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D) Respiratory alkalosis
E) Metabolic alkalosis with respiratory alkalosis
Q.8- A middle-aged person collapsed on the road side and
was brought to emergency, Blood chemistry revealed the
following:
pH- 7.51, PCO2- 35 mm Hg, PO2- 62mm Hg and HCO3--27
meq/L.
Which of the following is the most appropriate acid base
imbalance in the above said condition?
A) Metabolic acidosis
B) Metabolic alkalosis with respiratory acidosis
C) Respiratory alkalosis with metabolic compensation
D) Respiratory acidosis
E) Metabolic alkalosis with respiratory alkalosis.
Q.9- A 24 year female reported to the emergency with
difficulty in breathing. History revealed that she had
ingested some unknown drug. The blood chemistry revealed
the following:
PH-7.1; PCO2- 55 mm Hg; PO2-42 mm Hg and HCO317 meq/L
Which of the following is the most appropriate acid base
imbalance in the above said condition?
A) Metabolic acidosis with respiratory acidosis
B) Respiratory acidosis
C) Respiratory Alkalosis
D) Metabolic alkalosis
E) None of the above.
B) Excessive sweating
C) Renal failure
D) Mineralocorticoid deficiency
E) Chronic diarrhea
Q.14- Hypokalemia is serum K concentration < 3.5 mEq/L
and is caused by:
A) Renal losses
B) GI losses
C) Diuretics
D) Insulin administration
E) All of the above.
Q.15- Hyponatremia is decrease in serum Na concentration
< 136 mEq/L and is caused by :
A) Diuretic use
B) Crush injuries
C) Hemolysis
D) High fever
E) None of the above.
Q.16- Serum sodium concentration is regulated by:
A) Stimulation of thirst,
B) Secretion of ADH,
C) Renin-angiotensin-aldosterone system,
D) Variations in renal handling of filtered sodium
B) pH = pK + log (HA/A-)
C) pH = pK log(A-/HA)
D) pH = pK log(HA/A-)
E) pH = pK + log(H+/HA)
Q.6- Buffering effect of a buffering solution is optimum at :
A) pH ranges close to pKa 2 pH units
B) pH = pKa 3 pH units
C) pH = pKa 5 pH units
D) pH = pKa
E) None of the above.
Q.7- The pH of extracellular fluid must be maintained
between:
A) 6 to 7.4
B) 7 to 7.2
C) 7.35 to 7.45
D) 7.5 to 8
E) 8 to 8.5
Q.8- All are true for renal handling of acids in metabolic
acidosis except
A) Hydrogen ion secretion is increased
B) Bicarbonate reabsorption is decreased
C) Urinary acidity is increased
D) Urinary ammonia is increased
C) Bilirubin diglucuronate
D) Bilirubin Acetate
E) Methylated Bilirubin
15) In phenylketonuria (a congenital disorder of
phenylalanine metabolism that occurs due to deficiency of
phenylalanine hydroxylase), there is impaired conversion of
phenylalanine to tyrosine. The excess phenylalanine is
detoxified and excreted in urine. Which of the following
conjugating agents is used for detoxification of
phenylalanine?
A) Glutathione
B) Glutamine
C) S-Adenosyl Methionine
D) Active Sulfate (PAPS)
E) D- Glucuronic acid
16) Which of the following is not a cause of secondary
dehydration?
A) Excessive sweating
B) Comatose patient
C) Vomiting
D) Diarrhea
E) Congestive heart failure
17) The urinary concentration of sodium chloride (NaCl)
ranges between:
A) 2-6 G/litre
B) 4-8 G/litre
C) 5-10 G/litre
D) 6-16 G/litre
E) None of the above
18) The minimum excretory volume to eliminate waste
products from the body in dehydration is :
A) 100-200ml
B) 200-400 ml
C) 500-600 ml
D) 1500 ml
E) 600-800 ml
19) Aldosterone acts by promoting:
A) Excretion of Potassium
B) Reabsorption of potassium
C) Reabsorption of sodium
D) Excretion of sodium
E) Reabsorption of sodium and excretion of Potassium
20) Which of the following is not a cause of hypokalemia?
