The Annals of Internal Medicine, Vol. 127, Issue 5, pp 405-409 has the article “
ID: 3524196 • Letter: T
Question
The Annals of Internal Medicine, Vol. 127, Issue 5, pp 405-409 has the article “Survival” that describes the experiences of an Australian medical student, James Scott that went to Nepal, India for his training. On a hike in the Himalayan Mountains he became lost for 42 days due to a snow storm. He had not taken food, water or survival gear for this type of emergency. On presentation to the hospital in Nepal he was considered gaunt and emotionally labile. Overall he needed several weeks of care; however, after one or two days of care he had the following values: (see ‘commentary’ in article.
Weight: 61 kg, Estimated normal: 80 kg Temp: 98.2F Tenting of skin, edema of ankles
BP 114/70 and HR 108 while supine, BP 60/52 and HR 120 while sitting. Hct: 44%, WBC: 4,400
Sodium 128 mMol/L, Potassium 3.0 mMol/L, Glucose 5.11mMol/L (92 mg/dl), Urine Ketones +
Albumin: 44 g/L Prothrombin : +3sec, Creatinine day 1: 0.1mMol/L, day 4 0.06mMol/L BUN 30
After 1 day of fluids, 2000ml/24hr IV, 1500ml/day per os, urine output was 80ml/hour.
1. When a person is dehydrated, what body system is directly injured? ____________
From day one, his urine output was “80 ml/hour”, is that normal, high or low? _____________
Looking at his creatinine, does it appear that his kidneys are normal? ________
Should fluid intake be increased or decreased? _____________ Why? _____________________
______________________________________________________________________________
2. What percentage of his weight did he lose? ___________________________________________
Where did the weight “go”? _________________________________________________________
If you read the article, what kept him alive physically?________________________________________
What is the name of the chemical reaction that breaks down fatty acids? _________________
3. When using fats to get ATP, what waste product is often made? ____________
With that waste product, what pH problem would we expect?________________Did he have that in his urine? ___
What is a starving person using to make glucose?________________________________
His serum albumin is also normal, where would he get protein to make albumin?___________________________
4. Compare his blood pressure readings. Are they normal? _____________ Usually, when the blood pressure changes like that in a young patient, we think of hypovolemia or dehydration.
Do you think he is dehydrated? _____________________________________________________________
Why is his heart not pumping well? __________________________________________________________
He was given furosemide, what is that? _______________ and where does it act? ______________________
5. Thinking about edema, we think of capillary permeability, low osmotic pressure, heart failure, lymph obstruction, and renal failure and a patient can be “over hydrated”. He had edema, tachycardia and odd BP readings before the “iatrogenic over hydration”. What does Iatragenic mean? ____________________________________________
What is nystagmus and what does it indicate? ______________________________________________________
Thiamine is vitamin ___________ and is a coenzyme used to breakdown pyruvate to Acetyl CoA.
Thiamine is given to alcoholics too because typically they don’t have a good diet. Giving a starving person glucose and no thiamine can result in brain cell damage and even death! James was given food before thiamine and this is when a candy bar is a ‘bad thing’ in the Martha Stewart College of Medicine.
6. Please give a definition for the term Refeeding Syndrome: _______________________________________
_________________________________________________________________________________________
They were concerned he could have hypophosphatemia. What is that? _____________________________
Given his nutritional deficits, would you choose to give him a diet high in carbs, protein or fats?
_____________________________________________________________________________________
Explanation / Answer
1.
When a person is dehydrated the directly injured body system is the Immune System with the most affected organ being the Kidneys. This is because in case of dehydration the kidneys are unable to remove the toxic wastes and therefore the body becomes more susceptible to infectious diseases and there are high chances of Kidney stone.
The normal urine output ranges from 33 mL/hr to 85 mL/hr for 2L intake of water. Since the urine output of the patient is 80mL/hr so it can be considered as Normal.
In case of Day 1 the Creatinine level is high but on day 4 the creatinine level is normal. The creatinine level was higher in day 1 because the kidneys were unable to remove them due to dehydration but on day 4 the creatinine level was normal. So, the Kidneys are Normal.
The fluid intake should be increased after day 1 in order to rehydrate the body, normalize the creatinine levels by removing these wastes. Increase in fluid intake increases the water retention in skin, normalises blood pressure.
2. Normal weight = 80 kg
Reduced weight = 61 kg
Loss in weight = 19 kg and Percentage loss in weight = (19 / 80) * 100 = 23.75%
The weight is lost in the form of sweat and urine.
He was alive because his body was able to use fats and muscles as a source of fuel. Since he was trapped and didn't have to move therefore his body didn't require much energy to function and this energy was taken from fats and muscles. Also, in this state his response of the nervous system became nulled and he didn't have any feeling of hunger or thirst.
Chemical reaction that breaks down fatty acids is Fatty Acid Oxidation or Beta - oxidation.
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