Clinical problems- Acid base balance and

Imbalance; Water and electrolyte balance

and Imbalance
Q.1- A 64 year-old man who develops acute renal failure
while recovering from a severe acute myocardial infarction
(Acute MI), Blood chemistry reveals:
Na+ 140 mEq/L, K+ 4 mEq/L, Cl- 115 mEq/L, CO2 5 mEq/L, pH =
7.12, PaCO2 13 mmHg, and HCO3- 4 mEq/L. Calculate the
anion gap and then choose the best answer for acid-base
status.
A) His anion gap of 14 indicates he has metabolic alkalosis
B) His anion gap of 20 is conclusive of a respiratory acidosis.
C) His anion gap of 22 strongly suggests a respiratory alkalosis
D) His anion gap of 21 is conclusive of high anion gap metabolic
acidosis
E) His anion gap of 25 is conclusive of normal acid base status.
Q.2- A 48-year-old man with bronchiectasis presents to the
hospital emergency room with 3 days of increasing cough,
sputum, and dyspnea. About 1 month ago, his arterial blood
gas analysis showed pH 7.38, PaO2 55 mmHg, PaCO2 65
mmHg, and HCO3- 32 mEq/L. His current vital signs are BP
117/65 mmHg, Pulse 123/min, Temperature 100F. His
current ABG(Blood gas analysis) in the Emergency Room is
pH 7.28, PaCO2 70 mmHg, PaO2 50 mmHg, and HCO3- 23
mEq/L. Which of the following best characterizes the current
acid-base status?
A) Compensated metabolic acidosis
B) Compensated metabolic alkalosis
C) Uncompensated metabolic acidosis

D) Uncompensated respiratory acidosis

E) Uncompensated respiratory alkalosis
Q.3- A hospital patient with AIDS has diarrhea and becomes
hypovolemic within a short period of time. Which of the
following laboratory results would best fit this clinical
history?
A) pH: 7.15, pCO2: 55 mmHg, HCO3: 40 mEq/L
B) pH: 7.25, pCO2: 36 mmHg, HCO3: 15 mEq/L
C) pH: 7.40, pCO2: 40 mmHg, HCO3: 24 mEq/L
D) pH: 7.50, pCO2: 28 mmHg, HCO3: 24 mEq/L
E) pH: 7.35, pCO2: 40 mmHg, HCO3: 24 mEq/L.
Q.4- A 50-year-old chronic alcoholic is brought to the
emergency room in a semiconscious state. Blood pressure is
100/50 mmHg, heart rate 120 beats/min, respiratory rate
35/min, and his temperature is 104F (40C).
Blood chemistry reveals : Sodium 150mEq/L (135-145),
Potassium 2.5mEq/L (3.5-5.0), Chloride 107mEq/L (95105),Bicarbonate 10mEq/L (24-26), pH 7.2 (7.35-7.45), PCO2
25mmHg (35-45), Alcohol 40mmol/L (0), Osmolality
370mOsm/L (280-295), Glucose 50mg/dl (60-110) BUN
40mg/dl (5-22). What is the acid-base status?
A) Metabolic acidosis
B) Metabolic Alkalosis
C) Respiratory acidosis
D) Respiratory alkalosis
E) Metabolic acidosis with respiratory compensation

Q.5-All of the following statements are correct about

potassium balance, except:
A) Most of potassium is intracellular.
B) Three quarter of the total body potassium is found in skeletal
muscle.
C) Intracellular potassium is released into extra-cellular space in
response to severe injury.
D) Acidosis leads to movement of potassium from extracellular to
intracellular fluid compartment.
E) Aldosterone promotes excretion of potassium and reabsorption of
sodium.
Q.6- Normal anion gap metabolic acidosis is caused by all
except:
A) Cholera
B) Starvation
C) Ethylene glycol poisoning.
D) Lactic acidosis
E) Methanol poisoning.
Q.7- Which of the following is more appropriate for a 17year-old Female suffering from IDDM with the following
blood chemistry report:
pH: 7.2, PO2 : 108 mm Hg, PCO2 : 12 mmHg and HCO3- : 5
meq/L
A) Metabolic Acidosis with respiratory alkalosis
B) Respiratory Acidosis
C) Metabolic Alkalosis

D) Respiratory alkalosis
E) Metabolic alkalosis with respiratory alkalosis
Q.8- A middle-aged person collapsed on the road side and
was brought to emergency, Blood chemistry revealed the
following:
pH- 7.51, PCO2- 35 mm Hg, PO2- 62mm Hg and HCO3--27
meq/L.
Which of the following is the most appropriate acid base
imbalance in the above said condition?
A) Metabolic acidosis
B) Metabolic alkalosis with respiratory acidosis
C) Respiratory alkalosis with metabolic compensation
D) Respiratory acidosis
E) Metabolic alkalosis with respiratory alkalosis.
Q.9- A 24 year female reported to the emergency with
difficulty in breathing. History revealed that she had
ingested some unknown drug. The blood chemistry revealed
the following:
PH-7.1; PCO2- 55 mm Hg; PO2-42 mm Hg and HCO317 meq/L
Which of the following is the most appropriate acid base
imbalance in the above said condition?
A) Metabolic acidosis with respiratory acidosis
B) Respiratory acidosis
C) Respiratory Alkalosis
D) Metabolic alkalosis
E) None of the above.

Q.10- Which of the following is incorrect about minimum

excretory volume?
A) The exact quantity depends on the concentrating power of the
kidney
B) The exact quantity depends on the quantity of the solute load
C) The urinary volume is approximately 500 to 600 ml in 24 hrs
D) It is the minimum volume of urine excreted to eliminate the
waste products of metabolism.
E) It is the amount of urine excreted per day in normal health.
Q.11- The anion gap is calculated as follows:
A) [K+] + [HCO3- + Cl-]
B) [Na+] + [Cl- + HCO3-]
C) [Na+] [HCO3- + Cl-]
D) [Na+] + [K+]-[Cl- + HCO3-]
E) None of the above.
Q.12- ADH release is stimulated by any of the following
except:
A) Increased serum osmolality
B) Increased blood volume
C) Decreased Blood pressure
D) Stress
E) Hyponatremia
Q.13- Which of the following is not a cause of pure salt
depletion?
A) In mental patients who refuse to drink

B) Excessive sweating
C) Renal failure
D) Mineralocorticoid deficiency
E) Chronic diarrhea
Q.14- Hypokalemia is serum K concentration < 3.5 mEq/L
and is caused by:
A) Renal losses
B) GI losses
C) Diuretics
D) Insulin administration
E) All of the above.
Q.15- Hyponatremia is decrease in serum Na concentration
< 136 mEq/L and is caused by :
A) Diuretic use
B) Crush injuries
C) Hemolysis
D) High fever
E) None of the above.
Q.16- Serum sodium concentration is regulated by:
A) Stimulation of thirst,
B) Secretion of ADH,
C) Renin-angiotensin-aldosterone system,
D) Variations in renal handling of filtered sodium

E) All of the above.