A) Renal tubular acidosis
B) Cushing syndrome
C) GI losses
D) Crush injuries
E) Insulin administration
Key to answers
1)- A, 2)- A, 3)-A, 4)-D, 5)-A, 6)-A, 7)-C, 8)-B, 9)-A, 10)- B, 11)-E, 12)C, 13)-D, 14)-C, 15)-B, 16)-B, 17)-D, 18)-C, 19)-E, 20)-D.
Effect of pCO2
pCO2 Ventilation Eliminates CO2 Reduces [H+] and pH
pCO2 Ventilation CO2 [H+] & pH
HCO3 - re-absorption
With a serum HCO3 - concentration of 24 mEq/L, the daily glomerular
ultra filtrate of 180 L, in a healthy subject, contains 4300 mEq of
HCO3 -, all of which has to be reabsorbed. Approximately 90% of the
filtered HCO3 - is reabsorbed in the proximal tubule, and the
remainder is reabsorbed in the thick ascending limb and the
medullary collecting duct (figure-1).
The 3Na+ -2K+ ATPase (sodium-potassium adenosine
triphosphatase) provides the energy for this process, which
maintains a low intracellular Na+ concentration and a relative
negative intracellular potential. The low Na+ concentration indirectly
provides energy for the apical Na+/H+ exchanger, which transports
H+ into the tubular lumen. H+ in the tubular lumen combines with
filtered HCO3 - in the following reaction:
HCO3 - + H+ H2 CO3 H2 O + CO2
Carbonic Anhydrase (CA IV isoform) present in the brush border of
the first 2 segments of the proximal tubule accelerates the
dissociation of H2 CO3 into H2O + CO2, which shifts the reaction
shown above to the right and keeps the luminal concentration of
H+ low. CO2 diffuses into the proximal tubular cell perhaps via the
aquaporin-1 water channel, where carbonic anhydrase (CA II
isoform) combines CO2and water to form HCO3 - and H+. The
HCO3 - formed intracellularly returns to the pericellular space and
then to the circulation via the basolateral Na+/3HCO3 - co
transporter.
In essence, the filtered HCO3 - is converted to CO2 in the lumen,
which diffuses into the proximal tubular cell and is then converted
back to HCO3 - to be returned to the systemic circulation, thus
reclaiming the filtered HCO3 -
this system(figure-2) but other urine buffers include uric acid and
creatinine.
H2 PO4 H+ + HPO4
2-
NH4 + is trapped in the lumen and excreted as the Cl salt, and every
H+ ion buffered is an HCO3 - gained to the systemic circulation
(figure-3)
The kidneys can adjust the amount of NH3 synthesized to meet
demand, making this a powerful system to buffer secreted H+ in the
urine.
2) Carbonic acid is the chief acid (volatile acid) produced in the body
by the metabolic processes in the body. Approximately 300 litres of
CO2 are produced and eliminated daily in the body of an adult.
3) Sulphuric acid- it is produced during the oxidation of sulphurcontaining amino acids and vitamins.
4) Phosphoric acid- is produced from the metabolism of dietary
phosphoproteins, phospholipids, nucleic acids and hydrolysis of
phosphoesters.
