13th ANNUAL BOARD REVIEW

COURSE & UPDATE

******* ELECTROLYTE QUIZ *******
Biff F. Palmer, M.D.
and
Michael Emmett, MD
Question 1
A 64 year old female presented with the recent (2-3
months) onset of hypertension, diabetes mellitus, and for
the for the past two weeks had progressive weakness and
confusion. She had been in good health and held a
responsible position as an Arthur Anderson auditor.
Question 1 (continued)
Physical examination revealed the following: A confused
woman, BP: 165/105 mmHg, Afebrile, RR: 15/min; HEENT:
unrevealing but for brown discoloration of her forehead and
cheeks; Wheezing which cleared with coughing was noted;
Heart, Abdomen and Pelvic examinations were normal.
Neurological Examination: Although confused as to time
and place she had no localizing findings All four and place she had no localizing findings. All four
extremities revealed weakness (+1/+4).
Question 1 (continued)
Key Laboratory Observations included:
Electrolytes: Na 145 mM, K 1.7 mM, Cl 100 mM, Total CO2
30 mM.
BUN 25 mg%; Creatinine 1.2 mg%;
Glucose: 230 mg%; Plasma ACTH: 2,100 pg/ml;
24 Hour Urinary excretion of K: 150 mmols 24 Hour Urinary excretion of K: 150 mmols
Question 1-A: Which ONE of the
following diagnoses is the MOST
likely cause of this patients
syndrome?
a. Adenoma of the anterior pituitary gland (Cushings
Disease)
b Adenoma of the adrenal corte b. Adenoma of the adrenal cortex
c. Carcinoma of the adrenal cortex
d. Oat cell carcinoma of the lung
e. Surreptitious vomiting and volume contraction
Question 1-A: Which ONE of the
following diagnoses is the MOST
likely cause of this patients
syndrome?
a. Adenoma of the anterior pituitary gland (Cushings
Disease)
b Adenoma of the adrenal corte b. Adenoma of the adrenal cortex
c. Carcinoma of the adrenal cortex
d. Oat cell carcinoma of the lung *
e. Surreptitious vomiting and volume contraction
Question 1-B: Which ONE of the
following therapies would MOST
likely stop her kaliuresis?
a. Bilateral adrenalectomies
b. High dose ketoconazole
c Lisinopril c. Lisinopril
d. Trimethoprim
e. Amiloride
Question 1-B: Which ONE of the
following therapies would MOST
likely stop her kaliuresis?
a. Bilateral adrenalectomies
b. High dose ketoconazole
c Lisinopril c. Lisinopril
d. Trimethoprim
e. Amiloride *
Question 2
Two patients present with plasma Ks of 2.5 mEq/l. One of
the patients has hypokalemic periodic paralysis, while the
other has hypokalemia from vomiting.
Question 2: Which ONE of the following
statements is TRUE?
a. The patient with periodic paralysis is more
likely to be symptomatic because he has a
higher intracellular K concentration.
b. The patient with vomiting is more likely to be
t ti b f th i t t symptomatic because of the coexistent
metabolic alkalosis.
c. The patient with periodic paralysis is more
likely to be symptomatic because of coexistent
Na channel mutations.
d. Both are equally likely to be symptomatic.
Question 2: Which ONE of the following
statements is TRUE?
a. The patient with periodic
paralysis is more likely to be
symptomatic because he has a
higher intracellular K
concentration. *
b. The patient with vomiting is more likely to be symptomatic
because of the coexistent metabolic alkalosis.
c. The patient with periodic paralysis is more likely to be
symptomatic because of coexistent Na channel mutations.
d. Both are equally likely to be symptomatic.
Question 3: Which ONE of the following
therapeutic/diagnostic agents does NOT
cause hyperkalemia?
a. Lysine
b. Arginine
c Epsilon amino caproic acid c. Epsilon amino caproic acid
d. Meglumine
e. Tris Buffer (Tromethamine)
Question 3: Which ONE of the following
therapeutic/diagnostic agents does NOT
cause hyperkalemia?
a. Lysine
b. Arginine
c Epsilon amino caproic acid c. Epsilon amino caproic acid
d. Meglumine *
e. Tris Buffer (Tromethamine)
Question 4: A patient with diabetic
ketoacidosis presents with a serum K
concentration of 4 mEq/l. Which ONE of the
following statements is most likely TRUE?
a. This patient has normal K stores.
b. This patient has high potassium stores due to volume
contraction and the concomitant oliguria.
Th ti t h l t i t d t c. The patient has low potassium stores due to an
osmotic diuresis, but serum K is normal because K
losses are not large enough.
d. The patient has low potassium stores due to an
osmotic diuresis, but serum K is normal because K
shifts out of cells in response to the metabolic
acidosis.
e. The patient has low potassium stores due to an
osmotic diuresis, but serum K is normal because K
shifts out of cells in response to insulin deficiency.
Question 4: A patient with diabetic
ketoacidosis presents with a serum K
concentration of 4 mEq/l. Which ONE of the
following statements is most likely TRUE?
a. This patient has normal K stores.
b. This patient has high potassiumstores due to volume contraction and the
concomitant oliguria.
c. The patient has low potassiumstores due to an osmotic diuresis, but serum
K is normal because K losses are not large enough.
d. The patient has low potassiumstores due to an osmotic diuresis, but serum
K is normal because K shifts out of cells in response to the metabolic
acidosis.
e. The patient has low potassium
stores due to an osmotic diuresis,
but serum K is normal because K
shifts out of cells in response to
insulin deficiency. *
Question 5
J L is a 27 year old Caucasian male with stable renal failure
from chronic interstitial nephritis. His BUN, creatinine and
serum potassium have been measured daily for each of the
past five days and have all values have been 100 mg%, 10
mg% and 4.7 mM, respectively.
