Fred, a 68 y/o male who had an MI in April, 2015 was seen by his physician on Aug. 30, 2017 presenting with shortness of breath, fatigability, and swelling of the lower extremities. Upon physical examination, the man was found to have distended jugulars and pitting edema of the ankles. His breathing was rapid (20 breaths/min) and pulmonary crackles were heard bilaterally in the lower lobes of the lungs. He had a pulse rate of 110 beats/min and a BP of 152/98. Since his MI, he was taking digoxin and hydrochlorothiazide. At the time, the Px blood and urine work showed: Blood Values Urine Values Na+ (mEq/L) 128 Na+ (mEq/L) 110 K+ (mEq/L) 3.9 K+ (mEq/L) 80 Mg2+ (mg/dL) 1.7 Mg2+ (mg/day) 19 Ca2+ (mg/dL) 8.9 Ca2+ (mg/day) 105 HCO3 (mEq/L) 30 HCO3 1.7 Creatinine (mg/dl) 1.7 Creatinine (mg/L) 2080 PAH (mg/ml) 0.013 PAH (mg/ml) 5.91 Glucose (mg/dL) 85 Glucose 0 BUN (mg/dL) 14 24hr volume (L) 1.2 pCO2 (mmHg) 45 Osmolarity (mOsm/L) 750 pH 7.31 pH 6.8 The Px was admitted at that time and was treated with 2L of 5% saline and Lasix® which removed the excess blood volume. The Px’s blood pressure, heart rate and respiratory problems were reduced. Additional lab tests indicated that the Px was experiencing left ventricular failure. Once he was stable, the Px was sent home on Sept. 2. On Dec. 7, 2017, the Px was transported to the ER via ambulance after his daughter found him unresponsive. She told the ER physician that her father had been extremely fatigued at any level of effort, had extensive flank pain and that his mental alertness had decreased significantly over the past two weeks. Physical examination finds that the Px is doesn’t respond to questioning and appears to fall asleep during the examination. Once again, the Px exhibits excessive swelling in the lower extremities with distended jugulars. His heart rate is now 92 and irregular, his BP is 164/110. His breathing is 28 breaths/min and shallow but lung sounds are normal. His urine is dark and foamy. The ends of his fingers and toes have a bluish appearance and his abdomen is large and distended. Blood and urine values are: Blood Values Urine Values Na+ (mEq/L) 118 Na+ (mEq/L) 310 K+ (mEq/L) 2.9 K+ (mEq/L) 108 Mg2+ (mg/dL) 0.7 Mg2+ (mg/day) 29 Ca2+ (mg/dL) 5.9 Ca2+ (mg/day) 155 HCO3 (mEq/L) 29 HCO3 13.9 Creatinine (mg/dl) 2.2 Creatinine (mg/L) 1590 PAH (mg/ml) 0.013 PAH (mg/ml) 5.91 Glucose (mg/dL) 85 Glucose 0 pCO2 (mmHg) 53 Osmolarity (mOsm/L) 400 pO2 (mmHg) 67 24hr urine volume (mL) 600 pH 7.28 pH 6.8 RBC count / µL 3.8 x 106 Hemoglobin gm/dl 9.5 The attending physician immediately gave the Px 30 mg of propranolol and admitted the Px. An echocardiogram was conducted and showed right and left ventricular cardiomegaly. Does the Px have an acid-base imbalance? If so, what type of acid base imbalance it is and why did the Px develop this problem? How is his body compensating for this imbalance
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