Md2 Block4 Ccbs Test Q Review

Front 1

1
H2O and Na balance

Normal response to decreased plasma volume: Increased sodium
absorption.

Back 1

Increased sodium
absorption.

Front 2

Continued peripheral edema and increased sodium reabsorption:

Back 2

Because of the low albumin and hypoproteinemia, the colloid pressure
is decreased and fluid escapes to the interstitial areas outside the
vessels. Although the patient has excess retained fluid, the plasma
volume (or arterial plasma volume) is low, and this causes an increase
in aldosterone and sodium reabsorption.

Front 3

◆ Reabsorption of sodium:

Back 3

Primarily in the proximal kidney.

Front 4

2
Primarily in the proximal kidney.

Response of the kidney to metabolic acidosis:

Back 4

Increased excretion of
the excess fixed hydrogen as ammonia and increased reabsorption of
bicarbonate

Front 5

Response of the kidney to respiratory alkalosis

Back 5

Decreased hydrogen
excretion and decreased bicarbonate absorption

Front 6

Compensatory response to metabolic acidosis

Back 6

Decrease in
bicarbonate and in PCO2

Front 7

3
Anaphylaxis

What is anaphalaxis
vs
Allelrgic Reaction

Back 7

Anaphalaxis =
Hives
BP 80/40

Front 8

Anaphalx-Pt at ED dire reaction
1st intervention =

Back 8

airway

Front 9

Anaphalax-greatest determinant of good outcome is

Back 9

Airway

Front 10

airway secure in Dire anaphalax Pt .... next step is =

Back 10

Epi

Front 11

4
DKA

Triad of DKA =

Back 11

-Hyperglycemia
-Ketosis
-Acidosis

Front 12

25 yo M Pt, w DKA,
BP = 80/50
HR = 140
sugar = 950
K = 6
HCO3 = 5

Back 12

Fluid Recesutattion
IV Insulin

Front 13

57 yo M Pt
pH = 7.46
pCO2 = 24
pO2 = 110
HCO3 = 16
AG = 18
Sugar = 90

eitiology is =

Back 13

salicylate lead to
Anion Gap (GP) acidemia

This is typical of Salicylate intox.

Front 14

16 yo F Pt Mod-severe DKA
Sugar = 680
pH 7.21
10 hrs of Tx labs/vitals are:
sugar = 240
Ketones = hi
pH = 7.24

Best management is =

Back 14

Serum Glucose
drops more rapid than Ketoacidosis

Front 15

5
Hemorrhagic shock physiology

Response of sympathetic system

Back 15

Increased heart rate and
contractility, and increased total peripheral resistance.

Front 16

Response of the renin-angiotensin-aldosterone system

Back 16

: Increased
angiotensin II causes further vasoconstriction, and aldosterone increases
sodium-chloride reabsorption in the kidney to increase blood volume.

Front 17

Response of ADH

Back 17

Causes vasoconstriction and increases water
reabsorption in the kidney.

Front 18

#6
hemorragic Shock

what are next steps in this Pt =

Back 18

abc-s

Front 19

If Pt becomes Hypotensive what is cause =

Back 19

Hemmoragic Shock

Intraabdominal / Femur hemmorage

Front 20

7
Neonatal sepsis

Dx =

Back 20

Neonatal Sepsis

Front 21

Next step in mgmt

Back 21

obtain appropriate cultures & initiate antibiotics

Front 22

Best therapy =

Back 22

depends on local bacterial resistance patterns
but ofr community-acquired infections, it most commonly includes ampicillin
plus
either an aminoglycoside or a 2nd / 3rd Gen cephalosporin

Front 23

8
REGULATION OF
POTASSIUM, CALCIUM, AND MAGNESIUM

Effect of an ACE inhibitor on potassium

Back 23

ACE inhibitors block
conversion to angiotensin II and decrease potassium secretion (resulting
in hyperkalemia).