Question 5 (continued)
RL, his identical twin brother, has also had the same
chemical studies made on each of the past five days and
they have all been 10 mg%, 1.0 mg% and 4.7 mM,
respectively. Theyve been ingesting identical amounts of
an identical diet for the past five days. Their body weights
and muscle mass are identical. On day five both brothers
collected their urine for 24 hours collected their urine for 24 hours.
Question 5: Which ONE of the following
statements about the chemical
composition of their urine is CORRECT?
a. J L (CRF) excretes less potassium, creatinine and urea
than RL
b. J L (CRF) excretes the same amount of potassium but
less creatinine and urea than RL less creatinine and urea than RL
c. J L (CRF) and RL excrete equal amounts of potassium,
creatinine and urea
Question 5: Which ONE of the following
statements about the chemical
composition of their urine is CORRECT?
a. J L (CRF) excretes less potassium, creatinine and urea
than RL
b. J L (CRF) excretes the same amount of potassium but
less creatinine and urea than RL less creatinine and urea than RL
c. J L (CRF) and RL excrete equal
amounts of potassium,
creatinine and urea *
Question 6
A patient presents with a family history of hypertension
and hypokalemic alkalosis. He is found on work-up to
have low renin and aldosterone levels.
Question 6:All but ONE of the
following diagnoses could be
responsible for this patients disorder.
Select the INCORRECT diagnosis?
a. Liddles syndrome
b. Syndrome of Apparent Mineralocorticoid Excess y pp
c. Activating mutation of the mineralocorticoid receptor
d. Glycyrrhizinic acid
e. J uxtaglomerular Cell Tumors
Question 6:All but ONE of the
following diagnoses could be
responsible for this patients disorder.
Select the INCORRECT diagnosis?
a. Liddles syndrome
b. Syndrome of Apparent Mineralocorticoid Excess y pp
c. Activating mutation of the mineralocorticoid receptor
d. Glycyrrhizinic acid
e. J uxtaglomerular Cell Tumors *
Question 7: Which ONE of the following
statements regarding the therapy of a
paretic patient with thyrotoxic periodic
paralysis is TRUE?
a. Intravenous acetazolamide reliably reverses the
paresis.
b High dose propranolol should be begun immediately b. High dose propranolol should be begun immediately
after making the diagnosis.
c. Methimazole (Tapazole) reverses the symptoms and
signs within a few days.
d. After RAI administration other TPP therapies can be
stopped within 7 days.
e. When euthyroid, attacks often recur but are less severe
than when thyrotoxic.
Question 7: Which ONE of the following
statements regarding the therapy of a
paretic patient with thyrotoxic periodic
paralysis is TRUE?
a. Intravenous acetazolamide reliably reverses the paresis.
b. High dose propranolol should be g p p
begun immediately after making
the diagnosis. *
c. Methimazole (Tapazole) reverses the symptoms and signs within
a few days.
d. After RAI administration other TPP therapies can be stopped
within 7 days.
e. When euthyroid, attacks often recur but are less severe than when
thyrotoxic.
Question 8: A patient presents with a
family history of hypertension and
hypokalemic alkalosis. He has high renin
and aldosterone levels. Which ONE of the
following choices offers the MOST likely
diagnosis?
a. Familial renal artery stenosis
b. Gitelmans syndrome
c. Liddles syndrome
d. Pseudohypoaldosteronism type II
Question 8: A patient presents with a
family history of hypertension and
hypokalemic alkalosis. He has high renin
and aldosterone levels. Which ONE of the
following choices offers the MOST likely
diagnosis?
a. Familial renal artery stenosis *
b. Gitelmans syndrome
c. Liddles syndrome
d. Pseudohypoaldosteronism type II
Question 9: With regard to CHRONIC
SIADH, which ONE of the following
statements is TRUE?
a. If water intake is not carefully restricted, hyponatremia
will progressively worsen.
b. Knowing the amount of water retained allows for a
reasonably precise calculation of the serum Na
concentration.
c. Daily 24-hour urinary Na excretion generally exceeds
dietary salt intake.
d. Daily 24-hour urinary Na excretion generally is less
than dietary salt intake.
e. Despite chronic hypotonic hyponatremia, most SIADH
patients do not complain of diminished thirst.
Question 9: With regard to CHRONIC
SIADH, which ONE of the following
statements is TRUE?
a. If water intake is not carefully restricted, hyponatremia will progressively
worsen.
b. Knowing the amount of water retained allows for a reasonably precise
calculation of the serumNa concentration.
c. Daily 24-hour urinary Na excretion generally exceeds dietary salt intake.
d. Daily 24-hour urinary Na excretion generally is less than dietary salt
intake.
e. Despite chronic hypotonic
hyponatremia, most SIADH
patients do not complain of
diminished thirst. *
Question 10
A neurosurgeon asks for your advice regarding his patient
who underwent the removal of a craniopharyngioma five
days ago. The patient, a 42-year-old Caucasian male, is
doing well neurologically, has normal vital signs and is
receiving 0.6 mg of d-DAVP orally each day. Despite
intravenous 0.45% saline his serum sodium concentration
remains 150 mM His 24 hour urine volume is 5 5 L remains 150 mM. His 24-hour urine volume is 5.5 L
containing 80 mM Na and 40 mM K.
