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This situation occurs because vomiting is tonic saline and appropriate amounts of KCl cheap clomid 50 mg visa breast cancer uk. Fluid loss leads to a placement of Cl is a key component of therapy generic 25mg clomid with mastercard women's health clinic rockdale, this type decrease in effective arterial blood volume and engage- of metabolic alkalosis is said to be “chloride-responsive. Aldosterone stim- creted in the urine, and the kidneys will return blood pH ulates H secretion by collecting duct -intercalated cells. Clinical Evaluation of Acid-Base Disturbances respiratory acidosis; a low pH and low plasma [HCO3 ] in- Requires a Comprehensive Study dicate metabolic acidosis. A high blood pH and low Acid-base data should always be interpreted in the context plasma PCO2 indicate respiratory alkalosis; a high blood pH of other information about a patient. A complete history and high plasma [HCO3 ] indicate metabolic alkalosis. Inappropriate values suggest that more than values, it is best to look first at the pH. If aci- have two or more of the four simple acid-base disturbances dosis is present, for example, it could be either respiratory at the same time; in which case, they have a mixed acid- or metabolic. REVIEW QUESTIONS DIRECTIONS: Each of the numbered (E) 1,000:1 (B) Thin ascending limb items or incomplete statements in this 2. An arterial blood sample taken from a (C) Thick ascending limb section is followed by answers or by patient has a pH of 7. What (E) Collecting duct ONE lettered answer or completion that is is the plasma [HCO ]? Which segment can establish the (C) Excreted in the urine as free (B) 3:1 steepest pH gradient (tubular fluid-to- hydrogen ions (C) 3:2 blood)? An arterial Plasma Po2 Pco2 [HCO32] made in a healthy adult: blood sample revealed a pH of 7. Balti- (A) Acute renal failure Net acid excretion by the kidneys is more: Williams & Wilkins, 1998. Management of poisoning (B) 30 mEq/day life-threatening acid base disorders. N (C) Methanol intoxication (C) 88 mEq/day Engl J Med 1998;338:26–34, 107–111. In: Schrier RW, Gottschalk CW, (E) 92 mEq/day (E) Uncontrolled diabetes mellitus eds. Which of the following arterial blood Boston: Little, Brown, 1997;189–201. Philadelphia: Lippincott (A) 0 mEq Plasma Williams & Wilkins, 2000;391–442. Protection of acid- (C) 300 mEq pH (mm Hg) (mm Hg) (mEq/L) base balance by pH regulation of acid (D) 500 mEq (A) 7. Acid and basics: A guide to un- (B) Adrenal cortical insufficiency emergency department shortly before derstanding acid-base disorders. Clinical Physiology of Acid-Base (D) An increase in intracellular pH attempted to kill herself by swallowing and Electrolyte Disorders. New (E) An increase in tubular sodium the contents of a bottle of aspirin York: McGraw-Hill, 1994. A homeless woman was found on a hot the following set of arterial blood Basic Concepts and Clinical Manage- summer night lying on a park bench in values is expected? CASE STUDIES FOR PART IV • • • microscopy, but effacement of podocyte foot processes CASE STUDY FOR CHAPTER 23 and loss of filtration slits is seen with the electron micro- Nephrotic Syndrome scope. No immune deposits or complement are seen af- A 6-year-old boy is brought to the pediatrician by his ter immunostaining. The biopsy indicates minimal mother because of a puffy face and lethargy. The podocyte cell surface and weeks before, he had an upper respiratory tract infec- glomerular basement membrane show reduced staining tion, probably caused by a virus.

