James Scott that went to Nepal, India for his training. On a hike in the Himalay
ID: 3472664 • Letter: J
Question
James Scott that went to Nepal, India for his training. On a hike in the Himalayan Mountains he became lost for 42 days due to a snow storm. He had not taken food, water or survival gear for this type of emergency. On presentation to the hospital in Nepal he was considered gaunt and emotionally labile. Overall he needed several weeks of care; however, after one or two days of care he had the following values:
Weight: 61 kg, Estimated normal: 80 kg Temp: 98.2F Tenting of skin, edema of ankles
BP 114/70 and HR 108 while supine, BP 60/52 and HR 120 while sitting. Hct: 44%, WBC: 4,400
Sodium 128 mMol/L, Potassium 3.0 mMol/L, Glucose 5.11mMol/L (92 mg/dl), Urine Ketones +
Albumin: 44 g/L Prothrombin : +3sec, Creatinine day 1: 0.1mMol/L, day 4 0.06mMol/L BUN 30
After 1 day of fluids, 2000ml/24hr IV, 1500ml/day per os, urine output was 80ml/hour.
1. When a person is dehydrated, what body system is directly injured? ____________
From day one, his urine output was “80 ml/hour”, is that normal, high or low? _____________
Looking at his creatinine, does it appear that his kidneys are normal? ________
Should fluid intake be increased or decreased? _____________ Why? _____________________
______________________________________________________________________________
2. What percentage of his weight did he lose? ___________________________________________
Where did the weight “go”? _________________________________________________________
If you read the article, what kept him alive physically?________________________________________
What is the name of the chemical reaction that breaks down fatty acids? _________________
3. When using fats to get ATP, what waste product is often made? ____________
With that waste product, what pH problem would we expect?________________Did he have that in his urine? ___
What is a starving person using to make glucose?________________________________
His serum albumin is also normal, where would he get protein to make albumin?___________________________
4. Compare his blood pressure readings. Are they normal? _____________ Usually, when the blood pressure changes like that in a young patient, we think of hypovolemia or dehydration.
Do you think he is dehydrated? _____________________________________________________________
Why is his heart not pumping well? __________________________________________________________
He was given furosemide, what is that? _______________ and where does it act? ______________________
5. Thinking about edema, we think of capillary permeability, low osmotic pressure, heart failure, lymph obstruction, and renal failure and a patient can be “over hydrated”. He had edema, tachycardia and odd BP readings before the “iatrogenic over hydration”. What does Iatragenic mean? ____________________________________________
What is nystagmus and what does it indicate? ______________________________________________________
Thiamine is vitamin ___________ and is a coenzyme used to breakdown pyruvate to Acetyl CoA.
Explanation / Answer
1)Considering James Scott case ,he is a hiker .background score usually there more loss of fluid compared to people in normal atmosphere ,pressure in high altitude causes them to lose a lot fluid ,by sweating ,they breath harder which in turn leads to increased gas exchange causing more loss of body fluid.
As know first affected system os fluid homeostasis causing electrolyte imbalance which in turn causes next brain to be involved .He could present with confusion as first symptom and consequently follows with other systems depending on severity of dehydration .
1a)yes his urine output is normal ,normal expected urine output in person who consumes 2 litres per day is 1000 to 2000per ml /24 hrs.
1b)yes his kidneys seem completely normal as both day 1 and day 2 values are within normal limits ,first being borderline does not signify anything as again it is in normal limit.
1c) looking at his symptoms shows he is severely dehydrated ,hence he should be immediately started on iv fluids and oral par to correct the electrolytes and give the fluid 30ml/kg over 1 .5 hour and monitor every 15 minutes .,ors to be continued through the day orally ,hence to correct the imbalance and also to prevent the symptoms to aggravate fluids should be increased.
2a )he has lost 25% of his weight approximately,as he was starving at the same time he was dehydrated all his glycogen stores in the tissues were used up to produce glucose ,which is fuel for the body to work.
2c) ,as normally every person oa made of 75%of water and he weighing 80kg assuming he was healthy all his glycogen storage and fatty acids were released and broken down ,which made him survive all these days.
2d) fatty oxidation pathway which last product is aceyl co a ,which is the starting point of citric acid cycle which produces ATP.
3a )when using fats to produce ATP ,waste product produced is lot of ketone ,due to extra aceyl co a is converted to ketones.
3b)high ketones in the blood causes to de tease the ph causing acidosis.Yes James had ketones in his urine .
Starving person uses stored glycogen and fatty acids to convert to glucose ,even if these stores deplete the body starts to use proteins as well .
3c) his albumin levels are normal because his skeletal muscle proteins break down to supply the amino acids this used used only in extreme starvation .
4a) He seems to have orthostatic hypotension,w hich is due to dehydration ,as the patient changes the position blood rushes to the upper body ,when it is unable to do so it causes orthostatic hypotension main reason being dehydration ,not enough fluid within the blood vessels.
4 b) yes he is dehydrated .
4c)heart does not pump properly meaning it increase the work causing increased heart rate due to dehydration vessels do not stretch due to decreased fluid ,where tge stimuli is sent to brain via baroreceptors causing the heart to pump fast to increase the circulation through the body ,but due to dehydration it fails to do so .
4d) furosemide is a loop diuretic which acts on thick ascending loop of Henle .,during rapid correction of dehydration just to keep check on urine output at the same time not to overload the heart ,and also decrease peripheral edema loop diuretic was given.
5a)iatrogenic means hospital acquired ,either could be adverse effect of the treatment ,James could be be over hydrated due to excess fluids given to him which caused the above condition ,in such state furosemide is given for diuresis ,to throw out excess water.
5b)Nystagmus is rapid ,involuntary uncontrolled movement of eyes either upward ,downward or to sides can involve one or both the eyes.
Nystagmus indicates central nervous system suppression ,could be presenting symptom in heat stroke or if dehydrated patient presents with seizures and was given anti seizures this could also result in Nystagmus.
5c) Thiamine is vitamin B1 which is essential ,water soluble vitamin ,which is used to produce ATP ,it's deficiency causes ber beri .
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