病理生理学的任务是研究疾病发生的原因和条件-北京大学医学部课程

#17.3/12.0kPa(130/90mmHg),两肺(一)，血尿素氮下降至0.68g/L，血钾4.1mol/L。第二天透析8次，诉轻度腹胀痛，面部浮肿和淤斑开始消退，腹部平、软、轻压痛，肠鸣音稀少，为防止腹膜感染给氨苄青霉素每日7克。第三天透析10次，透析液微黄微浑，腹胀痛，体温37.7T，心率108次/分，血压18.6/12.0kPa(140/90mmHg)，血尿素氮为0.97g/L，血钾4.0mmol/L。加用庆大霉素每日16万单位。第4天透析8次，第5天透析8次，排液淡黄稍清亮，稍觉腹胀，血尿素氮！69g/L。第6天开始，精神食欲好转，能进半流质饮食，未感腹痛，排出透析液微浑。尿量已达1000ml，血尿素氮).69g/L，血钾4.1mmol/L。第11天患者无自觉不适，精神食欲基本正常，腹部体征消失，复查血尿素氮.51g/L，尿量每天1750ml思考题：什幺是肾功能衰竭？肾功能衰竭有哪些分类？该患者属于哪一类肾功能衰竭？其依据是什幺？该病人出现肾功能衰竭的原因是什幺？在治疗过程中出现了哪些并发症？试述该病人尿量由少转多的机制。该病人为什幺会出现精神、神经症状?有哪些诱因？为什幺要对该病人实行腹膜透析疗法？腹膜透析疗法有哪些优缺点？为什幺要给予NaHCO,对该病人的治疗原则是什幺?【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?附录1单纯性酸碱失衡预测代偿公式1单纯性酸碱失衡预测代偿公式代酸：△PaC02=1.2XA[HC0-3]