Question 10: Which ONE of the
following statements regarding this
patient is TRUE?
a. He has a complicating nephrogenic DI.
b. His resistance to d-DAVP requires that therapy with
aqueous pitressin be substituted.
c Circulating vasopressinase has inhibited the activity of c. Circulating vasopressinase has inhibited the activity of
the administered d-DAVP.
d. Hypothalamic damage has impaired ACTH secretion
causing polyuria.
e. He has a mixed polyuria.
Question 10: Which ONE of the
following statements regarding this
patient is TRUE?
a. He has a complicating nephrogenic DI.
b. His resistance to d-DAVP requires that therapy with
aqueous pitressin be substituted.
c Circulating vasopressinase has inhibited the activity of c. Circulating vasopressinase has inhibited the activity of
the administered d-DAVP.
d. Hypothalamic damage has impaired ACTH secretion
causing polyuria.
e. He has a mixed polyuria. *
Question 11
The first set of electrolytes from a chronic alcoholic who
complained of having the shakes,revealed the following.
Na: 140 mEq/L, K: 4.0 mEq/L; Cl: 105 mEq/L; CO
2
: 25
mEq/L. BUN and creatinine were normal. He then had a
grand mal seizure.
Question 11: Which ONE of the following
sets of electrolytes would be MOST typical
of the immediate post-seizure state?
a. Na: 140 mEq/L; K:5.4 mEq/L; Cl: 105 mEq/l; CO
2
: 15
mEq/L
b. Na: 140 mEq/L; K:4.0 mEq/L; Cl: 115 mEq/l; CO
2
: 15
mEq/L
c. Na: 145 mEq/L; K:4.0 mEq/L; Cl: 110 mEq/l; CO
2
: 15
mEq/L
d. Na: 135 mEq/L; K:4.0 mEq/L; Cl: 100 mEq/l; CO
2
: 15
mEq/L
Question 11: Which ONE of the following
sets of electrolytes would be MOST typical
of the immediate post-seizure state?
a. Na: 140 mEq/L; K:5.4 mEq/L; Cl: 105 mEq/l; CO
2
: 15
mEq/L
b. Na: 140 mEq/L; K:4.0 mEq/L; Cl: 115 mEq/l; CO
2
: 15
mEq/L
c. Na: 145 mEq/L; K:4.0 mEq/L; Cl:
110 mEq/l; CO
2
: 15 mEq/L *
d. Na: 135 mEq/L; K:4.0 mEq/L; Cl: 100 mEq/l; CO
2
: 15
mEq/L
Question 12
A 63 year old African American man with type II diabetes
mellitus and moderate renal insufficiency (BUN: 35 mg/dl;
creatinine: 3.0 mg/dl) developed lactic acidosis from
metformin. Six hours after the onset of the acidosis his
blood chemistries revealed: Electrolytes (mEq/L): Na: 138;
K: 5.0; Cl: 105; CO
2
: 14. Arterial Blood Gases (ABG):
pCO : 28 mmHg; HCO : 13 mEq/L; pH: 7 29 pCO
2
: 28 mmHg; HCO
3
: 13 mEq/L; pH: 7.29.
Question 12: If a lumbar puncture were
done immediately after the ABGs were
drawn, and the CSF pH, pCO
2
and HCO
3
were measured, which SET of CSF
acid-base parameters would MOST
typically be seen?
a. pH: 7.29; pCO
2
: 28 mmHg; HCO
3
: 13 mEq/L
b. pH: 7.40; pCO
2
: 40 mmHg; HCO
3
: 24 mEq/L
c. pH: 7.48; pCO
2
: 28 mmHg; HCO
3
: 21 mEq/L
Question 12: If a lumbar puncture were
done immediately after the ABGs were
drawn, and the CSF pH, pCO
2
and HCO
3
were measured, which SET of CSF
acid-base parameters would MOST
typically be seen?
a. pH: 7.29; pCO
2
: 28 mmHg; HCO
3
: 13 mEq/L
b. pH: 7.40; pCO
2
: 40 mmHg; HCO
3
: 24 mEq/L
c. pH: 7.48; pCO
2
: 28 mmHg;
HCO
3
: 21 mEq/L *
Question 13: All but ONE of the
following causes hyperkalemia.
Select the ONE exception.
a. amiloride
b. angiotensin converting enzyme inhibitors
c. pentamidine c. pentamidine
d. Heparin
e. Chloroquine
Question 13: All but ONE of the
following causes hyperkalemia.
Select the ONE exception.
a. amiloride
b. angiotensin converting enzyme inhibitors
c. pentamidine c. pentamidine
d. Heparin
e. Chloroquine *
Question 14
Following surgery for a craniopharyngioma, a 40 year old
Caucasian male developed polyuria, hypotonic urine and
hypernatremia. Pre-operatively, renal function and serum
electrolytes had been normal.
