Acid-Base status 판정pH 7.23 7.46 7.37 7.66 7.34 7.54 [HCO3-] mEq/L 10 30 28 22 26 18 PCO2 (mmHg) 25 44 50 20 50 22 disorder 체액 산-염기의 분석 CASE . Recently. However. Professor Simon's wife was very concerned and made an appointment for him to see his primary care physician.고알도스테론증(Hyperaldosteronism: Conn's Syndrome) Seymour Simon is a 54-year-old college physics professors who maintains a healthy lifestyle. He exercises regularly." He attributed the headaches to the stress of preparing his grant renewal. he experienced generalized muscle weakness and headaches that "just won't quit. His physician ordered laboratory tests on his blood and urine that yielded the information shown in Table. . both in the lying (supine) and the standing positions. however. Overthe-counter pain medication did not help. he appeared healthy. his blood pressure was significantly elevated at 180/100. and keeps his weight in the normal range. doesn't smoke or drink alcohol. On physical examination. Professor Simon's Laboratory Values Arterial blood pH PCO2 7.1 mg/dl (normal. 7. 40 mmHg) Venous blood Na+ K+ HCO3Cl142 mEq/L (normal.4) 48 mmHg (normal. 4. 105 mEq/L) Creatinine 1. 1.5 mEq/L) 36 mEq/L (normal. 140 mEq/L) 2.0 mEq/L (normal.2 mg/dl) Urine Na+ excretion K+ excretion Creatinine excretion 24-hr urinary catecholamines 200 mEq/24 hr (normal) 1350 mEq/24 hr (elevated) 1980 mg/24 hr Normal . 24 mEq/L) 98 mEq/L (normal.50 (normal. aldosterone. 이 결과들을 보고 이 환자 고혈압의 병태생리 (pathophysioloy)에 대해 설명하시오. 그 결과 renin은 감소. 감소 또는 정상)으로 예측 되는가 ? 4. 이 환자의 muscle weakness가 발생한 기젂을 설명하시오. 이 환자에서 Na+ 배설이 어떨 것(증가. 5. 이 환자의 hypokalemia 발생기젂을 설명하시오. 이 환자에게 KCl용액을 주사하면 hypokalemia가 교정될까요? 6. 혈압을 조젃하는 요인들을 설명하고 이 환자에서 혈압이 증가된 원인이 무엇인지 제시해보시오. cortisol을 측정하도록 하였다. cortisol은 정상이었다. 2. 이 환자에서 Na+ 배설이 정상인 이유를 설명해 보시오. 이 환자의 GFR은 얼마인가 ? 9. 주치의는 이 환자의 고혈압이 renin-angiotensin-aldosterone system과 관련이 있을 것으로 생각하고 혈장의 renin. 3. aldosterone은 증가. 이 환자를 수술하기 젂에 이뇨제를 투여한다면 적젃한 이뇨제는 ? 그 이뇨제를 선택한 논리적 근거는 ? . 7. 이 환자의 acid-base 상태는 ? 그 기젂은 ? 8.1. fractional Na+ excretion은 얼마인가 ? 10. 이환자의 혈압은 증가되어 있다. " Despite attempts to control the diarrhea with over-the-counter medications.Diarrhea Park's wedding to the man of her dreams was perfect in every respect. . Her respirations were deep and rapid(24 breaths/min). she continued to have 8-10 watery stools daily. She became progressively weaker. and her jugular veins were flat. Park had severe "traveler's diarrhea. Table shows the results of laboratory tests that were performed. while on her honeymoon in Mexico. On physical examination. Park's eyes were sunken. she was taken to the local emergency department. 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. She was pale. Her pulse rate was elevated at 120/min when she was supine. her mucous membranes were dry. However. and on the third day. where she was treated with strong antidiarrheal medications and an infusion of NaCl and KHCO3. 105mEq/L) Park was admitted to the hospital. . 7. Within 24 hours.4) 24 mm Hg (normal.5mEq/L) 111 mEq/L (normal.Park's Laboratory Values Aterial blood pH PCO2 7.3 mEq/L (normal.25 (normal. she felt well enough to be released from the hospital and enjoy the rest of her honeymoon. 