Acid-base and Sodium Disorders: Selected Lectures from the 1998 ASN Board Review Course
University of Minnesota
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CME TEST (33 questions)
1. Which one of the following choices makes intracellular acidosis more severe?
A. Increase in the arterial PCO2.
B. Large K+ deficit.
C. Contracted ECF volume.
D. Low cardiac output.
E. All of the above.
2. A 35 year old male presents with weakness; he denies previous illnesses. On physical exam, his ECF volume is contracted. The laboratory results reveal hypokalemia (1.8 mM) and metabolic acidosis (pH 7.30, HCO3 15 mM) with a normal plasma anion gap (12 mM), normal albumin; plasma creatinine is 1.0 mg/dL. The urinary studies reveal pH 6.3, NH4+ 200 mmol/day, urine Na 38 mM, K 23 mM, C1 10 mM. What is the most likely diagnosis?
A. Bartter's syndrome.
B. Distal RTA
C. Proximal RTA
D. Glue sniffing
E. Gitelman's syndrome.
3. Metabolic alkalosis from chronic, selective depletion of HC1-vomiting has a negative balance of which salt in steady-state in human subjects?
4. A 75 kg. patient is admitted with orthostatic hypotension and the following chemistry and arterial blood gas data:
Na+ = 130 mM, C1? = 94 mM, K+ = 5.0 mM, HCO3? = 11 mM, glucose = 523 mg/dL, ketones: plasma 4+ at 1:16, dilution arterial pH = 7. 25, PaCO2 = 24 mmHg, PaO2 = 100 mmHg.
Which one of the following choices provides the best initial therapy for this patient?.
A. I. V. regular insulin (100 units), and I.V. 0.22% NaCl
B. I.V. regular insulin (7.5 units per hour).
C. I.V. regular insulin (15 units per hour).
D. I.V. regular insulin (15 units per hour) and I.V. sodium phosphate
E. 0.9% NaC1 I.V.. and I.V. regular insulin (7.5 units initially, followed by 7.5 units/hour)
5. A 47 year old woman is admitted with acute cholecystitis which is treated by nasogastric suction and replacement of fluid losses with hypotonic saline containing 10mEq KC1/L. The following laboratory data are obtained:
Na+ = 139 mM, K+ = 2.4 mM, Cl? = 85 mM, and HCO3? = 42 mM pH = 7.55, PCO2 = 55 mm Hg, PO2 = 92 mmHg Urine Na+ = 42 mM, Urine K+ = 45 mM, and Urine Cl = 6 mM Urine pH = 6.9
Which one of the following choices best characterizes this acid-base disorder?
A. Respiratory acidosis and metabolic alkalosis
B. Respiratory alkalosis and metabolic alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
6. In the case above (question 5), which one of the following choices is most important in preventing the kidney from correcting this acid-base disturbance?
C. Chloride and potassium depletion
D. ECF volume expansion
7. Which one of the following choices provides the best corrective measure for the above (question 5) patient?
A. I.V. HC1
B. I.V. insulin
C. Stop giving any I.V. fluids
D. I.V. isotonic saline containing KCl 20 mEq/L
8. A 46 year old man with a history of recurrent urinary stones, nephrocalcinosis and recurrent pyelonephritis presents to your office. You obtain the following laboratory data:
Plasma: Na+ = 137 mM, Cl? = 112 mM, K+ = 3.0 mM, HCO3? = 15 mM, BUN = 28 mg/dL, Scr = 2.0 mg/dL Urine: Specific Gravity = 1.011, pH = 6.2; no protein or glucose was present. Urine calcium = 400 mg/day, urinary citrate 100 mg/day
Which one of the following choices is the most likely disorder responsible for these findings?
A. Aspirin overdose
B. Chronic renal failure
C. Proximal renal tubular acidosis (Type 2 RTA)
D. Classical distal renal tubular acidosis (type 1 RTA)
9. A 33 year old woman with recurrent calcium phosphate urolithiasis and intermittent muscle weakness is admitted with flaccid paralysis.
Laboratory studies: Na+ = 130 mM, K+ = 2.0 mM, Cl? = 112 mM, HCO3? = 12 mM pH = 7.15, PaCO2 = 33 mmHg, PO2 = 100 mmHg BUN 30 mg/dL, Cr 1.5 mg/dL, glucose 100 mg/dL, Plasma osmolality 285 mOsm/L Urine pH = 6.0, urine anion gap = + 36 mM (urine K+ = 32 mM, Na+ 34 mM, Cl? 30 mM)
The disorder represented by this case is best characterized by which one of the following choices?
A. Hyperchloremic metabolic acidosis
B. Respiratory acidosis
C. Hypokalemic periodic paralysis
D. Mixed hyperchloremic metabolic acidosis and respiratory acidosis
10. The most likely etiology of the acidosis in the above (question 9) patient is offered by which one of the following choices?
