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What structures are removed in total distally as the glans penis and transmits M – Distant metastasis purchase urispas 200 mg fast delivery spasms hands. How do you manage inguinal lymph the penile and glandular part of the short of the glans (Fig order generic urispas on-line gastric spasms symptoms. Combination chemotherapy or mono- therapy involving methotrexate generic 200mg urispas fast delivery muscle relaxant anxiety, bleomy- cin and cisplatin is advised in advanced cases that is, M1 or N3 case stages where other forms of treatment is not possible or efective. Superficial dorsal vein runs super- ficial to fascia penis (Back’s fascia) and drains into the great saphenous 20. Mild deformity does not require any The 15-year-old boy presents with outward fexion and extension occurs. He gives history of right by transposition of the nerve from its hand due to tardy ulnar nerve palsy, lateral condylar fracture a few years back. On examination, the carrying angle is As this case shows mild deformity and seen increased on the right side. Outward deviation of right forearm A 4-year-old male child presents with from the arm. The carrying angle is the outward devi- the outstretched hand, followed by pain and ation of the extended and supinated swelling at elbow. The angle disappears on pronation or On examination, there is reduced carry- on full fexion of the forearm. What problem may appear with this tip of oberanon, medial epicondyle and lateral deformity? The posterior interosseous nerve sup- sion and forearm supinated – A-P plies all the extensors of the back of view (To compare and assess the exact forearm. Lateral view of the afected elbow to and supplies the dorsum of forearm assess the posterior tilt/shif. At the axilla in case of fracture and dis- require any treatment but an ugly elbow in a location of upper end of humerus. How do you diferentiate the radial nerve injury at radial or spiral groove or above? The patient can extend the interphalan- styloid and the line joining lateral and The above muscles are the prime mover geal joints as this is performed by the medial epicondlyes of humerus on the and they are associated by the following interossei, supplied by the ulnar nerve. Radial nerve is assessed by the following The axis of arm is drawn by joining mid- b. Test for extensors of the wrist – Patient long axis of the arm and that of the fore- with paralyzed wrist extensors, has arm in fully extended elbow and fully wrist drop. Malunited supracondylar fracture fnger at metacarpophalangeal joint (commonest cause) against resistance. Splintage of the wrist with cock up plexus lesion involving C8 and T1nerve splint. Cervical rib causing friction of the low- put through the full range of move- est trunk of the brachial plexus. Volkmann’s ischemic contracture with of the paralyzed muscles and pas- or without associated nerve damage. Fibrosis secondary to suppurative improvement with conservative treat- joints are fexed. The Tese are reconstuctive procedures interphalangeal joints is mainly due patient is asked to touch the pen held and performed when there is no hope to paralysis of the interossei which are above the palm with tip of his thumb. Even though the nerve recovers extensor digitorum playing little part in paralysis of abductor pollicis brevis. Injury to which nerves is responsible for with tip of thumb is due to paralysis of mission of impulses impossible. What are the features of ulnar nerve injury usually done within a few days of injury. Flexor carpi ulnaris to long extensor of dorsal segment of spinal cord through of adduction by the palmar interossei fngers. Here all the interossei (four dorsal and the adductor pollicis and the frst dor- Tis is a case of claw hand deformity of four palmar) and the third and fourth sal interosseous muscle. Leprosy involving both ulnar and pollicis and the frst dorsal interosseous pophalangeal joints are hyperextended median nerves. The above efect (fexion) becomes tubercular or rarely rheumatoid afec- more pronounced if the examiner tries tion) of the ulnar bursa which is the to pull the book out while the patient common synovial sheath surrounding tries to hold it. It gives rise to an hour glass swelling, fexor muscles of the forearm following the constriction being produced by the ischemia, as a result of injury to the bra- fexor retinaculum. Unlike the is proved by the presence of cross fuc- claw hand Volkmann’s sign (extension of tuation between the two. Normally in fully extended knee, when Treatment is either conservative or opera- above and one below the fexor retinacu- the medial malleoli of both legs are tive in the same line as in case of wrist lum, it is called a compound ganglion. Tis intercondylar distance measured A 26-year-old female patient presents with a ganglion in the chapter 66 miscellaneous indicates the amount of the varus painless globular swelling on the dorsum of afections of the sof tissues. Medial measurement, as the ligamentous laxity located on the dorsum of right wrist deviation