hyperCa, hypoNa Flashcards by tiborko mojzis

hypercalcemia with high PTH

adenoma; hyperplasia; carcinoma
lithium
FHH
PTH r tumor

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PTH LOW under 25 and hypercalcemia

PTH r peptide - ca lung / renal 
MTS bones MM 
Vit D1/25 -- granulomatous dx sarcoid; histo, silicosis 
Vit D 25
granulomatous 
hyperthyroidism 
milk alkali sy 
hctz 
vit A
Immobilization

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Ca 10, PTH 50

This is still primary hyperPTH / PTH should be suppressed/

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which medication can mimick hyperPTH

Lithium

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PTH 325 Ca level 10

elderly frail; likely lack of vit D 0H25

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Tertiary hyperparathyroidism

ESRD with poor phosphorus binder compliance

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HIGH CALCIUM LOW PTH, HIGH1/22 VIT D DX

SARCOID

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WEIGHT LOST; LOW PTH, HIGH CA;

DIARRHEA

CHECK THYROID - HYPERTHYROIDISM

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low urine calcium; mild elevated calcium; PTH wnl, vit D wnl.; healthy person

FHCC

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TREATMENT OF HYPOCALCEMIA IN RHABDO?

released P is binded by calcium –> low calcium; do not replace as rhabdo stop you would have hypercalcemia

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vitamin D mediated hypercalcemia examples

sarcoid
any granulomatous disease
Lympho
Good paster

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jaundice and hyperalcemia

suspect vitamin A OD

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jaundice without eyes icterus

vitamin A

check for calcium

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confusion 
calcium 12
 PTH low 
D1/25 LOW 
high vitamin D 25OH over 150

HYPERVITAMINOSIS D
STORAGE TIME LONG
TRY STEROIDS

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which mechanism is MM causing hypercalceia

lytic release from bones

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high vitamin D 
low PTH 
low vitamin D 25OH,
low vitamin D 1/25
total protein elevated

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hypercalcemia with NL PTH
low vitamin D 1,25 and d25
mild elevated kappa chain in urin

ddx MGUS - with primary hyper PTH / PTH should be in this case suppressed /
MM would be much higher

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silicon implants and electrolyte abnormalities

hypercalcemia due to granulomatous mechanism
high D1/25
low pth
low D25OH
LEAKING SILICON - GRANULOMAS - MACROPHAGES CONVERTING 250H D TO 1-25D

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first two steps evaluation of hyponatremia

serum osmolarity

urine osmolarity

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true hyponatremia serum osmolarity

below 275

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second step to eval hyponatremia

urine osmolarity

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urine osmolarity over 100

urine omsolarity below 100

> 100 - ADH activated

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3d step of hyponatremia eval

urine sodium

Urine osmo over 100

urine sodium over 40

SIADH
thyroid
diuretics

URINE OSM 100 | URINE SODIUM BELOW 20

cirrhosis CHF hypovolemia

serum osmo <275 | urine osmo below 100

polydipsia | or solute

plasma osmolality

NA/ H2O

URINE Na < 20 ? RAAS?

RAAS is activated. Hypovolemia or kidney sense hypovolemia but edema / CHF, CIRRHOSIS/

``` Plasma osm 265 urine Sodium less then 13 urine chloride less then 14 Na 123 U osmo 700 ```

true hyponatremia if edema - cirrhosis, chf if no edema hypovolemia ADH is activated

