CASES IN ACID – BASE DISTURBANCE

Case #1

The patient is a 35 year -old female with AIDS brought to the emergency room with a fever of 39oC and a three month history of
copious diarrhea.

On physical exam the patient is a well-developed, thin female in moderate distress. Vital signs-(supine) blood pressure 100/60,
pulse 100 and (standing) blood pressure 80/40, pulse 125, respirations 18 and she was afebrile. HEENT exam was normal. Cardiac
exam demonstrated an S1 and S2 without S3, S4 or murmur. Lungs were clear to auscultation and percussion. The abdomen was
supple and minimally tender to palpation. Bowel sounds were hyperactive. Stool was guiac negative. Extremities were without
cyanosis, clubbing or edema. Neurological exam was intact.

Laboratory Data

Chemistry Normal Values Arterial Blood Gas

Sodium 136 136-146 mmol/L pH 7.35
Potassium 3.4 3.5-5.3 mmol/L PCO2 27 mmHg
PO2 90 mmHg
Chloride 112 98-108 mmol/L
bicarbonate 14 mmol/L
Total CO2 14 23-27 mmol/L
BUN 30 7-22 mg/dl
Creatinine 1.5 0.7-1.5 mg/dl
Glucose 105 70-110 mg/dl

Questions

1. What is/are the critical course of events that is going to alter her acid-base status?

2. What Acid base abnormalities would you expect based on this information?

3. What physical findings would you expect to see from such an acid base disturbance?

4. Review her blood gases. What is the primary acid-base abnormality? How did you decide that?

5. Calculate the anion gap in this patient. What is the normal anion gap. What is the gap due to in normals?

6. What is her bicarbonate gap?

7. Obviously this patient has nonanion gap metabolic acidosis  What is the relationship between the  bicarbonate gap and the anion
gap? 

8. Is there a compensatory mechanism for metabolic acidosis? How is that brought about? What are the sensors and effectors for
metabolic acidosis?

9. What is the predicted compensatory response? 

10. Is his respiratory compensatory effort appropriate? Can respiratory compensatory effort fully compensate for metabolic
acidosis?

11. Is this a simple or mixed disorder? How did you come to that conclusion?

12. What clinical condition(s) is (are) responsible for the acid-base disturbance in this patient?

13. What are the physiologic mechanisms responsible for the generation of this disturbance?
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14. What are the other causes for non-anion gap metabolic acidosis?

CASE 2

The patient is a 55 year-old male with a history of diabetes. His wife states that he has become increasingly lethargic and fatigued
over the past several days.

On physical exam the patient is a well-developed, obese male appearing older than his stated age. Blood pressure 160/98, pulse 76,
respirations 20 and he was afebrile. HEENT exam was unremarkable. Cardiac exam demonstrated an S1, S2 without S3, S4 or
murmur. Pulmonary auscultation and percussion were within normal limits. The abdomen was benign. Extremities were without
abnormality.

Laboratory Data

Chemistry Normal Values Arterial Blood Gas

Sodium  142 136-146 mmol/L pH 7.30
Potassium  4.4 3.5-5.3 mmol/L PCO2 22 mmHg
PO2 108 mmHg
Chloride 105 98-108 mmol/L
bicarbonate 10 mmol/L
Total CO2   10 23-27 mmol/L
BUN  22 7-22 mg/dl
Creatinine  1.5 0.7-1.5 mg/dl
Glucose  265 70-110 mg/dl

Questions

1. What is the primary acid-base abnormality? Explain your logic.

2. What are the signs and symptoms of metabolic acidosis?

3. Calculate the anion gap?

4. He has anion Gap metabolic acidosis. What is the hydrogen ion concentration?

5. Is there a compensatory mechanism for metabolic acidosis?

6. What is the predicted compensatory response?  Is his compensatory response adequate? If it is not adequate what would it mean?

7. Is this a simple or mixed disorder? Explain your conclusion.

8. What clinical condition(s) is (are) responsible for the acid-base disturbance in this patient?

9. What are the physiologic mechanisms responsible for the generation of this disturbance?

10. What are the other causes for anion gap metabolic acidosis?

Case #3
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The patient is a 28 year-old female who presents with a complaint of muscular weakness and fatigue. She has lost 30 pounds since
her last office visit one year ago. She has no other complaints.

Medications- multivitamins
Allergies-none

On physical exam she is a cachectic female appearing fatigued. Blood pressure 100/76, pulse 88, respirations 16 and she was
afebrile. HEENT exam was remarkable for an erythematous pharynx with scattered excoriations. The remainder of the exam was
normal except for her marked weight loss.

