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Who is teaching 'Fluid and Electrolytes'?

Kettritz R, Luft FC - Clin Kidney J (2012)

View Article: PubMed Central - PubMed

Affiliation: Nephrology/Critical Care Medicine, Charité Campus Virchow, Berlin, Germany ; Experimental and Clinical Research Centre, Joint Cooperation between Charité Medical Faculty and Max-Delbrück Centre for Molecular Medicine, Berlin, Germany.

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Post-operatively, the patient showed little improvement and a nephrology consult was obtained on the morning of the second post-operative day when her serum sodium had decreased to 120 mmol/L... The consultant found a lethargic patient who promptly fainted in an upright posture... The urine pH had been five on admission and was now six... The sum of urine sodium plus potassium greatly exceeded the urine chloride value, which caused the consultant to conclude that ammonium production in face of this metabolic acidosis might be decreased... Even though the patient was not hyperkalaemic, the consultant next calculated the transtubular potassium gradient from the relationship TTKG = (U/P potassium)/(U/P osmolality)... The result was a modest value of 2.3... On the next day, the sodium level was 130, potassium 4.1, chloride 102, HCO3 19 (all mmol/L), the glucose was 8.27 mmol/L, and the patient's Hb had decreased to 100 g/L... The consultant did not attribute the decrease in Hb to ‘blood letting’ but rather argued that restoration of volume was responsible (Figure 2), an opinion supported by a decrease in creatinine and urea nitrogen values... The combination of hyponatraemia, hyperkalaemia, mild hyperchloraemic metabolic acidosis and modest elevations in the plasma creatinine, blood urea nitrogen and haematocrit are classical findings of Addison's disease... She had entered with a haematocrit of 45 vol%... This value decreased to 30 vol%... Our patient had no evidence of diabetes or gonadal failure. (1) Nephrologists have a traditional teaching role for fluid and electrolytes... This patient exemplifies that we have failed in our mission. (2) We believe that this patient is not an exception and that a concerted international effort is necessary for nephrologists to fulfil their traditional fluid and electrolyte teaching role. (3) Hyponatraemia and acid–base disturbances must always be worked up, especially in patients being considered for surgery.

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Normal chest roentgenogram with a narrow cardiac silhouette consistent with Addison's disease.
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fig1: Normal chest roentgenogram with a narrow cardiac silhouette consistent with Addison's disease.

Mentions: A 22-year-old woman presented to the emergency department complaining of weakness and vomiting for the past 10 days. She had Hashimoto's thyroiditis treated with thyroxin 125 μg/day. Her blood pressure was 100/56 mmHg and abdominal tenderness in the lower abdomen was observed on deep palpation. The haemoglobin (Hb) was 142 g/L, creatinine 84 μmol/L and thyroid-stimulating hormone 0.11 μU/L. Urinalysis dipstick showed pH 5, ketones +4 and specific gravity 1.020. The sodium was 125 mmol/L, potassium 5.3 mmol/L, glucose 3.27 mmol/L and lactate 1.78 mmol/L. A venous blood gas sample revealed a pH of 7.17, PvO2 30 mmHg, PvCO2 28 mmHg and HCO3 11 mmol/L. The admitting physicians interpreted this constellation as ‘metabolic acidosis from vomiting’, ordered a chest roentgenogram (Figure 1) and an abdominal ultrasound examination. The ultrasound study showed that ‘acute appendicitis could not be ruled out’ and the appendix was laparoscopically removed. Pre-operatively, the patient received 1 L 0.9% saline and 500 mL 5% glucose solution. Post-operatively, the patient showed little improvement and a nephrology consult was obtained on the morning of the second post-operative day when her serum sodium had decreased to 120 mmol/L. The consultant found a lethargic patient who promptly fainted in an upright posture. Laboratory values were ordered (Table 1).


Who is teaching 'Fluid and Electrolytes'?

Kettritz R, Luft FC - Clin Kidney J (2012)

Normal chest roentgenogram with a narrow cardiac silhouette consistent with Addison's disease.
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4400521&req=5

fig1: Normal chest roentgenogram with a narrow cardiac silhouette consistent with Addison's disease.
Mentions: A 22-year-old woman presented to the emergency department complaining of weakness and vomiting for the past 10 days. She had Hashimoto's thyroiditis treated with thyroxin 125 μg/day. Her blood pressure was 100/56 mmHg and abdominal tenderness in the lower abdomen was observed on deep palpation. The haemoglobin (Hb) was 142 g/L, creatinine 84 μmol/L and thyroid-stimulating hormone 0.11 μU/L. Urinalysis dipstick showed pH 5, ketones +4 and specific gravity 1.020. The sodium was 125 mmol/L, potassium 5.3 mmol/L, glucose 3.27 mmol/L and lactate 1.78 mmol/L. A venous blood gas sample revealed a pH of 7.17, PvO2 30 mmHg, PvCO2 28 mmHg and HCO3 11 mmol/L. The admitting physicians interpreted this constellation as ‘metabolic acidosis from vomiting’, ordered a chest roentgenogram (Figure 1) and an abdominal ultrasound examination. The ultrasound study showed that ‘acute appendicitis could not be ruled out’ and the appendix was laparoscopically removed. Pre-operatively, the patient received 1 L 0.9% saline and 500 mL 5% glucose solution. Post-operatively, the patient showed little improvement and a nephrology consult was obtained on the morning of the second post-operative day when her serum sodium had decreased to 120 mmol/L. The consultant found a lethargic patient who promptly fainted in an upright posture. Laboratory values were ordered (Table 1).

View Article: PubMed Central - PubMed

Affiliation: Nephrology/Critical Care Medicine, Charité Campus Virchow, Berlin, Germany ; Experimental and Clinical Research Centre, Joint Cooperation between Charité Medical Faculty and Max-Delbrück Centre for Molecular Medicine, Berlin, Germany.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

Post-operatively, the patient showed little improvement and a nephrology consult was obtained on the morning of the second post-operative day when her serum sodium had decreased to 120 mmol/L... The consultant found a lethargic patient who promptly fainted in an upright posture... The urine pH had been five on admission and was now six... The sum of urine sodium plus potassium greatly exceeded the urine chloride value, which caused the consultant to conclude that ammonium production in face of this metabolic acidosis might be decreased... Even though the patient was not hyperkalaemic, the consultant next calculated the transtubular potassium gradient from the relationship TTKG = (U/P potassium)/(U/P osmolality)... The result was a modest value of 2.3... On the next day, the sodium level was 130, potassium 4.1, chloride 102, HCO3 19 (all mmol/L), the glucose was 8.27 mmol/L, and the patient's Hb had decreased to 100 g/L... The consultant did not attribute the decrease in Hb to ‘blood letting’ but rather argued that restoration of volume was responsible (Figure 2), an opinion supported by a decrease in creatinine and urea nitrogen values... The combination of hyponatraemia, hyperkalaemia, mild hyperchloraemic metabolic acidosis and modest elevations in the plasma creatinine, blood urea nitrogen and haematocrit are classical findings of Addison's disease... She had entered with a haematocrit of 45 vol%... This value decreased to 30 vol%... Our patient had no evidence of diabetes or gonadal failure. (1) Nephrologists have a traditional teaching role for fluid and electrolytes... This patient exemplifies that we have failed in our mission. (2) We believe that this patient is not an exception and that a concerted international effort is necessary for nephrologists to fulfil their traditional fluid and electrolyte teaching role. (3) Hyponatraemia and acid–base disturbances must always be worked up, especially in patients being considered for surgery.

No MeSH data available.


Related in: MedlinePlus