of the foot so as to obliterate exaggerates the nonweight bearing varus joint. The other line is drawn joining the is required for the physiological varus capsule or tendon sheath. Pathological: Tis results from dam- Case summary age of epiphyseal cartilage or condyle of lower femur or upper tibia on the The 10-year-old male patient presents with medial side. Traumatic, malunited fracture in ing was small but it gradually increased to adults. Blount’s disease – Medial side of becomes more prominent with the knee tibial epiphysis remains underde- straight. Painless lump on the posteromedial otomy in performed when the child osteomalacia. Before 1 year of age, there is varus Supracondylar wedge osteotomy of femur deformity, called physiological genu is done. Spontaneous correction of this valgus cially if the magnitude of the deformity is occurs and the normal valgus angle of large. How will you diferentiate between A few fbers of semimembranosus must be tibiofemoral angle. The normal Q-angle is semimembranosus bursitis and Baker’s removed to ensure complete removal and 10 to 15°. What are the other cystic swellings behind See ‘Morrant Baker’s cyst in the chapter 66 Because in genu valgum the Q angle is the knee? A 20-year-old female patient presents with may be caused by hypoplasia, poliomy- a. The patella got dislocated laterally to the ral condyle, which checks the lateral 8. Genu valgum deformity as mentioned to avoid crossing the transverse crease at On examination, the patella is small, above. Scar formation may lead to contracture of angle) is increased and apprehension test is b. Tis is a condition where patella is dis- unless it is infamed a bursa cannot be f. It is similar to the Acute dislocation of patella results from a sudden contraction of the quadriceps table 85.

If the answers to these questions are no and there was a period of time between the injury and time symptoms appeared buy urispas 200 mg visa muscle relaxant examples, the Typical symptoms like high grade fever buy urispas 200mg line muscle relaxant and pain reliever, and warmth or hot suspicion of infection should increase buy online urispas muscle relaxant yellow pill v. Knees and the hips being most commonly afected (80%), other commonly afected joints include the ankles, wrists, Many immunocompromised children fail to have fever and elbows, and shoulders. There may be irritability The damage to the cartilage, growth plate, and bone due to on handling, e. The avascularity sets in within 24–48 to hold the leg fexed, abducted, and externally rotated. The biggest challenge is, therefore, In the fulminant form of septic arthritis, signs of bone and to control the infection and drain the joint before the damage joint involvement may occur at the time of, or some times after takes place. The babies are lethargic with or without fever, for confrmation of diagnosis, it is important that physician do not tolerate feeds, and may have abdominal distension and should have high index of suspicion and should start treatment jaundice. It shows changes of marrow edema and helps to diferentiate between transient It includes hemarthrosis, traumatic efusion, transient synovitis, infammatory arthritis, and septic arthritis by virtue synovitis, reactive arthritis, Lyme arthritis, juvenile rheumatoid of changes in marrow edema and synovial lining. Tuberculosis and syphilis must be considered in atypical case Blood culture must be routinely performed and sometimes contexts. However, the blood sample must be promptly analyzed after collection and any contamination must be prevented. Organism identifcation is extremely important for both confrmation of the diagnosis and guiding antimicrobial selection. Needle aspiration is likely to grow an organism in The most important diagnostic test is clinical acumen. Positive almost 50–60% of cases whereas blood cultures yield positive changes on X-ray suggest that the disease is already in its results in one-third to little more than half of specimens. Early diagnosis and treatment of septic arthritis is usually The role of plain X-ray flm in the diagnosis of early bone highly efective and usually achieves a clinically normal joint. It is because the most Consequently, it is essential that children with septic arthritis sought after change is osteopenia or bone lysis, which takes are urgently referred to treatment centers and it is essential that 7–10 days to develop. Actually, deep soft tissue swelling with the latter centers commence treatment as soon as possible. Unlike older children, radiographic changes rewarding, but also saves the child from a lifelong disability. The thin periosteum The treatment is a team approach which involves pedia- ruptures easily, and osteolytic lesions, soft tissue swelling, trician, pediatric orthopedic surgeon, pediatric intensivist and periosteal elevation are often seen within 7 days of (particularly in sick neonates), microbiologist, and radiologist. Erosion of the cortex, cavitation in the Treatment is directed towards obtaining a rapid cure as metaphysic or epiphysis can be seen as