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Acid-Base status 판판

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Page 1: Case

Acid-Base status 판정

Page 2: Case

pH [HCO3-]

mEq/LPCO2

(mmHg) disorder

7.23 10 257.46 30 447.37 28 507.66 22 207.34 26 507.54 18 22

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체액 산 - 염기의 분석

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CASE

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고알도스테론증 (Hyperaldosteronism: Conn's Syndrome)Seymour Simon is a 54-year-old college physics professors who main-tains a healthy lifestyle. He exercises regularly, doesn't smoke or drink alcohol, and keeps his weight in the normal range. Recently, however, he experienced generalized muscle weakness and headaches that "just won't quit." He attributed the headaches to the stress of preparing his grant renewal. Over-the-counter pain medica-tion did not help. Professor Simon's wife was very concerned and made an appointment for him to see his primary care physician.

On physical examination, he appeared healthy. However, his blood pressure was significantly elevated at 180/100, both in the ly-ing (supine) and the standing positions. His physician ordered labora-tory tests on his blood and urine that yielded the information shown in Table.

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Professor Simon's Laboratory Values

Arterial bloodpH 7.50 (normal, 7.4)

PCO2 48 mmHg (normal, 40 mmHg)

Venous bloodNa+ 142 mEq/L (normal, 140 mEq/L)

K+ 2.0 mEq/L (normal, 4.5 mEq/L)

HCO3- 36 mEq/L (normal, 24 mEq/L)

Cl- 98 mEq/L (normal, 105 mEq/L)

Creatinine 1.1 mg/dl (normal, 1.2 mg/dl)

UrineNa+ excretion 200 mEq/24 hr (normal)

K+ excretion 1350 mEq/24 hr (elevated)

Creatinine excretion 1980 mg/24 hr

24-hr urinary catecholamines Normal

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1. 이환자의 혈압은 증가되어 있다 . 혈압을 조절하는 요인들을 설명하고 이 환자에서 혈압이 증가된 원인이 무엇인지 제시해보시오 .2. 주치의는 이 환자의 고혈압이 renin-angiotensin-aldosterone system 과 관련이 있을 것으로 생각하고 혈장의 renin, aldosterone, cortisol 을 측정하도록 하였다 . 그 결과 renin 은 감소 , aldosterone 은 증가 , cortisol 은 정상이었다 . 이 결과들을 보고 이 환자 고혈압의 병태생리 (pathophysioloy) 에 대해 설명하시오 .3. 이 환자에서 Na+ 배설이 어떨 것 ( 증가 , 감소 또는 정상 ) 으로 예측 되는가 ?4. 이 환자에서 Na+ 배설이 정상인 이유를 설명해 보시오 .5. 이 환자의 hypokalemia 발생기전을 설명하시오 . 이 환자에게 KCl 용액을 주사하면 hypokalemia 가 교정될까요 ?6. 이 환자의 muscle weakness 가 발생한 기전을 설명하시오 .7. 이 환자의 acid-base 상태는 ? 그 기전은 ?8. 이 환자의 GFR 은 얼마인가 ?9. fractional Na+ excretion 은 얼마인가 ?10. 이 환자를 수술하기 전에 이뇨제를 투여한다면 적절한 이뇨제는 ? 그 이뇨제를 선택한 논리적 근거는 ?

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Diarrhea Park's wedding to the man of her dreams was perfect in every respect. However, while on her honeymoon in Mexico, Park had severe "traveler's diarrhea." Despite attempts to control the di-arrhea with over-the-counter medications, she continued to have 8-10 watery stools daily. She became progressively weaker, and on the third day, she was taken to the local emer-gency department. On physical examination, Park's eyes were sunken, her mucous membranes were dry, and her jugular veins were flat. She was pale, and her skin was cool and clammy. Her blood pressure was 90/60 when she was supine(lying) and 60/40 when she was upright. Her pulse rate was elevated at 120/min when she was supine. Her respirations were deep and rapid(24 breaths/min). Table shows the results of laboratory tests that were performed.

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Aterial bloodpH 7.25 (normal, 7.4)

PCO2 24 mm Hg (normal, 40 mm Hg)

Venous blood

Na+ 132 mEq/L (normal, 140mEq/L)K+ 2.3 mEq/L (normal, 4.5mEq/L)Cl- 111 mEq/L (normal, 105mEq/L)

Park's Laboratory Values

Park was admitted to the hospital, where she was treated with strong antidiarrheal medications and an infusion of NaCl and KHCO3. Within 24 hours, she felt well enough to be released from the hospital and enjoy the rest of her honeymoon.

