Animal Physiology Questions

 

COMPARATIVE PHYSIOLOGY- Animal Physiology

 

course introduction, composition of air, water vapor in air, solubility of gases, respiration in water, gills, countercurrent exchange, boundary layers, respiration in air, mammalian lungs

 

 

air-breathing fish, bird respiration, insect respiration, cyclic respiration, oxygen transport in blood, respiratory pigments, oxygen dissociation curves, facilitated diffusion

 

 

carbon dioxide transport, pumps and channels, water compartments, circulation patterns, cardiac output, blood vessels, physics of pipe flow, blood pressure, capillaries, exercise, invertebrate circulation, clotting

 

 

feeding, food types and mechanisms, hydrothermal springs, digestion, enzymes, wood and cellulose digestion, ruminants, nutrition, vitamins, minerals, trace elements, chemical defense, metabolic rate, energy storage, oxygen

 

 

diving mammals and birds, metabolic rate and body size, size and scaling, energy cost of locomotion, running, swimming and flying, physiological time

Biology 451 – Comparative Physiology – Exam 1

Pledge: In recognition of and in the spirit of the honor code, I certify that I have neither given nor received aid on

this examination.

 

(Signature) _________________________________

 

(Full Name, printed) ________________________________Student I.D. Number ____________________

 

Water vapor over a free water surface: 46.9 mmHg @ 37C; 31.7 mmHg @ 30 C; 17.5 mmHg @ 20 C;

12.8 mmHg @ 15 C; 9.2 mmHg @ 10°C

Solubility Coefficients @ 20C:  = 31 ml O2/l H2O;  = 878 ml CO2/l H2O;  = 15 ml N2/l H2O

Solubility Coefficients @ 15C:  = 34.1 ml O2/l H2O;  = 1019.0 ml CO2/l H2O;  = 16.9 ml N2/l H2O

MW of O2 = 32, MW of CO2= 44, MW of N2 = 28

 

For complete credit please show all calculations and units for problems 1-4 below. Write the correct answer

in the blank on the left side of the page for questions 5-7 (2 points per question)

 

Following the disastrous earthquake in Haiti, you are part of a team that has been contracted to conduct a survey of

the fauna and to document its recovery.

 

1) You land in Port-de-Paix on the northern coast of the island to begin your survey. You find an interesting group

of anolid lizards living in the vegetation adjacent to the beach. The temperature is 30 C, the relative humidity is

73%, and the locality is at sea level (barometric pressure = 760 mmHg). What is the partial pressure of carbon

dioxide in the air?

 

 

 

 

 

2) You begin trekking inland and discover a small freshwater lake that is inhabited by a diverse assemblage of

aquatic crustaceans. The elevation is 1815m (barometric pressure = 610 mmHg), the relative humidity is 62% and

the temperature is 20 C. What is the tension of nitrogen of the water in the lake?

 

 

 

 

 

3) You continue travelling inland and ascend the highest mountain, Morne de la Selle (2715 meters, barometric

pressure = 545 mmHg). At the top you discover a small pond that is inhabited by an unusual small fish species.

The temperature is 15 C and the relative humidity is 85%. What is the oxygen content (ml O2/liter water) of the

water in the pond?

 

 

 

 

 

4) Before departing Haiti you receive an invitation from a colleague to join her in the Aquarius underwater habitat

that is currently situated at 10 meters depth on the seafloor near the Ile de la Tortue, north of Port-de-Paix. She is

conducting experiments on corals in the surrounding patch reef area. The Aquarius habitat has open ports in the

bottom through which divers can enter the water, so the internal pressure in the habitat is the same as the ambient

pressure at that depth (1520 mmHg, relative humidity =100%, temperature = 20 C) and normal atmospheric air is

pumped down to the habitat from the surface. What is the partial pressure of nitrogen in the habitat?

 

 

 

 

Name _________________________________________ 2

The Aquarius habitat includes a small laboratory in which your colleague has installed aquaria to maintain the coral

specimens. The aquaria, which are filled with seawater, are equilibrated with the ambient air. Freshwater for

drinking and washing is kept in a large tank in the habitat and is also equilibrated with the ambient air in the

chamber.