Laboratory Data

Chemistry . Normal Values Arterial Blood Gas Urine

Sodium  136 136-146 mmol/L pH 7.48  pH 6.0
Potassium  2.8 3.5-5.3 mmol/L PCO2 48 mmHg
PO2 80 mmHg
Chloride  85 98-108 mmol/L bicarbonate 36 mmol/L
Total CO2   36 23-27 mmol/L
BUN  20 7-22 mg/dl
Creatinine  1.0 0.7-1.5 mg/dl
Glucose  80 70-110 mg/dl

Questions

1. What is the primary acid-base abnormality? How did you arrive at that conclusion?

2. Calculate the anion gap? Is it important to calculate anion gap in metabolic alkalosis? When should we calculate anion gap?

3. What is the hydrogen ion concentration?

4. How did he compensate for metabolic alkalosis?

5. What is the predicted compensatory response?

6. Is this a simple or mixed disorder? How did you come to that conclusion?

7. What are the common causes for metabolic alkalosis?

8. If the urine chloride is < 10 mmol/L, what are the diagnostic possibilities?

9. If the urine chloride is > 10 mmol/L, what are the diagnostic possibilities?

10. What clinical condition(s) is (are) responsible for the acid-base disturbance in this patient? What addditional information would
you seek?

11. What are the physiologic mechanisms responsible for the generation of this disturbance?

Case #4

A 29 year-old male with a history of Type I diabetes mellitus is seen in your office for a routine insurance examination.

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On physical exam he is a well-developed, well-nourished male in no apparent distress. Blood pressure 110/70, pulse 76, respirations
26 and he was afebrile. HEENT was grossly unremarkable. Cardiopulmonary exam had a normal S1 and S2 without S3, S4 or
murmur. The abdomen was benign with normoactive bowel sounds. Extremities were without cyanosis, clubbing or edema.

Laboratory Data

Chemistry Normal Values  Arterial Blood Gas Urine

Sodium  140 136-146 mmol/L pH 7.35  pH 5.5
Potassium  6.4 3.5-5.3 mmol/L PC02 30mmHg
P02 105mmHg
Chloride 112 98-108 mmol/L
bicarbonate 16mmol/L
Total C02  16 23-27 mmol/L
BUN  44  7-22 mg/dl
Creatinine  2.5 0.7-1.5 mg/dl
Glucose  110 70-110 mg/dl

Questions

1. What is the primary acid-base abnormality? 

2. Calculate his anion gap.  Is there an increase in the anion gap? 

3. He has nonanion gap metabolic acidosis.  What is the hydrogen ion concentration? 

4. Is there a compensatory mechanism for this abnormality? 

5. What is the predicted compensatory response?

6. Is this disorder simple or mixed?

7. What are the common causes for non-anion gap metabolic acidosis?

8. What clinical condition(s) is (are) responsible for the acid-base disturbance in this patient? Explain your logic.

9. What are the physiologic mechanisms responsible for the generation of this disturbance?

QUESTIONS

1. What is normal pH?

2. What is the definition for acid base disorder?

3. What does acidosis or alkalosis refer to?

4. What does acidemia or alkalemia refer to?

5. Which organs are key players in maintaining acid base balance?

6. What are the primary acid base disorders?

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7. When would you consider metabolic acidosis?

8. When would you consider metabolic alkalosis?

9. When would you consider respiratory acidosis?

10. When would you consider respiratory alkalosis?

11. What are the required lab values and historical information you need to assess acid base disorders?

12. What are anions? List the anions?

13. What are cations? List the cations?

14. What is anion gap?

15. How do you calculate anion gap?

16. What are the compensatory measures for acid base disorders?

17. What is difference between bicarbonate value reported in arterial blood gases and bicarbonate reported in electrolytes?

18. What is the metabolic compensation for acute respiratory acidosis? How do you assess whether it is appropriate?

19. What is the metabolic compensation for chronic respiratory acidosis? How do you assess whether it is appropriate?

20. What is the metabolic compensation for acute respiratory alkalosis? How do you assess whether it is appropriate?

21. What is the respiratory compensation for chronic respiratory alkalosis? How do you assess whether it is appropriate?

22. What is the respiratory compensation for acute metabolic acidosis? What are the sensors and effectors for this response? 

23. What is the respiratory compensation for chronic metabolic acidosis? How do you assess whether it is appropriate?

24. What is the respiratory compensation for acute metabolic alkalosis? How do you assess whether it is appropriate?

25. What is the respiratory compensation for chronic metabolic alkalosis? How do you assess whether it is appropriate?

26. What is bicarbonate gap?

27. Explain renal mechanism for regulation of acid base disorders?

28. What are the common causes for high anion gap metabolic acidosis?

29. What are the common causes for normal anion gap metabolic acidosis?

30. What are the common causes for metabolic alkalosis?

31. What are the common causes for respiratory acidosis?

32. What are the common causes for respiratory alkalosis?

33. What are the factors that stimulate kidney to excrete acid?

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34. What are the factors that inhibit kidney to excrete acid?

