF volume and nonosmotic release of antidiuretic
hormone (ADH). High circulating ADH levels stimulate renal water reabsorption and
subsequent development of hyponatremia.]
b.
Edema is typical[ Patients with hypervolemic hyponatremia have excess total body
sodium manifested by edema. Physical examination in a patient with hypovolemic
hyponatremia typically shows features of hypovolaemia (tachycardia, orthostatic
hypotension, dry mucous membranes, flat neck veins, absence of edema)]
c.
Spot urine sodium concentration is always less than 20 mEq/L if renal function is
normal[ When volume losses are nonrenal (due to hemorrhage, diarrhea, dermal
losses, or third spacing of fluids as in pancreatitis or peritonitis), the spot urine
sodium concentration is typically less than 20 mEq/L. When volume losses are due
in part to renal sodium wasting, the spot urine sodium concentration is greater than
20 mEq/L. Such renal sodium wasting may be seen in the presence of active
diuretics, mineralocorticoid deficiency, osmotic diuresis, salt-losing nephropathy,
bicarbonaturia (most commonly from vomiting), and ketonuria.]d.All of the above
e.
22)
a.
Pulse and blood pressureT [ On physical examination, the best index of effective
arterial volume is the pulse and blood pressure. The earliest clinical evidence of
decreasing blood volume is tachycardia and postural fall in BP.]
b.
c.
Low urinary chloride d.Low fractional excretions of sodium and chloride in the urine
a.
Blood urea [ BUN is very sensitive to effective arterial volume. In patients with
normal serum creatinine, a high BUN suggests a low effective arterial volume and a
low BUN suggests a high effective arterial volume. The plasma uric acid can also be
used as a sensitive index of effective arterial volume.]
23)
Cause(s) of hyponatremia
a.
b.
d.
Primary polydipsia[ The normal kidneys can excrete about 12 L of water daily. In
psychogenic or primary polydipsia, compulsive water consumption may be much
more than this. These patients often have psychiatric illnesses.
e.
All of the aboveT [ Metabolism of a normal diet generates about 600 mosmol/d. The
minimum urine osmolality is 50 mosmol/kg. Therefore, the maximum daily urine
output will be about 12 L (600 ÷ 50 = 12).]
24)
What is the diagnosis in a patient with high urine sodium and low specific gravity?
a.
SIADH
b.
Adrenal insufficiency
c.
e.
Hypovolaemia
25)
d.
26)
a.
b.
c.
Can cause severe cerebral dysfunction[ Cerebral symptoms are anorexia, nausea,
vomiting, confusion, lethargy, seizures and coma. Brain cells adapt to hyponatremia
by losing cellular potassium, organic solutes, and then other organic osmolytes. This
adaptation requires 48 to 72 hours and is very effective in reducing brain swelling.
Thus, when hyponatremia occurs slowly, patients have few or no symptoms. When
hyponatremia develops in less than 48 hours, adaptation has not had time to occur.
These patients are at high risk for developing cerebral edema and intracranial
hypertension. Intracranial cell swelling in patients with acute severe hyponatremia
causes headaches and confusion that may rapidly progress to coma or seizures.]
d.
Clinical features depends on the rate of development of hyponatremia [ Cerebral
symptoms depends more on how fast hyponatremia develops than on the severity
of hyponatremia. This is because when the plasma osmolality falls rapidly, water
flows into cerebral cells which become swollen and ischaemic. When hyponatraemia
develops gradually, cerebral neurons respond by reducing the intracellular
osmolality. Cerebral neurons reduce intracellular osmolality by reducing its
potassium concentration and synthesis of intracellular organic osmolytes.]
e.
27)
a.Cardiovascularb.Respiratory
c.
SYMPTOMS OF HYPONATREMIA
28)
a.
29)
Intracranial hypotension
b.
d.
1.
Plasma osmolality
2.
Urine osmolality
3.
4.
Urine K+ concentration
Most patients with hyponatremia have a decreased plasma osmolality. The kidneys
respond to hypoosmolality by excreting maximum volume of dilute urine, i.e., urine
osmolality will be < 100 mosmol/kg and specific gravity will be < 1.003. This occurs
in patients with primary polydipsia.
Na+ is the major ECF cation and is largely restricted to this compartment.
Therefore, ECF volume contraction indicates a deficit in total body Na+ content.
Volume depletion in patients with normal underlying renal function results in
enhanced tubule Na+ reabsorption and a urine Na+ concentration < 20 mmol/L.
30)
a.
Plasma electrolytes [ Plasma and urine electrolytes and osmolality are the only tests
required to diagnose the cause of hyponatraemia.