Question 14: Which SET of
postoperative orders would be BEST
for this patient?
a. Give parenteral d-DAVP if serum sodium
exceeds 145 mEq/L; infuse two liters of
normal saline daily. y
b. Give parenteral d-DAVP if urine volume
exceeds 200 ml/hour; infuse 1L of normal
saline and 1 liter of normal saline daily.
c. Stable daily dose of parenteral d-DAVP, modify
intravenous saline and water to maintain blood
pressure and serum sodium at 138-142 mEq/L.
Question 14: Which SET of
postoperative orders would be BEST
for this patient?
a. Give parenteral d-DAVP if serum sodium exceeds 145 mEq/L;
infuse two liters of normal saline daily.
b. Give parenteral d-DAVP if urine volume exceeds 200 ml/hour;
infuse 1L of normal saline and 1 liter of normal saline daily. y
c. Stable daily dose of parenteral d-
DAVP, modify intravenous saline
and water to maintain blood
pressure and serum sodium at
138-142 mEq/L. *
Question 15
Following head trauma from a motor vehicle accident, a 50
year old oriental male developed diabetes insipidus.
Following recovery he was discharged on effective doses
of nasal d-DAVP. He reports that over the ensuing 4-6
weeks he has become progressively weaker and is
occasionally made dizzy when he stands up. Control of his
polyuria and nocturia has required decreasing doses of d polyuria and nocturia has required decreasing doses of d-
DAVP.
Question 15: Which ONE of the
following choices BEST describes
this clinical picture?
a. Worsening hyponatremia
b. Advancing renal failure
c. Adrenal insufficiency
d. Hyperparathyroidism
Question 15: Which ONE of the
following choices BEST describes
this clinical picture?
a. Worsening hyponatremia
b. Advancing renal failure
c. Adrenal insufficiency *
d. Hyperparathyroidism
Question 16
A 43 year old Caucasian woman complains of
muscle weakness and "not feeling well". The
symptoms have worsened over the past one
month. Physical examination, including blood
pressure, is normal. Laboratory studies reveal:
SerumElectrolytes (mM): Na: 137 Serum Electrolytes (mM): Na: 137,
Cl: 107, K: 2.6, HCO
3
: 20
Random Urine Electrolytes (mM): Na: 30,
Cl: 65, K: 8
Question 16: Which ONE of the
following disorders is the MOST
likely cause of her hypokalemia?
a. Liddle's Syndrome
b. Barrter Syndrome
c Type I Distal R T A c. Type I Distal R.T.A.
d. Laxative abuse
Question 16: Which ONE of the
following disorders is the MOST
likely cause of her hypokalemia?
a. Liddle's Syndrome
b. Barrter Syndrome
c Type I Distal R T A c. Type I Distal R.T.A.
d. Laxative abuse *
Question 17
A 27 year old woman presents to her physician
complaining of fatigue and has the following
laboratory values:
Serum Electrolytes (mM): Na: 138,
Cl: 87, K: 3.1, HCO
3
: 35
Random Urine Electrolytes (mM): Na: 40,
Cl: 3, K: 37
Question 17: Which ONE of the
following disorders is the MOST likely
cause of these electrolyte
abnormalities?
a. Vomiting a. Vomiting
b. Barrter Syndrome
c. Distal (Type I) Renal Tubular Acidosis
d. Laxative abuse
Question 17: Which ONE of the
following disorders is the MOST likely
cause of these electrolyte
abnormalities?
a Vomiting * a. Vomiting
b. Barrter Syndrome
c. Distal (Type I) Renal Tubular Acidosis
d. Laxative abuse
Question 18: Which ONE of the
following disorders does NOT cause
K to shift out of cells?
a. Cell necrosis
b. Intravenous infusion of HCl
c Insulin deficiency c. Insulin deficiency
d. A less negative resting membrane potential
e. Hypercalcemia
Question 18: Which ONE of the
following disorders does NOT cause
K to shift out of cells?
a. Cell necrosis
b. Intravenous infusion of HCl
c Insulin deficiency c. Insulin deficiency
d. A less negative resting membrane potential
e. Hypercalcemia *
Question 19: The hyperkalemia
associated with trimethaprim therapy
is caused by which ONE of the
following abnormalities?
a. Low aldosterone levels
b Reduced distal Na delivery b. Reduced distal Na delivery
c. Increased GI absorption of K+
d. Inhibition of the Na channel in the cortical
collecting duct (CCD)
e. Faster reabsorption of Cl in the CCD
Question 19: The hyperkalemia
associated with trimethaprim therapy
is caused by which ONE of the
following abnormalities?
a. Low aldosterone levels
b Reduced distal Na delivery b. Reduced distal Na delivery
c. Increased GI absorption of K+
d. Inhibition of the Na channel in the
cortical collecting duct (CCD) *
e. Faster reabsorption of Cl in the CCD
Question 20: Which ONE of the following sets of
urine electrolytes would you MOST expect to find
in a patient with a contracted ECF volume due to
recent vomiting? The patient has alkaline urine,
and 'perfect" kidneys. (All values are in mmol/L).
[Na] urine [Cl] urine
a. 5 75
b. 75 5
c. 5 5
d. 75 75
Question 20: Which ONE of the following sets of
urine electrolytes would you MOST expect to find
in a patient with a contracted ECF volume due to
recent vomiting? The patient has alkaline urine,
and 'perfect" kidneys. (All values are in mmol/L).
