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NephSAP Module 3 Fluid, Electrolytes, and Acid-Base Disturbaces Post toets

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1. A 47-yr-old man presents with new-onset as-cites. He has a significant history of heavy alcohol use during the past several years. His last drink was approximately 12 h ago. On physical examination, BP is 110/70 mmHg, pulse is 110, and respiratory rate is 28. Spider angiomas are noted on the skin. The abdomen shows shifting dullness, and there is 2[H11001] peripheral edema. Laboratory examination shows the following: Na[H11001] 130 mEq/L, K[H11001] 2.8 mEq/L, Cl[H11002] 90 mEq/L, HCO3 14 mEq/L, phosphate 3.5 mg/dl, calcium 6.5 mg/dl, and magnesium 1.6 mg/dl. Urine and serum ketones are positive. The patient is admitted and treated with thia-mine, folic acid, and multivitamins followed by maintenance fluids with D5% 1/2NS. Approximately 18 h after admission, the patient is restless and agitated and complains of severe weakness. The serum phosphate concentration is 0.9 mg/dl.

Which ONE of the following is TRUE regarding the change in serum phosphate in this patient?

A. On admission, total-body phosphate was likely normal.
B. Alcoholic ketoacidosis tends to cause a shift of phosphate into cells.
C. Respiratory alkalosis that develops in association with alcohol withdrawal shifts phosphate into cells.
D. The weakness is likely due to hypermagnesemia develo ping during the hospitalization.

2. A 38-yr-old man with a known history receives a diagnosis of chronic liver disease secondary to hepatitis C. He is treated with a 24-wk course of pegylated IFN-[H9251]-2a, combined with ribavirin. He tolerates the therapy without complications. Four weeks after completing treatment, he begins to complain of episodic weakness in the proximal limbs, particularly in the early-morning hours. He states that on one occasion, his weakness suddenly became worse immediately after completing a 30-min run on a treadmill. One day before admission, he developed sudden weakness after finishing his dessert at a workassociated banquet. He is on no medications. Physical examination reveals the following: BP 140/70 mmHg, pulse 120, and respiratory rate (RR) 18. There is no ophthalmopathy or lymphadenopathy. The thyroid gland is normal on palpation. He is noted to have severe symmetrical proximal weakness in the thighs (1/5) with intact distal muscle power. Laboratory examination reveals the following: White blood cell (WBC) count 7.8 mm3, Hg 13.5 gm/dl, Na 142 mEq/L, K 2.1 mEq/L, Cl 104 mEq/L, HCO3 23 mg/dl, creati-nine 1.0 mg/dl, and blood urea nitrogen (BUN) 15 mg/dl. Urine chemistries are as follows: Na 96 mEq/L, K 10 mEq/L, and Cl 110 mEq/L. The thyroid stimulating hormone is 0.1 [H9262]IU/ml.

Which ONE of the following statements is TRUE regarding the underlying cause of weakness in this patient?

A. This disorder tends to occur more frequently in women.
B. The patient should be immediately started on acetazolami de for treatment of the weakness.
C. Pegylated IFN was likely responsible for precipitating this disorder.
D. The serum magnesium is likely to be increased.
E. High K[H11001] intake is known to exacerbate this disorder.

3. A 68-yr-old man presents 2 wk after having undergone surgical treatment for a hip fracture. During the past 3 to 4 d, he has noticed abdominal distention and diarrhea. Physical examination shows decreased bowel sounds and a mildly tender abdomen but no rebound tenderness. Abdomen percussion is tympanitic. Imaging studies reveal a markedly dilated colon with no small intestine dilation. Laboratory findings show the following: Na 151 mEq/L, K 1.9 mEq/L, Cl 120 mEq/L, and HCO3 16 mEq/L. Despite the use of a rectal tube for drainage of stool and flatus, the patient continues to manifest colonic distention, and a diagnosis of colonic pseudo-obstruction is made. Over 8 wk, the patient's gastrointestinal manifestations resolve spontaneously.

Which ONE of the following findings is characteristic of the diarrhea found in patients with colonic pseudo-obstruction?