Initial laboratory evaluation also includes glucose, BUN, creatinine, and uric acid.]
b.Urine electrolytesc.Urine osmolality
d.
Plasma renin activity[ Measurement of plasma renin activity is useful when there is
doubt about clinical signs of ECF volume.]
e.
Plasma ADHT [ Plasma ADH is not very helpful in distinguishing between the causes
of hyponatraemic states. ADH is activated both in hypovolaemic and hypervolaemic
states. Most chronic hypervolaemic states (cardiac failure, cirrhosis and nephrotic
syndrome) have impaired circulation that activates ADH release through non-
osmotic mechanisms. Indeed, these disorders may have higher circulating ADH
levels than patients with SIADH. ADH is suppressed in primary polydipsia and
iatrogenic water intoxication.]31)Plasma ADH level is low ina.SIADHb.Cardiac
failurec.Cirrhosisd.Nephrotic syndrome
e.
Primary polydipsiaT
32)
What is the treatment of mild asymptomatic hyponatremia?a.Increase oral sodium
intake b.Stop loop diureticc.Loop diureticd.Water restriction
e.
33)
c.
e.
Isotonic salineT [ Give sodium as normal saline. The direct effect of the IV normal
saline on the plasma Na+ concentration is trivial. When euvolemia is restored by
normal saline, the stimulus for AVP release is removed allowing the excess free
water to be excreted. Acute or severe hyponatremia (plasma Na+ concentration
<110 to 115 mmol/L) usually present with altered mental status and/or seizures and
requires more rapid correction.]
34)
a.
Restrict Na+ intake[ The hyponatremia associated with edematous states reflect
the severity of the underlying disease. It is usually asymptomatic. These patients
have increased total body water that exceeds the increase in total body Na+
content. Treatment is restriction of Na+ and water intake.]
b.
Restrict water intake [ Dietary water intake should be less than the urine output.]
c.
Correct hypokalemia [ Correction of the K+ deficit may raise the plasma Na+
concentration by shifting of Na+ out of cells as K+ moves in.]
d.
Loop diuretic[ Use loop diuretics to increase water loss. Replace a proportion of the
urinary Na+ loss to ensure net free water excretion.]
e.
35)
a.
All of the aboveT [ Water restriction will ameliorate all forms of hyponatremia, but it
is not the optimal therapy in all cases. Hyponatremias associated with the depletion
of extracellular-fluid volume require correction of the sodium deficit.]
36)
a.
b.
e.
Furosemide
37)
50-year-old male admitted with seizures has a serum sodium level of 115 mEq/L.
What is the treatment?a.Oral sodium
b.Normal saline IV
c.
d.
IV frusemide
Children = 0.6
38)
How much sodium is needed to correct Na+ concentration from 115 mEq/L to 125
mEq/L in a 60-kg man?
a.
90 mEq/L
b.
180 mEq/L
c.
360 mEq/LT [ The quantity of Na+ required to increase the plasma Na+
concentration by a given amount is estimated by multiplying the deficit in plasma
Na+ concentration by the total body water. Normally, total body water is 60% of
lean body weight in men (50% of lean body weight in women). In this question
sodium needed is 125 – 115 X 60 X 0.60 = 360 mEq/L.]
d.
720 mEq/L
e.
1440 mEq/L
39)
a.
IV furosemideb.Dialysis
c.
e.
Half-normal saline
40)
a.
b.
Water and salt restrictionT
c.
d.
-receptor antagonists[ V
-receptor antagonists (conivaptan) will likely become the first-line treatment for
euvolemic and hypervolemic hypernatremia.]
e.
41)
b.
c.
d.
Within minutes after the development of hypotonicity, water gain causes swelling of
the brain and a decrease in osmolality of the brain. Partial restoration of brain
volume occurs within a few hours as a result of cellular loss of electrolytes (rapid
adaptation). The normalization of brain volume is completed within several days
through loss of organic osmolytes from brain cells (slow adaptation). Low osmolality
in the brain persists despite the normalization of brain volume. Proper correction of
hypotonicity reestablishes normal osmolality without risking damage to the brain.
Aggressive correction of hyponatremia can lead to irreversible brain damage.
42)
a.
d.
Intense thirst
43)
A previously healthy 30-year-old man has three generalized seizures two days after
an appendectomy. He was given diazepam and phenytoin intravenously and
undergoes laryngeal intubation with mechanical ventilation. Three liters of 5
percent dextrose in water had been infused during the first day after surgery. He
has subsequently drunk substantial amount of water. Clinically, he is euvolemic,
and he weighs 46 kg. He is stuporous and responds to pain but not to commands.