Front 24

Acidosis and potassium

Back 24

Decreases potassium secretion.

Front 25

◆ Competitive electrolyte of calcium: =.

Back 25

Magnesium

Front 26

9
Sepsis
etiology

Back 26

UTI / urosepsis

Front 27

32 yo F has hypotension from toxic shock syndrome despite 3 L of NS.
Next Best step!

Back 27

VASOPRESSOR IE

for hypotension for unresponsive to intravenous NS.

Front 28

45 yo acute Cholecystitis is noted w fever of 39.3 (101)
hypotensive & altered sensorium =

Back 28

Broadspectrum antibiotics & IV

i

Hint 28

Tite Glucose ctrl decreases mortality in septic Pt.
Activated Protein -C started 24 hrsof Dx of Sepsis decreases mortality by 20%

Front 29

32 yo F admitted for acute pyelonephritis.
Pt is Tx with Oral cipro. 4 Days later of therapy. Returns to ER w Fever 38.9 C (102F) & flank tenderness.

Urine shows Ecoli >100,000

Next best step =

Back 29

IVP would identify stone obstruciton.

Front 30

66 yo F w acute pneumococcal Pneumonia & is being Tx w ABx & dopamine & dobutamine to maintain BP & uro output.

What is a bad prognostic sign. =

Back 30

decreased arterial-venous O2 gradient connotes less excretion of O2 for Tissues meaning multi organ failure.
dying organs dont use O2, However the lactate levels are likely elveated.

Front 31

10
Septic abortion

1 A 34-year-old woman undergoes an elective termination of pregnancy
at 12 weeks’ gestation. She develops fever, uterine tenderness, and is
diagnosed with a septic abortion. Which of the following is the most
likely mechanism of her infection?

Back 31

. Ascending infection is the most likely mechanism of septic abortion.
The bacteria involved are typically polymicrobial, particularly
anaerobes that have ascended from the lower genital tract. Signs and
symptoms include uterine bleeding and/or spotting in the first
trimester with clinical signs of infection. There is usually lower abdominal
tenderness, cervical motion tenderness, and a foul-smelling vaginal
discharge. Also, careful attention should be given to the patient’s
urine output since oliguria is an early sign of septic shock.

Front 32

43.2 A 22-year-old woman is diagnosed with a septic abortion after an incomplete
abortion, fever, and uterine tenderness. She is treated with triple IV
antibiotics and D and C of the uterus. After 48 hours of antibiotic therapy,
she still has a fever of 102°F (38.88°C), BP of 80/40 mm Hg, and
HR of 105 bpm. A CT scan of the abdomen and pelvis is performed
revealing pockets of air within the muscle of the uterus. Which of the
following is the best treatment for this patient?

Back 32

43.2 D. This patient has a septic abortion which has been treated conventionally
with IV antibiotics and D and C to remove the nidus of the
infection. She is still febrile and hypotensive despite antibiotic therapy
for 48 hours. Also, due to the pockets of gas noted on CT scan, she
likely has a necrotizing metritis, with gas forming bacteria such as
Clostridial species. Hysterectomy should be performed urgently as she
may suffer severe morbidity or mortality if the procedure is delayed.

Front 33

43.3 A 32-year-old Hispanic female G1 P0 at 29 weeks’ gestation presents
to the obstetrical triage unit complaining of fever, chills, and nausea
and vomiting of 3 days duration. She also has myalgias. She denies
leakage of fluid per vagina and states that she has been in good health.
She has not been out of the country for 2 years. Questions about dietary
habits reveal that she does not eat raw or uncooked foods, does not eat
raw shellfish, but she does eat a fair amount of soft goat cheese. Her
temperature is 101°F (38.33°C), BP 100/80 mm Hg, HR 110 bpm. Her
abdominal examination reveals tenderness of the uterine fundus. The
fetal heart rate is 170 bpm. An ultrasound reveals a single gestation
that is viable consistent with 29 weeks’ gestational age, and a normal
amniotic fluid volume. An amniocentesis is performed revealing greenish
dark fluid, and a Gram stain of the amniotic fluid shows grampositive
rods. Which of the following is the most likely diagnosis?

