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Arrow ALL Possible Acid-base problems

Hi friends
These may be all possible Acid base case which may face in step 2 ck exam .
What is your diagnosis in each case
Case-1
A 55‐year‐old man is admitted with weakness, anorexia, weight loss and progressive anemia. BP 179/116 mmHg T 101 o F RR 22/min P 105/min
LABS: Na + =135 meq/L K + =5.4 meq/L Cl ‐ =101 meq/L HCO3 ‐ =12 meq/L pH=7.32 PaCO2=24 mmHg PaO2=104 mmHg

Case-2
A 88‐year‐old woman is admitted with a one week of severe diarrhea and fever.
BP 95/60 mmHg P 100/min lying T 100.3 o F P 85/min RR 16/min.
LABS: Na + =133 meq/L K + =2.5 meq/L Cl ‐ =118 meq/L HCO3 ‐ =5 meq/L
pH=7.11 PaCO2=16 mmHg PaO2=94 mmHg

Case-3
A 73‐year‐old woman with a 80 pack‐year smoking history, is admitted with pneumonia and diffuse abdominal pain. Rectal exam is positive for heme.
LABS: Na + =140 meq/L K + =5 meq/L Cl ‐ =95 meq/L HCO3 ‐ =15 meq/L,
Glucose = 80 mg/dl, Albumin 4.0
BUN=76 mg/dL Cr =8.1 mg/dL
pH=7.1 PaCO2=50 mmHg PaO2=51 mmHg

Case-4
A 64‐year‐old woman was admitted to the hospital yesterday with severe depression. Today she was found apneic and pulseless in bed by the nurse. CPR was started by the residents.
LABS: Na + =141 meq/L K + =6 meq/L Cl ‐ =104 meq/L HCO3 ‐ =9 meq/L
pH=6.99 PaCO2=34 mmHg PaO2=60 mmHg

Case-5
A 47‐year‐old woman with Inflammatory bowel disease and high output ileostomy, has had shaking chills and fever with abdominal pain for 36 hours.
Exam showed BP 100/40 mmHg T 105 P 110/min RR 16/min. LABS: Na + =136 meq/L K + =5.5 meq/L Cl ‐ =106 meq/L.
HCO3 ‐ = 8 meq/L pH=7.44 PaCO2=17 mmHg PaO2=111 mmHg

Case-6
A 64‐year‐old man with severe COPD and CAD has had watery diarrhea for 3 days.
LABS: Na + =136 meq/L K + =3.3 meq/L Cl ‐ =105 meq/L HCO3 ‐ =19 meq/L, pH=7.15 PaCO2=65 mmHg PaO2=48 mmHg

Case-7
A 58‐year‐old man who has been vomiting for several days is brought to the ED by his wife who claims he passed out in his garage. He is lethargic
and breathing with deep effort.
BP 70/40 mmHg P 140/min RR 28/min and deep
LABS: Na + =127 meq/L K + =3.1 meq/L Cl ‐ =75 meq/L HCO3 ‐ =5 meq/L
pH=7.01 PaCO2=13 mmHg PaO2=108 mmHg. Calculated serum Osmolality was 320

Case-8
A 40‐year‐old woman is brought to the ER 8 hours after ingesting a bottle of aspirin in a suicide attempt. On exam she is stuporous and tachypneic.
LABS: Na + =140 meq/L K + =4.1 meq/L Cl ‐ =106 meq/L HCO3 ‐ =10 meq/L, pH=7.54 PaCO2=12 mmHg PaO2=106 mmHg

Case-9
30 year‐old male with type 1 diabetes is admitted with DKA. He has experienced severe nausea and vomiting for several days and is quite anxious with moderate generalized pain.
VITALS: BP 120/80 mmHg P 124/min supine, BP 108/80 mmHg P 160/min upright
LABS: Na + =136 meq/L K + = 4 meq/L Cl ‐ =70 meq/L HCO3 ‐ =19 meq/L
pH=7.47 PaCO2=30 mmHg PaO2=104 mmHg

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Quote:
Case-1
A 55‐year‐old man is admitted with weakness, anorexia, weight loss and progressive anemia. BP 179/116 mmHg T 101 o F RR 22/min P 105/min
LABS: Na + =135 meq/L K + =5.4 meq/L Cl ‐ =101 meq/L HCO3 ‐ =12 meq/L pH=7.32 PaCO2=24 mmHg PaO2=104 mmHg
AG=22 (135-101-12)

AGMA with respiratory compensation + Anemia+ High K +HT

Most likely Renal failure
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Case-2
A 88‐year‐old woman is admitted with a one week of severe diarrhea and fever.
BP 95/60 mmHg P 100/min lying T 100.3 o F P 85/min RR 16/min.
LABS: Na + =133 meq/L K + =2.5 meq/L Cl ‐ =118 meq/L HCO3 ‐ =5 meq/L
pH=7.11 PaCO2=16 mmHg PaO2=94 mmHg
AG=10

NAGMA with Resp compensation & Low K.

