Renal
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| hyponatremia = | Na <135 (symptoms seen at Na <125)
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| Etiology of hypervolemic hypotonic hyponatremia | CHF, nephrotic syndrome, ARF, hepatic cirrhosis
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| Etiology of euvolemic hypotonic hyponatremia | hypothyroid, glucocorticoid excess, SIADH, polydipsia, beer potomania
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| Etiology of hypovolemic hypotonic hyponatremia | dehydration, diarrhea, vomiting
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| Hyperkalemia (K >5) etiologies | ARF (most common), increased K load, metabolic acidosis, cell death, hyporeninemic hypoaldosteronism
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| Hypokalemia (K <3.5) nonrenal (urine K <20) etiologies | GI losses (N/V/D, Z-E syndrome), metabolic alkalosis (increases K secretion)
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| Hypercalcemia etiologies | HyperPTH (most common). Neoplasm (lung, head/neck, MM, NHL, cervical, RCC). Vit D intox. Paget. Adrenal insuff. Milk alkali syndrome. Sarcoid. ZE syndrome. Acromegaly.
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| Dry skin, brittle nails, mx cramps, paresthesias, laryngospasm/stridor, hyper DTRs, SOB, crackles, S3, syncope & angina = | hypocalcemia (Ca <8.5); usu 2/2 CKD or hypoPTH
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| Hyperphosphatemia (1.0-2.5); severe (<1.0) can lead to: | rhabdo, paresthesia, encephalopathy
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| Hypermagnesemia (2.5 mEq/L) sx/sx | 1st: reduced DTRs; mx weak, hypoTN, resp depression, cardiac arrest; N/V, flushing; high bleeding time/coag
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| Normal range: pH: | 7.40 (7.35-7.45)
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| Normal range: pO2: | 80-100 mmHg
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| Normal range: pCO2: | 35-45 mmHg
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| Normal range: HCO3: | 22-26 mmol/L
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| Anion gap = | cations (Na+) – anions (Cl- + HCO3-); Normal AG = 8-16 mmol/L
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| Respiratory compensation for metabolic acidosis | pCO2 should fall 1.2 for every 1.0 drop in HCO3
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| Respiratory acidosis etiology | impairment in rate of alveolar ventilation; acute medullary resp ctr depression (narcotic OD), resp mx paralysis, airway obstruction; chronic (emphysema, pickwickian)
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| Resp acidosis Sx/Sx | metab encephalopathy: somnolence, confusion, narcosis, asterixis. Fundi: dilated, tortuous vessels, possible papilledema
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| Resp acidosis DDx/causes | COPD, airway obstruction, CNS depression (opioids, brainstem injury), neuromx (GBS, MG, botulism), myxedema
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| Resp alkalosis (hypocapnia) Patho | hyperventilation reduces PCO2, increases pH
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| Resp alkalosis Sx/Sx | lightheadedness, anxiety, perioral numbness, acroparesthesias (pain hands & feet)
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| Resp alkalosis DDx | PE, pulmo edema, PTX, ARDS, pulmo art HTN, asthma, interstitial pulmo fibrosis
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| NAGMA possible causes = | extrarenal bicarb loss (diarrhea, renal bicarb excretion); renal tubular acidosis; chronic renal failure, carbonic anhydrase inhibitors, diuretic, primary hyperPTHism, Addison dz
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| AGMA: MUDPILES | methanol, uremia, DKA, propylene glycol, isoniazid, lactic acidosis [shock, septicemia, hypoxemia], ethylene glycol, salicylates
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| AGMA: CUTE DIMPLES | C for Cyanide & T for Toluene plus MUDPILES
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| Metab acidosis Sx/Sx | CP, palpitations, HA, AMS, decreased visual acuity, N/V/abd pain, wt loss, mx weakness, bone pain; Kussmaul (profound DKA), lethargy, stupor, coma, seizures; V-tach, hypotension
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| Metabolic alkalosis: chloride-responsive (low urine Cl): due to: | diuretic tx (contraction alkalosis) or loss of gastric secretions (2/2 vomiting or NG tube)
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| Metabolic alkalosis: chloride-resistant (high urine Cl): etiology | Bartter or Gittelman syndrome; hyperaldosteronism; bicarb intake in CKD
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| Pathology of hypervolemic hypotonic hyponatremia | expansion of extracellular fluid relative to amount Na present
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| Pathology of hypovolemic hypotonic hyponatremia | 1) extrarenal. 2) renal salt/volume loss based on urine Na level
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| Conditions associated with isotonic hyponatremia | Hyperlipidemia (familial HLD or nephrotic syndrome), hyperproteinemia (multiple myeloma, macroglobulinemia)
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| Isotonic hyponatremia patho | Na amount in plasma stays same, but more of other solutes -> decrease in relative Na conc
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| Hypertonic hyponatremia etiology | Hyperglycemia (100mg/dL rise -> 1.5mEq/L Na drop); hypertonic tx (eg, mannitol) -> water leaves cells, Na leaves vascular space to extracellular space
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| Hypernatremia defn = | serum Na >145mEq/L (osmo >290)
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| Hypernatremia correction | Free water deficit = Wt x [(Na - 140)/140]. Correct over 48h; drop Na by 1mEq/L/hr.
