Respiratory Physiology Case

A 39-year old male diabetic patient was rushed to the emergency department due to
dyspnea for 3 hours. Manifestations started as colds and cough for 2 days, self-medicated with
Acetylcysteine and Brompheniramine affording no relief. At the time he developed respiratory
symptoms he also had fever at 38.5oC. His housemates recommended that he be brought to the
hospital but he declined. A day prior to admission, he complains of chest pain when coughing
especially when he cannot expectorate his phlegm. He then increased his fluid intake for the day.
Several hours prior to admission he observes that his cough is worsening and experiences
shortness of breath. He was seen gasping for breath and is stuporous hence he was rushed to the
hospital.

GS: Patient is pale looking, stuporous, stretcher-borne, pale – looking with a vital signs of BP at
80/50 mmHg; CR at 105 bpm; RR at 23, labored. To at 38.9oC; O2 Sat at 78%

Pertinent PE:
Chest and Lungs: Asymmetric chest expansion with more lag on the left; (+) suprasternal and
subcostal retractions. Tactile fremitus is increased on both lung fields but more on the left; Dull
on both lung fields on percussion. (+) wheezing, (+) rhonchi; (+) crackles.
Heart: Dynamic precordium, ( - ) heaves nor thrills, PMI is on the 5th ICS LMCL, ( - ) murmurs.
Abdomen: Unremarkable except for tender abdomen.

Past Medical History: Diabetic for 12 years with Metformin and Gliclazide as medications but
poorly maintained. Mother died after suffering from a hemorrhagic stroke. Father is hypertensive
and diabetic.

Personal and Social History: Patient is non – smoker, occasional alcoholic beverage drinker but
has increased frequency in this time of pandemic. He believes that COVID is an invention of the
medical professionals to gain more income and does not wear face shield nor face mask when
meeting with friends. He recently met with friends one of which died from COVID a week ago.
He is one of the people who campaigns against vaccination because he believes that people
vaccinated may become “zombies” in the future.
 Laboratory Exercise No. ____
Urine Dilution and Concentration Tests

The urinary system is primarily concerned with formation of urine. Water -

soluble waste products are found in the urine. It also contains excess electrolytes and
substances of the body. Regulation of urine formation is important because it
contributes in the body’s fluid volume, electrolyte composition and to some extent
acid- base balance in maintenance of homeostasis.

In this experiment, we would like to demonstrate how the kidney regulates

the concentration of urine as one ingests various concentrations of fluid.

Objectives:
1. Discuss the functional anatomy of the urinary system.
2. Discuss the formation of urine.
3. Explain the effect of countercurrent mechanisms in urine concentration.
4. Discuss factors that affects urine formation
5. Given a clinical condition, a medical student will be able to evaluate the
renal function of a patient.

Materials:
Distilled water
0.9% NaCl / Normal Saline Solution (NSS)
Urinometer / Refractometer
Beaker

Procedure:

A. Dilution Test (No precautions are taken before the test)

1. Subject empties his/ her urinary bladder and discards the urine.
2. After emptying the bladder, subject drinks Distilled Water at 15 ml / kg
body weight.
3. Subject urinates every 30 minutes for the next 3 hours.
4. The volume of urine every 30 minutes and the specific gravity are recorded.
5. Show the results in a graph.
 Renal Case

A 56 – year old woman consulted your clinic because of persistent bipedal edema for 7 days. This
was accompanied by difficulty of breathing especially when she climbs 3 stair cases. She cannot
sleep well because of nocturia. She had similar experience a month prior to consult was
hospitalized and was relieved of the symptoms. She is known diabetic for 12 years taking
medications irregularly because she believes that her blood sugar might drop very low when she
continues her medications. She is a smoker, 20 pack – years and an occasional alcoholic beverage
drinker.

In your clinic, patient is conscious, coherent and oriented to time, place and person. Vital signs
were as follows: BP – 160 / 110 mmHg; HR – 98 bpm; RR – 23 bpm; To – 37.8oC; O2 Sat – 96%.

