감별 진단학9
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감별 진단학
Fluid Compartments in the Body
Intracellular Fluid (ICF) comprises 2/3 of the body's water.The ICF is primarily a solution of potassium and organic anions, proteins
Extracellular Fluid (ECF) is the remaining 1/3 of your body's water.
The ECF is further subdivided into three subcompartments:
Interstitial Fluid (ISF) surrounds the cells, but does not
circulate.
Plasma circulates as the extracellular component of blood.
Transcellular fluid CSF, Digestive Juices, Mucus
fluid balance(x) → concentration of fluid (x)
balance of the solute(x)→ volume of fluid(x)
body water, extracellular fluid, osmotic pressure, Na
Hyponatremia
Hyponatremia is an electrolyte disturbance in which the
sodium concentration in the serum is lower than normal.
Normal serum sodium levels are between 135 and 145
mEq/L.
cause
Hypervolemic hyponatremia
cirrhosis ,
congestive heart failure,
nephrotic syndrome
Euvolemic hyponatremia
trauma or other damage to the brain ,
syndrome of inappropriate secretion of antidiuretic Hormone (SIADH) ,
Hypothyroidism ,
Glucocorticoid deficiency
Hypovolemic hyponatremia
prolonged vomiting,
decreased oral intake,
severe diarrhea ,
diuretic use
Clinical Symptoms
headache,
Nausea,
vomiting,
malaise,
lethargy,
seizures,
coma
diagnosis
plasma osmolality,
urine osmolality,
urine Na
275-299 milli-osmoles per kilogram,
50~1200 mOsmol/L,
Hypotonic hyponatremia (100mOsm/L)
Urine Na 20~200mEq/L
treatment
hypovolemiaintravenous administration of normal saline
Euvolemic fluid restriction
Hypervolemic hyponatremia
Hypervolemic hyponatremia should be treated by treating the underlying cause (e.g. heart failure, cirrhosis)
Vaptan drugs
Hypernatremia
Hypernatremia is an electrolyte disturbance that is defined by an elevated sodium level in the blood.
145 mEq/L
Clinical Symptoms
weakness,
neuromuscular irritability,
focal Nerve deficit,
lethargy,
seizures,
coma
cause
Hypovolemic
Excessive losses of water from the urinary tract,
Water losses associated with extreme sweating,
Severe watery diarrhea
Euvolemic
diabetes insipidus,
inadequate production of the hormone( vasopressin)
hypertonic fluid
Conn's syndrome ,
Cushing's disease
Treatment
Water can be replaced orally,
dextrose or saline infusion solutions
Hypokalemia
Hypokalemia or hypopotassemia
refers to the condition in which the concentration of potassium (K+) in the blood is low.
Normal serum potassium is 3.5 to 5.5 mEq/L
cause
Inadequate potassium intake,
Gastrointestinal/integument loss,
diarrhea,
excessive perspiration,
surgical procedures
Vomiting,
Urinary loss,
diuretics,
diabetic ketoacidosis ,
Conn's syndrome
HormonalInsulin , epinephrine, beta agonists
Signs and symptoms
muscular weakness,
myalgia,
muscle cramps ,
Constipation,
flaccid paralysis
electrocardiographic (ECG)
(1) K>6.5 mEq/L : peaked T
(2) K=7~8 mEq/L : prolonged PR, P wave loss, QRS widening
(3) K>7~8 mEq/L : ventricular fibrillation, cardiac standstill
Treatment
treating diarrhea (medication),
oral potassium chloride supplements,
green vegetables, tomatoes, oranges or bananas,
ventricular tachycardias (monitoring , medication)
acid-base equilibrium
Hydrogen ion 40 nmol / L
extracellular buffer system , respiratory compensa-tion ,
Intracellular buffer system , renal compensation
Acidemia, alkalemia : pH 7.35
Acidosis ,alkalosis : blood pH(x)
Treatment
metabolic acidosis:Alkalotherapy
metabolic alkalosis:acetazolamide ,aprepitant
hematuria
hematuria is the presence of red blood cells (ery-throcytes)
in the urine
cause
Kidney and bladder stones
Trauma (urinary tract or the prostate)
diagnosis
Microscopic examination: high-power field more than 2-5
Dipstick test
Proteinuria
The excess protein in the urine
150 mg a day of protein may be excreted by a nor-mal
person,
30 mg a day of Albumin may be excreted by a nor-mal
person
Causes
Renal disease ,
Diabetes ,
Dehydration,
low reabsorption at proximal tubule (Fanconi syn-drome)
urinary tract infection,
Congestive heart failure ,
Hypertension ,
Preeclampsia ,
Systemic lupus erythematosus
diagnosis
Evaluation of 24-hour urine ,: 30 mg/kg/24
Dipstick test
urinary stone
A kidney stone, also known as a renal calculus is a solid concretion or crystal aggregation formed in the kidneys from dietary minerals in the urine.
