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  1. #1
    tommyk is offline USMLE Advisor
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    Hy 2086 Super Duper Question (Electrolyte Physio Question)

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    Hy 2086 Super Duper Question (Electrolyte Physio Question)
    A 68-year-old woman named Claire Danes presents with an obviously incarcerated umbilical hernia. She has gross abdominal distention, is clinically dehydrated, and reports persistent fecaloid vomiting for the past 3 days. Although tired, weak, and thirsty, she is awake and alert and her sensorium is not particularly affected. Lab analysis reveals a serum sodium concentration of 108 mEq/L. Which of the following is the most likely physiologic explanation for the serum sodium? (LOW SODIUM QUESTIONS ARE SO HARD CAUSE THE DIFFERENTIAL IS ENDLESS)
    1-Water intoxication
    2-Medicine related low sodium
    3-She has vomited sodium-containing fluids, and has retained endogenous and ingested water.
    4-ADH secreting neoplasm not yet identified.
    5-Aldosterone secreting adrenal tumor
    6-Renal tubule failure
    7- Her diminished sense of thirst, especially when physical infirmity limits independent access to food and drink due to her age.
    8-Hypothyroid induced hyponatremia
    9-Excessive IV boluses given by intern
    10-Cortisol deficiency
    11-Nephrotic syndrome
    12-Lab error
    (PLEASE LOOK AT ALL THE CHOICES, YOU LIKELY WILL GET A QUESTION INVOLVING HYPONATREMIA. ALL ARE VERY POSSIBLE HERE).















































    a) Answer is choice #3....Gastrointestinal tract fluids have a sodium concentration very close to that of plasma; as they are lost (internally or externally), they should be replaced with isotonic, sodium-containing fluids. But that is not what patients typically do at home. Thirsty and unable to eat solid (sodium-containing) foods, they drink water, cola, and tea, fluids without significant amounts of sodium, which the body avidly retains because of the severe volume depletion. Endogenous water from catabolic activity is also retained. Dilutional hyponatremia eventually develops! SOOO TRICKY! SOOOOO Step1
    "All USMLE cases are original and are expressly not from questions seen, recalled, paraphraphrased from the real USMLE, the material is for the purpose of the education of future physicians and the safety of their patients."

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  2. #2
    IMG SURVIVOR's Avatar
    IMG SURVIVOR is offline Moderator 536 points
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    but tommy If you are in pain your body will secrete a lot of ADH that will not be also the answer??
    Moderator: USMLE AND Residency Forums.

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    why even bother with the obvious. Just know where you are need it and where you can help the most.

  3. #3
    manleyjb's Avatar
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    Quote Originally Posted by IMG SURVIVOR
    but tommy If you are in pain your body will secrete a lot of ADH that will not be also the answer??
    If you have alot of ADH, you will be retaining sodium, not losing it....Right?

  4. #4
    IMG SURVIVOR's Avatar
    IMG SURVIVOR is offline Moderator 536 points
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    Tommy or any body else please in put your opinion

    Quote Originally Posted by manleyjb
    If you have alot of ADH, you will be retaining sodium, not losing it....Right?
    DEAR MANLEY

    ADH will absorb only water and because of that your urine will be concentrated, but in our body you will suffer something call hyponatremia dilutional because of the excesive water you have been retaining.
    Moderator: USMLE AND Residency Forums.

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    why even bother with the obvious. Just know where you are need it and where you can help the most.

  5. #5
    usmlethinking is offline Junior Member 510 points
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    Quote Originally Posted by IMG SURVIVOR
    but tommy If you are in pain your body will secrete a lot of ADH that will not be also the answer??
    If she has a lot of ADH such as in SIADH then clinically she would show edema. This patient is dry and dehydrated. SIADH is part of the hypervolemic hyponatremia. This patient shows signs of hypovolemic hyponatremia and excessive fluid loss, especially GI, is supportive of this physiology.
    Last edited by usmlethinking; 03-21-2006 at 11:53 PM.

  6. #6
    tommyk is offline USMLE Advisor
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    Well done again usmlething. You are Johns Hopkins bound!

    Well done again usmlething. You are Johns Hopkins bound!

    Tommy
    "All USMLE cases are original and are expressly not from questions seen, recalled, paraphraphrased from the real USMLE, the material is for the purpose of the education of future physicians and the safety of their patients."

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  7. #7
    usmlethinking is offline Junior Member 510 points
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    Quote Originally Posted by tommyk
    Well done again usmlething. You are Johns Hopkins bound!

    Tommy
    Thanks for your compliment but I just got accepted into Skipper's Medical Univeristy of the Dutch West Indies Internal Medicine Residency Program.
    Last edited by usmlethinking; 03-23-2006 at 06:00 PM.

  8. #8
    manleyjb's Avatar
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    Quote Originally Posted by usmlethinking
    If she has a lot of ADH such as in SIADH then clinically she would show edema. This patient is dry and dehydrated. SIADH is part of the hypervolemic hyponatremia. This patient shows signs of hypovolemic hyponatremia and excessive fluid loss, especially GI, is supportive of this physiology.
    I agree as well. Thanks for the help.

  9. #9
    tommyk is offline USMLE Advisor
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    Excellent quality of thinking my friends..

    Excellent quality of thinking my friends..
    "All USMLE cases are original and are expressly not from questions seen, recalled, paraphraphrased from the real USMLE, the material is for the purpose of the education of future physicians and the safety of their patients."

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  10. #10
    tommyk is offline USMLE Advisor
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    I just have to add this for your understand.

    First of all, I need a few of you to pray for me because I caught my first cold of 2006! I mean, WHY ON EARTH do they keep the temperature so cold in the ORs??? I know it has stuff to do with the surgeon and his clothes and his "tense" mood causing him/her to be hot and also the microbial stuff, but still!

    Hy 2095 Directly related to Hy 2086 Super Question

    Ahhh….Hyponatremia….But the astute future medical doctors of ValueMD KNEW there was a difference between HYPOvolemic Hyponatremia and HYPERvolemic Hyponatremia. So, please tell me, if you have a patient with Congestive Heart Failure OR Nephrotic Syndrome, which type will you see (think first), and what is the treatment?














    a) I am SOOOOOOOOOOOOO glad someone pointed out this key fact that ADDS to our UNDERSTANDING of hyponatremia. Listen, the case I gave before was hypovolemic hyponatremia. But in the case of CHF or kidney disease, think of HYPERvolemic hyponatremia (think about why)…. Also, think as you see your future patients who would likely have which? For eg. A DIABETIC will have more likely have the hypovolemic hyponatremia. Same with a Marathon runner just jogging into your office. So, the tx/drug for HYPERvolemic hyponatremia is “restrict salt, restrict water” with possible diuretic augmentation.
    "All USMLE cases are original and are expressly not from questions seen, recalled, paraphraphrased from the real USMLE, the material is for the purpose of the education of future physicians and the safety of their patients."

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