病理生理學的任務是研究疾病發(fā)生的原因和條件-北京大學醫(yī)學部課程

#17.3/12.0kPa(130/90mmHg),兩肺(一)，血尿素氮下降至0.68g/L，血鉀4.1mol/L。第二天透析8次，訴輕度腹脹痛，面部浮腫和淤斑開始消退，腹部平、軟、輕壓痛，腸鳴音稀少，為防止腹膜感染給氨芐青霉素每日7克。第三天透析10次，透析液微黃微渾，腹脹痛，體溫37.7T，心率108次/分，血壓18.6/12.0kPa(140/90mmHg)，血尿素氮為0.97g/L，血鉀4.0mmol/L。加用慶大霉素每日16萬單位。第4天透析8次，第5天透析8次，排液淡黃稍清亮，稍覺腹脹，血尿素氮！69g/L。第6天開始，精神食欲好轉(zhuǎn)，能進半流質(zhì)飲食，未感腹痛，排出透析液微渾。尿量已達1000ml，血尿素氮).69g/L，血鉀4.1mmol/L。第11天患者無自覺不適，精神食欲基本正常，腹部體征消失，復查血尿素氮.51g/L，尿量每天1750ml思考題：什幺是腎功能衰竭？腎功能衰竭有哪些分類？該患者屬于哪一類腎功能衰竭？其依據(jù)是什幺？該病人出現(xiàn)腎功能衰竭的原因是什幺？在治療過程中出現(xiàn)了哪些并發(fā)癥？試述該病人尿量由少轉(zhuǎn)多的機制。該病人為什幺會出現(xiàn)精神、神經(jīng)癥狀?有哪些誘因？為什幺要對該病人實行腹膜透析療法？腹膜透析療法有哪些優(yōu)缺點？為什幺要給予NaHCO,對該病人的治療原則是什幺?【Case14]A47-yearoldsalesman,whowasaheavycigarettesmokerwithalonghistoryofbronchopulmonarydisease,wasadmittedtothehospitalwithcyanosis,dyspnea,andfever.Hisbloodpressurewas18.4/10.4kPa(138/78mmHg),hispulsewas95beats/min,respirationwas34perminute,andrectaltemperaturewas41.0°C.Thepatientperiodicallycougheduptenaciouspurulentsputum.Examinationofthechestrevealedralesandwheezesthroughoutalllungfields.Thelaboratorydataobtainedonadmissionwereasfollows:Hemoglobin171g/L〔Na+〕143mmol/L〔Cl-〕78mmol/L〔K+〕4.8mmol/L〔HCO-〕338mmol/LpH7.34PaCO29.7kPa(73mmHg)PaO26.3kPa(47mmHg)Thepatientwastreatedwithantibioticsandexpectorantstoloosenhissputum.Hewasalsoencouragedtocoughtoraiseasmuchsputumaspossible.Thenextmorningthepatientfeltmuchbetter,andhistemperaturewasdownto37.8C.Hiscyanosishaddisappearedandhewasbreathingeasily.Breathsoundsdemonstratedonlyanoccasionalcrackleorwheeze.RepeatbloodchemistriesthatmorningwereNa+Na+〕141mmol/LK+〕4.6mmol/LpH7.47PaCO5.9kPa(44mmHg)〔Cl-〕84mmol/L〔HCO-〕31mmol/LQuestions:Characterizetheacidbasedisturbanceinthispatientonthenightofadmission.Bycontrast,whatwashisacidbasestatusthenextmorning?Whywasoxygentherapynotused?Explainhowbloodchloridecouldhaverisenduringaperiodwhentherewasnoingestionofchloride.Whatisrespiratoryfailure?Andwhatkindofrespiratoryfailurehadoccurredinthispatient?Howwastherespiratoryfunctionofthispatientconvertedintofailure?【Case15]A47-yearoldmanwasbroughttothehospitalinastuporouscondition,exhibitingmusculartwitching.Hispulsewas88beats/min,bloodpressurewas16.0/9.3kPa(120/70mmHg),andrespiratoryratewas20perminute.Nothingofsignificancewasdetectedonphysicalexaminationexceptforhypoactivereflexes.Hishemoglobinwas171g/L.Thevaluesobtainedforhisadmissionbloodchemistrieswereasfollows:Na+〕143mmol/LPaCO2&5kPa(64mmHg)K+〕2.5mmol/L〔Cl-〕46mmol/LPh7.61〔HCO-〕362mmol/LPaO27.7kPa(58mmHg)Thepatientwastreatedwith1literof25%glucosein0.9%salinetowhich40mmol/Lofpotassiumwasadded.Thenextmorningthepatientremainedseverelydepressedwithsluggishandobtundedresponses.Hepassedadarkstool,whichlaboratorytestsconfirmedascontainingblood.TheurineatthistimehadapHvalueof7.07andaK+concentrationof65mmol/L.Arepetitionofhisbloodchemistriesgavethefollowingdat：a〔Na+〕138mmol/L〔HCO-〕356mmol/L〔K+〕1.7mmol/L〔Cl-〕64mmol/LPh7.57Overthenext24hoursthepatientwasgivenatotalof4litersofglucosein0.9%salinetowhich120mmol