1/ #UncleBob presented this patient at @midwesthospmed yesterday - here is my analysis:
41yo woman, s/p bariatric surgery (100# loss), “feeling drunk”
Chronic diarrhea - short gut syndrome
Mild gait instability
140/3.8/116/9/5/0.8/82
pH 7.2/pCO2 13/pO2 138/bicarb 5
#5goodminutes
2/
First, let's determine the acid-base disorders. The patient has an albumin of 2. Anion gap is 15, but should be around 6. Therefore a mildly increased anion gap acidosis.
Next, we have a delta gap of 9 (15-6). Therefore the patient also has a normal gap acidosis.
3/
Finally, let's do Winter's equation. Calculated bicarb from the ABG was 5. Therefore expected pCO2 = 1.5(bicarb)+8(+or-)2
7.5+8 = 15.5 - close enough to 13.
So we have two causes of metabolic acidosis - anion gap and normal gap.
4/
Final diagnosis - patient had a markedly elevated d-lactic acid - the patient had had this occur twice before without the diagnosis being made. My colleague Dr. Chad Burski (now a gastroenterologist) made this diagnosis as a resident.
5/
When he presented the patient at morning report, the data showed the double metabolic acidosis. We assumed that the normal gap acidosis occurred with the chronic diarrhea from short gut.
My favorite review of d-lactic acidosis - journals.lww.com/md-journal/Cit…
6/
We published this patient case - Formerly Obese, Now Thin and Confused: The Utility of Mnemonics in the Approach to Altered Mental Status amjmedsci.org/article/S0002-…
@uabimres @kidney_boy @CPSolvers @andrewolsonmd @thecurbsiders
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