Water and electrolytes

Case 1:
A man is trapped in a collapsed building after an earthquake, he has no serious injuries or
blood loss. He has no access to food and water until he is rescued after 72 hours.
What will have happed to his body fluid compartments?

Answer:
He will have lost fluids insensibly through sweating and respiration and also in urine. So both of
the intracellular and extracellular fluids were reduced.

Case 2:
A 42 years-old-man was admitted to the hospital with 2-days history of severe diarrhoea
with some nausea and vomiting. During this period, his only intake was water. He was
weak and unable to stand. His pulse was 104/min and blood pressure was 100/55 mmHg.
On admission his biochemistry results were:

Sodium  Potassium Chloride Bicarbonate Urea   Creatinine

(mmol/L) (mmol/L) (mmol/L) (mmol/L) (mg/dl) (mg/dl)
Patient 131 3  86 19 107 1.7
Normal 135‐ 145 3.5 ‐ 5 95 ‐ 105  22 ‐ 30 20 ‐ 40 0.6 ‐ 1.2 

What is the most appropriate treatment for this patient?

Answer:
Typical case of sodium and water depletion evidenced by decreased blood pressure and
increased pulse rate. Decreased ECF volume leads to pre-renal uraemia (acute renal failure)
evidenced by increased levels of urea and creatinine. Intravenous saline is the most appropriate
treatment to restore ECF volume and kidney function.
Case-3:
A 76-years-old man was admitted as an acute emergency. He was clinically dehydrated. His
skin was lax and his lips and tongue were dry. The patient had not eaten or drunken for 3
days. His pulse was 104/ min and his blood pressure was 95/65 mmHg. The following
biochemical results were obtained on admission.

Sodium  Potassium Chloride Bicarbonate Urea   Creatinine

(mmol/L) (mmol/L) (mmol/L) (mmol/L) (mg/dl) (mg/dl)

Patient 172 3.6  140 18 137 1.8

Normal 135‐ 145 3.5 ‐ 5 95 ‐ 105  22 ‐ 30 20 ‐ 40 0.6 ‐ 1.2 

A- Comment on these biochemical findings.

B- What is the diagnosis?

Answer:
A- Modest increase in serum creatinine and marked increase in serum urea strongly suggest
pre-renal uraemia. The patient has also sever hypernatraemia.
B- Sever pure water depletion (uncomplicated).

Case-4:
A 70-year-old woman attended her GP complaining of generalized bone pain. Biochemistry
results on a serum specimen taken at the surgery showed the following

Calcium (mgrd) Phosphate Albumin Calcium (adj)

(mg/dl) (mg/dl) (g/dl) (mg/dl)

Patient 7.2 3.4 3.9 7.28

Normal 3 – 4.5 3.5 - 5 8.4 -10.6

1- What further investigation would be appropriate?

Answer:
 As renal failure is the most common cause of hypocalcaemia, her serum urea and electrolytes
should be measured. However, unsuspected renal failure is unlikely as her serum phosphate
is normal. Her plasma PTH should be measured and if high (appropriate to the low calcium)
then vitamin D deficiency is the most likely diagnosis, and the cause should be sought. In
particular, a detailed dietary history should be taken. An increased serum alkaline
phosphatase would be compatible with vitamin D deficiency. The bone pain is due to the
underlying osteomalacia. A low PTH would indicate hypoparathyroidism. Other causes of
hypocalcaemia would be unlikely in this case.

Case-5:
A 48-year-old woman came to her GP with a 12-month history of increasing tiredness and
muscle fatigue. In recent weeks she had been increasingly thirsty and had polyuria. Her GP
tested a urine sample for glucose, which he found to be negative, and then arranged that her urea
and electrolytes be measured. He decided to request a calcium profile on the serum sample as
well. Biochemistry results in a serum specimen were:

Calcium Phosphate Albumin Calcium Sodium

(mgrd) (mg/dl) (g/dl) (adj) (mmol/L)
(mg/dl) (mg/dl)
Patient 13.2 1.58 3.5 13.6 149
Normal 3 – 4.5 3.5 - 5 8.4 -10.6 135- 145
Potassium Chloride Bicarbonate Urea Creatinine
(mmol/L) (mmol/L) (mmol/L) (mg/dl) (mg/dl)
Patient 3.5 109 20 137 1.8

Normal 3.5 - 5 95 - 105 22 - 30 20 - 40 0.6 - 1.2

1- What are the most likely diagnoses in this patient?