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| Hypokalemia (K <3.5) renal (urine K > 40) etiologies | diuretics, renal tubular acidosis, adrenal hormones, hyperaldosteronism, Cushing/steroids, digoxin, low Mg
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| Hypokalemia clinical features | Muscle cramps, ileus, dysrhythmia
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| Hypokalemia with acidosis & without HTN: suspect: | RTA
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| Hypokalemia with high urine Cl without HTN / acidosis: suspect: | Diuretics or Bartter syndrome (low urine Cl = N/V)
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| High dose K repletion for severe hypokalemia (<2.5 mEq/L) | Max 20 mEq/L/h and max 60 mEq/L. Should be via central venous access
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| Dysrhythmias associated with severe hyperkalemia (>6.5) | Brady, prolonged PR, peaked T waves progressing to long QRS; V-fib
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| Most potassium in body is found in: | Intracellular
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| Hyperkalemia from K shift from intracellular to extracellular space may be 2/2: | Burns, rhabdo, hemolysis, severe infxn, internal bleeding, extreme exercise
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| Hyperkalemia clinical findings | Initial hyperreflexia, then flaccid paralysis; vasodilation
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| Hyperkalemia mgmt | IV beta-agonists (salbutamol), Na bicarb, IV insulin (w/D5NS); Ca gluconate (stabilizes cardiac membrane); SPS; loop diuretics; ?HD
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| Ca distribution in body | 99% in bone. 0.01% in body fluids. 50% of Ca bound to albumin, 10% to other, 40% free.
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| Hypocalcemia etiologies | CKD (most common: 2/2 decreased vit D production). Low albumin. Sepsis. Acute pancreatitis. Post-thyroid surgery. hypoPTH. Blood transfusion. Medullary ca of thyroid (calcitonin secretion).
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| Hypocalcemia patho | Low Ca (2/2 low intake/absorption or low PTH or increased Ca into bone) -> lower NM excitation threshold -> reduced contractile force in vascular smooth & cardiac mm
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| Symptomatic hypocalcemia mgmt. | IV Ca gluconate 10% infusion, ?IV CaCl
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| Hypercalcemia clinical findings | Weakness, polydipsia, hyporeflexia, confusion, renal calculi, N/V, constipation, ileus, nephrogenic DI, bone pain/fx
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| Hypercalcemia mgmt. | IVF forces urinary excretion of Ca. +/- furosemide (thiazide may worsen high Ca). +/-HD.
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| Hypercalcemia mgmt.: underlying causes | Metastatic bone dz: calcitonin +/- pamidronate (inhibit bone resorption). Sarcoid/MM/leukeumia/BrCa/vit D intox: glucocorticoids
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| PO4 distribution in body | 70% intracellular, 29% intraskeletal, <1% serum
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| Hypophosphatemia etiology | Decreased GI absorption, vit D def, refeeding syndrome, hyper PTH, hyperthyroid, DKA, sepsis, ASA toxicity
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| Severe hypophosphatemia results in: | Decreased affinity of Hgb for O2
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| Hypophosphatemia workup | Serum PO4 <2.5. Urine PO4 >20 = renal loss. PTH. Bone bx: ?osteomalacia. CK (rhabdo)
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| Hyperphosphatemia etiology | CKD, AKI, hypoPTH, acromegaly. Increased intake, vit D, rhabdo, cell lysis, AGMA
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| Phosphate binders | Sevelamer, lanthanum, Aluminum hydroxide
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| Resp alkalosis (hypocapnia) etiology | Hyperventilation syndrome (?anxiety). GNR sepsis, cirrhosis, PE, CHF, ILD, PNA, pulmo edema, HAPE, CVA, anemia, PG (2/2 progesterone stim of resp ctr), acute ASA tox
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| Low anion gap seen in: | NAGMA, myeloma, hypoalbuminemia, lithium Rx
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