40 mm Hg) Venous blood Na+ K+ Cl132 mEq/L (normal. 4. 140mEq/L) 2. 이 환자의 anion gap은 얼마인가 ? 이 환자에서 anion gap은 무엇을 의미 하는가 ? 5. 이 환자의 심박수가 증가한 이유는 ? 서 있으면 심박수 어떻게 변할까? 그 이유는 ? 7. 이 환자의 호흡이 빨라지고 깊어진(과호흡) 이유는 ? 4.1. 이 환자의 혈압이 감소한 이유는 ? 6. 이 환자의 혈중 K+농도가 낮은 이유는 ? 10. 이 환자의 산-염기 불균형은 어떤 상태인가 ? 2. 이 환자의 renin-angiotensin-aldosterone system은 어떨까 ? 9. 이 환자의 피부가 차갑고(cool) 식은 땀(clammy)이 난 이유는 ? 8. 이 환자에게 NaCl과 KHCO3를 투여한 이유는 ? . 왜 설사가 산-염기 불균형을 유발하였는가? 3. Her blood values at that time are shown in table.Chronic obstructive pulmonary disease Lee was a 73-year-old retired seamstress who had chronic obstructive pulmonary disease secondary to a long history of smoking. she was examined by her physician. 40 mm Hg) 34 mm Hg (normal.32 mm Hg (normal. PO2 PCO2 HCO3pH 48 mm Hg (normal.4) . Six months before her death. 100 mm Hg) 69 mm Hg (normal. 7. 24 mEq/L) 7. Lee adamantly refused to stop smoking. 24 mEq/L) pH 7.09 mm Hg (normal.4) She remained in the hospital and died 2 weeks later. 100 mm Hg) 69 mm Hg (normal. 7. Lee was desperately ill and was taken to the emergency department by her sister. Her blood values at that time are shown in Table. 40 mm Hg) 20 mEq/L (normal. PO2 PCO2 HCO335 mm Hg (normal. Six months later. .Against her physician's warnings. 병원에 마지막 방문 시 이 환자의 pH가 6개월 젂에 비해서 왜 이렇게 낮았나? (HCO3-가 감소한 것을 근거로 그 이유를 설명하시오. 힌트: 산소분압이 감소 되어 있음.) 5. 이 환자가 사망 6개월 젂에 병원을 방문했을 때 산-염기 불균형 상태는 ? 이 불균형이 유발된 이유는 ? 2. 마지막 방문 시 anion gap은 어땠을까? .1. 사망 6개월 젂 방문 시 싞장의 보상 정도는 적젃했는가? 4. 사망 6개월 젂에 HCO3-가 증가한 이유는 ? 3. Blood and urine samples were obtained for evaluation(Table). was concerned. and her visual fields were normal. Lisa's life seemed to revolve around being close to a bathroom and a drinking fountain. Recently. Lisa's employer. Lisa was urinating every hour(polyuria) and drinking more than 5 L of water daily(polydipsia). The findings on physical examination were normal. and wondered whether Lisa had either a psychiatric disorder involving compulsive water drinking(primary polydipsia) or diabetes insipidus. She always carried a water bottle with her and drank almost constantly.Case 1 Lisa Kim is a 19-year-old prenursing students who works part-time in a pediatrician's office. . a physician. He convinced Lisa to make an appointment with her personal physician. Lisa's blood pressure was 105/70. her heart rate was 85 heats/min. Lisa's urine osmolarity increased to 500 mOsm/L and her plasma osmolarity decreased to 290 mOsm/L. 70-100 mg/dl) 70 mOsm/L Negative Urine Because of these initial laboratory findings. After the injection. 290 mOms/L) 90 mg/dl (normal. Lisa was then injected subcutaneously with dDAVP(an analogue of arginine vasopressin). 140 mEq/L) 301 mOsm/L (normal. At the end of the test. Lisa's physician performed a 2-hour water deprivation test. Lisa's urine osmolarity remained at 70 mOsm/L and her plasma osmolarity increased to 325 mOsm/L. .Lisa's Laboratory Values Plasma Na+ Osmolarity Glucose (fasting) 147 mEq/L (normal. As long as Lisa uses the nasal spray. her urine output is normal.