 

5)_____ The tension of oxygen in the seawater in the aquaria would be (a. greater than; b. less than; c. equal to)

the freshwater in the tank.

 

6)_____ The oxygen content of the seawater in the aquaria would be (a. greater than; b. less than; c. equal to) the

freshwater in the storage tank.

 

7)_____ The tension of oxygen in the seawater in the aquaria would be (a. greater than; b. less than; c. equal to)

the tension of oxygen in the seawater surrounding the habitat at that depth.

 

 

Write the letter of the correct answer in the blank on the left side of the page (2 points each).

 

8)_____ In a mammalian circulatory system, the lowest pressure would be found in the (a. aorta; b. capillaries; c.

veins; d. vena cava.)

 

9)_____ The rate of diffusion of oxygen in air is (a. greater than; b. less than; c. equal to) the rate of diffusion of

oxygen in water.

 

10)____If the colloidal osmotic pressure is 30 mmHg and the hydrostatic pressure at a particular point in the

capillary is 22 mmHg, one would expect (a. reabsorption; b. no fluid movement; c. bulk filtration) to

occur at that point.

 

11)_____ During the “closed” phase of the cyclical respiration in insects, the partial pressure of oxygen in the

tracheal system (a. increases; b. decreases; c. remains relatively constant).

 

12)_____ Suppose that you perform an experiment on a mammal in which you decrease the oxygen content in the

inhaled air by 2.5%. You would predict that respiration by the animal would (a. increase; b. decrease; c.

remain unchanged).

 

13)_____ During exhalation, most of the air leaving the anterior air sacs of a bird (a. exits the mouth; b. enters the

posterior air sacs; c. flows into the lungs).

 

14)_____ The apparent viscosity of blood (a. increases; b. decreases; c. does not change) as the blood flows from

the arterioles to the capillaries.

 

15)_____ During inhalation, air flows from the (a. lungs; b. posterior air sacs; c. mouth) of a bird into the anterior

air sacs.

 

16)_____ If you monitored the pressure in the tracheal system of an insect, you would observe the lowest pressure,

relative to ambient, during the (a. fluttering phase; b. closed phase; c. open phase)

 

17)_____ Respiratory pigment molecules that are enclosed in blood cells tend to have a molecular weight that is (a.

greater than; b. less than; c. equal to) the molecular weight of respiratory pigments that are in solution in

the blood.

 

18)_____ At the normal pH of mammalian blood, most of the total carbon dioxide present is in the form of (a.

carbonic acid; b. bicarbonate ion; c. carbonate ion; d. a dissolved gas).

 

19)_____ Nearly 70% of the fat free vertebrate body is water. The smallest percentage of the water is found in the

(a. intracellular; b. interstitial; c. blood) compartment.

 

 

 

 

 

Name _________________________________________ 3

Oxygen-hemoglobin dissociation curves (a, b, & c) are graphed below. Fill in the blank with the letter

indicating the correct curve or with the correct value (2 points per blank)

20) If curve b is for the blood of a fetal

mammal, curve _____ is most likely for

the blood of the mother.

21) If curve b is for the blood of a rhinoceros,

curve _____ is most likely for the

myoglobin of its muscle.

22) If you increased the pH of a sample of

blood, curve b would shift towards

curve _____.

23) If the concentration of ATP in a blood

sample decreases, the oxygen

dissociation curve would be expected to

shift from the position of curve b

towards the position of curve _____.

24) The approximate P50 for curve c is _____

25) Suppose that you measure the oxygen

dissociation curves for a giraffe, a

gerbil and a gopher. Curve ____ is

most likely the curve for the giraffe.

26) If curve b was obtained for a blood sample tested at 30ºC, curve _____ would be obtained when the blood

sample is tested at 15 ºC.

27) If curve b is for blood leaving the muscle of a swimming fish, curve _____ would be the same blood after

leaving the gills.