Mechanism of maintenance of Physiological pH
Under normal conditions, acids and, to a lesser extent, bases are
being added constantly to the extracellular fluid compartment but
still a physiologic [H+] of 40 nEq/L is maintained and the following 3
processes must take place:
Buffering by extracellular and intracellular buffers
Alveolar ventilation, which controls PaCO2
Renal H+ excretion, which controls plasma [HCO3 -]
Buffers
Buffers are weak acids or bases that are able to minimize changes in
pH by taking up or releasing H+. Phosphate is an example of an
effective buffer, as in the following reaction:
HPO4
2-
+ (H+) H2 PO4
Fasting
Effect Compensatory Re
on pH sponse
and
Ratio
of
Bicar
bonat
e:
Carbo
nic
acid
pH Respiratory
decrea Mechanismsed,
RespiratoryAlkalosis(
Hyperventilation)
Ratiodecrea Pa CO2 Decreased
sed
Renal
mechanisms
1) Increased
excretion of H+ ions
2) Lactic Acidosis
Shock
Seizures
2) Decreased
excretion of K+ ions
in the distal tubules
3) Decreased
bicarbonate
excretion
3) Renal Failure
4)Increased
ammonia formation
4) Toxins Metabolized to
acids
5) Increased acid
phosphate excretion
Alcohol
Methanol (formate)
Ethylene glycol
(oxalate)
Salicylates
Colostomy
Diarrhea
Enteric fistulas
Ileostomy
2)Urologic procedures
3) Renal HCO3 loss
Tubulointerstitial renal
disease
4) Ingestions
Acetazolamide
CaCl2
Mg sulfate (MgSO4)
Meta
bolic
Alkal
osis
Gain Chloride-responsive
in
alkalosis
HCO3
-or
Loss of gastric
loss
secretions Vomiting,
HCO3 of H+
NG suction
Increa
Loss of colonic
sed
secretions
Ingestion of large
doses of
nonabsorbable
antacids
Chloride-resistant
alkalosis
Primary
hyperaldosteronism
pH
Respiratory
increa Mechanismsed,
Respiratory
Ratio Acidosis(Hypoventila
increa tion)
sed
PaCO2 Increased.
Renal Mechanism
1) Decreased
excretion of H+ ions
2) Increased
excretion of K+ ions
in the distal tubules
3) Increased
bicarbonate
excretion
4) Decreased
ammonia formation
5) Decreased acid
Phosphate excretion
Cushing syndrome
Exogenous
mineralocorticoids or
glucocorticoids
Reno vascular
hypertension
Renin- or deoxy
corticosteronesecreting tumors
Current use of
thiazides and loop
diuretics
Hypomagnesaemia(Thr
ough Hypokalemia)
pHMetabolic Alkalosis
decrea
sed,
HCO3-Increased.
Ratio- Renal
decrea mechanisms 1)
sed
Increased excretion
Infections
of H+ ions
Diseases- Intracranial
tumor
2) Decreased
bicarbonate
excretion
3) Increased
ammonia formation
4) Increased acid
B)Airway obstruction
Severe asthma,
Anaphylaxis
Inhalational burn
Toxic injury
Laryngeal obstruction
End-stage obstructive
lung disease.
C) Parenchymatous
damage /Inflammation
Emphysema
Bronchitis
Adult Respiratory
distress syndrome
Pleurisy
Barotrauma
D) Neuromuscular
Poliomyelitis
Kyphoscoliosis
Myasthenia gravis
Muscular dystrophies
E) Misc.
Certain congenital
phosphate excretion
heart diseases
Mechanical ventilation
Rebreathing from a
closed space
Psychosis
Fever
Cerebrovascular
accident
Meningitis
Encephalitis
Tumor
Trauma
Hypoxia
o High altitude
o Severe anemia
o Right-to-left
pH Metabolic Acidosis
Increa
sed,
HCO3-Decreased
Ratio- Renal Mechanism
Increa
sed
1)Decreased
excretion of H+ ions
2)Increased
bicarbonate
excretion
3)Decreased
ammonia formation
4)Decreased
phosphate excretion
shunts
Drugs
o Progesterone
o Methylxanthines
o Salicylates
o Catecholamines
o Nicotine
Endocrine
o Pregnancy
o Hyperthyroidism
Pulmonary
o Pneumothorax/h
emothorax
o Pneumonia
o Pulmonary
edema
o Pulmonary
embolism
o Aspiration
o Interstitial lung
disease
o Asthma
o Emphysema
o Chronic
bronchitis
Miscellaneous
o Sepsis
o Hepatic failure
o Mechanical
ventilation
o Heat exhaustion
o Recovery phase
of metabolic
acidosis
o Congestive heart
failure
pH- 7.3
PCO2- 46 mm Hg
PO2- 55 mm Hg
HCO3- 24meq/L
What is your Interpretation?
