A 48 year old diabetic  with a history of alcohol abuse is admitted with abdominal pain and the following results:

Parameter

Value

Normal range

pH

6.87

7.35-7.45

PaCO2

8 mmHg (1.1 kPa)

35-45 mmHg (4.7-6.0 kPa)

PaO2

149 mmHg (20 kPa)

75-98 mmHg (10.0-13.0 kPa)

Actual bicarbonate

1.4 mmol/l

22-26 mmol/l

Lactate

16 mmol/l

<2 mmol/l

Sodium

142 mmol/l

134-145 mmol/l

Potassium

4.7 mmol/l

3.5-5.1 mmol/l

Urea

14 mmol/l

3.4-8.9 mmol/l

Creatinine

170 micromol/L

(60-110 micromol/L)

AST

60

(<40 U/L)

ALT

70

(<40U/L)

LDH

1400

50-150 U/L

Total bilirubin

20

4-25 micromol/L)

Glucose

6.5 mmol/l

Serum osmolality

314

275-295 mOsm/kg

a. Give the three most likely diagnoses
b. List two additional investigations that you would perform based on the above information

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College Answer

3.3
a) Diagnoses: 3 ischaemic bowel, 2 metformin induced lactic acidosis, thiamine deficiency, pancreatitis.

b) Two of the following investigations: Diagnostic laparoscopy or laparotomy, CT abdomen, red cell transketolase, lipase

Discussion

This question is identical to Question 15.3 from the second paper of 2009.