[Na] urine [Cl] urine
a. 5 75
b. 75 5 *
c. 5 5
d. 75 75
Question 21: Which ONE of the following sets of
urine electrolytes would you MOST expect to find
in a patient with a contracted ECF volume due to
use of diuretics in the recent past? No diuretic
exposure has occurred for several days and the
patient has perfect kidneys? (All values are in
mmol/L).
[Na] urine [Cl] urine
a. 5 75
b. 75 5
c. 5 5
d. 75 75
Question 21: Which ONE of the following sets of
urine electrolytes would you MOST expect to find
in a patient with a contracted ECF volume due to
use of diuretics in the recent past? No diuretic
exposure has occurred for several days and the
patient has perfect kidneys? (All values are in
mmol/L).
[Na] urine [Cl] urine
a. 5 75
b. 75 5
c. 5 5 *
d. 75 75
Question 22: In an ESRD patient with the serum
electrolytes shown below, which ONE of the
following therapies (A-D) is typically
INEFFECTIVE in lowering the serum potassium
level?
Serum Electrolytes (mM): Na: 135, Cl: 99,
K: 7.5, HC0
3
: 21; BUN: 85 mg/dL K: 7.5, HC0
3
: 21; BUN: 85 mg/dL
Creatinine: 8.0 mg/dL
a. Insulin
b. Bicarbonate
c. Beta adrenergic agonists
d. Kayexalate
Question 22: In an ESRD patient with the serum
electrolytes shown below, which ONE of the
following therapies (A-D) is typically
INEFFECTIVE in lowering the serum potassium
level?
Serum Electrolytes (mM): Na: 135, Cl: 99,
K: 7.5, HC0
3
: 21; BUN: 85 mg/dL K: 7.5, HC0
3
: 21; BUN: 85 mg/dL
Creatinine: 8.0 mg/dL
a. Insulin
b. Bicarbonate *
c. Beta adrenergic agonists
d. Kayexalate
Question 23
A 22 year old pregnant, otherwise healthy Caucasian
female in her third trimester, has had the recent onset
of polyuria and polydipsia.
Relevant laboratory data include:
Serum Electrolytes (mM): Na: 150, Cl: 115,
K: 4.0, HCO
3
: 22
BUN (mg/dL): 8, Creatinine (mg/dL): 0.7
Urine Studies: Tot Vol: 4,500 ml/dy,
Uosm: 150mOsm/L, UNa: 20 mM mEq/L
Administration of intravenous aqueous pitressin
exerted no effect on the urine whereas d-DAVP
rapidly reduced urine volume and increased her
Uosm to >500 mOsm/L.
Question 23: Which ONE of the
following statements BEST explains
the cause of her syndrome?
a. Hypothalamic secretion of vasopressin is
subnormal.
b Circulating enzymes consumed secreted b. Circulating enzymes consumed secreted
vasopressin.
c. A renal tubular defect impairs responsivity to
vasopressin.
d. Excess circulating cortisol impairs end-organ
response to vasopressin.
Question 23: Which ONE of the
following statements BEST explains
the cause of her syndrome?
a. Hypothalamic secretion of vasopressin is
subnormal.
b Ci l ti d b. Circulating enzymes consumed
secreted vasopressin. *
c. A renal tubular defect impairs responsivity to
vasopressin.
d. Excess circulating cortisol impairs end-organ
response to vasopressin.
Question 24
A 65 year old African American man with angina
controlled with nitroglycerine, has been taking 50
mg hydrochlorothiazide (HCTZ) daily for his
hypertension. He is normotensive on therapy but
has had repeated serum K values ranging
between 3 0 and 3 4 mEq/L His E C G's reveal between 3.0 and 3.4 mEq/L. His E.C.Gs reveal
frequent premature atrial and ventricular beats.
Question 24: Indicate which ONE of
the following statements is FALSE
regarding the best treatment of this
man's mild hypokalemia.
a. Restriction of Na intake to 70-80 mEq/day will
reduce his kaliuresis.
b. Reduction of his dose of HCTZ from 50 to 25
mg/day may maintain blood pressure control and
reduce renal potassium wasting.
c. Supplementing his diet with 2 bananas and an
orange each day is likely to correct the
Hypokalemia.
d. Salt substitutes may be used as cheap sources of
KCl.
Question 24: Indicate which ONE of
the following statements is FALSE
regarding the best treatment of this
man's mild hypokalemia.
a. Restriction of Na intake to 70-80 mEq/day will reduce
his kaliuresis.
b R d ti f hi d f HCTZf b. Reduction of his dose of HCTZ from
50 to 25 mg/day may maintain blood
pressure control and reduce renal
potassium wasting. *
c. Supplementing his diet with 2 bananas and an orange
each day is likely to correct the Hypokalemia.
d. Salt substitutes may be used as cheap sources of KCl.
Question 25
A 42 year old black female asthmatic came to the
E.R. with the acute onset of S.O.B. and wheezing.
She has a 5 year history of hypertension well-
controlled with 50 mg daily of hydrochlorothiazide.
Therapy with aerosolized albuterol has improved
her wheezing however she has become her wheezing, however, she has become
progressively weaker and her D.T.R.s have
dramatically decreased.
Question 25 (continued)
Physical Examination: as above with BP: 120/85 mmHg.