Typical of diarrhea.
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Quote:
Case-3
A 73‐year‐old woman with a 80 pack‐year smoking history, is admitted with pneumonia and diffuse abdominal pain. Rectal exam is positive for heme.
LABS: Na + =140 meq/L K + =5 meq/L Cl ‐ =95 meq/L HCO3 ‐ =15 meq/L,
Glucose = 80 mg/dl, Albumin 4.0
BUN=76 mg/dL Cr =8.1 mg/dL
pH=7.1 PaCO2=50 mmHg PaO2=51 mmHg
AG=30
HAGMA secondary to pneumonia in a pt with COPD & Renal failure
She needs dialysis ASAP.
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Quote:
A 58‐year‐old man who has been vomiting for several days is brought to the ED by his wife who claims he passed out in his garage. He is lethargic
and breathing with deep effort.
BP 70/40 mmHg P 140/min RR 28/min and deep
LABS: Na + =127 meq/L K + =3.1 meq/L Cl ‐ =75 meq/L HCO3 ‐ =5 meq/L
pH=7.01 PaCO2=13 mmHg PaO2=108 mmHg. Calculated serum Osmolality was 320
AG=47 (127-75-5)
Osmolar Gap= 25 (320-295)

HAGMA with Respiratory compensation (CO2 washout) & high Osmolar Gap = ethylene glycol poisoning
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Quote:
Case-8
A 40‐year‐old woman is brought to the ER 8 hours after ingesting a bottle of aspirin in a suicide attempt. On exam she is stuporous and tachypneic.
LABS: Na + =140 meq/L K + =4.1 meq/L Cl ‐ =106 meq/L HCO3 ‐ =10 meq/L, pH=7.54 PaCO2=12 mmHg PaO2=106 mmHg
AG=24(140-106-10)

HAGMA (due to aspirin shutting down mitochondrial factory) with combined Respiratory alkalosis (hyperventilation due to direct stimulatory effect of aspirin on respiratory centers) typical of Aspirin overdose.
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Case-9
30 year‐old male with type 1 diabetes is admitted with DKA. He has experienced severe nausea and vomiting for several days and is quite anxious with moderate generalized pain.
VITALS: BP 120/80 mmHg P 124/min supine, BP 108/80 mmHg P 160/min upright
LABS: Na + =136 meq/L K + = 4 meq/L Cl ‐ =70 meq/L HCO3 ‐ =19 meq/L
pH=7.47 PaCO2=30 mmHg PaO2=104 mmHg
AG= 47(136-70-19)

Mixed HAGMA (High Anion Gap Metabolic Acidosis) with Respiratory compensation (CO2 of 30) and Metabolic Alkalosis due to vomitting (loss of H+ and Cl-).

Remember, if the AG is over 20 then there must be a Primary metabolic acidosis regardless of the pH or HCO3.
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Case-1
Quote:
A 55‐year‐old man is admitted with weakness, anorexia, weight loss and progressive anemia. BP 179/116 mmHg T 101 o F RR 22/min P 105/min
LABS: Na + =135 meq/L K + =5.4 meq/L Cl ‐ =101 meq/L HCO3 ‐ =12 meq/L pH=7.32 PaCO2=24 mmHg PaO2=104 mmHg
Quote:
Originally Posted by Novobiocin View Post
AG=22 (135-101-12)

AGMA with respiratory compensation + Anemia+ High K +HT

Most likely Renal failure
Yup U R right
But ketoacidosis due to starvation (weakness, anorexia, weight loss and progressive anemia) or Renal Failure?
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Case-2
Quote:
A 88‐year‐old woman is admitted with a one week of severe diarrhea and fever.
BP 95/60 mmHg P 100/min lying T 100.3 o F P 85/min RR 16/min.
LABS: Na + =133 meq/L K + =2.5 meq/L Cl ‐ =118 meq/L HCO3 ‐ =5 meq/L
pH=7.11 PaCO2=16 mmHg PaO2=94 mmHg
Quote:
Originally Posted by Novobiocin View Post
AG=10

NAGMA with Resp compensation & Low K.