Urinary stones are typically classified by their location in the kidney (nephrolithiasis), ureter (ureterolithiasis), or bladder (cystolithiasis)
Symptoms
rib flank tenderness ,
renal colic,
nausea,
vomiting,
hematuria
lower ureteral calculi urinary frequency
Diagnosis
KUB test ,
urine tests,
intravenous pyelogram (IVP),
spiral computed tomography
Treatment
Buscopan ,
Demerol,
extracorporeal shock wave lithotripsy (ESWL),
Percutaneous Nephrolithotomy
acute renal failure
Glomerular filtration rate (GFR)↓
accumulation of Blood Urea Nitrogen and Creatinine
without ARF BUN
BUN ↑
Increase in production(BUN),
increase in protein intake,
Gastrointestinal bleeding
without ARF Cr
Cr ↑
Release from the increase in muscle,
Decrease in proximal tubular secretion
cause 1) Prerenal ARF
Reduction in intravascular fluid,
Bleeding,
gastrointestinal damage,
skin damage,
third-space,
cardiac diseases,
drug : antihypertensives , NSAIDs ,
Sepsis
2) Renal ARF
Embolism ,
glomerulonephritis,
Vasculitis,
Radiation,
Vasoconstriction: malignant hypertension, toxemia of pregnancy, scleroderma, hypercalcemia, drugs
Invasive disease:
lymphoma,
leukemia,
sarcoma
3) Postrenal ARF
Ureteral Obstruction,
Ureter in diseases: stones, blood clots
Ureter edema
Bladder neck obstruction ,
Bladder disease: stones, blood clots,
Other bladder diseases:prostate hypertrophy and prostate cancer
ARF vs CRF ddx.
Anemia,
hyperphosphatemia,
hypocalcemia,
Neuropathy,
band keratopathy,
renal osteodystrophy,
small scared kidney
Symptoms
thirst ,
postural hypotension,
tachycardia,
jugular venous pressure reduction,
reduced skin elasticity,
dry mucous membranes,
weight loss,
skin ulcers and rashes,
joint pain,
high blood pressure,
edema,
Nausea,
vomiting,
flank pain,
abdominal pain
Treatment
Saline 0.45%
antiarrhythmic
renal dose dopamine
high-dose IV diuretics
Corticosteroid
dialysis
ARF complications
a) excessive intravascular fluid
b) Hyperkalemia
c) metabolic acidosis d) hyperphosphatemia
E) Hypermagnesemia
F) Hypomagnesemia
G)Hypocalcemia
H) Anemia
Chronic Renal Failure
Chronic renal failure (CRF) is the progressive loss of kidney function.The kidneys attempt to compensate for renal dam-
age by hyperfiltration within the remaining functional
nephrons Over time, hyperfiltration causes further loss of
function.
Cause
Diabetic nephropathy,
Hypertensive nephrosclerosis,
Glomerulonephritis,
ischemic kidney,
Polycystic Kidney Disease,
Hereditary renal reflux,
Interstitial nephritis,
Renal transplant rejection
Clinical
1) Water and sodium metabolism disorders
2) Potassium Metabolic Disorders
3) metabolic acidosis
4) Hypertension 5) Neuromuscular disorders
6) Endocrinology and Metabolism: parathyroid func-tion, glucose tolerance , insulin Metabolism
7) Bone disease: overproduction of parathyroid hormone, vitamin D, metabolic disorders
exacerbation of chronic renal failure (Factors)
1)dehydration
2) congestive heart failure
3) Infection
4) urinary tract obstruction
5) NSAIDs or nephrotoxic drugs
6) severe hypertension
Treatment
Water and sodium restriction,
control of blood pressure,
protein intake restriction,
potassium limitation,
Calcium phosphorus intake , limitation
bicarbonate intake,
Limitation of nephrotoxicity Drugs,
treatment of anemia (supply iron folic acid)