28) If the blood sample shown by curve b was exposed to air with a high partial pressure of CO2, the curve would

be expected to shift toward the position of curve _____.

29) If curve b is for the blood of a deer, curve _____ is most likely for the blood of a seal of the same body mass.

 

The flow of blood through a portion of an unusual circulatory system is illustrated below. Fill in the blanks with the

number identifying the correct answer from the list below. The fluid has viscosity (i.e., it is not an ideal

fluid). (2 points per blank)

1. greater than 2. less than 3. equal to 30) The velocity at point B is _____ that at point C.

31) The pressure at point A is _____ that at point C.

32) In five minutes, the volume of water flowing past point A is ____ that at point B.

33) The tension in the wall at point B is ______ that at point D.

34) If the blood is stationary for a moment, the pressure at point C is ____ that at point D.

(You are viewing the vessels of the circulatory system from the side so point D is lower than point C.)

 

35) _____ Suppose that there is a mutation in mice that dramatically reduces surfactant secretion in the lungs. One

would predict that the muscular effort required to inflate the lungs during inhalation would (a. increase; b.

decrease; c. be unchanged) compared with a wild type mouse.

 

 

A B

C

D

% Sat

100

40 80

PO2 (mmHg)

a b c

 

 

Name _________________________________________ 4

36) _____ Suppose that you measured the breathing rate of a kangaroo (number of breaths per minute) while

hopping at sea level and while hopping at high altitude. If the stride frequency (number of hops per

minute) is identical at sea level and at altitude, you would predict that the breathing rate at altitude would

be (a. greater than; b. less than; c. equal to) that at sea level.

 

37) _____The lowest blood velocity in a mammalian circulatory system would be found in the (a. aorta; b.

capillaries; c. veins; d. vena cava.)

 

38) _____ The carbon dioxide content of air in the posterior air sacs of a bird is likely to be (a. greater than; b.

less than; c. equal to) that of the anterior air sacs.

 

39) _____ When compared at the same carbon dioxide tension, deoxygenated blood binds (a. more; b. less; c.

the same amount of) carbon dioxide compared with oxygenated blood.

 

40) _____ Suppose that you are a respiratory physiologist interested in the function of fish gills. You are also

unusually skilled in surgical techniques. You perform a series of experiments in which you swap the

arterial blood supply to, and venous return from, each gill arch so that blood flow through the gill lamellae

is reversed compared to the control fish. All other aspects of the experimental and control fish are

identical. You would predict that oxygen extraction in the experimental fish would be (a. greater than; b.

less than; c. equal to) that of the control fish.

 

41) _____ Suppose that you decide to repeat Scholander’s famous experiments on facilitated diffusion. If you

added gelatin to the hemoglobin solution you predict that the facilitation would (a. increase; b. decrease; c.

be unaffected).

 

42) _____ Gas exchange through the skin of most reptiles (a. is much greater than; b. is much less than; c. is

approximately equal to) gas exchange in the lungs.

 

43) _____ During the “fluttering” phase of cyclical respiration in insects, the partial pressure of carbon dioxide in

the tracheal system (a. increases; b. decreases; c. remains relatively constant).

 

44) _____ When carbon dioxide dissolves in water, the formation of (a. carbonate ion; b. bicarbonate ion; c.

carbonic acid) is the rate-limiting step. This step is accelerated by the enzyme called

45) ____________________________________________.

 

Fill in the blank with the correct word or words (2 points per blank).

46) If a gill removes oxygen from completely still water, the immediately adjacent

___________________________________ of water will soon be depleted of oxygen. Renewal of this

water is therefore important in supplying oxygen.

47) The tubeworm, Riftia pachyptilia, is an important member of many deep sea rift communities. Although it

lacks a mouth and intestinal tract, it grows remarkably rapidly and to great size. A large organ called the

___________________________________ fills the greater part of the coelom and is packed with bacteria

which provide the tubeworm with energy obtained from the oxidation of hydrogen sulfide.

48) In birds, the finest branches of the respiratory system, known as ________________________________ permit

through passage of air and are the site of exchange of the respiratory gases with the blood.

