questions 24

Electrolyte Disturbances

Topic updated on 09/15/17 11:46am

Snapshot
  • A 56-year-old man is brought to the emergency department by his son due to mild confusion and shortness of breath. Prior to symptom develop he needed to sleep on a recliner due to feeling short of breath while supine. Medical history is significant for chronic obstructive pulmonary disease and a prior myocardial infarction requiring coronary artery bypass grafting. On physical exam, the patient is altered but able to follow commands. There is jugular venous distension, an S3 heart sound, and 2+ lower extremity pitting edema. Laboratory testing is significant for a brain natriuretic peptide 950 pg/mL and serum sodium of 130 mmol/L. (Hyponatremia secondary to congestive heart failure)
Potassium
 
Electrolyte Disturbances
Hyponatremia Hypernatremia
  • Definition
    • serum sodium of < 135 mmol/L
  • Etiology
    • pseudohyponatremia
      • hyperglycemia
      • hyperlipidemia
    • hypervolemic hyponatremia
      • congestive heart failure
      • nephrotic syndrome
      • cirrhosis
      • renal insufficiency
    • hypovolemic hyponatremia
      • vomiting and diarrhea
      • burns
      • sweating
      • cystic fibrosis
      • diuretic use (e.g., thiazides)
      • angiotensin converting enzyme (ACE) inhibitor
      • adrenal insufficiency
    • euvolemic hyponatremia
      • psychogenic polydipsia
      • hypothyroidism
      • syndrome of inappropriate anti-diuretic hormone (SIADH)
      • diuretic use
      • ACE inhibitors
  • Presentation
    • stupor
    • coma
    • seizures
    • nausea
    • malaise
  • Studies
    • assess volume status
    • serum electrolyte and urine studies
  • Treatment
    • address underlying cause
    • asymptomatic
      • free water restriction
    • moderate hyponatremia
      • IV normal saline
        • loop diuretics may be added
    • severe hyponatremia
      • hypertonic (3%) saline
  • Complications
    • rapid correction of hyponatremia can lead to osmotic demyelination syndrome
  • Definition
    • serum sodium of > 145 mmol/L
  • Etiology
    • insensible losses (e.g., sweating)
    • osmotic diarrhea
    • osmotic diuresis
      • e.g., diabetic ketoacidosis
    • poor fluid intake
    • diuretic use
    • osmotic diuresis
    • vomiting and diarrhea
    • central and nephrogenic diabetes insipidus
    • hypertonic sodium gain
  • Presentation
    • stupor
    • coma
    • seizure
  • Studies
    • assess volume status
    • serum electrolyte and urine studies
  • Treatment
    • address underlying cause
    • intravenous (IV) 5% dextrose in water (D5W)
  • Complications
    • rapid corrrection of hypernatremia can lead to cerebral edema and herniation
Hypokalemia Hyperkalemia
  • Defintion
    • serum potassium of < 3.5 mEq/L
  • Etiology
    • ↑ insulin
    • hyperglycemia
      • this stimulates endogenous insulin secretion from the pancreas in normal conditions
    • β2-adrenergic agonists
    • alkalosis
    • hyposmolality
    • diarrhea
  • Presentation
    • muscle and cardiac dysfunction
      • muscular symptoms
        • abdominal cramping
        • muscle weakness and cramping
      • cardiac symptoms
        • palpitations
    • parasthesias
    • nausea and vomiting
  • Studies
    • electrocardiogram (ECG) findings
      • U waves
      • T wave flattening
  • Treatment
    • address underlying cause
    • potassium repletion
      • remember to not use dextrose-containing fluids as this will stimulate insulin release and shift potassium within the cell
        • this worsens the hypokalemia
    • replace magnesium in magnesium deficiency
  • Definition
    • serum potassium of > 5-5.5 mEq/L
  • Etiology
    • insulin deficiency
    • β2-adrenergic antagonists
    • acidosis
      • cells attempt to buffer excess hydrogen ions to shift these ions into the cells
        • in exchange for this intracellular uptake of hydrogen, potassium is transferred out the cell
          • this attempts to achieve electroneutrality
    • digitalis
      • secondary to dose-dependent Na+/K+ -ATPase pump inhibition
    • cell lysis (e.g., rhabdomyolysis)
    • exercise
    • hyperosmolarity
    • succinylcholine
    • TMP-SMX
    • ACE inhibitors
  • Presentation
    • muscle and cardiac dysfunction
      • muscular symptoms
        • myalgias
        • muscle paralysis
        • chest pain
      • cardiac symptoms
        • arrhythmias and palpitations
    • nausea and vomiting
    • parasthesias
  • Studies
    • ECG findings
      • peaked T waves and wide QRS
  • Treatment 
    • address underlying cause
    • IV calcium gluconate
      • has no effect on potassium levels but stabilizes the myocardium
    • shifting potassium within cells
      • insulin plus glucose
      • β2-adrenergic agonists
    • lowering body potassium
      • sodium polystyrene sulfonate
