Critically unwell patient in shock requiring immediate resuscitation and further investigation of underlying illness.

Triple disorder (normal pH)

1. Hypokalaemic hypochloraemic metabolic alkalosis – classically occurs with gastric outlet obstruction

This patient had a gastric outlet tumour causing obstruction

Consider other causes of metabolic alkalosis

2. Respiratory acidosis – likely COPD (chronic CO2 retention)

Consider aspiration, pneumonia, other

compensation for metabolic alkalosis – 0.7XHCO3+20 = 48 (actual 63)

3. High anion gap metabolic acidosis

shock, sepsis, renal failure, other

Anion Gap = 19

Other relevant results – renal failure (pre renal – urea >> Creatinine and renal component), moderate to severe hypokalaemia (requires replacement), high WCC and Neutrophils (sepsis), high lactate (sepsis, dehydration)