The serum sodium concentration is 112mEq per liter, the serum potassium
concentration is 4.1 mEq per liter, serum osmolality is 228 mOsm per kilogram of
water, and urine osmolality is 510 mOsm per kilogram of water. What is the
treatment?a.Water restriction
b.
c.
Intravenous furosemide
d.
All of the aboveT [ This patient has hypotonic hyponatremia due to water retention
caused by the impaired excretion of water that is associated with the postoperative
state. The estimated volume of total body water is 23 liters (0.5 X 46). The retention
of 1 liter of 3 percent sodium chloride will increase the serum sodium concentration
by 16.7 mmol per liter (513 – 112) ÷ (23+1) =16.7.]
e.
44)
A 58-year-old man with small-cell lung carcinoma presents with severe confusion
and lethargy. Clinically, he is euvolemic, and he weighs 60 kg. The serum sodium
concentration is 108 mEq per liter, the serum potassium concentration is 3.9 mEq
per liter, serum osmolality is 220 mOsm per kilogram of water, the serum urea
nitrogen concentration is 5 mg per deciliter, the serum creatinine concentration is
0.5 mg per deciliter per liter, and urine osmolality is 600 mOsm per kilogram of
water. What is the treatment?
a.
Water restriction
b.
c.
IV furosemide
d.
45)
a.
b.
c.
d.
46)
b.
Thiazide diuretic[ Loop, but not thiazide, diuretics reduce urine concentration and
augment excretion of electrolyte-free water. Therefore, loop diuretics permit
relaxation of fluid restriction.]
c.
Loop diuretics with high sodium intake[ In the syndrome of inappropriate secretion
of antidiuretic hormone, but not in edematous disorders, loop diuretics should be
combined with plentiful sodium intake (in the form of dietary sodium or salt tablets).
This treatment increases water loss. If these measures fail, demeclocycline per day
can help by inducing nephrogenic diabetes insipidus.]
d.
Demeclocycline
47)
A 72-year-old woman presents with a 2-day history of presyncope when rising from
a chair. She has been taking hydrochlorothiazide, 25 mg/d, for 5 years for systolic
hypertension. Last week she had a bout of viral gastroenteritis with marked
diarrhea. She has been replacing the lost fluids by drinking 3 L of water per day.
When she rises from a seated position, her blood pressure drops 20 mm Hg. Serum
levels are as follows: sodium 128 mEq/L, potassium 3.1
mEq/L, creatinine 1.5 mg% and urea nitrogen 60mg%. Which is/are true statements
regarding this patient?
a.
ECF volume is contracted [ The patient has postural hypotension which indicates
ECF volume contraction. The most likely cause is gastrointestinal losses of salt and
water, with only water replacement. It is also likely that the thiazide diuretic is
contributing to the hyponatremia. Thiazides impair the kidney’s ability to reabsorb
sodium and to excrete free water.
b.
Release of AVP is stimulated[ ECF volume contraction from any cause (diarrhea,
vomiting, excessive sweating, diuretic use), stimulates the release of AVP. AVP
increases renal water reabsorption and ECF volume.]
c.
d.
She needs potassium replacement[ The ECF volume contraction, diarrheal losses
and diuretic use have resulted in hypokalemia in this patient. As ECF volume
contraction develops, the kidneys actively excrete potassium in exchange for
sodium in an attempt to preserve ECF volume. Volume restoration with normal
saline and potassium replacement is required until the postural drop in blood
pressure is less than 10 mm Hg. She should then be treated conservatively with oral
sodium and potassium replacement.]
e.
All of the aboveT [ The management of this patient should include temporary
discontinuation of the thiazide diuretic.]Water restriction will ameliorate all forms of
hyponatremia, but it is not the optimal therapy in allcases. Hyponatremias
associated with the depletion of extracellular-fluid volume require correction of the
sodium deficit. Isotonic saline is unsuitable for correcting the hyponatremia of the
syndrome of inappropriate secretion of antidiuretic hormone; if administered, the
resulting rise in serum sodium is both small and transient, with the infused salt
being excreted in concentrated urine and thereby causing a net retention of water
and worsening of the hyponatremia. Great vigilance is required in order to
recognize and diagnose hypothyroidism and adrenal insufficiency, since these
disorders tend to masquerade as cases of the syndrome of inappropriate secretion
of antidiuretic hormone. The presence of hyperkalemia should alwaysalert the
physician to the possibility of adrenal insufficiency.Whereas patients with persistent
asymptomatic hyponatremia require slow-paced management, those with
symptomatic hyponatremia must receive rapid but controlled correction.