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. She describes the spray as “amazing”. Lisa started treatment with dDAVP nasal spray. and she is no longer constantly thirsty. Lisa's physician concluded that Lisa had developed a form of central diabetes insipidus in which there are circulating antibodies to ADH-secreting neurons. . urine과 plasma 검사 후에 주치의는 central DI나 nephrogenic DI를 의심하 였다. polyuria와 polydipsia가 있는 환자에서 가능성이 있는 진단명은 ? 3.1. 혈청의 ADH를 측정하였다면 central DI와 nephrogenic DI와는 어떠한 차이 가 있을까 ? . 이 환자에서 primary polydipsia가 ruled out 된 이유는 ? 4. 주치의가 이 환자를 central DI로 확진하게 된 이유는 ? 6. 2. 주치의는 검사결과를 토대로 왜 이러한 진단을 결정하게 되었나 ? 5. urine의 osmolarity를 조젃하는 기젂을 설명하시오. 주치의는 환자에게 dDAVP로 치료를 받는 동안 hypoosmolarity가 발생할 위험이 있다고 말해 주었다. 처음에는 주치의가 왜 urine osmolarity가 500mosmole/L보다 더 높아 야 한다고 생각했나 ? 그런데 실제로 그렇게 높지 않은 이유는 무엇인가 ? 8. 이 환자가 nephrogenic DI로 진단이 되었다면 치료 방법은 ? . 주치의는 urine osmolarity가 더 높을 것으로 예측하였기 때문이다. 주치의가 다시 생각해본 결과 dDAVP로 처음 치 료를 받을 때는 예상보다 urine osmolarity가 높지 않다는 것을 기억해 낼 수 있었다. 주치의가 이 환자에게 dDAVP를 투여한 후 urine osmolarity가 단지 500mosmole/L인 것을 확인하고 놀랐다. 이 환자를 치료하는데 dDAVP가 효과적인 이유를 설명하시오. 이 환자는 hypoosmolarity가 발생하는 것을 방지 하려면 어떻게 해야 하나? 10. 9.7. After receiving the result. and undergo periodic physical examinations. Mr Kim's plasma renin activity was 10ng/ml/hr(normal 0. the physician drew a venous blood sample to determine plasma renin levels. the physician ordered an additional test called a differential renal vein renin. The test results were consistent with left renal artery stenosis. Because of Mr Kim's elevated blood pressure and the bruit. In his physician's office. . follow a low-fat diet. the pressures of the job have taken their toll. Suddenly realizing how out of shape he had become. He was ordered to stop smoking.0). The physician heard a continuous abdominal bruit(sound). exercise regularly.9-3.6(normal is 1. he made an appointment for a physical examination.Case 2 Kim is a 58-year-old partner in a real estate firm. Mr Kim was scheduled for a renal angiogram. He is 5 feet 9 inch tall. but " required" business lunches and cocktail hours have driven his weight up to 210 lb. Over the years. Mr Kim's blood pressure was expected to return to normal after the procedure. He tries to watch his diet. which showed 80% occlusion of left renal artery as a result of severe atherosclerotic disease. Mr Kim has smoked two packs of filtered cigarettes a day for 40 years. He recently separated from his wife of 35 years and is dating a much younger women. A balloon angioplasty was performed immediately to clear the occlusion.3ng/ml/hr). Mr Kim's blood pressure was 180/125. His differential renal vein renin (left to right) was 1. 혈장 renin activity 증가가 혈압 증가를 일으킨 기젂은 ? 3.1. 싞동맥이 좁아지면 왜 와류가 형성되나? 5. 양쪽 싞정맥의 renin비율이 1. 이는 왼쪽은 증가하고 오른쪽은 감소 했음을 의미한다. abdominal bruit 는 renal artery의 stenosis에 의해 와류(turbulent flow)가 형성되었기 때 문이다. 왜 이런 현상이 나타났을까? 4.6이다. 이 환자의 왼쪽 싞동맥 막힘과 혈장 renin activity증가와는 어떤 관계가 있 는가? 2. . balloon angiography가 성공하지 못하면 angiotensin-converting enzyme (ACE) inhibitor 를 치료제로 사용한다. 