{"id":37029,"date":"2026-06-11T20:40:38","date_gmt":"2026-06-11T15:10:38","guid":{"rendered":"https:\/\/atsixty.com\/?p=37029"},"modified":"2026-06-11T20:44:30","modified_gmt":"2026-06-11T15:14:30","slug":"electrolytes-the-renal-lens","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/morning-rounds\/electrolytes-the-renal-lens\/","title":{"rendered":"Electrolytes: The Renal Lens"},"content":{"rendered":"\n\n\n\n\nMorning Rounds \u00b7 Electrolytes \u2014 The Renal Lens<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&display=swap\" rel=\"stylesheet\">\n<style>\n#nep05 *,#nep05 *::before,#nep05 *::after{box-sizing:border-box;margin:0;padding:0}\n#nep05{\n --nep:#2A5470;--nep-light:#3A7499;--nep-pale:#EBF3F8;--nep-dark:#1C3D52;\n --correct:#2D6B47;--correct-bg:#EAF6EF;--correct-border:#3A9960;\n 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.mr-retry:hover{background:var(--nep);color:#F0F7FC}\n@media(max-width:480px){#nep05 .mr-title{font-size:1.4rem}#nep05 .mr-num{font-size:1.7rem}#nep05 .mr-stem{font-size:0.9rem}#nep05 .mr-opt-text{font-size:0.86rem}}\n<\/style>\n\n<!-- Hyponatraemia diagnostic algorithm for Q1 debrief -->\n<div id=\"nep05-img1\" style=\"display:none\">\n <figure class=\"mr-img-wrap\">\n <svg viewBox=\"0 0 540 195\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" style=\"width:100%;max-width:540px;display:block;margin:0 auto\">\n <rect x=\"0\" y=\"0\" width=\"540\" height=\"195\" rx=\"8\" fill=\"#f0f6fa\"\/>\n <text x=\"270\" y=\"15\" text-anchor=\"middle\" fill=\"#1A2C38\" font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Hyponatraemia \u2014 Diagnostic Framework<\/text>\n <!-- Step 1: Osmolality -->\n <rect x=\"185\" y=\"20\" width=\"170\" height=\"24\" rx=\"4\" fill=\"#2A5470\"\/>\n <text x=\"270\" y=\"35\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"8.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Serum Osmolality<\/text>\n <!-- Branches -->\n <line x1=\"185\" y1=\"44\" x2=\"80\" y2=\"66\" stroke=\"#2A5470\" stroke-width=\"1.2\"\/>\n <line x1=\"270\" y1=\"44\" x2=\"270\" y2=\"66\" stroke=\"#2A5470\" stroke-width=\"1.2\"\/>\n <line x1=\"355\" y1=\"44\" x2=\"460\" y2=\"66\" stroke=\"#2A5470\" stroke-width=\"1.2\"\/>\n <!-- High -->\n <rect x=\"20\" y=\"66\" width=\"118\" height=\"22\" rx=\"3\" fill=\"#fdf0f0\"\/>\n <text x=\"79\" y=\"80\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">High (>290): Hyperglycaemia<\/text>\n <!-- Normal -->\n <rect x=\"185\" y=\"66\" width=\"170\" height=\"22\" rx=\"3\" fill=\"#fff5e0\"\/>\n <text x=\"270\" y=\"78\" text-anchor=\"middle\" fill=\"#7a5000\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Normal (280\u2013290): Pseudohyponatraemia<\/text>\n <text x=\"270\" y=\"87\" text-anchor=\"middle\" fill=\"#7a5000\" font-size=\"7\" font-family=\"Georgia,serif\">(hyperlipidaemia, hyperproteinaemia)<\/text>\n <!-- Low -->\n <rect x=\"403\" y=\"66\" width=\"118\" height=\"22\" rx=\"3\" fill=\"#eaf6ef\"\/>\n <text x=\"462\" y=\"80\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Low (<280): True hyponatraemia<\/text>\n <!-- Step 2: Volume status -->\n <line x1=\"462\" y1=\"88\" x2=\"462\" y2=\"106\" stroke=\"#2D6B47\" stroke-width=\"1.2\"\/>\n <rect x=\"375\" y=\"106\" width=\"174\" height=\"20\" rx=\"3\" fill=\"#2A5470\"\/>\n <text x=\"462\" y=\"119\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Assess volume status + urine Na<\/text>\n <!