Back 33

43.3 C. Chorioamnionitis, also called intra-amniotic infection, almost
always complicates pregnancies with rupture of membranes. One
exception to this rule is the gram-positive rod Listeria monocytogenes,
which can be acquired through unpasteurized milk products such as
soft goat cheese. The bacterial infection in the maternal gastrointestinal
tract, which presents as a flu-like illness, then is spread hematogenously
358 CASE FILES: Obstetrics and Gynecology
to the fetus, through the placenta. The diagnosis is largely from clinical
suspicion and confirmed by amniocentesis. Often the amniotic fluid
is meconium stained, and gram-positive rods may be seen on Gram
stain. The microbiology laboratory should be alerted not to dismiss this
finding as skin (bacteroid) contaminants. Treatment is with IV ampicillin.
Many times the infection may be treated with antibiotic therapy
and avoid delivery (again, an exception to the usual rule of needing to
deliver the baby in chorioamnionitis). Listeria

Front 34

[25.1] A 24-year-old man was admitted to the emergency department and
complained of abdominal pain, dizziness when standing, and nausea
leading to occasional vomiting. The patient’s blood pressure was low,
and his heart rate was elevated. Laboratory tests revealed a reduced
hematocrit, hypoalbuminemia, very modest hyponatremia, and elevated
creatinine, blood urea nitrogen (BUN), and renin levels. Urine
output was minimal. The patient informed the physician that he had
been taking extra aspirin recently to alleviate back pain. Which of the
following is the most like diagnosis?

Back 34

[25.1] B. This patient probably has gastrointestinal bleeding caused by sensitivity
to aspirin. It is well known that aspirin can induce erosions in
the gastrointestinal lining that can lead to bleeding ulcers. The bleeding
will lead to loss of blood and hypovolemia that causes a decrease
in capillary pressure and, as a result, a shift of fluid from the interstitial
space into the vasculature. This fluid shift is apparent from the
decrease in hematocrit and dilution of plasma proteins (hypoalbuminemia).

Front 35

[25.2] A student in a clinical study had her normal diet changed to a diet high
in potassium, but everything else was unremarkable. The student noted
that she had gained nearly 2 lb within a few days after starting the diet.
Laboratory tests indicated a modest elevation in plasma K+ but no
change in plasma Na+ levels. Interestingly, plasma levels of arginine
vasopressin and renin were depressed, results consistent with volume
expansion. What is the most likely reason for the hypervolemia?

Back 35

[25.2] D. The consumption of a diet high in K+ will lead to K+ loading,
which is known to stimulate directly the secretion of aldosterone
from the adrenal gland. The elevated aldosterone will stimulate the
synthesis of new Na+-K+ exchange pumps and luminal membrane
Na+ channels in the renal cortical collecting ducts, leading to stimulation
of Na+ (and Cl−) reabsorption and fluid retention (K+ secretion
also is stimulated). The salt and fluid retention will lead to volume
expansion as ma

Front 36

[25.3] A 37-year-old man is stabbed in the arm and chest in a bar fight and
experiences an estimated blood loss of 1000 mL. His blood pressure
is 100/50 mm Hg, and his heart rate is 110 beats per minute. Which
of the following describes this patient’s physiologic response?

Back 36

25.3] B. Hypovolemia triggers several responses, including sympatheticmediated
vasoconstriction to renal afferent and efferent arterioles,
which decrease GFR. Meanwhile, ADH release induces more concentrated
urine (retention of free water), and aldosterone induces
sodium retention.

Front 37

[27.1] Recovery from a severe metabolic acidosis is most dependent on
which of the following?