35. How do you determine whether an acid base disorder is simple or mixed?

36. Explain CSF barrier for acid base disorders. How does it come into play clinically?

37. Give me your step by step approach to interpreting acid base disorders.

38. Describe the buffer system.

39. Describe how kidney excretes acid.

40. What is the relationship between Ventilation and pCO2

41. How do you calculate the hydrogen ion concentration?

Acid-Base Disorders
Practice Cases

Case 1

A 26 year old man with unknown past medical history is brought in to the ER by ambulance, after friends found him unresponsive
in his apartment. He had last been seen at a party four hours prior.

ABG: pH 7.25 Chem 7: Na+ 137

PCO2 60 K+ 4.5
HCO3- 26 Cl- 100
HCO3- 25
PO2 55

1. What is the predominant acid-base disorder?

2. Is the degree of compensation appropriate?

3. Is there another disorder present?

4. What is the differential diagnosis?

Case 2

A 67 year old man with diabetes and early diabetic nephropathy (without overt renal failure) presents for a routine clinic visit. He is
currently asymptomatic. Because of some abnormalities on his routine blood chemistries, you elect to send him for an ABG.

ABG: pH 7.35 Chem 7: Na+ 135

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 PCO2 34 K+ 5.1
HCO3- 18 Cl- 110
HCO3- 16
PO2 92 Cr 1.4

Urine pH 5.0

1. What is the predominant acid-base disorder?

2. Is the degree of compensation appropriate?

3. Is there another disorder present?

4. What is the differential diagnosis?

5. Why is this patient hyperkalemic?

Case 3

A 68 year old woman with metastatic colon cancer presents to the ER with 1 hour of chest pain and shortness of breath. She has no
known previous cardiac or pulmonary problems.

ABG: pH 7.49 Chem 7: Na+ 133

PCO2 28 K+ 3.9
HCO3- 21 Cl- 102
HCO3- 22
PO2 52

1. What is the predominant acid-base disorder?

2. Is the degree of compensation appropriate?

3. Is there another disorder present?

4. What is the differential diagnosis?

Case 4

A 6 year old girl with severe gastroenteritis is admitted to the hospital for fluid rehydration, and is noted to have a high [HCO3-] on
hospital day #2. An ABG is ordered:

ABG: pH 7.47 Chem 7: Na+ 130

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 PCO2 46 K+ 3.2
HCO3- 32 Cl- 86
HCO3- 33
PO2 96
Urine pH 5.8

1. What is the predominant acid-base disorder?

2. Is the degree of compensation appropriate?

3. Is there another disorder present?

4. What is the differential diagnosis?

5. Why is she hypokalemic?

6. Why is she hyponatremic?

Case 5

A 75 year old man with morbid obesity is sent to the ER by his skilled nursing facility after he developed a fever of 103° and rigors
2 hours ago. In the ER he is lucid and states that he feels “terrible”, but offers no localizing symptoms. His ER vitals include a
heart rate of 115, and a blood pressure of 84/46.

ABG: pH 7.12 Chem 7: Na+ 138

PCO2 50 K+ 4.2
HCO3- 13 Cl- 99
HCO3- 15
PO2 52
Urine pH 5.0

1. What is the “predominant” acid-base disorder?

2. Is the degree of compensation appropriate?

3. Is there another disorder present?

4. What is the differential diagnosis?

Case 6

A 25 year old man with type I diabetes presents to the ER with 24 hours of severe nausea, vomiting, and abdominal pain.

ABG: pH 7.15 Chem 7: Na+ 138

PCO2 30 K+ 5.6
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 HCO3- 10 Cl- 88
HCO3- 11
PO2 88 Cr 1.1

Urine pH 5.0

1. What is the predominant acid-base disorder?

2. Is the degree of compensation appropriate?

3. Is there another disorder present?

4. What is the differential diagnosis?

5. Why is this patient hyperkalemic?

6. Are his total body potassium stores elevated, depleted, or normal?

Case 7

A 62 year old woman with severe COPD comes to the ER complaining of increased cough and shortness of breath for the past 12
hours. There are no baseline ABGs to compare to, however, her HCO3- measured during a routine clinic visit 3 months ago was 34
mEq/L.

ABG: pH 7.21 Chem 7: Na+ 135

PCO2 85 K+ 4.0
HCO3- 33 Cl- 90
HCO3- 34
PO2 47
Urine pH 5.5

1. What is the “predominant” acid-base disorder?

2. Is the degree of compensation appropriate?

3. Is there another disorder present?

4. What is the differential diagnosis?

Case 8

A 36 year old man with a history of alcoholism is brought to the ER after being found on the floor of his apartment unresponsive,
soiled with vomit, and with an empty pill bottle nearby.

ABG: pH 7.03 Chem 7: Na+ 134

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 PCO2 75 K+ 5.2
HCO3- 19 Cl- 90
HCO3- 20
PO2 48
Urine pH 5.0

1. What is the predominant acid-base disorder?

2. Is the degree of compensation appropriate?

3. Is there another disorder present?

4. What is the differential diagnosis?

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