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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 L
d. None
6) ECF osmole(s)
a. Na+
b. Cl-
c. HCO3-
d. All of the above T [ 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 above T [ 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.]
9) What maintains the difference in cation concentration between the ICF and ECF?
a. Sodium-potassium pump T [ The major force maintaining the
difference in cation concentration between the ICF and ECF is the sodium-potassium
pump (Na,K-activated ATPase) See figure below. Na+,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+-ATPase activity is a net negative intracellular charge.]
b. RMP
c. Osmotic pressure
d. Intracellular proteins
10) What maintains the difference in cation concentration between the ICF and ECF?
a. Na+, K+-adenosine triphosphate
b. Cell membrane sodium conductance pathways
c. Cell membrane potassium conductance pathways
d. Free movement of water
e. All of the above T [ 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+-adenosine
triphosphate (ATPase) operating in concert with cell membrane sodium and potassium
conductance pathways. The free movement of water ensures that the sodium
concentration in ECF is nearly equivalent to the potassium concentration in ICF.]
c ÿ
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. Stool T [ Gastrointestinal excretion is only a minor
component of total water output. It becomes an important route of water loss in patients
with vomiting, diarrhea, or high enterostomy output states.]
c. Evaporation from the skin [ Evaporative or insensitive water losses are
important in the regulation of body temperature.]
d. Evaporation from the respiratory tract
Hypovolaemia Hypervolaemia
Symptoms Thirst Edema
Dizziness on standing Breathlessness
Weakness
Signs Tachycardia Peripheral edema
Hypotension Raised JVP
Dry tongue Lung crepitations
Reduced skin turgor Pleural effusion
Reduced urine output Ascites
Confusion Weight gain
HYPOVOLEMIA
Mechanism Examples
c Y
Inadequate intake Environmental deprivation, inadequate therapeutic replacement
In internal sequestration total body sodium and water may be normal or increased.
History can determine the cause of hypovolemia (bleeding, vomiting, diarrhea, polyuria,
medications, diaphoresis).
3) Diarrhea causes
a. Metabolic alkalosis T [ Diarrhea often causes metabolic alkalosis
because biliary, pancreatic, and intestinal secretions are alkaline (high HCO3-
concentration).]
b. Metabolic acidosis [ Gastric secretions have high H+
concentration (low pH). Therefore, vomiting often causes metabolic acidosis.]
c. Lactic acidosis
d. Hyperkalemia
4) Sweat
a. Usually hypertonic but may be isotonic
b. Usually isotonic but may be hypertonic
c. Hypotonic T [ Sweat is hypotonic. Therefore, excessive
sweating (e.g., febrile illnesses, prolonged heat exposure), more loss of water than
Na+, but continued Na+ loss is manifest as hypovolaemia. The Na+ concentration of
sweat is normally 20 to 50 mEq/L and decreases with profuse sweating due to the
action of aldosterone.]
d. Hypertonic
10) In hypovolemia
c Y[
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 above T [ 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
H2O. If a maximum level of ADH is circulating in plasma, the osmolality of urine
produced by the kidney can exceed 1200 mmol/kg H2O.]
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. Peripheral vasoconstriction with cool extremities
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 H2O)
f. Normal hemoglobin ± Hemoglobin may remain constant initially. Normal hemoglobin
levels do not rule out bleeding as a cause of hypovolemia. Later, hemoglobin falls
due to movement of ECF from the interstitial to the intravascular compartment
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
5% dextrose 50 g 200 0 0 0
13) What is the increase in plasma volume if 1 L of isotonic saline is given IV?
a. 1000 mL
b. 600 mL
c. 300 mL T [ Retention of 1 L of infused isotonic saline
increases plasma volume by about 300 mL. The remaining portion is distributed in
the interstitial subcompartment of the ECF.]
d. 150mL [ In contrast, a solution of 5% dextrose in
water (D5W) is equivalent to administering solute-free water. It distributes uniformly
throughout all body fluid compartments. A third of the retained volume of 5% dextrose
remains in the ECF compartment and only 10 to 15% remains in the intravascular
compartment). The retained solute-free volume reduces body tonicity and the plasma
sodium concentration. 5% dextrose in water is useful when hypovolemia is
accompanied by hypertonicity and hypernatremia.]
