The Annals of Internal Medicine, Vol. 127, Issue 5, pp 405-409 has the article “
ID: 3524237 • 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.a).when a person is dehydrated,both circulatory system and excretory system are greatly affected. To compensate increased heart rate to maintain blood pressure. While kidneys fail to get sufficient amount of blood for filtration process.
b)80m/hr is the condition of oligouria -low urine where decreased blood supply to kidney is observed. The normal range should be 2000ml/day
c) The normal level of creatinine excreted per day is 1.8g but the report gives 0.1-0.06 which says kidneys are effected badly.fluid intake should be decreased otherwise liver is effected because creatinine is produced in the liver.so low levels can cause liver damage.
2.initially estimated weight was 80kg,after sick it went down to 61kg.as there was no proper food for 42 days,the carbohydrates, proteins,fat reduced into simpler forms and less intake of water lead to decrease in weight for about 19kg.
Patient is in serious condition, because blood pressure varies a lot,completely low levels serious damage to heart ,kidneys are damaged, low potassium levels(normal 756mEq/day)but the report has only 3mEq but the serum albumin levels are normal.
The process of breakdown of fatty acids is called beta oxidation.
When using triglycerides, heat,carbon dioxide,water,ATP are formed.18c fatty acids require 146 ATP molecules, 20c fatty acids require 168molecules of fatty acids.
PH would be around 8,low levels are present in his urine.
Starving person don't have glucose for direct uptake from the cells,so gluconeogenesis is the process where non carbohydrates are breakdown to get carbon(glucose) as a source.
Serum albumin levels are maintained normal by drawing fluid from the body into blood vessels.
Very low blood pressure is observed. Yes,he is dehydrated.
The thickness of the blood is reduced in dehydrated conditions. Thereby to compensate the pressure developed, the heart rate gets increased.
Furosamide is given to the patient in case of edema and hypertension conditions. In case of edema,to assess the heart,during acute pulmonary edwmic conditions and increased intracranial pressure it is prescribed as following dosage. Injected: 10mg/ml,oral: 10mg/ml,tablets: 20mg or 40mg or 80mg is recommended.
Acute renal function: 1-3g/day,avoid using in oligouric state,hepatic impairment-monitor high dose.Hyperkalemia 40-80mg IV ,Hypermagnesemia 20-40IV,93-4hrPRN is recomemded.
Latragenic means a condition due to action of physician or by a therapy,Iatrogenic means a condition caused by medication or physician.
Nystagmus: involuntary eye movement rapidly from side-side,up-down in a circle .it is detected by ENG- electronystagmograph form of electroculography(electrical methods of measurement of eye movement with electrodes).
It indicates damage to vestibule, semicircular canals or otolith organs or vestibule cerebellum.
Thiamine is a water soluble vitamin and the syndrome is Wernicke's korsakoff syndrome-thiamine deficiency..
Hypophosphatemia is the low condition of phosphate where serum phosphate is (<2.5mg/DL),causes alcoholism, diruretic,starvation. Clinical features include muscle weaknesses, respiratory failure,and heart failure, seizures,and coma can even occur.
Carbs,protein or fats can be recommended not so immediately, but after he gain consciousness,can be given.protein-10-35% in daily food he take.
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