Typical of diarrhea.
Yes, Diarrhea leading to hyperchloremic metabolic acidosis.
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Quote:
Case-3
A 73‐year‐old woman with a 80 pack‐year smoking history, is admitted with pneumonia and diffuse abdominal pain. Rectal exam is positive for heme.
LABS: Na + =140 meq/L K + =5 meq/L Cl ‐ =95 meq/L HCO3 ‐ =15 meq/L,
Glucose = 80 mg/dl, Albumin 4.0
BUN=76 mg/dL Cr =8.1 mg/dL
pH=7.1 PaCO2=50 mmHg PaO2=51 mmHg
Quote:
Originally Posted by Novobiocin View Post
AG=30
HAGMA secondary to pneumonia in a pt with COPD & Renal failure
She needs dialysis ASAP.
This is complicated
Answer = Mixed of Respiratory Acidosis + HAGMA + Metabolic Alkalosis
1- Respiratory acidosis (due to COPD).
2- high anion gap metabolic acidosis (due to ischemic bowel and sepsis).
3- metabolic alkalosis (chronic hypercapnea from COPD= cause retention of bicarbonate, so the initial or starting HCO3 state of the body before bowel ischemia and sepsis is > 24 . HOW TO KNOW THAT--> The equation used for calculating starting HCO3= current HCO3 + Delta gap{Delta gap= anion gap – 12}. So starting HCO3= 15 +{30-12}= 33. this confirm that the initial HCO3 is > 24 and so there is previous state of Metabolic alkalosis that compansate Respiratory acidosis before patient developed metabolic acidosis from ischemia and sepsis)
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Quote:
Case-7
A 58‐year‐old man who has been vomiting for several days is brought to the ED by his wife who claims he passed out in his garage. He is lethargic
and breathing with deep effort.
BP 70/40 mmHg P 140/min RR 28/min and deep
LABS: Na + =127 meq/L K + =3.1 meq/L Cl ‐ =75 meq/L HCO3 ‐ =5 meq/L
pH=7.01 PaCO2=13 mmHg PaO2=108 mmHg. Calculated serum Osmolality was 320
Quote:
Originally Posted by Novobiocin View Post
AG=47 (127-75-5)
Osmolar Gap= 25 (320-295)

HAGMA with Respiratory compensation (CO2 washout) & high Osmolar Gap = ethylene glycol poisoning

OK
same as previous one
Anion gap = 47 --> HAGMA
Delta gap (anion gap – 12) = 35
Starting bicarbonate (starting HCO3= current HCO3 + Delta gap )= 40 this means that the previous state is metabolic alkalosis from vomiting for several days
Answer = High anion gap metabolic acidosis and a metabolic alkalosis
1-Metabolic alkalosis due to vomiting.
2- High anion gap metabolic acidosis due to lactic acidosis and ethylene glycol intoxication.
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Quote:
Case-8
A 40‐year‐old woman is brought to the ER 8 hours after ingesting a bottle of aspirin in a suicide attempt. On exam she is stuporous and tachypneic.
LABS: Na + =140 meq/L K + =4.1 meq/L Cl ‐ =106 meq/L HCO3 ‐ =10 meq/L, pH=7.54 PaCO2=12 mmHg PaO2=106 mmHg
Quote:
Originally Posted by Novobiocin View Post
AG=24(140-106-10)

HAGMA (due to aspirin shutting down mitochondrial factory) with combined Respiratory alkalosis (hyperventilation due to direct stimulatory effect of aspirin on respiratory centers) typical of Aspirin overdose.
Excellent
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Quote:
Case-9
30 year‐old male with type 1 diabetes is admitted with DKA. He has experienced severe nausea and vomiting for several days and is quite anxious with moderate generalized pain.
VITALS: BP 120/80 mmHg P 124/min supine, BP 108/80 mmHg P 160/min upright
LABS: Na + =136 meq/L K + = 4 meq/L Cl ‐ =70 meq/L HCO3 ‐ =19 meq/L
pH=7.47 PaCO2=30 mmHg PaO2=104 mmHg
Quote:
Originally Posted by Novobiocin View Post
AG= 47(136-70-19)

Mixed HAGMA (High Anion Gap Metabolic Acidosis) with Respiratory compensation (CO2 of 30) and Metabolic Alkalosis due to vomitting (loss of H+ and Cl-).

