Question

1. A 66-year-old white male presents with a history of increasing shortness of breath over the last month. He noticed that his feet and ankles have been swellingby the end of the day. He also states he has been waking up in the middle of the night with acute shortness of breath and feels very tired most of the time.When you do a routine weight, he tells you that is 10 pounds heavier than his last hospitalization. He is ordered on a low salt diet and a fluid restriction of 1500 ml/24 hours.

What type of fluid imbalance might you suspect and why?

ANSWER: Hypernatremia because of the edema, lethargy, weight gain, and dyspnea.

He has a history of 2pack/day smoker for 40 years, coronary artery disease and type 2 diabetes. Family history: Father died at age 50 of an MI

                        Mother dies at age 82 with a history of hypertension, diabetes and a CVA

                        Brother has hypertension secondary to renal failure.

Labs are drawn and the results are:

Na = 130

K = 5.6

Cl =105

Mg =1.4

Ionized calcium =4

Glucose 155

HGb 16

HCT 30

BNP -natriuretic peptide 576 (normal is less than 100)

ABG’s   pH 7.40

            PaCO2  65

            Bicarb  32

            PaO2  80

O2 satuation  92%

What  electrolyte imbalances do you see?

ANSWERS:

Low: Na+, Mg++, HCT, PaO2, O2 saturation

High: K+, glucose, paCo2, bicarbonate

Identify a probable cause for each of the identified imbalances.

Hyponatremia is caused by renal problems, such as adrenal insufficiency, diuretic therapy, and more.  Hypomagnesemia is caused by renal failure, malnutrition, drugs such as diuretics, and many more.Hyperkalemia is caused by alkalosis, diuretic therapy, depletion of Na+, and more. Hypocalcemia is caused by hypomagnesemia, renal failure, and more.

In your assessment, what clinical manifestations do you expect to see with each of the imbalances you see.

ANSWERS: Hyponatremia: weakness, lethargy, muscle cramps, vomiting

Hyperkalemia: Muscle weakness, dizziness

Hypomagnesemia: Muscle cramps, Chvostek’s & Trousseau’s sign, hypertension, uncontrollable movements

Hypocalcemia: tetany, Chvostek’s & Trousseau’s sign, hypotension, seizure

Discuss what is happening with the pressures inside the body that support his edema (define hydrostatic pressure, osmotic pressure, oncotic pressure and tell the effect of each of these on his edema).

THIS IS WHAT I NEED HELP WITH.

Does he have an acid base imbalance, if so what type of imbalance, is it compensated, what might have caused the imbalance and what might you see to compensate for this imbalance?

Why is he on a restricted salt diet and restricted water intake?

What does his weight tell you?

Is there anything about his family history that is significant.

Answer 1

Hydrostatic pressure is defined as the pressure exerted by the fluid in the compartment.Capillary hydrostatic pressure increases the net filtration pressure while the interstitial fluid hydrostatic pressure decreases the net filtration pressure.

Oncotic pressure is defined as the pressure due to the presence of osmotically active particles.Plasma oncotic pressure decreases the net filtration pressure while that of the interstitium increases the filtration pressure.

Those factors which increase the filtration pressure contribute to edema.

PCO2 is 65 mm Hg (normal = 35-45 ) and HCO3- = 32 (Normal = 22-26)

But pH is normal (7.35-7.45).

So the patient had respiratory acidosis or metabolic alkalosis, which is compensated .Since he had patient has shortness of breath, he had respiratory acidosis,which is compensated by increase in HCO3-.

Restricted salt diet and restricted water intake reduce the hydrostatic pressure and hence decrease the edema.Restricted salt intake also decreases the risk of hypertension.

He is heavier now ,which will worsen the insulin resistance. Also there is obstructive sleep apnea due to the increased weight.

All the family members had cardiovascular problems.So he is at high risk for hypertension.