Q.17- Factors that shift Potassium in or out of cells include
the following:
A) Blood glucose concentration
B) Blood volume
C) Acid-base status
D) Serum Sodium concentration
E) All of the above.
Q.18- Which of the following is not a cause of hyperkalemia?
A) Acute renal failure
B) Trauma
C) Metabolic acidosis
D) Respiratory alkalosis
E) Intake of bananas.
Q.19- The Henderson-Hassel Balch equation is represented
asA) pH = pKa + log (A-/HA)
B) pH = pKa + log (HA/A-)
C) pH = pKa log(A-/HA)
D) pH = pKa log(HA/A-)
E) pH = pKa + log(H+/HA)
Q.20- All are true for renal handling of acids in metabolic
alkalosis except

A) Hydrogen ion secretion is decreased

B) Bicarbonate reabsorption is decreased
C) Urinary acidity is decreased
D) Urinary ammonia is decreased
E) Renal Glutaminase activity is increased.
Key to answers
1)- D, 2)- D, 3)-B, 4)- E, 5)-D, 6)-A, 7)- A, 8)-E, 9)-A, 10)-E, 11)-C, 12)B, 13)-A,14)-E, 15)- A, 16)- E, 17)- E, 18)- D, 19)- A, 20)-E.

Acid base balance and Imbalance, Water and

electrolyte balance and detoxificationMultiple choice questions
Published October 28, 2014 | By Namrata Chhabra
Q. 1- What is the normal physiological concentration of
Hydrogen ion in body fluids?
A) 40 nEq/L
B) 24 mEq/L
C) 400 mEq/L
D) 7.4 nEq/L
E) 100 mEq/L

Q.2- Which of the following is not a source of hydrogen ion

in the body?
A) Ingestion of Citrus fruits
B) High protein diet
C) Ingestion of red meat
D) Starvation
E) Chronic alcohol consumption
Q.3- Which of the following is the most important chemical
buffer of the plasma?
A) HCO3 -/H2 CO3
B) HPO42/H2PO4
C) Organic Phosphate Esters
D) Proteins
E) Hemoglobin
Q.4- A primigravida in labor is breathing rapidly, what you
expect out of the following
A) Metabolic Acidosis
B) Metabolic Alkalosis
C) Respiratory Acidosis
D) Respiratory Alkalosis
E) Any of the above.
Q.5- The Henderson-Hasselbalch equation is represented asA) pH = pK + log (A-/HA)

B) pH = pK + log (HA/A-)
C) pH = pK log(A-/HA)
D) pH = pK log(HA/A-)
E) pH = pK + log(H+/HA)
Q.6- Buffering effect of a buffering solution is optimum at :
A) pH ranges close to pKa 2 pH units
B) pH = pKa 3 pH units
C) pH = pKa 5 pH units
D) pH = pKa
E) None of the above.
Q.7- The pH of extracellular fluid must be maintained
between:
A) 6 to 7.4
B) 7 to 7.2
C) 7.35 to 7.45
D) 7.5 to 8
E) 8 to 8.5
Q.8- All are true for renal handling of acids in metabolic
acidosis except
A) Hydrogen ion secretion is increased
B) Bicarbonate reabsorption is decreased
C) Urinary acidity is increased
D) Urinary ammonia is increased

E) Renal glutaminase activity is increased

Q.9- Which of the following is most appropriate for a female
suffering from Insulin dependent diabetes mellitus with a pH
of 7.2, HCO3-17 mmol/L and pCO2-20 mm Hg?
A) High anion gap metabolic Acidosis
B) Metabolic Alkalosis
C) Respiratory Acidosis
D) Respiratory Alkalosis
E) Normal anion gap metabolic acidosis
Q.10-A 50-year-old homeless man was brought to the
emergency room in a stuporous state. Below are his lab
results, Bicarbonate 10mEq/L (24-26), pH 7.2 (7.35-7.45),
PCO2 25mmHg (35-45), Alcohol 40mmol/L (0), Osmolality
370mOsm/L (280-295), Glucose 50mg/dl (60-110) BUN
40mg/dl (5-22). What is the acid-base status?
A) Metabolic acidosis and metabolic alkalosis
B) Metabolic acidosis with partial respiratory compensation
C) Respiratory acidosis and partial metabolic compensation
D) Respiratory acidosis
E) Metabolic alkalosis
Q.11- A 44-year-old man is brought to the emergency room
stuporous and obtunded. Serum chemistries are: HCO3 = 42
mEq/L; arterial pH = 7.5; PCO2 = 50mmHg. What is the acidbase status?
A) Metabolic acidosis and metabolic alkalosis
B) Metabolic acidosis with partial respiratory compensation

C) Respiratory acidosis and partial metabolic compensation

D) Respiratory acidosis
E) Metabolic alkalosis
Q.12-The medical student next to you, realizing that there is
an examination question on acid base balance, begins
nervously hyperventilating and then faints. You make him
breathe into a paper bag and he recovers. If you had drawn
and analyzed his blood when he fainted you would have
expected to see :
A) Decreased pH, decreased pCO2
B) Decreased pH, elevated pCO2
C) Elevated pH, decreased pCO2
D) Elevated pH, elevated pCO2
E) Normal pH, normal pCO2
Q.13- All except one are examples of entoxification:
A) Conversion of methanol to formaldehyde
B) p- methyl amino benzene to p-dimethyl amino azo benzene
C) Conversion of procarcinogens to Ultimate carcinogens
D) Conversion of Aspirin to Acetic acid and Salicylic acid
E) Conversion of Ethyl alcohol to Acetaldehyde.
Q.14- In physiological jaundice of new-born, due to less
availability of substrate and immature enzyme system, there
is an impaired formation of soluble, non toxic form of
bilirubin which is :
A) Bilirubin Sulphate
B) Bilirubin Phosphate

C) Bilirubin diglucuronate
D) Bilirubin Acetate
E) Methylated Bilirubin
15) In phenylketonuria (a congenital disorder of
phenylalanine metabolism that occurs due to deficiency of
phenylalanine hydroxylase), there is impaired conversion of
phenylalanine to tyrosine. The excess phenylalanine is
detoxified and excreted in urine. Which of the following
conjugating agents is used for detoxification of
phenylalanine?
A) Glutathione
B) Glutamine
C) S-Adenosyl Methionine
D) Active Sulfate (PAPS)
E) D- Glucuronic acid
16) Which of the following is not a cause of secondary
dehydration?
A) Excessive sweating
B) Comatose patient
C) Vomiting
D) Diarrhea
E) Congestive heart failure
17) The urinary concentration of sodium chloride (NaCl)
ranges between:
A) 2-6 G/litre
B) 4-8 G/litre

C) 5-10 G/litre
D) 6-16 G/litre
E) None of the above
18) The minimum excretory volume to eliminate waste
products from the body in dehydration is :
A) 100-200ml
B) 200-400 ml
C) 500-600 ml
D) 1500 ml
E) 600-800 ml
19) Aldosterone acts by promoting:
A) Excretion of Potassium
B) Reabsorption of potassium
C) Reabsorption of sodium
D) Excretion of sodium
E) Reabsorption of sodium and excretion of Potassium
20) Which of the following is not a cause of hypokalemia?
A) Renal tubular acidosis
B) Cushing syndrome
C) GI losses
D) Crush injuries
E) Insulin administration

Key to answers
1)- A, 2)- A, 3)-A, 4)-D, 5)-A, 6)-A, 7)-C, 8)-B, 9)-A, 10)- B, 11)-E, 12)C, 13)-D, 14)-C, 15)-B, 16)-B, 17)-D, 18)-C, 19)-E, 20)-D.