        • this is a cation exchange resin
    • dialysis
      • used in patients unresponsive to medical therapy
Hypocalcemia Hypercalemia
  • Definition
    • serum total calcium < 8.4 mg/dL
    • ionized fraction of calcium < 4.4 mg/dL
  • Etiology
    • renal failure
    • hypoparathyroidism
    • vitamin D deficiency
    • hypomagnesemia
      • inhibits PTH release
    • pancreatitis
    • alkalemia
  • Presentation
    • seizures
    • tetany
    • Chvostek sign
      • ipsilateral facial muscle contraction caused by tapping the facial nerve
    • Trousseau sign
      • carpopedal spasms by inflating the sphygmomanometer above systolic blood pressure
  • Studies
    • QTc prolongation
  • Treatment
    • address underlying cause
    • asymptomatic or patients with chronic hypocalcemia
      • oral calcium replacement therapy such as
        • calcium citrate
        • calcium carbonate
      • vitamin D supplementation
      • thiazides for patients with hypoparathyroidism
    • symptomatic patients
      • IV calcium gluconate
        • first-line
    • chronic renal failure
      • phosphate binders
      • oral calcium replacement
      • calcitriol
  • Definition
    • serum total calcium > 10.5 mg/dL
    • ionized fraction of calcium > 5.6 mg/dL
  • Etiology
    • hyperparathyroidism
    • humoral hypercalcemia of malignancy
      • secondary to parathyroid hormone-related peptide (PTHrP)
      • associated with squamous cell cancer and solid tumors involving the
        • lung
        • esophageus
        • skin
        • cervix
        • breast
        • kidney
    • vitamin D overdose
    • granulomatous diseases like
      • sarcoidosis
    • thiazide diuretics
    • lithium
    • calcium-containing antacids
    • familial hypocalciuric hypercalcemia
    • immobilization
  • Presentation
    • nephrolithiasis
    • polyuria
    • muscle weakness
    • bone pain
    • abdominal pain
      • secondary to bowel hypomotility and constipation
    • confusion
    • stupor
    • coma
    • mnemonic: stones (renal), bones (pain), groans (abdominal pain), thrones (↑ urinary frequency), and psychiatric overtones (altered mental status)
  • Studies
    • ECG
      • shortened QTc interval
  • Treatment
    • address underlying cause
    • IV isotonic normal saline
      • increases urinary calcium excretion
    • calcitonin
      • impairs bone resorption
      • increases urinary calcium excretion
    • bisphosphonates (e.g., zoledronic acid and pamidronate)
      • has a delayed onset of action
      • impairs bone resorption
    • loops diuretics
      • increases urinary calcium excretion
Hypomagnesemia Hypermagnesemia
  • Definition
    • typically serum magnesium < 1.8 mg/dL
  • Etiology
    • magnesium redistribution
      • refeeding syndrome
    • malnutrition
    • alcohol use disorder
    • anorexia nervosa
    • proton pump inhibitors
    • loop diuretics
    • digoxin
  • Presentation
    • tetany
    • torsades de pointes
    • hypokalemia
    • hypocalcemia
      • when significant (< 1.2 mg/dL)
  • Studies
    • ECG
      • U waves
      • T wave flattening
      • QT prolongation
      • widened QRS complexes
  • Treatment
    • magnesium repletion
      • asymptomatic
        • oral magnesium supplementation
      • severe or symptomatic hypomagnesemia
        • IV magnesium sulfate
  • Definition
    • typically serum magnesium > 2.6 mg/dL
  • Etiology
    • increased magnesium ingestion
      • magnesium cathartics
      • antacids
      • laxatives
      • dietary supplements
    • renal insufficiency
  • Presentation
    • ↓ deep tendon reflexes
    • bradycardia
    • cardiac arrest
    • hypocalcemia
  • Studies
    • ECG
      • PR, QRS, and QT prolongation
      • heart block
  • Treatment
    • address underlying cause
    • IV isotonic saline
    • loop diuretics can be considered
Hypophosphatemia Hyperphosphatemia
  • Definition
    • serum phosphate < 2.5 mg/dL
  • Etiology
    • refeeding syndrome
    • hungry bone syndrome
    • inadquate phosphate intake
    • hyperparathyroidism
    • phosphate binders
  • Presentation
    • weakness
    • muscle and bone pain
    • osteomalacia
    • rickets
  • Treatment
    • address underlying cause
    • mild hypophosphatemia
      • increase dietary phosphate intake
    • moderate hypophosphatemia
      • oral phosphate replacement therapy
        • IV phosphate replacement in patients who are on a ventilator
    • severe hypophosphatemia
      • IV phosphate replacement
  • Definition
    • serum phosphate > 4.5 mg/dL
  • Etiology
    • acute phosphate ingestion
    • hypoparathyroidism
    • vitamin D toxicity
    • renal failure
    • rhabdomyolysis
    • tumor lysis syndrome
  • Presentation
    • typically asymptomatic
  • Treatment
    • address underlying cause
    • dietary modifications
    • phosphate binders
      • calcium carbonate or acetate
 