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. 66
c. 33
d. 15
HYPERNATREMIA
c Yÿ
CAUSES OF HYPERNATREMIA
Pure water
Unreplaced insensible losses (dermal and respiratory)
Hypodipsia
Diabetes insipidus
Hypotonic fluid
Renal causes
p Diuretics
p Osmotic diuresis (glucose, urea, mannitol)
p Postobstructive diuresis
p Polyuric phase of acute tubular necrosis
p Intrinsic renal disease
Gastrointestinal causes
p Vomiting
p Diarrhea
p Nasogastric drainage
p
Cutaneous causes
p Burns
p Excessive sweating
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 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 L
d. None
6) Fecal osmolality
a. Equal to the sum of stool concentrations of Na+ and K+
b. Half the sum of stool concentrations of Na+ and K+
c. Twice the sum of stool concentrations of Na+ and K+
T [ The stool osmolality is assumed to be
300 mosmol/kg H2O. 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. Thrice the sum of the stool concentrations of Na+ and K+
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 carries
the 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. 2.9 L T [ (20 ÷ 140) X (0.4 × 50). Rapid correction
of hypernatremia can be dangerous. A sudden decrease in osmolality may cause a rapid
shift of water into brain cells. Therefore, correct the water deficit slowly over at least 48.
The safest route of administration of water is by mouth. 5% dextrose in water or half-
isotonic saline can be given intravenously safely.]
c. 3.9 L
c è
d. 4.9 L
17) What is the preferred route for administering fluids in a patient with hypernatremia?
a. Intravenous through a peripheral vein
b. Intravenous through a central vein
c. Oral route T [ 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
19) A 76-year-old man presents with confusion, dry mucous membranes, 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. 34 T [ 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.]
c
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. 2.4 mEq per liter
b. 4.8 mEq per liter T [ Change in serum Na+ = (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. 9.6 mEq per liter
d. 19.2 mEq per liter
21) A 58-year-old woman with postoperative ileus is undergoing nasogastric suction. She is
obtunded with diminished skin turgor and mild orthostatic hypotension. The serum sodium
concentration is 158 mEq per liter, the potassium concentration is 4.0 mEq per liter, and the
body weight is 63 kg. What is the treatment?
a. 0.45% sodium chloride IV T [ 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 62-year-old man with advanced alcoholic cirrhosis is on lactulose for hepatic encephalopathy.
Examination shows confusion, ascites, and asterixis. The blood pressure is 105/58 mm Hg in
the supine position, and the pulse is 110 beats per minute. The serum sodium concentration is
160 mEq per liter, the potassium concentration is 2.6 mEq per liter, and the body weight is 64
kg. What is the treatment?
a. Increase the dose of lactulose and give IV normal saline
b. Withdraw lactulose and give IV 0.2 percent sodium chloride
T [ 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. Furosemide IV
d. Liver transplantation
c ÿ
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. Furosemide [ The hypernatremia is caused by hypertonic
sodium gain. For its correction, the excess sodium and water be excreted. Furosemide
alone is not enough, because furosemide- induced diuresis is equivalent to one-half
isotonic saline solution. Thus, the hypernatremia will be aggravated.]
b. Furosemide and electrolyte-free water T [ The correct treatment is administration of
both furosemide and electrolyte-free water. The estimated volume of total body water is
51 liters (0.6 X85). If 1 liter of 5 percent dextrose is given, it will decrease the serum
sodium concentration by 3.0 mEq per liter (0 ± 156) ÷ (51+1) = - 3.0. Since the patient¶s
extracellular-fluid volume is expanded, fluids can be administered only with great
caution. Adjust fluid administration based on close monitoring of the patient¶s clinical
status and serum sodium concentration.]
c. Hemodialysis [ Hypernatremia with concurrent renal failure
and volume overload is a special problem. Diuretics cannot be relied on to reduce the
expanded extracellular-fluid volume. Therefore, hemodialysis, hemofiltration, or
peritoneal dialysis may be necessary.]