-- Three volume states -->\n <line x1=\"400\" y1=\"126\" x2=\"330\" y2=\"144\" stroke=\"#2A5470\" stroke-width=\"1.2\"\/>\n <line x1=\"462\" y1=\"126\" x2=\"462\" y2=\"144\" stroke=\"#2A5470\" stroke-width=\"1.2\"\/>\n <line x1=\"524\" y1=\"126\" x2=\"524\" y2=\"144\" stroke=\"#2A5470\" stroke-width=\"1.2\"\/>\n <!-- Hypovolaemic -->\n <rect x=\"268\" y=\"144\" width=\"126\" height=\"44\" rx=\"3\" fill=\"#d4e8f4\"\/>\n <text x=\"331\" y=\"156\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Hypovolaemic<\/text>\n <text x=\"331\" y=\"167\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">U-Na <20: GI\/skin loss<\/text>\n <text x=\"331\" y=\"178\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">U-Na >20: diuretics, RTA<\/text>\n <text x=\"331\" y=\"188\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Adrenal insufficiency<\/text>\n <!-- Euvolaemic -->\n <rect x=\"400\" y=\"144\" width=\"124\" height=\"44\" rx=\"3\" fill=\"#e8f3f9\"\/>\n <text x=\"462\" y=\"156\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Euvolaemic<\/text>\n <text x=\"462\" y=\"167\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">SIADH (U-Na >40,<\/text>\n <text x=\"462\" y=\"178\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">U-Osm >100)<\/text>\n <text x=\"462\" y=\"188\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Hypothyroid, polydipsia<\/text>\n <!-- Hypervolaemic -->\n <rect x=\"464\" y=\"144\" width=\"68\" height=\"44\" rx=\"3\" fill=\"#fdf0f0\"\/>\n <text x=\"498\" y=\"156\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Hypervolaemic<\/text>\n <text x=\"498\" y=\"167\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">CCF, cirrhosis,<\/text>\n <text x=\"498\" y=\"178\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">nephrotic<\/text>\n <text x=\"498\" y=\"188\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">U-Na <20<\/text>\n <!-- Note -->\n <text x=\"150\" y=\"160\" text-anchor=\"middle\" fill=\"#3d5a6a\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Correction rate:<\/text>\n <text x=\"150\" y=\"172\" text-anchor=\"middle\" fill=\"#3d5a6a\" font-size=\"7\" font-family=\"Georgia,serif\">Chronic: ≤8 mEq\/L\/day<\/text>\n <text x=\"150\" y=\"183\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7\" font-family=\"Georgia,serif\" font-weight=\"bold\">ODS risk if over-corrected<\/text>\n <\/svg>\n <figcaption>\n Hyponatraemia workup begins with serum osmolality to exclude pseudo- and hypertonic causes. True hyponatraemia (low osmolality) is then classified by volume status and urine sodium. SIADH is the commonest euvolaemic cause. The correction rate ceiling of 8 mEq\/L\/day prevents osmotic demyelination syndrome (ODS).\n <\/figcaption>\n <\/figure>\n<\/div>\n\n<!-- Hyperkalaemia ECG changes for Q3 debrief -->\n<div id=\"nep05-img3\" style=\"display:none\">\n <figure class=\"mr-img-wrap\">\n <svg viewBox=\"0 0 520 120\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" style=\"width:100%;max-width:520px;display:block;margin:0 auto\">\n <rect x=\"0\" y=\"0\" width=\"520\" height=\"120\" rx=\"8\" fill=\"#f0f6fa\"\/>\n <text x=\"260\" y=\"14\" text-anchor=\"middle\" fill=\"#1A2C38\" font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Hyperkalaemia \u2014 Progressive ECG Changes<\/text>\n <!