Chairman Rounds

Medicine I
Jesse Lester, Kannan Samy, Matt
Skomorowski, Dan Verrill
 Patient Presentation
54 year old African American female
presents to the ED with vomiting and
depression on 12/3
Vitals: BP 103/62, HR 119, RR 20, T 98F
Her symptoms began four days ago.
What else would you like to ask her?
 History of Present Illness
Patient reports a recent increase in her
alcohol intake and depressed mood.
Her sister recently died and the patient is
having difficulty coping with the loss.
What things would you suspect knowing
this information?
 Past Medical History
Non-insulin dependent diabetes mellitus
Alcoholic Hepatitis
Hypertension
s/p C-section
Medications:
ASA 81mg
Nexium 40 mg
Januvia 100mg
Diovan 80 mg
Magnesium Oxide 400mg BID
 Social History
Current smoker
Patient reports occasional alcohol
consumption. Daily alcohol use is approx.
1/4c gin.
Not employed, single and lives alone
 Review of Systems
Patient denies fever, diarrhea, abdominal
pain, ill contacts, change in bowel
movements, problems with urination.
Patient does report orthostatic
weakness/dizziness, and feels she cannot
eat and continues to vomit because of
emotional upset. Whatever she puts in
comes back up.
 Physical Exam
Gen: No acute distress, appears moderately ill,
alert and oriented
ENT: Neck is supple, no adenopathy, sclerae
are non icteric
Pulmonary: Unlabored respiration, good breath
sounds bilaterally
CV: RRR, no murmors, normal S1S2
Abd: soft, nontender, no organomegaly, normal
bowel sounds
Psych: Flat affect, poor eye contact
 Labs
CBC: WBC 2.4, HGB 11.1, HCT 31.9,
MCV 116.5, Plt 81
BMP: Glucose 74, BUN 14, Creatinine
1.20, Na 138, K 3.8, Cl 97, HCO3 8, Ca
7.3
ABG: 7.12/21/98/7/95%
Blood Osmolality 350
Ethanol: 0.166
Lactate: 4.4
 Labs, continued
Urinalysis: Nitrite negative, leukocyte
esterase trace, glucose negative
Utox Panel: negative
Differential Diagnosis?
 Step 1: Determine the primary insult

1) pH acidosis or alkalosis? Our patient: pH=7.12

- normal 7.4
pCO2=21
pO2=98
2) Metabolic or respiratory?
- Normal bicarbonate=24 Bicarbonate=7
>24=alkalosis O2 sat=95%
<24=acidosis

-Normal pCO2=40
>40 acidosis
<40 alkalosis
 Step 2: Compensation

1) Respiratory compensation for primary metabolic disorder

Acidosis:

Winters formula: 1.5 * HCO3 + 8 +/-2 = PCO2 (if compensated)

Another method: 1.2 *HCO3 +/-2 = PCO2 (if compensated)

Alkalosis: 0.6 *HCO3 +/-2 = PCO2 (if compensated)

Our patient:
1.5 * (7) + 8 +/- 2 = 16.5 <> 20.5

Patients pCO2 = 21, therefore the metabolic acidosis is compensated

 Step 2: Compensation

2) Metabolic compensation for primary respiratory disorder

Acidosis:

Acute: 0.1 * PCO2 +/- 2= HCO3

Chronic: 0.3 * PCO2 +/- 2= HCO3

Alkalosis:

Acute: 0.2 * PCO2 +/- 2= HCO3

Chronic: 0.4 * PCO2 +/- 2= HCO3

 Step 3: Anion Gap

1) Only applicable with metabolic acidosis

2) Will be elevated if there is another serum anion creating the acid-base

disturbance

Normal AG = Na - (Cl+HCO3) = 12 +/- 2

(or 6-12 depending on who you are asking)

Our patient = 138 (97+7) = 138 104 = 34

Therefore the patient has an elevated anion gap metabolic acidosis
 Step 4: / Gap

1) Only applicable with an anion gap metabolic acidosis

2) Will be abnormal if a mixed disorder is present

In a sole AG metabolic acidosis AG = HCO3 should hold true

Our patient:
AG = 34 12 = 22
the predicted HCO3 = 24 22 (AG) = 2
Patients bicarb = 7, there is a base excess of 5
Therefore there is a coexisting metabolic alkalosis, possibly due to
her nausea/vomiting or contraction alkalosis.
 Step 5: Osmolal Gap

1) Calculated when there is an anion gap metabolic acidosis

2) Will be abnormal if there is another electrolyte or ion present in serum

OG = 2 * Na + glucose/18 + BUN/2.8
The calculated number should be compared to the patients serum osmolality
- if the gap is greater than 10 it is abnormal

Our patient = 138 + 74/18 + 14/2.8 = 286.6

Serum osmolality (lab value) = 350
Therefore the patient has an elevated osmolal gap
 Step 6: Urine Anion Gap

1) Can be used to differentiate between gastrointestinal or renal cause of

metabolic acidosis

2) Will be abnormal if there is another electrolyte or ion present in serum

UAG = (Na + K) Cl
The normal urinary anion gap is near zero or positive.
A positive value indicates a renal insult, such that there is a problem with
acidification of urine.
A negative value indicates a gastrointestinal insult, such as the loss of
bicarbonate in diarrhea.
 Differential Diagnosis
Differential for anion gap metabolic acidosis:
Methanol
Uremia
DKA
Paraldehyde
Infection, Iron, INH
Lactic Acidosis
Ethylene Glycol
Salicylates, Sepsis
 Differential Diagnosis
Differential Diagnosis for elevated osmolar
gap:
Methanol
Ethylene Glycol
Ethanol
Isopropyl Alcohol

What tests would you order to differentiate

these conditions?
Calcium oxalate crystals
 Differential Diagnosis
Differential diagnosis for non-anion gap
metabolic acidosis:
Diarrhea
Uremia
RTA
Addisons Disease
Acetazolamide
 Differential Diagnosis
Differential diagnosis for metabolic
alkalosis:
Vomiting
NG suction
Contraction alkalosis
 Differential Diagnosis
Differential diagnosis for respiratory
acidosis:
Hypoventilation or other conditions that
interfere with respiratory drive
Obstructive and restrictive lung disorders
 Differential Diagnosis
Differential diagnosis for respiratory
alkalosis:
Hypoxia leading to hyperventilation
Primary hyperventilation