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PAH clearance is used to measure re- effective arterial blood volume buy 100 mg clomid mastercard menstruation history, which stimulates thirst order clomid 50mg visa menopause the musical laguna beach. Liddle’s syndrome is due to excessive level would have the opposite effect. Distension of the atria (increased blood volume) or stomach inhibits activity of the Na channel in collecting duct principal cells, leading to salt retention and hypertension. Volume expansion and a low plasma osmolality ter and Gitelman syndromes are salt-wasting disorders; both inhibit thirst. AVP is synthesized in the cell bodies betes insipidus and renal glucosuria produce excessive of nerve cells located in the supraoptic and paraven- fluid loss and would not be likely causes of the patient’s tricular nuclei of the anterior hypothalamus. If the pressin, the kidneys produce a large volume of osmot- hematocrit ratio is 0. An increase in central blood volume highest (it is nearly equal to the renal plasma flow) be- will stretch the atria, cause the release of atrial natri- cause PAH is not only filtered by the glomeruli but is uretic peptide, and result in diminished Na reabsorp- also secreted vigorously by proximal tubules. All other choices produce increased tubular Na nine is filtered and secreted, to a small extent only, in reabsorption. The loop of Henle (mostly the thick tered and variably reabsorbed; its clearance is always ascending limb) reabsorbs about 65% of the filtered 2 below the inulin clearance in people. Infusion of isotonic saline tends to est clearance of all because filtered Na is extensively reabsorbed. The filtered load of the substance is activity, and increase fluid delivery to the macula Px GFR 2 mg/mL 100 mL/min 200 mg/min. All The rate of excretion is Ux 10 mg/mL 5 mL/min other choices result in increased renin release. Skeletal muscle cells contain large than was excreted, and the difference, 200 mg/min amounts of K ; injury of these cells can result in addi- 50 mg/min 150 mg/min, gives the rate of tubular re- tion of large amounts of K to the ECF. Hyperaldosteronism causes increased renal ex- ˙ a rv a- CPAH/EPAH UPAH V/PPAH (P PAH P PAH)/P cretion of K and a tendency to develop hypokalemia. The renal blood flow RPF/(1 hematocrit) 2 phosphate, stimulates tubular reabsorption of Ca , 300/(1 0. PTH secretion is in- APPENDIX A Answers to Review Questions 723 creased in patients with chronic renal failure. Its secre- plasma osmolality but inappropriately concentrated 2 tion is stimulated by a fall in plasma ionized Ca. The subject in choice B has a low plasma os- and Na reabsorption by cortical collecting ducts. Autoregulation refers to the relative the subject in choice E is producing concentrated urine constancy of renal blood flow and GFR despite and may be water-deprived. The low blood pH and hyper- escape refers to the fact that the salt-retaining action of glycemia (or hyperosmolality) would tend to raise mineralocorticoids does not persist but is overpowered plasma [K ], yet the plasma [K ] is normal. Satura- findings suggest that the total body store of K is re- tion of transport occurs when the maximal rate of tu- duced. Remember that most of the body’s K is within bular transport is reached. In uncontrolled diabetes mellitus, the osmotic di- results in afferent arteriolar constriction when fluid de- uresis (increased Na and water delivery to the corti- livery to the macula densa is increased; it contributes to cal collecting ducts), increased renal excretion of renal autoregulation. Nephrogenic diabetes insipidus is evated plasma aldosterone level (secondary to volume characterized by increased output of dilute urine. Plasma osmolality is on the high side of the nor- pokalemia or hyperkalemia. The plasma AVP level will fall because of vol- mellitus because there is no glucose in the urine and ume expansion and cardiovascular stretch receptor in- the urine is very dilute. The plasma aldosterone level produce very dilute urine because Na reabsorption is will be low because of inhibited release of renin and inhibited. Neurogenic diabetes insipidus is unlikely be- less angiotensin II formation. The plasma ANP level cause the plasma AVP level is reduced in this case. A mary polydipsia produces output of a large volume of large part of the infused isotonic saline will be filtered dilute urine, but plasma osmolality and AVP levels are through capillary walls into the interstitial fluid. Na is the major osmotically active creased, but these should promote Na excretion, not solute in the ECF and is the major determinant of the lead to Na retention by the kidneys.