49) In insects, the openings of the tracheal system to the outside are called

__________________________________ and are highly complex structures that can be opened or closed

to allow a variable amount of gas exchange.

50) The flow of a fluid such as blood, water or air is characterized by two radically different regimes. In

_______________________________ the fluid “particles” move more or less parallel to one another in

paths that are smooth and regular. The large and small scale movements of the fluid in this regime are the

same.

 

Please print your name in the upper right corner of the back of this page.

 
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Statistics Quiz Biology

1. A sample of 80 juvenile salmon is grouped into the resulting frequency distribution based on their weights.

Weight (in grams) Frequency
100-149 15
150-199 10
200-249 30
250-299 25

If a cumulative frequency distribution were constructed for the weights of the salmon, what would be the cumulative frequency for the class weighing less than 200 grams? (Points : 0.5)

15        25        55        80

2. Select the complement of the event: All 80 participants in a study are kidney donors. (Points :

At least one of the participants is a kidney donor.        Less than 40 of the participants are kidney donors.        None of the participants are kidney donors.        More than 40 of the participants are kidney donors.

3. Use the following probability distribution for this next question. Biologists researching a certain type of hawk, Accipiter spp., found the following probability values for x, the number of offspring.

x P(x)
0 .05
1 .19
2 .32
3 .21
4 .12
5 .08
6 .03

Find the mean of the probability distribution for offspring of Accipiter spp. . Give your answer to one decimal, e.g., 1.2 . (Points : 0.5)

 

4. Use the binomial distribution for this question. A doctor knows from experience that 10% of the patients to whom she gives a certain medication will experience undesirable side effects. Assume the doctor gives medication to the next 12 patients. Referring to the binomial distribution for the medication, find the probability that exactly three of these patients will experience undesirable side effects. Give your answer to three decimals, e.g., .987 . (Points : 1)

 

 

5.Use the Standard Normal distribution to answer this question. Identify the probability corresponding to a z-score of less than -1.33. (Points : 1)

.0918        .9082        .8165        .6239

6. Use the Poisson distribution for this question. For a science laboratory experiment, the average number of radioactive particles passing through a counter in a millisecond is four. Find the probability that six particles pass through the counter in a given millisecond. Give your answer to three decimals, e.g., .987 . (Points : 1)

 

7. Use the normal distribution for this question. The mean maximum aerobic power (VO2MAX) score for women ages 20 to 29 is 36 ml/min/kg with a standard deviation of 7 ml/min/kg. Find the probability of a woman between the ages of 20 to 29 having a VO2MAX score of greater than 45 ml/min/kg. Give your answer to three decimals, e.g., .987 . (Points : 1)

 

 

8. Find the minimum sample size required to estimate a population proportion p . Margin of error: four percentage points; confidence level: 95%; from a prior study, p is estimated by = .125 . Round your answer up to the nearest integer. (Points : 1)

 

9. Assume that a simple random sample has been taken, the population standard deviation is not known, and the population is normally distributed. Medical researchers studying cochlear implants, devices placed behind the bone in the ear to improve hearing, found the following number of implants over the last twelve years in children under 3 years old. Use a 90% confidence level and the following sample data: 40    90    99    120   150   220   300   320   460   520   600   650 Use the sample data and confidence level to construct a confidence interval estimate of the population mean µ. Give your answer to with one decimal, e.g., (123.4,567.8) . (Points : 0.5)

 

10. Biologists measure the water temperature of the Merrimack River in New Hampshire. What type of data is collected? (Points : 1)

Nominal        Ordinal        Interval        Ratio

 

 

$StudentAnswer

 

892567174

 

FillInTheBlank

 

10

 

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892567176

 

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13

 

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22

 

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MultipleChoice

 

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Case Study Metatherian Mammals

Follow the directions for each activity. Answer the essay questions completely using thoughtful ideas, the course text, and outside reference sources, where applicable. Proofread answers for potential writing errors. 

Part A. Metatherian Mammals

 

Part A Question1) What are metatherian mammals? What are distinguishing characteristics of metatherian mammals?