Acid base balance- Lecture-2 (Role of lungs

and kidney)
Published February 18, 2014 | By Namrata Chhabra
Normal Acid-Base Homeostasis and Role of Lungs
Systemic arterial pH is maintained between 7.35 and 7.45 by
extracellular and intracellular chemical buffering together with
respiratory and renal regulatory mechanisms. The control of arterial
CO2 tension (paCO2) by the central nervous system and respiratory

systems; and the control of the plasma bicarbonate by the kidneys

stabilize the arterial pH by excretion or retention of acid or alkali.
The metabolic (bicarbonate) and respiratory components (carbonic
acid) that regulate systemic pH are described by the HendersonHassel Balch equation:
pH = 6.1 + log (HCO-3/ H2 CO3)
H2 CO3 = PCO2 (mm Hg) X 0.03
Under most circumstances, CO2 production and excretion are
matched, and the usual steady-state paCO2 is maintained at 40 mm
Hg. Under excretion of CO2 produces hypercapnia, and over
excretion causes hypocapnia. Nevertheless, production and
excretion are again matched at a new steady-state paCO2.
Therefore, the PaCO2 is regulated primarily by neural respiratory
factors and is not subject to regulation by the rate of
CO2 production. Hypercapnia is usually the result of hypoventilation
rather than of increased CO2 production. Increases or decreases in
paCO2 represent derangements of neural respiratory control or are
due to compensatory changes in response to a primary alteration in
the plasma [HCO3].
In conditions of low plasma [HCO3] due to acidity in the medium
(high H+ concentration), medullary chemo receptors are stimulated
with the resultant hyperventilation and elimination of H2CO3(CO2),
the ratio of HCO-3/ H2 CO3 is restored back to normal , pH is
also restored back to normal.
Reverse occurs in conditions of high plasma bicarbonate
concentration (low H +), the medullary chemo receptors are
depressed with the resultant hypoventilation and retention of
CO2 (H2CO3). The ratio is restored, bringing pH also back to normal.

Effect of pCO2
pCO2 Ventilation Eliminates CO2 Reduces [H+] and pH
pCO2 Ventilation CO2 [H+] & pH

Doubling the ventilation pH

of normal ventilation pH
Effect of [H+]
[H+] Alveolar Ventilation CO2
pH (from 7.4-7.0) Alveolar Ventilation by 4 times normal.
pH Alveolar Ventilation
Respiratory Mechanism has effectiveness between 50-75% and is 12 times as great as the buffering power of all other chemical buffers
in ECF. The lungs should be healthy for these compensatory
changes.
Role of Kidney in maintaining acid base homeostasis
Acids are added daily to the body fluids. These acids first are
buffered by the HCO3 -/H2 CO3 system as follows:
H2 SO4 + 2NaHCO3 Na2 SO4 + 2H2 CO3 2H2O +2 CO2
The net result is buffering of a strong acid (H2 SO4) by 2 molecules of
HCO3 - and production of a weak acid (H2 CO3), which minimizes the
change in pH. The lungs excrete the CO2 produced, and the kidneys
replace the consumed HCO3 -, to prevent progressive HCO3 - loss and
metabolic acidosis, (principally by H+ secretion in the collecting
duct).
To maintain normal pH, the kidneys must perform 2 physiological
functions.
The first is to reabsorb all the filtered HCO3 - (any loss of HCO3 - is
equal to the addition of an equimolar amount of H +), a function
principally of the proximal tubule.
The second is to excrete the daily H+ load (loss of H+ is equal to
addition of an equimolar amount of HCO3 -), a function of the
collecting duct.

HCO3 - re-absorption
With a serum HCO3 - concentration of 24 mEq/L, the daily glomerular
ultra filtrate of 180 L, in a healthy subject, contains 4300 mEq of
HCO3 -, all of which has to be reabsorbed. Approximately 90% of the
filtered HCO3 - is reabsorbed in the proximal tubule, and the
remainder is reabsorbed in the thick ascending limb and the
medullary collecting duct (figure-1).
The 3Na+ -2K+ ATPase (sodium-potassium adenosine
triphosphatase) provides the energy for this process, which
maintains a low intracellular Na+ concentration and a relative
negative intracellular potential. The low Na+ concentration indirectly
provides energy for the apical Na+/H+ exchanger, which transports
H+ into the tubular lumen. H+ in the tubular lumen combines with
filtered HCO3 - in the following reaction:
HCO3 - + H+ H2 CO3 H2 O + CO2
Carbonic Anhydrase (CA IV isoform) present in the brush border of
the first 2 segments of the proximal tubule accelerates the
dissociation of H2 CO3 into H2O + CO2, which shifts the reaction
shown above to the right and keeps the luminal concentration of
H+ low. CO2 diffuses into the proximal tubular cell perhaps via the
aquaporin-1 water channel, where carbonic anhydrase (CA II
isoform) combines CO2and water to form HCO3 - and H+. The
HCO3 - formed intracellularly returns to the pericellular space and
then to the circulation via the basolateral Na+/3HCO3 - co
transporter.
In essence, the filtered HCO3 - is converted to CO2 in the lumen,
which diffuses into the proximal tubular cell and is then converted
back to HCO3 - to be returned to the systemic circulation, thus
reclaiming the filtered HCO3 -

Figure-1- Re-absorption of HCO3Acid excretion

Excretion of the daily acid load (50-100 mEq of H +) occurs principally
through H+ secretion by the apical H+ ATPase in A-type intercalated
cells of the collecting duct.
HCO3 - formed intracellularly is returned to the systemic circulation
via the basolateral Cl-/HCO3 - exchanger, and H+ enters the tubular
lumen via 1 of 2 apical proton pumps, H+ ATPase or H+ -K+ATPase.
The secretion of H+ in these segments is influenced by
Na+ reabsorption in the adjacent principal cells of the collecting
duct. Hydrogen ions secreted by the kidneys can be excreted as free
ions but, at the lowest achievable urine pH of 5.0 (equal to free
H+ concentration of 10 Eq/L), would require excretion of 500010,000 L of urine a day. Urine pH cannot be lowered much below 5.0
because the gradient against which H+ ATPase has to pump protons
(intracellular pH 7.5 to luminal pH 5) becomes too steep. Maximally
acidified urine, even with a volume of 3 L, would thus contain a
mere 30 Eq of free H+. Instead, more than 99.9% of the H+ load is
excreted buffered by the weak bases NH3 or phosphate.
Titratable acidity
The amount of secreted H+ that is buffered by filtered weak acids is
called titratable acidity. Phosphate as HPO4 2- is the main buffer in

this system(figure-2) but other urine buffers include uric acid and
creatinine.
H2 PO4 H+ + HPO4

2-

The amount of phosphate filtered is limited and relatively fixed, and

only a fraction of the secreted H+ can be buffered by HPO4 2-.

Figure-2- showing the buffering of secreted H+ by HPO4Ammonia mechanism

A more important urine-buffering system for secreted H+ than
phosphate, ammonia (NH3) buffering occurs via the following
reaction:
NH3 + H+ NH4

Ammonia is produced in the proximal tubule from the amino acid

glutamine, and this reaction is enhanced by an acid load and by
hypokalemia. Ammonia is converted to ammonium (NH 4 +) by
intracellular H+ and is secreted into the proximal tubular lumen by
the apical Na+/H+ (NH4 +) antiporter. It can be secreted as such also
and can later combine with H+ in the lumen to form NH4+.

