docnikki
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A 40-year-old woman is brought to the emergency department with complaints of severe weakness, back pain, and anorexia for the past three days. She has a history of a well-controlled connective tissue disease. Physical examination is remarkable for dry oral mucosa and decreased muscular strength, symmetrically. She has a history of coronary artery disease and does not know which medications she takes. The following lab values are obtained:
White cell count 14,000/mm3; hematocrit 36%; sodium 134 mEq/L; potassium 3.0 mEq/L; chloride mEq/L 118; bicarbonate 15 mEq/L; BUN 42 mg/dL; creatinine 1.9 mg/dL; glucose 100 mg/dL.
Arterial blood gas on room air -- pH 7.30; PCO2 29 mm/Hg; HCO3- 12 mm Hg; PO2 70 mm Hg.
Urinalysis -- specific gravity 1.030; pH 6.5; protein 1+; red cells 10-20/hpf.
Which of the following would be the most appropriate test?
(A) Urine electrolytes
(B) Spiral CT scan of abdomen
(C) Urine osmolarity
(D) Serum osmolarity
([font size="2"]E) Fludrocortisone stimulation test[/font]
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| sprint123
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looks like a picture of addison's disease...Is it E?
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| doc_clotaire
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I agree that it could be Addison but ................
Is that the name of the test Fludrocortisone stimulation test ? I remember from step 2 that it was COSYNTROPIN STIMULATION TEST or ACTH STIMULATION TEST but fludrocortisone is actually a corticosteroid analogue and is the treatment
I don t know man , this question is very confusing . Either I got them mixed up or it s probably the same thing
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The elevator to succes is broke ,you must take the stairs
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| sprint123
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Hey clotaire...same confusion here...... ..Hey nikki, good question!
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| doc_clotaire
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May be it s B ...............to look for adrenal enlargement  . That s the only one that could fit better here .
Wao Nikki , you are killing us here 
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The elevator to succes is broke ,you must take the stairs
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| farnsworth
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E: fludricortison test to rule out renal tubular acidosis type I (if the urine pH drops below 5.3, RTA I is ruled out)
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| dr.wad
Forum Senior
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( A )
this is not addison disease ....
in addison there is hyperkalemia . , but the pt has the opposite .
this case straight foreword to renal tubular acidosis.
many connective diseases can cause RTA.
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| docnikki
Forum Guru
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hmm none of you got it right!
Its C...
This patient has type I (classic distal) renal tubular acidosis (RTA). The presence of a normal anion gap, metabolic acidosis with hypokalemia, and elevated urinary pH suggests this etiology. Although urine electrolytes could be used to calculate a urinary anion gap, an elevated gap would not distinguish between the types of RTA. Also, a normal gap would be helpful to distinguish gastrointestinal bicarbonate loss from RTA types I, II, and IV. Type I RTA has an alkaline urinary pH, which is not seen in any of the other conditions. A spiral CT scan may be helpful to evaluate for nephrolithiasis and nephrocalcinosis in this patient. In general, patients with type I RTA often have associated hypercalciuria, nephrocalcinosis, and stone formation because of the high urinary pH. A fludrocortisone stimulation test would be helpful in type IV RTA
Is it clear in the explaination why its C osmolarity?..to me its not. 
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| hope4dabest
Forum Elite
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I was thinking in terms of pre-renal failure but pre-renal could be due to addison's and then potassium should be high in that case
and urine is also alkaline in RTA type 2....
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