A. Secretory diarrhea as a result of inhibition of active intestinal absorption of NaCl
B. Secretory diarrhea as a result of active Cl[H11002] secretion followed by passive Na[H11001] secretion
C. Markedly increased stool osmotic gap
D. Secretory diarrhea as a result of active colonic K[H11001] secretion

4. A 58-yr-old man with type 2 diabetes and stage 3 chronic kidney disease receives a diagnosis of transitional cell carcinoma of the bladder. He has received chemotherapy and radiation therapy during the past year for treatment of this disorder. His clinical course has been complicated by the development of an enterocutaneous fistula. The surgical team now recommends that the patient undergo a radical cystectomy. Given the likelihood of extensive pelvic fibrosis and presence of the fistula, the surgeons are concerned that the procedure will be complicated. The surgeons inform the patient that a urinary diversion into the bowel will be performed, but the segment of bowel used can be determined only at the time of the procedure. Preoperative laboratory examination shows the following: Na 138 mEq/L, K 4.7 mEq/L, Cl 100 mEq/L, HCO3 22 mEq/L, and creatinine 1.8 mg/dl. The patient undergoes the procedure without complications. Repeat laboratory examination 7 d after the procedure shows the following values: Na 138 mEq/L, K 2.9 mEq/L, Cl 85 mEq/L. HCO3 36 mEq/L, pH 7.51, and creatinine 1.7 mg/dl.

On the basis of postoperative laboratory values, which ONE of the following segments of bowel did the surgeon use for the urinary diversion procedure?

A. Stomach
B. Jejunum
C. Ileum
D. Sigmoid colon

5. A 33-yr-old African American man with sickle cell disease presents with severe back pain typical of sickle cell crisis. His medical history is pertinent for frequent episodes of hemolytic crisis. The patient was not on diuretic therapy. Physical examination shows an anxious man in mild discomfort with BP of 156/94 mmHg, pulse 98, RR 22. There is scleral icterus. Lung examination shows basilar crackles, and he has hepatomegaly and trace peripheral edema. Laboratory examination shows hematocrit of 21%, reticulocyte count of 12%, and total bilirubin of 38 mg/dl. Chemistry studies reveal the following: Na 136 mEq/L, K 2.2 mEq/L, Cl 85 mEq/L, HCO3 29 mEq/L, and creatinine 0.6 mg/dl. Urine studies reveal the following: Na 63 mEq/L, K 49 mEq/L, Cl 58 mEq/L, plasma renin activity 1.1 ng/ml per h (3 to 9 ng/ml per h), and aldosterone 2 ng/dl (n [H11021] 10). The patient is treated with exchange transfusion and given K supplements to correct the hypokalemia. BP at the time of discharge is 118/78 Hg, and laboratory studies show a total bilirubin of 8 mg/dl and a serum potassium of 4.1 mEq/L off potassium supplements. Five months later, the patient is readmitted with a hemolytic crisis. BP is again noted to be increased at 158/98 mmHg. Laboratory examination shows a total bilirubin of 45 mg/dl. The serum potassium is 2.1 mEq/L. A transtubular K gradient at this time shows a value of 12. The serum aldosterone is 2.5 ng/dl.

Which ONE of the following is the BEST explanation for the recurrent hypokalemia in this patient?

A. Liddle syndrome
B. Shift of K into cells
C. Acquired deficiency of 11[H9252]-hydroxysteroid dehydrogenase II
D. Surreptitious loop diuretic use
E. Dexamethasone-suppressible hyperaldosteronism

6. A 45-yr-old man with ESRD presents to the emergency department with the chief complaint of palpitations and weakness. He has been stable on dialysis for 2 yr. He had an aortic valve replacement as a result of rheumatic aortic stenosis approximately 4 yr ago. Physical examination shows a pleasant, slightly anxious man in no acute distress. The BP is 100/65 mmHg, and the pulse is 180 bpm. An electrocardiogram shows atrioventricular nodal reentrant tachycardia. Laboratory examination shows the following: Na 136 mEq/L, K 8.2 mEq/L, Cl 100 mEq/L, HCO3 19 mEq/L, creatinine 12 mg/dl, BUN 68 mg/dl, hemoglobin 8.1 g/dl, lactate dehydrogenase 512 U/L (normal 100 to 190 U/L), and indirect bilirubin 4.5 mg/dl. Hyperkalemia has not been an issue for this patient before. His most recent Kt/V is 1.5. His diet is unchanged, and he has not missed any dialysis treatments.