-- Stages -->\n <rect x=\"10\" y=\"20\" width=\"95\" height=\"88\" rx=\"4\" fill=\"#eaf6ef\"\/>\n <rect x=\"112\" y=\"20\" width=\"95\" height=\"88\" rx=\"4\" fill=\"#e8f3f9\"\/>\n <rect x=\"214\" y=\"20\" width=\"95\" height=\"88\" rx=\"4\" fill=\"#fff5e0\"\/>\n <rect x=\"316\" y=\"20\" width=\"95\" height=\"88\" rx=\"4\" fill=\"#fde8d0\"\/>\n <rect x=\"418\" y=\"20\" width=\"92\" height=\"88\" rx=\"4\" fill=\"#fdf0f0\"\/>\n <!-- Labels -->\n <text x=\"57\" y=\"34\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">K 5.5\u20136.0<\/text>\n <text x=\"159\" y=\"34\" text-anchor=\"middle\" fill=\"#2A5470\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">K 6.0\u20136.5<\/text>\n <text x=\"261\" y=\"34\" text-anchor=\"middle\" fill=\"#7a5000\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">K 6.5\u20137.0<\/text>\n <text x=\"363\" y=\"34\" text-anchor=\"middle\" fill=\"#a04010\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">K 7.0\u20138.0<\/text>\n <text x=\"464\" y=\"34\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">K > 8.0<\/text>\n <!-- Changes -->\n <text x=\"57\" y=\"52\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Peaked T-waves<\/text>\n <text x=\"57\" y=\"64\" text-anchor=\"middle\" fill=\"#3d5a6a\" font-size=\"7\" font-family=\"Georgia,serif\">(tall, narrow,<\/text>\n <text x=\"57\" y=\"74\" text-anchor=\"middle\" fill=\"#3d5a6a\" font-size=\"7\" font-family=\"Georgia,serif\">symmetric)<\/text>\n <text x=\"57\" y=\"86\" text-anchor=\"middle\" fill=\"#3d5a6a\" font-size=\"7\" font-family=\"Georgia,serif\">EARLIEST sign<\/text>\n\n <text x=\"159\" y=\"52\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">PR prolongation<\/text>\n <text x=\"159\" y=\"64\" text-anchor=\"middle\" fill=\"#3d5a6a\" font-size=\"7\" font-family=\"Georgia,serif\">P-wave flattening<\/text>\n <text x=\"159\" y=\"76\" text-anchor=\"middle\" fill=\"#3d5a6a\" font-size=\"7\" font-family=\"Georgia,serif\">QRS widening<\/text>\n <text x=\"159\" y=\"88\" text-anchor=\"middle\" fill=\"#3d5a6a\" font-size=\"7\" font-family=\"Georgia,serif\">begins<\/text>\n\n <text x=\"261\" y=\"52\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Wide QRS<\/text>\n <text x=\"261\" y=\"64\" text-anchor=\"middle\" fill=\"#3d5a6a\" font-size=\"7\" font-family=\"Georgia,serif\">Absent P-waves<\/text>\n <text x=\"261\" y=\"76\" text-anchor=\"middle\" fill=\"#3d5a6a\" font-size=\"7\" font-family=\"Georgia,serif\">Sine-wave<\/text>\n <text x=\"261\" y=\"88\" text-anchor=\"middle\" fill=\"#3d5a6a\" font-size=\"7\" font-family=\"Georgia,serif\">pattern emerging<\/text>\n\n <text x=\"363\" y=\"52\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Sine-wave<\/text>\n <text x=\"363\" y=\"64\" text-anchor=\"middle\" fill=\"#3d5a6a\" font-size=\"7\" font-family=\"Georgia,serif\">QRS merges<\/text>\n <text x=\"363\" y=\"76\" text-anchor=\"middle\" fill=\"#3d5a6a\" font-size=\"7\" font-family=\"Georgia,serif\">with T-wave<\/text>\n <text x=\"363\" y=\"88\" text-anchor=\"middle\" fill=\"#a04010\" font-size=\"7\" font-family=\"Georgia,serif\" font-weight=\"bold\">Imminent VF<\/text>\n\n <text x=\"464\" y=\"52\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">VF \/ Asystole<\/text>\n <text x=\"464\" y=\"64\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7\" font-family=\"Georgia,serif\">Cardiac arrest<\/text>\n <text x=\"464\" y=\"78\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7\" font-family=\"Georgia,serif\" font-weight=\"bold\">IV Ca-gluconate<\/text>\n <text