Case discussion-
Low p H acidosis
Low PO2 and PCO2 excess signify Primary respiratory
problem
HCO3:24 -normal
Thus, the patient is suffering from Acute respiratory
acidosis.
Case details -2
A 4 day old girl neonate became lethargic and uninterested
in breast-feeding. Physical examination revealed tachypnea
(rapid breathing) with a normal heart beat and breath
sounds. Initial blood chemistry values included normal
glucose, sodium, potassium, chloride, and bicarbonate
(HCO3-) levels.
Blood gas values revealed a pH of 7.53, partial pressure of
oxygen (PO2) was normal (103 mm Hg) but PCO2 was 27
mmHg.
What is the probable diagnosis?
Case discussion
The baby is suffering from Respiratory Alkalosis
Case details-3
A new-born with tachypnea and cyanosis (bluish color) is
found to have a blood pH of 7.1. Serum bicarbonate is
measured as 12 mM while pCO2 is 40 mm Hg.
What is the probable diagnosis?
Case discussion
Low p H and low bicarbonate indicate metabolic acidosis. Since p
CO2 is normal it can not be compensatory respiratory acidosis ( If
the baby had respiratory acidosis, the PCO2 would have been
elevated).This is a hypoxia related metabolic acidosis.
Hyperventilation is as a compensation to metabolic acidosis.
Case details -4
A 60-year-old man was brought to hospital in a very serious
condition. The patient complained of constant vomiting
containing several hundred mL of dark brown fluid from the
previous two days plus several episodes of melaena. Past
history of alcoholism, cirrhosis, portal hypertension and a
previous episode of bleeding varices was there.
Arterial Blood Gases revealedpH 7.10
pCO2 13.8 mmHg
pO2- 103 mmHg
HCO3- 14.1 mmol/l
Laboratory Investigations
Na+ 131 mmol/l., Cl- 85 mmol/l. K+ 4.2 mmol/l., total CO2 5.1,
glucose 52mg/dl, urea 38.6mg/dl, creatinine1.24mg/dl, lactate 20.3
mmol/l Hb 6.2 G%, and WBC- 18x103/mm3
Case discussion
The patient is severely ill with circulatory failure and GI bleeding on
a background of known cirrhosis with portal hypertension.
Case details-5
A 56- year -old man who smoked heavily for many years
developed worsening cough with purulent sputum and was
admitted to the hospital because of difficulty in breathing.
He was drowsy and cyanosed. His arterial blood gas analysis
was as follows;
pH - 7.2
p CO2 70 mm Hg
HCO3- 26 mmol/L
P O2- 50 mm Hg
What is the likely diagnosis?
Case discussion
The patient is suffering from Respiratory acidosis. Difficulty in
breathing, cough and purulent sputum signify the underlying lung
pathology. Low p H and raised pCO2 indicate respiratory acidosis.
Slightly high HCO3- may be due to compensation as a result of
increased reabsorption from the kidney. The low pO2 is due to
associated hypoxia. The treatment is based on the treating the
primary cause.O2 and mechanical ventilation are often needed.
Case details -6
A 5-year old girl displayed increased appetite, increased
urinary frequency, and thirst. Her physician suspected new
onset diabetes mellitus and confirmed that she had elevated
urine glucose and ketones.
Blood gas analysis revealed
pH-7.33
Bicarbonate-12.0 mmol/L
Arterial PCO2- 21
Case discussion
The patient is suffering from Diabetic ketoacidosis
In the presence of insulin deficiency, a shift to fatty acid oxidation
produces the ketones that cause metabolic acidosis. The pH and
bicarbonate are low, and there is frequently some respiratory
compensation (hyperventilation with deep breaths) to lower the
PCO2. A low pH with high PCO2 would have represented respiratory
acidosis which is not there in the given case.
