Mr. K.B. is age 81 and has had gastritis with severe vomiting for 3 days. He has

Question

Mr. K.B. is age 81 and has had gastritis with severe vomiting for 3 days. He has a history of heart problems and is presently feeling dizzy and lethargic. His eyes appear sunken, his mouth is dry, he walks unsteadily, and he complains of muscle aching, particularly in the abdomen. He is thirsty but is unable to retain food or fluid. A neighbor has brought Mr. K.B. to the hospital, where examination shows that his blood pressure is low, and his pulse and respirations are rapid. Laboratory tests demonstrate elevated hematocrit, hypernatremia, decreased serum bicarbonate, serum pH 7.35, and urine of high specific gravity (highly concentrated)

For clarity, this case study is discussed in three parts, the early stage, middle stage, and advanced stage of the imbalances. Further information about the specific problems involved is given in each part and is followed by a series of questions.

Part A: Day 1

Initially, Mr. K.B. lost water, sodium in the mucus content, and hydrogen and chloride ions in the hydrochloric acid portion of the gastric secretions, resulting in “hypochloremic alkalosis.”

1.which compartments are likey to be affected in this case by early fluid loss?

2.Explain how a loss of sodium ions contributes to dehydration?. Be specific in your answer.

3.Describe the early signs of dehydration that would be seen in Mr. K.B?

4..What serum PH could be expected in Mr K.B after this early vomitting?
5.Describe the compensations for the losses of fluid and electrolytes that should be occurring in Mr. K.B?
6.Explain why Mr. K.B. may not be able to compensate for losses as well as a younger adult.?

Part B: Days 2 to 3

As Mr. K.B. continues to vomit and is still unable to eat or drink any significant amounts, and loss of the duodenal contents, which include intestinal, pancreatic, and biliary secretions, occurs. No digestion and absorption of any nutrients occurs. Losses at this stage include water, sodium ions, potassium ions, and bicarbonate ions. Also, intake of glucose and other nutrients is minimal. Mr. K.B. shows elevated serum sodium levels.

7.Explain why serum sodium levels appear to be high in this case and

8.how they might affect the intracellular fluid.
9.Using your knowledge of normal physiology, explain how continued fluid loss is likely to affect:
blood volume
cell function
kidney function
10.Given Mr. K.B.’s history, why might potassium imbalance have more serious effects on him?

Part C: Day 3: Admission to the Hospital

After a prolonged period of vomiting, metabolic acidosis develops. This change results from a number of factors:

Loss of bicarbonate ions in duodenal secretions
Lack of nutrients leading to catabolism of stored fats and protein with production of excessive amounts of ketoacids
Dehydration and decreased blood volume leading to decreased excretion of acids by the kidney
Decreased blood volume leading to decreased tissue perfusion, less oxygen to cells, and increased anaerobic metabolism with increased lactic acid
Increased muscle activity and stress leading to increased metabolic acid production
These factors lead to an increased amount of acids in the blood, which bind with bicarbonate buffer and result in decreased serum bicarbonate and decreased serum pH or metabolic acidosis.

11.List several reasons why Mr K.B is lethargic and weak?

12.Predict the serum level of carbon dioxide or carbonic acid in this case?

13.If Mr. K.B. continues to lose body fluid, why might serum pH decrease below 7.35?
14.If serum pH drops below 7.35, what signs would be observed in Mr. K.B.?
15.Describe the effect of acidosis on serum potassium levels.
16.Mr. K.B. will be given replacement fluid therapy. Why is it important that sodium and potassium be given as well as water?

Explanation / Answer

1) The intercellular compartments are most probably to get affection in the very beginning , as cells are the fundamental part of living any change in the normal metabolism affects them very first. When the water will get pulled out of the cell inturn it will get damaged. In this case body will utilize whole amount of reserved water and for body's proper functioning it can even squeeze it out from the cell.

2)When a person is suffering from chronic, severe vomitting , his/her body faces many abnormalities like loss of water and even electrolytes such as sodium. And because of vomiting there is always an urge of thrist, so the person drinks exessive amount of water and thus overwhlms the kidneys' ability to excrete it out.Condition is called as Hyponatrimea.

3) Early signs of dehydration are increasing thrist , dry lips , nausea , headache , weakness , constricton in blood vessels etc.

4) After vomitting the serum pH will be more towards the alkaline( nearly 6.9-7.2) side because of the loss of hydrogen particles lost which where present in the gastric juice inorder to neutralize the conditions.

5) Use of isotonic solution would be best, as they are safe to give in boluses, like normal saline . As it wont worsen the condition of hyponatremia.

6) Mr K.B. is not able to compensate because he is continuosly vomitting. His stomach is not accepting any kind of fluid or food , in addition his body is already dehydrated , all the cellular water is drained , body's mechanism is completely distrubed. So , in this situation be that a young adult or an old adult , weak body can manage this condition anyhow.

7)Sr. Sodium will come to a normal range when intake of fluid is sufficient. Here, bicarbonates exceed the range thud making the condition even worse.

8) The high sodium levels drains water out of the cells which hs host of complications primarily in the cardiovascular system and nervous system.In short, the Osmolality is hindered.

9)a. Obviously the blood volume will get lowerd down. It is one of the most serious complications of dehydration as the low blood volume causes a drop in blood pressure indirectly a huge drope in oxygen in the body. Condition called as Hypovolemic shock.

b.   Cell funtion is hindered from the very beginning because of the drainning of intercellular fluid caused by Sodium ions, the cell shinks continuosly , if not treated soon can case the cell to die ultimately due to fuid loss.

c.   Kidney funtion gets redused because of low blood supply ( hypotension) and can even cause acute kidney failure.

10) Potassium imbalane ( hypokalamia) will take the case to its extreme worst condition because potassium imbalance causes more nausea and vomitting , adrenal disorder , weakness , cramps , a person in severe case can even get paralysed , amd develops abnormal heart rhythms.

11)Mr. K.B. is lathargic and weak due to muscle strain, ketoacidosis , gastroenteritis , acute kidney failure , intestinal ilues etc

12) Lose of excessive fluid results in chnge in CO2 level. which is regulated by kidneys and lungs . It will elevate as the kidneys are not able to mainetain the bicarbonate level of the blood.

13)It will get more to the acidic side because of the body fat metabolism ( ketoacidosis) , it will change the whole body balance causing the blood to become more acidic.

14) Signs are , Metabolic acidosis , Renal tubular acidosis , Bone resorbtion acidosis and so on.

15) Renal acid secreation is influenced by K+ and my result from transcellualr shift of K+ when intracellular K+ is exchanged for extracellular H+ or vise versa.

16)Because body is defecit of water providing only elctrolytes can cause Hypernatremia or Hyperkalemia. Inorder to over come this condition water should be also added.

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