Back 37

[27.1] C. The rate of recovery from a severe metabolic acidosis is most
dependent on the rate of H+ excretion. Pulmonary compensation
occurs rapidly; however, it can only minimize the change in pH.
Pulmonary compensation cannot restore the balance after a metabolic
disturbance. Recovery necessitates the excretion of the entire acid
load to the system. Renal acid excretion is limited by the availability
of titratable acids and ammonia for ammonium ion formation from
CLINICAL CASES 229
230 CASE FILES: PHYSIOLOGY
secreted H+. The primary adaptive response of the kidney to an acidosis
is ammoniagenesis. Ammoniagenesis can augment the daily
excretion of acids as much as threefold. When an equivalent amount
of acid is excreted, acid–base balance will be restored.

Front 38

[27.2] After a rapid ascent to very high altitude, one begins to hyperventilate
because of hypoxic drive. The hyperventilation will cause a decrease
in the arterial PCO2. What is the renal response to this condition?

Back 38

[27.2] B. The two most important drivers of renal bicarbonate reabsorption
are CO2 and H+. The hyperventilation experienced at high altitude
decreases the PCO2, which generates a respiratory alkalosis.
Reducing both CO2 and H+ will decrease renal H+ secretion and thus
bicarbonate reabsorption. The filtered bicarbonate load will exceed
the rate of H+ secretion with a loss of excess bicarbonate in the urine.

Front 39

[27.3] A 21-year-old man with gastroenteritis developed severe vomiting
with a loss of stomach acids. A metabolic alkalosis is present. Which
of the following is most likely to occur?

Back 39

[27.3] D. The loss of gastric (hydrochloric) acid leads to an increase in the
plasma bicarbonate concentration and a metabolic alkalosis. The
increase in the pH will depress peripheral chemoreceptors to slow ventilation
and increase the PCO2 to compensate for the increased bicarbonate.
The increase in PCO2 will bring the pH nearer to 7.4 and at the
same time increase renal H+ secretion. Because there is an increased
level of bicarbonate in the glomerular filtrate, there will be an increase
in bicarbonate reabsorption. The rate of filtration will exceed the rate
of H+ secretion, and there will be a continuous loss of bicarbonate. As
the plasma bicarbonate falls, the pH will continue to approach the normal
of 7.4 and the ventilatory rate will increase gradually. When all the
excess bicarbonate has been excreted, the plasma bicarbonate and pH
will have returned to normal with a normal respiratory rate.

Front 40

[51.1] An individual comes to the emergency room complaining of weakness,
dizziness, and fatigue. She states that she has had diarrhea for
several days. Examination reveals a low blood pressure and tachycardia
consistent with low cardiac output. Plasma bicarbonate is low, and
other plasma electrolytes are unremarkable. Urine volume was minimal.
The patient most likely has which of the following?

Back 40

[51.1] C. Diarrhea over several days can lead to dehydration from loss of fluid
in the stool. In severe cases, the individual can become volumedepleted
to the point of circulatory collapse. The reduced blood volume
and the fall in mean arterial pressure will be sensed by both low-pressure
receptors (volume receptors in the atria, pulmonary veins) and
high-pressure baroreceptors (carotid, aortic, and afferent arteriole
baroreceptors), inducing increased sympathetic nervous activity. This
leads to an increase in heart rate, cardiac contractility, and venoconstriction
that will serve to elevate mean arterial pressure. In addition,
the increase in sympathetic nervous activity stimulates the release of
renin from the afferent arteriole, activating the renin-angiotensin-aldosterone
system and leading to aldosterone-induced reabsorption of Na+
and Cl−from the cortical collecting duct; this also stimulates secretion
of ADH from the posterior pituitary, leading to enhanced water reabsorption
a

Front 41

[51.2] An individual was in a car accident and is brought to the emergency room
in an unconscious state. Examination shows a very low blood pressure
(80/40 mm Hg), tachycardia, a very weak thready pulse, a distended
abdomen, and clammy skin. Laboratory values indicate a very low hematocrit
(18%) and hypoalbuminemia. He is diagnosed as having internal
hemorrhage leading to severe hypovolemia and circulatory shock. To
avoid having the patient go into irreversible shock, the emergency room
doctor immediately should initiate which of the following treatments?