Extinct mammals, they are very few living. Metatherians, which comprise marsupials and their closest fossil relatives, were one of the most dominant clades of mammals during the Cretaceous and are the most diverse clade of living mammals after Placentalia. The only living metatherian mammals are the marsupials. There were some extinct metatherians that were not marsupials, such as the Sparassodonts, but as these have gone extinct, a metatherian is now just a synonym for a marsupial Metatherians belong to a subgroup of the northern tribosphenic mammal clade or Boreosphenida. They differ from all other mammals in certain morphologies like their dental formula, which includes about five upper and four lower incisors, a canine, three premolars, and four molar. In metatherians, marsupium is present which is required for carrying the infants

Part A Question2) Describe the biogeography of metatherian mammals.

Part A Question3) Using the following websites choose one extant (currently living) metatherian (marsupial) mammal species. Conduct research about the species. Discuss and analyze the species’ anatomy, ecology, and life history. Write a species account of at least 300 words correctly citing the reference source(s) you used. Scientific names are comprised of the genus (capitalized) followed by the species name (not capitalized) and they are italicized. For example, Ornithorhynchus anatinus.

 

Site Name

Web Site URL/Address

 

Mammalogy on the Internet

http://www.mammalsociety.org/mammalogy-internet

 

Tree of Life Web Project

http://www.tolweb.org/Mammalia

 

Animal Diversity Web 

http://animaldiversity.ummz.umich.edu/site/accounts/information/Mammalia.html

 

Wilson & Reeder’s Mammal Species of the World

http://www.vertebrates.si.edu/msw/mswcfapp/msw/index.cfm

 

American Society of Mammalogists: Mammalian Species

http://www.mammalsociety.org/publications/mammalian-species

 

Mammalian Species pdf Site

http://www.science.smith.edu/departments/Biology/VHAYSSEN/msi/

 

National Geographic Mammals

http://animals.nationalgeographic.com/animals/mammals/

Species Scientific Name:

Species Common Name:

Species Account:

Part B. Comparison of Metatherian and Eutherian Mammal Ecology

 

Complete the table using the websites listed in Part B. Match the eutherian (placental) mammal with a similar ecological equivalent metatherian.

 

Scientific Name of Metatherian   Mammal

Common Name

Ecological Description

Eutherian Mammal Match

 

Petaurus   breviceps

 

Vombatus ursinus

 

Myrmecobius fasciatus

 

Notoryctes typhlops

 

Dasycercus cristicauda

 

Sarcophilus harrisii

 

Thylacinus   cynocephalus

List of Eutherian Mammals to Match

Peromyscus polionotus

Talpa europaea 

Glaucomys volans

Taxidea taxus

Myrmecophaga tridactyla

Canis latrans

Marmota flaviventris

Part B Essay Question: What are potential hypotheses (explanations) regarding why there are ecological equivalents between many metatherians and eutherians? Discuss your hypothesis in terms of the processes that could lead to the current ecologies and distributions of metatherians and eutherians. 

Follow the directions for each activity. Answer the essay questions completely using thoughtful ideas, the course text, and outside reference sources, where applicable. Proofread answers for potential writing errors. 

Part A. Metatherian Mammals

 

Part A Question1) What are metatherian mammals? What are distinguishing characteristics of metatherian mammals?

Extinct mammals, they are very few living. Metatherians, which comprise marsupials and their closest fossil relatives, were one of the most dominant clades of mammals during the Cretaceous and are the most diverse clade of living mammals after Placentalia. The only living metatherian mammals are the marsupials. There were some extinct metatherians that were not marsupials, such as the Sparassodonts, but as these have gone extinct, a metatherian is now just a synonym for a marsupial Metatherians belong to a subgroup of the northern tribosphenic mammal clade or Boreosphenida. They differ from all other mammals in certain morphologies like their dental formula, which includes about five upper and four lower incisors, a canine, three premolars, and four molar. In metatherians, marsupium is present which is required for carrying the infants

Part A Question2) Describe the biogeography of metatherian mammals.

