Question

Case 4

Seth Johnson is a 54 year old college physics professor with a history of coronary artery disease who was admitted to the hospital for increasing lower extremity edema, abdominal swelling, and shortness of breath. Professor Johnson noted a 30-pound weight gain over the past month, and during the past week he has had three-pillow orthopnea.

Professor Johnson is in moderate respiratory distress in the hospital. His skin is cool, pale, and clammy. His pulse is 95, irregular, and weak. His respirations are 28, regular, adequate volume, labored, with bilateral rales. His blood pressure is 140/80. His abdomen is enlarged, and lower extremities are remarkable for pitting edema. His physician orders laboratory tests, results are as follows:

Plasma Na+: 133 mEq/L (normal 136-140 mEq/L) Plasma K+: 6.0 mEq/L (normal 3.5-5.3 mEq/L)
Plasma Cl-: 93 mEq/L (normal 98-108 mEq/L)
Plasma HCO3-: 16 mEq/L (normal 24 mEq/L)
Plasma Creatinine: 3.7 mg/dLL (normal 0.7-1.5 mg/dL) Plasma PO43-: 6.8 mg/dL (normal 2.7-4.5 mg/dL)

pCO2: 36 mmHg (normal 40 mmHg)
Blood urea nitrogen: 101 mg/dL (normal 7-22 mg/dL) pH: 7.25
SpO2: 96%

Upon evaluation of the findings, Professor Johnson’s physician diagnoses him with both congestive heart failure and acute renal failure.

Questions:

14.Discuss Professor Johnson’s signs and symptoms in the context of his diagnoses (edema, weight gain, skin, pulse, respiration, shortness of breath, blood pressure).

15.Discuss Professor Johnson’s electrolyte levels in the context of his diagnoses (Na+ K+ PO43-). Why are these findings common in acute renal failure? When a health care practitioner reads these values, what might they expect in terms of his behavior or ability to move? (Hint for PO43-: it binds with calcium, so the effects of high phosphate are similar to those of low calcium)

16.Why are congestive heart failure and renal failure often found together?

17.Which acid-base disorder does he have? What caused it? What is the compensation? (identify laboratory values)

Case 5

Daniel Purcel was diagnosed with type 1 diabetes mellitus when he was 12 years old. He is now a nursing student. He has managed to control his diabetes throughout school. However, when he began his clinicals, his regular schedule of meals and insulin injections was completely disrupted. One morning, Daniel completely forgot to take his insulin. At 7am he drank orange juice and ate two doughnuts. At 8am he drank more juice because he was very thirsty. He mentioned to a fellow student that he felt confused, weak, and that his heart was racing. At 9:06 am, he fell unconscious. He was transferred immediately to the emergency room, where the following information was obtained:

Blood pressure: 90/40
Pulse: 130, regular, strong
Respirations: 32, regular rhythm, deep, labored (“Kussmaul”) Plasma glucose: 560 mg/dL (normal fasting 70-110 mg/dL) Plasma HCO3-: 8 mEq/L (normal 24 mEq/L)
Plasma ketones: ++ (normal none)
Arterial PO2: 112 mmHg (normal 100 mmHg)
Arterial PCO2: 20 mmHg (normal 40 mmHg)
Arterial pH: 7.22

The physician determined that Daniel was in diabetic ketoacidosis. He was given an intravenous infusion of isotonic saline and insulin. Later, after his blood glucose had decreased to 175 mg/dL, glucose was added to the infusion. Daniel stayed in the hospital overnight. By the next morning, his blood glucose, electrolytes, and blood gas values were normal.

Questions:

18.Which acid-base disorder did Daniel have? What caused it? Why did he present with Kussmaul respirations? Explain these all in the context of the laboratory test results.

19.How did Daniel’s failure to take insulin cause this acid-base disorder?

20.Explain Daniel’s thirst, low blood pressure, tachycardia, confusion, and weakness.

21.Explain the basis for the treatments provided (saline, insulin, and glucose).

Answer 1

Answer 14

Mr Johnson signs and symptoms are

Pain areas: he is feeling pain in chest

Whole body: Mr Johnson feel dizziness, fatigue, inability to exercise,

Respiratory: shortness of breath at night, shortness of breath on exercise, and shortness of breath on lying down

Gastrointestinal: water retention or bloating

Other: excess urination at night, palpitations, swollen feet, and weight gain

Answer 15 electrolyte finding in Mr Johnson are

Sodium level = 133mEq/l

Potassium level = 6mEq/lit

Phosphate level = 6.8mEq/l

According to reference value sodium electrolyte is less

Potassium level is more Nd phosphate level is More then usual or reference value cause metabolic acidosis

In renal failure, one most commonly sees patients who have a tendency to develop hypervolemia, hyperkalemia, hyperphosphatemia, hypocalcemia, and bicarbonate deficiency (metabolic acidosis). Sodium is generally retained, but may appear normal, or hyponatremic, because of dilution from fluid retention. Following the relief of a urinary tract obstruction, hypovolemia, hyponatremia (true loss of sodium), hypokalemia, hypocalcemia, hypomagnesemia, and bicarbonate loss are most apt to occur. Electrolyte imbalances after urinary diversion vary depending on the site of urine diversion.

Answer 16

When the heart is no longer pumping efficiently it becomes congested with blood, causing pressure to build up in the main vein connected to the kidneys and leading to congestion of blood in the kidneys,

reduced kidney perfusion due to decreased forward flow, increased right ventricular and venous pressure, and neurohormonal adaptations.

Answer 17 he is suffering from metabolic acidosis

1.loss of bicarbonate which act buffer

2. Drug induced hypovolemia

3 decrease tubular resorption of bicarbonate

4 acute renal failure

Treatment

sodium bicarbonate or sodium citrate pills