By Farahnak Assadi
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Extra resources for Clinical decisions in pediatric nephrology: a problem-solving approach to clinical cases
She is taking oxcabazepine for an anxiety disorder. Upon examination, she appears restless and confused and is complaining of significant pain in her right wrist. Temp is 37 ◦ C, pulse 115, respiratory rate 28. The chest is clear. There is no abdominal distention, tenderness, or guarding. There is no organomegaly. There is no edema. The neurological examination is within normal limits except for mild to moderate confusion. 5 mg/dl. 0 g/dl. 0 g/dl. Urinalysis shows trace protein, negative glucose, and no blood, RBC, or WBC.
Which of the following studies would you like to order at this time (select all that apply)? A. Serum cortisol concentration B. Diuretic screen concentration 1 Fluid and Electrolyte Disorders 41 C. Plasma aldosterone concentration D. Plasma aldosterone and renin activity E. Plasma magnesium concentration The correct answers are C and D. Because we are considering the causes of hypokalemia associated with metabolic alkalosis and hypertension, measurements of plasma aldosterone concentration and plasma renin activity are necessary to differentiate the various conditions.
This patient’s urine osmolality exceeded 500 mOsm/kg, demonstrating that desmopressin was effective enough to produce a high rate of free water absorption (high urine flow rate on post-operative days) that undoubtedly contributed to his hyponatremia. Diabetes insipidus did not appear to be a major factor in this patient’s decompensations. The etiology of a solute diuresis can be determined by measuring urine electrolyte concentrations. The sum of this patient’s urine sodium and chloride levels approximated his urine osmolality.