Laboratory Studies on Admission:
Serum Electrolytes (mM): Na: 141, Cl: 103, K: 3.1,
HCO
3
: 32
Arterial Blood Gases: pCO
2
: 40mmHg, HCO
3
: 31 mM,
pH: 7.51
Laboratory Studies Two Hours Later:
Serum Electrolytes (mM): Na: 140, Cl: 102, K: 1.9,
HCO
3
: 29
Arterial Blood Gases: pCO
2
: 51mmHg, pH: 7.40,
HCO
3
: 31 mM
Question 25: Which ONE of the
following choices is the MOST likely
cause of her worsening hypercapnia?
a. She is developing status asthmaticus.
b. Pneumonia is superimposed on her asthmatic
tt k attack.
c. She has diffuse vasculitis affecting her lungs
and muscles.
d. The bronchodilator therapy.
Question 25: Which ONE of the
following choices is the MOST likely
cause of her worsening hypercapnia?
a. She is developing status asthmaticus.
b. Pneumonia is superimposed on her asthmatic
tt k attack.
c. She has diffuse vasculitis affecting her lungs
and muscles.
d. The bronchodilator therapy. *
Question 26: Which ONE of the following
findings would BEST distinguish between
the chronic hypokalemia of Gitelman's
syndrome (thiazide-like disease) and
Barrter's syndrome (furosemide-like
disease)?
a. Hypomagnesemia
b. Supernormal magnesium excretion
c. Urine osmolality of 900 mOsm/Kg H;0
d. Supernormal K excretion
e. Metabolic alkalosis
Question 26: Which ONE of the following
findings would BEST distinguish between
the chronic hypokalemia of Gitelman's
syndrome (thiazide-like disease) and
Barrter's syndrome (furosemide-like
disease)?
a Hypomagnesemia a. Hypomagnesemia
b. Supernormal magnesium excretion
c. Urine osmolality of 900
mOsm/Kg H;0 *
d. Supernormal K excretion
e. Metabolic alkalosis
Question 27
A 68 year old, homeless, hypertensive man with
arteriosclerotic heart disease was admitted for diuretic
therapy of CHF. He refused to eat or drink.
Physical Examination: BP: 155/95 mmHg, neck vein
distension, rales, +2 peripheral edema.
Therapy: Furosemide 40 mg BID Therapy: Furosemide 40 mg BID
Laboratory Studies:
Serum Electrolytes (mM): Na: 145, Cl: 108,
K: 4.0, HCO
3
: 25
BUN: 23mg/dL, Creatinine: 1.3mg/dL
Urine Values: Volume: 2L/24hr, Osm: 300mOsm/L,
Na: 50mEq/L, K: 20mEq/L
Question 27: While replacing lost K,
which ONE of the following regimens
would be BEST?
a. D5/NS: give 1 cc for each cc of urine
b. D5/1/2 NS: give 1 cc for each cc of urine
c. D5/1/2 NS: keep open IV. (250 cc/day)
d. D5W: give cc for each cc of urine
Question 27: While replacing lost K,
which ONE of the following regimens
would be BEST?
a. D5/NS: give 1 cc for each cc of urine
b. D5/1/2 NS: give 1 cc for each cc of urine
c. D5/1/2 NS: keep open IV. (250 cc/day)
d. D5W: give cc for each cc of
urine *
Question 28
A 16-year-old Caucasian male was treated for the 'flu' at
home. Despite improvement in his fever and cough,
worsening lethargy prompted his overbearing mother to
bring him to the E.R.
Physical Examination: Afebrile; 140/85 mmHg, disoriented,
no focal neurological findings.
Laboratory Studies:
Serum Electrolytes (mM): Na: 149, Cl: 112,
K: 3.9, HCO
3
: 26
BUN: 8mg%, Creatinine: 0.5mg%
Urine Studies: Tot Vol: 4L/dy, Na: 125 mM,
K: 20 mM, Osm: 320 mOsm/L
Question 28: Which ONE of the
following is the MOST likely cause of
his hypenatremia?
a. Complete diabetes insipidus
b. Partial diabetes insipidus
c. Osmotic diuresis
d. Under-replaced water loss from sweating
Question 28: Which ONE of the
following is the MOST likely cause of
his hypenatremia?
a. Complete diabetes insipidus
b. Partial diabetes insipidus
c. Osmotic diuresis
d. Under-replaced water loss from
sweating *
Question 29
A cachectic 40-kg, 52 year old Caucasian male
with an oat cell carcinoma of the lung is admitted
to the hospital for chemotherapy. He has received
1L of D5W and 1L of 0.9% saline daily for two
days. He has become progressively more
lethargic lethargic.
Question 29 (continued)
Serum Electrolytes (mM): Admission At 48 Hours
Na 130 112
K 3.4 3.2
Cl 95 82
HC0
3
24 23
Urine Electrolytes:
Na 40 300
K 30 20
Question 29: Which ONE of the
following contributed the MOST to his
worsening hyponatremia?
a. Worsening hypokalemia
b. Osmotic diuresis due to glucose
E ti f h t i l l f i c. Excretion of hypernatric, low volumes of urine
d. Hyperlipidemia
Question 29: Which ONE of the
following contributed the MOST to his
worsening hyponatremia?
a. Worsening hypokalemia
b. Osmotic diuresis due to glucose
c. Excretion of hypernatric, low
volumes of urine *
d. Hyperlipidemia
Question 30: With regard to the
above-described patient, at 48 hours,
which ONE of the following therapies
would have been MOST appropriate?