early as 3 days of the sequelae of septic arthritis can be quite devastating (Figs 1 onset of infection. Any suspicion of the infection in a neonate should initiate prompt investigation to identify the site and source of the infection. Prompt surgical drainage and thorough wash of the joint Bone scans are both sensitive and specifc. Open surgical drainage of the certain joints abnormal within 2–3 days of onset of symptoms. Involvement of pediatric orthopedic surgeon at the onset of treatment itself is important as he or she is the person who is going to manage the sequelae in future. Up to 50% of joint aspirates are sterile in septic arthritis, possibly because joint fuid is bacteriostatic or because the organisms are limited to the synovium. Since Gram-positive organisms are most frequently responsi- ble for the infection, an antibiotic that is efective against these organisms should be started empirically. Linezolid, vancomycin, teicoplanin, and tobramycin are reserved until there is a positive report to support their use. The current trend is towards mini-invasive surgeries narrowed based on results of susceptibility testing. Smaller joints can usually be efectively treated by regular aspiration and rarely need open surgical drainage. Drainage of pus by a pediatric orthopedic surgeon The initiation of treatment should be with intravenous anti- decompresses the joint with drainage of pus leading to biotics only. The antibiotics which were not able to reach the local site due to tight compartment like pressure are able to reach the infection site after drainage of pus. This ultimately results in rapid healing of bone and joint due to clearance of tissue-destroying fuid and also due to decrease in the tamponade efect on the delicate circulation The duration of parenteral antimicrobial therapy is a matter around the growth plate. While the fnal choice is decided by the prevalent Pus or fuid obtained during surgery must be sent for Gram pathogen in the bacteriological and culture report, the duration staining and appropriate culture which helps in selection of intravenous treatment varies from 7 days to 5 weeks. There are many studies which has proven efcacy of intensive care unit/pediatric intensive care unit room. It should minimum 3 weeks of intravenous antibiotics followed by 2–3 be done by a person well worse with anatomy of particular weeks of oral therapy (total 4–6 weeks). Few studies have indicated a shortened course of appropriate antibiotics for 3 weeks is as efcacious as 6 weeks of parenteral therapy. Close monitoring of the clinical, blood, and radiological Joint wash gives an additional advantage of reducing the parameters is required to ensure that the treatment is efective bacterial load and thereby better chances of healing. Antibiotics can usually be whenever a pediatric orthopedic surgeon is available he stopped by 6 weeks if the child has improved. Radiographs should be involved in the management and a thorough joint must be taken 6 monthly to see for any sequelae which develop wash should be done rather than simple aspiration. Based on the latest review of literature, use of intravenous antibiotics till child improves clinically and starts weight Plaster cast/splints help in immobilization of the joint and bearing, followed by oral antibiotics for 4–6 weeks seems to better healing particularly initial 1–2 weeks of treatment. The duration of antibiotics depends spica is needed in cases of septic hip dislocations to achieve the on the clinical recovery rather than a fxed time frame. Joint should not be immobilized for prolonged with, an intravenous route is preferred. Tachdjian’s Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children. Avascular necrosis of the capital femoral epiphysis as a complication of closed reduction of congenital dislocation of the hip. The role of ultrasound in the diagnosis and management of congenital dislocation and dysplasia of the hip. Pitfalls in the use of the Pavlik harness for treatment of congenital dysplasia, subluxation, and dislocation of the hip. Contribution to the knowledge of congenital dislocation of the hip joint: late results of closed reduction and arthrographic studies of recent cases. Congenital hip dislocation: techniques for primary open reduction ) including femoral shortening. Certain dynamic endocrine tests A thrombotic tendency should be investigated in require the sampling to follow a complex timetabled all patients who: protocol. Once the sample had been obtained it is vital that present with spontaneous thrombosis it is placed in the correct specimen tube, with or (especially if young) without the correct anticoagulant, e. Quantitative data can provide useful infor- mation on the function of organs such as the liver, kidneys and thyroid. Short term Long term Biochemical tests are not only valuable for diagno- Posture Age sis but are also useful in monitoring the response to Exercise Sex treatment. As with haematological investigations, it is important to be familiar with each laboratory’s Circadian rhythm Nationality/race normal ranges.