Case details-7
A 19-year-old boy was brought to the emergency
department with loss of consciousness. Apparently the
patient was a homeless found on the street.
Arterial blood gases revealedpH 7.33,
pCo2 28 mm Hg,
pO2- 117 mmHg and
HCO3- 14 mmol/L
The blood level of methanol was 0.4 mg/dl.
What is your diagnosis?
Case discussion
The patient is suffering from metabolic acidosis as evident from the
low p H and low bicarbonate levels. Low p CO2 and high p O2 signify
that the patient is in a state of respiratory compensation. Blood
methanol level is high, so it might be the case of Methanol poisoning
producing metabolic acidosis.
Case details-8
A 66-year-old man had a postoperative cardiac arrest. Past
history of hypertension treated with an ACE inhibitor was
there. There was no past history of Ischemic heart disease.
Following reversal and extubation, myocardial ischemia was
noticed on ECG. He was transferred to ICU for overnight
monitoring. On arrival in ICU, BP was 90/50, pulse 80/min,
respiratory rate was 16/min and S pO2 99%. During
handover to ICU staff, he developed ventricular fibrillation
Case discussion
1) p H- low , Acidosis is present.
2) p CO2- high, hypoventilation(The residual depressant effect of
the Anesthetic agents is considered the most likely cause)
3) Bicarbonate- near normal
4) pO 2- high- This is because the patient is breathing a high
inspired oxygen concentration. If the patient had been breathing
room air (FIO2 = 0.21), then a depression of alveolar pO2 must have
occurred. Most ill patients in hospital breathe supplemental oxygen
so it is common for the pO2 to be elevated on blood gas results.
5) An acidemia with the pattern of elevated pCO2 and normal HCO3
is consistent with an acute respiratory acidosis.
6) Anion gap- The anion gap is about 11 which is normal so no
evidence of a high anion gap acidosis.
Case details -9
A 72-year-old male with diabetes mellitus is evaluated in the
emergency room because of lethargy, disorientation, and
long, deep breaths (Kussmaul respiration). Initial
chemistries on venous blood demonstrate high glucose level
of 380 mg/dl (normal up to 120 mg/dl) and pH of 7.3.
Bicarbonate 15mM and PCO2 30 mmHg, What is the
probable diagnosis ?
Case discussion
The man is acidotic as defined by pH lower than normal 7.4. His
hyperventilation with Kussmaul respiration can be interpreted as
compensation by lungs to blow off CO2 to lower PCO2, to increase
[HCO3-]/[CO2] ratio, and to raise pH. Thus the patient has metabolic
acidosis due to underlying Diabetic ketoacidosis.
Case details-10
A 24 year female with broken ankle was brought to
emergency with acute pain.
Blood gas analysis revealed the following
pH- 7.55
PCO2- 27
PO2- 105,
HCO3- 23
Case discussion
pH:- 7.55 indicates Alkalosis
PCO2: 27 -low, it is a Primary respiratory disturbance
PCO2 Deficit = 40-27 = 13
HCO3 = 23 (Normal)
Interpretation:
It is Respiratory alkalosis due to pain related hyperventilation.
d) Respiratory Alkalosis
Q.7- A post operative surgical patient had a naso gastric
tube in for three days. The nurse caring for the patient
stated that there was much drainage from the tube that is
why she felt so sick. What could be the reason?
a) Metabolic Acidosis
b) Metabolic Alkalosis
c) Respiratory Acidosis
d) Respiratory Alkalosis
Q.8- The p H of the body fluids is stabilized by buffer
systems. Which of the following compounds is the most
effective buffer system at physiological pH ?
a) Bicarbonate buffer
b) Phosphate buffer
c) Protein buffer
d) All of the above
Q.9- Which of the following laboratory results below
indicates compensated metabolic alkalosis?
a) Low p CO2, normal bicarbonate and, high pH
b) Low p CO2, low bicarbonate, low pH
c) High p CO2, normal bicarbonate and, low p H
d) High pCO2, high bicarbonate and High pH
Q.10- The greatest buffering capacity at physiological p H
would be provided by a protein rich in which of the following
amino acids?