x=\"464\" y=\"89\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7\" font-family=\"Georgia,serif\">stabilises membrane<\/text>\n <text x=\"464\" y=\"100\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7\" font-family=\"Georgia,serif\">within minutes<\/text>\n <\/svg>\n <figcaption>\n ECG changes in hyperkalaemia progress with rising K\u207a. Peaked T-waves are the earliest finding. Calcium gluconate is membrane-stabilising (onset 1\u20133 min) and must be given first when ECG changes are present \u2014 it does not lower potassium. Definitive K\u207a lowering requires insulin-glucose, salbutamol, or dialysis.\n <\/figcaption>\n <\/figure>\n<\/div>\n\n<div id=\"nep05\">\n <div class=\"mr-header\">\n <div class=\"mr-eyebrow\">Morning Rounds \u00b7 Nephrology Series \u00b7 Round 05<\/div>\n <div class=\"mr-title\">Electrolytes<br><em>The Renal Lens<\/em><\/div>\n <div class=\"mr-subtitle\">Five cases · Read carefully · Trust your instinct<\/div>\n <div class=\"mr-chips\">\n <span class=\"mr-chip\">5 Cases<\/span>\n <span class=\"mr-chip\">+4 \/ −1 scoring<\/span>\n <span class=\"mr-chip\">Options reshuffled<\/span>\n <\/div>\n <\/div>\n\n <div class=\"mr-sentinel\" id=\"nep05-sentinel\"><\/div>\n <div class=\"mr-progress\" id=\"nep05-progress\">\n <div class=\"mr-prog-inner\"><div class=\"mr-pips\" id=\"nep05-pips\"><\/div><\/div>\n <\/div>\n\n <div class=\"mr-body\">\n <div id=\"nep05-cases\"><\/div>\n <div class=\"mr-submit-wrap\">\n <button class=\"mr-btn\" id=\"nep05-submit\">Submit for Debrief<\/button>\n <\/div>\n <div class=\"mr-score\" id=\"nep05-score\">\n <div class=\"mr-score-in\">\n <div class=\"mr-score-ey\">Round Complete<\/div>\n <div class=\"mr-ring\" id=\"nep05-ring\">\n <div class=\"mr-ring-in\">\n <span class=\"mr-ring-pct\" id=\"nep05-pct\">0%<\/span>\n <span class=\"mr-ring-sub\">net<\/span>\n <\/div>\n <\/div>\n <div class=\"mr-score-title\">Your Debrief<\/div>\n <div class=\"mr-score-net\" id=\"nep05-net\"><\/div>\n <div class=\"mr-verdict\" id=\"nep05-verdict\"><\/div>\n <div class=\"mr-bands\">\n <span class=\"mr-band mr-band-c\" id=\"nep05-ct-c\"><\/span>\n <span class=\"mr-band mr-band-w\" id=\"nep05-ct-w\"><\/span>\n <span class=\"mr-band mr-band-s\" id=\"nep05-ct-s\"><\/span>\n <\/div>\n <button class=\"mr-retry\" id=\"nep05-retry\">↻ New Round<\/button>\n <\/div>\n <\/div>\n <\/div>\n<\/div>\n\n<script>\n(function(){\n 'use strict';\n var NS='nep05',TOTAL=5,MAX=20,LTRS=['A','B','C','D'];\n\n var QS=[\n {\n id:1,\n tag:'Electrolytes — SIADH vs Hypovolaemic Hyponatraemia',\n stem:'A <strong>68-year-old man<\/strong> is admitted with nausea and confusion. Serum sodium <strong>118 mEq\/L<\/strong>. Serum osmolality <strong>248 mOsm\/kg<\/strong>. He has no oedema, normal skin turgor, and JVP is not elevated. Urine sodium <strong>54 mEq\/L<\/strong>, urine osmolality <strong>620 mOsm\/kg<\/strong>. He is on sertraline. Thyroid and cortisol are normal. What is the diagnosis and the most critical treatment principle?',\n correct:'SIADH (euvolaemic hyponatraemia); fluid restriction is first-line; correct at ≤8 mEq\/L\/day to avoid ODS',\n opts:[\n 'SIADH (euvolaemic hyponatraemia); fluid restriction is first-line; correct at ≤8 mEq\/L\/day to avoid ODS',\n 'Hypovolaemic hyponatraemia from vomiting; give IV normal saline rapidly',\n 'Hypervolaemic hyponatraemia from occult cardiac failure; give furosemide',\n 'Pseudohyponatraemia from hypertriglyceridaemia; no treatment required'\n ],\n exp:'<strong>SIADH diagnostic criteria<\/strong>: (1) true hypoosmolar hyponatraemia, (2) urine osmolality >100 mOsm\/kg (here 620 \u2014 inappropriately concentrated), (3) urine Na >40 mEq\/L (here 54 \u2014 kidneys cannot dilute urine), (4) clinically <em>euvolaemic<\/em>, (5) normal thyroid and adrenal function. <strong>SSRIs<\/strong> (sertraline) are a classic cause. The hallmark is that the kidney is retaining water under inappropriate ADH drive despite normal or expanded volume. <strong>Treatment<\/strong>: fluid restriction (800\u20131000 mL\/day) is first-line. Hypertonic saline (3% NaCl) is reserved for symptomatic\/severe hyponatraemia (seizures, coma). The <strong>correction rate ceiling is 8 mEq\/L in 24 hours<\/strong> (some guidelines say 10\u201312 mEq\/L). Overcorrection causes <strong>osmotic demyelination syndrome (ODS)<\/strong> \u2014 central pontine myelinolysis \u2014 with locked-in state, dysarthria, spastic quadriplegia. Risk is highest in chronic hyponatraemia, alcoholism, malnutrition, hypokalaemia.',\n imgId:'nep05-img1'\n },\n {\n id:2,\n tag:'Electrolytes — Hypernatraemia',\n stem:'A <strong>78-year-old woman<\/strong> in a nursing home is found confused and lethargic. She has been febrile for 3 days and has not been drinking. Serum sodium <strong>162 mEq\/L<\/strong>, serum osmolality <strong>338 mOsm\/kg<\/strong>, urine osmolality <strong>810 mOsm\/kg<\/strong>, creatinine mildly elevated. She has no diabetes insipidus history. What is the primary cause and the correct fluid for replacement?',\n correct:'Hypovolaemic hypernatraemia from insensible losses and inadequate intake; replace with hypotonic fluid (0.45% saline or 5% dextrose) slowly',\n opts:[\n 'Hypovolaemic hypernatraemia from insensible losses and inadequate intake; replace with hypotonic fluid (0.45% saline or 5% dextrose) slowly',\n 'Central DI; give IV desmopressin immediately and replace with free water',\n 'Hypervolaemic hypernatraemia from iatrogenic sodium loading; give furosemide + free water',\n 'Replace with isotonic saline rapidly; speed of correction does not matter in hypernatraemia'\n ],\n exp:'<strong>Hypernatraemia<\/strong> always means a deficit of free water relative to sodium. The high urine osmolality (810) confirms the kidneys are concentrating maximally \u2014 this is <em>not<\/em> DI (DI would give dilute urine). This is <strong>pure water loss<\/strong> from fever, insensible losses, and inability to access water (elderly, nursing home). <strong>Treatment<\/strong>: replace the free water deficit. Formula: <strong>Water deficit = 0.6 × weight × [(Na\/140) − 1]<\/strong>. Use <strong>hypotonic fluid<\/strong> \u2014 0.45% saline or 5% dextrose. <strong>Correct slowly<\/strong>: no faster than <strong>0.5 mEq\/L\/hour<\/strong> or 10\u201312 mEq\/L\/day. Rapid correction of hypernatraemia causes cerebral oedema \u2014 the brain has generated idiogenic osmoles to maintain cell volume, and sudden osmotic gradient reversal causes water influx. Isotonic saline would worsen hypernatraemia.',\n imgId:null\n },\n {\n id:3,\n tag:'Electrolytes — Hyperkalaemia Management',\n stem:'A <strong>55-year-old man<\/strong> with CKD G4 and diabetes presents with weakness. ECG shows <strong>peaked T-waves and a widened QRS (140 ms)<\/strong>. Serum K⁺ is <strong>7.4 mEq\/L<\/strong>. He is haemodynamically stable. In the correct sequence of management, what is