Part A Question3) Using the following websites choose one extant (currently living) metatherian (marsupial) mammal species. Conduct research about the species. Discuss and analyze the species’ anatomy, ecology, and life history. Write a species account of at least 300 words correctly citing the reference source(s) you used. Scientific names are comprised of the genus (capitalized) followed by the species name (not capitalized) and they are italicized. For example, Ornithorhynchus anatinus.

 

Site Name

Web Site URL/Address

 

Mammalogy on the Internet

http://www.mammalsociety.org/mammalogy-internet

 

Tree of Life Web Project

http://www.tolweb.org/Mammalia

 

Animal Diversity Web 

http://animaldiversity.ummz.umich.edu/site/accounts/information/Mammalia.html

 

Wilson & Reeder’s Mammal Species of the World

http://www.vertebrates.si.edu/msw/mswcfapp/msw/index.cfm

 

American Society of Mammalogists: Mammalian Species

http://www.mammalsociety.org/publications/mammalian-species

 

Mammalian Species pdf Site

http://www.science.smith.edu/departments/Biology/VHAYSSEN/msi/

 

National Geographic Mammals

http://animals.nationalgeographic.com/animals/mammals/

Species Scientific Name:

Species Common Name:

Species Account:

Part B. Comparison of Metatherian and Eutherian Mammal Ecology

 

Complete the table using the websites listed in Part B. Match the eutherian (placental) mammal with a similar ecological equivalent metatherian.

 

Scientific Name of Metatherian   Mammal

Common Name

Ecological Description

Eutherian Mammal Match

 

Petaurus   breviceps

 

Vombatus ursinus

 

Myrmecobius fasciatus

 

Notoryctes typhlops

 

Dasycercus cristicauda

 

Sarcophilus harrisii

 

Thylacinus   cynocephalus

List of Eutherian Mammals to Match

Peromyscus polionotus

Talpa europaea 

Glaucomys volans

Taxidea taxus

Myrmecophaga tridactyla

Canis latrans

Marmota flaviventris

Part B Essay Question: What are potential hypotheses (explanations) regarding why there are ecological equivalents between many metatherians and eutherians? Discuss your hypothesis in terms of the processes that could lead to the current ecologies and distributions of metatherians and eutherians. 

 
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Pathophisiology Assignment

Instructions

· This week’s case study will introduce concepts related to the pulmonary system and shock states. Read the scenario and thoroughly complete the questions. Some of the answers will be short answers and may not require a lot of details. For example: what is the most common organism to cause a hospital acquired infection? The answer is pseudomonas aeruginosa. Answers to questions that relate to the pathogenesis of a disease must include specific details on the process. For example: How does hypoxia lead to cellular injury? Simply writing that a lack of blood flow, causes a lack of oxygen available to the cell and the cell cannot function without oxygen is not sufficient. This type of response is NOT reflective of an advanced understanding of the concept or graduate level work. This answer should discuss the cascade of events leading to the lack of oxygen and how it specifically impairs cellular function. All answers to these type of questions should address the effects at the cellular level, then the effects on the organ and then the body as a whole. Additionally describing the normal anatomical and/or physiologic processes underlying the pathogenesis will be necessary to thoroughly answer the question.

It is very likely that you will need to reference multiple sources to answer the questions thoroughly. Your text book will not necessarily have all the answers. Only professional sources may be used to complete the assignment. These include text books, primary and secondary journal articles from peer reviewed journals, government and university websites, and publications from professional societies who establish disease management guidelines and recommendations. Sources such as Wikipedia or other generic websites are not considered professional references and should not be used to complete the case studies.

 

 

· Reason for Consultation: Desaturation to 64% on room air 1 hour ago with associated shortness of breath.

