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  <head>
    <title>018-01 Foundations</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Sodium, water, potassium, and volume regulation">
      <outline text="Content versus concentration">
        <outline text="Sodium content sets extracellular fluid volume"/>
        <outline text="Water relative to solute sets plasma sodium"/>
        <outline text="Volume depletion with any plasma sodium value"/>
        <outline text="Potassium shifts change plasma without content"/>
      </outline>
      <outline text="Compartments and tonicity">
        <outline text="Intracellular fluid holds most body water"/>
        <outline text="Extracellular fluid: plasma, interstitial, transcellular"/>
        <outline text="Sodium outside cells, potassium salts inside"/>
        <outline text="Sodium-potassium pump maintains the gradients"/>
        <outline text="Measured against calculated gives an osmolar gap"/>
        <outline text="Tonicity counts only the effective osmoles">
          <outline text="Urea adds osmolality, little sustained tonicity"/>
          <outline text="Hyperglycaemia draws water out, dilutes sodium"/>
        </outline>
      </outline>
      <outline text="Water balance and antidiuretic hormone">
        <outline text="Osmoreceptors drive thirst and hormone release"/>
        <outline text="Hormone raises collecting-duct water permeability"/>
        <outline text="Low effective volume stimulates through baroreceptors">
          <outline text="Volume defence can override osmotic regulation"/>
        </outline>
        <outline text="Dilute urine: suppression, filtration, diluting segments"/>
        <outline text="Concentrated urine: gradient and responsive ducts"/>
        <outline text="Available solute limits free-water excretion"/>
      </outline>
      <outline text="Hyponatraemia">
        <outline text="Excess water relative to exchangeable cations"/>
        <outline text="First ask whether it is hypotonic">
          <outline text="Hyperglycaemia gives hypertonic hyponatraemia"/>
          <outline text="Lipid or protein gives pseudohyponatraemia"/>
        </outline>
        <outline text="Hypovolaemic: gastrointestinal or renal sodium loss"/>
        <outline text="Euvolaemic: inappropriate hormone, deficiency, low solute"/>
        <outline text="Hypervolaemic: heart failure, cirrhosis, kidney, nephrotic"/>
        <outline text="Acute severe disease causes cerebral oedema"/>
        <outline text="Chronic adaptation reduces brain swelling">
          <outline text="Rapid correction risks osmotic demyelination"/>
        </outline>
        <outline text="Hypertonic saline with closely controlled correction"/>
      </outline>
      <outline text="Hypernatraemia">
        <outline text="Water deficit relative to body sodium"/>
        <outline text="Poor access, failed thirst, concentrating defect"/>
        <outline text="Gastrointestinal or skin loss, osmotic diuresis"/>
        <outline text="Risk with impairment, infancy, frailty, dependence"/>
        <outline text="Diabetes insipidus: deficient hormone or resistance"/>
        <outline text="Free water plus volume, ongoing loss, cause"/>
        <outline text="Chronic cases corrected gradually"/>
      </outline>
      <outline text="Effective circulating volume and oedema">
        <outline text="Body senses effective arterial filling"/>
        <outline text="Heart failure and cirrhosis: oedema with underfilling"/>
        <outline text="Sympathetic, aldosterone, hormone and thirst activate"/>
        <outline text="Retention worsens oedema and dilutional hyponatraemia"/>
        <outline text="No single volume sign is definitive"/>
        <outline text="Venous congestion itself reduces kidney function"/>
      </outline>
      <outline text="Potassium distribution and renal handling">
        <outline text="Most potassium resides inside cells"/>
        <outline text="Insulin and beta two stimulation drive uptake"/>
        <outline text="Acidosis shift depends on acid and transport"/>
        <outline text="Lysis, exercise, hyperosmolality, low insulin release it"/>
        <outline text="Distal secretion is the variable step">
          <outline text="Raised by aldosterone, potassium, delivery, flow"/>
          <outline text="Reduced by kidney failure or channel blockade"/>
        </outline>
      </outline>
      <outline text="Potassium disorders">
        <outline text="Hypokalaemia: loss, shift, or low intake">
          <outline text="Diuretics, mineralocorticoid excess, vomiting, diarrhoea"/>
          <outline text="Weakness, ileus, arrhythmia, concentrating defect"/>
          <outline text="Flat T waves, S T depression, U waves"/>
          <outline text="Magnesium deficiency makes correction difficult"/>
        </outline>
        <outline text="Hyperkalaemia: release, shift, retention, intake">
          <outline text="Haemolysed sample can mimic it"/>
          <outline text="Peaked T waves, P-wave loss, Q R S widening"/>
          <outline text="Danger without classic electrocardiographic change"/>
          <outline text="Calcium stabilises, insulin and glucose shift"/>
          <outline text="Kidneys, binders or dialysis remove potassium"/>
        </outline>
      </outline>
      <outline text="Calcium, magnesium, and phosphate">
        <outline text="Ionised calcium is the active fraction">
          <outline text="Alkalosis raises binding, lowers ionised calcium"/>
        </outline>
        <outline text="Hypocalcaemia: vitamin D, parathyroid, kidney, pancreatitis"/>
        <outline text="Hypercalcaemia: hyperparathyroidism or malignancy"/>
        <outline text="Magnesium depletion: gut loss, diuretics, alcohol">
          <outline text="Refractory hypokalaemia and torsades risk"/>
        </outline>
        <outline text="Phosphate depletion impairs energy and muscle">
          <outline text="Refeeding drives phosphate into cells"/>
        </outline>
      </outline>
      <outline text="Fluid prescription and monitoring">
        <outline text="Maintenance supplies expected needs"/>
        <outline text="Replacement matches abnormal ongoing losses"/>
        <outline text="Resuscitation addresses impaired perfusion"/>
        <outline text="Weight, balance, examination, laboratory, urine output"/>
        <outline text="A positive charted balance prompts examination"/>
      </outline>
    </outline>
  </body>
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