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. Isotonic saline T [ Isotonic saline is unsuitable for correcting
hypernatremia. Estimated volume of total body water is 42 liters (0.6 X 70). The retention
of 1 liter of 0.9 percent sodium chloride will decrease the serum sodium concentration by
only 0.2 mEq per liter ( 154 ± 162) ÷ (42 + 1) = - 0.2). Although the sodium concentration
of the infusate is lower than the patient¶s serum sodium concentration, it is not sufficiently
low to alter the hypernatremia substantially. The only indication for administering isotonic
saline to a patient with hypernatremia is a depletion of extracellular-fluid volume that is
sufficient to cause substantial hemodynamic compromise. Even in this case, after a
limited amount of isotonic saline has been administered to stabilize the patient¶s
circulatory status, give a hypotonic fluid (i.e., 0.2 percent or 0.45 percent sodium
chloride). If a hypotonic fluid is not substituted for isotonic saline, the extracellular-fluid
volume may become seriously overloaded.]
b. 0.2 percent sodium chloride
c. 0.45 percent sodium chloride
d. All of the above
c ·
HYPONATREMIA
8) Diuretic-induced hyponatremia is almost always due to
a. Thiazides T [ Diuretic-induced hyponatremia is almost
always due to thiazide diuretics. Thiazide diuretics lead to Na+ and K+ depletion and
AVP-mediated water retention. Thiazide diuretics reduce the reabsorption of Na+ and Cl-
in the first half of the distal convoluted tubule and a portion of the cortical ascending limb
of the loop of Henle. However, thiazides can cause excretion of a hypertonic urine and
contribute to dilutional hyponatremia.]
b. Furosemide [ Furosemide, bumetanide, and torsemide
are "loop" diuretics. They reversibly inhibit the reabsorption of Na+, K+, and Cl- in the
thick ascending limb of Henle's loop. Hypokalemia, hyperuricemia, and hyperglycemia
are observed occasionally. The reabsorption of free H2O is decreased. Loop diuretics
decrease the tonicity of the medullary interstitium and impair maximal urinary
concentrating capacity. This limits the ability of AVP to promote water retention.]
c. Bumetanide
d. Ethracrynic acid
e. Spiranolactone
9) What is/are the cause(s) of hyponatremia with increased ECF volume (hypervolemia)?
a. Congestive heart failure [ Hypotonic hyponatremia is subdivided
according to the clinical ECF volume status. Hyponatremia with ECF volume expansion
is seen in edematous states, such as congestive heart failure, hepatic cirrhosis, and the
nephrotic syndrome. All these conditions have decreased effective circulating arterial
volume, leading to increased thirst and increased AVP levels.]
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 above T [ The severity of hyponatremia often
correlates with the severity of the underlying condition and is an important prognostic
factor. See figure below.]
c èY
CAUSES OF HYPONATRAEMIA
Adults
Thiazides
Postoperative state
SIADH
Polydipsia in psychiatric patients
Transurethral prostatectomy
SIADH ± DIAGNOSIS
20) What is/are the cause(s) of hyponatraemia with hypovolaemia due to increased renal loss of
sodium and water?
a. Diuretic therapy [ Diuretic induced hyponatremia is more
common with thiazide diuretics than after loop diuretics. Though less potent than loop
diuretics, thiazide diuretics do not disrupt the medullary countercurrent concentrating
mechanism.]
b. Mineralocorticoid deficiency
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. All of the above T
24) What is the diagnosis in a patient with high urine sodium and low specific gravity?
a. SIADH
b. Adrenal insufficiency
c. Diuretic T
d. Cardiac failure
e. Hypovolaemia
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.
SYMPTOMS OF HYPONATREMIA
1. Plasma osmolality
2. Urine osmolality
3. Urine Na+ concentration
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.
If primary polydipsia is not present, decreased plasma osmolality suggests impaired free
water excretion due to the action of AVP on the kidney. The secretion of AVP may be a
c [
physiologic response to hemodynamic stimuli or it may be inappropriate in the presence of
hyponatremia and euvolemia.
SIADH is characterized by hyponatremia with decreased plasma osmolality and
concentrated urine (urine osmolality > 100 mosmol/kg and urine Na+ concentration usually
greater than 40 mmol/L). Urine Na+ excretion rate is equal to intake. Patients are typically
normovolemic.
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.
Urine Na+ concentration > 20 mmol/L in hypovolemic hyponatremia suggests diuretic
therapy, hypoaldosteronism, a salt-wasting nephropathy, or occasionally vomiting.
33) What is the treatment of asymptomatic hyponatremia with ECF volume contraction?
a. Increase oral sodium intake
b. Stop loop diuretic
c. Give thiazide
d. Water restriction
e. Isotonic saline T [ 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.]
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. Hypertonic saline IV T [ Severe symptomatic hyponatremia
should be treated with hypertonic saline. Patients who have symptomatic hyponatremia
with concentrated urine (osmolality > 200 mOsm per kilogram of water) and clinical
euvolemia or hypervolemia require infusion of hypertonic saline. Hypertonic saline is
usually combined with furosemide to limit treatment induced expansion of the
extracellular-fluid volume. The plasma Na+ concentration should not be raised by more
than 12 mEq/L during the first 24 h.]
d. IV frusemide
In addition to its complete distribution in the extracellular compartment, this infusate induces osmotic
removal of water from the intracellular compartment.