She is 132 cm tall buy urispas 200mg low cost spasms early pregnancy, weighs 44 kg order urispas 200 mg mastercard spasms eye, has swelling (c) Submetacentric around the neck buy urispas 200 mg with visa muscle relaxant reviews, increased carrying angle at the elbow (d) Acrocentric and poorly developed secondary sexual characteristics. Chromosomal abnormality in Mongolism is (a) Balanced translocation (a) Trisomy 21 (Karnataka 2005) (b) Chiasma (b) Trisomy 22 (c) Mosaicism (c) Trisomy 17 (d) Spermiogenesis (d) Trisomy 5 60. Trisomy 13 is identifed as (Karnataka 2005) has a testicular biopsy that shows sparse, completely (a) Edward’s syndrome hyalinized seminiferous tubules with a complete (b) Patau’s syndrome absence of germ cells and only rare Sertoli cells. Leydig (c) Down’s syndrome cells are present in large clumps between the hyalinized (d) Klinefelter’s syndrome tubules. The number of chromosomes in Klinefelter syndrome is: (a) 47 (b) 46 (c) 45 (d) 44 Read the pedigree. Chromosomes are visualized through light microscope (a) Autosomal recessive type with resolution of: (b) Autosomal dominant type (a) 5 Kb (b) 50 mb (c) X-linked dominant type (c) 5 (d) 500 Kb (d) X-linked recessive type 60. Kinky hair disease is a disorder where an affected child exact localisation of a genetic locus? A is hesitant about having children because her (c) Comparative genomic hybridization two sisters had sons who had died from kinky hair (d) Western blot disease. The mother has sickle cell disease; Father is normal; which of the following genetic disorders? Gene for major histocompatibility complex is located (e) Truncation on which chromosome? Ability of stem cells to cross barrier of differentiation to (d) Loss of normal allele in normal gene transform into a cell of another lineage expressing the 81. A one year old boy presented with hepatosplenomegaly (b) Granulosa cell tumor and delayed milestones. These techniques are used in forensic medicine to compare specimens from the suspect with 76. The gene that regulates normal morphogenesis during those of the forensic specimen. Which one of the (b) Patient B following individuals would be most at risk for (c) Patient C developing also hemophilia A? True statement about inheritance of an X linked recessive trait is: (a) 50% of boys of carrier mother are affected (b) 50% of girls of diseased father are carrier (c) Father transmits disease to the son (d) Mother transmits the disease to the daughter 87. A 22-year-old woman, Sheena presents with (b) Autosomal recessive disease progressive bilateral loss of central vision. You obtain (c) X-linked dominant disease a detailed family history from this patient and produce (d) Genomic imprinting the associated pedigree (dark circles or squares 87. Which of the following (a) Study of multiple genes transmission patterns is most consistent with this (b) Study of disease patient’s family history? He notes the following (b) 12 characteristics in the four placentas: (c) 4 Patient A: fused dichorionic diamnionic (d) 7 Patient B: dichorionic diamnionic 87. In cystic fbrosis the most frequent pulmonary pathogen Patient C: circumvallate placenta is Patient D: monochorionic diamnionic. About 10 - 20% of newborn with a1 – antitrypsin defciency develop neonatal hepatitis and cholestasis. A broad generalization is that the physiologic metabolic enzyme defciencies are all autosomal recessive whereas Structural defects are autosomal dominant. Huntington’s disease (Ref: Harrison 17th/401 Robbins 7th/1393, 8th/141,168, 9/e p141) 7. It is an autosomal recessiveQ genetic disorder that affects most critically the lungs, and also the pancreas, liver, and intestine. In children, its value is inversely related with body mass index and insulin values. Direct quote from Pediatric endocrinology ‘fasting ghrelin levels were obtained in children with Prader Willi syndrome and found to be elevated 3-4 times when compared to children who are obese’. It reduces energy intake and its reduced levels in the patients of Prader Willi syndrome may contribute to hyperphagia and obesity. If the mutation affects only cells destined to form the gonads, the gametes carry the mutation, but the somatic cells of the individual are completely normal. A phenotypically normal parent who has germ line mosaicism can transmit the disease-causing mutation to the offspring through the mutant gamete. Since the progenitor cells of the gametes carry the mutation, there is a defnite possibility that more than one child of such a parent would be affected. All code for thin flament–associated proteins, suggesting disturbed assembly or interplay of these structures as a pivotal mechanism. There is mutation in the Gs a subunit; individuals express the disease only when the mutation is inherited from the mother). Structural proteins that contribute