Back 41

[51.2] A. The best immediate therapy for a person in hemorrhagic shock is
usually isotonic crystalloid colloid-free solution such as normal
saline, until red blood cells are available. These agents are usually
stocked immediately in the emergency center, whereas blood products
require the blood bank to ensure matching blood type. The infusion
will increase vascular volume and restore hemodynamics to near
normal. Crystalloid such as normal saline cannot restore the hematocrit,
but a patient normally can withstand a decrease in hematocrit
of up to 20% or so without serious consequences. The use of vasoconstrictors
and oxygen can be helpful, but again, if the volume
depletion is severe, replacement of fluids will be essential to avoid
having the patient go into irreversible shock.

Front 42

[51.3] A 35-year-old man had a tractor accident and lost approximately 1500 mL
of blood. His initial blood pressure is 90/60 mm Hg, and the heart rate
is 120 beats per minute. On resuscitation with intravenous lactated
Ringer solution, his blood pressure increases to 110/70 mm Hg. Two
hours later, he is noted to have significant peripheral edema of the hands
and feet. Which of the following is the best explanation for the edema?

Back 42

[51.3] A. Diffuse capillary leakage is the primary reason for the peripheral
edema that occurs regardless of which resuscitation fluid is used.

Front 43

[26.1] A 56-year-old patient has chronic renal failure that results in fewer
functioning nephrons. The patient’s dietary intake of potassium has
not changed, and this could lead to dangerous hyperkalemia in the
face of fewer functioning nephrons. However, because of adaptive
responses to the potassium load, plasma potassium is noted to rise
only slightly (< 0.5 mEq/L). Although numerous renal and extrarenal
responses may underlie this K+ adaptation, what is the dominant
adaptive response of the kidney to maintain plasma K+ levels in this
chronic condition?

Back 43

[26.1] D. The continuous ingestion of a constant potassium load in the face
of a reduced number of functioning nephrons leads to a chronic overload
of K+, but without the development of extreme hyperkalemia.
The kidney slowly adapts to the increased potassium load in a process
called K+ adaptation, which leads to a kaliuresis caused by an
enhanced rate of K+ secretion by the late distal tubule and cortical
collecting tubule (the early part of the outer medullary collecting duct
also may participate). This enhanced K+ secretion arises from both a
direct effect of the elevated plasma K+ on the expression of new Na+-
K+ exchange pumps at the basolateral membrane in these segments
and an indirect effect through K+-induced stimulation of aldosterone
secretion from the adrenal gland.

Front 44

[26.2] The occurrence of hypocalcemia can have dire consequences for
numerous physiologic processes. The kidney plays a major role in
maintaining calcium balance during hypocalcemic states by decreasing
calcium excretion. The major mechanism underlying the response
of the kidney during hypocalcemia is which of the following?

Back 44

[26.2] A. The occurrence of low plasma calcium levels is sensed by a calcium
receptor on the surface of the parathyroid gland, leading to
stimulation of synthesis and secretion of parathyroid hormone. PTH,
along with vitamin D and to a lesser extent calcitonin, plays a dominant
role in regulating calcium balance. In the kidney, PTH has
diverse actions, but its key action appears to be to promote calcium
reabsorption. The key sites regulating calcium reabsorption are the
thick ascending limb and the distal convoluted tubule.

Front 45

[26.3] A 56-year-old woman receives chemotherapy for ovarian cancer and
develops hypomagnesemia as a result. Urine chemistries reveal a
large amount of magnesium in the urine. Which of the following areas
most likely was affected by the chemotherapeutic agent?

Back 45

[26.3] C. The majority of magnesium is resorbed in the thick ascending
limb of the renal tubule.