Acid Base Questions

Case 1

On July 4
th
, a 15 year old male presents to the emergency room following a
seizure. While being examined, he had another grand mal seizure. Immediate
post seizure laboratory work was drawn and he was given 4 ampules (200
mEq) of NaHCO
3
. Laboratory values:

Initial 2 hr.
Na (mEq/L) 140 146
K 4.0 3.5
Cl 105 100
HCO
3
10 36
ABG: pH 7.02 7.60
pCO
2
40 37

Questions:
a. What is the initial acid-base disorder?
b. What are the most likely etiologies of this acid base disturbane?
c. Is the initial compensation appropriate (physiologic)?
d. What is the acid-base disorder at 2 hours? How did it develop?

























Case 2

A 68 year old woman is admitted for profuse, watery diarrhea for one week.
Examination revealed flat neck veins in the supine position, no edema and dry
mucous membranes; the BP was 100/60, pulse 114/min. She was found to
have salmonella enteritis. Laboratory values:

Day: 1 __2__
Na (mEq/L) 133 137
K 2.5 4.2
Cl 118 114
HCO
3
5 13
Creat (mg/dL) 3.5
ABG: pH 7.24 7.51
pCO
2
12 17
Urine: pH 5.0
Na (mEq/L) 16
K 14
Cl 68

Questions:
a. What is the acid-base disturbance on day 1?
b. What is the cause of her metabolic acidosis? How can this be verified?
c. Is the compensation appropriate (ie physiologic)?
d. What accounts for the alkalemia on day 2?






















Case 3

A 58 year old male with stomach flu for two days, presents to the
emergency room with squeezing substernal chest pain for two hours. He is
an obese Type 2 diabetic for 20 years taking insulin, metformin, and lisinopril.
Physical exam revealed BP 70/44, pulse 120/min., respiratory rate 28/min.,
bilateral rales; he was cold and clammy. EKG showed marked ST segment
elevation anteriorly. Laboratory values:

Na (mEq/L) 134 ABG: pH 7.41
K 5.9 pCO
2
14
Cl 92 paO
2
52
HC0
3
8
BUN (mg/dL) 35 Ketones moderate
Creat 1.8
Glucose 520

Questions:
a. What is the primary acid base disturbance?
b. What is the differential diagnosis? How would you confirm your
suspicion?
c. Do the ketones account for the entire metabolic acidosis? What are the other
possibilities?
d. Is there a second primary disturbance? What is its differential diagnosis?
e. Is there a third primary disturbance?






















Case 4

A 54 year old diabetic woman is admitted on the fourth day of an acute illness
characterized by fever (39.5), chills, myalgias and diarrhea. She denied taking
any medications, drugs or alcohol. Physical exam revealed the BP 84/52
supine, pulse 118/min., respirations 40/min. and labored; mucous membranes
were dry, neck veins were flat and she had no edema. The abdomen was
distended, firm, mildly tender with hyperactive bowel sounds. Laboratory
values:

BUN (mg/dL) 38 Hgb. 15.5 g/dL
Creat 2.4 WBC 22,300 (66segs, 23 bands)
Glucose 343 Plts. 102,000
Na (mEq/L) 138
K 4.2 ABG: pH 7.29
Cl 108 pCO
2
17
HCO
3
10 pO
2
71
Lactate 3
Ketones Neg

Questions:
a. What is the principal acid-base disturbance? What is the cause?
b. Does the elevated anion gap (AG) explain the entire metabolic acidosis?
c. Is the compensation appropriate? Is there a second primary (ie
pathologic) disturbance?





















Case 5

A 35 year old woman was brought to the ER comatose. According to the
family she had been complaining of progressive weakness for two months.
Physical exam revealed: blood pressure 110/62, pulse 100/min, respiratory
rate 36/min. and a generalized decrease in deep tendon reflexes. Laboratory
values:

Na (mEq/L) 135 ABG: pH 6.88
K 1.5 pCO
2
40
Cl 118 paO
2
62
HCO
3
7

Urine : SG 1.012
pH 6.5
protein 1+

Questions:
a. What is the primary acid base disturbance?
b. What is the differential diagnosis?
c. Is there a second primary disturbance? What is its differential diagnosis?
d. How should she be treated?

























Case 6

A 76-year-old man with mild CHF and COPD is admitted to the hospital with
recurrent pneumonia. Physical exam reveals a BP 188/102, pulse 110/min.
and 2+ peripheral edema. The chest X ray reveals a right upper lobe infiltrate
and possible mass. He requires intubation for 2 days and is treated with
ceftriaxone. Five days later, he is extubated, alert, and ambulating when the
following laboratory values were obtained:

Na (mEq/L) 129 ABG: (on 1L/min)
K 3.2 pH 7.51
Cl 81 pCO
2
48
HCO
3
38 pO
2
68

Glucose (mg/dL) 108 Urine: Na 51 mEq/L
BUN 21 K 75
Creat 1.8 Cl 46
Creat 66 mg/dL

Questions:
a. What is the primary acid-base disturbance? What is the likely cause?
b. How does the serum and urine potassium influence your diagnosis?
c. Is the compensation appropriate?
d. What factors are necessary for the patient to correct his metabolic alkalosis?