NH4 + is trapped in the lumen and excreted as the Cl salt, and every
H+ ion buffered is an HCO3 - gained to the systemic circulation
(figure-3)
The kidneys can adjust the amount of NH3 synthesized to meet
demand, making this a powerful system to buffer secreted H+ in the
urine.

Figure 3- showing ammonia mechanism. Glutamine is first

converted to glutamate and then to alpha keto glutarate
Renal glutaminase activity is increased in conditions of acidosis, to
excrete out the excess acid load whereas it is decreased in
conditions of alkalosis to conserve acids (H+) to maintain the acid
base balance of the body.

Acid base balance- Lecture-1

Published February 17, 2014 | By Namrata Chhabra
An acid is a substance that can donate hydrogen ions (H+), and a
base is a substance that can accept H+ ions, regardless of the
substances charge.
H2 CO3 (acid) H+ + HCO3 - (base)
Strong acids are those that are completely ionized in body fluids,
and weak acids are those that are incompletely ionized in body
fluids.
HCl H+ + ClHydrochloric acid (HCl) is considered a strong acid because it is
present only in a completely ionized form in the body, whereas
H2 CO3 is a weak acid because it is ionized incompletely, and, at
equilibrium, all 3 reactants are present in body fluids.
H2 CO3 (acid) H+ + HCO3 - (base)
In body fluids, the concentration of hydrogen ions ([H+]) is
maintained within very narrow limits, with the normal physiologic
concentration being 40nEq/L. The concentration of HCO3- (24mEq/L)
is 600,000 times that of [H+]. The tight regulation of [H+] at this low
concentration is crucial for normal cellular activities.
Significance of pH

1) Specific tautomeric forms exist at physiologic pH. This helps in

proper hydrogen bonding between the complementary base pairs in
the structure of DNA.
2) The solubility and biologic activity of a protein depends upon its
3D structure and that depends upon net charge on protein for the
maintenance of hydrogen and ionic interactions. The net charge
depends upon the pH of the medium.
3) The movement of ions across the membrane depends upon their
net charge as determined by the pH.
4) Ionic state of the nucleic acids, lipids and mucopolysaccharides is
also determined by the physiological pH
5) All enzymes function best within an optimum pH range.
6) Nerve conduction and muscle contractions are also pH dependent
7) All metabolic processes are pH dependent.
8) Oxygen and CO2 transport, release or gaseous exchange is pH
dependent.
Maintenance of pH is important for proper physiological
functioning of cells and tissues. Any changes in pH can alter enzyme
activity, cellular uptake, incorporation and use of minerals and
metabolites, uptake and release of oxygen, and the formation of
biological structural components.
Normal plasma pH = 7.40 (0.05). The pH range that is
compatible with life is from 6.8 to 7.8. The body can comfortably
tolerate a shift in pH of about 0.04. Most cells of the body have a pH
= 7.0, but RBCs boast a pH of 7.2. The pH of the body affects its
acid-base balance and the pH of blood has the greatest effect.
Sources for pH disturbances
1) Organic acids- The most common sources for pH disturbances are
the bodys production of organic acids (acetic, acetoacetate,
propionic, butyric, lactic, etc.), which are the major sources of
hydrogen ion.

2) Carbonic acid is the chief acid (volatile acid) produced in the body
by the metabolic processes in the body. Approximately 300 litres of
CO2 are produced and eliminated daily in the body of an adult.
3) Sulphuric acid- it is produced during the oxidation of sulphurcontaining amino acids and vitamins.
4) Phosphoric acid- is produced from the metabolism of dietary
phosphoproteins, phospholipids, nucleic acids and hydrolysis of
phosphoesters.
Mechanism of maintenance of Physiological pH
Under normal conditions, acids and, to a lesser extent, bases are
being added constantly to the extracellular fluid compartment but
still a physiologic [H+] of 40 nEq/L is maintained and the following 3
processes must take place:
Buffering by extracellular and intracellular buffers
Alveolar ventilation, which controls PaCO2
Renal H+ excretion, which controls plasma [HCO3 -]
Buffers
Buffers are weak acids or bases that are able to minimize changes in
pH by taking up or releasing H+. Phosphate is an example of an
effective buffer, as in the following reaction:
HPO4

2-

+ (H+) H2 PO4

Upon addition of an H+ to extracellular fluids, the monohydrogen

phosphate binds H+ to form dihydrogen phosphate, minimizing the
change in pH. Similarly, when [H+] is decreased, the reaction is
shifted to the left. Thus, buffers work as a first-line of defense to
blunt the changes in pH that would otherwise result from the
constant daily addition of acids and bases to body fluids. With the
constant pouring in of H+, the concentration of the monohydrogen
phosphate will ultimately diminish and the pH will start falling.
The major Buffer system of the body

(1) HCO3 -/H2 CO3 buffering system HCO3/CO2 (bicarbonate/carbon

dioxide)
(2) HPO42/H2PO4 (phosphate),
(3) Organic Phosphate Esters, and
(4) Proteins.
Proteins with side chains that contain more carboxyl terminal groups
than amino terminal groups promote an acidic environment. Proteins
with side chains that contain more amino terminal groups than
carboxyl terminal groups promote an alkaline environment. Protein
with side chains containing equal numbers of amino and carboxyl
side groups are neutral, not affecting the pH.
Details of Buffers
(1) HCO3 -/H2 CO3 buffering system
In the ECF bicarbonate buffer is the most important buffer. Its
function is illustrated by the following reactions:
H2 O + CO2 H2 CO3 H+ + HCO3

When an acid load (H+) is added to the body fluids, it results in

consumption of HCO3 - by the added H+. Carbonic acid thus formed,
in turn, forms water and CO2. CO2 concentration is maintained within
a narrow range via the respiratory drive, which eliminates
accumulating CO2. The kidneys regenerate the HCO3 - consumed
during this reaction.
Put simply, whereas simple buffers rapidly become ineffective as the
association of the hydrogen ion and the weak anion of the weak acid
reaches equilibrium, the bicarbonate system keeps working because
the carbonic acid is removed as CO2. The limit to the effectiveness of
the bicarbonate system is the initial concentration of bicarbonate.
The acid base status of the patient is assessed by the bicarbonate
concentration in the plasma. The association of hydrogen ion with
bicarbonate occurs rapidly but the dissociation of H 2CO3 to CO2 and
H2O is slow. This process is accelerated by the enzyme Carbonic
anhydrase, which is present in the erythrocytes and in the kidney

whenever this reaction is needed. Buffering at the expense of

bicarbonate effectively removes hydrogen ions from ECF. CO2 is
removed from the lungs and water assimilates in the ECF without
producing any change in p H. The ECF contains a large amount of
bicarbonate to the extent of 24 mmol/L, when the H+ concentration
increases the bicarbonate concentration comes down since it is used
up during the process of buffering.
This reaction continues to move to the left as long as CO2 is
constantly eliminated or until HCO3 - is significantly depleted,
making less HCO3 - available to bind H+. Since HCO3 - and PaCO2 can
be managed independently (kidneys and lungs, respectively) that
makes this a very effective buffering system. One of the major
factors that make this system very effective is the ability to control
PaCO2 by changes in ventilation. As can be noted from this reaction,
increased carbon dioxide (CO2) concentration drives the reaction to
the right, whereas a decrease in CO2 concentration drives it to the
left.
Assessing acid base status
An indication of the acid base status of the patient can be
determined by measuring the components of the bicarbonate
system.
The Henderson-Hassel Balch equation describes the relationship
between blood pH and the components of the H2 CO3 buffering
system.
pH = 6.1 + log (HCO-3/ H2 CO3)
Bicarbonate (HCO3-) is in equilibrium with the metabolic
components.
Bicarbonate production in the kidney
Acid production from endogenous or exogenous sources
Carbonic acid (H2 CO3) is in equilibrium with the respiratory
component, as shown by the below equation:
H2 CO3 = PCO2 (mm Hg) X 0.03

