Question

Mrs. K.B. is age 64 and has been a patient of yours for many years. You are calling her today to tell her the results of her Pap test which was done last week during her routine annual checkup in your office. The test showed marked dysplasia of cervical cells but no sign of infection. Unfortunately, when you call, there is no answer.

Since you saw Mrs. K.B. last week she has had gastritis with severe vomiting for 3 days. She has a history of heart problems and is presently feeling dizzy and lethargic. Her eyes appear sunken, her mouth is dry, she walks unsteadily, and she complains of muscle aching, particularly in the abdomen, and she is concerned about her chronic back pain as well and how she is going to handle her pain if she can’t keep her medication down. She is thirsty but is unable to retain food or fluid. A neighbor has brought Mrs. K.B. to the hospital, where examination shows that her blood pressure is low, and her pulse and respirations are rapid. Laboratory tests demonstrate elevated hematocrit, hypernatremia, decreased serum bicarbonate, serum pH 7.35, and urine of high specific gravity. This case study illustrates a combination of fluid, electrolyte, and acid-base imbalances. Specific laboratory values are not given to focus on the basic concepts. For clarity, this case study is discussed in multiple parts. Further information about the specific problems involved is given in each part and is followed by a series of questions.

Part 1

Later in the afternoon, you receive a phone call from Mrs. K.B.’s daughter Sara who tells you that she has been admitted to the hospital with vomiting. Sara is asking about her mother’s test results. Please answer the following questions regarding your conversation with Sara.

1. Sara is requesting her Mother’s test results and she seems to know that her Mom had a Pap test last week. Sara is really concerned because her Mom had an abnormal Pap test a few years ago and her sister also has a history of Ovarian Cancer. How do you handle this conversation with Sara?
2. In thinking about how you might discuss these results with Mrs. K.B. or Sara, explain how each of these terms might apply to this scenario: prognosis, latent stage, remission, exacerbations, and predisposing factors.
3. Explain cellular adaptations and in particular, dysplasia and how testing and or additional testing is done regarding this condition.

Part 2: Day 1

Initially, Mrs. K.B. lost water, sodium in the mucus content, and hydrogen and chloride ions in the hydrochloric acid portion of the gastric secretions.

Alkalosis develops for two reasons, the first being the direct loss of ________ ions, and the second being the effects of chloride ion loss. When chloride ions are lost in the gastric secretions, it is replaced by chloride from the serum (See Fig. 2.9 in Chapter 2 of your Gould text). To maintain equal numbers of cations and ________ in the serum, chloride ions, and bicarbonate ions can exchange places when needed. Therefore, more bicarbonate ions shift into the serum from storages sites in the _______________ to replace the lost chloride ions. More bicarbonate ions in the serum raise serum pH, and the result is hypochloremic alkalosis.

1. Which compartments are likely to be affected in this case by early fluid-loss?
2. Explain how a loss of sodium ions contributes to dehydration.
3. Describe the early signs of dehydration in Mrs. K.B.
4. Describe the compensations for the losses of fluid and electrolytes that should be occurring in Mrs. K.B.
5. Explain why Mrs. K.B. may not be able to compensate for losses as well as a younger adult.

Part 3: Days 2-3

As Mrs. K.B. continues to vomit and is still unable to eat or drink any significant amounts, 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. Mrs. K.B. shows elevated serum sodium levels.

Sara has been at the hospital all morning waiting for the provider to come by with an update. Sara is rubbing her Mom’s back and she continues to complain back pain.

1. Explain why serum sodium levels appear to be in high in this case
2. Explain how high serum sodium levels might affect the intracellular fluid
3. Using your knowledge of normal physiology, explain how continued fluid loss is likely to affect the following:
   1. Blood volume
   2. Cell function
   3. Kidney function
4. Given Mrs. K.B.’s history, why might a potassium imbalance have more serious effects on her?
5. As the provider, when you enter the room, you find Sara rubbing her Mom’s back – you introduce yourself and what is the first thing that you would then need to do?
6. In regard to Mrs. K.B.’s back pain, what type of questions or history would you like to obtain?