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1. 이 환자의 산 - 염기 불균형은 어떤 상태인가 ?

2. 왜 설사가 산 - 염기 불균형을 유발하였는가 ?

3. 이 환자의 호흡이 빨라지고 깊어진 ( 과호흡 ) 이유는 ?

4. 이 환자의 anion gap 은 얼마인가 ? 이 환자에서 anion gap 은 무엇을 의미 하는가 ?

5. 이 환자의 혈압이 감소한 이유는 ?

6. 이 환자의 심박수가 증가한 이유는 ? 서 있으면 심박수 어떻게 변할까 ? 그 이유는 ?

7. 이 환자의 피부가 차갑고 (cool) 식은 땀 (clammy) 이 난 이유는 ?

8. 이 환자의 renin-angiotensin-aldosterone system 은 어떨까 ?

9. 이 환자의 혈중 K+ 농도가 낮은 이유는 ?

10. 이 환자에게 NaCl 과 KHCO3 를 투여한 이유는 ?

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Chronic obstructive pulmonary disease Lee was a 73-year-old retired seamstress who had chronic ob-structive pulmonary disease secondary to a long history of smok-ing. Six months before her death, she was examined by her physician. Her blood values at that time are shown in table.

PO2 48 mm Hg (normal, 100 mm Hg)

PCO2 69 mm Hg (normal, 40 mm Hg)

HCO3- 34 mm Hg (normal, 24 mEq/L)

pH 7.32 mm Hg (normal, 7.4)

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PO2 35 mm Hg (normal, 100 mm Hg)

PCO2 69 mm Hg (normal, 40 mm Hg)

HCO3- 20 mEq/L (normal, 24 mEq/L)

pH 7.09 mm Hg (normal, 7.4)

Against her physician's warnings, Lee adamantly refused to stop smoking. Six months later, Lee was desperately ill and was taken to the emergency department by her sister. Her blood values at that time are shown in Table.

She remained in the hospital and died 2 weeks later.

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1. 이 환자가 사망 6 개월 전에 병원을 방문했을 때 산 - 염기 불균형 상태는 ? 이 불균형이 유발된 이유는 ?

2. 사망 6 개월 전에 HCO3- 가 증가한 이유는 ?

3. 사망 6 개월 전 방문 시 신장의 보상 정도는 적절했는가 ?4. 병원에 마지막 방문 시 이 환자의 pH 가 6 개월 전에 비해서 왜 이렇게 낮았나 ? (HCO3

- 가 감소한 것을 근거로 그 이유를 설명하시오 . 힌트 : 산소분압이 감소 되어 있음 .)

5. 마지막 방문 시 anion gap 은 어땠을까 ?

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Case 1Lisa Kim is a 19-year-old prenursing students who works part-time in a pediatrician's office. Recently, Lisa's life seemed to revolve around being close to a bathroom and a drinking fountain. Lisa was urinating every hour(polyuria) and drinking more than 5 L of water daily(polydipsia). She always carried a water bottle with her and drank almost constantly. Lisa's employer, a physician, was con-cerned, and wondered whether Lisa had either a psychiatric disor-der involving compulsive water drinking(primary polydipsia) or dia-betes insipidus. He convinced Lisa to make an appointment with her personal physician.The findings on physical examination were normal. Lisa's blood pressure was 105/70, her heart rate was 85 heats/min, and her vis-ual fields were normal. Blood and urine samples were obtained for evaluation(Table).

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Lisa's Laboratory ValuesPlasma Urine

Na+ 147 mEq/L (normal, 140 mEq/L)Osmolarity 301 mOsm/L (normal, 290 mOms/L) 70 mOsm/L

Glucose (fasting) 90 mg/dl (normal, 70-100 mg/dl) Negative

Because of these initial laboratory findings, Lisa's physician per-formed a 2-hour water deprivation test. At the end of the test, Lisa's urine osmolarity remained at 70 mOsm/L and her plasma osmolarity increased to 325 mOsm/L. Lisa was then injected sub-cutaneously with dDAVP(an analogue of arginine vasopressin). Af-ter the injection, Lisa's urine osmolarity increased to 500 mOsm/L and her plasma osmolarity decreased to 290 mOsm/L.

