METABOLIC ACIDOSIS

CASE STUDY
Hala Kilany, MD.

CASE-1
A patient with diarrhea:
-pH=7.23
-HCO3-=10meq\l
-PCO2=23 mmHg

A patient with diarrhea has an arterial pH of 7.23,

bicarbonate concentration of 10 meq/L, and PCO2 of 23
mmHg. The low pH indicates acidemia, and the low
plasma bicarbonate concentration indicates metabolic
acidosis. The plasma bicarbonate concentration is 14
meq/L below normal, which should lead to a 17 mmHg
fall in the PCO2 (14 x 1.2 = 17) from 40 to 23 mmHg.
Thus, this patient has a simple metabolic acidosis. A
PCO2 significantly higher than this level would indicate a
concurrent respiratory acidosis. If, on the other hand, the
PCO2 were lower than 20 mmHg, then a concurrent
respiratory alkalosis would be present, as might be seen
with salicylate intoxication.

CASE-2
A 51 year-old man passes out while waiting in the
Emergency department. He is noted to have no pulse
and cardiopulmonary resuscitation is begun. Initial
laboratory data show:
Arterial pH = 7.30
Arterial PCO2 = 30 mmHg
Plasma sodium = 140 meq/L
Plasma potassium = 4.1 meq/L
Plasma chloride = 100 meq/L
Plasma bicarbonate = 15 meq/L
A. What is the acid-base disorder?
B. Calculate the anion gap?
C. What is the most likely diagnosis?

 This is a simple case of high AG

metabolic acidosis.
-AG= 140-(100+15)=25
-Na\Cl=1.4, so single disorder
-Pco2: 1.2 x 9=10.8, almost the same: 30
The 2 most frequent diagnosis:
-Diabetes
-Alcohol intoxication

CASE-3
A 23 year-old man with no prior history
complains of polyuria, polydipsia, and
polyphagia for 2 weeks. He also notes
some shortness of breath. The physical
examination reveals a blood pressure
of 120/80 supine, 90/60 standing,
increased respiratory rate, and
decreased skin turgor. The initial
laboratory data reveal:

 Plasma
Plasma
Plasma
Plasma

sodium = 140 meq/L

potassium = 6.1 meq/L
chloride = 100 meq/L
bicarbonate = 5 meq/L

 Plasma glucose = 840 mg/dL

BUN = 40 mg/dL
Plasma creatinine = 4.2 mg/dL
Serum ketones = 4+ at 1:4 dilution
Urine ketones = 4+
Urine glucose = 4+
Urine sodium = 53 meq/L
Urine potassium = 32 meq/L

 This is a case of high AG metabolic acidosis:

-AG=35
-Na\Cl=1.4: simple condition
With the presence of ketones in the body,
this is diabetic ketoacidosis.
The uremia may be a cause in the high AG,
specially that it seems to be a chronic renal
failure not a prerenal state,
BUN\Creatinine=9.5.

CASE-4
A 1 year-old child was seen by his pediatrician for
a routine evaluation and was found to weigh 10
kg. Two days later, he is seen in the Emergency
Department for diarrhea and dehydration. At this
time, the physical examination reveals:
-a pulse of 140, respiratory rate 32/min,
-blood pressure 90/, and weight
8.9 kg. He appears moderately dehydrated with
dry mucous membranes and no tears when he
cried. There are no other significant
abnormalities. Laboratory data on admission
reveal:

 Plasma sodium = 138 meq/L

Plasma potassium = 4.0 meq/l
Plasma chloride = 104 meq/L
Plasma bicarbonate = 11 meq/L
BUN = 32 mg/dL
Plasma creatinine = 0.6 mg/dL
Arterial pH = 7.24
Arterial PCO2 = 24 mmHg
Urine pH = 5.0
Urine specific gravity = 1.031

 What is the acid-base disorder?

What is the anion gap and what
does it tell you about the etiology of
the acid-base disorder?

 Na+\Cl-=138\104=1.32: hyperchloremic
metabolic acidosis.
AG=23 high AG metabolic acidosis
Hco3-=24-11=13,PCO2 drop should be:
1.2x13=15.6 almost 24
So, it is a combined condition of:
-high AG metabolic acidosis, probably due to
lactic acidosis secondary to the severe
diarrhea.
-hyperchloremic metabolic acidosis, due to
diarrhea.

CASE-5
A 31 year-old man with a history of
epilepsy has a grand mal seizure.
Laboratory tests taken immediately after
the seizure has stopped reveal:
-pH=7.14
-PCO2=45mmHg
-plasma [Na+]=140meq\l
-[K+]=4meq\l
-[Cl-]=98meq\l
-[HCO3-]=17meq\l

 What is the acid-base disturbance?

Does the patient needs bicarbonate?

 This is a combined:
-high AG metabolic acidosis: AG= 25
-respiratory acidosis, C02 is much
higher than expected.
Usually, for nephrologists the value of
a pH=7.2, is a requirement for
treating the acidosis, some references
and studies done by ICU specialist go
below that, to a value of pH=7.1.

HYPONATREMIA CASES
Case-1:A 56 year-old man presents to the
doctor for the first time complaining of fatigue
and weight loss. He has never had any health
problems, but he has smoked a pack of
cigarettes per day for about 35 years. He is a
day laborer and is currently homeless and
living in a shelter. His physical examination is
notable for a low to normal blood pressure,
skin hyperpigmentation, and digital clubbing.
He appears euvolemic. You do some blood
tests, and it showed the following:

Lab tests

Na+=126meq/l
K+=6,7meq/l
Chloride and bicarbonate are low.
Creatinine normal.
What is your diagnosis?
A-SIADH
B-hypothyroidism
C-GI losses
D-Adrenal insufficiency
E-Renal insufficiency