to multimeric structures are vulnerable to dominant negative effects, e. It occurs in children and typically presents with an abdominal mass as well as with hypertension, hematuria, nausea and intestinal obstruction. Since it is derived from mesonephric mesoderm, it can include mesodermal derivatives such as bone, cartilage, and muscle. Multifactorial inheritance is similar to polygenic inheritance in that multiple alleles at different loci affect the outcome; the difference is that multifactorial inheritance includes environmental effects on the genes. Huntington disease is transmitted as an autosomal dominant trait with 100% penetrance, meaning that if a child inherits the abnormal gene, that child will inevitably develop Huntington disease. An earlier age of onset is associated with a larger number of trinucleotide repeats. Thus, patients who receive an abnormal gene from their fathers tend to develop the disease earlier in life. Anticipation is common in disorders associated with trinucleotide repeats as in Fragile X syndrome, myotonic dystrophy and Frie- dreich ataxia. The likelihood that the properties of a gene will be expressed is called penetrance. Dissecting aortic aneurysm (Ref: Robbins 8th/145, 9/e 145) The patient has Marfan syndrome, an autosomal dominant disorder caused by a defect in the gene on chromosome 15 encoding fbrillin, a 350 kD glycoprotein. Fibrillin is a major component of elastin associated microfbrils, which are common in large blood vessels and the suspensory ligaments of the lens. Abnormal fbrillin predisposes for cystic medial necrosis of the aorta, which may be complicated by aortic dissection. Other features of the syndrome are subluxated lens of the eye, mitral valve prolapse, and a shortened life span (often due to aortic rupture). Thus, maternal imprinting refers to transcriptional silencing of the maternal allele, whereas paternal imprinting implies that the paternal allele is inactivated. Imprinting occurs in the ovum or the sperm, before fertilization, and then is stably transmitted to all somatic cells through mitosis. The genomic imprinting is best illustrated by the following disorders: Prader-Willi syndrome and Angelman syndrome. It is also seen in other conditions like molar pregnancy and Beckwith-Wiedemann syndrome. There are three key mechanisms by which unstable repeats cause diseases: • Loss of function of the affected gene occurs in fragile X syndrome.

Malignancy (commonest cause)-Due The diagnosis of Mg-defciency cannot be renal failure cheap 200 mg urispas with amex muscle relaxant erectile dysfunction, Hemo and peritoneal dialy- to osteolytic metastasis buy cheap urispas 200 mg line muscle relaxant guidelines, e buy urispas 200 mg mastercard muscle relaxant in surgeries. Hyperparathyroidism postoperative period, magnesium defciency The total amount of calcium in the body is 3. The normal daily intake is 1 to 3 a patient confned to bed there is both Treatment gm. Blood - Whole blood should be used for risks of thrombophlebitis and sepsis are transfusion when there is signifcant bleed- Magnesium excess is seen in massive trauma also avoided. The compo- Clinical Features The rate of infusion is controlled by adjust- sition of various crystalloid solutions is given Tere is drowsiness at a plasma level of ing the number of drops per minute. Tis provides the taken place, with resultant loss of chloride this curare are other features. Death is due to car- number of drops of the fuid to be adminis- is a more suitable fuid than Ringer’s lactate. Crystalloids form a true Af the same time the glucose provides sis or hemodialysis is required. Colloid - Tese are regarded as plasma solution) - As can be seen in the table substitutes; colloids do not dissolve into below this fuid closely approximates the a true solution and cannot pass through composition of tissue fuid. Tey contain high molecu- whether on the surface or into the third lar weight molecules and remain in space Hartmann’s solution constitutes the intravascular compartment longer the appropriate replacement. Lactated Ringer’s – solutions 130 4 3 - - 110 28* Oral fuid replacement is suitable if the G. M/6 sodium lactate 167 - - - - - 167* • It gives the patient a sense of satiety and is 6. In the frst 24 hours afer noncardiac sur- Ringer’s lactate some of this chloride is • High Mol. Tere is a tendency for potas- bufer to neutralize the excess acid, pro- therefore stays in circulation longer. M/6 Sodium or Molar lactate - Used to tran 40) passes through the kidney and action of ‘Insulin’ by stress hormones and bufer excess acid produced in cases of has a relatively transient efect. Darrow’s solution - Contains sufcient • In patients whose hemostatic function estimation. Prediction - Prediction is according to surgical practice, it is a safe and con- dose limit