Note that changes in pH or [H+] are a result of relative changes in

the ratio of PaCO2 to [HCO3 -] rather than to absolute change in
either one. In other words, if both PaCO2 and [HCO3 -] change in the
same direction, the ratio stays the same and the pH or [H+] remains
relatively stable. To diminish the alteration in pH that occurs when
either HCO3 - or PaCO2 changes, the body, within certain limits,
changes the other variable in the same direction.
2) Phosphate buffer system (Na2HPO4/NaH2PO4)
The phosphate buffer system is directly linked up with kidney.
Upon addition of acid, the H+ is neutralized by the Na2
HPO4 component forming NaH2PO4 that is eliminated through the
kidney without any change in pH.
Na2 HPO4 + HCl>> NaH2PO4 + NaCl
Similarly upon addition of OH-, the acid component reacts to form,
Na2 HPO4 that can be eliminated as well through the kidney without
any change in pH
NaH2PO4 + Na OH>> Na2 HPO4 + H2O
In other words Phosphate buffer system works in conjunction with
the kidney.
Chemically it is a very good buffer, as pKa is close to Physiological
pH, but physiologically due to its less concentration (1.0 mmol/L as
compared to bicarbonate 26-28 mmol/L) it is less efficient.
3) Role of Haemoglobin as a buffer
The buffering capacity of Hb is due to the presence of Imidazole
nitrogen group of Histidine. Oxygenated Hb is a stronger acid than
deoxygenated Hb. Acidity of the medium favors delivery of oxygen
to the tissues. Alkalinity of the medium favors oxygenation of Hb.
Sequence of events that occur in lungs and tissues is as follows;
In the lungs

The formation of oxy hemoglobin from deoxy hemoglobin, must

release H+, which will react with HCO3- to form H2CO3. Due to the low
CO2 tension in the lungs H2CO3, dissociates to form CO2 and H2O .
CO2 is then eliminated in the expired air (Figure-1).

Figure-1- Role of Hb as a buffer in the lungs.

In the tissues
Oxy Hb dissociates to give O2 to the tissues and the deoxy Hb
(Reduced Hb) is formed. At the same time CO2 produced as a result
of metabolism, is hydrated to for H2CO3, which ionizes to form
H+ and HCO3-. Deoxy Hb acts as anion and accepts H+ to form acid
reduced Hb (Figure-2)

Figure-2- Role of Hb as a buffer at the tissue level.

4) Protein buffer system
Buffering capacity of plasma proteins is much less than Hb. In acidic
medium protein acts a base and NH2 group takes up H+ forming
NH3+, protein becomes positively charged.
Reverse occurs in the alkaline medium. Acidic COOH to give H+ that
neutralizes the OH- forming H2O. Overall protein becomes negatively
charged in the alkaline medium.
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Posted in Acid Base Balance, Theory Notes

Acid Base Imbalance- Quick revision

Published May 1, 2012 | By Namrata Chhabra
Prim Defe Causes
ary
ct
Disor
der

Meta Gain (A) High anion gap (Acid

bolic inH+ gain)
Acido orloss
sis
ofHC 1) Ketoacidosis
O3HCO3
Diabetes
Chronic alcoholism
Decre
ased
Under nutrition

Fasting

Effect Compensatory Re
on pH sponse
and
Ratio
of
Bicar
bonat
e:
Carbo
nic
acid
pH Respiratory
decrea Mechanismsed,
RespiratoryAlkalosis(
Hyperventilation)
Ratiodecrea Pa CO2 Decreased
sed
Renal
mechanisms
1) Increased
excretion of H+ ions

2) Lactic Acidosis

Shock

Primary hypoxia due to

lung disorders

Seizures

2) Decreased
excretion of K+ ions
in the distal tubules
3) Decreased
bicarbonate
excretion

3) Renal Failure

4)Increased
ammonia formation

4) Toxins Metabolized to
acids

5) Increased acid
phosphate excretion

Alcohol

Methanol (formate)

Ethylene glycol
(oxalate)

Salicylates

B) Normal Anion GapAcidosis(Bicarbonate

loss- Hyperchloremic
acidosis)
1) GI HCO3 loss

Colostomy

Diarrhea

Enteric fistulas

Ileostomy

2)Urologic procedures
3) Renal HCO3 loss

Tubulointerstitial renal

disease

Renal tubular acidosis

4) Ingestions

Acetazolamide

CaCl2

Mg sulfate (MgSO4)

Meta
bolic
Alkal
osis

Gain Chloride-responsive
in
alkalosis
HCO3
-or
Loss of gastric
loss
secretions Vomiting,
HCO3 of H+
NG suction
Increa
Loss of colonic
sed
secretions

Thiazides and loop

diuretics (after
discontinuation)

Cystic fibrosis( Due to

loss of chloride in the
sweat)

Ingestion of large
doses of
nonabsorbable
antacids

Chloride-resistant
alkalosis

Primary
hyperaldosteronism

pH
Respiratory
increa Mechanismsed,
Respiratory
Ratio Acidosis(Hypoventila
increa tion)
sed
PaCO2 Increased.
Renal Mechanism
1) Decreased
excretion of H+ ions
2) Increased
excretion of K+ ions
in the distal tubules
3) Increased
bicarbonate
excretion
4) Decreased
ammonia formation
5) Decreased acid
Phosphate excretion

Cushing syndrome

Exogenous
mineralocorticoids or
glucocorticoids

Reno vascular
hypertension

Renin- or deoxy
corticosteronesecreting tumors

Current use of
thiazides and loop
diuretics

Hypomagnesaemia(Thr
ough Hypokalemia)

Milk Alkali Syndrome

Respi CO2 A) Central

rator Reten
y
tion
Drugs- Sedatives,
Acido
Alcohol, General
sis
Anesthetic agents
PaCO
2
Increa
sed

pHMetabolic Alkalosis
decrea
sed,
HCO3-Increased.
Ratio- Renal
decrea mechanisms 1)
sed
Increased excretion

Infections

Injuries- head trauma

of H+ ions

Diseases- Intracranial
tumor

2) Decreased
bicarbonate
excretion

Syndromes of sleepdisordered breathing,

including the primary
alveolar and obesityhypoventilation
syndromes.

