Question

Mr. Puffy. This gentleman is 65 years old. He has smoked two packs of non-filter cigarettes per day since he was 15 years old. His face is ruddy with a nose like WC Fields. His lips and nose are blue and he is breathing through pursed lips, having trouble evacuating the air from his lungs. He has a barrel chest. The expiratory area of his respiratory center is fully activated. He sips a small glass of port wine and reminisces about the old days.

Questions: What is your understanding of Mr. Puffy’s respiratory diagnosis? Is Mr. Puffy at risk for respiratory or metabolic / alkalosis or acidosis? What is the compensatory mechanism working to rectify his self-induced condition?

Young couple with their first baby. This is their first excursion out of the house with baby. They’ve been unable to sleep because baby is awaking all-night and asleep all day. Baby has been vomiting for the past 2-3 days, unable to keep down clear liquid or formula. Her mother told them not to worry; “spitting up” is normal. They're both exhausted and trying to enjoy their first restaurant dinner together for months. Baby is in her car seat trying to sleep but appears fidgety.

Questions: Is baby at risk for an acid- base imbalance? If so, is it respiratory or metabolic alkalosis or acidosis? What is the compensatory mechanism working to rectify this condition?

Aquarius. She's sitting alone at a table drinking distilled water hoping to be discovered by a famous movie producer. She has the lead role in a small off-Broadway play. Directors in the past have often told her that she should drink a lot of water before a performance to help with her voice quality. Her aesthetician recommends 4-5 liters of pure water per day for her skin hydration. Taking this to heart, she has been drinking at least this much water a day and more. She will only eat protein, no carbohydrates, and takes laxatives to maintain a slender figure. She's also a novice jogger with great determination, putting in at least five miles per day. She rehydrates with pure water only. The only thing she has had to drink today is distilled water.

Questions: Is Aquarius at risk for water intoxication, dehydrated, or in fluid balance? What factors are affecting her body fluid level and which hormones are affected by her lifestyle? Is her fluid volume dropping? If so, which hormones are released to compensate for this loss? Is Aquarius at risk for respiratory or metabolic / alkalosis or acidosis? What is the compensatory mechanism working to rectify her self-induced condition?

Answer 1

Q1. Mr. Puffy

Questions: What is your understanding of Mr. Puffy’s respiratory diagnosis? Is Mr. Puffy at risk for respiratory or metabolic / alkalosis or acidosis? What is the compensatory mechanism working to rectify his self-induced condition?

Ans. Mr. Puffy is suffering from emphysema. Ruddy face, breathing through pursed lips, cyanosis and a barrel chest are all typical symptoms of emphysema. Smoking is an etiological factor for emphysema. Emphysema is defined as abnormal permanent enlargement of air spaces distal to the terminal bronchioles, accompanied by the destruction of alveolar walls and without obvious fibrosis. Due to the destruction of the alveolar walls, exchange of gases is impaired. This puts him at an increased risk for accumulation of carbon dioxide in the blood leading to respiratory acidosis. To compensate for this the kidneys increase the urinary excretion of hydrogen ions and resorption of HCO3−.

Q2. Young couple with baby

Questions: Is baby at risk for an acid- base imbalance? If so, is it respiratory or metabolic alkalosis or acidosis? What is the compensatory mechanism working to rectify this condition?

Ans. The baby has been vomiting since the past 2-3 days. The baby can develop metabolic alkalosis. This leads to excess loss of water and electrolytes from the body. The secretions of the stomach are rich in HCl which are lost in the vomitus. Along with this Na and K are also lost. This causes the kidneys to retain Na in exchange of H+. As the H+ ions are excreted into the urine, there is metabolic alkalosis. To compensate for the respiratory rate will reduce, leading to accumulation of carbon dioxide. CO2 is then consumed toward the formation of the carbonic acid intermediate, thus decreasing pH.

Q3. Aquarius and overhydration

Questions: Is Aquarius at risk for water intoxication, dehydrated, or in fluid balance? What factors are affecting her body fluid level and which hormones are affected by her lifestyle? Is her fluid volume dropping? If so, which hormones are released to compensate for this loss? Is Aquarius at risk for respiratory or metabolic / alkalosis or acidosis? What is the compensatory mechanism working to rectify her self-induced condition?

Ans) Aquarius is at the risk for water intoxication and also electrolyte imbalance. She is consuming only proteins and no carbohydrates in her diet. She has also been abusing laxatives. Laxative abuse will put her at risk of developing hypokalemia and metabolic alkalosis. Overhydration also causes hyponatremia.

Her fluid volume is not dropping. Due to overhydration she has excess fluid volume. She is not at the risk of respiratory or metabolic alkalosis/acidosis. The main concern is electrolyte imbalance and fluid overload. She has to be treated with diuretics and her diet has to be modified to include carbohydrates.