the <em>first<\/em> intervention and why?',\n correct:'IV calcium gluconate 10% \u2014 membrane stabilisation; it does not lower potassium but protects the myocardium within 1\u20133 minutes',\n opts:[\n 'IV calcium gluconate 10% \u2014 membrane stabilisation; it does not lower potassium but protects the myocardium within 1\u20133 minutes',\n 'IV insulin + dextrose \u2014 shifts K⁺ intracellularly; this is the fastest definitive treatment',\n 'Salbutamol nebulisation \u2014 beta-2 stimulation drives K⁺ into cells rapidly',\n 'Emergency haemodialysis \u2014 removes potassium definitively and should be the first step'\n ],\n exp:'Management of severe hyperkalaemia with ECG changes follows a strict sequence: <strong>C-B-D-E-R<\/strong> \u2014 Calcium, Bicarbonate (if acidotic), Dextrose-Insulin, Excretion (resonium\/loop diuretic), Renal replacement. <strong>Step 1 \u2014 Calcium gluconate (or chloride)<\/strong>: does not lower K⁺ but <em>antagonises<\/em> the membrane-depolarising effect, raising the threshold for cardiac excitability. Onset <strong>1\u20133 minutes<\/strong>, duration 30\u201360 min. Essential when QRS is widened \u2014 buys time. <strong>Step 2 \u2014 Insulin-dextrose<\/strong>: 10 units actrapid + 50 mL 50% dextrose IV; shifts K⁺ intracellularly within 15\u201330 min, lowers K by 0.5\u20131.5 mEq\/L. <strong>Step 3 \u2014 Salbutamol<\/strong>: 10\u201320 mg nebulised; additive to insulin. <strong>Step 4 \u2014 Resonium \/ patiromer \/ sodium zirconium cyclosilicate<\/strong>: removes K from the body (slower, hours\u2013days). <strong>Dialysis<\/strong>: when medical management fails or in anuric patients.',\n imgId:'nep05-img3'\n },\n {\n id:4,\n tag:'Electrolytes — Hypokalemia & the Kidney',\n stem:'A <strong>40-year-old woman<\/strong> is found to have serum K⁺ <strong>2.6 mEq\/L<\/strong> on a routine check. She is on <strong>no medications<\/strong> and denies vomiting or diarrhoea. BP is <strong>158\/96 mmHg<\/strong>. Serum bicarbonate 28 mEq\/L. Urine potassium-to-creatinine ratio (UK:UCr) is <strong>elevated<\/strong> at 42 mEq\/g. Plasma renin is <strong>suppressed<\/strong> and aldosterone is <strong>elevated<\/strong>. What is the most likely diagnosis?',\n correct:'Primary hyperaldosteronism (Conn syndrome); adrenal CT + aldosterone:renin ratio for confirmation',\n opts:[\n 'Primary hyperaldosteronism (Conn syndrome); adrenal CT + aldosterone:renin ratio for confirmation',\n 'Renovascular hypertension (renal artery stenosis); high renin drives aldosterone',\n 'Gitelman syndrome; hypomagnesaemia and hypocalciuria would confirm',\n 'Diuretic abuse; urine K:Cr would be low if diuretics had been recently stopped'\n ],\n exp:'The combination of <strong>hypertension + hypokalaemia + metabolic alkalosis + renal K wasting (elevated UK:UCr)<\/strong> points to excess mineralocorticoid activity. The key differentiator: <strong>suppressed renin + elevated aldosterone = primary hyperaldosteronism<\/strong> (Conn syndrome \u2014 autonomous adrenal aldosterone excess, independent of the RAAS). If renin were <em>high<\/em>, secondary hyperaldosteronism from renovascular disease (renal artery stenosis) would be the diagnosis. Gitelman has <em>normal<\/em> BP and low magnesium. <strong>Conn syndrome workup<\/strong>: (1) aldosterone:renin ratio (ARR) >30 with aldosterone >15 ng\/dL is highly suggestive; (2) confirmatory test \u2014 oral sodium loading