  RATE CONTENT
3.0
AVERAGE 3.0 of 9 RATINGS

Qbank (20 Questions)

TAG
(M3.RL.70) A 60-year-old patient with a complex medical history presents for evaluation of weakness, paresthesias and recurrent episodes of nausea and vomiting. An EKG reveals peaked T waves and a widened QRS complex. After the patient is stabilized, a full medical history, including current medications, is obtained. Which medication may have contributed to the patient's clinical presentation? Topic Review Topic

1. Albuterol
2. Rosuvastatin
3. Insulin
4. Lisinopril
5. Metformin

PREFERRED RESPONSE ▶
TAG
(M3.RL.75) A 92-year-old female with CAD, hypertension, atrial fibrillation, hyperlipidemia, and type II diabetes is brought to the emergency room from her nursing home due to altered mental status. The patient had been confused and lethargic for one day prior to her arrival in the hospital. While being examined by the emergency room physician, the patient has a seizure. Physical examination reveals decreased deep tendon reflexes symmetrically. Jugular venous pressure is normal, mucous membranes are moist, and no edema is present in the patient’s extremities. CT scan of the head is shown in Figure A. Laboratory studies reveal the following:

Sodium: 115 mEq/L
Potassium: 4.5 mEq/L
Chloride: 86 mEq/L
Bicarbonate: 16 mEq/L
BUN: 41 mg/dL
Creatinine: 2.09 mg/dL
Glucose: 213 mg/dL

Urine studies show:
Urine sodium: <10 mEq/dL
Urine osmolality: 75mOsm/kg
Urine creatinine: 14 mg/dL

Which of the following is the most likely cause of the patient’s neurological symptoms?
Topic Review Topic
FIGURES: A          

1. Poor solute intake
2. Syndrome of inappropriate anti-diuretic hormone secretion (SIADH)
3. Cerebrovascular accident
4. Congestive heart failure
5. Intrinsic renal azotemia

PREFERRED RESPONSE ▶
TAG
(M3.RL.76) A 68-year-old woman is brought to the emergency room by her husband following confusion and lethargy of a week’s duration. Two weeks ago she was diagnosed with small cell cancer of the lung but has not yet begun any chemotherapy regimens. She has a 30-pack year history of smoking. She does not take medications. Physical examination reveals decreased deep tendon reflexes symmetrically. Jugular venous pressure is normal, mucous membranes are moist, and no edema is present in the patient’s extremities. CT scan of the brain reveals no abnormalities. Laboratory studies reveal the following:

Sodium: 112 mEq/L
Potassium: 4.0 mEq/L
Chloride: 95 mEq/L
Bicarbonate: 24 mEq/L
BUN: 6 mg/dL
Creatinine: 0.65 mg/dL