a. Lithium
b D l li b. Demeclocycline
c. Increased salt intake and oral thiazide diuretics
d. 3% saline and furosemide
Question 30: With regard to the
above-described patient, at 48 hours,
which ONE of the following therapies
would have been MOST appropriate?
a. Lithium
b D l li b. Demeclocycline
c. Increased salt intake and oral thiazide diuretics
d. 3% saline and furosemide *
Question 31: Indicate which ONE of
the pathophysiologic diagnoses (a-c)
BEST describes the following set of
electrolytes (mM):
Na: 140 mM; Cl: 105 mM; pCO
2
: 25 mmHg;
K: 3 8 mM; HCO : 15 mM; pH: 7 40 K: 3.8 mM; HCO
3
: 15 mM; pH: 7.40
a. Simple metabolic acidosis
b. Mixed acid-base disorder
c. Compensated metabolic acidosis
Question 31: Indicate which ONE of
the pathophysiologic diagnoses (a-c)
BEST describes the following set of
electrolytes (mM):
Na: 140 mM; Cl: 105 mM; pCO
2
: 25 mmHg;
K: 3 8 mM; HCO : 15 mM; pH: 7 40 K: 3.8 mM; HCO
3
: 15 mM; pH: 7.40
a. Simple metabolic acidosis
b. Mixed acid-base disorder *
c. Compensated metabolic acidosis
Question 32: Indicate which ONE of
the following findings is NOT caused
by acidosis.
a. Decreased ionized calcium
b. Leukocytosis y
c. Arteriolar vasodilatation
d. Increased alveolar ventilation
Question 32: Indicate which ONE of
the following findings is NOT caused
by acidosis.
a. Decreased ionized calcium *
b Leukocytosis b. Leukocytosis
c. Arteriolar vasodilatation
d. Increased alveolar ventilation
Question 33: Which ONE of the
following abnormalities INCREASES
renal bicarbonate excretion?
a. Hypercapnia
b. Extracellular fluid volume contraction
c. Hypokalemia
d. High circulating parathyroid hormone levels
Question 33: Which ONE of the
following abnormalities INCREASES
renal bicarbonate excretion?
a. Hypercapnia
b. Extracellular fluid volume contraction
c. Hypokalemia
d. High circulating parathyroid
hormone levels *
Question 34
A 60-year-old hypertensive took 120 mg of
furosemide daily while continuing to ingest 250
mEq/day of NaCl. He was admitted to the hospital
within hours of suffering a mid-brain stroke. His
blood pressure was 220/130 mmHg; respirations
were 40 per minute and deep He was afebrile were 40 per minute and deep. He was afebrile.
Papilledema was noted.
Question 34 (continued)
With control of his blood pressure his BUN and
creatinine progressively rose to 100 mg/dL and 8.5
mg/dL, respectively, and the remainder of his
studies revealed:
Serum Electrolytes (mM): Na: 144; Cl: 93;
K: 3.0; HCO
3
: 20
Arterial Blood Gases: pCO
2
: 20 mmHg;
pH: 7.62
Question 34: Which ONE of the
following choices BEST characterize
his acid-base status?
a. Simple acid-base disorder
b. Double acid-base disorder
c. Triple acid-base disorder
d. Quadruple acid-base disorder
Question 34: Which ONE of the
following choices BEST characterize
his acid-base status?
a. Simple acid-base disorder
b. Double acid-base disorder
c. Triple acid-base disorder *
d. Quadruple acid-base disorder
Question 35
You are called to see a 42-year-old Hispanic
woman who developed renal failure 4 days ago
following an I.V.P. She complained of worsening
back pain, progressive lethargy and was
moderately anemic. Vital signs were normal and
the physical examination was unrevealing the physical examination was unrevealing.
Serum Electrolytes (mM): Na: 135; Cl: 115;
K: 4.5; HCO3: 18
BUN: 85 mg/dL; Creatinine: 9 mg/dL
Question 35: Which ONE of the
following statements regarding her
disease is True and which is False?
a. Her type of renal failure is characterized by
RBC casts? True or False?
b. Her type of renal failure may cause a negative
urinary anion gap? True or False?
c. She has a hyperchloremic acidosis? True or
False?
Question 35: Which ONE of the
following statements regarding her
disease is True and which is False?
a. Her type of renal failure is characterized by
RBC casts - True or False?
b. Her type of renal failure may cause a negative
urinary anion gap - Trueor False?
c. She has a hyperchloremic acidosis - Trueor
False?
Question 35: Which ONE of the
following statements regarding her
disease is FALSE?
a. Her type of renal failure is characterized by
RBC casts.
b. Her type of renal failure may cause a negative
urinary anion gap.
c. She has a hyperchloremic acidosis.
Question 35: Which ONE of the
following statements regarding her
disease is FALSE?
a. Her type of renal failure is
characterized by RBC casts * characterized by RBC casts.
b. Her type of renal failure may cause a negative
urinary anion gap.
c. She has a hyperchloremic acidosis.
Question 36
A comatose 82-year-old Caucasian woman was
brought to the E.R. No history was available.
Temperature: 37 C; blood pressure: 130/80
mmHg; respiration: 30 per min.. Many ecchymoses
covered her body. No focal neurological signs
were noted were noted.