Which ONE of the following is the BEST explanation for the hyperkalemia in this patient?

A. Recirculation in vascular access
B. Use of an angiotensin-converting enzyme inhibitor (ACEI)
C. Hemolysis as a result of shear stress across the prosthetic aortic valve
D. Disseminated intravascular coagulation secondary to methycillin-resistant Staphylococcus aureus
E. Occult hyperthyroidism

7. A cardiology colleague indicates that his patient has bilateral renal arterial disease demonstrated during a coronary angiogram. He has stable coronary disease after stent placements. BP control has been maintained at 130/80 mmHg with irbesartan, metoprolol, and furosemide. Medications also include clopidogrel, aspirin, atorvastatin, and isosorbide. Doppler velocities measured over the stenotic segments are as follows: Right, 150 cm/s; left, 200 cm/s; aortic velocity, 60 cm/s. Creatinine is 1.2 mg/dl; electrolytes and urinalysis are normal.

Which ONE of the following is TRUE regarding the risk for developing hyperkalemia in association with packed red blood cell trans-fusion?

A. Hyperkalemia risk is related to the number but not the rate of red blood cell transfusions.
B. Washing cells before transfusion increases hyperkalemia risk.
C. Increasing the amount of additive solution minimizes hyperkalemia risk.
D. Hyperkalemia risk is increased with use of irradiated blood.
E. Hyperkalemia risk is inversely related to the duration of blood storage.

8. A 14-yr-old boy was observed to collapse on a tennis court during a midmorning practice session. He was conscious and oriented but unable to move his arms or legs. He stated that his last meal was at 7:00 the night before. The weakness spontaneously resolved during the course of 2 h. His history was significant for several other episodes of intermittent weakness that all resolved within 30 to 45 minutes after onset. On several of these occasions, the weakness occurred after the ingestion of large quantities of orange juice. Physical examination reveals the following: BP 130/80 mmHg, pulse 86, RR 18, cranial nerves intact, and 1/5 strength in all major muscle groups. The sensory examination is normal. Laboratory values that were obtained 30 min after collapse reveal the following: Na 143 mEq/L, K 5.7 mEq/L, Cl 100 mEq/L, HCO3 22 mEq/L, and creatinine 0.9 mg/dl.

Which ONE the following statement is correct regarding treatment of the underlying disease in this patient?

A. The patient should be prescribed a [H9252] blocker to reduce the frequency of attacks.
B. ACEI therapy will decrease the frequency of attacks.
C. He should initiate exercise or eat a high-carbohydrate meal to abort attacks.
D. Albuterol inhaler is likely to worsen the acute weakness.

9. A 38-yr-old woman with a strong family history of cardiovascular diseases and hypertension recently received a diagnosis of essential hyper-tension. Her BP on three separate measurements averages 154/94 mmHg. Current medications include a daily multivitamin and birth control pills. The physical examination and laboratory examination are normal. Because the patient is using birth control pills, her primary care physician was comfortable prescribing lisinopril 10 mg/d. One month later, the patient returns for follow-up. BP is 142/88 mmHg. Laboratory examination shows the following: Na 140 mEq/L, K 5.5 mEq/L, Cl 100 mEq/L, HCO3 22 mEq/L, creatinine 0.8 mg/dl, and BUN 10 mg/dl. The physician refers the patient to a nephrologist for hyperkalemia evaluation.

Which ONE of the following is the MOST likely risk factor for hyperkalemia development after prescribing an ACEI for this patient?

A. High-grade bilateral renal artery stenosis
B. Pseudohypoaldosteronism type II
C. Acquired adrenal insufficiency
D. Mineralocorticoid-blocking activity in birth control pill
E. Daily ingestion of bananas