2- What other investigations would be appropriate?

Answer:
The two most likely diagnoses in this case are primary hyperparathyroidism and hypercalaemia
of malignancy. The most important biochemical investigation to be performed at this stage
would be plasma PTH measurement, which will be high in primary hyperparathyroidism and
suppressed in hypercalcaemia of malignancy. In patients with hypercalcaemia of malignancy, the
underlying disease is usually detectable by a careful clinical history and examination. There are,
however, notable exceptions, multiple myeloma being one, and therefore a sample of serum and
urine should be sent for protein electrophoresis to see if a paraprotein band can be identified. A
blanket request for tumour markers such as CEA or AFP should not be requested unless there is
a clear clinical indication for doing so. The patient’s alkaline phosphatase activity should be
measured and alkaline phosphatase isoenzyme studies may be indicated, especially if the plasma
PTH concentration is suppressed. The patient shows evidence of dehydration and has severe
hypercalcaemia, which should be treated by rehydration in the first instance.

Case-6:
A 46-year-old woman, known to have radiation enteritis with chronic diarrhoea and associated
malabsorption syndrome, presented to the outpatient department complaining of severe tingling
of recent onset in her hands and feet. The patient had a past history of hypocalcaemic tetany 18
months previously, but serum calcium had since remained normal on therapy with 1α-
hydroxycholecalciferol, 0.75 μg daily, plus oral calcium supplements.

Calcium Phosphate Albumin Calcium Alk Magnesiu

(mgrd) (adj) phos m
(mg/dl) (g/dl)
(mg/dl) (mg/dl) U/L Mg/dl

Patient 5.2 3.4 3.9 5.84 110 0.6

Normal 3 – 4.5 3.5 - 5 8.4 -10.6 30 - 130 1.3 – 2.1

The patient did not respond to treatment with increased calcium supplements and continued 1α-
hydroxycholecalciferol.

1- What would you predict the patient’s PTH status to be?

2- What treatment is appropriate and why?

Answer:
Though this patient is hypocalcaemic, the expected compensatory rise in PTH may not occur in 
view  of  the  severe hypomagnesaemia.  Thus,  the  PTH  may be  low. This  patient  needs 
magnesium  supplements. As  magnesium  salts  cause diarrhoea  they  need  to  be  given 
parenterally, especially in this case where there is established diarrhoea and malabsorption. It is 
likely  that  once  the  patient  is magnesium  replete,  her  original  vitamin D  and  calcium 
supplements  will  be  sufficient to  maintain  her  in  a  normocalcaemic state.  However,  she  may 
require regular ‘top‐ups’ of intravenous magnesium in the future.
 The Kidneys & General Urine Examination

Case-1:
A 35-years-old man suffering of loin pain admitted to the hospital. His serum creatinine
was 1.2 mg/dl and the 24-hour urine volume was 2160 ml and the urinary creatinine was 65
mg/dl.

A- Calculate the creatinine clearance and comment on the results.

B- An error in the urine collection time was reported by the nurse and the correct
collection time was reported to be 17 hours. How does this affect the results of
creatinine clearance and its interpretation?

Answer:

A- UV/P = (65 X 1.5)/1.2 = 81 ml/min (lower than normal level;

B- UV/P = (65 X 2.1)/1.2 = 114 ml/min (Normal person. Normal level 90-140 ml/min)

Case-2:

A 35-years-old woman, fractured her skull in an accident. She had no major other injuries,
no significant blood loss and her cardiovascular system was stable. She was unconscious for
two days after the accident. On the 4th day of her admission to the hospital, she was noted
to be producing large volume of urine and complaining of thirst. Her biochemical finding
were

Sodium Potassium Chloride Bicarbonate Urea Creatinine

(mmol/L) (mmol/L) (mmol/L) (mmol/L) (mg/dl) (mg/dl)
Patient 150 3.6 105 25 33 0.9
Normal 135- 145 3.5 - 5 95 - 105 22 - 30 20 - 40 0.6 - 1.2

Glucose = 97 mg/dl (normally 70- 110)

Serum osmolality = 310 mmol/kg (Normally 280-290)
Urine osmolality = 110 mmol/kg (Normally 300-900)
Urine volume = 8 liters/day (Normally 1.5)
 A- What is the most probable diagnosis of this case?
B- Is the water deprivation test required to make the diagnosis of this patient?