a) Lysine
b) Histidine
c) Aspartic acid
d) Leucine
Q.11- Which of the following is most appropriate for a
female suffering from Insulin dependent diabetes mellitus
with a pH of 7.2, HCO3-17 mmol/L and pCO2-20 mm HG
a) Metabolic Acidosis
b) Metabolic Alkalosis
c) Respiratory Acidosis
d) Respiratory Alkalosis
Q.12- Causes of metabolic alkalosis include all the following
except.
a) Mineralocorticoid deficiency.
b) Hypokalemia
c) Thiazide diuretic therapy.
d) Recurrent vomiting.
Q.13- Renal Glutaminase activity is increased ina) Metabolic acidosis
b) Respiratory Acidosis
c) Both of the above
d) None of the above
Q.14- Causes of lactic acidosis include all excepta) Acute Myocardial infarction
b) Hypoxia
c) Circulatory failure
d) Infections
Q.15- Which out of the following conditions will not cause
respiratory alkalosis?
a) Fever
b) Anxiety
c) Laryngeal obstruction
d) Salicylate toxicity
Q.16- All are true about metabolic alkalosis except onea) Associated with hyperkalemia
b) Associated with decreased ionic calcium concentration
c) Can be caused due to Primary hyperaldosteronism
d) Can be caused due to Renin secreting tumor
Q.17- Choose the incorrect statement out of the following
a) Deoxy hemoglobin is a weak base
b) Oxyhemoglobin is a relatively strong acid
c) The buffering capacity of hemoglobin is lesser than plasma
protein
d) The buffering capacity of Hemoglobin is due to histidine residues.
Q.18- Carbonic anhydrase is present at all places excepta) Gastric parietal cells
b) Red blood cells
Answers- 1-a, 2-b, 3-c, 4-d, 5-a, 6-c, 7-b, 8-a, 9-d, 10-b, 11-a,
12-a, 13-c, 14-d, 15-c, 16-a, 17-c, 18-d, 19-b, 20-d, 21-a.
What is the acid base status of the girl? Discuss in detail about the
imbalance
How would the kidneys try to compensate for the girls acid-base
imbalance?
Q.10- A 76-year-old man complained to his wife of severe substernal chest pain that radiated down the inside of his left arm.
Shortly afterwards, he collapsed on the living room floor. Paramedics
arriving at his house just minutes later found him unresponsive, not
breathing, and without a pulse. CPR and electro convulsive shock
were required to start his heart beating again. Upon arrival at the
Emergency Room, the man started to regain consciousness,
complaining of severe shortness of breath (dyspnea) and continued
chest pain. On physical examination, his vital signs were as follows:
Systemic blood pressure
85 mm Hg / 50 mm Hg
Heart rate
Respiratory rate
32 breaths / minute
Temperature
99.2oF
His breathing was labored, his pulses were rapid and weak
everywhere, and his skin was cold and clammy. An ECG was done,
revealing significant Q waves in most of the leads. Blood testing
revealed markedly elevated creatine phosphokinase (CPK) levels of
cardiac muscle origin. Arterial blood was sampled and revealed the
following:
pH
7.22
pCO2
30 mm Hg
pO2
70 mm Hg
Hemoglobin O2 saturation
88 %
[HCO3-]
2 meq / liter
7.50
pCO2
30 mm Hg
pO2
100 mm Hg
Hemoglobin O2 saturation
98%
[HCO3-]
24 meq / liter
Q.12-A 28-year-old woman has been sick with the flu for the past
week, vomiting several times every day. She is having a difficult
time keeping solids and liquids down, and has become severely
dehydrated. After fainting at work, she was taken to a walk-in clinic,
where an IV was placed to help rehydrate her. Arterial blood was
drawn first, revealing the following:
pH
7.50
pCO2
40 mm Hg
pO2
95 mm Hg
Hemoglobin O2 saturation
97%
[HCO3-]
32 meq / liter