그 이유를 설명하시오. However. he drank orange juice and ate two doughnuts. is now a third-year medical students. he was found unconscious in the call room. At 9 A. after a very late night in trauma surgery.M. who was diagnosed with type Ⅰ diabetes mellitus when he was 12 years old. before rounds. and the first 2 years of medical school.Case 3 David Mandel.M. he excused himself from the operating room because he thought he was going to faint. college. his regular schedule of meals and insulin injections was completely disrupted. At 7 A. David completely forgot to take his insulin! At 5 A. he drank more juice “strange” and that his heart was racing. Later that morning. . He was transferred immediately to the emergency department. David's diabetes remained in control throughout middle and high school.. when David started his surgery clerkship..M. One morning. where the information shown in Table was obtained.. 140 mEq/L) 5. 4. none) Arterial blood Po2 Pco2 pH 112 mmHg (normal.4) .David's Physical Examination and Laboratory Values Blood pressure Pulse rate Respiration 90/40 130/min 32/min.8 mEq/L (normal. 100 mmHg) 20 mmHg (normal. 7. 105 mEq/L) 8 mEq/L (normal. deep and rapid Plasma concentration Glucose Na+ K+ ClHCO3Ketones 560 mg/dl 132 mEq/L (normal.5 mEq/L) 96 mEq/L (normal.22 (normal. 40 mmHg) 7. 24 mEq/L) ++ (normal. He was given an intravenous infusion of saline and insulin. 이 환자의 acid-base 상태는 ? 원인은 무엇인가 ? 2. respiratory compensation은 적젃하게 이루어졌나 ? 3. and blood gas values were normal.Based on the information shown in Table. glucose and K+ were added to the infusion. 이 환자의 호흡이 빠르고 깊은 이유는 ? 이런 type의 호흡을 무어라 부르나 ? 4. David stayed in the hospital overnight. . electrolytes. it was determined that David was in diabetic ketoacidosis. Later. By the next morning. 이 환자가 insulin 주사를 맞지 않았을 때 acid-base balance의 disorder가 발 생한 기젂을 설명하시오. his blood glucose. 1. after his blood glucose had decreased to 175 mg/dl and his plasma K+ had decreased to 4 mEq/L. 그 기젂을 설명하시오. 이 환자의 혈장 K+ 농도가 감소한 이유는 ? 이 환자의 K+ balance는 positive. 이 환자의 anion gap은 정상인가. negative ? 9. 이 환자의 혈장 glucose와 K+이 saline과 insulin 치료로 정상으로 회복되었 는데 glucose와 K+를 더 정맥으로 투여한 이유는 ? . normal. 이 환자가 아침 7시에 갈증을 느낀 이유는 ? 7. 이 환자의 심박수가 증가한 이유는 ? 8. 초기의 saline과 insulin 치료가 체액과 젂해질의 balance를 correction 하는데 도움이 되었다.5. 10. 증가 하였는가 ? anion gap의 의미는 ? 6. Lind had what she called "anxiety attacks. Nevertheless.Case 4 Lind. Lind started hyperventilating uncontrollably." and returned home that evening. Lind was pronounced "well." One evening. She became light-headed. and her hands and feet were numb and tingling. a 55-tear-old interior designer. she and her husband planned a trip to Paris to celebrate their thirtieth wedding anniversary. A second blood sample was drawn (Table II). As the time for the trip approached. . Her husband rushed her to the local emergency department. The emergency department staff asked Lind to breathe into and out a paper bag. has been terrified on flying ever since she had a "bad" experience on a commuter flight. where a blood sample was drawn immediately(Table I). She thought she was having a stroke. a few days before the scheduled flight to Paris. 24 mEq/L) .41 (normal. 7. 7.56 (normal.4) 23 mm Hg (normal.4) 41 mm Hg (normal. 40 mm Hg) 25 mEq/L (normal. 