The patient is a 50 year old woman who admits to “serious drinking” of at least 1 pint of vodka a day for at least 2 weeks. She is admitted looking ill and slightly confused. Her initial labs:
| Electrolyte panel | |||||
|---|---|---|---|---|---|
| Na | 137 | Cl | 89 | BUN | 8 |
| K | 4.3 | HCO3 | 7 | creat | 0.7 |
| Blood Sugar | 55 |
Other labs included an albumin of 4.9, ALT 109, AST 169, alk phos 134, Total bili 1.5
Question #1
Just from the labs, please suggest her likely diagnoses and suggest treatment. I am hiding some history for teaching purposes.
{ 6 comments… read them below or add one }
Its alcoholic keoacidosis
you kept back that she has been throwing up
you also kept back that she smelled of ketones
treatment is hydration with Dextrose and 0.9 NACL
Comment #2
you also kept back that she smelled of ketones
treatment is hydration with Dextrose and 0.9 NACL
1) Acidemia
2) Metabolic acidosis(HCO3 <24)
3) Anion gap is 137-96 = 41
4) combined? delta-delta is (41-10)/(24-7) = 31/17 = 1.8 so most likely a pure AGMA.
5) is there an OSMOLAR GAP?!?
the differential diagnosis of an AGMA is MUDPILECATS… although Dr. Topf of Precious Bodily Fluids prefers GOLDMARK.
http://www.pbfluids.com/2009/02/student-lecture-on-acid-base.html
Given the history, it is likely that alcohol consumption plays a role.
The osmolar gap, along with the levels of EtOH, ethylene glycol and methanol will help us determine the appropriate course of action. If it is an advanced case of ethylene glycol poisoning, a UA may show crystals. Green fluorescence of urine with UV light will also show antifreeze consumption.
D5 and thiamine should be administered along with the appropriate antidote::
methanol poisoning: ethanol
ethylene glycol poisoning: fomepizole
Consider gastric lavage, activated charcoal and dialysis prn.
She has a delta gap of 29. Which means her measured bicarb should by -5. Since its +7, she has a combined anion gap metabolic acidosis and a presumed alkalosis. Without blood gas it gets tricky. Should could possibly have a respiratory alkalosis as a compensation to the floating anion gap. She could also have a metabolic acidosis, say from vomiting.
Review MUDPILES. Consider the toxic alcohols. Check the urine for crystals. Certainly she could be a type one diabetic as well and perhaps overdosed on her insulin. Ketones, acetone.
Albumin of 4.9 in an alcohol with coagulatopathy would be highly unusual, unless profound dehydration. Which could account for the alkalosis. Although the BUN and Cr may be low because of malnutrition.
I would start D5NS infusion and, would even consider antedote for toxic alcohol while you wait for the levels to come back.
should say metabolic alkalosis from vomiting, not acidosis
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