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45 Cards in this Set
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- Back
- 3rd side (hint)
1
H2O and Na balance Normal response to decreased plasma volume: Increased sodium absorption. |
Increased sodium
absorption. |
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Continued peripheral edema and increased sodium reabsorption:
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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. |
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◆ Reabsorption of sodium:
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Primarily in the proximal kidney.
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2
Primarily in the proximal kidney. Response of the kidney to metabolic acidosis: |
Increased excretion of
the excess fixed hydrogen as ammonia and increased reabsorption of bicarbonate |
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Response of the kidney to respiratory alkalosis
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Decreased hydrogen
excretion and decreased bicarbonate absorption |
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Compensatory response to metabolic acidosis
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Decrease in
bicarbonate and in PCO2 |
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3
Anaphylaxis What is anaphalaxis vs Allelrgic Reaction |
Anaphalaxis =
Hives BP 80/40 |
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Anaphalx-Pt at ED dire reaction
1st intervention = |
airway
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Anaphalax-greatest determinant of good outcome is
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Airway
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airway secure in Dire anaphalax Pt .... next step is =
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Epi
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4
DKA Triad of DKA = |
-Hyperglycemia
-Ketosis -Acidosis |
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25 yo M Pt, w DKA,
BP = 80/50 HR = 140 sugar = 950 K = 6 HCO3 = 5 |
Fluid Recesutattion
IV Insulin |
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57 yo M Pt
pH = 7.46 pCO2 = 24 pO2 = 110 HCO3 = 16 AG = 18 Sugar = 90 eitiology is = |
salicylate lead to
Anion Gap (GP) acidemia This is typical of Salicylate intox. |
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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 = |
Serum Glucose
drops more rapid than Ketoacidosis |
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5
Hemorrhagic shock physiology Response of sympathetic system |
Increased heart rate and
contractility, and increased total peripheral resistance. |
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Response of the renin-angiotensin-aldosterone system
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: Increased
angiotensin II causes further vasoconstriction, and aldosterone increases sodium-chloride reabsorption in the kidney to increase blood volume. |
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Response of ADH
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Causes vasoconstriction and increases water
reabsorption in the kidney. |
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#6
hemorragic Shock what are next steps in this Pt = |
abc-s
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If Pt becomes Hypotensive what is cause =
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Hemmoragic Shock
Intraabdominal / Femur hemmorage |
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7
Neonatal sepsis Dx = |
Neonatal Sepsis
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Next step in mgmt
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obtain appropriate cultures & initiate antibiotics
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Best therapy =
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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 |
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8
REGULATION OF POTASSIUM, CALCIUM, AND MAGNESIUM Effect of an ACE inhibitor on potassium |
ACE inhibitors block
conversion to angiotensin II and decrease potassium secretion (resulting in hyperkalemia). |
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Acidosis and potassium
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Decreases potassium secretion.
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◆ Competitive electrolyte of calcium: =.
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Magnesium
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9
Sepsis etiology |
UTI / urosepsis
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32 yo F has hypotension from toxic shock syndrome despite 3 L of NS.
Next Best step! |
VASOPRESSOR IE
for hypotension for unresponsive to intravenous NS. |
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45 yo acute Cholecystitis is noted w fever of 39.3 (101)
hypotensive & altered sensorium = |
Broadspectrum antibiotics & IV
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Tite Glucose ctrl decreases mortality in septic Pt.
Activated Protein -C started 24 hrsof Dx of Sepsis decreases mortality by 20% |
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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 = |
IVP would identify stone obstruciton.
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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. = |
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. |
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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? |
. 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. |
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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? |
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. |
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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? |
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 |
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[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? |
[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). |
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[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? |
[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 |
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[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? |
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. |
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[27.1] Recovery from a severe metabolic acidosis is most dependent on
which of the following? |
[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. |
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[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? |
[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. |
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[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? |
[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. |
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[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? |
[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 |
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[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? |
[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. |
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[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? |
[51.3] A. Diffuse capillary leakage is the primary reason for the peripheral
edema that occurs regardless of which resuscitation fluid is used. |
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[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? |
[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. |
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[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? |
[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. |
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[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? |
[26.3] C. The majority of magnesium is resorbed in the thick ascending
limb of the renal tubule. |
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