/Lofpotassiumwasadded.Thenextmorningthepatientwasremarkablyimproved;hisplasmapotassiumwasupto3.1mmol/Landhisplasmabicarbonatewasdownto32mmol/L.HewasexcretinglargevolumesofurinewithapHvalueof7.92.Hishemoglobinwas137g/L;BUNwas0.26g/L.ArepeatofhisarterialbloodgasesshowedaPoOf11.4kPa(86mmHg)anaPCO?of6.4kPa(48mmHg).Forthefirsttimeitwaspossibletoobtainanaccuratehistory.Thepatientclaimedthathehadneverpreviouslytouchedalcohol.Followingtherecentdeathofhismother,however,hehadbecomesodespondentthathehadconfinedhimselftothehousewithalargesupplyofliquor,whichheconsumedoverathreedayperiod.Herememberedlittleofthatperiodexceptthattheliquormadehimverysickandhevomitedagreatdeal.Anx-rayexaminationofhisgastrointestinaltractwasreportedasnormal;nofurtherevidenceofbloodinhisstoolswasfound.Hewasdischargedtwodayslater.Questions：Whatwasthemajordisturbanceinthispatientthatwasdemonstratedbythebloodchemistryatthetimeofadmission?Whattwoadditionaldisturbancesinacidbasechemistrydoesthispatientexhibit?(3)Whydidhefailtorespondtotreatmentforthefirst12hours?Whatishypokalemia？Whatisthemajorreasonforthehypokalemiathathadoccurredtothispatient？Canyouimagewhatwillhappentothemaninthenearfutureasaresultofhypokalemia?Whatistheruleforthetherapyofthispatient?【Case16]A74yearoldwidowwasbroughttothehospitalafteraneighborfoundhercollapsedonthefloorofherapartment.Shewasverypale,extremelyweak,andcomplainedoffatigue.Shewasveryemotionallydepressed.Sherespondedrathersluggishlybutreasonablyandcoherentlytoquestioning.Sheexplainedastaindownthefrontofherdressastheresultofspillingacupofteathatshehadbeentooweaktohold.Herbloodpressurewas11.7/8.2kPa(88/62mmHg),herpulseratewas56beats/min,andherbodytemperaturewas34.0°C.Herrespiratoryratewas22perminuteandlabored.Auscultationofthechestrevealedcongestionatbothlungbasesandanenlargedheart.Shewasadmittedtotheintensivecareunit,andavenouscatheterwaspassedandwedgedintoherpulmonaryvasculaturetoprovideanestimateofleftatrialpressure,whichwasfoundtobe2.1kPa(16mmHg).Admissionlaboratorydatawereasfollows：〔Na+〕149mmol/LPaCO21.3kPa(10.1mmHg)〔K+〕4.9mmol/L〔Cl-〕84mmol/LpH7.18〔HCO-〕33.6mmol/LPaO216.8kPa(126mmHg)Lactate64mmol/LHemoglobin27g/LOverthenext12hoursthepatientwastransfusedwithpackedredcells,whichraisedherhemoglobinto61g/L.Sherespondedtothistreatmentwithariseinbloodpressureto17.3/7.3kPa(130/55mmHg),andherpulserateandbodytemperaturerosewasto74beats/min,36.1Crespectively.AtthistimeherarterialPO11.8kPa(89mmHg),PCOwas4.7kPa(35.2mmHg),pHwas7.36，andbicarbonatewas19.3mmol/L;PAWPwasl.lkPa(8mmHg).wasQuestions:Tounderstandtheacuteprobleminthispatient,estimateherarterialoxygencontentatthetimeofadmission,andrelatethistotheclinicalfindings.Howdoyouaccountforthedramaticresponsetothetransfusionofredbloodcells?Whywasthepatientgivenpackedcellsratherthanwholeblood?Whatisthemostobviousexplanationforthistypeofanemia?