History of Present Illness: Mrs. X is 73-year-old Caucasian female who was admitted to the general surgery service 3 days ago for a leaking j-tube which was surgically replaced 2 days ago. This morning at 07:30, the RN reported that the patient was sleeping and doing fine, then the CNA made rounds at 0900 and Mrs. X was found to be mildly dyspneic.  Vital signs were checked at that time and were; temperature 38.6, pulse 120, respirations 20, blood pressure 138/38.  O2 sat was 64% on room air.  The general surgeon was notified by the nursing staff of the hypoxia, an order for a chest x-ray and oxygen therapy were given to the RN. The O2 sat is maintaining at 91-92% on 4L NC. The patient was seen and examined at 10:10 a.m.  She reported that she has had mild dyspnea for 2 days that has progressively gotten worse. She does not use oxygen at home.  Her respiratory rate at the time of this visit was 20 and she feels short of breath. She has felt this way in the past when she had pneumonia.  She is currently undergoing radiation treatment for laryngeal cancer and her last treatment was 1 to 2 weeks ago.  She reported that she has 2 to 3 treatments left.  She denied any chest pain or previous history of CHF. Review of her vital signs showed that she had been having intermittent fevers since yesterday morning.  Of note, she was admitted to the hospital 3 weeks ago for an atrial fibrillation with RVR for which she was cardioverted and has not had any further problems.  The cardiologist at that time said that she did not need any anticoagulation unless she reverted back into A-fib.

Review of Systems:  Constitutional:  Negative for diaphoresis and chills.  Positive for fever and fatigue. HEENT:  Negative for hearing loss, ear pain, nose bleeds, and tinnitus.  Positive for throat pain secondary to her laryngeal cancer.   Eyes:  Negative for blurred vision, double vision, photophobia, discharge and redness.   Respiratory:  Positive for cough and shortness of breath. Negative for hemoptysis and wheezing.   Cardiovascular:  Negative for chest pain, palpitations, orthopnea, leg swelling and PND.   Gastrointestinal:  Negative for heartburn, nausea, vomiting, abdominal pain, diarrhea, constipation, blood in stool and melena.   Genitourinary:  Negative for dysuria, urgency, frequency, hematuria and flank pain.   Musculoskeletal:  Negative for myalgias, back pain and falls.  Skin:  Negative for itching and rash.   Neurological:  Negative for dizziness, tingling, tremors, sensory change and speech changes.   Endocrine/hematologic/allergies:  Negative for environmental allergies or polydipsia.  Does not bruise or bleed easily.   Psychiatric:  Negative for depression, hallucinations and memory loss.

Past Medical History:

1.    Diabetes mellitus that was diagnosed 12 years ago with neuropathy. This resolved after gastric bypass surgery, which she had approximately 3 years ago.

 

2.    Laryngeal cancer

 

3.    Hypertension

 

4.    Hypercholesterolemia

 

5.    Pneumonia

 

6.    Arthritis

 

7.    Hypothyroidism

 

8.    Atrial fibrillation

 

9.    Acute renal failure

 

10.Chronic kidney disease, stage IV – 4 months ago a renal biopsy was completed, which showed focal acute tubular necrosis and patchy tubular atrophy, moderate to severe interstitial fibrosis with patchy acute and chronic interstitial nephritis, normal cellular glomeruli with no white microscopic evidence of a primary glomerulopathy. Baseline creatinine is 1.9.

 

11.Peptic ulcer disease

 

12.Skin cancer

 

13.Anemia

 

14.Osteoporosis

 

Past Surgical History:

 

15.Gastric bypass 4 years ago

 

16.Closure of mesenteric defect.

 

17.Radical neck resection on 1 year ago.

 

Family History:

 

18.Mother had diabetes diagnosed at age 55 and high blood pressure. Deceased.

 

19.Father had heart disease diagnosed at age 60. Deceased.

 

20.She had a sister with diabetes, thyroid disease, CKD, on dialysis, with unknown etiology.

 

Social History: She denies any smoking or alcohol use.  She denies any drug use.

