Fred, a 68 y/o male who had an MI in April, 2015 was seen by his physician on Au
ID: 3483046 • Letter: F
Question
Fred, a 68 y/o male who had an MI in April, 2015 was seen by his physician on Aug. 30, 2017 presenting with shortness of breath, fatigability, and swelling of the lower extremities. Upon physical examination, the man was found to have distended jugulars and pitting edema of the ankles. His breathing was rapid (20 breaths/min) and pulmonary crackles were heard bilaterally in the lower lobes of the lungs. He had a pulse rate of 110 beats/min and a BP of 152/98. Since his MI, he was taking digoxin and hydrochlorothiazide. At the time, the Px blood and urine work showed:
Blood
Values
Urine
Values
Na+ (mEq/L)
128
Na+ (mEq/L)
110
K+ (mEq/L)
3.9
K+ (mEq/L)
80
Mg2+ (mg/dL)
1.7
Mg2+ (mg/day)
19
Ca2+ (mg/dL)
8.9
Ca2+ (mg/day)
105
HCO3 (mEq/L)
30
HCO3
1.7
Creatinine (mg/dl)
1.7
Creatinine (mg/L)
2080
PAH (mg/ml)
0.013
PAH (mg/ml)
5.91
Glucose (mg/dL)
85
Glucose
0
BUN (mg/dL)
14
24hr volume (L)
1.2
pCO2 (mmHg)
45
Osmolarity (mOsm/L)
750
pH
7.31
pH
6.8
The Px was admitted at that time and was treated with 2L of 5% saline and Lasix® which removed the excess blood volume. The Px’s blood pressure, heart rate and respiratory problems were reduced. Additional lab tests indicated that the Px was experiencing left ventricular failure. Once he was stable, the Px was sent home on Sept. 2.
On Dec. 7, 2017, the Px was transported to the ER via ambulance after his daughter found him unresponsive. She told the ER physician that her father had been extremely fatigued at any level of effort, had extensive flank pain and that his mental alertness had decreased significantly over the past two weeks. Physical examination finds that the Px is doesn’t respond to questioning and appears to fall asleep during the examination. Once again, the Px exhibits excessive swelling in the lower extremities with distended jugulars. His heart rate is now 92 and irregular, his BP is 164/110. His breathing is 28 breaths/min and shallow but lung sounds are normal. His urine is dark and foamy. The ends of his fingers and toes have a bluish appearance and his abdomen is large and distended. Blood and urine values are:
Blood
Values
Urine
Values
Na+ (mEq/L)
118
Na+ (mEq/L)
310
K+ (mEq/L)
2.9
K+ (mEq/L)
108
Mg2+ (mg/dL)
0.7
Mg2+ (mg/day)
29
Ca2+ (mg/dL)
5.9
Ca2+ (mg/day)
155
HCO3 (mEq/L)
29
HCO3
13.9
Creatinine (mg/dl)
2.2
Creatinine (mg/L)
1590
PAH (mg/ml)
0.013
PAH (mg/ml)
5.91
Glucose (mg/dL)
85
Glucose
0
pCO2 (mmHg)
53
Osmolarity (mOsm/L)
400
pO2 (mmHg)
67
24hr urine volume (mL)
600
pH
7.28
pH
6.8
RBC count / µL
3.8 x 106
Hemoglobin gm/dl
9.5
The attending physician immediately gave the Px 30 mg of propranolol and admitted the Px. An echocardiogram was conducted and showed right and left ventricular cardiomegaly.
Does the Px have an acid base imbalance? If so, what type of acid base imbalance it is and why did the Px develop this problem? How is his body compensating for this imbalance
Blood
Values
Urine
Values
Na+ (mEq/L)
128
Na+ (mEq/L)
110
K+ (mEq/L)
3.9
K+ (mEq/L)
80
Mg2+ (mg/dL)
1.7
Mg2+ (mg/day)
19
Ca2+ (mg/dL)
8.9
Ca2+ (mg/day)
105
HCO3 (mEq/L)
30
HCO3
1.7
Creatinine (mg/dl)
1.7
Creatinine (mg/L)
2080
PAH (mg/ml)
0.013
PAH (mg/ml)
5.91
Glucose (mg/dL)
85
Glucose
0
BUN (mg/dL)
14
24hr volume (L)
1.2
pCO2 (mmHg)
45
Osmolarity (mOsm/L)
750
pH
7.31
pH
6.8
Explanation / Answer
Acid base balance is the state of equilibrium between proton donors and proton acceptors in the buffering system of the blood that is maintained at approximately pH 7.35 to 7.45 under normal conditions in arterial blood.
When the levels of acid in the blood are too high, it is called acidosis. When blood alkaline is high, it is called alkalosis.
In above person,the pH is acidic at both times, indicating acidosis. This person has an acid base imbalance. It is acidosis. Person seems to have both respiratory and metabolic acidosis.
Respiratory acidosis:
Symptoms are fatigue, shortness of breath and confusion. So,earlier he is suffering from respiratory acidosis. As next time he has normal lung functions.
Metabolic acidosis:
Symptoms are rapid breathing, fatigue and confusion.
It occurs when the body produces too much acid or when kidneys are unable to remove it properly.
3 types are
diabetic keto acidosis- uncontrolled type 1 diabetes
hyperchloremic acidosis- body loses too much sodium bicarbonates
lactic acidosis- prolonged exercise, lack of oxygen, liver failure, medications like salicylate etc.
In above person,in second case he has metabolic acidosis. He is compensating it by losing sodium in both the case.
Normal urine Na+ levels in urine are 20mEq/L and 40 to 220mEq/L in random samples. Which in above patient is high in both the cases. Thus,he is trying to compensate acidosis by loss of sodium in urine.That he has excess sodium loss is indicated by fluid built up in his legs and by blood sodium levels ( 135 to 145 mEq/l) which have decreased.
This is jus to compensate the acidosis.
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