【Case17]A59yearoldmalewasadmittedtothehospitalcomplainingofshortnessofbreath,fatigue,andmuscularweakness.HereportedthattwoyearsagohehadbeentoldthathehadhighbloodpressurefollowingaroutineexaminationThisratherobeseandobviouslyapprehensivepatienthadabloodpressureof28.0/12.0kPa(210/90mmHg)andanirregularpulseofabout90beats/min.Hehaddyspneicrespirationatarateof38perminute.Hisheartwasenlargedandtherewasdullnessatbothlunggases.Neckveinsweredistendedandtheliveswassignificantlyenlarged.Hehadmarkedankleedema.AchestX-rayconfirmedtheenlargedheartandshowedpulmonarycongestion.Anelectrocardiagramdemonstratedatrialfibrillationandleft-axisdeviation.Thepatientwasdigitalizedandplacedonbedrest.Forthreedayshisconditionremainedessentiallyunchanged.Thoughheatewellandwasreasonablycomfortable,atrialfibrillationpersisted,herequiredthreepillowsatnighttoavoidexcessivedyspnea,andhefailedtoshowanydiuresis.Onthefourthdaythenursewhobathedhimreportedthatthepatientwastooweaktositupandhavehisbackwashed.Clinicallaboratorydatawereasfollows〔Na+〕144mmol/LPaCO21.3kPa(10.1mmHg)〔K+〕3.4mmol/L〔Cl-〕110mmol/LpH7.46Glucose1.07g/LCholesterol3.1mmol/L24-hoururine:4.3gmofcreatineThepatientwasreferredtotheEndocrinologyDepartmentforfurtherstudyandtreatment.Questions:Whatunderlyingdiseasecanyouidentifyinthispatient?Why?Howdoesthisrelatetohiscongestiveheartfailure?Whatevidenceofheartdiseasecanbeseeninthispatient?Whataccountsforhismuscularweakness?Whataccountsforhisobesity?【Case18]The18yearoldsonofamillworkerwasadmittedtothehospitalcomplainingofshortnessofbreath.Accordingtohisfather,thepatienthadbeenbornwitha“heartmurmur,”andtheparentshadbeenadvisedtorestricthisactivities.Hehaddevelopednormally,however,andneithertheparentsnorthepatienthadpaidmuchattentiontotheadmonition,althoughschoolphysicianshadrefusedtopermithimtoparticipateinscholasticsports.Hischildhoodhadbeennormal,andhisparentswereneverawareofanabnormalexertionaldyspneaorcyanosis.Fiveweekspriortoadmission,hesuddenlybecameextremelydyspneicwhilewalkinghomefromhighschoolandfeltdizzy,Afterlyingdownforafewmomentshisconditionimprovedenoughsothathewasabletoreachhome.Subsequenttothisepisodeheexhibitedlethargy,greatfatigability,andmarkedexertionaldyspnea.Hisboutsofdyspneawereaccompaniedbycyanosisofthelips.Afewdayslater,swellingoftheankleswasnotedandtwoweekslatersomeswellingoftheabdomenappeared.Hewastakentothefamilyphysician,whotreatedhimwithdigitalisandwithoutsignificantimprovement.Physicalexaminationrevealedaratherslightbutotherwisenormallydevelopedyoungman.Hewasnotablypaleandinsevererespiratorydistress.Hispulsewas92beats/minandgrosslyirregular;hisbloodpressurewas17.3/8.0kPa(130/60mmHg).Therewasduskycyanosisofhislipsandnailbeds,withvenousengorgementinhisneck.Hischestrevealeddullnesstopercussionatbothbaseswithdecreasedbreathsoundsandmoistrales.Therewasmarkedprecordialactivitywithapalpablesystolicthrillovertheapexandatthebase,withcardiacenlargementstotheleft.Aloud,rumblingsystoliemurmurwasheardnearthesternumintheleftfourthintercostalspace,transmittedovertheapexandheardclearlyintheback.Femoralpulseswerepistol-shotincharacter.Theabdomenwasdistendedwithmoderateascites;theliverwaspalpable3to4fingersbelowtherightcostalmargin.Therewasmarkedscrotaledemaandmarkedpittingedemaofthelowerextremitiesfromthetoestotheknees.Anadmissionbloodsampledemonstrated5.8X10i2RBCwithahemoglobinof160g/L.Urinaryfindingswerenormal.Anelectrocardiogramshowedatrialfibrillationwithslurringoftheventricularcomplexes.Thepatientwasgivendigitalis,diuretics,andoxygen.Hebecameprogressivelymoredyspneicandorthopneieandexpired23hoursafteradmission.Questions:Whatistheexplanationforthesuddenappearanceofcyanosisinpreviouslyacyanoticheartdisease?Whatsuddenchangeinfunctionalstatuscouldhaveconvertedthissymptomfreeeonditionintoseriouslydeeompensatedcardiacfailure?Whywasthepatientpaleatthetimeofhishospitaladmission?Whatistherelationshipbetweenthealteredfunctionalstatusandtheevidenceofmassivefluidretention?Howmuchoftheterminalpicturerelatestochronicchangesthatwerewelladvancedbeforetheepisodethreeweeksbeforedeath,andhowmuchindicatesacutedevelopmentsthatarerelatedtotheterminalcomplications?【Case19】A43yearoldhousewifewassenttothehospitalcomplainingofbackpain,urinaryfrequency,andburningonurination.Herurinewascloudyandtestedpositiveforglucose.Microscopicexaminationoftheurinarysedimentrevealedalargeamountofdebriscontainingnumerouswhitebloodcells.Thediagnosisofcystitiswasmadeandshewastreatedwithurinarytractantibiotics.Inafollow-upexaminationonemonthlater,shereportedthatshewascompletelyfreeofurinarytractsymptomsbutcomplainedofcontinuingbackpain,lethargy,andsomeweightlossinspiteofagoodappetite.Herurinewasclearandcontainedminimalsedimentbutgaveweaklypositivetestsforalbuminandglucose.Hospitalizationwasadvisedforadiagnosticworkup.Onexaminationinthehospital,shehadapulserateof76beats/min,abloodpressureof16.8/11.2kPa(126/84mmHg)，andrespirationof18perminute.Herphysicalexaminationwasnegativeexceptfortendernessinthelowerbackthatradiatedintoherthighs.Bloodchemistrydeterminationswereasfollows〔Na+〕138mmol/L〔Cl-〕122mmol/L〔K+〕3.8mmol/L〔P3+〕1.7mmol/L〔Ca2+〕2.0mmol/LBUN0.25g/LPaCO24.4kPa(33mmHg)〔HCO-〕314mmol/LPH7.24Creatinine0.021g/LGlucose4.5mmol/LHemoglobin118g/LBecauseglucosewasfoundintheurine,aglucosetolerancetestwascarriedout,andplasmaglucoselevelsfellatanormalratefollowingthetestdoseofglucose.ThePatient'surinehadaspecificgravityof1.020，albumin(+)，glucose(++)，andapHvalueof6.95.A24hoururinecollectiondemonstratedtheexcretionof117gramofcreatininewithaplasmaconcentrationof0.018g/Lofcreatinine,0.018g/Lofphosphate(normalis1),and0.018g/Lofalphaaminoacids(normalis0.2).X-rayofthespinedemonstratedrareficationofthevertebralbodies,withpartialcollapseofonevertebral.Longbonex-raysdemonstrateddiffusepatchyrarefaction.Thepatientwasdischargedwithappropriateinstructions.Questions：

(1)Whatrenalfunctionsareessentiallynormalandwhatotherrenalfunctionsareabnormal?Whatanatomicalsitesppearstobethefocusofthisdisease?Howdoyouexplaintherarefactionoftheskeleton?Howdoyouaccountforthepatient'sbloodchemistrydata?附錄1單純性酸堿失衡預測代償公式1單純性酸堿失衡預測代償公式代酸：△PaC02=1.2XA[HC0-3]