Remember, if the AG is over 20 then there must be a Primary metabolic acidosis regardless of the pH or HCO3.
Amazing Novo
High anion gap metabolic acidosis due to ketoacidosis.
Metabolic alkalosis due to nausea and vomiting .
Respiratory alkalosis due to pain.
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Case-4
A 64‐year‐old woman was admitted to the hospital yesterday with severe depression. Today she was found apneic and pulseless in bed by the nurse. CPR was started by the residents.
LABS: Na + =141 meq/L K + =6 meq/L Cl ‐ =104 meq/L HCO3 ‐ =9 meq/L
pH=6.99 PaCO2=34 mmHg PaO2=60 mmHg
pH=6.99 -->Severely acidemic.
anion gap = 28 HAGMA
PaCO2=34 mmHg PaO2=60 mmHg --> Respiratory Acidosis
Answer = High anion gap metabolic acidosis (Lactic acidosis due to hypoperfusion) and a respiratory acidosis (due to inadequate ventilation during a cardiac arrest).
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Quote:
Case-5
A 47‐year‐old woman with Inflammatory bowel disease and high output ileostomy, has had shaking chills and fever with abdominal pain for 36 hours.
Exam showed BP 100/40 mmHg T 105 P 110/min RR 16/min. LABS: Na + =136 meq/L K + =5.5 meq/L Cl ‐ =106 meq/L.
HCO3 ‐ = 8 meq/L pH=7.44 PaCO2=17 mmHg PaO2=111 mmHg
pH=7.44--> Alkalemic
anion gap = 22 HAGMA
delta gap = 10
starting bicarbonate = 18 indicating an additional hyperchloremic (nongap) metabolic acidosis.
PaCO2=17 mmHg PaO2=111 mmHg--> Respiratory alkalosis
Answer = High anion gap metabolic acidosis (due to sepsis and lactic
acidosis) + non‐anion gap metabolic acidosis (secondary to the high output ileostomy fluid loss) + respiratory alkalosis (due to fever and chills)
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Quote:
Case-6
A 64‐year‐old man with severe COPD and CAD has had watery diarrhea for 3 days.
LABS: Na + =136 meq/L K + =3.3 meq/L Cl ‐ =105 meq/L HCO3 ‐ =19 meq/L, pH=7.15 PaCO2=65 mmHg PaO2=48 mmHg
pH=7.15-->Acidemic
anion gap = 12 NAGMA
PaCO2=65 mmHg PaO2=48 mmHg--> Respiratory Acidosis
Answer = Respiratory acidosis (due to COPD)and hyperchloremic metabolic acidosis (due to diarrhea).
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A Stepwise Approach for any Acid-base problems in the step 2 ck exam

1 ‐ What is the likely clinical diagnosis (based on history)
*ASA overdose – mixed
*Vomiting – alkalosis
*COPD with sepsis – mixed resp and met acidosis
*COPD with sepsis and vomiting – triple acid base – resp acidosis, gap acidosis and metabolic alkalosis
*COPD with sepsis and diarrhea – triple acid base – respiratory acidosis, gap and non‐gap metabolic acidosis
2 ‐ Alkalosis or acidosis
*< 7.40 primary disorder = acidosis
*> 7.40 primary disorder = alkalosis
3 ‐ Calculate the anion Gap
*Anion gap = Na – HCO3 – Cl
*Normal gap is 12 +/‐ 2 (10 to 14)
4 ‐ Calculate the Delta gap (To verify if a there is a “hidden” coexistent)
*Delta gap = anion gap – 12 (the calculated anion gap – normal anion gap)
*Compared to normal range
> Normal (24) → metabolic alkalosis
< Normal (24) → hyperchloremic acidosis
5- Calculate and starting HCO3
* starting HCO3= Delta gap + current HCO3
If starting HCO3 < 24 = a coexistent non‐gap metabolic acidosis is present
If starting HCO3 > 24 = a coexistent metabolic alkalosis is present
6‐ check for respiratory compensation
7 ‐ Is it simple or mixed acid‐base disorder
8 ‐ Make clinical correlation and final diagnosis
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Quote:
Originally Posted by heartbeat View Post
pH=7.44--> Alkalemic
anion gap = 22 HAGMA
delta gap = 10
starting bicarbonate = 18 indicating an additional hyperchloremic (nongap) metabolic acidosis.
PaCO2=17 mmHg PaO2=111 mmHg--> Respiratory alkalosis
Answer = High anion gap metabolic acidosis (due to sepsis and lactic
acidosis) + non‐anion gap metabolic acidosis (secondary to the high output ileostomy fluid loss) + respiratory alkalosis (due to fever and chills)


why dint u include K+ in AG calculation then it would show normal starting bicarb?
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Quote:
Originally Posted by Novobiocin View Post
AG=10

NAGMA with Resp compensation & Low K.

Typical of diarrhea.

can we say it hyperchloramic meta. acidosis with hypokalamia and hypotension ???
and how can we explain it as resp. compensation ?
the metabolic parameter hco3- is decreased here, but there is no evidence of resp. compensation . the R/R is within normal limit , so no hyperventilation....
i am getting confused
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