of 1. A simple guidance venient method of supplying this cation, mended to avoid increased risk of bleeding for assessing third-space losses afer provided alkalosis is not present. Quantifcation-Quantifcation is done ring colloid and solutions are prepared from stable at room temperature and have long by measuring the fuids coming out of human plasma. Estimation-Estimation is the insen- • Tere is no clear evidence that the use of ing. Continuing abnormal losses over and above and intravenous) and all output records, • Half life 8 to 10 hours. Preexisting dehydration and electrolyte balance for each 24 hours, once insensible • Commonest plasma expander used in loss. The • Tey are glucose polymers of varying children the fuid replacement is accord- instruction ‘and repeat’ is never used in molecular weight producing an osmotic ing to weight using 4,2,1 rule as mentioned fluid management as it has led to disasters pressure similar to that of plasma. The success of fuid compartments, already mentioned and Laboratory tests replacement may be monitored by: the patients history and clinical examina- a. The hematocrit which is a guide to the • Fall in pulse rate tion, one can usually decide from where degree of hemoconcentration. From the knowledge tenance rate) plus a rapid replacement of fuid defcit, so replacement is carried out on about the movement of fuid between any pre-existing defcit. Plasma Bufer - Bicarbonate/carbonic carbonic acid which is a weak acid and is very Blood Hydrogen Ion acid system. Since, the reaction is bidirectional and the of hydrogen ion output against hydrogen ion The bufer systems of the body fuids can rate of forward or backward reaction is deter­ intake and production due to various meta­ act within a fraction of a second to prevent mined by the product of ionic concentra­ bolic activities. On tions, this system serves as a good bufering The diet normally contains H+ ion mostly the other hand it takes 1 to 12 minutes for the mechanism. Finally, the kidneys, increases, Hence backward reaction is 50 to 80 mmol/day much the same as sodium although providing the most powerful of all enhanced, resulting in utilization of more and potassium. Section 1  Physiological Basis of Surgery Other buffers in blood as mentioned above. The carbonic ↓ response system that allows carbon dioxide to acid is formed in the presence of carbonic Weak acid making the pH change relatively slight. In efect, respiratory regulation of and carbon dioxide in the presence of car­ However, the concentration of phosphate acid base balance is a physiological type of bufer bonic anhydrase in the tubular membrane. Terefore, its total piratory system is one to two times as great as plasma or combines with water in the renal bufering power is far less than that of the that of all the chemical bufers combined. Terefore, even though the phosphate Ammonia Buffer System so moves freely across the tubular mem­ bufer is very weak in the blood, it is a much The ammonia buffer system is composed brane), then reacts with hydrogen ions to more powerful bufer in the tubular fuid. It will be ally synthesize ammonia and this diffuses excreted into the urine in combination seen that for each hydrogen ion bound by the into the tubular urine. Tis contributes to the correction of aci­ percent from other amino acids or amines. It Metabolic acidosis is a condition in which tive decrease in plasma bicarbonate con­ tells about the metabolic status of the patient. Anion Gap In metabolic alkalosis there is quantita­ Henderson – Hasselbalch The anion gap is a calculated estimation of tive increase in plasma bicarbonate concen­ Equation the undetermined or unmeasured anions in tration and when not complicated by other The bicarbonate ­ carbonic acid is the major the blood. Metabolic acidosis compensated ↓ ↓ ↓ acute renal failure ­ phosphates and sulfates 3. Respiratory alkalosis uncompensated ↑↑ ↓↓ N due and salicylates (salicylic acid), par­ 8. In volume and chloride depletion, mainte­ Due to diarrhea, fstulae, ureterosig­ been lost or the degree of acidosis is nance of metabolic alkalosis is most ofen moidostomy. Tere is associated Na+ and • In the presence of renal disease or mark­ sorption by the kidney. Clinical features ments of Na+ and H O should be given in Alkalosis is sustained until volume 2 • Related to the underlying disorder. Tis diminishes tubular avid­ is stimulation of respiration by the raised solution. Excess bicarbonate can be When blood [H+] exceeds 70 nmol/liter Na+ and H O depletion, infusion of NaCl excreted with sodium. Depression of the respiratory center: plasma bicarbonate is initiated by urinary is due to volume contraction and diu­ viz. Stimulation of tubular acid secre­ mmol/liter) in cases of hyperadrenal­ infarction.

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