``` Na 125 Plasma osmo 260 urine osmo 500 urine Sodium 44 urine Chloride 41 ```

edema --> CHF---> ON LASIX / URINE SODIUM HIGH/ THAT WHY NEED TO CHECK URINE CHLORINE

``` Na 120 serum osmo 260 urine osmo 500 urine sodium 12 urine chloride 12 ```

if no edema suspected dehydration | hypovolemic hyponatremia

disproportionally elevated urine Na compare to CL

ddx diuretics | or metabolic alkalosis - N/V

Na 120 plasma osmo 250 urine Na 100 urine Cl 90

IF NO HTN SIADH

HOW MUCH NEED TO DRINK HEALTHY PERSON OF WATER BEFORE BECOMING HYPONATRIEMIC?

DIET 800-900 osm per 24 hr / sodium, urea/ to excrete 1l of water you need 50 osmo you need to drink 18l of water with norma diet before you becoming hyponatriemic

how much can be urine dilute maximally in healthy person?

50 osmo

toast and coffee diet ---> sodium implication

- daily osmol intake 100 - if elderly can dilute urine max to 100 person can only excrete 1L so if intake of more then 1l of water result is hyponatremia

beer intake and sodium

- beer no sodium; if poor diet and only beer intake whole day let say intake of 150 osmo max can be excreted 3l after hyponatremia

Na 125 plasma osmo 250 urine osmo 60 urine sodium 12

possible psychogenic polydipsia or low solute / sodium intake / eg toast an tea diet

two cases of pseudohyponatriemia

hyperproteinemia eg MM OR TAG elevated eg pancreatitis and TAG 3000 OBGAIN ABG/ VBG SODIUM DO NOT TREAT

why hyperglycemia creating hyponatremia

shift free water from IC space

correction of Na for hyperglycemia

add 2 Na for each 100 glucose over 100 | anion gap use measured sodium

hctz effect on sodium

can last days of even weeks | dc and re-eval in 1week

``` what can look like SIADH 120 Na plasma osmo 262 urine osmo 340 urine Na 45 ```

RESET OSMOSTAT - IF YOU GIVE WATER YOU WILL NOT SEE ANY CHANGE IN SODIUM - SIADH IF GIVEN WATER SODIUM WILL DROP - CHRONIC MILD HYPONATREMIA

SIADH like picture with WBC up an Eo increased

Adrenal insufficiency | cosyntropin stim test

``` Na 123 seruem osmo 265 urine osmo 500 urine sodium 80 urine chloride 75 WBC up increased eosinophilia ```

adrenal insuficiency;

``` Na125 serum osmo 265 urine osmo 500 urine sodium 88 urine chloride 82 ```

SIADH | if smoking look for lung ca

SIADH TREATMENT

- fluid restriction - diuretics - salt tablets - urea tablets

NA vs urea

1000mg of NaCl is 17mmosm of Na 15gm of urea is 250mosm 30gm of urea is 500 roughly 18gm of NaCl urea comes from protein; a high protein diet will increase urea and help to excrete water with an improvement of sodium level SIADH lasix fluid restrict and sodium /urea/ tablets

``` SIADH Na122 serum osmo 255 urine osmo fixed 500 urine Na110 calculate fluid restriction ```

excretion can be done | 500mosm/500 per liter is 1 L with insenisble losses 1.5L

How to assist a patient on fluid restriction eg SIADH?

Add salt tablets or urea supplementation - if urine osmo is 500 patient can do 1L urine output so max is 1l fluid intake add on 2 doses of urea --> 250x 2 500 osm result is ability to excrete additional 1 L fluid intake can be 2L and insensible losses

Na 122 serum osm 265 urine osmo 600 urine sodium 90 step wise therapy

SIADH - fluid restriction - patient can excrete 1L of urine if taking low normal intake of solutes eg 600 - add lasix - dilute urine to 300 with same solute intakes fluid restriction can be 2l - add on urea or salt tablets and fluid restriction can be lifted up

SIADH urine sodium is greater then?

40 | / check if not on lasix; /

correction of hyponatremia of unknown acuity

MAX 8MOSM / 24HR if confusion do 3-5 in first few hours Na check q 2hr if overcorrection use D5/W

WHY hypovolemia is creating hyponatremia

increased ADH | correction of hypovolemia resulting to quick resolution of stimulus for ADH and sodium is corrected

cirrhosis mechanism in hyponatremia

vasodilation --> stimulation of RAAS AND ADH