3) Increased
ammonia formation
4) Increased acid

B)Airway obstruction

Severe asthma,

Anaphylaxis

Inhalational burn

Toxic injury

Laryngeal obstruction

End-stage obstructive
lung disease.

C) Parenchymatous
damage /Inflammation

Emphysema

Bronchitis

Adult Respiratory
distress syndrome

Pleurisy

Barotrauma

D) Neuromuscular

Poliomyelitis

Kyphoscoliosis

Myasthenia gravis

Muscular dystrophies

E) Misc.

Certain congenital

phosphate excretion

heart diseases

Mechanical ventilation

Rebreathing from a
closed space

Respi CO2 A) Central nervous

rator Wash system
y
out
Alkal
Pain
osis
Hyperventilation
PaCO
syndrome
2
Decre
Anxiety
ased

Psychosis

Fever

Cerebrovascular
accident

Meningitis

Encephalitis

Tumor

Trauma

Hypoxia
o High altitude
o Severe anemia
o Right-to-left

pH Metabolic Acidosis
Increa
sed,
HCO3-Decreased
Ratio- Renal Mechanism
Increa
sed
1)Decreased
excretion of H+ ions
2)Increased
bicarbonate
excretion
3)Decreased
ammonia formation
4)Decreased
phosphate excretion

shunts

Drugs
o Progesterone
o Methylxanthines
o Salicylates
o Catecholamines
o Nicotine

Endocrine
o Pregnancy
o Hyperthyroidism

Pulmonary
o Pneumothorax/h
emothorax
o Pneumonia
o Pulmonary
edema
o Pulmonary
embolism
o Aspiration
o Interstitial lung
disease
o Asthma
o Emphysema
o Chronic

bronchitis

Miscellaneous
o Sepsis
o Hepatic failure
o Mechanical
ventilation
o Heat exhaustion
o Recovery phase
of metabolic
acidosis
o Congestive heart
failure

Case studies- Acid Base Balance and

Imbalance
Published March 18, 2012 | By Namrata Chhabra
Case details-1
A 45 year-old-female suffering from bronchial asthma was
brought to emergency in a critical state with extreme
difficulty in breathing.
The blood gas analysis revealed the following

pH- 7.3
PCO2- 46 mm Hg

PO2- 55 mm Hg
HCO3- 24meq/L
What is your Interpretation?

Case discussion-

Low p H acidosis
Low PO2 and PCO2 excess signify Primary respiratory
problem
HCO3:24 -normal
Thus, the patient is suffering from Acute respiratory
acidosis.

Case details -2
A 4 day old girl neonate became lethargic and uninterested
in breast-feeding. Physical examination revealed tachypnea
(rapid breathing) with a normal heart beat and breath
sounds. Initial blood chemistry values included normal
glucose, sodium, potassium, chloride, and bicarbonate
(HCO3-) levels.
Blood gas values revealed a pH of 7.53, partial pressure of
oxygen (PO2) was normal (103 mm Hg) but PCO2 was 27
mmHg.
What is the probable diagnosis?

Case discussion
The baby is suffering from Respiratory Alkalosis

Tachypnea in term infants may be due to brain injuries and

metabolic diseases that irritate the respiratory center. The increased
respiratory rate removes carbon dioxide from the lung alveoli and
lowers blood CO2, forcing a shift in the indicated equilibrium
towards left
CO2 + H2O H2CO3 H+ + HCO3Carbonic acid (H2CO3) can be ignored because negligible amounts
are present at physiological pH, leaving the equilibrium
CO2 + H2O H+ + HCO3The leftward shift to replenish exhaled CO2 decreases the hydrogen
ion (H+) concentration and increases the pH to produce alkalosis.
This respiratory alkalosis is best treated by diminishing the
respiratory rate to elevate the blood [CO2], to force the above
equilibrium to the right, elevate the [H+], and decrease the pH.

Case details-3
A new-born with tachypnea and cyanosis (bluish color) is
found to have a blood pH of 7.1. Serum bicarbonate is
measured as 12 mM while pCO2 is 40 mm Hg.
What is the probable diagnosis?

Case discussion
Low p H and low bicarbonate indicate metabolic acidosis. Since p
CO2 is normal it can not be compensatory respiratory acidosis ( If
the baby had respiratory acidosis, the PCO2 would have been
elevated).This is a hypoxia related metabolic acidosis.
Hyperventilation is as a compensation to metabolic acidosis.

This condition can be treated by administration of oxygen to

improve tissue perfusion and decrease metabolic acidosis.

Case details -4
A 60-year-old man was brought to hospital in a very serious
condition. The patient complained of constant vomiting
containing several hundred mL of dark brown fluid from the
previous two days plus several episodes of melaena. Past
history of alcoholism, cirrhosis, portal hypertension and a
previous episode of bleeding varices was there.
Arterial Blood Gases revealedpH 7.10
pCO2 13.8 mmHg
pO2- 103 mmHg
HCO3- 14.1 mmol/l
Laboratory Investigations
Na+ 131 mmol/l., Cl- 85 mmol/l. K+ 4.2 mmol/l., total CO2 5.1,
glucose 52mg/dl, urea 38.6mg/dl, creatinine1.24mg/dl, lactate 20.3
mmol/l Hb 6.2 G%, and WBC- 18x103/mm3

Case discussion
The patient is severely ill with circulatory failure and GI bleeding on
a background of known cirrhosis with portal hypertension.

The very low pH indicates a severe acidosis. The combination of a

low pCO2 and low bicarbonate indicates either a metabolic acidosis
or a compensatory respiratory alkalosis (or both). As this patient has
a severe acidosis, so the most probable diagnosis is metabolic
acidosis. The anion gap is 31 indicating the presence of a high anion
gap disorder. The lactate level of 20.3mmol/l is extremely high and
this confirms the diagnosis of a severe lactic acidosis. Hb is very low
consistent with the history of bleeding and hypovolemia. Urea and
creatinine are elevated (renal failure) but at these levels there
would not be retention of anions sufficient to result in a renal
acidosis. Hence,
Lactic acidosis can be suspected. The respiratory efforts may be due
to the distress or as a consequence of a metabolic acidosis (ie
compensatory).

Case details-5
A 56- year -old man who smoked heavily for many years
developed worsening cough with purulent sputum and was
admitted to the hospital because of difficulty in breathing.
He was drowsy and cyanosed. His arterial blood gas analysis
was as follows;
pH - 7.2
p CO2 70 mm Hg
HCO3- 26 mmol/L
P O2- 50 mm Hg
What is the likely diagnosis?

Case discussion
The patient is suffering from Respiratory acidosis. Difficulty in
breathing, cough and purulent sputum signify the underlying lung
pathology. Low p H and raised pCO2 indicate respiratory acidosis.
Slightly high HCO3- may be due to compensation as a result of
increased reabsorption from the kidney. The low pO2 is due to
associated hypoxia. The treatment is based on the treating the
primary cause.O2 and mechanical ventilation are often needed.

Case details -6
A 5-year old girl displayed increased appetite, increased
urinary frequency, and thirst. Her physician suspected new
onset diabetes mellitus and confirmed that she had elevated
urine glucose and ketones.
Blood gas analysis revealed
pH-7.33
Bicarbonate-12.0 mmol/L
Arterial PCO2- 21

Case discussion
The patient is suffering from Diabetic ketoacidosis
In the presence of insulin deficiency, a shift to fatty acid oxidation
produces the ketones that cause metabolic acidosis. The pH and
bicarbonate are low, and there is frequently some respiratory
compensation (hyperventilation with deep breaths) to lower the
PCO2. A low pH with high PCO2 would have represented respiratory
acidosis which is not there in the given case.

