Lab Case 15

A 65 year old man is brought to your Emergency Department by ambulance following several brown vomits.

On examination – jaundice, tachypnoea

BP 95/55, PR 120/min

Abd – soft and non tender

Describe and Interpret

pH 7.10  (7.36-7.44)                                  Na 130 (137-145)

CO2 15 (35-45)                                          K 4.2 (3.3-5)

HCO3 5 (24)                                               Cl 90 (99-111)

HB 60  (>110)                                            Glucose 40 (4-6)

WCC 22 (4-11)                                           Urea 22 (3-7)

Creat 245 (<130)                                        Lactate 18 (<2)

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2 thoughts on “Lab Case 15

  1. Great case !!

    Life threatening, primary metabolic acidosis [HAGMA, elevated lactate & urea + hyperglycaemia ?ketones] with maximal respiratory compensation.
    – marked anaemia ?acute GI bleed + decompensated liver failure + AKI
    – marked lactaemia = ?sepsis/haemorrhage with hypoperfusion, ??toxic alcohol
    – associated ?DKA/HUS.

    1* metabolic acidosis.
    – exp CO2 = (1.5 x 5) + 8 = 15.5, therefore maximal resp. compensation !
    – Anion Gap = 130 – (5 + 90) = 35, therefore HAGMA (marked lactaemia & elevated uraemia are likely causes, however severe hyperglycaemia raises possibility of ketoacidosis as contributor)
    – Delta ratio = (35 -12) / (24 – 5) = 23/19 = 1.2, therefore pure HAGMA.

    Hyperosmolar.
    – calc Osmol: (2×130) + 22 + 40 + ?alcohol = 322 [?DKA vs HHS]

    Severe anaemia.
    – Hb 60. ?acute GIT loss (varices vs PUD), likely coagulopathy

    Elevated urea & creatinine.
    – likely acute, given clinical context (hypoperfusion +/- volume depletion)
    – Ur:Cr > 1, ?urea 2* GI bleed.

    Normokalaemia.
    – 4.2 in setting of severe acidosis likely represents whole body depletion ! Caution with correction of acidosis. Consider replacement.

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    • Great comment Chris, as you know the high lactate is associated with high mortality >90%.

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