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Near the halfway point from rest to maximal bathed by cerebrospinal fluid—no stimulus proportional to dynamic work discount clomid 100mg amex menstruation jokes, lactic acid formed in working muscles be- the exercise demand exists 50 mg clomid otc women's health clinic doncaster. This point, which de- chemoreceptor is immersed in increasing alkalinity as exer- pends on the type of work involved and the person’s cise intensifies, a consequence of blood-brain barrier per- training status, is called the lactate threshold. Perhaps exercise concentration gradually rises with work intensity, as respiratory control parallels cardiovascular control, with a more and more muscle fibers must rely on anaerobic me- central command proportional to muscle activity directly tabolism. Almost fully dissociated, lactic acid causes stimulating the respiratory center and feedback modulation metabolic acidosis. During exercise, healthy lungs re- from the lung, respiratory muscles, chest wall mechanore- spond to lactic acidosis by further increasing ventilation, ceptors, and carotid body chemoreceptors. Through a range of exercise Unchanged by Training levels, the pH effects of lactic acid are fully compensated The effects of training on the pulmonary system are mini- by the respiratory system; however, eventually in the mal. Lung diffusing capacity, lung mechanics, and even hardest work—near-exhaustion—ventilatory compensa- lung volumes change little, if at all, with training. The wide- tion becomes only partial, and both pH and arterial PCO2 spread assumption that training improves vital capacity is may fall well below resting values (see Table 30. Tidal false; even exercise designed specifically to increase inspi- volume continues to increase until pulmonary stretch re- ratory muscle strength elevates vital capacity by only 3%. The demands placed on respiratory muscles increase their Frequency increases at high tidal volume produce the re- endurance, an adaptation that may reduce the sensation of mainder of the ventilatory volume increases. Nonetheless, the primary respiratory Hyperventilation relative to carbon dioxide produc- changes with training are secondary to lower lactate pro- tion in heavy exercise helps maintain arterial oxygena- duction that reduces ventilatory demands at previously tion. The blood returned to the lungs during exercise is heavy absolute work levels. Because the pulmonary arterial PO2 is re- In Lung Disease, Respiratory Limitations May Be duced in exercise, blood shunted past ventilated areas can Evidenced by Shortness of Breath or Decreased profoundly depress systemic arterial oxygen content. Oxygen Content of Arterial Blood Other than having a diminished oxygen content, pul- monary arterial blood flow (cardiac output) rises during Any compromise of lung or chest wall function is much exercise. In compensation, ventilation rises faster than more apparent during exercise than at rest. One hallmark of cardiac output: The ventilation-perfusion ratio of the lung disease is dyspnea (difficult or labored breathing) dur- lung rises from near 1 at rest to greater than 4 with stren- ing exertion, when this exertion previously was unprob- uous exercise (see Table 30. Restrictive lung diseases limit tidal volume, reduc- nearly constant arterial PO2 with acute exercise, although ing the ventilatory reserve volumes and exercise capacity. This in- Obstructive lung diseases increase the work of breathing, crease shows that, despite the increase in the ventilation- exaggerating dyspnea and limiting work output. Lung dis- perfusion ratio, areas of relative pulmonary underventila- eases that compromise oxygen diffusion from alveolus to tion and, possibly, some mild diffusion limitation exist blood exaggerate exercise-induced widening of the alveo- even in highly trained, healthy individuals. Second, Normally, the respiratory system does not limit exercise their primary complaint is usually shortness of breath, or tolerance. In fact, patients with chronic obstructive pul- tion with oxygen, which averages 98% at rest, is main- monary disease often first seek medical evaluation be- tained at or near 98% in even the most strenuous dy- cause of dyspnea experienced during such routine activi- namic or isometric exercise. In healthy people, includes the ability to augment ventilation more than car- exhaustion is rarely associated solely with dyspnea. In em- diac output; the resulting rise in the ventilation-perfusion physematous patients, exercise-induced dyspnea results, ratio counterbalances the falling oxygen content of in part, from respiratory muscle fatigue exacerbated by di- mixed venous blood. Third, in emphysematous patients, arterial oxygen exercise occur long before ceilings are imposed by either saturation will characteristically fall steeply and progres- skeletal muscle oxidative capacity or by the ability of the sively with increasing exercise, sometimes reaching dan- cardiovascular system to deliver oxygen to exercising gerously low levels. These limitations are manifest during a stress test oxygenate blood at rest is compounded during exercise by on the basis of three primary measurements. First, patients increased pulmonary blood flow, and by increased exer- with ventilatory limitations typically cease exercise at rela- cise oxygen extraction that more fully desaturates blood tively low heart rate, indicating that exhaustion is due to returning to the lungs. The signs and symptoms of a respiratory limitation to Although strenuous exercise can reduce intramuscular pH exercise include exercise cessation with low maximal heart to values as low as 6. The best correlate prospects of training-based rehabilitation are modest, al- of fatigue in healthy individuals is ADP accumulation in the though locomotor muscle-based adaptations can reduce face of normal or slightly reduced ATP, such that the lactate production and ventilatory demands in exercise. Because the complete oxida- Specific training of respiratory muscles to increase their tion of glucose, glycogen, or free fatty acids to carbon diox- strength and endurance is of minimal benefit to patients ide and water is the major source of energy in prolonged with compromised lung function.