Case details-7
A 19-year-old boy was brought to the emergency
department with loss of consciousness. Apparently the
patient was a homeless found on the street.
Arterial blood gases revealedpH 7.33,
pCo2 28 mm Hg,
pO2- 117 mmHg and
HCO3- 14 mmol/L
The blood level of methanol was 0.4 mg/dl.
What is your diagnosis?

Case discussion
The patient is suffering from metabolic acidosis as evident from the
low p H and low bicarbonate levels. Low p CO2 and high p O2 signify
that the patient is in a state of respiratory compensation. Blood
methanol level is high, so it might be the case of Methanol poisoning
producing metabolic acidosis.

Case details-8
A 66-year-old man had a postoperative cardiac arrest. Past
history of hypertension treated with an ACE inhibitor was
there. There was no past history of Ischemic heart disease.
Following reversal and extubation, myocardial ischemia was
noticed on ECG. He was transferred to ICU for overnight
monitoring. On arrival in ICU, BP was 90/50, pulse 80/min,
respiratory rate was 16/min and S pO2 99%. During
handover to ICU staff, he developed ventricular fibrillation

which reverted to sinus rhythm with a single 200J counter

shock. Soon after, blood gases were obtained from a radial
arterial puncture:
Arterial Blood Gases
pH -7.27
pCO2 -55.4 mmHg
pO2- 144 mmHg
HCO3- 24.3 mmol/l
Biochemistry Results (all in mmol/l): Na+ 138, K+ 4.7, Cl- 103, urea
6.4, creatinine 0.07
What is the probable diagnosis?

Case discussion
1) p H- low , Acidosis is present.
2) p CO2- high, hypoventilation(The residual depressant effect of
the Anesthetic agents is considered the most likely cause)
3) Bicarbonate- near normal
4) pO 2- high- This is because the patient is breathing a high
inspired oxygen concentration. If the patient had been breathing
room air (FIO2 = 0.21), then a depression of alveolar pO2 must have
occurred. Most ill patients in hospital breathe supplemental oxygen
so it is common for the pO2 to be elevated on blood gas results.
5) An acidemia with the pattern of elevated pCO2 and normal HCO3
is consistent with an acute respiratory acidosis.
6) Anion gap- The anion gap is about 11 which is normal so no
evidence of a high anion gap acidosis.

Diagnosis- Acute respiratory acidosis

Cause- Resuscitation from postoperative ventricular
fibrillation

Case details -9
A 72-year-old male with diabetes mellitus is evaluated in the
emergency room because of lethargy, disorientation, and
long, deep breaths (Kussmaul respiration). Initial
chemistries on venous blood demonstrate high glucose level
of 380 mg/dl (normal up to 120 mg/dl) and pH of 7.3.
Bicarbonate 15mM and PCO2 30 mmHg, What is the
probable diagnosis ?
Case discussion
The man is acidotic as defined by pH lower than normal 7.4. His
hyperventilation with Kussmaul respiration can be interpreted as
compensation by lungs to blow off CO2 to lower PCO2, to increase
[HCO3-]/[CO2] ratio, and to raise pH. Thus the patient has metabolic
acidosis due to underlying Diabetic ketoacidosis.

Case details-10
A 24 year female with broken ankle was brought to
emergency with acute pain.
Blood gas analysis revealed the following
pH- 7.55
PCO2- 27
PO2- 105,
HCO3- 23

What is the probable diagnosis?

Case discussion
pH:- 7.55 indicates Alkalosis
PCO2: 27 -low, it is a Primary respiratory disturbance
PCO2 Deficit = 40-27 = 13
HCO3 = 23 (Normal)
Interpretation:
It is Respiratory alkalosis due to pain related hyperventilation.

Multiple Choice Questions- Acid Base Balance

Published March 18, 2012 | By Namrata Chhabra
Q.1- A person was admitted in a coma. Analysis of the
arterial blood gave the following values: PCO2 16 mm Hg,
HCO3- 5 mmol/l and pH 7.1. What is the underlying acid-base
disorder?
a) Metabolic Acidosis
b) Metabolic Alkalosis
c) Respiratory Acidosis
d) Respiratory Alkalosis
Q.2- In a man undergoing surgery, it was necessary to
aspirate the contents of the upper gastrointestinal tract.
After surgery, the following values were obtained from an
arterial blood sample: pH 7.55, PCO2 52 mm Hg and HCO3- 40
mmol/l. What is the underlying disorder?
a) Metabolic Acidosis
b) Metabolic Alkalosis
c) Respiratory Acidosis
d) Respiratory Alkalosis
Q.3- A young woman is found comatose, having taken an
unknown number of sleeping pills an unknown time before.
An arterial blood sample yields the following values: pH

6.90, HCO3- 13 meq/liter, PaCO2 68 mmHg. This patients

acid-base status is most accurately described as
a) Uncompensated metabolic acidosis
b) uncompensated respiratory acidosis
c) simultaneous respiratory and metabolic acidosis
d) respiratory acidosis with partial renal compensation
Q.4- A student is nervous for a big exam and is breathing
rapidly, what do you expect out of the following
a) Metabolic Acidosis
b) Metabolic Alkalosis
c) Respiratory Acidosis
d) Respiratory Alkalosis
Q.5- A 45- year-old female with renal failure, missed her
dialysis and was feeling sick, what could be the reason ?
a) Metabolic Acidosis
b) Metabolic Alkalosis
c) Respiratory Acidosis
d) Respiratory Alkalosis
Q.6- An 80-year-old man had a bad cold. After two weeks he
said, It went in to my chest, I am feeling tightness in my
chest, I am coughing, suffocated and unable to breathe!
What could be the possible reason?
a) Metabolic Acidosis
b) Metabolic Alkalosis
c) Respiratory Acidosis

d) Respiratory Alkalosis
Q.7- A post operative surgical patient had a naso gastric
tube in for three days. The nurse caring for the patient
stated that there was much drainage from the tube that is
why she felt so sick. What could be the reason?
a) Metabolic Acidosis
b) Metabolic Alkalosis
c) Respiratory Acidosis
d) Respiratory Alkalosis
Q.8- The p H of the body fluids is stabilized by buffer
systems. Which of the following compounds is the most
effective buffer system at physiological pH ?
a) Bicarbonate buffer
b) Phosphate buffer
c) Protein buffer
d) All of the above
Q.9- Which of the following laboratory results below
indicates compensated metabolic alkalosis?
a) Low p CO2, normal bicarbonate and, high pH
b) Low p CO2, low bicarbonate, low pH
c) High p CO2, normal bicarbonate and, low p H
d) High pCO2, high bicarbonate and High pH
Q.10- The greatest buffering capacity at physiological p H
would be provided by a protein rich in which of the following
amino acids?
a) Lysine