Case 7

A 46 year man drinking heavily is admitted with vomiting and abdominal
pain. He had a long history of alcohol abuse with previous episodes of GI
bleeding and pancreatitis. On admission, he was stuporous, BP 90/50, pulse
110/min., respirations 8/min..Massive ascites and 2-3+ peripheral edema were
present. Laboratory values:

Day: 1 4 7 10
BUN (mg/dL) 69 53 75 42
Creat 4.8 3.7 3.9 3.5
Glucose 84
Na (mEq/L) 143 146 138 139
K 2.7 4.2 4.3 4.3
Cl 65 92 93 102
HCO
3
56 39 35 25
Lactate 4
Ketones 4+
ABG: pH 7.55 7.54 7.47 7.42
pCO
2
66 47 50 42
Urine Na (mEq/L) 6
K 52
______ Cl 2__________________________________________

Questions:
a. What is the acid-base disturbance on day 1? What is the most likely
etiology?
b. What is the cause of hypokalemia?
c. Is the compensation appropriate (physiologic)?
d. What explains the anion gap (AG)?
e. How should the patient be treated?


















Case 8

A man with known COPD, hypertension and ischemic cardiomyopathy is
admitted the morning following his 72
nd
birthday party at a local barbeque
restaurant. Physical findings include elevated JVD, rales, 3+ edema and an S
3

gallop. He is treated with salt restriction, ACE inhibitor and a loop diuretic
and improves substantially. Laboratory values:

__________________Day 1 3 6____
Na (mEq/L) 139 136 135
K 4.9 4.0 4.6
Cl 98 83 98
HCO
3
31 42 27

BUN (mg/dL) 22 44 30
Creat 1.0 1.5 1.1

ABG: pH 7.34 7.43 7.36
pCO
2
60 65 50
paO
2
60 85 72

Questions:
a. What is the primary acid base disturbance on day 1?
b. Is the compensation appropriate?
c. What is the cause of the acid base status on day 3? What therapy is
appropriate?
d. Characterize the acid-base disturbance on day 6.
























Case 9

A 36 year old woman is admitted with an acute (<24 hr) illness characterized
by nausea, vomiting, abdominal pain and extreme hyperglycemia. She has a
history of diabetes mellitus with triopathy (including nephrotic syndrome),
juvenile RA and chronic hypertension. Her medications include daily NPH
and TID humalog insulins, clonidine, lisinopril, atorvastatin and paroxetine.
Physical exam: BP 102/48, pulse 114/min, respirations 24/min. There was 1+
peripheral edema but no rales, JVD or gallop rhythm. Laboratory values:

Na (mEq/L) 149 ABG: (on RA)
K 5.1 pH 7.68
Cl 105 pCO
2
13
HCO
3
19 pO
2
108

Glucose (mg/dL) 530 Ketones small

BUN 41
Creat 1.7
AST 428 UA: 3 + protein
ALT 358 WBC 5-10/ hpf
Alk Phos 624 RBC >200/ hpf
Bilirubin 1.9
Albumin (g/dL) 3.9

Questions:
a. What is the acid-base disturbance?
b. Is the compensation appropriate?
c. Is there another primary acid base disturbance?
d. Is there a third?














Case 10

A 44 year old male complains of fatigue and weakness progressing over 3
months. He has diarrhea (8-10 loose stools per day) and had lost 100 pounds
over the previous year on a diet of his own. He denied vomiting. He denied
laxatives of any kind, diuretics, corticosteroids or oral bicarbonate. He did
have a history of schizo-affective disorder and was taking buspirone,
risperidone, trazodone and sertraline. Hospitalization was precipitated by
severe weakness as he was unable to arise from the commode. Physical exam:
BP 120/63, pulse 98/min, respirations 18/min, O
2
sat 96% on RA; there was
neither JVD nor edema, lungs were clear, and there was so muscle tenderness.
Admitting laboratory values:


Na (mEq/L) 143 ABG: pH 7.51
K 1.7 pCO
2
52
Cl 96 pO
2
68
CO
2
42

BUN (mg/dL) 3 Urine: SG 1.015
Creat 0.6 pH 6.5
Ca 8.1 ketones 15
Phos 2.8 Na (mEq/L) 56
Mg 1.1 K 8
Alb. (g/dL) 3.7 Cl 94
Creat (mg/dL) 94

Questions:
a. What is the principal acid-base disturbance?
b. Is the compensation appropriate?
c. What is the cause of the metabolic alkalosis?