 

Medications:

 

21.Calcitriol 0.5 mcg PO every other day

 

22.Vitamin B12 2500 mcg sublingual every Monday and Thursday

 

23.Docusate sodium 100 mg PO BID

 

24.Fentanyl patch 100 mcg every 72 hours

 

25.Gabapentin 800 mg PO BID

 

26.Levothyroxine 50 mcg daily

 

27.Multivitamin 1 PO Daily

 

28.Oxybutynin 5 mg PO BID

 

29.Hydrocodone 5/325 1-2 tablets every 6 hours PRN pain

 

Allergies: She is allergic to Cipro, which causes Uticaria and hives, contrast dye, honey and bee venom, adhesive, and sulfas, which causes hives

 

Physical Examination:  Vital signs:  38.6, 120, 20, 138/38, 64% on room air.  She is maintaining O2 sat of 91 to 92 on 4 liters nasal cannula.   Constitutional:  She is somnolent.  Oriented to person and place.  Appears ill and mildly dyspneic. Head:  Normocephalic and atraumatic.  Nose:  Midline, right and left maxillary and frontal sinuses are nontender bilaterally.  Oropharynx:  Clear and moist. No uvula swelling or exudate noted.   Eyes:  Conjunctivae, EOM and lids are normal.  PERL. Right and left eyes are without drainage or nystagmus.  No scleral icterus. Neck:  Normal range of motion and phonation.  Neck is supple.  No JVD.  No tracheal deviation present.  No thyromegaly or thyroid nodules.  No cervical lymphadenopathy noted bilaterally. Cardiovascular:  rapid rate, S1 and S2 without murmur or gallop.  Brachial, radial, dorsalis pedis, and posterior tibial are 2+/4+ bilaterally. Chest: Respirations are regular and even with mild dyspnea. Lungs are coarse and with some rales in the posterior bases. Abdomen:  Soft.  Bowel sounds are active, nontender, no masses noted.  No hepatosplenomegaly noted.  No peritoneal signs.   Musculoskeletal:  Full range of motion of the bilateral shoulders, wrists, elbows. Neurologic:  Somnolent.  Cranial nerves II-XII are intact. Skin:  Warm and dry.   Psychiatric:  Mood and affect are normal.  Calm and cooperative.  Behavior, judgment is intact.

 

Laboratories and Diagnostics:  WBC 7.2, Neutrophil 63%  Creatinine 2.0, BUN 45, Na 144, Potassium 4.4  BNP 242 Lactate 1.0 All other labs are unremarkable Chest x-ray: Right lower lobe infiltrate  EKG: NSR, no ST or T wave changes

 

One hour after your saw Mrs. X, you get a call from the RN to report that her BP is now 75/40, pulse is 140, RR is 34 and dyspneic, temperature is 39.6 and she is minimally responsive.  Mrs. X is transferred to the MICU.

 

Upon re-evaluation of Mrs. X you note that she is obtunded, struggling to breath, using accessory muscles and O2sats are 85% on a Non-rebreather. She is intubated and placed on a ventilator. A central line is placed and confirmation obtained via CXR. A foley is placed and fluid resuscitation has begun.

 

WBC 20 Hgb 12 HCT 36 Platelets 98,000 Na 148 Chloride 110 Potassium 5.6 Glucose 190 Creatinine 3.0 BUN 68 Albumin 3.0 Anion Gap 21 Lactate 5.2 Procalcitonin 15, INR is 1.0, aPTT 23 ABG (prior to intubation) pH 7.28, PCO2 36, HCO3 17

 

EKG: Atrial Fibrillation with RVR at 156 CVP 3

 

Answer the following questions:

 

30.What are 4 plausible differential diagnoses for Mrs. X’s hypoxemia that are specific to her clinical scenario? How would each diagnosis cause a hypoxemia?

 

31.What is your final diagnosis for the hypoxemia?

 

32.What are the most likely organisms to cause the diagnoses you identified in question 2?

 

33.Upon initial evaluation what category of sepsis was Mrs. X?

 

34.Upon re-evaluation what category of sepsis was Mrs. X?

 

35.Why is a gram negative bacteremia more serious than one caused by a gram positive organism?

 

36.What is the most likely source of Mrs. X sepsis?

 

37.What is a CVP and what does a value of 3 indicate? Why is Mrs. X CVP 3?

 

38.What is a Procalcitonin and what is its purpose?

 
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