Physical Examination
Head and Neck: Unremarkable with the jugular venous pressure is at 12 cms H2O
Chest and Lungs: ( - ) Lagging of chest, (+) bibasal crackles on both lung fields, ( - ) wheezes
Heart: Dynamic precordium, PMI at 6th ICS left anterior axillary line, (-) heaves, (-) thrills, ( - )
murmurs
Abdomen: Slightly globular, bowel sounds at 15 per minute, tympanitic, ( - ) fluid wave, ( - )
kidney punch test
Extremities: unequal skin tone, (+2) pitting bipedal edema

Bloo d Chemistry CBC Urinalysis

Hgb – 11.6 g/dL Yellow

Blood glucose 200mg/dL
Hct – 34.3% SG 1.035
HbA1C 8.3% RBC – 4.4 M / mm3 CHON +3
BUN 52mg/dL WBC– 5,000 / mm3 Glucose - +2
Neutro – 65% RBC +
Creatinine - 1.2mg/dL
Lympho – 30% WBC ++
Uric acid 5.3mg/dL
Mono – 3% Nitrite ( - )
Cholesterol 313mg/dL Eos – 1%

Triglycerides 144mg/dL

Albumin 1.9g/dL
 Case Conference # _____
Renal Physiology

Case: An 18 year old man presents with a 2-day history of reddish-brown scanty
urine. He was diagnosed with streptococcal pharyngitis 2 weeks prior to consult and
was given Amoxicillin. Physical examination showed bilateral edema – (2+). Blood
pressure was 160 / 100 mmHg. Other vital signs were unremarkable. Urine dipstick
detects 3+ blood, 1+ protein and 2+ for glucose. Urine sediment reveals 12 RBCs /
hpf, RBC casts, and dysmorphic RBCs. FBS – 230 mg/dL

Diagnosis: Nephritic Syndrome

Questions:
1. Discuss the blood supply of the kidney from renal artery.

2. Discuss the presence of glucose in the urine of the patient.

3. Discuss the role of immune system in the development of nephritic syndrome.

4. Explain the occurrence of hypertension in this patient.

5. Discuss the filtration barrier.

6. What is the physiologic basis in the development of edema of the patient in the
case?
Total protein 4.4g/dL

Serum K+ 6 mEqs/L

GUIDE QUESTIONS:
1. Discuss the functional anatomy of the urinary system.

2. Discuss the process of excretion / urine formation.

3. Differentiate transport maxima and gradient – time limited transports in proximal tubule.

4. Correlate the importance of transport maxima and renal threshold.

5. Correlate the manifestations of the patient with the renal physiology.

6. Correlate the laboratory findings with the renal handling of electrolytes and water.
B. Concentration Test (No precaution are necessary before a test)
1. Subject empties his/ her urinary bladder and discards the urine.
2. After emptying the bladder, subject drinks NSS at 15 ml / kg body weight.
3. Subject urinates every 30 minutes for the next 3 hours.
4. The volume of urine every 30 minutes and the specific gravity are recorded.
5. Show the results in a graph.

Note: Collection may take a while. Be honest in the collection of the specimen.

30 60 90 120 150 180

A. Dilution Test
mins. mins. mins. mins. mins. mins.
Urine Volume
Urine Specific Gravity

30 60 90 120 150 180

B. Concentration Test
mins. mins. mins. mins. mins. mins.
Urine Volume
Urine Specific Gravity

Questions:
1. Discuss how urine is formed.

2. Discuss the concept of renal clearance. What are substances that maybe used to
measure renal clearance? Explain.
3. Differentiate Gradient-Time Limited transport from Transport Maxima. Give
examples of each.

4. Discuss the transport of electrolytes in the renal tubules especially sodium,

potassium, chloride, bicarbonate and calcium.
5. What are hormones that influence urine formation? Explain their mechanism of
action/s.

6. Site some clinical conditions that affect urine formation. Explain.

7. Explain the results in the experiment.

8. Discuss the fluid shifts in the body in a patient with Syndrome of Inappropriate
ADH secretion.
Guide Questions:
1. Trace the airflow from conducting system to the respiratory portion of the respiratory tract
thru an ARROW DIAGRAM (Label appropriately).

2. Correlate the concept of mechanics of breathing with the patient’s respiration.

3. Correlate the normal structure of blood air barrier (respiratory membrane) with the respiratory
lesion secondary to COVID – 19. ILLUSTRATE

4. Discuss the factors that can affect diffusion of gases. Correlate with the lesion above.
5. Based on your knowledge in static and dynamic lung volumes, predict the results on the
affected volumes and capacities (Just indicate if decreased, increased or unaffected for both static
and dynamic parameters). Explain.

6. Correlate the following regulation of respiration with the patients respiration.

A. Nervous

B. Chemoreceptors (Central versus Peripheral)

C. Mechanoreceptors