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Based on the test results and her response to vasopressin [also called antidiuretic hormone(ADH)], Lisa was diagnosed with central diabetes insipidus. Because she had no history of head injury and subsequent magnetic resonance imaging scans ruled out a brain tumor, Lisa's physician concluded that Lisa had developed a form of central dia-betes insipidus in which there are circulating antibodies to ADH-se-creting neurons. Lisa started treatment with dDAVP nasal spray. She describes the spray as “amazing”. As long as Lisa uses the nasal spray, her urine output is normal, and she is no longer constantly thirsty.

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1. urine 의 osmolarity 를 조절하는 기전을 설명하시오 .2. polyuria 와 polydipsia 가 있는 환자에서 가능성이 있는 진단명은 ?3. 이 환자에서 primary polydipsia 가 ruled out 된 이유는 ? 4. urine 과 plasma 검사 후에 주치의는 central DI 나 nephrogenic DI 를 의심하였다 . 주치의는 검사결과를 토대로 왜 이러한 진단을 결정하게 되었나 ?5. 주치의가 이 환자를 central DI 로 확진하게 된 이유는 ?6. 혈청의 ADH 를 측정하였다면 central DI 와 nephrogenic DI 와는 어떠한 차이가 있을까 ?

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7. 주치의가 이 환자에게 dDAVP 를 투여한 후 urine osmolarity 가 단지 500mosmole/L 인 것을 확인하고 놀랐다 . 주치의는 urine osmolarity 가 더 높을 것으로 예측하였기 때문이다 . 주치의가 다시 생각해본 결과 dDAVP 로 처음 치료를 받을 때는 예상보다 urine osmolarity 가 높지 않다는 것을 기억해 낼 수 있었다 . 처음에는 주치의가 왜 urine osmolarity 가 500mosmole/L 보다 더 높아야 한다고 생각했나 ? 그런데 실제로 그렇게 높지 않은 이유는 무엇인가 ?

8. 이 환자를 치료하는데 dDAVP 가 효과적인 이유를 설명하시오 .

9. 주치의는 환자에게 dDAVP 로 치료를 받는 동안 hypoosmolarity 가 발생할 위험이 있다고 말해 주었다 . 이 환자는 hypoosmolarity 가 발생하는 것을 방지하려면 어떻게 해야 하나 ?

10. 이 환자가 nephrogenic DI 로 진단이 되었다면 치료 방법은 ?

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Case 2

Kim is a 58-year-old partner in a real estate firm. Over the years, the pres-sures of the job have taken their toll. Mr Kim has smoked two packs of fil-tered cigarettes a day for 40 years. He tries to watch his diet, but " re-quired" business lunches and cocktail hours have driven his weight up to 210 lb. He is 5 feet 9 inch tall. He recently separated from his wife of 35 years and is dating a much younger women. Suddenly realizing how out of shape he had become, he made an appointment for a physical examination.In his physician's office, Mr Kim's blood pressure was 180/125. The physician heard a continuous abdominal bruit(sound). Because of Mr Kim's elevated blood pressure and the bruit, the physician drew a venous blood sample to determine plasma renin levels. After receiving the result, the physician or-dered an additional test called a differential renal vein renin. Mr Kim's plasma renin activity was 10ng/ml/hr(normal 0.9-3.3ng/ml/hr). His differen-tial renal vein renin (left to right) was 1.6(normal is 1.0).The test results were consistent with left renal artery stenosis. Mr Kim was scheduled for a renal angiogram, which showed 80% occlusion of left renal artery as a result of severe atherosclerotic disease. A balloon angioplasty was performed immediately to clear the occlusion. Mr Kim's blood pressure was expected to return to normal after the procedure. He was ordered to stop smoking, follow a low-fat diet, exercise regularly, and undergo periodic physical examinations.

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1. 이 환자의 왼쪽 신동맥 막힘과 혈장 renin activity 증가와는 어떤 관계가 있는가 ? 2. 혈장 renin activity 증가가 혈압 증가를 일으킨 기전은 ?3. 양쪽 신정맥의 renin 비율이 1.6 이다 . 이는 왼쪽은 증가하고 오른쪽은 감소 했음을 의미한다 . 왜 이런 현상이 나타났을까 ?4. abdominal bruit 는 renal artery 의 stenosis 에 의해 와류 (turbulent flow) 가 형성되었기 때 문이다 . 신동맥이 좁아지면 왜 와류가 형성되나 ? 5. balloon angiography 가 성공하지 못하면 angiotensin-converting en-zyme (ACE) inhibitor 를 치료제로 사용한다 . 그 이유를 설명하시오 .