Serum osmolality is 220 mOsm/kg and urine osmolality is 400 mOsm/kg. Which of the following is the most appropriate next step in management of this patient:
Topic Review Topic

1. Volume repletion with normal saline
2. Administer demeclocycline
3. Administer hypertonic saline
4. Administer desmopressin (dDAVP)
5. Administer 5% dextrose in water (D5W) and furosemide

PREFERRED RESPONSE ▶
TAG
(M2.RL.1) A 32-year-old man with a history of chronic alcoholism presents to the ED with vomiting and diarrhea for 1 week. On physical exam, he is found to have orthostatic hypotension and dry mucus membranes. Laboratory results show serum sodium, potassium, chloride, bicarbonate, BUN, creatinine, glucose, calcium, magnesium, and phosphate within normal limits. The patient is treated with IV administration of normal saline, dextrose, thiamine, and folic acid. The following day he complains that he feels too weak to move his arms or legs. Which of the following is the most likely explanation for his new onset weakness? Topic Review Topic

1. Hypomagnesemia
2. Hypoglycemia
3. Hyponatremia
4. Hypophosphatemia
5. Hypocalcemia

PREFERRED RESPONSE ▶
TAG
(M2.RL.2) You are seeing a patient in the emergency room for "extensive vomiting." The patient is a 54-year-old man with a Stage IV adenocarcinoma of the stomach who recently enrolled in hospice. The patient notes that for the past 4 days he has been unable to keep any food or water down due to non-bloody, non-billious emesis every time he eats or drinks. He has become progressively weaker and the emesis has not improved. On physical exam you note a very thin man with the following vital signs: temperature is 37.5 deg C (99.5 deg F), blood pressure is 90/60 mmHg, pulse is 105/min, respiratins are 16/min, Oxygen saturation is 96% on room air. Initial lab work reveals the following: Na+: 140 mEq/L, Cl-: 99 mEq/L, HCO3-: 33 mEq/L, BUN: 30 mg/dL, Cr: 1.3 mg/dL, Glucose: 98 mg/dL. Which acid-base status and serum potassium level would you expect in this patient? Topic Review Topic

1. Anion gap metabolic acidosis, hypokalemia
2. Non anion gap metabolic acidosis, hypokalemia
3. Respiratory acidosis, hyperkalemia
4. Metabolic alkalosis, hyperkalemia
5. Metabolic alkalosis, hypokalemia

PREFERRED RESPONSE ▶
TAG
(M2.RL.3) A 64-year-old man presents for a routine physical. He states that he is not doing very well and, in fact, has not had a bowel movement in over a week. Upon further questioning, the patient notes that for about 4 months he has experienced significant back pain and finds that he is easily fatigued. His wife has remarked that he is unusually "pale." In addition to his lack of a bowel movement for the past week, the patient has also had a loss of appetite, has been urinating more than usual, and has had a depressed mood. Which of the following is the most likely cause of this patient's constipation? Topic Review Topic

1. Hyperkalemia
2. Hypermagnesemia
3. Hypophosphatemia
4. Hypercalcemia
5. Hypocalcemia

PREFERRED RESPONSE ▶
TAG
(M2.RL.6) You are the medical doctor on call at an inpatient psychiatric facility, where you are asked to see a 38-year-old woman who has been hospitalized for the past 4 days. She has a history of schizophrenia and was admitted after assaulting a passenger on the public transit service. The psychiatric team has been titrating her antipsychotics, and she has been relatively well during her stay thus far. You learn from the orderly that she has been experiencing nausea and malaise now for 24 hours. Currently, she is complaining of headache and weakness and appears confused. On exam, she appears euvolemic. While awaiting preliminary blood test results, you perform a urine dipstick which shows the following:

Specific gravity: 1.001
pH: 5.9
Protein: negative
Leukocyte esterase: negative
Nitrites: negative
Blood: negative
Ketones: negative

Her serum sodium returns at 121 mEq/L. Urine osmolality is 90 mOsm/kg. Which of the following is the most likely diagnosis? Topic Review Topic

1. Renal tubular acidosis (RTA)
2. Medication side effect
3. Psychogenic polydipsia
4. Acute renal failure
5. Central diabetes insipidus (DI)

