Approach to metabolic alkalosis Quiz: Ace Your Exams
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A 78-year-old man was admitted to the intensive care unit three days ago for severe respiratory failure requiring intubation and mechanical ventilation. He was found to have an exacerbation of heart failure with preserved ejection fraction and is currently undergoing diuresis. The patient has severe chronic obstructive pulmonary disease and uses 4 liters of supplemental oxygen chronically. His respiratory status has significantly improved, and the plan is to extubate him today. He was also found to have a partial small bowel obstruction upon admission and a nasogastric tube was placed for decompression. Temperature is 37.0 ºC (98.6 ºF), pulse is 66/min, respiratory rate is 14/min and in synchrony with the ventilator, blood pressure is 110/74 mm Hg, and SpO2 is 99% on minimal ventilator settings. Current medications include acetazolamide, bumetanide, lisinopril, and metoprolol. Results from bloodwork done that morning can be seen below. Which of the following is the most probable cause of this patient’s metabolic alkalosis?
| Laboratory Study | Result |
| Serum bicarbonate | 38 mEq/L (baseline 32 mEq/L) |
| Serum blood urea nitrogen (BUN) | 34 mg/dL |
| Serum creatinine | 1.9 mg/dL |
| Urine chloride | 18 mEq/L |
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