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Case 3David Mandel, who was diagnosed with type Ⅰ diabetes mellitus when he was 12 years old, is now a third-year medical students. David's diabetes remained in control throughout middle and high school, college, and the first 2 years of medical school. However, when David started his surgery clerkship, his regular schedule of meals and insulin injections was completely disrupted. One morn-ing, after a very late night in trauma surgery, David completely forgot to take his insulin! At 5 A.M., before rounds, he drank or-ange juice and ate two doughnuts. At 7 A.M., he drank more juice “strange” and that his heart was racing. At 9 A.M., he excused himself from the operating room because he thought he was going to faint. Later that morning, he was found unconscious in the call room. He was transferred immediately to the emergency depart-ment, where the information shown in Table was obtained.

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David's Physical Examination and Laboratory ValuesBlood pressure 90/40

Pulse rate 130/min

Respiration 32/min, deep and rapid

Plasma concentrationGlucose 560 mg/dl

Na+ 132 mEq/L (normal, 140 mEq/L)

K+ 5.8 mEq/L (normal, 4.5 mEq/L)

Cl- 96 mEq/L (normal, 105 mEq/L)

HCO3- 8 mEq/L (normal, 24 mEq/L)

Ketones ++ (normal, none)

Arterial blood

Po2112 mmHg (normal, 100 mmHg)

Pco220 mmHg (normal, 40 mmHg)

pH 7.22 (normal, 7.4)

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Based on the information shown in Table, it was determined that David was in diabetic ketoacidosis. He was given an intravenous in-fusion of saline and insulin. Later, after his blood glucose had de-creased to 175 mg/dl and his plasma K+ had decreased to 4 mEq/L, glucose and K+ were added to the infusion. David stayed in the hospi-tal overnight. By the next morning, his blood glucose, electrolytes, and blood gas values were normal.

1. 이 환자의 acid-base 상태는 ? 원인은 무엇인가 ?2. respiratory compensation 은 적절하게 이루어졌나 ?3. 이 환자의 호흡이 빠르고 깊은 이유는 ? 이런 type 의 호흡을 무어라 부르나 ?4. 이 환자가 insulin 주사를 맞지 않았을 때 acid-base balance 의 disorder가 발 생한 기전을 설명하시오 .

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5. 이 환자의 anion gap 은 정상인가 , 증가 하였는가 ? anion gap 의 의미는 ?6. 이 환자가 아침 7 시에 갈증을 느낀 이유는 ?7. 이 환자의 심박수가 증가한 이유는 ?8. 이 환자의 혈장 K+ 농도가 감소한 이유는 ? 이 환자의 K+ balance 는 positive, normal, negative ?

9. 초기의 saline 과 insulin 치료가 체액과 전해질의 balance 를 correction 하는데 도움이 되었다 . 그 기전을 설명하시오 .

10. 이 환자의 혈장 glucose 와 K+ 이 saline 과 insulin 치료로 정상으로 회복되었 는데 glucose 와 K+ 를 더 정맥으로 투여한 이유는 ?

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Case 4Lind, a 55-tear-old interior designer, has been terrified on flying ever since she had a "bad" experience on a commuter flight. Neverthe-less, she and her husband planned a trip to Paris to celebrate their thirtieth wedding anniversary. As the time for the trip approached, Lind had what she called "anxiety attacks." One evening, a few days before the scheduled flight to Paris, Lind started hyperventilating un-controllably. She became light-headed, and her hands and feet were numb and tingling. She thought she was having a stroke. Her hus-band rushed her to the local emergency department, where a blood sample was drawn immediately(Table I). The emergency department staff asked Lind to breathe into and out a paper bag. A second blood sample was drawn (Table II), Lind was pronounced "well," and re-turned home that evening.