B. Lactic acidosis
C. Classical distal renal tubular acidosis
D. Absorptive hypercalciuria
11. Which one of the following choices would be a possible cause(s) of the electrolyte abnormalities in the above (question 9) case?
C. Sjogren's syndrome
D. All of the above.
12. A 53 year old man was admitted to the hospital with abdominal pain, distension, nausea, vomiting, weakness and dizziness. The past history was remarkable for prior abdominal surgery for peptic ulcer disease. The patient admitted to alcohol intake of approximately three cocktails daily for the last six years. The physical examination revealed an alert well nourished but obviously volume depleted man with a recumbant BP 70/56 mmHg, pulse 115 bpm, RR 28 per min., T. 37.2? C, a distended, diffusely tender abdomen, mild hepatomegaly, tympany, but no fluid wave or shifting dullness.
Laboratory studies: Na+ 131 mM, K+ 2.7 mM, Cl- 70 mM, HCO3 28mM, BUN 36 mg/dL, Cr 3.6 mg/dL, glucose 218 mg/dL, pH 7.41, PaCO2 45 mmHg, PO2 82 mmHg, Urine Na+ 18 mM.
The acid-base disturbance in this case is best characterized by which one of the following choices?
A. High anion gap metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis and high anion gap metabolic acidosis
D. High anion gap metabolic acidosis, metabolic alkalosis and respiratory acidosis
13. A 48 year old I.V. drug abuser was admitted with fever, hypotension, and bilateral 'pneumonia'. Physical examination revealed evidence of volume depletion, a murmur of tricuspid regurgitation, and hepatojugular reflux.
Na+ = 140 mM, K+ 4.0 mM, Cl- 106 mM, HCO3- = 14 mM, PO2 = 74 mmHg pH = 7.39, PaCO2 = 24 mmHg
Choose the acid-base disturbance which best characterizes this patient's disorder:
A. High anion gap metabolic acidosis and metabolic alkalosis
B. Respiratory alkalosis and metabolic alkalosis
C. High anion gap metabolic acidosis and respiratory acidosis
D. High anion gap metabolic acidosis and respiratory alkalosis.
14. This acid-base disorder (Quest. 13) could be seen in all of the following except one. Select the incorrect choice.
A. Lactic acidosis and gram negative sepsis
B. Aspirin intoxication
C. DKA with pneumonia
D. RTA with pneumonia
15. You are requested to evaluate a 45 year old obese woman in the surgical ICU who has an acid- base disturbance which has puzzled the surgeons. They are adamant that the patient is not volume depleted, the PCWP is 15 mmHg. The patient is on a ventilator, has an NG tube in place and is receiving Ringer's lactate with 15 mM KCl.
Laboratory studies: Na+ = 140 mM, K+ = 3.8 mM, Cl- = 88 mM, HCO3-= 37 mM, pHa = 7.49, PaCO2 = 50 mmHg, Urine Na+ = 75 mM, urine K+ = 88 mM, urine Cl- = 5 mM, and urine pH = 7.5.
The acid-base disturbance in this patient is best characterized as:
A. Simple metabolic alkalosis
B. Mixed metabolic alkalosis and metabolic acidosis
C. Mixed metabolic alkalosis and respiratory acidosis
D. Mixed metabolic alkalosis and respiratory alkalosis
16. Which one of the following choies provides the best therapy for the patient in question 15?
A. I.V. isotonic sodium chloride
C. I.V. isotonic sodium chloride and 40 mEq/L KCl
17. All but one of the following disorders are associated with chronic respiratory alkalosis. Select the incorrect choice.
A. Third trimester pregnancy
B. Hepatic failure
C. Sedative drug overdose
D. Anxiety reaction
18. Select the single correct statement regarding plasma AVP levels.
A. There are elevated in all patients with SIADH
B. They are most useful in the diagnosis of central diabetes insipidus
C. Following a standard water deprivation test, they can differentiate nephrogenic DI from primary polydipsia
D. They can differentiate appropriate from inappropriate stimulation of AVP
19. Select the single correct statement regarding the possible diagnosis of glucocorticoid insufficiency in cases of hyponatremia.
A. The diagnosis can be effectively ruled out by the absence of clinical symptomatology
B. The diagnosis can be adequately evaluated via a random plasma cortisol level
C. The diagnosis can be excluded if the serum potassium concentration is normal
D. The diagnosis should always be evaluated with an ACTH infusion test
20. Select the single correct answer regarding which hyponatremic patients should be treated with isotonic saline.
A. All hyponatremic patients without edema
B. Clinically euvolemic hyponatremic patients
C. Patients with a spot urine sodium <30 mmol/L
D. Only in patients with clinical signs of hypovolemia
21. Select the single correct statement regarding AVP V2 receptor antagonists.
A. They will cause a free water diuresis regardless of the etiology of the hyponatremia
B. They will correct serum (Na+) only in patients with SIADH
C. They will eliminate the risk of myelinolysis with correction of hyponatremia
D. They will cause hypotension from blocking the pressor effects of AVP on arterioles
22. Select the one single best answer regarding pontine and extra-pontine myelinolysis.
A. Can occur with too rapid correction of hyponatremia regardless of the method used for the correction.
B. Rarely occurs following correction of acute symptomatic hyponatremia
C. Both of the above are correct
D. Neither of the above is correct
23. All but one of the following patients are at risk for developing severe cerebral edema when their serum sodium level decreases rapidly. Select the incorrect choice.
