Internal Medicine

0521779407-22 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:23

Vitiligo Volume Depletion and Edema 1543

➣decreased body weight, orthostatic change in blood pressure and

pulse, decreased skin turgor, flat neck veins, dry mucous mem-

branes

Edema

■clinical setting, history and physical usually can identify abnorma-

lity

➣congestive heart failure: dyspnea, orthopnea, paroxysmal noc-

turnal dyspnea

➣cirrhosis: history of chronic liver disease, ethanol abuse, hepatitis

BorC

➣nephrotic syndrome: diabetes

➣end-stage renal disease

■Signs & Symptoms

➣pitting edema, increased body weight, hypertension, distended

neck veins, S3 gallop, ascites, jaundice

tests

■hemodynamic monitoring

➣central venous pressure

➣pulmonary capillary wedge pressure

■blood tests

➣BUN/creatinine ratio >20 (normal ratio 10:1): low effective arte-

rial blood volume (EABV)

➣hemoconcentration of hematocrit and albumin: low EABV

➣increased serum uric acid concentration: low EABV

➣assess acid base status

normal gap metabolic acidosis: diarrhea

metabolic alkalosis: vomiting, diuretics (loop or thiazide)

■urinary tests

➣renal response to contracted EABV is to conserve sodium and

water

➣urine [Na] or [Cl] < 10–15 mEq/L is appropriate response to

extrarenal volume loss

➣fractional excretion of Na or Cl <.005-.01 is appropriate response

to extrarenal volume loss

FENa=(UNa×PCr)/(UCr×PNa) FECl=(UCl×PCr)/(UCr

×PCl)

➣special situations where either urine [Na] or [Cl] or FENa or FECl

are not reflective of existing volume depletion

increased [Na] and increased [Cl] or increased FENa and

increased FECl