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Stimulation of the receptors within the viscera causes the Historically discount 50 mg clomid amex menstrual after birth, both the organs of Ruffini and the bulbs of perception of visceral pain cheap clomid 25mg otc women's health issues today. Through precise neural pathways, Krause have been considered to be thermoreceptors—the former the brain is able to perceive the area of stimulation and project the pain sensation back to that area. The sensation of pain from certain visceral organs, however, may not be perceived as braille: from Louis Braille, French teacher of the blind, 1809–52. The organs of Ruffini: from Angelo Ruffini, Italian anatomist, 1864–1929 sensation of referred pain is relatively consistent from one per- bulbs of Krause: from Wilhelm J. Krause, German anatomist, 1833–1910 son to another and is clinically important in diagnosing organ Van De Graaff: Human V. Sensory Organs © The McGraw−Hill Anatomy, Sixth Edition Coordination Companies, 2001 492 Unit 5 Integration and Coordination FIGURE 15. The pain of a heart attack, for example, may be per- Phantom pain is frequently experienced by an amputee ceived subcutaneously over the heart and down the medial side of who continues to feel pain from the body part that was ampu- the left arm. Ulcers of the stomach may cause pain that is perceived tated, as if it were still there. After amputation, the severed sen- as coming from the upper central (epigastric) region of the trunk. Although it is not known why impulses that are in- localized visceral pain or as referred pain arising from the right neck terpreted as pain are sent periodically through these neurons, the and shoulder regions. There are thought to be some common nerve pathways that are Proprioceptors used by sensory impulses coming from both the cutaneous areas Proprioceptors monitor our own movements (proprius means “one’s and from visceral organs (fig. Consequently, impulses own”) by responding to changes in stretch and tension, and by along these pathways may be incorrectly interpreted as arising transmitting action potentials to the cerebellum. Acute pain is sory impulses from proprioceptors reach the level of consciousness as sudden, usually short term, and can generally be endured and attrib- uted to a known cause. Chronic pain, however, is long term and the kinesthetic sense, by which the position of the body parts is per- tends to weaken a person as it interferes with the ability to function ceived. Certain diseases, such as arthritis, are characterized by the limbs can be determined without visual sensations, such as when chronic pain. In these patients, relief of pain is of paramount con- dressing or walking in the dark. Treatment of chronic pain often requires the use of moderate pain-reducing drugs (analgesics) or intense narcotic drugs. Sensory Organs © The McGraw−Hill Anatomy, Sixth Edition Coordination Companies, 2001 Chapter 15 Sensory Organs 493 FIGURE 15. Pain originating from the myocardium of the heart may be perceived as coming from the skin of the left arm because sensory impulses from these two organs are conducted through common nerve pathways to the brain. Proprioceptors are located in and around synovial joints, in Neural Pathways for Somatic Sensation skeletal muscle, between tendons and muscles, and in the inner ear. They are of four types: joint kinesthetic receptors, neuromus- The conduction pathways for the somatic senses are shown in cular spindles, neurotendinous receptors, and sensory hair cells. Sensations of proprioception and of touch and pres- sure are carried by large, myelinated nerve fibers that ascend in • Joint kinesthetic receptors are located in synovial joint the posterior columns of the spinal cord on the ipsilateral (same) capsules, where they are stimulated by changes in body po- side. These fibers do not synapse until they reach the medulla sition as the joints are moved. They consist of the medulla oblongata with second-order sensory neurons, informa- endings of sensory neurons that are spiraled around special- tion in the latter neurons crosses over to the contralateral (oppo- ized individual muscle fibers (fig. Third-order sensory caused by the lengthening or stretching of the individual neurons in the thalamus that receive this input in turn project to fibers, and thus provide information about the length of the postcentral gyrus in the cerebral cortex. Sensations of heat, cold, and pain are carried by thin, un- • Neurotendinous receptors (Golgi tendon organs) are lo- myelinated sensory neurons into the spinal cord. They within the spinal cord with second-order association neurons that are stimulated by the tension produced in a tendon when cross over to the contralateral side and ascend to the brain in the the attached muscle is either stretched or contracted. Fibers that mediate touch and pres- • Sensory hair cells of the inner ear are located in a fluid- sure ascend in the ventral spinothalamic tract.

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