AcidBase - Department of Medicine：酸碱-医学系.pptVIP

* Acid/Base Saleem Bharmal 1/6/2009 HPI: 75 year old M with PMHx of DM, HTN, CKD (baseline Cre 3.0), bladder cancer s/p resection and orthotopic neobladder who was initially admitted for workup of intermittent chest pain. On admission labs patient was noted to be in acute on chronic renal failure with a Cre of 4.9 and was noted to have a serum HCO3 of 7. Patient at time of admission described some shortness of breath and weakness. He denied any diarrhea, recent illness or nausea/vomiting. He did state that he his urine contained more mucous which in the past represented possible infection of the neobladder. Patient wife straight cath neobladder daily and flushes it. Per patient wife he has a night bag to collect urine and is usually full in the AM, but she noticed over the last few night the amount of urine in the bag has progressively declined. Past Medical History IDDM CKD stage IV, baseline Cre 3.0 Bilateral Renal Artery stenosis; s/p RAS stent to R CAD s/p stent S/P bladder resection for neoplasm and orthotopic neobladder Anemia COPD (FEV1 65%) Hyperlipidemia Outpatient Medications Physical Exam T 97.2 P 87 BP 157/55 R 16 O2Sat 97% Wt 66 kg Gen: Elderly male in NAD. Pt did not appear short of breath of tachypnic HEENT: MMM, no elevated JVD appreciated Heart: S1/S2 no murmurs Pulm: Clear to auscultation b/l, no crackles or wheeze Abd: soft, NT ND; + bowel sounds, medial surgical scar well healed Ext: +1 pitting edema in LE bilaterally up to the knees Neuro: AAOx3 Admission Labs and Studies WBC 10.7/HGB 8.3/HCT 25.7/PLT 99 Na 140/K 4.7/CL 119/HCO 7/BUN 103/Cre 4.9/Gluc 112/Ca 8.0 Anion Gap: 14 Urinalysis: Yellow/clear/neg gluc/neg bili/neg ketones/ SG 1.011/trace blood/pH 7.0/prot 30/neg nit/+ leuk/4-8 WBC/1-3 RBC CXR: No evidence of focal consolidation, vascular congestion, or pleural effusions Brief Hospital Course Once admission labs were obtained ABG was drawn which revealed: ABG: 7.11/20.0/157/HCO3 6.0/lact 0.3 (This shows a primar