Acid-Base Cases

Ziyadeh

CASES on ACID-BASE DISORDERS

Case 1
A 42-year-old alcoholic man is brought to the hospital in a coma. Physical examination reveals normal vital signs,
except for tachypnea (increased respiratory rate = 24). Mild hepatosplenomegaly is present, but there is no edema
or jaundice. There are no focal neurological signs. The fundi were not visualized.
Laboratory examination revealed:
BUN (mg/dl) 30 Arterial pH 7.02
Cr (mg/dl) 1.5 pCO2 (mm Hg) 16
Glucose (mg/dl) 90 pO2 (mm Hg) 88
Na (mEq/L) 140 HCO3 (mEq/L) 4
K (mEq/L) 5.5
Cl (mEq/L) 105
Total CO2 content (mmoles/L) 5
Blood ketones trace positive
Serum osmolality (mOsm/kg) 340
Note that the total CO2 content in the serum is related to how the laboratory measures bicarbonate, and it
roughly reflects the serum bicarbonate concentration (plus the usually small amount of dissolved CO2 of
approximately 1-2 mmoles/L)

Questions
Part A
1. What is the acid-base disturbance?
2. What may cause this disturbance in alcoholics?
3. What additional physical or laboratory findings would help with the differential diagnosis of the acid-base
disturbance?
4. How does serum osmolality help with diagnosis?
5. If it is decided to raise the plasma HCO3 to a safer level of 10 mEq/L, how much NaHCO 3 would you estimate
is needed to be given? (The patient weighs 56 Kg).
Suppose that the patient is treated with intravenous NaHCO 3, and that 120 mEq are given over 2 hours. Repeat
laboratory studies then show:
Na (mEq/L) 148 Arterial pH 7.09
K (mEq/L) 3.8 pCO2 (mm Hg) 17
Cl (mEq/L) 102 pO2 (mm Hg) 90
Total CO2 (mmoles/L) 6 HCO3 (mEq/L) 5
Part B
1. Has the primary disturbance in acid-base metabolism improved?
2. Why did the treatment have so little effect on arterial pH?
3. Which of the possible causes of metabolic acidosis is most likely now?

1
Acid-Base Cases
Ziyadeh

Case 2
A 78-year-old woman is admitted to the hospital with episodic diarrhea and weight loss for 3 months. Physical
examination is unremarkable except for orthostatic hypotension and tachycardia. During the first week in the
hospital the patient is observed to have 8-10 watery bowel movements daily, and loses 2.5 Kg from her admission
weight despite medication to control the diarrhea. The patient is thirsty and drinks fluids liberally.
Laboratory evaluation on admission and one week later showed:
Admission After 1 week
BUN (mg/dl) 18 28
Na (mEq/L) 138 135
K (mEq/L) 3.9 3.0
Cl (mEq/L) 100 110
Total CO2 (mmoles/L) 27 13
Arterial pH 7.27
pCO2 (mm Hg) 27
pO2 (mm Hg) 100
HCO3 (mEq/L) 12
Questions
1. What is the acid-base disturbance after 1 week?
2. What is the cause of the acid-base disturbance?
3. Assuming no further diarrhea, what would be appropriate treatment?

Case 3
A 28-year-old woman with a 15 year history of diabetes mellitus is brought to the hospital in a coma. She is
afebrile, but is breathing rapidly and deeply (Kussmaul respirations). Her blood pressure is 120/70, and her pulse
90 and regular. The patient is comatose, but has no other neurological findings. Apart from diabetic retinopathy,
the remainder of her physical examination is normal. She weighs 70 kg.
The following laboratory data are obtained on admission:
Glucose (mg/dl) 500 Arterial pH 7.02
BUN (mg/dl) 20 pCO2 (mm Hg) 16
Cr (mg/dl) 1.3 pO2 (mm Hg) 98
Na (mEq/L) 133 HCO3 (mEq/L) 4
K (mEq/L) 4.0
Cl (mEq/L) 96
Total CO2 content 5
(mmoles/L)

Questions
1. What is the acid-base disturbance?
2. What is the etiology of the disturbance?
3. What would be appropriate therapy?

2
Acid-Base Cases
Ziyadeh

Case 4
A 22-year-old man recently returned from a trip to Africa. He developed severe nausea and vomiting on the day of
his return. He regrets having eaten some food sold by a roadside vendor in one of the popular open markets. He
has been vomiting incessantly for three days when he comes to the ER. He says he has been unable to keep
anything down and feels terribly weak and dizzy.

On physical examination he appears pale and clammy. His BP is 100/60 when supine with a HR of 100. When
you stand him up he becomes markedly dizzy and his HR increases to 140 and his systolic BP is barely 80 by
palpation. The rest of the examination is unremarkable.
A set of emergency labs is drawn and the nurse inserts an intravenous catheter. The laboratory technician
calls you back with the following labs:
BUN (mg/dl) 50
Cr (mg/dl) 1.5
Glucose (mg/dl) 80
Na (mEq/L) 145
K (mEq/L) 3.0
Cl (mEq/L) 95
Total CO2 content 36
(mmoles/L)
The nurse gets only a very small sample of urine for a urinalysis, and it shows:
Urine osmolality 895 mOsm/kg, pH 5.5, trace ketones, and no glucose, protein or cells.
Questions
1. What has happened to this young man? Does he have an acid-base disorder?
2. Do you need a blood gas to help with the diagnosis?
3. What are the pathophysiological factors responsible for the acid-base problem?
4. What do you think his urinary electrolytes are likely to be?
5. The ER attending orders a liter of normal saline to be infused as rapidly as possible. Do you agree?
6. If you were to check a urinalysis after the patient has received 3 liters of normal saline, with improvement in
his BP and urine output, what is it likely to show?

END