PREFERRED RESPONSE ▶
TAG
(M2.RL.24) A 27-year-old female suffers from a panic disorder. She describes her typical panic attack with the symptoms of sweating, palpitations, chest pain, and hyperventilation. She also reports feeling perioral numbness. Which of the following is the most likely physiological cause of this localized numbness? Topic Review Topic

1. Increased blood pH
2. Decreased blood pH
3. Decreased albumin-bound calcium
4. Decreased total blood calcium concentration
5. Decreased blood oxygen concentration

PREFERRED RESPONSE ▶
TAG
(M2.RL.25) A 18-year-old female presents to her primary care physician for a pre-sports physical. She has no prior medical history except that her mother states she has recently lost weight and that she has become concerned about her weight. On physical exam she is 5’6” and weighs 102 lbs. A serum electrolyte panel is drawn, which reveals a calcium level of 8.5 mg/dL. Serum albumin is 3.0 g/dL. What is this patient’s corrected serum calcium level? Topic Review Topic

1. 8.4 mg/dL
2. 8.7 mg/dL
3. 9.0 mg/dL
4. 9.3 mg/dL
5. 9.5 mg/dL

PREFERRED RESPONSE ▶
TAG
(M2.RL.31) A 30-year-old woman is brought to the emergency department following a major automobile accident in which she was an unrestrained passenger. She has no significant past medical history and takes no medications. Her temperature is 37.5 C (99.5 F), blood pressure is 70/40 mm Hg, heart rate is 120/min, and respiratory rate is 22/min. On physical exam, she is in acute distress due to pain. She is alert and oriented to person, place, and time, with no signs of head trauma. She has chest wall bruising bilaterally with tenderness to palpation. Cardiac and pulmonary auscultation are within normal limits. Her abdominal exam reveals tenderness to palpation with rebound. There is also severe pain with palpation and passive movement of the right hip. Given this patient's hemodynamic instability, she is taken to the operating room, where exploratory laparotomy reveals a splenic laceration and significant hemoperitoneum. She receives twelve units of packed red blood cells during the procedure. On the first post-operative day, her physical exam reveals hyperactive deep tendon reflexes. Which of the following electrolyte abnormalities is most likely present? Topic Review Topic

1. Hypercalcemia
2. Hypocalcemia
3. Hyperkalemia
4. Hypokalemia
5. Hypermagnesemia

PREFERRED RESPONSE ▶
TAG
(M2.RL.36) An 84-year-old man is brought to the emergency room from his nursing residence with symptoms of nausea, diarrhea, and poor oral intake for the last three days. He has also appeared weak and fatigued. His past medical history is significant for hypertension and Alzheimer's disease. His medications include enalapril, metoprolol, amlodipine and donepezil. His temperature is 99.1 F, blood pressure 128/70 mm Hg, heart rate 96/min, and respiratory rate 17/min. On physical exam, he appears fatigued but in no acute distress, with normal skin turgor but dry mucous membranes. Cardiac, pulmonary, and abdominal exams are within normal limits. His electrocardiogram (ECG) is shown in Figure A. In addition to initial laboratory evaluation, which of the following is the best next step in the management of this patient? Topic Review Topic
FIGURES: A          

1. Administer calcium gluconate
2. Administer kayexalate
3. Administer magnesium
4. Administer thiazides
5. Cardioversion

PREFERRED RESPONSE ▶
TAG
(M2.RL.37) A 48-year-old male with a history of chronic alcoholism presents to the emergency department with complaints of fatigue, muscle cramps and weakness, and constipation. He reports that these symptoms have developed over the past several weeks, and he admits to currently drinking 750 ml of whiskey daily. Physical examination is significant for 1+ reflexes at the bilateral patellar tendons and absent reflexes distally at the bilateral Achilles tendons. A complete blood count, complete metabolic panel, and EKG are ordered. The patient's EKG is shown in Figure A. The results of the complete blood count and metabolic panel are pending. Which of the following is the best management for the most likely cause of this patient's condition? Topic Review Topic
FIGURES: A          

1. IV potassium replacement alone
2. IV magnesium and potassium replacement
3. Calcium gluconate followed by sodium bicarbonate, albuterol, insulin, and glucose
4. Kayexalate and furosemide
5. Hemodialysis

PREFERRED RESPONSE ▶
TAG
(M2.RL.38) A 70 year-old man is brought to the emergency department by his daughter due to lethargy and change in mental status. His daughter states he was recently diagnosed with Alzheimer's disease and had to move in with her family to help with his activities of daily living. The patient has not had any fevers, chills, coughing, or changes in urination or stool. He has no other medical problems and takes no medications. Vital signs include Temp 36.9 C, BP 104/68 mmHg, HR 100/min, and RR 16/min. After standing for 10 minutes, his blood pressure is 82/58 mmHg. On physical exam, he is a frail, elderly man with dry oral mucosa. He is oriented to person only. His skin examination is shown in Figure A. Cardiac and pulmonary auscultation are within normal limits.

