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.

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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.