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 (4.7-6.0 kPa) |
|
PaO2 |
149 mmHg (20 kPa) |
75 - 98 (10.0-13.0 kPa) |
|
Actual bicarbonate* |
1.4 mmol/l |
22 - 26 |
|
Lactate* |
16 mmol/l |
<2 |
|
Sodium |
142 mmol/l |
134 -145 |
|
Potassium |
4.7 mmol/l |
3.5 - 5.1 |
|
Chloride* |
107 mmol/L |
95 - 105 |
|
Urea* |
14 mmol/l |
3.4 - 8.9 |
|
Creatinine* |
170 micromol/L |
60 - 110 |
|
AST* |
60 |
<40 U/L |
|
ALT* |
70 |
<40 U/L |
|
LDH* |
1400 |
50 - 150 U/L |
|
Total bilirubin |
20 micromol/L |
4 - 25 |
|
Glucose* |
6.5 mmol/l |
4 - 6 |
|
Serum osmolality* |
314 mOsm/kg |
275 - 295 |
a) Give the three most likely diagnoses.
b) List two additional investigations that you would perform based on the above information.
College Answer
a) Give the three most likely diagnoses.
Diagnoses: 3 ischaemic bowel, 2 metformin induced lactic acidosis, thiamine deficiency, pancreatitis
b) List two additional investigations that you would perform based on the above information.
Two of the following investigations: Diagnostic laparoscopy or laparotomy, CT
abdomen, red cell transketolase, lipase
Discussion
This question is identical to Question 21.2 from the second paper of 2009, and Question 26.4 from the second paper of 2013 . The answer to the latter contains a comprehensive discussion.