Skip to Main Content

++

INTRODUCTION

++

CASE LEARNING OBJECTIVES

  • Systematically interpret laboratory values and correctly identify metabolic acidosis

  • Apply routine formulas to clinical data to assess the adequacy of respiratory compensation for metabolic acidosis

  • Integrate the concepts of the anion gap and the excess anion gap to better understand a patient's current acid–base status

  • Formulate a differential diagnosis for a high-anion-gap metabolic acidosis

  • Anticipate the effects of metabolic acidosis on serum electrolyte concentrations

  • Incorporate basic concepts of volume resuscitation and appreciate the implications of inadequate volume status in perpetuating an anion gap metabolic acidosis

++

PATIENT PRESENTATION

++

Chief Complaint

++

N/V, HA, and decreased appetite

++

History of Present Illness

++

Rachel Willis is a 43-year-old African American female who presented to the emergency department (ED) with the complaints above. On her initial assessment by the ED staff, she was promptly transferred to the ICU for management by the critical care team. The patient reports that she was doing well until 2 days ago, at which time she ran out of her insulin. Since then she has felt dizzy and fatigued. She had two episodes of N/V, and progressive SOB today. The patient is a poor historian who frequently gives conflicting information to different care providers.

++

Past Medical History

++

Type 1 DM for 12 years

++

History of cesarean section

++

Family History

++

Father deceased from complications of DM and HTN. Mother is alive but has SLE. Her brother and one of her sisters have "emphysema" and another sister takes medications for HTN. The only other family history she knows is that her grandmother took insulin for diabetes and her grandfather died of metastatic colon cancer.

++

Social History

++

She works part time in a local pawn shop and has been intermittently homeless. Because she does not have health care insurance, she does not have a primary care physician and frequently visits the ED for hyperglycemia. The ED records suggest that she does not check her blood sugar at home and that she is not adherent with her insulin therapy.

++

Tobacco/Alcohol/Substance Use

++

She has smoked one ppd of cigarettes for 25 years. She drinks alcohol regularly on the weekends (∼12 beers a day) and admits to marijuana use when she is "partying hard."

++

Allergies/Intolerances/Adverse Drug Events

++

Unknown reaction to codeine

++

Medications (Outpatient)

++

Insulin NPH 36 units SC am and 6 units pm

++

Insulin regular 15 units SC am and 6 units pm

++

Multivitamin PO daily

++

Loratadine 10 mg PO daily

++

Omeprazole OTC 10 mg PO as needed

++

Review of Systems

++

Decreased appetite for ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.