감별 진단학9

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)