Children = 0.6
Nonelderly men = 0.6
Nonelderly women = 0.5
Elderly men = 0.5
c [
Elderly women = 0.45
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/L T [ 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
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.
c [·
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. Infusion of 3 percent sodium chloride
c. Intravenous furosemide
d. All of the above T [ 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. None of the above
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. Infusion of 3 percent sodium chloride
c. IV furosemide
d. All of the above T [ The diagnosis is tumor-induced
syndrome of inappropriate secretion of antidiuretic hormone on the basis of the presence
of hypotonic hyponatremia and concentrated urine in a euvolemic patient, the absence of
a history of diuretic use, and the absence of clinical evidence of hypothyroidism or
hypoadrenalism. The estimated volume of total body water is 36 liters. The retention of 1
liter of 3 percent sodium chloride is estimated to increase the serum sodium
c [å
concentration by 10.9 mEq per liter {(513 ± 108) ÷ (36+1) = 10.9}. The initial goal is to
increase the serum sodium concentration by 5 mEq per liter over the next 12 hours.
Therefore, 0.46 liter of 3 percent sodium chloride (5 ÷ 10.9), or 38 ml per hour, is
required.]
e. None of the above
45) A 68-year-old woman is brought to the hospital because of progressive drowsiness and
syncope. She is being treated with a low-sodium diet and hydrochlorothiazide daily for essential
hypertension; she has had diarrhea for the past three days. She is lethargic but has no focal
neurologic deficits. She weighs 60 kg. Her blood pressure while in a supine position is 96/56
mm Hg, and the pulse is 110 beats per minute. The jugular veins are flat, and skin turgor is
decreased. The serum sodium concentration is 106 mEq per liter, the serum potassium
concentration is 2.2 mEq per liter, the serum urea nitrogen concentration is 46 mg per deciliter,
the serum creatinine concentration is 1.4 mg per deciliter, serum osmolality is 232 mOsm per
kilogram of water, and urine osmolality is 650 mOsm per kilogram of water. What is the
treatment?
a. 0.9% sodium chloride first followed by 0.45 % sodium chloride
T [Diagnosis is hypotonic hyponatremia
caused by thiazide therapy and gastrointestinal losses of sodium. There is associated
depletion of potassium also. Treatment is to withhold hydrochlorothiazide and to infuse
0.9 percent sodium chloride solution containing 30 mEq of potassium chloride per liter.
The estimated volume of total body water is 27 liters (0.45 X 60). The retention of 1 liter
of this infusate will increase the serum sodium concentration by 2.8 mEq per liter {(154 +
30) ± 106 ÷ (27 + 1) = 2.8}. As soon as the extracellular-fluid volume nears restoration,
the nonosmotic stimulus to arginine vasopressin release will cease resulting in rapid
excretion of dilute urine and correction of the hyponatremia at a rapid pace. Therefore,
switch to 0.45 percent sodium chloride containing 30 mmol of potassium chloride per
liter.]
b. 0.45 % sodium chloride first followed by 0.9 % sodium chloride
c. 5 % dextrose in water containing 30 mmol of potassium chloride
d. 3 percent sodium chloride
46) What is the long-term treatment of asymptomatic hyponatremia that accompanies cardiac
failure?
a. Water restriction T [Asymptomatic hyponatremia is common
in edematous states and in syndrome of inappropriate secretion of antidiuretic hormone.
Hyponatremia is due to a defect of water excretion. Water restriction (to <800 ml per day)
is the mainstay of long-term management. Goal is to induce negative water balance.]
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).
c [
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. Low urine sodium concentration [ Volume contraction decreases renal
perfusion which stimulates renin release, and this causes the kidneys to avidly retain
sodium. The retention of water and sodium is appropriate in this setting and is supported
by a low urine sodium concentration (< 20 mmol/L) and a low urine volume. Often the
person who has a contracted ECF volume will drink water or another low-solute fluid
(e.g., tea), which contributes further to the hyponatremia. These patients have serum
sodium and body water levels that are lower than normal but have more loss of sodium
relative to loss of water.]
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 above T [ 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 all
cases. 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 always
c
alert the physician to the possibility of adrenal insufficiency.