Serum Electrolytes (mM): Na: 140; Cl: 113;
K: 3.3; HCO3: 10
Arterial Blood Gases: pCO2: 16 mmHg;
pH: 7.42
Question 36: Which ONE of the
choices is NOT characteristically
associated with the electrolyte/ABG
pattern seen in this patient?
a. Cirrhosis, ascites and hypotension
b E d t i d t l f il b. Endotoxemia and acute renal failure
c. Salicylate toxicity
d. Proximal RTA
Question 36: Which ONE of the
choices is NOT characteristically
associated with the electrolyte/ABG
pattern seen in this patient?
a. Cirrhosis, ascites and hypotension
b E d t i d t l f il b. Endotoxemia and acute renal failure
c. Salicylate toxicity
d. Proximal RTA *
Question 37
A 65 year old man presents with the chief complaint
of progressive weakness over the last several months.
He is normotensive and his physical examination is
unremarkable.
Labs: Hematocrit 25%; WBC 5600; Plt 340K; Labs: Hematocrit 25%; WBC 5600; Plt 340K;
Na 135; Cl 105; K 3.0; HCO
3
18, creatinine 1.8;
BUN 22; glucose 110, pCO
2
28; pH 7.33
Urinalysis: trace protein, 1+glucose, normal sediment
24 hour urine protein 2.8 g/24h
Question 37: Which ONE of the
following is MOST characteristic of
the renal lesion present in this
patient?
a. Evidence of nephrocalcinosis on KUB of the
abdomen.
b. If bicarbonate therapy sufficient to normalize
the plasma HCO3 is suddenly stopped the
plasma HCO3 will rapidly fall to a value of 18.
c. Bicarbonate therapy will cause the serum K to
decline slightly due to a shift into cells.
d. The urine pH is likely to be alkaline.
Question 37: Which ONE of the
following is MOST characteristic of
the renal lesion present in this
patient?
a. Evidence of nephrocalcinosis on KUB of the abdomen.
b. If bicarbonate therapy sufficient to py
normalize the plasma HCO3 is
suddenly stopped the plasma HCO3
will rapidly fall to a value of 18. *
c. Bicarbonate therapy will cause the serum K to decline slightly due
to a shift into cells.
d. The urine pH is likely to be alkaline.
Question 38
A patient has the following laboratory tests:
Electrolytes (mM): Na 138; K 3.2; Cl 100;
Serum HCO
3
13;
pH 7.48; pCO
2
21 mmHg pH 7.48; pCO
2
21 mmHg
Question 38: Which ONE of the
following patients is MOST likely to
have these acid-base abnormalities?
a. A 2 year old child who has accidentally
swallowed an unknown quantity of his Mothers
aspirin. p
b. A 28 year old women with bulimia and vomiting.
c. A 35 year old man who has ingested a large
amount of aspirin in a suicide attempt.
d. A 50 year old women with surreptitious laxative
abuse.
Question 38: Which ONE of the
following patients is MOST likely to
have these acid-base abnormalities?
a. A 2 year old child who has accidentally swallowed an
unknown quantity of his Mothers aspirin.
b. A 28 year old women with bulimia and vomiting.
c. A 35 year old man who has
ingested a large amount of
aspirin in a suicide attempt. *
d. A 50 year old women with surreptitious laxative abuse.
Question 39
A 48 year old man with known HIV infection
presents to the emergency room with a three day
history of abdominal pain, nausea, vomiting, and
increasing confusion. He has a history of alcohol
abuse and his last drink was 36 hours ago. He is
also known to be diabetic His current medications also known to be diabetic. His current medications
include zidovudine, stavudine, and didanosine for
treatment of his HIV infection and metformin for
treatment of his diabetes. On PE he is acutely ill.
BP 110/70, pulse 98, RR 28, afebrile. The
abdomen is soft and has normoactive bowel
sounds.
Question 39 (continued)
Laboratory Studies:
WBC 12K, Hct 38 %, Platelets 280K,
Electrolytes (mM): Na 141, K 3.5, Cl 90, HCO
3
10;
Glucose 150mg%, BUN 16mg%, creatinine 1.3mg% Glucose 150mg%, BUN 16mg%, creatinine 1.3mg%
Arterial Blood Gases: pH 7.18, pCO
2
20 mmHg
Urinalysis: trace ketones, normal sediment
Question 39 (continued)
The patient is admitted to the hospital and given IV
fluids consisting of D5NS. Blood cultures are drawn
and broad spectrum antibiotics are given.
24 hours later laboratory examination shows:
Electrolytes (mM): Na 141, K 3.8, Cl 100, HCO
3
12,
Glucose 128mg%, BUN 16mg%, creatinine 1.2mg%
Arterial Blood Gases: pH 7.21, pCO
2
22 mmHg
Question 39: Which ONE of the
following is the MOST likely cause of
this patients acid-base disturbance?
a. Metformin-induced lactic acidosis
b Alcoholic ketoacidosis b. Alcoholic ketoacidosis
c. Lactic acidosis secondary to a seizure prior to
admission
d. Lactic acidosis secondary to stavudine
Question 39: Which ONE of the
following is the MOST likely cause of
this patients acid-base disturbance?
a. Metformin-induced lactic acidosis
b Alcoholic ketoacidosis b. Alcoholic ketoacidosis
c. Lactic acidosis secondary to a seizure prior to
admission
d. Lactic acidosis secondary to
stavudine *