Laboratory results are as follows:
sodium 165 mEq/L
potassium 4.8 mEq/L
bicarbonate 30 mEq/L
chloride 124 mEq/L

The patient is started on IV 0.9% normal saline. Twenty-four hours later, his blood pressure is 120/74 mmHg sitting and 118/72 mm Hg after standing for 10 minutes. He is still rather lethargic but is now oriented to person and place. He now has moist mucous membranes and normal skin turgor.

His post-resuscitation labs are as follows:
sodium 156 mEq/L
potassium 4.2 mEq/L
bicarbonate 24 mEq/L
chloride 112 mEq/L

What is the best next step in the management of this patient? Topic Review Topic
FIGURES: A          

1. Continue IV 0.9% saline
2. Switch to IV 0.45% saline
3. Switch to oral free water
4. Switch to IV free water
5. Discharge the patient

PREFERRED RESPONSE ▶
TAG
(M2.RL.40) A 62-year-old man presents to the emergency department with worsening shortness of breath. Two days ago, he developed fever, rhinorrhea, and worsening of his chronic cough. His past medical history is significant for chronic obstructive pulmonary disease (COPD). His medications include ipratropium, but his prescription ran out a few days ago. He does not take supplemental oxygen at home. His temperature is 37.8 C (100.0 F), blood pressure 136/78 mm Hg, heart rate 98/min, respiratory rate 24/min, and oxygen saturation is 87 percent on room air. On physical exam, he is in acute respiratory distress, using accessory muscles for breathing. He has increased anteroposterior diameter of his chest, as well as diffuse wheezing on auscultation. His cardiac and abdominal exams are normal. There is no evidence of clubbing or cyanosis. After an hour of noninvasive positive pressure ventilation, the patient's respiratory distress continues to worsen, requiring endotracheal intubation. Which of the following is a contraindication to the use of succinylcholine in rapid-sequence intubation? Topic Review Topic

1. Hypercalcemia
2. Hypocalcemia
3. Hyperkalemia
4. Hypokalemia
5. COPD exacerbation

PREFERRED RESPONSE ▶
TAG
(M2.RL.42) A 40-year-old woman with a history of triple negative metastatic breast cancer presents with colicky groin pain and hematuria. CT of the abdomen and pelvis reveals the following (shown in Figure A). She also reports several days of constipation, weakness, and confusion. Vital signs are as follows: Temp 37 C, HR 90, BP 110/70, RR 12, and O2 99% on room air. Physical examination is within normal limits. Serum calcium is 14 mg/dL (normal range 8.5-10.3). PTH is 5 pg/mL (normal range 11-54). A PTHrP is pending. Besides starting IV normal saline, long-term therapy with which of the following should be started: Topic Review Topic
FIGURES: A          

1. A medication that may cause gray baby syndrome
2. A medication that may cause osteonecrosis of the jaw
3. A medication that may cause coronary vasospasm
4. A medication that may cause pulmonary fibrosis
5. A medication that may cause hot flashes

PREFERRED RESPONSE ▶
TAG
(M2.RL.47) An 81-year-old woman is brought to her primary care physician's office by her daughter, who says that her mother has been having nausea, diarrhea, and poor oral intake for the last three days. Her mother has appeared weak and fatigued. Her past medical history is significant for hypertension. Her medications include enalapril, metoprolol, amlodipine. Her temperature is 37 C (98.6 F), blood pressure 125/70 mm Hg, heart rate 98/min, and respiratory rate 16/min. On physical exam, she appears fatigued but in no acute distress. She has normal skin turgor but dry mucous membranes. Her cardiac, pulmonary, and abdominal exams are within normal limits. Her electrocardiogram (ECG) is shown in Figure A. In addition to initial laboratory evaluation, which of the following would be an appropriate step in management of this patient? Topic Review Topic
FIGURES: A          