or fludrocortisone suppression; (3) adrenal CT \u00b1 adrenal vein sampling (AVS) to distinguish adenoma from bilateral hyperplasia. Treatment: unilateral adenoma (adrenalectomy); bilateral hyperplasia (spironolactone or eplerenone).',\n imgId:null\n },\n {\n id:5,\n tag:'Electrolytes — Metabolic Alkalosis',\n stem:'A <strong>32-year-old woman<\/strong> presents with muscle cramps and tetany. She has been using <strong>large quantities of antacids<\/strong> for heartburn. ABG: pH 7.54, pCO₂ 48 mmHg (appropriate compensation), HCO₃⁻ <strong>38 mEq\/L<\/strong>. Serum Cl <strong>88 mEq\/L<\/strong> (low). Urine chloride <strong>8 mEq\/L<\/strong>. What is the type of metabolic alkalosis and why does urine chloride matter here?',\n correct:'Chloride-responsive metabolic alkalosis (saline-responsive); low urine Cl <20 indicates chloride depletion \u2014 treat with IV normal saline',\n opts:[\n 'Chloride-responsive metabolic alkalosis (saline-responsive); low urine Cl <20 indicates chloride depletion \u2014 treat with IV normal saline',\n 'Chloride-resistant alkalosis from primary hyperaldosteronism; saline will not correct it',\n 'Respiratory alkalosis with metabolic compensation; pCO₂ rise confirms this is primary respiratory',\n 'Mixed alkalosis; treat with acetazolamide to lower HCO₃⁻ directly'\n ],\n exp:'Metabolic alkalosis is classified by <strong>urine chloride<\/strong> \u2014 a more reliable marker than urine sodium in this context. <strong>Urine Cl <20 mEq\/L = chloride-responsive (saline-responsive)<\/strong>: chloride depletion is maintaining the alkalosis because HCO₃⁻ is retained to compensate for the anion gap. Causes: vomiting, nasogastric suction, antacid excess (NaHCO₃ load), loop\/thiazide diuretics (post-diuretic state). Treatment: <strong>IV normal saline<\/strong> replenishes Cl⁻, allowing renal HCO₃⁻ excretion. <strong>Urine Cl >20 mEq\/L = chloride-resistant<\/strong>: excess mineralocorticoid activity (primary hyperaldosteronism, Cushing) is maintaining K⁺ loss and H⁺ secretion \u2014 saline will not correct it; treat the underlying cause. The tetany here is from <strong>hypocalcaemia<\/strong> \u2014 alkalosis increases protein binding of calcium, reducing ionised calcium. Correction formula for respiratory compensation in metabolic alkalosis: expected pCO₂ = 0.7 × HCO₃⁻ + 21 (±2); here 0.7×38+21 = 47.6 — the measured 48 fits perfectly, confirming pure metabolic alkalosis.',\n imgId:null\n }\n ];\n\n var answers={},answered=0,shuffled={},done=false;\n function byId(id){return document.getElementById(id);}\n function gid(s){return byId(NS+'-'+s);}\n function shuffleArr(arr){var a=arr.slice(),i,j,tmp;for(i=a.length-1;i>0;i--){j=Math.floor(Math.random()*(i+1));tmp=a[i];a[i]=a[j];a[j]=tmp;}return a;}\n function countVal(val){var k,n=0;for(k in answers){if(answers.hasOwnProperty(k)&&answers[k]===val)n++;}return n;}\n function buildPips(){\n var cont=gid('pips'),i,q,wLine,wPip,line,pip;cont.innerHTML='';\n for(i=0;i<QS.length;i++){\n q=QS[i];\n if(i>0){wLine=document.createElement('div');wLine.className='mr-pip-wrap';line=document.createElement('div');line.className='mr-pip-line';line.id=NS+'-pl'+q.id;wLine.appendChild(line);cont.appendChild(wLine);}\n wPip=document.createElement('div');wPip.className='mr-pip-wrap';pip=document.createElement('div');pip.className='mr-pip';pip.id=NS+'-pip'+q.id;pip.textContent=String(q.id);wPip.appendChild(pip);cont.appendChild(wPip);\n }\n }\n function build(){\n var cont,i,q,opts,card,top,numDiv,meta,tag,stem,rule,optsDiv,expDiv,lbl,txt,imgDiv,imgSrc,j,optEl,ltrSpan,txtSpan;\n cont=gid('cases');cont.innerHTML='';answers={};answered=0;shuffled={};done=false;gid('score').style.display='none';buildPips();\n for(i=0;i<QS.length;i++){\n q=QS[i];opts=shuffleArr(q.opts);shuffled[q.id]=opts;\n card=document.createElement('div');card.className='mr-case';\n top=document.createElement('div');top.className='mr-case-top';\n numDiv=document.createElement('div');numDiv.className='mr-num';numDiv.textContent=q.id<10?'0'+q.id:String(q.id);\n meta=document.createElement('div');meta.className='mr-meta';\n tag=document.createElement('div');tag.className='mr-tag';tag.innerHTML=q.tag;\n stem=document.createElement('div');stem.className='mr-stem';stem.innerHTML=q.stem;\n meta.appendChild(tag);meta.appendChild(stem);top.appendChild(numDiv);top.appendChild(meta);card.appendChild(top);\n rule=document.createElement('div');rule.className='mr-rule';card.appendChild(rule);\n optsDiv=document.createElement('div');optsDiv.className='mr-opts';\n for(j=0;j<opts.length;j++){\n optEl=document.createElement('div');optEl.className='mr-opt';optEl.id=NS+'-o'+q.id+'-'+j;optEl.setAttribute('role','button');optEl.setAttribute('tabindex','0');\n ltrSpan=document.createElement('span');ltrSpan.className='mr-ltr';ltrSpan.textContent=LTRS[j];\n txtSpan=document.createElement('span');txtSpan.className='mr-opt-text';txtSpan.innerHTML=opts[j];\n optEl.appendChild(ltrSpan);optEl.appendChild(txtSpan);optsDiv.appendChild(optEl);\n (function(qid,oi){optEl.addEventListener('click',function(){pick(qid,oi);});}(q.id,j));\n }\n card.appendChild(optsDiv);\n expDiv=document.createElement('div');expDiv.className='mr-exp';expDiv.id=NS+'-exp'+q.id;\n lbl=document.createElement('div');lbl.className='mr-exp-lbl';lbl.textContent='Debrief';\n txt=document.createElement('div');txt.className='mr-exp-text';txt.innerHTML=q.exp;\n expDiv.appendChild(lbl);expDiv.appendChild(txt);\n if(q.imgId){imgSrc=byId(q.imgId);if(imgSrc){imgDiv=document.createElement('div');imgDiv.innerHTML=imgSrc.innerHTML;expDiv.appendChild(imgDiv);}}\n card.appendChild(expDiv);cont.appendChild(card);\n }\n }\n function pick(qid,oi){\n var q,opts,i,el,correct;\n if(answers[qid]!==undefined||done)return;\n q=null;for(i=0;i<QS.length;i++){if(QS[i].id===qid){q=QS[i];break;}}if(!q)return;\n opts=shuffled[qid];correct=(opts[oi]===q.correct);answers[qid]=correct?'c':'w';answered++;\n for(i=0;i<opts.length;i++){\n el=byId(NS+'-o'+qid+'-'+i);\n if(opts[i]===q.correct){el.className='mr-opt correct locked';}\n else if(i===oi){el.className='mr-opt wrong locked';}\n else{el.className='mr-opt dimmed locked';}\n }\n byId(NS+'-exp'+qid).style.display='block';\n byId(NS+'-pip'+qid).className='mr-pip '+(correct?'correct':'wrong');\n if(qid>1){var pl=gid('pl'+qid);if(pl)pl.className='mr-pip-line done';}\n }\n function showScore(){\n var c,w,s,net,pct,disp,verdicts,vi,sc;\n if(done)return;done=true;\n c=countVal('c');w=countVal('w');s=TOTAL-answered;\n net=(c*4)-w;pct=Math.max(0,Math.round((net\/MAX)*100));disp=Math.min(100,Math.max(0,pct));\n gid('ring').style.background='conic-gradient(#2A5470 '+disp+'%, #D8E6EE 0%)';\n gid('pct').textContent=pct+'%';gid('net').textContent='Net Score: '+net+' \/ '+MAX;\n verdicts=[[5,'Perfect round. 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