Mrs. K.B. reports using herbal compresses at home to help her back pain and that she usually takes two “extra-strong” Acetaminophen tablets every 4 hours and a Tylenol #3 whenever the pain is severe. Sara states that she has tried to get her Mom to use “more natural” treatments for her back but she “loves her Tylenol.”

1. When considering sources for Herbal and Natural Remedies there are many to choose from but not all are FDA approved, and who has time to vet every website. Take a look at Natural Medicines, which is in the Research Guides at the Regis Library. What type of Natural Medicine treatment would you recommend for Mrs. K.B. knowing that her back pain is due to arthritis that was diagnosed 10 years prior, that could offer her relief from her back pain?
2. What should Mrs. K.B. and Sara understand about the dosage of acetaminophen that she is taking?
3. Finally, Sara commented that her Mom seems to be suffering more frequently from insomnia but claims that her medication controls her back pain. Could the Tylenol #3 tablets be interring with her sleep and if so how is this occurring?

Part 4: Day 3

Mrs. K.B. has spent the night in the ED due to a bed shortage and she is finally admitted to Med-Surg.

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

• Loss of bicarbonate ions in duodenal secretions
• Lack of nutrients leading to __________ 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 __________
• Decreased blood volume leading to decreased tissue perfusion, less oxygen to cells, and increased __________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 ___________.

1. List several reasons why Mrs. K.B. is lethargic and weak.
2. Predict the serum level of carbon dioxide, lactic acid, pH, pO2, K+, Na+, LFTs – note you should indicate low, normal or high and explain why in a brief sentence to indicate you understand the pathophysiology of the process.
3. If Mrs. K.B. continues to lose body fluid, why might serum pH decrease below 7.35?
4. If serum pH drops below 7.35 what signs would be observed in Mrs. K.B.
5. Describe the effect of acidosis on serum potassium levels.
6. Mrs. K.B. will be given replacement fluid therapy. Why is it important that sodium and potassium be given as well as water?

Answer 1

Part 2: Day 1

Initially, Mrs. K.B. lost water, sodium in the mucus content, and hydrogen and chloride ions in the hydrochloric acid portion of the gastric secretions.

Alkalosis develops for two reasons, the first being the direct loss of hydrogen ions, and the second being the effects of chloride ion loss. When chloride ions are lost in the gastric secretions, it is replaced by chloride from the serum (See Fig. 2.9 in Chapter 2 of your Gould text). To maintain equal numbers of cations and cations in the serum, chloride ions, and bicarbonate ions can exchange places when needed. Therefore, more bicarbonate ions shift into the serum from storages sites in the erythrocytes to replace the lost chloride ions. More bicarbonate ions in the serum raise serum pH, and the result is hypochloremic alkalosis.

Which compartments are likely to be affected in this case by early fluid-loss?

The intracellular compartment is most likely affected in case of fluid loss. Because the intracellular fluid moves excessively to the extracellular space to compensate for the loss of fluid.

Explain how a loss of sodium ions contributes to dehydration.

When the sodium ions are lost, the water present in the intracellular fluid enters into extracellular space and causes swelling. Thus the shifting of intracellular fluid results in dehydration.

Describe the early signs of dehydration in Mrs. K.B.

The early signs of dehydration are

• increased thirst
• dry mouth
• decreased urine
• dizziness
• sunken eyes
• Confusion
• dry skin
• Decreased pulse and blood pressure.

Describe the compensations for the losses of fluid and electrolytes that should be occurring in Mrs. K.B.

The fluid and electrolytes are compensated by a change in the ratio of the proportion of bicarbonate and carbonate ions to maintain normal pH and electrolyte level. Thus the kidney excretes less acid and decreases bicarbonate absorption to compensate for the fluid and electrolyte losses.

Explain why Mrs. K.B. may not be able to compensate for losses as well as a younger adult.

Mrs. K.B has vomiting and loss of duodenal contents results in dehydration. Thus kidney unable to receive enough blood to compensate for the loss results in decompensation. This leads to increased bicarbonate ions and results in metabolic alkalosis.