A. Men following prostatectomies in which glycine irrigation was used
B. Women following hysterectomies
C. Patients with psychogenic polydipsia
D. Patients who had a hypoxemic event
E. Elderly women on thiazide diuretics
Indicate which of the following statements (Quest. 36, 37) regarding symptomatic patients with hyponatremia of unknown duration, are true and which are false.
24. Serum sodium should be increased to 125 mEq/L and then water should be restricted.
25. If the sum of the urinary Na concentration plus the urinary K concentration is lower than the serum sodium level, electrolyte free water is being excreted and serum sodium concentration should increase.
Indicate which of the following statements (questions 38-40) regarding the treatment of hypernatremia are true and which are false.
26. If the patient is hypovolemic the ideal replacement fluid is 0,45% NaCl.
27. The excretion of a hyperosmotic urine (> 300 mOsm/kg) reflects the kidney's ability to conserve water and hypernatremia will correct without further therapy.
28. It is usually advisable to correct half of the water deficit in the first 24 hours at a rate of approximately 2 meq/L/hr.
29. A 28 year old white female underwent a total hysterectomy for recurrent metrorrhagia. Thirty-six hours after surgery she complained of severe nausea and headache. The intravenous fluid regimen consisted of 1/4 normal saline with 20 mEq/L KCl infused at the rate of 100 ml/hr. On physical examination she was confused but had an otherwise unremarkable exam. Laboratory studies revealed:
Glucose: 80 mg/dL Sodium: 121 mM BUN: 5 mg mg/dL Potassium: 4.2 mM Creatinine: 0.6 mg/dL Chloride: 91 mM Total CO2: 23 mM Arterial blood gases: pH: 7.45
pCO2: 33 mmHg pO2: 62 mmHg
Which one of the following choices offers the most appropriate treatment for this patient?
A. Fluid restriction to less than 800 mL/24 hours
B. Oral urea
C. Administration of demeclocycline
D. Administration of 3% saline and furosemide
30. Which of the following drugs has/have been associated with increased antidiuretic hormone release?
D. All of the above
31. Which one of the following factors is most important in preventing hypernatremia?
A. An intact urine concentrating mechanism
B. Intact ADH production
C. Intact ADH sensitivity by the kidney
D. Intact thirst mechanism
32. A 60 year old woman with long-standing left hemiparesis has been treated with hydrochlorothiazide for hypertension. She is admitted with a 5-day history of diarrhea, poor oral intake, and increasing confusion. Physical examination reveals a thin, confused woman with decreased skin turgor. Her blood pressure is 85/60 mmHg supine and she has a pulse of 120 bpm. Laboratory findings include:
Sodium: 170 mM Urine Sodium: 6 mM Potassium: 4 mM Urine osmolality: 650 mOsml/L Chloride: 135 mM HCO3: 20 mM
The most appropriate initial I.V. fluid for this patient would be which one of the following choices?
B. D5 0.25 NS
C. D5 0.45 NS
D. Normal saline
33. A 32 year old woman was brought to the ER one evening with seizures. Earlier that day, she had undergone outpatient liposuction under general anesthesia. On physical exam, her blood pressure was 126/76 mmHg. She was lethargic but had no focal neurologic deficits. Her serum sodium concentration was 112 mEq/L. Her serum osmolality was 230 mOsm/kg and her urine osmolality was 420 mOsm/kg. Which one of the following choices is the most appropriate treatment for her hypernatremia?
A. Fluid restriction to 800 ml/day
B. 20 mg furosemide I.V. every six hours
C. 3% saline at a rate to increase the serum sodium to 120 mEq/L over 8 hours
D. O.9% saline at 150 ml/hr
E. Demeclocycline 250 mg every six hours
Course Evaluation Form
Please rate each session:
101. Introduction to Metabolic Acidosis (Robert G. Narins, MD)
102. Pathogenesis and Diagnosis of Hypo- and Hypernatremia (Juan Carlos Ayus, M.D.)
103. Treatment of Hypo- and Hypernatremia (Tomas Berl, M.D.)
104. Questions concerning the dysnatremias (Drs. Ayus, Berl, and Narins)
105. Metabolic Alkalosis (Thomas D. Dubose, Jr., M.D.)
106. A Pathophysiologic Approach to Renal Tubular Acidosis (Thomas D. Dubose, Jr., M.D.)
107. Respiratory Acid-Base Disorders (Thomas D. Dubose, Jr., M.D.)
Please rate the symposium:
108. The program content overall
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