Teaching cases
TheOne - 06-29-06 14:20

A 48~year-old homeless man is brought to the emergency room after being 7
found wandering the streets near the hospital mumbling to himself, apparently intoxicated. He is well known to the emergency room staff and has had multiple admissions for alcohol-related complications including alcoholic hepatitis, multiple episodes of minor trauma while intoxicated, and an episode of aspiration pneumonia six months earlier. He spends his time living either on the street or occasionally in homeless shelters and had failed multiple attempts at rehabilitation for his alcohol abuse. Upon ques-; tioning him in the emergency room, he is oriented to his name and place but is confused regarding the month and year. He actually recognizes you from his prior visits to the emergency room. He appears extremely disheveled and pleads with you to bring him a hospital meal since 1 haven’t eaten in four days, doc.” On examination, he has extremely poor hygiene, has a blood pressure of 122/68 and a heart rate of 104. His blood pressure falls to 100/60 when standing and his heart rate rises to
116. His respiratory rate is 26. His temperature is 98.9. He is anicteric. His mucous membranes are dry. His lungs are clear and he has a regular heart rhythm. His liver is 14cm by percussion in the mid clavicular line. There is no ascites and his spleen tip is not palpable. There is no peripher al edema and there are multiple healed abrasions and bruises on his lower extremities. A chest x-ray is done and reveals no infiltrates or cardiomegaly. A calcified node is seen at the right apex. An electrocardiogram reveals sinus tachycardia at 105 and no ischemic changes. Laboratory results reveal a white blood cell count of 8,900, hemoglobin of 14g and a hematocrit of 42%. His sodium is 130, potassium is 5.2, bicarbonate is 12, chloride is 96, BUN is 26, creatinine is 1.1 and his glucose is 64.



Appropriate management of this patient would include each of the following EXCEPT

A. Placing an intravenous catheter and starting an infusion of normal saline with 5% dextrose at 150cc an hour
B. Administering an injection of thiamine.
C. Initiating an intravenous infusion of sodium bicarbonate.
D. Obtaining an arterial blood gas.
F. Measuring serum osmolality.

Appropriate measures are taken. Additional blood tests reveal that his pH is 7.26, pCO2 is 26 and his P02 is 94. Measured serum osmolality is 364. Which of the following is true regarding his acid-base status?

A. He has a high anion gap metabolic alkalosis.
B. He has a normal anion gap metabolic acidosis.
C. He has a high anion gap respiratory acidosis.
D. He has a high anion gap metabolic acidosis in addition to a primary respiratory alkalosis.
F. He has a high anion gap metabolic acidosis with appropriate respiratory compensation.


The patient’s respiratory rate is an indication of

A. Active tuberculosis.
B. Active bacterial bronchopneumon ?a.
C. A depressed ventilatory drive because of alcohol intoxication.
D. A response to a metabolic acidosis.
F. Alcohol withdrawal at this time.


The patient’s osmolal gap is closest to:

A. 35.
B. 45.
c. 65.
D. 75.
F. 95.


The most likely explanation for his osmolal gap is:

A. Decreased renal excretion of anions.
B. Inappropriate hyponatrem ?a.
C. Hypoglycemia.
D. The presence of ethyl alcohol in the blood stream.
F. Laboratory error
The most appropriate treatment for this patients acid-base disturbance is.

A. Additional infusion of bicarbonate intravenously
B. Oral administration of bicarbonate.
C. Intubation because of impending respiratory fatigue.
D. Infusion of hypertonic saline.
F. Administration of intravenous fluids containing glucose and saline.


This patient’s anion gap is due to:

A. Lactic acid.
B. Sulfuric acid.
C. Ketoacids.
D. Hydrochloric acid.
F. Formic acid