Answers:
A- Head trauma with high urine volume with complaining of thirst strongly suggest
diabetes insipidus. Blood glucose level excludes diabetes mellitus as a cause of
polyuria. With this hypernatraemia (150 mmol/l), antidiuretic hormone (ADH) should
normally concentrate urine and conserve water. The urine is diluted as evidenced by
decreased urine osmolality while the serum is concentrated. Based on all of these
finding, the diagnosis is diabetes insipidus (decreased ADH).

B- Water deprivation test is dangerous in this case because the patient already suffers of
severe dehydration (urine volume is 8 liter/day).

Case-3:

A 50-years-old man presented with pyrexia. He was clinically dehydrated and oliguric. His
biochemical results were as the following

Sodium Potassium Chloride Bicarbonate Urea Creatinine

(mmol/L) (mmol/L) (mmol/L) (mmol/L) (mg/dl) (mg/dl)
Patient 140 5.9 112 16 137 1.7
Normal 135- 145 3.5 - 5 95 - 105 22 - 30 20 - 40 0.6 - 1.2

Serum osmolality = 305 mmol/kg (Normally 280-290).

Urine osmolality = 629 mmol/kg (Normally 300-900).

What do these biochemical results indicate about the patient’s condition?

Answer:
Dehydration, oliguria, normal urine osmolality and increased serum creatinine and urea are
consistent with pre-renal uremia. Decreased bicarbonate level indicate metabolic acidosis.
Metabolic acidosis and pre-renal uremia works to cause hyperkalemia (H/K exchange and
decreased K excretion because of low glomerular filtration rate).
Case-4:

MH is a 40-year-old woman with chronic renal failure who is being treated with
haemodialysis. His serum biochemistry just prior to her last dialysis showed:

Sodium Potassium Chloride Bicarbonate Urea Creatinine

(mmol/L) (mmol/L) (mmol/L) (mmol/L) (mg/dl) (mg/dl)
Patient 130 5.7 100 16 153 16
Normal 135- 145 3.5 - 5 95 - 105 22 - 30 20 - 40 0.6 - 1.2

A) Should hemodialysis be continued?

B) What other biochemical tests should be performed, and how might the results
influence treatment?

Answer:
A- Yes, because both urea and creatinine are increased (creatinine is markedly increased
than urea consistent with low protein intake) indicating low glomerular filtration rate
(GFR). While bicarbonate is low, the anion gab is normal excluding acidosis.
Hyperkalaemia is thus is entirely due to decreased GFR. Hyponatraemia is due to
impaired water excretion. These results indicate that the patient should continue on
dialysis.

B- In chronic renal failure, it is important to monitor serum calcium level. Elevated serum
parathyroid hormone and alkaline phosphatase indicate the presence of metabolic bone
diseases. The aim in chronic renal failure patient is to correct hypocalcaemia and
hyperphosphataemia with calcium and vitamin D supplementation.
 Case 5:

A patient attending the hospital outpatient clinic is found to have proteinuria on dipstick
testing. On examination, he has pitting edema of both ankles.

What might explain these findings?

Answer:
Pitting edema is caused commonly by nephrotic syndrome due to loss of albumin or congestive
heart failure both are accompanied by protein urea

Blood Glucose & Diabetes mellitus

Case-1

Interpret these results from the four oral glucose tolerance test below 75g glucose was given
at time 0. Venous plasma glucose was determined.

Case Clinical details Minutes post glucose load

#
0 30 60 90 120
Venous plasma glucose mg/dl
1 65 years old male, obese, NIDDM 158 248 315 302 300
2 62 years old female, complain of burning mouth 108 210 274 295 306

3 41 years old male, glycosuria 133 171 195 182 171

4 75 years old female, high RBG results 90 155 193 198 184

Answer

1- Classical diabetes (based of fasting and 2 hrs. postprandial)

2- Diabetic (2 hrs. is diagnostic despite of the normal fasting where symptoms are present)
3- Impaired glucose tolerance

4- Impaired glucose tolerance

Case-2

A 22-year-old patient with diabetes comes to the accident and emergency department. She
gives a 2-days history of vomiting and abdominal pain. She is drowsy and her breathing is
deep and rapid. There is a distinctive smell from her breath.

A- What is the most likely diagnosis?