1. Starting intravenous glucagon
2. Starting a beta-1-adrenergic blocker
3. Starting a beta-1-adrenergic agonist
4. Starting a beta-2-adrenergic blocker
5. Starting a beta-2-adrenergic agonist

PREFERRED RESPONSE ▶
TAG
(M2.RL.48) A 74-year-old man is brought to the emergency department from a nursing home due to decreased responsiveness. His caretaker adds that the patient has not been having fevers, chills, coughing, or changes in urination or stool. The patient's past medical history is significant for Alzheimer's disease, hypercholesterolemia, and hypertension. His medications include memantine, simvastatin, and hydrochlorothiazide. Vitals include T is 36.9 C, BP 104/68 mmHg, HR 100/min, and RR 16/min. After standing for 10 minutes, his blood pressure is 82/58 mmHg. On physical exam, he is a frail, elderly man, with dry oral mucosa. His skin examination is shown in Figure A. Cardiac exam reveals regular tachycardia and pulmonary auscultation is wiithin normal limits . Laboratory results are as follows:

Sodium 165 mEq/L, potassium 4.8 mEq/L, bicarbonate 30 mEq/L, chloride 124 mEq/L.

What is the best first step in the management of this patient? Topic Review Topic
FIGURES: A          

1. IV 0.45% saline
2. IV 5% dextrose in 0.45% saline
3. IV 0.9% saline
4. IV 5% dextrose in water (D5W)
5. Oral free water

PREFERRED RESPONSE ▶
TAG
(M2.RL.50) A 78 year-old woman is brought to the emergency department by her maid, who found her lethargic and less responsive than usual this morning. The maid had been on vacation for the last week and reports that the woman was alert and active previously. The patient has a past medical history of hypertension and early dementia, and her medications include metoprolol and memantine. Her temperature is 36.8 C, blood pressure 94/60 mmHg, heart rate 96/min, and respiratory rate 16/min. Her blood pressure decreases to 84/50 mmHg while standing. She is lethargic and oriented to person and place only. She has dry oral mucosa and decreased skin turgor. Her heart, lung, and abdominal exams are within normal limits and stool guaiac is negative. Initial labs are as follows:
Sodium 124 mEq/L, potassium 3.4 mEq/L, chloride 95 mEq/L, bicarbonate 31 mEq/L, BUN 28 mg/dL, creatinine 1.0 mg/dL, and glucose 120 mg/dL.
Which of the following best describes the levels of renin, aldosterone, and ADH in this patient's blood? Topic Review Topic

1. Decreased renin, decreased aldosterone, increased ADH
2. Decreased renin, increased aldosterone, increased ADH
3. Increased renin, increased aldosterone, decreased ADH
4. Increased renin, increased aldosterone, increased ADH
5. Increased renin, decreased aldosterone, decreased ADH

PREFERRED RESPONSE ▶
TAG
(M2.RL.51) A 48-year-old female presents to the emergency department with complaints of intractable nausea and vomiting as well as generalized weakness over the last two days. She is currently on day 2 of a 7-day course of trimethoprim-sulfamethoxazole for a urinary tract infection. On examination, she appears fatigued with delayed skin turgor and dry mucus membranes. An EKG is obtained and is shown in Figure A. A complete blood count and basic metabolic panel are obtained. Which of the following laboratory abnormalities would best explain this patient's clinical presentation? Topic Review Topic
FIGURES: A          

1. Hyperkalemia
2. Hyponatremia
3. Normal creatinine
4. Hypochloremia
5. Anemia

PREFERRED RESPONSE ▶
TAG
(M2.RL.143) A 70-year-old male is diagnosed with multiple myeloma after several months of persistent back pain. One week after his diagnosis he presents to the ED with acute onset confusion, vomiting, and constipation. He produces 750ml of urine in one hour. His vitals are BP 150/90, HR 60, T 98.3, SpO2 98%. His EKG is shown in Figure A. What is the next best step in his management? Topic Review Topic
FIGURES: A          

1. Hydrochlorothiazide
2. IV sodium bicarbonate
3. IV normal saline and calcium carbonate
4. Naloxone
5. IV normal saline

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