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
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.
History of cesarean section
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.
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.
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
Insulin NPH 36 units SC am and 6 units pm
Insulin regular 15 units SC am and 6 units pm
Loratadine 10 mg PO daily
Omeprazole OTC 10 mg PO as needed
Decreased appetite for ...