b) Histidine
c) Aspartic acid
d) Leucine
Q.11- Which of the following is most appropriate for a
female suffering from Insulin dependent diabetes mellitus
with a pH of 7.2, HCO3-17 mmol/L and pCO2-20 mm HG
a) Metabolic Acidosis
b) Metabolic Alkalosis
c) Respiratory Acidosis
d) Respiratory Alkalosis
Q.12- Causes of metabolic alkalosis include all the following
except.
a) Mineralocorticoid deficiency.
b) Hypokalemia
c) Thiazide diuretic therapy.
d) Recurrent vomiting.
Q.13- Renal Glutaminase activity is increased ina) Metabolic acidosis
b) Respiratory Acidosis
c) Both of the above
d) None of the above
Q.14- Causes of lactic acidosis include all excepta) Acute Myocardial infarction

b) Hypoxia
c) Circulatory failure
d) Infections
Q.15- Which out of the following conditions will not cause
respiratory alkalosis?
a) Fever
b) Anxiety
c) Laryngeal obstruction
d) Salicylate toxicity
Q.16- All are true about metabolic alkalosis except onea) Associated with hyperkalemia
b) Associated with decreased ionic calcium concentration
c) Can be caused due to Primary hyperaldosteronism
d) Can be caused due to Renin secreting tumor
Q.17- Choose the incorrect statement out of the following
a) Deoxy hemoglobin is a weak base
b) Oxyhemoglobin is a relatively strong acid
c) The buffering capacity of hemoglobin is lesser than plasma
protein
d) The buffering capacity of Hemoglobin is due to histidine residues.
Q.18- Carbonic anhydrase is present at all places excepta) Gastric parietal cells
b) Red blood cells

c) Renal tubular cells

d) Plasma
Q.19- All are true for renal handling of acids in metabolic
acidosis except
a) Hydrogen ion secretion is increased
b) Bicarbonate reabsorption is decreased
c) Urinary acidity is increased
d) Urinary ammonia is increased.
Q.20- Choose the incorrect statement about anion gap out of
the following
a) In lactic acidosis anion gap is increased
b) Anion gap is decreased in Hypercalcemia
c) Anion gap is decreased in Lithium toxicity
d) Anion gap is decreased in ketoacidosis.
Q.21- Excessive citrate in transfused blood can cause which
of the following abnormalities?
a) Metabolic alkalosis
b) Metabolic acidosis
c) Respiratory alkalosis
d) Respiratory acidosis

Answers- 1-a, 2-b, 3-c, 4-d, 5-a, 6-c, 7-b, 8-a, 9-d, 10-b, 11-a,
12-a, 13-c, 14-d, 15-c, 16-a, 17-c, 18-d, 19-b, 20-d, 21-a.

Subjective Questions Acid Base Balance and

Imbalance
Published March 18, 2012 | By Namrata Chhabra
Q.1- Explain clearly how hyperventilation and hypoventilation affect
blood p H ? Give suitable examples in support of your answer.
Q.2- Explain the role of hemoglobin as a buffer in the maintenance
of acid base balance in the body.
Q.3-The maintenance of intracellular pH within narrow limits is
essential for life processes. Briefly discuss why this is so and
describe the mechanism by which the human body maintains a
relatively constant pH despite continuous acid production from
cellular metabolism.
Q.4- Name 3 physiological buffer systems, and explain the mode of
action of any one of them.
Q.5-A person was brought to the hospital after ingesting a large
amount of ammonium chloride. His arterial blood pH was found to
be 7.29. Calculate the ratio of [HC03] to [dissolved CO2] in the blood.
Dissolved CO2 + H20 H2CO3 H+ + HCO3- (pKa = 6.1) How might
changes in the pulmonary ventilation help to minimize the fall in pH?
Q.6- Discuss the role of kidneys in the maintenance of acid base
balance of the body. Support your answer with flow charts showing
the details of the mechanisms.

Q.7- What is anion gap? State all the conditions of variations of

anion gap in the body?
Q.8- Calculate the anion gap for a patient who has reported to
emergency in a state of shock with following blood reports
p H- 7.2
Pco2- 45 mm Hg
HCO312 meq/L
Serum Na + 135 meq/L
Cl - - -85 meq/L
Q.9-A 14-year-old girl with cystic fibrosis has complained of an
increased cough productive of green sputum over the last week. She
also complained of being increasingly short of breath, and she is
noticeably wheezing on physical examination. Arterial blood was
drawn and sampled, revealing the following values:
pH
pCO2
pO2
Hemoglobin O2 saturation
[HCO3-]

What is the acid base status of the girl? Discuss in detail about the
imbalance
How would the kidneys try to compensate for the girls acid-base
imbalance?

Q.10- A 76-year-old man complained to his wife of severe substernal chest pain that radiated down the inside of his left arm.
Shortly afterwards, he collapsed on the living room floor. Paramedics
arriving at his house just minutes later found him unresponsive, not
breathing, and without a pulse. CPR and electro convulsive shock
were required to start his heart beating again. Upon arrival at the
Emergency Room, the man started to regain consciousness,
complaining of severe shortness of breath (dyspnea) and continued
chest pain. On physical examination, his vital signs were as follows:
Systemic blood pressure

85 mm Hg / 50 mm Hg

Heart rate

175 beats / minute

Respiratory rate

32 breaths / minute

Temperature

99.2oF

His breathing was labored, his pulses were rapid and weak
everywhere, and his skin was cold and clammy. An ECG was done,
revealing significant Q waves in most of the leads. Blood testing
revealed markedly elevated creatine phosphokinase (CPK) levels of
cardiac muscle origin. Arterial blood was sampled and revealed the
following:
pH

7.22

pCO2

30 mm Hg

pO2

70 mm Hg

Hemoglobin O2 saturation

88 %

[HCO3-]

2 meq / liter

a) What is the diagnosis? What evidence supports your diagnosis?

b) How would you classify his acid-base status? What specifically
caused this acid-base disturbance?
c) How has his body started to compensate for this acid-base
disturbance?
d) What would his blood pH be if his body had not started
compensating for the acid-base disturbance? Show your work.
e) List some other causes of this type of acid-base disturbance.

Q.11-An elderly gentleman is in a coma after suffering a severe

stroke. He is in the intensive care unit and has been placed on a
ventilator. Arterial blood gas measurements from the patient reveal
the following:
pH

7.50

pCO2

30 mm Hg

pO2

100 mm Hg

Hemoglobin O2 saturation

98%

[HCO3-]

24 meq / liter

a) How would you classify this patients acid-base status?

b) How does this patients hyperventilation pattern raise the pH of
the blood?

c) How might the kidneys respond to this acid-base disturbance?

d) List some other causes of this type of acid-base disturbance.

Q.12-A 28-year-old woman has been sick with the flu for the past
week, vomiting several times every day. She is having a difficult
time keeping solids and liquids down, and has become severely
dehydrated. After fainting at work, she was taken to a walk-in clinic,
where an IV was placed to help rehydrate her. Arterial blood was
drawn first, revealing the following:
pH

7.50

pCO2

40 mm Hg

pO2

95 mm Hg

Hemoglobin O2 saturation

97%

[HCO3-]

32 meq / liter

a) How would you classify her acid-base disturbance?

b) Why might excessive vomiting cause her particular acid-base
disturbance?
c) How would the kidneys compensate for this acid-base
disturbance?
d) List some other causes of this type of acid-base disturbance.