, 10 tweets, 3 min read Read on Twitter
Interesting basic metabolic. Don’t you think?
The hyponatremia is due to the hyperglycemia. #ProblemSolved
Don’t be deceived by the normal bicarbonate, there is an anion gap big enough to drive a truck.
The bicarbonate before reveals a massive pre-existing metabolic alkalosis. The anion gap metabolic acidosis completely covers it up leaving a Norma HCO3 of 24.
If you prefer a Gap-Gap analysis (or delta-gap), it likewise shows a massive pre-existing metabolic alkalosis.
Anyone think it will get simpler if I show you the VBG?
And yup, things gets murkier...respiratory alkalosis.
If you look at the compensation, if the respiratory alkalosis is chronic, then it is well compensated with an appropriate HCO3. If the respiratory alkalosis is acute then there is an additional metabolic acidosis (which we know about because of the anion gap)
In addition to some uremia, the anion gap seemed to be entirely due to DKA. We do not have serum ketones available in our hospital lab, so a urinalysis is the best we got. Sorry.
Jason Kidd, the nephrologist not the basketball player, nailed the diagnosis here:

No satisfactory explanation for the respiratory alkalosis beyond abdominal pain and mild liver disease.
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