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pH 7.56 (normal, 7.4)23 mm Hg (normal, 40 mm Hg)20 mEq/L (normal, 24 mEq/L)

pH 7.41 (normal, 7.4)41 mm Hg (normal, 40 mm Hg)25 mEq/L (normal, 24 mEq/L)

Lind's Laboratory Values on Arrival in the Emergency Depart-ment

Lind's Laboratory Values After Breathing into and Out of a Paper Bag

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1. 이 환자가 응급실에 왔을 때 산 - 염기 불균형 상태는 ? 그 이유는 ?2. 이 환자의 HCO3

- 농도가 낮은 이유는 ? 신장에 의한 보상은 적절하게 이루어 졌는가 ? 적절하지 않다면 그 이유는 ? ( 힌트 : 급성 또는 만성 ) 3. 이 환자가 어지러움 (light-headed) 을 느낀 이유는 ?4. 이 환자의 팔 다리가 저린 (tingling, numbness) 이유는 ?5. 이 환자가 비닐 주머니 (paper bag) 을 이용하여 호흡을 했을 때 산 - 염기 불균형이 교정 된 이유는 ?

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Case 5Maria Cuervo is a 20-year-old philosophy major at a state univer-sity. When the “24 hour” stomach flu went around campus dur-ing final exams, she was one of the unlucky students to become ill. However, instead of 24 hours, Maria vomited for 3 days. Dur-ing that time, she was unable to keep anything down, and she sucked on ice chips to relieve her thirst. By the time she was seen in the student health center, the vomiting had stopped, but she could barely hold her head up. On physical examination, Maria's blood pressure was 100/60, and she had decreased skin turgor and dry mucous membranes. The blood values shown in Table were obtained.

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Maria's Laboratory ValuesArterial blood

pH 7.53 (normal, 7.4)

HCO3- 37 mEq/L (normal, 24 mEq/L)

Pco2 45 mmHg (normal, 40 mmHg)

Venous blood

Na+ 137 mEq/L (normal, 140 mEq/L)

Cl- 82 mEq/L (normal, 105 mEq/L)

K+ 2.8 mEq/L (normal, 4.5 mEq/L)

Maria was admitted to the infirmary, where she received an infusion of isotonic saline and K+. She was released the next day, after her fluid and electrolyte status had re-turned to normal.

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1. 이 환자는 3 일간 구토를 한 후 acid-base 상태가 어떻게 되었나 ? 기전은 ?2. 이 환자의 혈중 Cl- 농도가 감소한 이유는 ?3. 정상인에 비하여 이 환자의 호흡은 ?4. 이 환자의 혈압이 감소한 이유는 ? 점막이 마른 이유는 ?5. 이 환자의 renin-angiotensin-aldosterone system 은 ? 그 이유는 ?6. 이 환자의 혈장 K+ 농도가 낮은 이유는 ?7. 이 환자의 ECF volume contraction 이 acid-base 상태에 미치는 영향은 ?8. 이 환자의 anion gap 은 ?9. 이 환자에게 saline 을 정맥 주사하는 이유는 ?10. 정맥주사액에 K+ 이 들어 있는 이유는 ?

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Mr. Sharma's Laboratory ValuesPlasma Na+ 112 mEq/L(normal, 140 mEq/L)

Plasma osmolarity 230 mOsm/L(normal, 290 mOsm/L)

Urine osmolarity 950 mOsm/L

Case 6Krishna Sharma is a 68-year-old mechanical engineer who retired 1 year ago, when he was diagnosed with oat cell carcinoma of the lung. Always an active person, he has tried to stay busy at home with con-sulting work, but the disease has sapped his energy. After dinner one evening, his wife noticed that he seemed confused and lethargic. While he was sitting in his recliner watching television, he had a grand mal seizure. His wife called the paramedics, who took him to took emergency department of the local hospital. In the emergency department, the information shown in Table was obtained.

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Mr. Sharma's blood pressure was normal, both supine(lying) and upright. He was treated immediately with an infusion of hyper-tonic(3%) NaCl. He was released from the hospital a few days later, with strict instructions to limit his water intake.

1. 이 환자의 혈장 Na+ 농도가 낮은 이유는 ?2. 이 환자의 혈장 삼투농도가 낮은 이유는 ?3. 이 환자의 소변 삼투농도가 높은 이유는 ?4. 이 환자가 grand mal seizure 를 한 이유는 ?5. 이 환자의 총 체액은 증가 , 정상 , 감소 ? 이 환자의 혈압이 정상인 이유는 ?6. 이 환자가 물의 섭취를 적절하게 절제하야만 되는 이유는 ? 7. 이 환자에게 hypertonic NaCl(3%) 를 주사하는 것 이 도움이 되는가 ? 그 이유는 ?