B- Which bedsides tests could you do to help you to confirm this diagnosis?
C- Which laboratory test would you request?

Answer:
A- Rapid breathing and distinctive smell in diabetic patient most likely indicate diabetic
ketoacidosis (DKA).
B- Blood glucose level and urinary ketone bodies
C- Blood urea to assess renal function (a consequence of severe dehydration caused by
DKA). Electrolyte to check the hyperkalemia and the severity of acidosis.

Case – 3

A 14-year-old boy was found by his mother in a drowsy and uncooperative state. When the
GP arrived, she told her that her son had seemed to be unusually thirsty for the last 1-2
months and she thought that he had lost weight. Recently, he had been complaining of
abdominal pain and discomfort. He was admitted to the hospital as an emergency. On
examination, he was semi-conscious, with deep sighing respiration, a pulse rate of 120/min.
a blood pressure of 94/56 and cold extremities. Biochemical investigation on blood after
admission showed the following:

Sodium Potassium Glucose Bicarbonate Urea

(mmol/L) (mmol/L) (mg/dl) (mmol/L) (mg/dl)
Patient 128 6.9 640 7 147
Normal 135-145 3.5-5 70-110 22-30 20-40

A- What is the probable diagnosis, and how would you confirm this quickly?
B- What principle should guide the treatment of this patient?

Answer
 A- High blood urea, high pulse rate and low blood pressure are consistent with
depletion of ECF. High blood glucose, acidosis and hyperkalemia all are
consistent with DKA. To confirm the diagnosis quickly, test ketone bodies
in urine.
B- Refer to treatment of DAK (lecture)

Case-4

An elderly man was visited by his son and was found to be semi-conscious. He had last been
seen by neighbors about 10 days previously when he had seemed well. He was admitted to
the hospital. On examination, he appeared extremely dehydrated. The results of his
biochemical investigations were as follows:

Sodium Potassium Glucose Bicarbonate Urea Osmolality

(mmol/L) (mmol/L) (mg/dl) (mmol/L) (mg/dl) (mmol/kg)
Patient 151 4.8 1100 18 228 417
Normal 135-145 3.5 - 5 70-110 22 - 30 20 - 40 280 - 290

Comment on these findings

Answer

The very high blood glucose level increases diuresis and loss of water leading to dehydration and
hypernatremia. Water loss decreases ECF leading to per-renal uremia (increased urea). High
blood glucose and urea levels increase the blood osmolality. The patient has border line acidosis
(near normal bicarbonate level) consistent with non-ketotic hyperglycemia that always occur in
type II diabetes. Absence of sever acidosis excludes the DKA. The patient needs fluid
replacement and insulin to restore the very high blood glucose level then he can use the oral
hypoglycemic agents only without insulin.
Case -5

A 25-year-old woman with IDDM complained of repeated episodes of sleep disturbances,

night sweats, vivid and unpleasant dreams.

What is the most likely cause of this woman’s symptoms and how might the diagnosis be
confirmed

Answer
Nocturnal hypoglycemia. Can be confirmed by
1- Measuring the blood glucose level while symptomatic
2- Measuring the overnight urinary catecholamines (counter insulin)
3- Normal level of glycated hemoglobin while having hyperglycemia during the day

Lipids, lipoproteins and cardiovascular disease

Case -1

A 53-year-old man was found to have the following results on a fasting blood sample:

Cholesterol Triglycerides
(mg/dl) (mg/dl)
Patient 300 420
Normal < 200 mg/dl < 150 mg/dl

1- What other tests would you suggest to evaluate risk for developing ischemic heart
diseases
2- Indicate whether suggested test can be calculated or should be directly measured

Answer
1- LDL, HDL
2- Should be directly measured
Case -2

A 28-year-old man requested cholesterol testing because his father had died of a myocardial
infarction in his thirties, his paternal grandfather had developed angina in his early forties and
died suddenly in his late forties, presumably of an infarction, and there was a further history of
ischaemic heart disease at a young age in his more extended family. The following are his
biochemical results

Cholesterol (mg/dl) Triglycerides (mg/dl) HDL-C (mg/dl)

Patient 310 240 30

Normal < 200 mg/dl < 150 mg/dl < 40 mg/dl

1- Calculate the LDL-C

2- Calculate his cholesterol risk ratio and discuss whether he is at higher risk for developing
ischemic heart diseases or not