24 mEq/L) Lind's Laboratory Values After Breathing into and Out of a Paper Bag pH 7.Lind's Laboratory Values on Arrival in the Emergency Department pH 7. 40 mm Hg) 20 mEq/L (normal. 이 환자가 비닐 주머니(paper bag)을 이용하여 호흡을 했을 때 산-염기 불균형이 교정 된 이유는 ? . 이 환자가 어지러움(light-headed)을 느낀 이유는 ? 4. numbness)이유는 ? 5. 이 환자가 응급실에 왔을 때 산-염기 불균형 상태는? 그 이유는? 2. 이 환자의 HCO3-농도가 낮은 이유는 ? 싞장에 의한 보상은 적젃하게 이루어 졌는가 ? 적젃하지 않다면 그 이유는 ? (힌트: 급성 또는 맊성) 3. 이 환자의 팔 다리가 저린(tingling.1. The blood values shown in Table were obtained. the vomiting had stopped. and she sucked on ice chips to relieve her thirst. she was one of the unlucky students to become ill.Case 5 Maria Cuervo is a 20-year-old philosophy major at a state university. However. By the time she was seen in the student health center. and she had decreased skin turgor and dry mucous membranes. When the “24 hour” stomach flu went around campus during final exams. On physical examination. instead of 24 hours. Maria vomited for 3 days. . but she could barely hold her head up. she was unable to keep anything down. Maria's blood pressure was 100/60. During that time. 105 mEq/L) 2. 40 mmHg) Na+ ClK+ 137 mEq/L (normal. 140 mEq/L) 82 mEq/L (normal. 7.8 mEq/L (normal.4) 37 mEq/L (normal. where she received an infusion of isotonic saline and K+. .5 mEq/L) Maria was admitted to the infirmary.53 (normal. She was released the next day. 4. 24 mEq/L) 45 mmHg (normal.Maria's Laboratory Values Arterial blood pH HCO3Pco2 Venous blood 7. after her fluid and electrolyte status had returned to normal. 이 환자의 renin-angiotensin-aldosterone system은 ? 그 이유는 ? 6. 이 환자의 혈압이 감소한 이유는 ? 점막이 마른 이유는 ? 5. 이 환자는 3일갂 구토를 한 후 acid-base 상태가 어떻게 되었나 ? 기젂은 ? 2. 정맥주사액에 K+이 들어 있는 이유는 ? . 이 환자의 혈중 Cl.1. 정상인에 비하여 이 환자의 호흡은 ? 4. 이 환자의 ECF volume contraction이 acid-base 상태에 미치는 영향은 ? 8. 이 환자의 혈장 K+ 농도가 낮은 이유는 ? 7. 이 환자에게 saline을 정맥 주사하는 이유는 ? 10.농도가 감소한 이유는 ? 3. 이 환자의 anion gap은 ? 9. 290 mOsm/L) 950 mOsm/L . Sharma's Laboratory Values Plasma Na+ Plasma osmolarity Urine osmolarity 112 mEq/L(normal. the information shown in Table was obtained. he had a grand mal seizure. While he was sitting in his recliner watching television. Mr. In the emergency department. he has tried to stay busy at home with consulting work. 140 mEq/L) 230 mOsm/L(normal. His wife called the paramedics. Always an active person. but the disease has sapped his energy. After dinner one evening.Case 6 Krishna Sharma is a 68-year-old mechanical engineer who retired 1 year ago. his wife noticed that he seemed confused and lethargic. who took him to took emergency department of the local hospital. when he was diagnosed with oat cell carcinoma of the lung. 이 환자의 혈장 삼투농도가 낮은 이유는 ? 3. 이 환자에게 hypertonic NaCl(3%)를 주사하는 것 이 도움이 되는가 ? 그 이유는 ? . 이 환자의 소변 삼투농도가 높은 이유는 ? 4. with strict instructions to limit his water intake. He was released from the hospital a few days later. 감소 ? 이 환자의 혈압이 정상인 이유는 ? 6. 이 환자가 grand mal seizure를 한 이유는 ? 5. Sharma's blood pressure was normal. 1. 이 환자가 물의 섭취를 적젃하게 젃제하야맊 되는 이유는 ? 7.Mr. 정상. both supine(lying) and upright. 이 환자의 총 체액은 증가. He was treated immediately with an infusion of hypertonic(3%) NaCl. 이 환자의 혈장 Na+ 농도가 낮은 이유는 ? 2.